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.

P-BN56 Anti-Reflux Surgery in the end-stage of the pandemic: Early results of the ARROW audit

Background Gastro-oesophageal reflux disease (GORD) affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS). We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of compliance with available guidelines. Methods International guidelines and consensus statements were collated and reviewed by the ARROW steering committee. Sources included NICE, ICARUS and BSG guidelines and AUGIS commissioning guidelines. Definitions were adopted from the Montreal consensus statements and the Chicago Classification of Esophageal Motility Disorders. Audit fields were then iteratively developed by the steering committee and an online tool was developed to prospectively collect pseudo-anonymised patient data. Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI trainees. The online tool was piloted in three centres. The protocol was published in Diseases of The Esophagus in January 2021. Results Of 240 registered patients on 25th August 2021, 171 had complete data. Median age was 57(range 19-83), 60.2% were females. 156 (91.2%) had OGD performed prior to surgery. 105 (61.4%) had manometry and 97 (56.7%) had 24-hour pH studies performed. 91 DeMeester scores were recorded, median score 38 (IQR 24-70). Median days from referral to surgery was 471, (range 1 to 1374). 167 patients (93.3%) underwent some variant of fundoplication. The most common wrap was a posterior 360° (44%) followed by a posterior 270°(27%) and anterior 180°(23%). 2 patients returned to theatre, 1 for recurrent hernia and 1 for ischaemia. Conclusions In keeping with all non-cancer elective work in the UK, ARS is recovering from the effects of the COVID pandemic, and this is reflected in long delays between referral and surgery. Compliance with established guidelines and consensus opinions has similarly been affected as access to diagnostic services has been impeded. Variation persists in the interventions offered to individuals and long-term outcomes monitoring to compare interventions is beyond the scope of this audit. Complication rates are very small with only 2 returns to theatre, 9 patients experiencing any short-term complication and only 24 delayed discharges.

Endovideogernioplasty in patients with inguinal hernias: advantages and disadvantages

This study analyzed the results of treatment of patients with inguinal hernias, with an assessment of the advantages and disadvantages of endovideosurgical hernioplasty techniques. The clinical study used the data of 1317 patients with inguinal hernias. The results revealed that the totally extraperitoneal inguinal hernia repair had some advantages over laparoscopic hernioplasty, such as a shorter duration of surgery (43 15 min), mild pain on a visual analog scale, and an average bed-day after surgery. Complications were diagnosed in 16 (1.2%) patients, and most had ClavienDindo grade II complications. Relapses were detected in 7 (0.5%) cases. Thus, endoscopic hernioplasty (laparoscopic and totally extraperitoneal inguinal hernioplasty) was the preferred surgery for patients with bilateral inguinal hernia, recurrent hernia after traditional hernioplasty, and metabolic syndrome and young people of working age. The use of a modified technique of totally extraperitoneal inguinal hernioplasty with a clear understanding of the multifascial structure of the anterior abdominal wall may reduce the risks of both intraoperative and postoperative complications and increase the cost-effectiveness of treatment of patients with inguinal hernias, allowing us to obtain good results.

O33 TREATMENT OF INCARCERATED GROIN HERNIA - EMERGING EVIDENCE BASED ON THE SWEDISH HERNIA REGISTER

Aim The evidence base for statements about risk factors, morbidity and mortality for emergency hernia repair is mostly low quality. The aim of this study is to elucidate risk factors for the development of incarcerated hernia and outcome after adult emergency hernia repair using data from the Swedish Hernia Register (SHR). Material and Methods Data in this observational study were extracted from the SHR. It included registered cases between January 1, 2009 and December 31, 2019. Maximal follow-up was until December 31, 2020. Demographic data were analysed descriptively, risk analyses were performed using multivariate- and Cox-regression models. Results A total of 164.844 cases could be included after application of the in- and exclusion criteria. Women [odds ratio (OR) 1.42 99%CI 1.32–1.51], patients with lateral hernia [OR 1.54, 99%CI 1.47–1.61], femoral hernia [OR 14.63, 99%CI 13.32–16.06] and hernia recurrence [OR 2.46, 99%CI 2.33–2.60] were at higher risk of developing an incarcerated hernia. The highest strangulation risk was seen among women [OR 2.36, 99%CI 1.91–2.90], femoral hernia [OR 7.00, 99%CI 5.40–9.11] and recurrent hernia [1.90, 99%CI 1.54–2.33]. Patients with hernia incarceration or strangulation suffer significantly more frequent from postoperative complications [16.7% and 40.9% respectively, both p < 0.001]. Conclusions The data demonstrate that certain risks groups exist, which are prone to suffer from hernia incarceration and strangulation. These at risk patients should be prioritized, especially during the reorganisation of services to cope with the massive surgical backlog in the aftermath of the COVID-19 pandemic.

P064 DURABLE REPAIR OF PRIMARY AND RECURRENT INCISIONAL HERNIA BASED ON BIOMECHANICAL PRINCIPLES

Aim Durable composite constructions of polymers follow specific mechanical principles. Can incisional hernia can be repaired durably based on biomechanical principles considering the abdominal wall a polymer composite? Material and Methods Biomechanical principles of the reconstruction of the abdominal wall were analyzed ex vivo with cyclic loading common in material sciences. The resulting GRIP concept was clinically applied. The tissue quality of the individual patient was assessed with computed tomography at rest and during Valsalva’s maneuver. Hernia meshes with high GRIP factors (Progrip®, Dahlhausen® Cicat) were used. 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. Primary hernia was repaired in 119, recurrence in 44 patients. Recurrent hernia was significantly larger (median 161 cm² versus 78 cm²; u-test: p = 0.00714) resulting in a 30 % lower mesh defect area ratio. Redo-surgery took significantly longer (median 229 min versus 150 min; p < 0.00001) as recurrent disease is more likely to require transversus abdominis release (70 % versus 47 %). GRIP tended to be higher in recurrent repair (p = 0.01828). Complication rates (15 %) and duration of hospitalization were the same (6 days; p = 0.28462). After one year, no recurrence was detected in either group. Pain levels were equally low in both groups (median NAS = 0 at rest and under load, p = 0.88866). Conclusions Incisional hernia can be repaired safely and durably based on biomechanical principles.

P118 MORBIDITY, MORTALITY AND RECURRENCE FACTORS OF INCARCERATED FEMORAL HERNIA

Aim Aimed to search the factors affecting morbidity, mortality, and recurrence in incarcerated femoral hernia cases. Material and Methods After ethical committee approval, patients operated due to incarcerated femoral hernia between 2010 and 2020 were included in the study. Patients in the pediatric age group (0-18 years), and pregnant patients were excluded from the study. Preoperative, intraoperative, and postoperative factors of the patients were gathered. Morbidity, mortality, and recurrence factors were evaluated with Mann-Whitney U test, χ² test, and Likelihood ratio test, p value lower than 0.05 as significant. Results The mean age of 50 patients was 54.56±19.34 years (19-91) and the female to male ratio was 33/17. Right-sided hernia was present in 27 (54%) patients and recurrent hernia in 5 (10%) patients. The most common surgery type was Mc Vay repair in 33 (66%) patients. Other surgery types were as follows: Lichtenstein procedure in 9 (18%) patients and Rutkow plug procedure in 8 (16%) patients. The morbidity and mortality rates of the study were 14% and 4%, respectively. Postoperative recurrence was seen in only 3 (6%) patients. Patients with preoperative nausea (p = 0.003), vomiting (p < 0.001), and tachycardia (p < 0.001), presence of recurrent hernia (p < 0.001), surgery under general anesthesia (p < 0.001), performing both laparotomy (p = 0.007) and organ resection during surgery (p < 0.001) had more morbidity. Also, patients with preoperative tachycardia (p = 0.005) and organ resection during surgery (p = 0.029) had more mortality. However, no factors affecting recurrence were found in the study. Conclusions Morbidity and mortality probability are higher in patients with preoperative septic and obstructive symptoms.

P146 ROBOTIC REPAIR OF COMPLICATED INGUINAL HERNIAS

Aim In this video, the authors provide an educational demonstration on the use of robotic surgery in management of two patients with complicated and recurrent inguinal hernias. The two patients demonstrated in these videos show the benefits of use of robotics in the approach to a patient with a recurrent hernia after previous open repair with plug and patch method as well as repair in a very obese patient with large hernias causing obstruction of the left ureter. Material and Methods N/a Results N/a Conclusions Robotic surgery is an emerging technology in surgery and can be a useful modality in treating patients with complex and recurrent inguinal hernias. Furthermore, the visualization in these complex cases can be helpful in identifying the important structures during dissection. Regardless of technique, the two videos presented demonstrate a complex dissection which may be needed when repairing recurrent or very large inguinal hernias.

O52 LAP-T MINI LAPAROSCOPIC TECHNIQUE FOR THE REPAIR OF RECURRENT UMBILICAL HERNIA ON PRIMARILY UNTREATED DIASTASIS

Aim “This retrospective analysis on 1000 cases of Diatasis Recti (DR) complicated by single/multiple, primary/recurrent hernias, all treated with the Laparoscopic Abdominoplasty Technique (LAP-T), aims at evaluating the possible correlation of higher recurrence rate and complications when DR is left untreated” Material and Methods “This review on 1000 patients, <65yrs, BMI<30, 3>IRD>12, based on CT Scan/MRI study, showed 235 (23,5%) of them to be recurrent umbilical/midline hernias engaged on untreated RMD, independently from the surgical technique used for primary repair. Re-operation with LAP-T technique, consisted in removal of recurrent hernia and dislocated mesh when present, closure by self-locking running sutures of the hernia defect and the DR. Repair is consolidated placing an intra-peritoneal mesh” Results “In all patients, recurrence was repaired, DR reconstructed and abdominal wall anatomy and physiological functionality successfully restored. No intra operative bleeding, seroma formation, chronic pain, nor mesh infection have been recorded. 98% follow up at 12 months, 91% at 24, no recurrences observed” Conclusions “Higher incidence of recurrent umbilical/midline hernias observed in this analysis, compared to average recurrence rate reported in literature, suggest that regardless primary repair technique, the repair of the sole hernia engaged on a DR is likely to lead to a recurrent hernia, further midline hernia defects formation and worsening of the DR. A significant correlation between the recurrency after primary umbilical/midline repair when a concomitant RMD is left untreated is likely to lead to a more invasive and complicated re-intervention, higher complication rate and discomfort for the patient”

O24 10 YEARS PARTICIPATING IN THE HERNIAMED-REGISTRY: REFLECTING ON RESULTS OF THE PAST HELPS US TO SHAPE THE FUTURE

Aim Between 01/2011 and 12/2020 5,068 AWR-patients at our department (tertiary referral center) – 884 (17.4%) incisionals. Over this 10-years period considerable changes (patients characteristics, surgical techniques, results) were analyzed. Material and Methods Herniamed® offers an internet-based registry-platform to document all kinds of abdominal wall repairs on a voluntary basis since 2009. Demographic data, interventional details and outcomes are documented using the EHS-classification-system. Follow-up is standardized and sheduled for 10 years. Results Up to 54.7% of patients (in 2020) show at least one risk factor (diabetes, smoking ….), in contrast to the age pyramid patients >70 years are decreasing (47.2% in 2011 down to 29.3% in 2020), share of ASA III/IV is initially increasing (up to 42.9% in 2017) with a constant decrease after 2017 to 25.3% in 2020. Emergent cases are increasing (6.9% in 2011 up to 10.8% in 2019). Recurrent hernia repairs stays almost constant at median 21.7%. After 2015 we decided – for various reasons - not to routinely apply the laparoscopic IPOM-technique (with an interim ratio of up to 46.2%) – with a post-OP complication rate of median 23.3% anymore. From 2016 onwards we performed an increasing number of „other techniques“ (E-MILOS, E-TEP, ….) up to 36% in 2020 instead. Conclusions By analysing trends we recognized that patients show increasing numbers of risk factors and ASA-scores which led us to implement a prehabilitational strategy in clinical routine. However rate of post-OP complication is still high representing AWR as demanding in many aspects. A temporary cessation of MIS did not led to an extensive increase in post-OP wound complications.

O45 OUTCOMES OF INCISIONAL HERNIA REPAIR SURGERY AFTER MULTIPLE RE-RECURRENCES: A PROPENSITY SCORE MATCHED ANALYSIS

Aim Patients with a re-recurrent hernia may account for up to 20% of all incisional hernia (IH) patients. IH repair in this population may be complex due to an altered anatomical and biological situation as a result of previous procedures and outcomes of IH repair in this population have not been thoroughly assessed. This study aims to assess outcomes of IH repair by dedicated hernia surgeons in patients who have already had two or more re-recurrences. Material and Methods A propensity score matched analysis was performed using a registry-based, prospective cohort. Patients who underwent IH repair after ≥ 2 re-recurrences operated between 2011 and 2018 and who fulfilled 1 year follow-up visit were included. Patients with similar follow-up who underwent primary IH repair were propensity score matched (1:3) and served as control group. Patient baseline characteristics, surgical and functional outcomes were analyzed and compared between both groups. Results Seventy-three patients operated on after ≥ 2 IH re-recurrences were matched to 219 patients undergoing primary IH repair. After propensity score matching, no significant differences in patient baseline characteristics were present between groups. The incidence of re-recurrence was similar between groups (≥ 2 re-recurrences: 25% versus control 24%, p = 0.811). The incidence of complications, as well as long-term pain, was similar between both groups. Conclusions IH repair in patients who have experienced multiple re-recurrences results in outcomes comparable to patients operated for a primary IH with a similar risk profile. Further surgery in patients who have already experienced multiple hernia re-recurrences is justifiable when performed by a dedicated hernia surgeon.