Self-adhesive hydrogel meshes reduce tissue incorporation and mechanical behavior versus microgrips self-fixation: a preclinical study

Purpose Atraumatic mesh fixation for abdominal hernia repair has been developed to avoid the disadvantages of classical fixation with sutures, which is considered a cause of chronic pain and discomfort. This study was designed to analyze, in the short and medium term, the biological and mechanical behavior of two self-fixing meshes compared to that of a polypropylene (PP) mesh fixed with a cyanoacrylate (CA) tissue adhesive. Methods Partial abdominal wall defects (6 × 4 cm) were created in New Zealand rabbits (n = 36) and repaired using a self-adhesive hydrogel mesh (Adhesix™), a self-gripping mesh (ProGrip™) or a PP mesh fixed with CA (Surgipro™ CA). After 14 and 90 days, the host tissue incorporation, macrophage response and biomechanical strength were examined. Results At 14 and 90 days, the ProGrip and Surgipro CA meshes showed good host tissue incorporation; however, the Adhesix implants presented poor integration, seroma formation and a higher degree of shrinkage. The Adhesix hydrogel was completely reabsorbed at 14 days, whereas ProGrip microhooks were observed at all study times. The macrophage response was higher in the ProGrip and Surgipro CA groups at 14 and 90 days, respectively, and decreased over time. At 90 days, the ProGrip implants showed the highest tensile strength values and the Adhesix implants showed the highest failure stretch. Conclusion Meshes with mechanical microgrip self-fixation (ProGrip) show better biological and mechanical behavior than those with adhesive hydrogel (Adhesix) in a preclinical model of abdominal hernia repair in rabbits.

An Emergent Nexus between Striae and Thoracic Aortic Dissection

Current approaches to stratify the risk for disease progression in thoracic aortic aneurysm (TAA) lack precision, which hinders clinical decision making. Connective tissue phenotyping of children with TAA previously identified the association between skin striae and increased rate of aortic dilation. The objective of this study was to analyze associations between connective tissue abnormalities and clinical endpoints in adults with aortopathy. Participants with TAA or aortic dissection (TAD) and trileaflet aortic valve were enrolled from 2016 to 2019 in the setting of cardiothoracic surgical care. Data were ascertained by structured interviews with participants. The mean age among 241 cases was 61 ± 13 years. Eighty (33%) had history of TAD. While most participants lacked a formal syndromic diagnosis clinically, connective tissue abnormalities were identified in 113 (47%). This included 20% with abdominal hernia and 13% with skin striae in atypical location. In multivariate analysis, striae and hypertension were significantly associated with TAD. Striae were associated with younger age of TAD or prophylactic aortic surgery. Striae were more frequent in TAD cases than age- and sex-matched controls. Thus, systemic features of connective tissue dysfunction were prevalent in adults with aortopathy. The emerging nexus between striae and aortopathy severity creates opportunities for clinical stratification and basic research.

Non-closure of the Free Peritoneal Flap During Laparoscopic Hernia Repair of Lower Abdominal Marginal Hernia: A Retrospective Analysis

Background: During lower abdominal marginal hernia repair, the peritoneal flap is routinely freed to facilitate mesh placement and closed to conclude the procedure. This procedure is generally called trans-abdominal partial extra-peritoneal (TAPE). However, the necessity of closing the free peritoneal flap is still controversial. This study aimed to investigate the safety and feasibility of leaving the free peritoneal flap in-situ.Methods: A retrospective review was conducted on 68 patients (16 male, 52 female) who underwent laparoscopic hernia repair between June 2014 and March 2021. Patients were diagnosed as the lower abdominal hernia and all required freeing the peritoneal flap during the operation. Patients were divided into 2 groups: one group was TAPE group with the closed free peritoneal flap, another group left the free peritoneal flap unclosed. Analyses were performed to compare both intraoperative parameters and postoperative complications.Results: There were no significant differences in demographic, comorbidity, hernia characteristics and ASA classification. The intra-operative bleeding volume, visceral injury, hospital stay, urinary retention, visual analog scale (VAS) score, dysuria, intestinal obstruction, surgical site infection, mesh infection, recurrence rate and hospital stay were similar among the two groups. Mean operative time of the flap closing procedure was higher than for patients with the free peritoneal flap left in-situ (p = 0.002). Comparisons of postoperative complications showed flap closure resulted in a higher incidence of seroma formation (p = 0.005).Conclusion: Providing a barrier-coated mesh is used during laparoscopic lower abdominal marginal hernia repair, it is safe to leave the free peritoneal flap in-situ and this approach may prevent the occurrence of seromas.

New Insights into the Application of 3D-Printing Technology in Hernia Repair

Abdominal hernia repair using prosthetic materials is among the surgical interventions most widely performed worldwide. These materials, or meshes, are implanted to close the hernial defect, reinforcing the abdominal muscles and reestablishing mechanical functionality of the wall. Meshes for hernia repair are made of synthetic or biological materials exhibiting multiple shapes and configurations. Despite the myriad of devices currently marketed, the search for the ideal mesh continues as, thus far, no device offers optimal tissue repair and restored mechanical performance while minimizing postoperative complications. Additive manufacturing, or 3D-printing, has great potential for biomedical applications. Over the years, different biomaterials with advanced features have been successfully manufactured via 3D-printing for the repair of hard and soft tissues. This technological improvement is of high clinical relevance and paves the way to produce next-generation devices tailored to suit each individual patient. This review focuses on the state of the art and applications of 3D-printing technology for the manufacture of synthetic meshes. We highlight the latest approaches aimed at developing improved bioactive materials (e.g., optimizing antibacterial performance, drug release, or device opacity for contrast imaging). Challenges, limitations, and future perspectives are discussed, offering a comprehensive scenario for the applicability of 3D-printing in hernia repair.

VP010 INTRA-ABDOMINAL HERNIA AS A CAUSE OF ACUTE SMALL INTESTINE OBSTRUCTION. LAPAROSCOPIC EMERGENCY TREATMENT - SMALL INTESTINE OBSTRUCTION DUE TO INTERNAL HERNIA WITH CONCOMITANT ACALCULOUS CHOLECYSTITIS

Aim Nowadays, in vast majority of emergency patients with gastrointestinal obstruction laparoscopy is not the treatment of choice. In our department laparoscopy is routinely used in emergency admitted patients, also those with abovementioned condition, sometimes yielding unexpected and thrilling results. The aim of this work is to present a laparoscopic internal hernia repair with simultaneous “Phrygian-cap-type” gallbladder excision, performed on a patient with small intestine obstruction and chronic acalculous cholecystitis. Material and Methods A 57-year-old patient was admitted to our department as an emergency, with a one week history of symptomatic cholecystitis accompanied by gastrointestinal obstruction. CT revealed atypical suprahepatic displacement of the small intestine. An attempt of conservative treatment failed after the re-initiation of oral nutrition. The patient was qualified for laparoscopy. Results An anatomical variant of the liver ligaments was visualized with two defects in the anteriorly displaced coronary ligament and shortening of the falciform ligament. Those defects formed the hernia ring entrapping a small intestine of a total length of about 1.5 m. The falciform ligament was dissected. To avoid re-entrapment of the intestine, most of the coronary ligament was severed. Consecutively the inflamed gallbladder was removed. The unusual anatomical variation of its structure, the so-called “Phrygian cap”, was an additional difficulty. The postoperative course was uneventful. Conclusions The presented material demonstrates the possibility of immediate treatment of intestinal obstruction, even in a complicated cases, with laparoscopic manner, without the need of conversion to the open method.

P086 A NOVEL CALIBRATION ALGORITHM FOR COMPARISON ACROSS PATIENT REPORTED OUTCOMES (PROS) IN VENTRAL HERNIA

Aim While there are many patient-reported outcome measures (PROMs) used for ventral hernia (VH), disease-specific instruments, like the Hernia-related Quality-of-Life (QoL) Survey (HerQLes) and Abdominal Hernia-Q (AHQ), have greater accuracy in capturing broad VH-related QoL. We present a novel calibration that allows providers to convert scores between the AHQ and HerQLes, enabling unification of QoL data. Material and Methods VH patients were prospectively identified and simultaneously administered the AHQ and HerQLes pre-and post-operatively. To ensure validity of the calibration, responses were excluded if patients answered instruments on different dates or if responses were discordant on corresponding questions on each instrument. The calibration was estimated using a linear mixed-effects model, including linear and quadratic scores, timing of survey relative to surgery and their interactions as fixed effects, and patients as random effects to account for multiple surveys from the same patient. Results In total, 109 patients were included, responding to 300 pairs of surveys (112 pre-operative and 188 post-operative). Seventeen (5.6%) were statistically excluded due to discordant responses. Conversion of the HerQLes to AHQ was most accurate when including whether the survey was completed pre-or post-operatively, with a mean square error (MSE) of 0.0091. Similarly, converting the AHQ to HerQLes was most accurate when factoring in the timing of survey administration, with a MSE of 0.016. Conclusions We present a novel and accurate method to convert scores between the AHQ and HerQLes. Portability of PROMs will be crucial in efforts to more broadly integrate PROMs into routine care in VH.

P089 THE IMPACT OF VENTRAL HERNIA REPAIR ON PATIENT-REPORTED QUALITY OF LIFE: IDENTIFYING FACTORS ASSOCIATED WITH IMPROVEMENT

Aim Assessing pre- and postoperative quality of life (QoL) is essential to quantify the magnitude of improvement in disease burden after ventral hernia repair (VHR). Here, we identify patient and operative factors associated with QoL improvement after VHR. Material and Methods Patients that underwent VHR by a single surgeon were retrospectively identified and included if they had minimum 1 year of follow-up, and completed pre- and postoperative Abdominal Hernia-Q (AHQ) questionnaires. Patients were divided into quintiles based on absolute pre- to postoperative improvement in AHQ score. Chi-squared and fisher’s exact tests were used for categorical data, and Student’s t-test for continuous data, as appropriate. Results Compared to the lowest quintile (n = 27, follow-up 32.6 months, mean improvement 3.24 [SD 10.4]), patients in the highest quintile (n = 26, follow up 23.9 months, mean improvement 66.3 [SD 12.1]) were female (76.9% vs 37.0%, p = 0.005) with a greater number of previous hernia repairs (mean 2.12 vs. 0.78, p < 0.005) and previous abdominal surgeries (mean 4.0 vs 2.0, p < 0.001). Patients with greater improvement also had higher incidences of delayed healing (42.3% vs 7.41%), required more office visits (5.54 vs 3.89), and had higher inpatient costs ($30,084 USD vs. $16,886, all p < 0.05). No significant differences were seen in terms of race, ethnicity, body mass index, age, length of stay, Clavien-Dindo scores, hernia recurrence, or other postoperative complications. Conclusions Despite increased preoperative risk and healthcare burden, some of the most significant QoL improvement after VHR is demonstrated in patients with complex repairs and recoveries. This indicates the global utility of VHR regardless of patient demographics and complicating perioperative factors.

P099 READMISSIONS AND EMERGENCY ROOM VISITS FOLLOWING OUTPATIENT AND INPATIENT HERNIORRHAPHIES

Aim Analysis of all healthcare encounters (readmissions and emergency department visits, EDV) following both inpatient and outpatient abdominal hernia repairs (AHR), with respect to the timeline of such encounters. Material and Methods Patients undergoing AHR were identified in Maryland State Inpatient and State Ambulatory Surgery and Services Databases, 2016-2017, and all their hospital and ED encounters were assembled into a comprehensive database, covering almost 95% of all AHR performed in Maryland. Results Of the total 26,215 patients who underwent AHR (3,333 inpatient and 22,950 outpatient; 48.7% inguinal and 53.0% ventral/umbilical), 5,802 (22.1%) had at least one postoperative encounter (4,186 EDV, 1,415 readmissions, and 248 encounters for mostly outpatient another AHR). 419 (80.4%) post-operative encounters within the first 48 hours were EDV and 98 (18.8%) were readmissions. Fraction of EDV within later encounters was in 69.6–71.1% range. Most frequent reasons for EDV were urinary complaints (24.1%, 10.6% and 4.0% on POD 0–2, 3–7, and 8–30, respectively), followed by pain control issues (18.1%, 24.9%, 14.4%) and delayed return of bowel function or constipation (10.5%, 9.9%, 3.4%). Readmissions mainly occurred for aforementioned GI complaints (15.3%, 19.9%, 6.9% on POD 0–2, 3–7, and 8–30, respectively), local surgical site infections (5.1%, 15.5%, 26.8%), and respiratory complications (8.2%, 6.6%, 4.1%). Conclusions 2.3% of all patients had at least one readmission while 6.4% patients had at least one EDV within 30 days following herniorrhaphy. Early postoperative EDV were mainly caused by urinary complaints, inadequately controlled pain, or delayed bowel function. Factors associated with these largely preventable complications require dedicated analysis.

P085 CLINICAL AND LONGITUDINAL PATIENT REPORTED OUTCOMES AFTER TRANSVERSUS ABDOMINIS RELEASE: A SINGLE SURGEON EXPERIENCE

Aim Posterior component separation with transversus abdominis release (TAR) is a novel complex abdominal wall repair technique that maximizes medial myofascial flap advancement in a vascularized, pre-peritoneal plane. Here, we add to a growing body of literature on this technique by assessing longitudinal clinical and patient reported outcomes (PROs) after ventral hernia repair (VHR) with TAR. Material and Methods Adult patients undergoing VHR with TAR between 10/1/2015 and 01/15/2020 by a single surgeon were retrospectively identified. Patients with parastomal hernias and <12 months of follow-up were excluded. Clinical outcomes and PROs using the Abdominal Hernia Questionnaire (AQH) and Hernia Related Quality of Life Survey (HerQLes) were assessed. Results 57 patients were included with a median age and body mass index of 60 and 30.6 kg/m2, respectively. The average hernia defect was 384 cm2 [IQR 205-471], and all patients had retro-muscular mesh placed. The most common complications were delayed healing (19.3%) and seroma (14.0%). One patient required return to the OR for management of a complication and there were no cases of mesh infection or explantation. Previous hernia repair and concurrent panniculectomy were risk factors for developing any complication (p < 0.05). One patient (1.8%) recurred at a median follow-up of 25.7 months [IQR 18.2-42.1]. Significant improvement in disease-specific PROs was observed and maintained throughout the follow-up period (pre to post p < 0.05). Conclusions Longitudinal clinical and patient-reported outcomes after VHR with TAR are limited. We conclude that TAR is a safe and efficacious adjunct in the repair of complex hernia defects.