P017 COMPLEX ABDOMINAL WALL RECONSTRUCTION IN ELDERLY PATIENTS

Aim Our study aims to analyze and evaluate the results obtained in patients older than 80 years old who underwent complex abdominal wall reconstruction (CAWR) in a multicenter abdominal wall unit using different surgical approaches. Material and Methods Patients were identified from a prospective maintained multicenter database. Demographic characteristics, incisional hernias’ (IH) characteristics, as well as postoperative outcomes, including short and long-term complications have been analyzed. Results 21 patients were identified. The mean age was 82.5 (+/- 2.4) years old . There were 10 (47.6%) midline IH, 5 (23.8%) lateral IH, 4 (19%) synchronous midline and lateral IHs, and 2 (9.6%) parastomal hernias (PH). 9 (42.8%) Madrid TAR modification technique, 5 (23.8%) Rives-Stoppa, 3 (14.3%) lateral preperitoneal approaches, 1 (4.8%) midline preperitoneal approach and 1 (4.8%) anterior component separation were performed. In patients with PH, a modification of the Pauli technique (4.8%), and a unilateral TAR with a keyhole repair associated (4.8%) were performed. There were 7 (33,3) surgical site occurrences (SSO), 1 (4.8%) seroma, 3 (14.3%) hematomas and 3 (14.3%) surgical site infections. Only 3 (14.3%) SSO required procedural intervention. During a mean follow-up of 20.6 (+/- 15.9) months, 1 (4.8%) hernia recurrence was diagnosed. No cases of postoperative bulging were recorded. There were also no cases of chronic pain in the sample. During follow-up, 3 patients died from surgery unrelated causes. Conclusions CAWR in the elderly patient, after an adequate preoperatively selection of patients, presented acceptable short- and long-term results, despite the advanced population age.

P019 OUTCOMES OF OPEN LATERAL APPROACHES FOR L3-L4 INCISIONAL HERNIAS

Aim Our study aimed to compare and evaluate results of two different open lateral approaches for L3–L4 incisional hernias (IH) operated in a multicentric complex abdominal wall unit. Material and Methods Patients who underwent surgery for L3–L4 IH were identified from a prospective maintained multicenter database. The lateral IH were approached laterally, performing a reverse transversus abdominis release (TAR) or a lateral retromuscular preperitoneal approach (LRP). Outcomes included short and long-term complications, such as recurrence, bulging and pain. Results 61 patients were identified. There were 28 (45.9%) cases of L3 IH and 33 (54.1%) cases of L4 IH. 28 (34.7%) LRP approaches and 33 (24.5%) reverse TAR techniques were performed. There were surgical site occurrences (SSO) in 13 (21.3%) patients, 7 (11.5%) in the reverse TAR group and 6 in the LRP group. 8 (13.1%) SSO required procedural intervention (4 in each group). During a mean follow-up of 26.57 (+/- 19.23) months, no cases of recurrence were diagnosed. There were 12 (19.7%) cases of asymptomatic bulging that did not required reintervention (7 in the LRP group), and only one case of symptomatic bulging that needed intervention (in the LRP group). Furthermore, two patients (3.3%) required daily no opioids treatment for pain. Two (3.3%) cases of mortality were registered (both in the LRP group). Conclusions Despite the high complexity associated of L3-L4 IH, both lateral approaches showed acceptable long-term results, without any statistical difference between groups.

OV16 MASSIVE COMPLEX INGUINAL HERNIA

Aim Massive complex inguinal hernias can be exceptionally difficult to repair, especially when they are associated with loss of domain (LOD). We aim to demonstrate an open preperitoneal approach to a complex massive inguinal hernia extending into the scrotum with severe LOD. Material and Methods Footage from clinic, diagnostic imaging, and all operative procedures was included. This included botulinum toxin A (BTA) injection, diagnostic laparoscopy and placement of a peritoneal catheter, outpatient pre-operative progressive pneumoperitoneum (PPP), and the preperitoneal hernia repair. Results A 53-year-old male construction worker with a known inguinal hernia presented with worsening groin and scrotal pain, associated with fever. CT imaging showed an abscess secondary to perforated diverticulitis within his massive inguinal hernia, as well as massive loss of domain with almost all small and large intestine within the hernia. He was treated with antibiotics and percutaneous drainage in preparation for surgery. He received pre-operative bilateral BTA injection in the oblique abdominal musculature. Subsequently, he underwent diagnostic laparoscopy and peritoneal catheter placement. He received 2 weeks of outpatient PPP. He then underwent open inguinal hernia repair with left orchiectomy and total abdominal colectomy. The hernia was repaired with a biologic mesh placed in the pre-peritoneal plane. The patient recovered very well and had no wound complications post-operatively. He has since followed up in clinic multiple times with no recurrence and excellent cosmetic results. Conclusions In this patient with a complex massive inguinal hernia and loss of domain, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection and PPP.

OV03 TEP IN COLORS: ANATOMICAL VIEW USING ARTICULATED FORCEPS

Aim Present through an illustrative and educational video, an anatomical and colorful vision of the totally extraperitoneal laparoscopic approach (TEP) of inguinofemoral hernias, with the aim of favoring the learning process of this technique, facilitating the identification of the main anatomical structures, ensuring a safe and effective approach. Material and Methods In this video we show the laparoscopic approach to inguinofemoral hernias via TEP, highlighting the most important anatomical structures with different colors. Additionally, the surgical technique of this approach using articulated forceps is shown, which we consider to be a good resource for dissection in a space as small as the preperitoneal one. Results The anatomical study of the inguinofemoral area constitutes the basis of a correct preperitoneal approach, especially in PET, where the most difficult is probably the space location and the identification of the structures. Conclusions The preperitoneal PET route is a relatively novel approach for inguinofemoral hernia repair. Its benefits are based on the ability to identify all the anatomical structures of the myopectineal orifice from a preperitoneal view without the need to access the peritoneal cavity. The knowledge of preperitoneal anatomy is the cornerstone for learning the TEP approach, and we consider that anatomical videos of real surgeries are good strategies to shorten the learning curve. Mastering the preperitoneal anatomy ensures obtaining the benefits inherent to the TEP approach, such as bilateral exploration of the myopectineal orifice, direct visualization of the pain and doom triangles, tension-free repair with mesh of all possible defects and faster postoperative recovery.

OV13 LAPAROSCOPIC APPROACH IN EMERGENCY HERNIA SURGERY: MANAGEMENT OF ACUTE SMALL BOWEL OBSTRUCTION SECONDARY TO STRANGULATED OBTURATOR HERNIA

Aim Acute small bowel obstruction secondary to strangulated obturator hernia is a rare condition, with high rates of morbidity and mortality in the absence of prompt diagnosis and intervention. We aim to describe a case with the above presentation, managed using a minimally-invasive approach with positive outcomes. Material and Methods We describe a case of an 82-year-old female who presented with acute small bowel obstruction secondary to strangulated obturator hernia on cross-sectional imaging. Results The patient underwent emergency surgery using laparoscopic approach for repair of obturator hernia and assessment of obstructed small bowel. Our approach involved identification and reduction of small bowel loop. A transabdominal preperitoneal approach was made to obturator hernia and ischaemic sac was reduced followed by closure of defect with a plug of biologic mesh. A linear segment of ischaemic small bowel was oversewn. Total operative time was 90 minutes. Conclusions Minimally-invasive surgery is an important tool in the armamentarium of the acute care surgeon. A laparoscopic approach will reduce the insult of intervention in already physiologically deplete patients. This case demonstrates the feasibility of laparoscopy for small bowel obstruction secondary to strangulated obturator hernia in the acute setting, requiring advanced laparoscopic skill as demonstrated in this video.

VP020 ENDOSCOPIC PREPERITONEAL APPROACH IN STRANGULATED INGUINAL HERNIA

Aim According to the clinical sympthoms and radiological findings minimal invasive surgery can be an option to repair an strangulated inguinal hernia. Material and Methods We present the different ways we have used in our Hospital to treat incarcerated inguinal hernia combining endoscopic preperitoneal and laparoscopic approach Results Multiple treatment schemes are possible for inguinal incarcerated hernia. The choice must be made according to the surgeońs experience, patient´s characteristic and the risk of intestinal ischemia. Laparoscopy combined with preperitoneal endoscopic inguinal repair allows us to explore and to treat possible complications of intestinal ischemia with no need of laparotomy. Conclusions Laparoendoscopic techniques are an option to consider when treating an incarcerated inguinal hernia, even if bowel resection is needed. Thanks to laparoscopic approach, laparotomy can be avoided in many cases.

P038 MINIMALLY INVASIVE SURGERY & INCARCERATED INGUINAL HERNIA. CAN WE COMBINE THEM?

Aim After a long experience of more than 20 years in TEP hernioplasty we explore if it can also be suitable for emergency patients. Material and Methods We present different laparoendoscopic schemes that we have used in our Hospital to treat strangulated inguinal hernia according to clinical and radiological findings. Results TEP in now assumed to be one of the best options in scheduled surgery to treat inguinal hernia. Is now the time to change the paradigm by using it also in emergency surgery? Incarcerated inguinal hernia presents two problems: first of all the clinical emergency, an irreducible inguinal bulge that causes pain, obstruction and bowel ischemia; and second, the need to repair inguinal wall. While treating both problems, we have explored different minimally invasive surgery approaches according to each patient´s characteristics and the preoperative risk of intestinal resection based on CT findings. To reduce the incarcerated bulge, we use a laparoendoscopic methods. After a preperitoneal dissection, and with the help of external maneuvers, we try to reduce the content. If we are not successful, a quelotomy becomes necessary. To treat the inguinal defect we use TEP or TAPP approaches. Conclusions We seek to show that endoscopic preperitoneal approach in an incarcerated inguinal hernia is safe and possible, allowing us to maintain minimal invasive techniques. Laparoscopy allows us to explore and to treat possible complications of intestinal ischemia with no need of laparotomy. Multiple treatment schemes are possible for inguinal incarcerated hernia. The choice must be made according to the surgeońs experience, patient´s characteristic and the risk of intestinal ischemia.

Surgical sequale of transabdominal preperitoneal approach versus Lichtenstein open repair in a rural setting

Background: The objective was to compare the outcomes perioperative outcomes of transabdominal preperitoneal approach (TAPP) versus Lichtenstein tension (open) free repair for adult unilateral uncomplicated inguinal hernia patients (including both direct and indirect hernias).Methods: The prospective study was conducted between July 2018 to August 2020. A total of 60 patients, 30 in the Lichtenstein tension free repair group and 30 in the TAPP repair group data were collected and analysed.Results: The mean age was 55 in our study. On comparing open versus TAPP, significant difference of p value ≤0.05 was observed in terms of surgical site infections, time to discharge, time to return to work and mesh related pain in TAPP. Operative time was shorter in open group.Conclusions: Laparoscopic transabdominal preperitoneal repair is a valid alternative to open traditional method with lesser morbidity to the patients.