Long Term Evaluation of Paraumbilical Hernioplasty by Onlay Technique

Objective: To evaluate long term results of paraumbilical hernioplasty by onlay technique. Material & Methods: This prospective study was started in Jan 2017 and completed in Oct 2021. A total number of 196 patients having paraumbilical hernia were included in the study by convenient sampling. Patients with recurrent, strangulated and obstructed hernia as well as patients with ulcerated skin over the hernia were excluded from the study. All the patients were operated under general anesthesia with muscle relaxants. A non-absorbable standard prolene mesh (15x15 cm or 30x30 cm) was used and fixed with prolene 3-0 suture. Redivac drain was used over the mesh for minimum of three days. After discharge, all the operated cases were advised to visit the outpatient department after one week, one month, three months, six months, one year and two years. Maximum follow-up was two years and minimum was one year to assess the long term complication including recurrence. Demographic data along with diagnosis, complication, were collected and analyzed with Excel 2019. Results: Total 196 patients were operated for paraumbilical hernia. From which 53 were male and 143 were female. Minimum age was 18 years old and oldest patient was 78 years old. Average age was 40.19± 10 years, median age was 38 years. Seroma was seen in 04 patients. Superficial wound infection was observed in 02 patient no deep-seated infection was reported in our study. During three months of follow-up, numbness was noted in 03 patients and 02 patients had pain at the operation site during manual work. After two years recurrence was observed in two female patients, who failed to control their weight. Conclusion: Paraumbilical hernia is very common presentation in female patients. In order to prevent complication of hernia like, incarceration, strangulation and obstruction, early repair of the hernia is recommended in all the cases. Onlay mesh hernioplasty is one of the safest techniques which is relatively easy procedure, has a short learning curve with promising results. It has a low recurrence rate. Keywords: Onlay Mesh hernioplasty, Paraumbilical Hernia, PUH.

P139 LAPAROSCOPIC TRANSABDOMINAL PREPERITONEAL REPAIR FOR SMALL AND MEDIUM PRIMARY UMBILICAL AND MIDLINE HERNIAS

Aim Complications of open mesh repair for primary umbilical and midline hernias (PUMH) may lead to significant re-admissions and follow-up costs. Although laparoscopic intraperitoneal onlay mesh repair reduces infection rates, especially in overweight patients, it’s controversial in these hernias, mainly due to potential adhesions’ formation. Laparoscopic transabdominal preperitoneal technique (lap-TAPP) may address these issues, as it combines advantages of both open and laparoscopic approaches. The aim of this study is to present the initial results of lap-TAPP for PUMH in regard to its feasibility and complication rates. Material and Methods We evaluated 25 consecutive cases of lap-TAPP repair for PUMH. Patients’s characteristics, intraoperative findings, and postoperative complications after 30-days follow-up were analyzed. Results 21 male and 4 female patients were included in analysis (mean BMI 29.8 kg/m2). Surgery time was 82 minutes (55-120). We found 20 umbilical and 11 epigastric linea alba hernias. Mesh size was 144cm2 (120-225); mean hernia defect width was 25mm (10-40). In 9 patients (36%) the peritoneal rents were created which were easily closed with sutures. All patients were discharged on 1 POD with no complications. After 30-days we found no recurrences or bulging, no pain complaints. We found one subcutaneous small hematoma with no need for intervention. Conclusions Laparoscopic TAPP for small and medium PUMH is a safe and feasible technique with low complication rate. However, this method is technically demanding and time consuming while performed with laparoscopic approach as it requires precise and subtle plane dissection, and non-ergonomic closure hernia defect.

P053 COMPARISON OF CLINICAL OUTCOMES BETWEEN INTRAPERITONEAL ONLAY MESH REPAIR (IPOM PLUS) AND ENHANCED-VIEW TOTALLY EXTRAPERITONEAL REPAIR (ETEP) FOR VENTRAL HERNIAS

Aim We have been performing intraperitoneal on lay mesh repair (IPOM plus) as the standard laparoscopic procedure for ventral hernia in our department. We introduced enhanced-view totally extraperitoneal repair (eTEP) for ventral hernia repair in 2018, and have performed 31 cases so far. We compared the outcomes of IPOM Plus and eTEP at our institution. Material and Methods Ventral hernia cases who underwent surgery at our department between 2018 and 2020 were included in the study. The postoperative outcomes and complications of the IPOM Plus and eTEP groups were evaluated retrospectively. Results There were 12 cases of IPOM plus, and all were incisional hernias. There were 31 cases of eTEP, including 7 cases of primary hernias and 24 cases of incisional hernias. Transversus abdominis muscle release (TAR) was added in 24 cases. The mean hernia size was 6.6 x 7.9 cm with IPOM Plus and 8.0 x 10.1 cm with eTEP, and the average meshes size was 15.5 x 22.0 cm and 20.3 x 23.6 cm, respectively. The mean postoperative hospital stay was 7.8 days and 5 days. Postoperative complications included 1 case of mesh bulging and 1 case of recurrence in the IPOM Plus group, 1 case of seroma and 1 case of intestinal obstruction in the eTEP. Conclusions The surgical outcomes for ventral hernias up to 8 cm wide were similar for IPOM Plus and eTEP. The eTEP can insert a larger mesh and may be useful for wider hernias (>8cm).

P127 ROBOTIC TRANSABDOMINAL RETRO-RECTUS HERNIA REPAIR VS. LAPAROSCOPIC INTRAPERITONEAL ONLAY MESH REPAIR: IMPROVING POSTOPERATIVE OUTCOMES

Aim “The optimal repair technique for small and medium-sized ventral hernias in obese patients remains unknown. We aimed to evaluate results after robotic-assisted laparoscopic transabdominal repair with retro-rectus mesh placement (rTARUP) compared with laparoscopic intraperitoneal onlay mesh repair (IPOM).” Material and Methods “Retrospective cohort study of consecutive patients undergoing rTARUP or IPOM repair for small or medium-sized primary ventral and incisional hernias. The primary outcome was postoperative need for transverse abdominis plane (TAP) block or epidural catheter, and secondary outcomes were 30-day complications, and length of stay. All patients underwent elective surgery and were followed for 30 days postoperatively.” Results “A total of 27 patients (rTARUP) and 32 (IPOM) were included. Patients in the two groups were comparable in terms of age, sex, comorbidities, smoking status, body mass index (BMI), and type of hernia. The median BMI was 32.4 kg/m2 and the fascial defect area was comparable (rTARUP median 16.8 cm2 vs. IPOM 11.7 cm2, P = 0.303). The duration of surgery was longer in the rTARUP group (median 117.2 min. vs. 84.4, P = 0.003), whereas the postoperative need for TAP block or epidural analgesics was less in the rTARUP group compared with IPOM (n = 14 vs. n = 1, P = 0.002). There were no severe complications or reoperations in the two groups. The length of stay was shorter in the rTARUP group (median 0 vs. 1 days, P < 0.001).” Conclusions “rTARUP was associated with reduced postoperative analgesic requirement and shorter length of stay compared with laparoscopic IPOM.”

O26 INFECTIOUS COMPLICATION IN RELATION TO THE PROPHYLACTIC MESH POSITION: THE PRIMA TRIAL REVISITED

Aim Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position. Material and Methods Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure. Results Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group. Conclusions Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

O31 SUTURE OR MESH REPAIR FOR THE SMALLEST UMBILICAL HERNIAS: A NATIONWIDE DATABASE STUDY

Aim High level evidence recommends the use of mesh for umbilical hernias with defects >1 cm to reduce recurrence rates without increasing the risk of postoperative complications. For umbilical hernias with defect width ≤1 cm, the literature is sparse. The aim of the study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width <1 cm on a nationwide basis, and to evaluate outcomes after onlay mesh repair specifically. Material and Methods By merging data from the Danish Hernia Database and the National Patients Registry from January 2007 until December 2018, patients receiving elective repair of an umbilical hernia with defect width ≤1 cm were identified. Available data included details about comorbidity, surgical technique, 90-days readmission, 90-days reoperation and reoperation for recurrence. Results A total of 7,849 patients were included, of whom 25.7% (2,013/7,849) underwent mesh repair. The cumulative 5-year incidence of reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1-4.1) compared with suture repair 6.7% (95% C.I. 6.0-7.4), P < 0.001. Onlay mesh repairs had the lowest cumulative risk of recurrence at 5 years 2.0% (95% C.I. 0.6-3.5). For onlay mesh repairs, readmission 7.9%, (65/826)) and reoperation (3.9% (32/826)) rates within 90-days were comparable to suture repairs (6.5% (381/5,836) and 3.3% (192/5,836), P = 0.149 and P = 0.382, respectively. Conclusions Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with the lowest risk of recurrence without increasing early complications.

P121 ONLAY MESH FOR TREATMENT OF SMALL UMBILICAL HERNIAS IN ADULTS - A SINGE CENTER INVESTIGATION

Aim Previous studies on the repair of small umbilical hernias have suggested a lower recurrence rate with mesh compared to suture repair. A remaining important question is in what anatomical position the mesh should be placed. The purpose of this study was to investigate the outcome of using a standardized 4x4 cm onlay-mesh for umbilical hernias ≤2cm. Material and Methods A retrospective study was conducted at a single institution in Sweden on all umbilical hernia repairs during 2015-2019. The follow up time was at least four months. Patients were identified using the hospital medical record database. Repairs performed with suture, sublay, ventral patch or laparoscopic mesh positioning were excluded. Patient’s demographics, comorbidities, intra – and postoperative details were considered. Primary outcome was surgical site complications within 30 days. Secondary outcome was recurrence. Results 80 patients were repaired with a small onlay-mesh for an umbilical hernia ≤ 2 cm and were included for statistical analysis. Median (range) follow-up time was 29.0 (4.3-50.1) months. Median age was 46 (26-76) years old. Median body mass index was 28 (19-38) kg/m2. Men to female ratio was 2.1. 4 patients were identified with a surgical site postoperative complication; 3 with seroma and 1 with superficial wound infection. 3 of these were given antibiotics. 2 patients were treated with wound opening bedside. There were no registered cases of a recurrence. Conclusions Repairing small umbilical hernias with a small onlay-mesh was safe with a low surgical site complication rate. Randomized trials are needed to assess weather mesh reduce recurrences in umbilical hernia repairs ≤2cm.

P003 SUMMER TRIAL: MESH VERSUS SUTURE REPAIR IN SMALL UMBILICAL HERNIAS IN ADULTS: A STUDY PROTOCOL FOR A PROSPECTIVE, RANDOMIZED, DOUBLE-BLIND, MULTICENTER CLINICAL TRIAL

Aim A gold standard procedure for small umbilical hernia repairs is still lacking today. There is an increasing evidence that mesh could be advantageous in lowering recurrence rates. A question remains with regard to optimal anatomical positioning of the mesh. We hypothesize that the use of an onlay-mesh can reduce recurrence rates without increasing complications compared to a simple-suture repair. Material and Methods A prospective, national, multicenter, randomized, double-blind clinical trial comparing a standardized 4x4 cm onlay mesh to a conventional suture repair will be conducted. 288 patients with a primary elective umbilical hernia ≤ 2 cm from 7 participating Swedish surgical centers will be enrolled. Intraoperative randomization will take place. Trial participants and follow-up clinical surgeons will be blinded to the assigned allocation. The primary outcome assessed will be postoperative recurrence at 1 and 3 years. Secondary outcomes assessed will be postoperative complications at 30 days and pain 1 year after surgery. Results 140 participants are included since February 2020 and 95 participants are randomized. Conclusions How to best repair a small umbilical hernia continues to be debated. A small onlay-mesh may become an easy and a safe method of choice to reduce recurrence rates in small umbilical hernia defects. This trial design should allow for a good assessment of differences in recurrence rate with due to the large sample size and the adequate follow-up. Guidelines for small umbilical hernia repairs have stressed the need for reliable data to improve treatment recommendations. We can expect that this trial will have a direct implication on small umbilical hernia repair standards.

P002 POST-PARTUM ABDOMINAL WALL INSUFFICIENCY SYNDROME. LESSON LEARNED FROM THE SINGLE SURGEON'S EXPERIENCE BASED ON 200 CASES

Aim Post-partum abdominal wall insufficiency with rectus diastasis is present in over 30% of women after pregnancy. Little is known about how PPAWI affects the social, sexual life and self-esteem of patients. This study was designed to evaluate the safety of onlay mesh combined with abdominoplasty and its impact on the well-being of the patients. Material and Methods Two hundred patients with PPAWI underwent surgery with onlay mesh and abdominoplasty. The safety of the procedure was assessed by postoperative complications, time of hospitalization and time of drainage. Before the operation and 6 months later, a questionnaire asking about the patient’s sexual and social life and the presence of back pain was completed. The cosmetic effect was assessed separately. Results The onlay procedure with abdominoplasty was found to be safe and fast. The mean operation time was 82 min, and the drainage time was 2.1 days. In this group <2% postoperative complications were noted. There were no recurrences within the 6 month.p. Significant improvements in social and sexual life and the level of self-esteem were noted. Back pain was relieved or minimalized in all patients. The cosmetic effect was insufficient for 2 patients (1%). Conclusions PPAWI can be treated safely with onlay mesh and abdominoplasty. The patients’ symptoms were strongly correlated with the morphological status of the front abdominal wall and improved after the procedure. The authors are the first to propose PPAWI syndrome as a complex disorder with a disease classification, which can help patients with their choice of proper surgical intervention.

Postoperative Pain After Robot-Assisted Laparoscopic Ventral Hernia Repair

Background: Robot-assisted ventral hernia repair, when performed correctly, may reduce the risk for pain and discomfort in the postoperative period thus enabling shorter hospital stay. The aim of the present study was to evaluate postoperative pain following robot-assisted laparoscopic repair. The approach was selected after an intraoperative decision to complete the repair as: (1). Transabdominal Preperitoneal Repair (TAPP); (2). Trans-Abdominal RetroMuscular (TARM) repair; or (3). Intraperitoneal Onlay Mesh (IPOM) repair depending on anatomical conditions.Methods: Twenty ventral hernia repairs, 8 primary and 12 incisional, were included between 18th Dec 2017 and 11th Nov 2019. There were 8 women, mean age was 60.3 years, and mean diameter of the defect was 3.8 cm. The repairs were performed at Södersjukhuset (Southern General Hospital, Stockholm) using the Da Vinci Si Surgical System®. Sixteen repairs were completed with the TAPP technique, 2 with the TARM technique, and 2 as IPOM repair.Results: Mean hospital stay was 1.05 days. No postoperative infection was seen, and no recurrence was seen at 1 year. At the 30-day follow-up, fifteen patients (75%) rated their pain as zero or pain that was easily ignored, according to the Ventral Hernia Pain Questionnaire. After 1 year no one had pain that was not easily ignored.Conclusion: The present study shows that robot-assisted laparoscopic ventral hernia is feasible and safe. More randomized controlled trials are needed to show that the potential benefits in terms of shorter operation times, earlier discharge, and less postoperative pain motivate the extra costs associated with the robot technique.