Primary and Recurrent Repair of Incisional Hernia Based on Biomechanical Considerations to Avoid Mesh-Related Complications

Aim: Mechanical principles successfully guide the construction of polymer material composites in engineering. Since the abdominal wall is a polymer composite augmented with a textile during incisional hernia repair we ask: can incisional hernia be repaired safely and durably based on biomechanical principles?Material and Methods: Repair materials were assessed on a self-built bench test using pulse loads to elude influences on the reconstruction of the abdominal wall. Tissue elasticity was analyzed preoperatively as needed with computed tomography at rest and during Valsalva's maneuver. Preoperatively, the critical retention force of the reconstruction to pulse loads was calculated and a biomechanically durable repair was designed based on the needs of the individual patient. Intraoperatively, the design was adjusted as needed. Hernia meshes with high grip factors (Progrip®, Dahlhausen® Cicat) were used for the repairs. Mesh sizes, fixation elements and reconstructive details were oriented on the biomechanical design. All patients recieved single-shot antibiosis. Patients were discharged after full ambulation was achieved.Results: A total of 163 patients (82 males and 81 females) were treated for incisional hernia in four hospitals by ten surgeons. Primary hernia was repaired in 119 patients. Recurrent hernia was operated on in 44 cases. Recurrent hernia was significantly larger (median 161 cm2 vs. 78 cm2; u-test: p = 0.00714). Re-do surgery took significantly longer (median 229 min vs. 150 min; p < 0.00001) since recurrent disease required more often transversus abdominis release (70% vs. 47%). GRIP tended to be higher in recurrent repair (p = 0.01828). Complication rates (15%) and hospital stay were the same (6 vs. 6 days; p = 0.28462). After 1 year, no recurrence was detected in either group. Pain levels were equally low in both primary and recurrent hernia repairs (median NAS = 0 in both groups at rest and under load, p = 0.88866).Conclusion: Incisional hernia can safely and durably be repaired based on biomechanical principles both in primary and recurrent disease. The GRIP concept provides a base for the application of biomechanical principles in incisional hernia repair.

Long-term follow-up of full-thickness skin grafting in giant incisional hernia repair: a randomised controlled trial

Purpose Conventional repair of a giant incisional hernia often requires implantation of a synthetic mesh (SM). However, this surgical procedure can lead to discomfort, pain, and potentially serious complications. Full-thickness skin grafting (FTSG) could offer an alternative to SM, less prone to complications related to implantation of a foreign body in the abdominal wall. The aim of this study was to compare the use of FTSG to conventional SM in the repair of giant incisional hernia. Methods Patients with a giant incisional hernia (> 10 cm width) were randomised to repair with either FTSG or SM. 3-month and 1-year follow-ups have already been reported. A clinical follow-up was performed 3 years after repair, assessing potential complications and recurrence. SF-36, EQ-5D and VHPQ questionnaires were answered at 3 years and an average of 9 years (long-term follow-up) after surgery to assess the impact of the intervention on quality-of-life (QoL). Results Fifty-two patients were included. Five recurrences in the FTSG group and three in the SM group were noted at the clinical follow-up 3 years after surgery, but the difference was not significant (p = 0.313). No new procedure-related complication had occurred since the one-year follow-up. There were no relevant differences in QoL between the groups. However, there were significant improvemnts in both physical, emotional, and mental domains of the SF-36 questionnaire in both groups. Conclusion The results of this long-term follow-up together with the results from previous follow-ups indicate that autologous FTSG as reinforcement in giant incisional hernia repair is an alternative to conventional repair with SM. Trial Registration The study was registered August 10, 2011 at ClinicalTrials.gov (ID NCT01413412), retrospectively registered.

P058 INCISIONAL HERNIA REPAIR IN PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Aim Patients with inflammatory bowel disease (IBD) are likely to undergo several abdominal operations and may thus be at increased risk for incisional hernia repair (IHR). The aim of the present study was to investigate risk and predictors of IHR in patients undergoing surgery for ulcerative colitis (UC) or Crohn’s disease (CD). Material and Methods Nationwide register-based study (1996-2018). Patients were followed from date of first abdominal operation until the date of the first IHR. Cumulative incidence proportion were estimated treating death as competing risk. Cox proportional hazard regression was used to explore pre-study defined predictors of IHR. Results Patients with inflammatory bowel disease (IBD) are likely to undergo several abdominal operations and may thus be at increased risk for incisional hernia repair (IHR). The present study analyzed the risk and predictors of IHR in patients undergoing surgery for ulcerative colitis (UC) or Crohn’s disease (CD). Conclusions The risk for incisional hernia repair is relatively low after IBD-surgery, although increased in UC compared with CD patients. Hernia repair predictors varied between UC and CD patients.

OV10 LAPAROSCOPIC-GUIDED TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK IN HERNIA SURGERY - HOW WE DO IT

Aim “COVID has been a great challenge for Hospitals around the world. At our surgical department a new protocol of TAP block was designed and implemented in our laparoscopic incisional ventral hernia repairs, to allow these patients to be operated in ambulatory regime, without compromising pain control and the outcomes. In this video we aim to present the technique for the Laparoscopic-guided TAP Block during a Laparoscopic IPOM Plus ventral hernia repair.” Material and Methods “We implemented this protocol in July 2020 and since then, we performed 18 TAP block in laparoscopic incisional hernia repairs, laparoscopic guided by the Surgeon or ultrasound-guided by the Anesthesiologist. In this case, the video reports to a Laparoscopic IPOM Plus incisional hernia repair performed on a 54-year-old patient, male, with obesity, arterial hypertension and dyslipidemia. He had a 6 centimeter incisional hernia post-colorectal surgery in 2013.” Results “As detailed in the video, we show all the steps to perform a TAP block under laparoscopic direct visualization” Conclusions “TAP block can be performed by the Surgeon, with direct visualization at the beginning of the laparoscopic procedure.”

P149 THE IMPACT OF COVID-19 ON TACKOMESH RANDOMISED CONTROLLED TRIAL COMPARING SPIRAL-TACK MESH-FIXATION DEVICES IN LAPAROSCOPIC INCISIONAL HERNIA REPAIR USING THE MANCHESTER TECHNIQUE

Aim Provide a report on all patients who underwent laparoscopic incisional hernia repair as part of the TACKoMesh RCT prior to unblinding of treatment arms. Material and Methods Trial recruitment was for primary incisional hernia with a defect diameter of 3–10cm. 63 patients (target 74-136) were operated on prior to the outbreak of COVID-19. Post-operative pain is the primary trial outcome. Surgery was performed with either spiral-tack mesh-fixation device (Protack (permanent) or Reliatack (absorbable)), Symbotex IPOM mesh, and fascial closure with no 1 Maxon suture(s) using extracorporeal knot ties – the Manchester Technique. Data was collected on trial forms and lifestyle questionnaires (SF-36 and CCS). All data were explored and described in RStudio v1.4.1106. Results Patients were aged 36-80 and 36(57.1%) patients were male. Mean preoperative BMI was 30.91(sd5.11,range21.15–43.93). Mean operating time was 80.81(37.34,20-240)minutes. In 13(20.6%) patients multiple hernia defects were identified. A good degree of fascial closure was achieved in all patients using a median of 3(IQR 2.0-3.5)knots. Median mesh-fixation time was 286(159.5-428.0)seconds and a mean 25.24(5.49,14-41)tacks/patient were used. Median length of hospital stay was 3.5(2.0–6.0)days. Patients were asked “Please indicate on this scale [VAS 0–10] the pain that you currently experience from your incisional hernia during activity?”. Median responses for Day0/pre-op, Day1, Day6, Day30 and Day365 were 4.5, 8.0, 6.0, 3.0 and 1.5 respectively. At one year, 7(11%) patients had experienced hernia recurrence and 33(52%) post-operative seroma. Conclusions Target recruitment was not possible owing to COVID-19. The Manchester Technique has comparable recurrence rates. Reported pain increases post-operatively but is reduced at post-operative day30 and day365.

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.