P-BN43 Giant Hiatus Hernia Repair Significantly Improves Quality of Life

Background Giant hiatus hernias (GHH), defined as more than 30% of the stomach herniating into the chest cavity accounts for 5%-10% of all hiatus hernias. GHH repair is undertaken electively in symptomatic patients, to prevent complications such as volvulus of the stomach with resultant mortality. Advances in laparoscopy and perioperative care have reduced the risk of operation, and improvement in quality of life (QoL) has become an important outcome measure. “Quality of Life in Reflux and Dyspepsia” (QOLRAD) questionnaire is a disease specific validated tool used to assess QoL. We present our prospective data assessing change in QoL following GHH repair. Methods Symptomatic patients undergoing elective repair of GHH, by a single surgical team, between January 2010 and June 2021 were identified from a prospectively kept database. Demographic data and operative details were recorded from patient notes. From 2015 onwards the QOLRAD questionnaire was introduced. Patients who underwent GHH repair completed the questionnaire pre-operatively and then at 6 weeks, 6 months, 1 year and 2 years post-operatively. Patients, who were not operated on, completed the questionnaire at 6 month intervals over 2 years. Mann-Whitney U test was used to compare QOLRAD scores between hernia size, type and symptomatology. Results Sixty-eight patients underwent GHH repair from 2010 to 2014. Statistically significant(p < 0.001) improvement in QoL was only seen in patients with ‘heartburn’ symptoms. Thirty patients were included in the post 2015 group. Statistically significant improvement in all QOLRAD domains was observed as demonstrated the table below. Conclusions GHH repair is a safe operation in symptomatic patients that results in an improvement in QoL across all QOLRAD domains and may prevent deterioration in QoL.

Feasibility of Umbilical Hernia Repair Under Local Anesthesia and Monitored Anesthesia Care at a Veteran Affairs Hospital

Background Local anesthesia (LA) for open umbilical hernia tissue repair (OUHTR) is not widely utilized in academic centers in the United States. We hypothesize that LA for OUHTR is feasible in a veteran patient population. Methods From 2015 to 2019, 449 umbilical hernias were repaired at our institution utilizing a standardized technique in veteran patients. OUHTR was included in this analysis (n = 283). Since 2017, 18.7% (n = 53) UH were repaired under LA. We compared outcomes and operative times between general anesthesia and LA in patients undergoing OUHTR. Univariable and multivariable analyses were performed to determine significance. Results The entire cohort was composed of older (56.3 ± 12.1 years), White (75.5%), obese (body mass index [BMI] = 32.3 ± 4.6 kg/m2) men (98.0%). The average hernia size for the entire cohort was 2.42 ± 1.2 cm. The groups were similar in age and BMI. Patients with higher American Society of Anesthesiologists (ASA) (Odds ratio [OR] 3.1; 95% CI 1.5-6.8) and cardiovascular disease (OR 2.7; 95% CI 1.0-7.2) were more likely to receive LA. Recurrence (0.0% vs 6.0%; P = .9) and 30-day complications (6.0% vs 13%; P = .9) were similar between LA and GA after correcting for hernia size. Operating room times were reduced in the LA group (17.7 minutes; P < .05). None of the patients with LA required postanesthesia care unit for recovery. The patients who received LA reported being comfortable (78.9% of patients), with the worst reported pain being 2.4 ± 2.4 (out of a scale of 10), and 94.7% would elect to receive LA if they had another hernia repair. Conclusion Patients who received LA had more cardiac disease and a higher ASA. Complications were similar between both groups. LA reduced operating room times. Patients were satisfied with LA.

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 (&gt;8cm).

OV11 GIANT SPIEGEL HERNIA: 3D PLANNING AND MINIMALLY INVASIVE TREATMENT

Aim Demonstrate the advantages of 3D technology planning in complex cases of hernia surgery and technical tricks for giant Spiegel hernia repair. Material and Methods 71 year old patient, BMI 38, asthma, hypertensive; long history of symptomatic left flank mass. Giant Spiegel hernia was diagnosed, with significant omentum and colon migration to hernial cavity. It was decided to perform minimally invasive surgery. 3D model of the abdominal scan was performed, assessing hernia size, volume and its relationship with the abdominal cavity. We were able to rule out the possibility of compartment syndrome, and foresee that we could probably close the defect. Results preperitoneal transabdominal repair (TAPP) is performed, beginning with herniated content reduction, a delicate step where injuries should be avoided, with careful traction of the colon and omentum. Hernial defect is assessed, coinciding with the 3D model, the peritoneum sac is reduced, taking as much as possible to facilitate its posterior closure. The entire peritoneum of the Spiegel and inguinal region are dissected en bloc. Defect tension-free closure is performed with 2 continuous V-LOOK 2.0, subsequent placement of 15x15cm polypropylene mesh and posterior peritoneum closure. The patient is discharged the same day without incidents. Conclusions The 3D model allows us to assess the actual abdominal and hernia volume to simulate surgery findings. Its benefits are yet to be developed. Laparoscopic preperitoneal repair is an excellent approach for Spiegel's hernia. Complex cases are also candidates for outpatient surgery.

Abdominal Wall Expanding System. Intraoperative Abdominal Wall Expansion as a Technique to Repair Giant Incisional Hernia and Laparostoma. New and Long-Term Results From a Three-Center Feasibility Study

Background The abdominal wall expanding system (AWEX) was first applied in 2012 and published in 2017. This novel technique was developed to reconstruct complex incisional hernias and residual skin-grafted laparostoma after treatment of an open abdomen, when primary midline closure was impossible. The main aim was the anatomical reconstruction of the abdominal wall and the avoidance of dissecting techniques (component separation). Methods Between 2012 and 2019, 33 patients underwent AWEX hernia repair in three certified hernia centers. The retracted abdominal wall was stretched with the AWEX system intraoperatively for approximately 30 min. Hernia size was measured preoperatively, on CT, and intraoperatively. The gain in length on the lateral abdominal wall (decrease in width of the defect) after stretching and any residual midline gap were determined in the OR. Results 33 patients underwent AWEX procedures. Six cases were evaluated separately because of additional procedures (TAR, four cases) and preoperative application of botulinum toxin (two cases). The median (95% confidence interval) measured width of hernia defects was 13 (12–16) cm, the median gain in length on the lateral abdominal wall was 12 (10–15) cm. After median follow-up of 29 (12–54) months, one recurrence from the broken mesh was observed. No method-related complications occurred. Conclusion Based on the 2017 and current results, the AWEX system represents an alternative or supplemental procedure to current techniques for complex abdominal wall reconstruction. The system proved again to be time-saving, safe, effective, and easy to learn. Further studies with enhanced technology are in progress.

791 RECURRENT HIATAL HERNIA A HIGH PREDICTOR OF PATHOLOGIC REFLUX AND NEED FOR REINTERVENTION

Anti-reflux surgery (ARS) has been postulated to have high failure rates, which may approach 50% depending upon hiatal hernia size. Most failures are thought to be related to wrap disruption or hiatal hernia recurrence. Recently, diaphragmatic mesh augmentation has been shown to reduce hiatal hernia recurrence. We aimed to determine factors that influence recurrence based on vigilant imaging and diagnostic pH studies, and the need for surgical reintervention. Methods A prospectively maintained database of all patients undergoing index robotic ARS (including Hill, Nissen, Toupet, and Linx procedures) with Phasix ST ® mesh was queried. Between December 2016 and July 2020, 134 patients were identified of which 92 met inclusion criteria for post-operative barium esophagram performed at routine intervals (6, 12, or 24-months) or for recurrent symptoms. Median follow-up time was 11.4 months. Clinical characteristics, manometry, pH studies, as well as surgical approach was evaluated. Radiographic recurrences were then associated with endoscopic confirmation and rates of surgical re-intervention. Results Radiographic recurrence &gt;2 cm was noted in 9 (9.8%) patients, of which 44% were symptomatic, compared to 36% of those without radiographic recurrence (p = 0.620). Endoscopy confirmed recurrence in 67% of patients with radiographic recurrence versus 0% without (p = 0.001). When all radiographic recurrences, including those &lt;2 cm, were evaluated, 17 (18%) were identified, of which 53% of patients were symptomatic. Endoscopic and pH studies confirmed recurrences in 75% and 71% of these patients, respectively. Overall reintervention rates were 23% in the setting of any radiographic recurrence versus 1.3% without (p = 0.001). Conclusion Recurrence rates following robotic ARS and hiatal hernia repair with mesh augmentation appear low with nearly 1-year follow-up. Prior to surgical reintervention, endoscopic and pH studies are warranted to confirm symptomatic recurrence. Recurrent hiatal hernias, including those &lt;2 cm, can lead to abnormal pH studies that merit reintervention at rates higher than those without evidence of recurrence. Longer term follow-up is required to optimally delineate true recurrence patterns.

Spontaneous Resorption of Spinal Disk Herniation and Its Adjacent-level Complications: A Case Report

Objectives: Symptoms associated with spinal disk herniation may heal without surgery. In some patients, imaging reveals a reduction in hernia size, too. This phenomenon is referred to as spontaneous regression of the herniated disk. It was first reported in 1984 and is widely covered in today’s research papers. Case Presentation: This paper describes a case of spontaneous regression of lumbar disk herniation at L5-S1, where another disk was herniated at L4-L5 after only 8 months. The patient (F) sought help complaining of pain in the lumbar region. An MRI scan revealed a 6.2-mm hernia at L5-S1. The patient was prescribed conservative treatment comprising non-steroidal anti-inflammatory drugs and kinesitherapy, to which she refused to adhere and decided to treat the condition on her own. Eight months later, the patient sought help again, reporting other symptoms of pronounced constant pain in the rear lateral surface of the left leg and lameness. A further MRI scan revealed spontaneous hernia resorption at L5-S1 with an emergent vacuum phenomenon and a different disk herniated at L4-L5 to 9.4 mm. Discussion: Since the symptoms were pronounced and non-steroidal anti-inflammatory drugs did not have a therapeutic effect, the patient required surgery.

External and internal oblique abdominis muscle release (eimr) for complex incisional hernia repair: Modification of partition surgical technique

Incisional hernia is the name given to hernias that form in the incision site after abdominal operations. The only treatment option for incisional hernias is surgery and the repair of incisional hernias is still a serious issue for surgeons. The aim of this study is to present an alternative surgical treatment procedure for the treatment of incisional hernias. The study included patients who were diagnosed with complex incisional hernia and underwent surgery between November 2016 and December 2017. In addition to demographic data such as age and gender, the operative and postoperative morbidity and mortality rates were documented. The patients who underwent additional surgical procedure other than herniography were excluded from the study. The study included 16 patients who met the inclusion criteria. Of 16 patients, nine (56.25%) were male and seven (43.75%) were female. The mean age of the patients was 51.25 years and the mean body mass index was 25.3 kg/m2. The hernia size measured in the computed tomography was 11.01 cm on average in men and 11.56 cm on average in women. The intravesical pressure measured intraoperatively before the surgery was 3.4 mmHg on average. While the mean intravesical pressure was found as 12.25 mmHg after the abdomen was closed, the mean intravesical pressure was measured as 6.43 mmHg after the relaxation incision and graft installment. The duration of the surgery was 48 minutes on average. In the postoperative period, paralytic ileus responsive to treatment was observed in two patients and skin necrosis was observed in one patient. No pulmonary embolism, respiratory problems and compartment syndrome that may cause mortality developed in patients. No recurrence was observed in patients in the control one year after the surgery. The golden standard surgical method for the incisional hernia surgery has yet to be determined. There is still a need for prospective randomized studies. We believe that our technique can be an alternative to other techniques in the incisional hernia surgery due to its easy applicability and low rate of complications.

LINX: How I Do It and Why

The LINX device consists of a “bracelet” of magnetic beads in titanium cases, connected by individual wires placed noncompressively around the distal esophagus during laparoscopic surgery. This augments the native lower esophageal sphincter’s (LES) ability to resist reflux by increasing yield pressure and resisting shortening of the LES. Magnetic sphincter augmentation (MSA) was conceived as a safe, stomach sparing, minimally invasive, reversible implantable device for patients seeking an alternative to laparoscopic Nissen fundoplication. Though initially studied in patients with limited hiatal hernias, its use has expanded to include patients with large and even giant or paraesophageal hernias with excellent results. The author’s techniques of complete esophageal dissection, precise hiatal repair, current concepts on noncompressive sizing and placement of the MSA device are reviewed in this article. MSA can be considered first-line surgical therapy for GERD patients with adequate peristalsis regardless of hernia size.

Evaluation of dynamic MRI data in patients with herniated intervertebral discs after the complex treatment including osteopathic correction

Introduction. Pain in the lumbosacral region is one of the most common causes of disability and medical attention acquiring. Magnetic resonance imaging (MRI) of the spine in these patients quite often demonstrates multiple hernias. Despite the success of modern, including complex, methods of treating patients with herniated discs of lumbosacral spine, the problem of objective revealing of the applied therapy effect with modern instrumental examination methods is actual.The goal of research — study was to study the changes in the MRI picture in patients with herniated intervertebral discs during treatment with inclusion of osteopathic correction.Materials and methods. The study involved 15 patients with herniated intervertebral discs of lumbosacral spine. The patients received outpatient conservative treatment with inclusion of osteopathic correction. Participants underwent MRI of the lumbar spine at the beginning of the study and 3 months after treatment. The obtained data were processed by methods of nonparametric statistics.Results. After the complex treatment, such indicators of MRI as the hernia size, the lateral pocket width and the pelvis configuration significantly improved. These parameters are important indicators of pathomorphological changes in the spinal motion segment, affecting the discoradicular conflict. At the same time, there were no obtained convincing data about the therapy effect on the L5 vertebra rotation, on the presence of sequestration and changes in the Tchaikovsky index. Perhaps this is due to the small sample and short follow-up period for patients.Conclusion. After the course of treatment with inclusion of osteopathic correction, the statistically significant changes in MRI images were revealed in patients with herniated intervertebral discs, indicating a positive dynamics in the parameters of the hernia size, the width of the lateral pocket and the configuration of the pelvis.