Comparison of Post-Operative Complications Between Sublay and Onlay Mesh Repair in Incisional Hernia

Objective: To compare the post-operative complications between sublay and onlay mesh repair in incisional hernia. Materials & Methods: This randomized controlled trial was conducted at Department of Surgery, Sandeman Provincial Hospital Quetta from May 2019 to November 2019. Total 250 patients with incisional hernias for more than 3 months, having age 20-40 years either male or female were selected. Then selected patients were placed randomly into two groups i.e. Group A (Sublay group) & Group B (Onlay group), by using lottery method. Patients were called for follow up 15th day for post-operative complications in term of wound infection and seroma formation. Results: The mean age of patients in group A was 34.73 ± 4.32 years and in group B was 34.51 ± 4.67 years. Out of these 250 patients, 161 (64.40%) were female and 89 (35.60%) were males with female to male ratio of 1.8:1. Wound infection was seen in 07 (5.60%) patients in group A (Sublay technique) and 17 (13.60%) patients in group B (Onlay technique) with p-value of 0.033. Seroma formation was seen in 09 (7.20%) patients in group A (Sublay technique) and 26 (20.80%) patients in group B (Onlay technique) with p-value of 0.002. Conclusion: This study concluded that rate of wound infection and seroma formation is less after sublay mesh repair for incisional hernia as compared to onlay repair. Keywords: Hernia, incisional, onlay, sublay, seroma.

ANALYSIS OF IMMEDIATE AND LONG-TERM RESULTS OF SUBLAY AND TAPP TECHNIQUES IN THE TREATMENT OF VENTRAL HERNIAS

The accumulated clinical experience has proven that the “sublay” technique allows to achieve greater functional activity of the anterior abdominal wall and is the method of choice in the treatment of ventral hernia. The use of self-adhesive nets during laparoscopic transabdominal preperitoneal plasty (TAPP- Transabdominal Preperitoneal Plastic) in the treatment of small and medium ventral hernia is safe and effective, with low values of postoperative pain syndrome and rapid functional recovery after surgery, without increasing the recurrence in the short term. The aim – was to analyze the immediate and long-term results of “sublay” and TAPP techniques in the treatment of ventral hernias of lower and median localization. The author noted that the search for technical methods aimed to reduce the intra-abdominal pressure in this hernioplasty technique was relevant and practically significant. Material and Methods. The work was performed on the basis of the surgical department of the State Institution “Specialized Multi-Purpose Hospital №1 of Ministry of Health of Ukraine”, Department of General Surgery of the State Institution “Dnipro State Medical University of Ministry of Health of Ukraine”. Results. Comparison of immediate and long-term results of peritoneal-prosthetic-aponeurosis thickness studies showed a statistically significant difference (p < 0.001) using different techniques. When analyzing the separated results, reliable differences (p <0.001) depending on the gender of patients were recorded. Thus, in males, when using the “sublay” technique the peritoneal-prosthetic-aponeurosis thickness was greater by 1.15 mm (by 42.43 %) in comparison with the Tapptechnique, and in females, by 1.16 mm (by 42.09 %), respectively. Conclusions. The analysis of the immediate and long-term results of the “sublay” and TAPP techniques in the treatment of ventral hernias of lower and median localization showed that the “sublay” technique was characterized by traumatic surgical intervention, shift of the prosthesis to one side, as a consequence of its deformation. When using this technique, peritoneum-prosthetic-aponeurosis thickness values were significantly higher – by 13.16 % and 42.40 % in the early and distant postoperative periods, respectively. Also, when using the Tapp technique in the distant period the thickness was significantly reduced (p <0,0001) by 49,47 % in comparison with the immediate results.

P062 IMPLEMENTATION OF ETEP (EXTENDED TOTALLY EXTRAPERITONEAL REPAIR) AS A NEW METHOD OF INCISIONAL HERNIA REPAIR

Aim To assess the outcomes of implementation of extended Totally Extraperitoneal Repair (eTEP) for incisional hernia in our clinic. Material and Methods In our clinic abdominal wall hernias are predominantly repaired in eMILOS (endoscopic Mini or Less Open Sublay)-technique. However, we hoped for advantages in repairing incisional hernias in eTEP-technique. From 19.09.2019 till 28.04.2021 there were 13 patients with incisional hernias included to be operated in eTEP-technique. Results Among 13 patients, mean age was 64,6 years (range 47 – 78 years), 7 females (54%) and 6 males (46%). Average diameter of the hernia was 6,46 cm (range 2 – 14 cm). The mean Body Mass Index of the patients was 29,41 kg/m² (range 18,4 – 48,76 kg/m²). The mean duration of the operation was 162,38 minutes (range 106 – 237 minutes). The mean surface of the mesh was 612 cm² (range 225 – 1200 cm²). Hospital stay lasted mean of 5,8 days (range 2 – 28 days). We observed one postoperative complication as a lung artery embolism occurred in one patient with preperitoneal heamatoma due to needed anticoagulation. Till today we have not observed any recurrence. Conclusions Our study shows that a new method of incisional hernia repair with mesh placement can be a safely implemented and may have advantages compering with other laparoscopic methods. It has low complication rate, shows good cosmetic results and is cost effective.

O36 LOD (LOSS-OF-DOMAIN) HERNIA TREATMENT WITH INTRAOPERATIVE FASCIA TRACTION. DOES THIS TECHNIQUE MAKE RELEASE OPERATIONS SUPERFLUOUS?

Aim Measurable and controlled stretching of the fascia for 30 minutes during surgery to achieve primary tension-free abdominal wall closure in LOD hernias. This prospective observational study aimed to clarify the extent to which this traction method can function as an alternative to component separation methods. Material and Methods We have already applied this technique in &gt; 50 procedures of LOD hernias. We published the data of first 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. The average patient age was 58 years with a gender ratio of 2.5 males: 1 female. ASA scores were III in 66.7% and II in 33.3%. The body mass index (BMI) averaged 32.5 kg/m2. Thirteen patients were treated with BTA 4 weeks before surgery. Results Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5–44 cm). After application of diagonal-anterior traction &gt;10 kg for an average duration of 32.3 min (range 30–40 min), the fascial distance decreased by 9.8 cm (1–26 cm) to an average 7.5 cm (range 2–19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusions This method allows primary closure of complex LOD hernias and is potentially less prone to complications than component separation methods.

P104 POSTOPERATIVE OUTCOME AND COMPLICATIONS AFTER STOMA REVERSAL SURGERY WITH CICATRIAL HERNIA HERNIA PROPHYLAXIS BY MESH AUGMENTATION IN SUBLAY TECHNIQUE USING GORE® BIO A® MESH

Aim At the surgery hospital of Klinikum Mittelbaden in Baden-Baden (Prof. Dr. Dieter Berger) stoma reversal surgery was performed on 127 patients in the time from Nov. 15, 2010 to Mar. 11, 2015. All 127 patients were treated with a resorbable synthetic mesh (GORE® BIO-A® mesh) in sublay technique to close abdominal wall incisions. Primary wound closure was carried out in all cases. In order to evaluate the rate of postoperative hernias, which literature reports to be over 30 percent and a common complication, all 127 patients were included in a prospective study. Material and Methods In total, 104 of the included patients (n = 127) took part in the follow-up examinations. 72 patients underwent clinical examinations and imaging diagnostics, 21 were surveyed on the telephone whenever their presentation at a follow-up exam was impossible, whereas 11 patients deceased during the follow-up period. These cases were analyzed on the basis of the previous examinations which had been part of the respective health records. The follow-up examination took place after a median time span of 87 weeks (8 -218 weeks). Results The total herniation rate of 7.7 percent (n = 8/104) in the examined patient population was thus much lower than described in the literature. Conclusions According to our own prospective analysis, we were able to register a very low herniation rate compared to the literature when the resorbable synthetic mesh (GORE® BIO-A®) was applied in sublay technique for stoma reversal. One disadvantage could lie in the increased perioperative wound infection rate. 5/8 hernias were observed after the occurrence of perioperative wound infections.

General views on treatment technologies for patients with incisional ventral hernia

Nowadays, the problem of surgical treatment of incisional ventral hernia (IVH) still remains significant. According to the statistical data, the number of patients with postoperative ventral hernias has increased by more than 9 times over the past 25 years. Experts offer many solutions to this problem every year and the surgeon have to find the best method of postoperative rehabilitation in the flow of information. Academic research databases Google Scholar, CyberLeninka and others were used to search for the relevant literature. The following conclusions were drawn from this review. The etiology of IVH is multifactorial. There is no generally accepted evidence-based gradation of risk factors. There is no unified system for selecting the method of hernia repair of the anterior abdominal wall in patients with IVH. The choice of allotransplant material and the method of hernia repair are often individual. The value of the critical level of intraabdominal pressure have not been specified, however, all authors agree that its monitoring should become routine. The sublay technique remains the "gold standard" of plastic surgery by aponeurotic flap, inlay should be used when sublay is impossible to perform. Onlay should be used as a reserve method. In some situations, combinations of techniques are required. More and more laparoscopy is being introduced in the treatment of IVH as an assistance and in therapy. The introduction of new methods of hernia repair based on the uncontrolled separation of the anatomical structures of the abdominal wall imposes special requirements on surgical technology: plastic material, instrumental and technical support, wound closure and pharmacological support, especially in conditions of increased intra-abdominal pressure and tissue tension. We can use medication of pyrimidine’s row (xymedon) for a better implantation of the mesh implant and to increase the resistance of local tissues.

OPTIMIZATION OF THE CHOICE OF LAPAROSCOPIC AND OPEN ALLOPLASTICS IN CASE OF INCISIONAL VENTRAL HERNIAS

The aim of the work – to increase the effectiveness of surgical treatment of incisionalventral hernias (IVH) by optimizing the choice of laparoscopic and open allohernioplasty.Material and methods. The analysis of surgical treatment of 508 patients with IVH from2009 to 2020 was conducted. According to the Europenian Herniology Association(EGA) classification (Ghent, Belgium, 2008) IVH was distributed as follows: MW1-2R0 was diagnosed in 217 (42,7%), MW3R0 – in 291 (57,3%) patients. Diastasis of therectus abdominis muscles up to 5 cm was present in 217 (42,7%) patients, diastasis5-10 cm – in 127 (25%), diastasis greater than 10 cm – in 164 (32.3%) patients.Depending on the size of the hernia and the width of diastasis of the rectus abdominis,patients were divided into 3 groups.In group I, laparoscopic allohernioplasty was performed in 109 (21,5%) patients withsmall and medium-sized IVH with diastasis of up to 5 cm, in particular the developedlaparoscopic preperitoneal in 63 patiens and laparoscopuc retromuscular alloplastiesin 46 patients. The comparison group IIa consisted of 108 (15,1%) patients whounderwent open retromuscular allohernioplasty.In group II, 64 (12,6%) patients with large IVH and diastasis of the rectus abdominis5-10 cm underwent open allohernioplasty by «sublay» technique. The comparison groupIIa consisted of 63 (12,4%) patients who were performed the open method «onlay».In group III, in 82 (16,1%) patients with giant IVH and diastasis more than 10 cm ananterior component separation technique of the abdominal wall in combination withalloplasty with intra-abdominal placement of a mesh implant with anti-adhesive coatingwas performed according to the developed method. Comparison group IIIa consistedof 82 (16,1%) patients who underwent anterior component separation technique of theabdominal wall in combination with alloplasty «onlay».Results. For small and medium-sized IVH and diastasis of the rectus abdominis musclesup to 5 cm, laparoscopic allohernioplasty with preperitoneal and retromuscularplacement of a mesh implant and elimination of diastasis is optimal in comparisonwith open retromuscular allohernioplasty, contributes to a significant decrease in theincidence of seroma from 35,2% to 3,7 %, postoperative wound suppuration – from6,5% to 0%, inflammatory infiltrate – from 4,6% to 0%, chronic postoperative pain –from 6,4% to 2,6%, hernia recurrence – from 6,4% up to 0%.The optimal method of allohernioplasty for large IVH and diastasis of the rectusabdominis muscles from 5 to 10 cm is the open «sublay» technique in comparison withthe open «onlay» technique, reduces the incidence of seroma from 23,8% to 6,3%,postoperative wound suppuration – from 4,8% to 1,6%, chronic postoperative pain –from 4,8% to 1,6%, hernia recurrence – from 7,9% to 3,1%.In case of gigantic IVH, contracture of the rectus abdominis muscles and diastasisof more than 10 cm the anterior component separation technique of the anatomicalcomponents of the abdominal wall in combination with intra-abdominal alloplasty isoptimal in comparison with the use of an anterior component separation techniqueof an abdominal wall combined with «onlay» significant improvement in treatmentoutcomes, namely, reduction of seroma frequency from 25,6% to 7,3%, postoperativewound suppuration – from 4,9% to 2,4%, postoperative wound infiltrate – from 13,4%to 2,4 %, chronic postoperative pain – from 8,1% to 1,6%, recurrence of IVH – from6,5% to 1,6%.Conclusion. Optimization of the choice of laparoscopic and open allohernioplastyenables to increase significantly ventral hernias and to decrease the quantity of thepost-operative complications.