Volume 18 • Supplement 1 • March 2014
123
The World Journal of Hernia
and Abdominal Wall Surgery
Abstract Book
16th ANNUAL
HERNIA REPAIR
LAS VEGAS, USA
March 12-15, 2014
Invited Papers
Free Papers
Posters
Now indexed and included in ✽
Science Citation Index Expanded
Journal Citation Reports/Science Edition
Current Contents ®/Clinical Medicine
♦
♦
♦
✽
See complete list below the table of contents
Official Organ of the European Hernia Society (EHS-GREPA)
Official Organ of the American Hernia Society (AHS)
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HERNIA
The World Journal of Hernia and
Abdominal Wall Surgery
1 Aims and Scope
“Hernia” was founded in 1997 with the
purpose of promoting clinical studies and
basic research as they apply to groin
hernias, internal hernias, the abdominal
wall (anterior and postero-lateral aspects),
the diaphragm and the perineum. “Hernia”
is the official organ of the European Hernia
Society (GREPA), established in 1979, and
of the American Hernia Society (AHS)
established in 1997. These associations have
common objectives:
◆ the advancement of abdominal wall and
hernia surgery in all aspects,
◆ the study of anatomical, physiological,
pathological and therapeutic issues
concerning the abdominal wall and hernias,
◆ the creation of associated groups which
will promote research and teaching in this
field,
◆ the development of interdisciplinary
relations.
“Hernia” is a journal written by surgeons
who have made abdominal wall surgery
their special field of interest.
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Hernia (2014) 18 (Suppl 1): S1-S6
PROGRAM
16th Annual Hernia Repair
March 12-15, 2014
Las Vegas, USA
© Springer-Verlag 2014
SCIENTIFIC SESSIONS
Wednesday, March 12, 2014
11:15 am-12:00 pm
Bruce Ramshaw, MD
Presidential Address
8:00-8:15 am
Brent Matthews, MD & Michael Rosen, MD
Welcome
12:00-12:15 am
Session 1
Abdominal wall reconstruction
Moderators: J. Scott Roth, MD
& Yuri Novitsky, MD
8:15-8:35 am
Robert Martindale, MD
USA
IP-12560: Risk reduction: preoperative patient
optimization
Jaime Cavallo, MD
USA
FP-12596: 2013 Resident Research Grant – A risk
prediction model for ventral hernia recurrence and
surgical site occurrences requiring procedural
intervention following ventral hernia repair in
clean-contaminated and contaminated surgical
sites
12:30-1:30 pm
Lunch & learn
Session 2A
Scientific session I
Moderators: Gina Adrales, MD
& Ricardo Abdalla, MD
8:35-8:55 am
S8
Michael Rosen, MD
USA
IP-139: Rives-Stoppa, Ramirez, TAR or endoscopic
CST: decision analysis
S11
8:55-9:15 am
Alfredo Carbonell, DO
USA
IP-156: Preoperative pneumoperitoneum, botox
injection, tissue expanders
1:45-2:00 pm
Alexander Morrell, MD
Brazil
FP-12504: Obturator hernia treated by Tapp
approach
9:15-9:35 am
Parog Bhanot, MD
USA
IP-12548: AWR and mesh infection
2:00-2:15 pm
9:35-9:55 am
Pranay Parikh, MD
USA
IP-12583: AWR requiring muscle flaps and/or
panniculectomy
Giel G Koning, MD, Ph.D
USA
FP-126: TIPP versus Lichtenstein: a randomized
controlled clinical trial
2:15-2:30 pm
Clayton Petro, MD
USA
FP-131: Predicting 90-day wound morbidity
following incisional hernia repair with retrorectus
mesh reinforcement
2:30-2:45 pm
Christopher Rettenmaier, BS
USA
FP-116: Component separation index (CSI) and
width of diastasis predict complications after open
component separation for abdominal hernias
9:55-10:15 am
B. Todd Heniford, MD
USA
IP-140: The consequence of complications in AWR:
healthcare cost, reintervention, hernia recurrence
10:15-10:45 am
Panel discussion
10:45-11:15 am
Break & exhibits
S2
2:45-3:00 pm
Hernia (2014) 18 (Suppl 1): S1-S6
Lucas Timmermans, MD
USA
FP-207: Short term results of a randomized
controlled trial comparing primary suture with
primary glued mesh augmentation as a means to
reduce incisional hernia
3:00-3:15 pm
Jason Souza, MD
USA
FP-109: In vivo evaluation of a novel suture design
for abdominal wall closure
3:15-3:30 pm
Bindhu Oommen, MD, MPH
USA
FP-209: Predictors of 30-day readmission after
ventral hernia repair
3:30-3:45 pm
Session 2B
1:45-2:00 pm
2:00-2:15 pm
2:15-2:30 pm
2:30-2:45 pm
2:45-3:00 pm
3:00-3:15 pm
Jacob Greenberg, MD
USA
IP-160: Prophylactic neurectomy during inguinal
hernia repair to prevent chronic inguinodynia: does
it work?
William Hope, MD
USA
IP-12545: Impact of novel mesh technology and
fixation methods in the incidence of chronic
inguinodynia
Parviz Amid, MD
USA
IP-12557: Anterior approach with triple
neurectomy for chronic inguinodynia
David Chen, MD
USA
IP-165: Posterior laparoscopic approach with
triple neurectomy for chronic inguinodynia
Sergio Roll, MD
Brazil
IP-12556: International guidelines for prevention
and management of postoperative chronic pain
after inguinal hernia repair
Panel discussion
3:45-4:15 pm
Break & exhibits
S18
8:00-8:15 am
Brent Matthews, MD & Michael Rosen, MD
Welcome
Session 4
Controversies in open and laparoscopic
inguinal hernia repair
Moderators: Bruce Ramshaw, MD
& David Earle, MD
8:15-8:30 am
Matthew Goldblatt, MD
USA
IP-162: Concomitant laparoscopic inguinal hernia
repair during minimally invasive retropubic
prostatectomy: do or don’t?
8:30-8:45 am
Carl Boyd, MD
USA
IP-12597: Is watchful waiting appropriate for
asymptomatic or minimally symptomatic inguinal
hernia?
8:45-9:00 am
Kristi Harold, MD
USA
IP-12550: Inguinal hernia repair in woman:
laparoscopic or open repair?
9:00-9:15 am
Leandro Cavazzola, MD
Brazil
IP-12572: Over 45 prospective, randomized trials
comparing laparoscopic and open inguinal hernia
repair: what do I offer the patient?
9:15-9:30 am
Guy Voeller, MD
USA
IP-12558: Is there a role for tissue-based inguinal
hernia repair in adults?
9:30-9:45 am
James Bittner, MD
USA
IP-12598: Is laparoscopic inguinal hernia repair an
advanced minimally invasive technique?
Credentialing, training and quality assessment
9:45-10:15 am
Panel discussion
10:15-10:45 am
Break & exhibits
10:45-11:15 am
B. Todd Heniford, MD
Nyhus-Wantz Lectureship
S15
Melissa Phillips, MD
USA
IP-12562: Assessment, evaluation and nonoperative
treatment of patients with inguinodynia after
inguinal hernia repair
3:15-3:45 pm
4:15-6:15 pm
Americas Hernia Society Quality
Collaborative
Moderators: Benjamin Poulose, MD, MPH
& Michael Rosen, MD
IP-12582: Americas Hernia Society Quality
Collaborative
Thursday, March 13, 2014
Joseph Fernandez-Moure, MD
USA
FP-12574: 2012 Resident research grant –
Synthetic hernia mesh with nitric oxide induced
bacteriacidal properties – A paradigm shift
Chronic inguinodynia
Moderators: Parviz Amid, MD
& David Chen, MD
Session 3
S19
Hernia (2014) 18 (Suppl 1): S1-S6
S3
Session 5A
Expert debates:
S21
Ventral hernia repair:
this is the ideal location for mesh placement
Moderators: Harry Van Goor, MD
& Sergio Roll, MD
2:30-2:45 pm
Mimi Kim, MD
USA
FP-12493: The effect of component separation
for large open ventral hernia repair (OVHR) on
post-operative physical activity
11:15-11:20 am
Harry Van Goor, MD & Sergio Roll, MD
Introduction
2:45-3:00 pm
11:20-11:30 am
Guy Voeller, MD
USA
IP-12559: Onlay repair after primary fascial
closure
Samuel Wade Ross, MD, MPH
USA
FP-12520: Long-term quality of life (QOL) between
TEP, TAPP and modified Lichtenstein inguinal
hernia repair (IHR): A two-year follow-up
3:00-3:15 pm
11:30-11:40 am
Benjamin Poulose, MD, MPH
USA
IP-12571: Underlay retrorectus or preperitoneal
repair
Baukje Heuvel, MD
The Netherlands
FP-11345: A new method of follow-up after inguinal
hernia repair; validation of the Pinq-Phone
3:15-3:30 pm
11:40-11:50 am
Kent Kercher, MD
USA
IP-12553: Sublay intraperitoneal repair with
barrier coated mesh
HT Brandsma, MD
The Netherlands
FP-178: One-year results of prophylactic mesh
placement during formation of an end-colostomy
for prevention of parastomal hernia; the dutch
Prevent-trial
3:30-3:45 pm
Alex Cuenca, MD, PhD
USA
FP-12213: Laparoscopic repair of a paraduodenal
hernia
Session 6B
Biomaterial science session I
Evidence based literature
Moderator: Bruce Ramshaw, MD
1:45-2:05 pm
Corey Deeken, MD
USA
IP-12549: Preclinical evaluation of biomaterials:
material characterization and predictability of
clinical performance
2:05-2:25 pm
David Earle, MD
USA
IP-12547: Barrier coated mesh for laparoscopic
ventral hernia repair
2:25-2:45 pm
James Bittner, MD
USA
IP-12564: Biologic, absorbable synthetic or
permanent mesh for laparoscopic paraesophageal
and hiatal hernia repair
2:45-3:05 pm
Klaus-Joachim Conze, MD
Germany
IP-12566: Lightweight mesh for open inguinal
hernia repair: effect on recurrence, patientcentered outcomes
3:05-3:25 pm
Harry Van Goor, MD
The Netherlands
IP-12551: Biologic mesh for abdominal wall
reconstruction
3:25-3:45 pm
Panel discussion
3:45-4:15 pm
Break & exhibits
11:50 am-12:10 pm
Faculty debate
12:10-12:15 pm
Panel discussion
Session 5B
International Hernia Collaboration:
S22
Hernia consultation through social
media
Moderator: Brian Jacob, MD
IP-12595: International Hernia Collaboration:
Hernia consultation through social media
11:15-11:30 am
Brian Jacob, MD
Introduction: Facebook for international hernia
collaboration
11:30 am-12:15 pm
Panel: Shirin Towfigh, MD
& Matthew Goldblatt, MD
Cases
12:30-1:30 pm
Lunch & learn
Session 6A
Scientific session II
Moderators: William Cobb, MD
& Yuri Novitsky, MD
S23
1:45-2:00 pm
Vít Novacek, PhD
France
FP-186: A new methodology for abdominal wall
biomechanical strain analysis
2:00-2:15 pm
Wolfgang Reinpold, MD
Germany
FP-12505: Endoscopic assisted mini open
transhernial sublay repair of ventral and
incisional hernias – Matched pair analysis of
300 cases of the German hernia registry
2:15-2:30 pm
Michael Rosen, MD
USA
FP-182: One-year outcomes in a prospective,
multicenter study of contaminated ventral hernia
repairs using a biosynthetic material
S27
S4
Session 7
4:15-4:30 pm
4:30-4:45 pm
4:45-5:00 pm
5:00-5:15 pm
5:15-5:30 pm
5:30-5:45 pm
Hernia (2014) 18 (Suppl 1): S1-S6
AHS Journal Club:
Articles all hernia surgeons should know
Moderators: Leandro Cavazzola, MD
& James Bittner, MD
Johannas Jeekel, MD
The Netherlands
Paper #1: Long term follow up of a randomized
controlled trial of suture vs mesh repair of
incisional hernia (Ann Surg 2004)
Alfredo Carbonell, DO
USA
Paper #2: Effect of stitch length on wound
complications after closure of midline incisions:
a randomized controlled trial (Arch Surg 2009)
Giampero Campanelli, MD
Italy
Paper #3: Randomized, controlled, blinded trial of
tisseel/tissucol for mesh fixation in patients
undergoing lichtenstein technique for primary
inguinal hernia repair: results of the Timeli trial
(Ann Surg 2012)
Brent Matthews, MD
USA
Paper #4: Comparison of laparoscopic and open
repair with mesh for the treatment of ventral
incisional hernia: a randomized trial
(Arch Surg 2010)
Richard Pierce, MD
USA
Paper #5: Randomized clinical trial comparing
suture and mesh repair of umbilical hernia in
adults (Br J Surg 2001)
Gina Adrales, MD
USA
Paper #6: A randomized, double-blind, placebocontrolled trial to determine effectiveness of
antibiotic prophylaxis for tension-free mesh
herniorrhaphy (J Am Coll Surg 2005)
5:45-6:00 pm
Panel discussion
Session 8
Humanitarianism:
Honoring those who serve others
Moderators: Brent Matthews, MD
& Charles Filipi, MD
6:00-6:10 pm
6:10-6:20 pm
S29
Andrew Kingsnorth, MD
United Kingdom
IP-12599: Operation hernia
Friday, March 14, 2014
8:00-8:15 am
Brent Matthews, MD & Michael Rosen, MD
Welcome
Session 9
Instruction through video:
Laparoscopic and open hernia repair
Moderators: Ricardo Abdalla, MD
& William Cobb, MD
8:15-8:30 am
Melissa Phillips, MD
USA
IP-12563: Myofascial release: Rives-Stoppa and
posterior component separation/TAR
8:30-8:45 am
Yuri Novitsky, MD
USA
IP-137: Laparoscpoic ventral hernia repair: defect
closure, positioning systems, myofascial release
8:45-9:00 am
J. Scott Roth, MD
USA
IP-166: Anterior component separation release:
open ramirez and endoscopic techniques
9:00-9:15 am
Nathaniel Stoikes, MD
USA
IP-161: Laparoscopic paraesophageal and type I
hiatal hernia repair
9:15-9:30 am
Karl LeBlanc, MD
USA
IP-159: Laparoscopic parastomal hernia repair
9:30-9:45 am
Ricardo Abdalla, MD
Brazil
IP-12591: Laparoscopic TAPP and TEP inguinal
hernia repair
9:45-10:15 am
Panel discussion
10:15-10:45 am
Break & exhibits
Session 10A
Scientific session III
Moderators: Harry Van Goor, MD
& Richard Pierce, MD
10:45-11:00 am
Clayton C Petro, MD
USA
FP-214: Suprapubic hernia repair with a rectus
femoris flap
11:00-11:15 am
Sean Orenstein, MD
USA
FP-200: Outcomes of transversus abdominis muscle
release (TAR) with synthetic mesh sublay for
abdominal wall reconstruction
11:15-11:30 am
Phillip Rowse, MD
USA
FP-133: TEP and Lichtenstein anatomy – Does
simulation accelerate acquisition among interns?
S30
Panel Discussion
S31
S33
Hernia (2014) 18 (Suppl 1): S1-S6
11:30-11:45 am
11:45 am-12:00 pm
12:00-12:15 pm
S5
Eva Deerenberg, MD
USA
FP-148: A multicenter randomized controlled trial
evaluating the effect of small stitches on the longterm incidence of incisional hernia after midline
laparotomy (Stitch-trial)
Jerrold Young, MD
USA
FP-113: Long acting local anesthesia for groin
hernia repair with a new product: liposomal
bupivacaine. a preliminary study of efficacy for
reduction of post-operative pain
Blair Wormer, MD
USA
FP-220: A novel intervention for augmenting
postoperative urination in patients undergoing
laparoscopic inguinal hernia repair
4:15-4:25 pm
Carl Doerhoff, MD
USA
IP-12561: Incarcerated umbilical hernia in a
morbidly obese 56 year old male
4:25-4:35 pm
Alan Schuricht, MD
USA
IP-135: Strangulated femoral hernia in a 82 year
old female resident of a nursing home
4:35-4:45 pm
Jacob Greenberg, MD
USA
IP-12580: Incarcerated recurrent ventral incisional
hernia in a 55 year old diabetic female with
possible mesenteric ischemia
4:45-4:55 pm
Deron Tessier, MD
USA
IP-138: Incarcerated inguinal hernia in a 62 year
old male with a small bowel obstruction
4:55-5:05 pm
J. Scott Roth, MD
USA
IP-12589: Umbilical hernia with epidermal erosion
and ascites leak in a 44 year old male with
cirrhosis
Session 10B
Athletic pubalgia
Moderator: L. Michael Brunt, MD
10:45-11:00 am
Garth Jacobson, MD
USA
IP-154: Epidemiology and pathoanatomy of athletic
pubalgia
5:05-5:15 pm
Brent Matthews, MD
USA
IP-12573: Examination and imaging characteristics
in a patient with athletic pubalgia
Matthew Goldblatt, MD
USA
IP-163: Internal hernia in a 26 year old female 6
months after laparoscopic gastric bypass
5:15-5:30 pm
Panel discussion
Session 12B
Expert debates:
Fixation for laparoscopic inguinal
hernia repair
Moderators: Reinhard Bittner, MD
& Guy Voeller, MD
4:15-4:25 pm
Introduction
4:25-4:35 pm
William Cobb, MD
USA
IP-164: Mechanical nonabsorbable fixation
4:35-4:45 pm
Marc Miserez, MD
Belgium
IP-12565: Mechanical absorbable fixation
4:45-4:55 pm
Giampero Campinelli, MD
Italy
IP-12555: Fibrin sealants
4:55-5:05 pm
Brian Jacob, MD
USA
IP-141: Self adherent mesh
5:05-5:15 pm
Edward Felix, MD
USA
IP-153: No fixation is required
5:15-5:30 pm
Faculty debate & Panel discussion
11:00-11:15 am
S36
11:15-11:45 am
L. Michael Brunt, MD
USA
IP-12552: Nonoperative and operative treatment
strategies in a patient with athletic pubalgia
11:45 am-12:15 pm
Panel discussion
12:15-1:45 pm
Lunch & learn
Session 11
1:45-3:45 pm
Complication management:
S37
Morbidity conference
at the Americas Hernia Society
Moderator: Kristi Harold, MD
IP-12594: Complication management: Morbidity
conference at the Americas Hernia Society
Panel:
Marc Miserez, MD, Belgium
Brent Matthews, MD, USA
Eduardo Parra-Davila, MD, USA
Salvador Morales-Conde, MD, Spain
Garth Jacobson, MD, USA
3:45-4:15 pm
Break & exhibits
Session 12A
Hernia emergencies for the
on call general surgeon
Moderators: Maurice Arregui, MD
& Jerrold Young, MD
S38
S40
S6
Hernia (2014) 18 (Suppl 1): S1-S6
Saturday, March 15, 2014
8:00-8:15 am
Brent Matthews, MD
& Michael Rosen, MD
Welcome
Sharon Bachman, MD
USA
IP-12600: Mesh selection will be determined by
genetic profiling: hernia repair 2030
11:50 am-12:15 pm
Panel discussion
Session 14B
Posters of distinction
Moderators: David Earle, MD
& Andrew Kingsnorth, MD
10:30-10:36 am
Rebeccah Baucom, MD
USA
FP-10933: Does normothermia reduce the risk of
surgical site infection in ventral hernia patients?
Session 13
The future of hernia surgery
Moderators: Marc Miserez, MD
& Bruce Ramshaw, MD
8:15-8:30 am
Johannas Jeekel, MD
The Netherlands
IP-12570: Prophylactic mesh placement after
laparotomy: primary mesh augmentation to prevent
ventral hernia
8:30-8:45 am
J. Scott Roth, MD
USA
IP-167: Quality of life metrics for hernia repair:
functionality of abdominal wall reconstruction
10:36-10:42 am
Siavash Raigani, MD
USA
FP-130: Single-center experience with parastomal
hernia repair using sublay mesh placement
8:45-9:00 am
Michael Franz, MD
USA
IP-12546: Biomimetic materials for ventral hernia
repair: eliciting specific cellular responses
10:42-10:48 am
9:00-9:15 am
Alfredo Carbonell, DO
USA
IP-158: Routine use of synthetic mesh in cleancontaminated and contaminated ventral hernia
repairs
Carl Tadaki, MD
USA
FP-172: Comparing perioperative outcomes of
laparoscopic vs open inguinal hernia repair using
two national large data bases
10:48-10:54 am
Clayton Petro, MD
USA
FP-144: Apples to apples: a validated staging
system (I-IV) for incisional hernias
10:54-11:00 am
Jacob Greenberg, MD
USA
FP115: A summative assessment of laparoscopic
ventral hernia repair for general surgery residents:
perception does not equal reality
11:00-11:06 am
Yuhsin Wu, MD
USA
FP-132: Efficacy of antibiotic pulse lavage
irrigation for contaminated retro-rectus abdominal
wall reconstructions
11:06-11:12 am
Bindhu Oommen, MD, MPH
USA
FP-12503: Do patients follow-up with their
original surgeon when ventral hernia repairs
(VHR) fail?
11:12-11:18 am
Siavash Raigani, MD
USA
FP-121: The impact of developing a comprehensive
hernia center on referral patterns and cost of
hernia care
9:15-9:30 am
Ricardo Abdalla, MD
Brazil
IP-118: Robotic abdominal wall reconstruction
9:30-9:45 am
Benjamin Poulose, MD, MPH
USA
IP-152: Public disclosure of outcomes and cost
after hernia repair: surgeon-centered metrics
9:45-10:15 am
Panel discussion
10:15-10:30 am
Break
S42
11:30-11:50 am
Session 14A
Biomaterial science session II
Moderators: Salvador Morales-Conde, MD
& Dwijen Misra, MD
S45
10:30-10:50 am
John Murphy, MD
USA
IP-12590: Inguinodynia – Causes and prevention
10:50-11:10 am
Garth Jacobson, MD
USA
IP-155: Absorbable synthetic mesh for abdominal
wall reconstruction: clinical value or an
inexpensive alternative to biologic mesh
11:10-11:30 am
Igor Belyansky, MD
USA
IP-136: Antimicrobial mesh as prophylaxis for
mesh infection: preclinical and clinical support for
technology
Meeting adjourned
S47
Hernia (2013) 17 (Suppl 1): S8-S10
ABSTRACTS
Wednesday, March 12, 2014
Session 1: Abdominal wall reconstruction
© Springer-Verlag 2014
IP-12560
Risk reduction: preoperative patient optimization
Martindale R
Oregon Health and Science University
The success of hernia repair is measured by absence of recurrence,
appearance of the surgical scar, and perioperative morbidity.
Perioperative surgical site occurrence (SSO), defined as infection,
seroma, wound ischemia, and dehiscence, increases the risk of recurrent hernia by at least 3-5 fold. The surgeon should optimize all
measures that promote healing, reduce infection, and enhance early
postoperative recovery. In the population with ventral hernia, the
most common complication in the immediate perioperative period is
surgical site infection. Several factors such as smoking, obesity, poor
glycemic control, malnutrition, and surgical site contamination are
all detrimental to wound healing and should be optimized before surgery. Wound healing or a propensity for postoperative infections is
the primary target, both of which increase the incidence of hernia
recurrence, and there are some management options that improve
wound healing. Obesity and smoking have been shown to be independent risk factors associated with increased recurrence of abdominal hernia and SSO. Poor glycemic control in the remote preoperative period (30-60 days), immediate perioperative and intraoperative
period, and postoperative periods has been repeatedly shown to lead
to an increase in superficial and deep tissue infections. Malnourished
patients have significant alterations in wound healing and immune
function and consequently have an increased incidence of postoperative hernia recurrence and SSI. In select populations recent studies
now support the use of preoperative metabolic modulating formulations to minimize the catabolic effect of surgical intervention.
Many of the things that surgeons do routinely that have been said
to decrease infections and wound complications are steeped in tradition, have few if any randomized prospective trials, and are not
evidence based. Examples including using shoe covers, scrubs not
leaving the operating theater, and even wearing surgical masks have
limited or no significant data to support them; one large prospective
randomized clinical trial of performing surgery with and without surgical masks showed that it made no difference.
IP-139
Rives-Stoppa, Ramirez, TAR or endoscopic CST:
decision analysis
Rosen M
University Hospitals Case Medical Center
The field of abdominal wall reconstruction has seen tremendous
growth in the last decade. Several innovative technical advancements
have now allowed reconstruction of some of the most complex defect
imaginable. This lecture will detail the technical aspects of many of
these novel approaches. In addition, a careful assessment of indications, contraindications, and reasonable expected outcomes of each
of these approaches will be provided. It is likely that no one approach
will address all types of ventral hernia repairs. Ultimately, the comprehensive reconstructive surgeon will require a full complement of
procedures to approach all ventral hernia repairs.
Hernia (2013) 17 (Suppl 1): S8-S10
IP-156
Preoperative pneumoperitoneum, botox injection,
tissue expanders
Carbonell A
Greenville Health System
Patients with loss of domain have chronically herniated abdominal
contents residing outside the abdominal cavity, in a secondary
abdomen. Hernia repair in these patients is dangerous due to respiratory compromise and the risk of abdominal compartment syndrome
when an attempt is made to relocate the herniated contents back into
the abdominal cavity.
Numerous techniques abound for abdominal wall repair in these
patients such as progressive preoperative pneumoperitoneum (PPP),
botulinum toxin injection of the abdominal wall, tissue expanders,
and sequential abdominal wall closure utilizing the artificial burr
technique. The technique of PPP employs the gradual insufflation of
the abdominal cavity with ambient air which acts as a pneumatic tissue expander, stretching the abdominal wall musculature, dissecting
adhesions, and pressurizing the abdomen. This allows for a safer hernia repair since the herniated contents can be relocated to the abdominal cavity without respiratory embarrassment due to elevated intraabdominal pressures. Botulinum toxin paralysis of the abdominal
wall allows for oblique muscle lengthening preoperatively, in an
effort to increase the elasticity of the abdominal wall and allow for
complete abdominal wall reconstruction. Tissue expanders are salinefilled devices which act to slowly lengthen abdominal wall muscles
is a similar fashion to botulinum toxin injection. The use of an artificial burr device helps to exert constant medial traction on the midline abdominal wall muscles and slowly lengthens the oblique muscles via isotonic contraction. Each of these techniques are adjunctive
maneuvers utilized preoperatively to prepare patients with large hernias and loss of domain for definitive reconstruction
The purpose of this talk is to review these innovative preparatory
techniques and review their outcomes.
IP-12548
AWR and mesh infection
Bhanot P
Georgetown University Hospital
Background: Infection of synthetic mesh following abdominal wall
hernia repair is a complex problem. The purpose of this study is to
determine whether a staged approach to abdominal wall reconstruction using a porcine acellular dermal matrix is beneficial in the
setting of infected synthetic mesh.
Methods: The authors performed a retrospective review of 27
patients who underwent immediate, staged complex AWR using
porcine acellular dermal matrix (PADM) from 2007-2012.
Results: Primary fascial closure was achieved with component separation in 21/27 (78%) patients while 6/22 (22%) received a bridged
hernia repair with PADM. Wound related complications developed
in 7/27 patients (26%) including wound dehiscence 6/27 (22%), surgical site infection 5/27 (18.5%), and hematomas 1/27 (4%). The
hernia recurrence rate observed by 19 months was 18.5%. A bridged
hernia repair and the development of a post-operative infection were
associated with hernia recurrence, p<0.05.
Conclusion: A 2-stage approach to abdominal wall reconstruction
with PADM can provide a safe and effective solution for patients
with infected synthetic mesh.
S9
IP-12583
AWR requiring muscle flaps and/or panniculectomy
Parikh P
Baystate
IP-140
The consequence of complications in AWR:
healthcare cost, reintervention, hernia recurrence
Heniford B, Augenstein V, Colivita P
Carolinas Medical Center
Objectives: To measure the expense of wound complications.
Background: Wound and mesh complications following ventral hernia repair (VHR) are costly, but the price is more than just money.
Methods: Prospective, consecutive, open VHRs from 2008-2011
were analyzed. Wound infection, wound complications (breakdown,
seroma requiring intervention, abscess), and mesh infection were
examined. Charges incorporated all hernia-related visits, interventions, and re-admissions within one year. Wilcoxon-Mann-Whitney
tests were used to compare charges. Quality of life (QOL) was measured using Carolinas Comfort Scale.
Results: Five hundred consecutive open VHRs were analyzed.
Patients were 57.2% female, mean age of 56.4 years, BMI of 33.1,
and 60.6% had recurrent hernias. Average defect and mesh sizes were
198.3 cm2 and 784 cm2. Panniculectomy and component separation
were performed in 31.8% and 25.4% of cases, respectively. Mean
hospital changes included - mesh infections [11 patients (2.2%)]:
$82,779; wound infections [## patients (XX%)]: $65,240; wound
complications [## patients (XX%)]: $59,118; no wound complications: $38,677 (p<0.001). Mean follow-up charges were: mesh infections- $63,389, wound infections- $20,232, wound complications $15,144 and no complications - $1,393 (p<0.001). Complications significantly impacted office efficiency. Patients without complications
had 2.4 average post-operative visits, wound infections yielded 6.7,
and mesh infections averaged 9.2. 51.7% and 90.9% of wound and
mesh infection patients required readmission. At 2 week and 1 month
follow-up, there were no differences in QOL in patients with and
without infection or complications. At 6-month follow-up, 57.6% of
patients with complications or infection had symptomatic discomfort
versus 35.4% without complications (p=0.01), 58.6% versus 29.9%
(p<0.001) had activity limitation, and 52.5% versus 34.2% reported
mesh sensation (p=0.031).
Conclusion: VHR wound-related complications are responsible for
significant cost on many levels: the financial impact during hospitalization and after discharge, the increased patient and physician
time investment, and the reduction in patient QOL. Efforts to reduce
VHR wound-related complications should be strongly pursued.
S10
FP-12596
A risk prediction model for ventral hernia recurrence
and surgical site occurrences requiring procedural
intervention following ventral hernia repair in cleancontaminated and contaminated surgical sites
Cavallo J
Washington University School of Medicine
Introduction: The study purpose is to create multivariable risk prediction models that use patient characteristics, surgical site classifications, and planned mesh type to pre-operatively calculate the risk
of hernia recurrence (HR) and the risk of surgical site occurrences
requiring procedural intervention (SSOPI) for patients undergoing
clean-contaminated and contaminated ventral hernia repair (VHR).
We hypothesize that mesh type will remain in the multivariable risk
prediction models for both the risk of HR and the risk of SSOPI,
and that permanent synthetic mesh reinforcement would incur
reduced risk for both outcomes compared to biologic mesh
reinforcement.
Methods: Leveraging existing resources of the MESH Consortium,
the presence and frequencies of HR and SSOPI will be assessed from
a prospectively maintained multi-institutional database for clean-contaminated and contaminated VHR. Univariate analyses between preoperative patient characteristics, surgical site classifications, or mesh
type (independent variables) and HR or SSOPI (dependent variables)
will be conducted. Statistically-significant univariate associations
(p<0.2) will be entered into the multivariable risk prediction models
for HR and SSOPI, and evaluated via logistic or linear regression
models. Multivariable models will be reduced via backward elimination using a p<O.OS, and all possible combinations of models will
be evaluated for best fit.
Potential: These pre-operative risk prediction tools will calculate risk
values that aid appropriate patient selection for elective VHR in
clean-contaminated and contaminated surgical sites, assist patient
counseling about modifiable risk factors for HR or SSOPI, enable
patient participation in decision making about the planned VHR, and
inform surgeon selection of mesh type for VHR
reinforcement.
Hernia (2014) 18 (Suppl 1): S8-S10
Hernia (2014) 18 (Suppl 1): S11-S14
ABSTRACTS
Wednesday, March 12, 2014
Session 2A: Scientific session I
© Springer-Verlag 2014
FP-12504
Obturator hernia treated by TAPP approach
Morrell A, Ribeiro D, Riberio G, Furtado M, Pareja T, Cavazzola L,
Malcher F, Farah F, Meyer A, Costas M
Brazil
Obturator hernia is a rare but important cause of intestinal obstruction.
Because it’s an unusual pathology, the diagnoses is usually delayed
and is done during surgery or by the CT Scan in the pre operative
evaluation of an acute abdomen.
The Obturator hernia represents 0.1 to 1.0% of all hernias and it is
6 times more frequent in woman in the 5th to 6th decade.
In the etiology, we have factors as multiparity with format and progressive relaxation and tilt of the female pelvis and slimming sharp.
The video show a TAPP approach for an Obturator Hernia in a 55
years old woman presented at emergency room.
The video shows the CT Scan, a brief case description and the trans
abdominal pre peritoneal (TAPP) procedure done in this case.
At the end it’s enhanced some aspects in the diagnoses and pathology
of the Obturator hernia.
FP-126
TIPP versus Lichtenstein: a randomized controlled
clinical trial
Koning G, Keus F, Koeslag L, Cheung C, Avci M, van Laarhoven C,
Vriens P
Radboud University Nijmegen Medical Centre
Background: Preliminary experience has suggested that preperitoneal mesh positioning causes less chronic pain than Lichtenstein’s
technique for inguinal hernia repair. Therefore, a randomised controlled trial was conducted with the aim of evaluating the incidence
of postoperative chronic pain after transinguinal preperitoneal (TIPP)
mesh repair versus Lichtenstein’s technique.
Methods: Patients with a primary unilateral inguinal hernia were
randomised to either TIPP or Lichtenstein’s repair in two teaching
hospitals. The primary outcome was the number of patients with
chronic pain after surgery. Secondary outcomes were adverse events.
Follow-up was scheduled after 14 days, 3 months and 1 year. Patients
and outcome assessors were blinded.
Results: A total of 302 patients were randomised to TIPP (143) or
Lichtenstein (159) repair. Baseline characteristics were comparable
in the two groups. Some 98.0 per cent of the patients were included
in the analysis (141 in the TIPP group and 155 in the Lichtenstein
group). Significantly fewer patients in the TIPP group had continuous
chronic pain 1 year after surgery: five patients (3.5%) versus 20
patients (12.9%) in the Lichtenstein group (p=0.004). An additional
12 patients (8.5%) in the TIPP group and 60 (38.7%) in the
Lichtenstein group experienced pain during activity (p=0.001). There
were two patients with recurrence in the TIPP group and four in the
Lichtenstein group, but no significant differences were found in other
severe adverse events between the groups.
Conclusion: Fewer patients had continuous chronic pain or pain during activity at 1 year after the TIPP mesh inguinal hernia repair compared with Lichtenstein’s repair.
Registration number: ISRCTN93798494 (http://www.controlled-trials.com).
S12
FP-131
Predicting 90-day wound morbidity following incisional
hernia repair with retrorectus mesh reinforcement
Petro C, Posielski N, Raigani S, Wang J, Criss C, Orenstein S,
Rosen M, Novitsky Y
University Hospitals Case Medical Center
Background: Predicting wound morbidity after complex abdominal
wall reconstructions (AWR) remains a challenge. While retrorectus
repairs are gaining in popularity, specific risk factors for wound complications for this approach remain unclear. We aimed to identify the
incidence and predictors of 90-day wound morbidity for patients
undergoing complex AWR with retrorectus mesh placement.
Methods: Consecutive retrorectus hernia repairs performed at Case
Medical Center were identified in our prospective database and analyzed. Primary outcome measure was the incidence of surgical site
occurrence (SSO) requiring an intervention. Statistical analysis was
performed utilizing univariate analysis using Chi-squared and logistic
regression as well as multivariate regression; p<0.05 was considered
significant.
Results: From 2006-2013, 307 patients met inclusion criteria with
at least 90-day follow-up. Eighty-nine SSOs were identified. Seven
seromas required drainage, 3 at the bedside and 4 by interventional
radiology (IR). There were 65 (21.2%) surgical site infections (SSI)
with the majority being superficial. SSIs were treated with antibiotics
alone in 27/34 superficial and 3/29 deep infections. Bedside drainage
was necessary for 7 superficial and 4 deep SSIs, while IR drainage
was necessary for 13/28 deep SSIs. Operative debridement was performed in the remaining 9 deep and 1 organ space SSIs (necessitating
the only instance of mesh excision in the setting of perforated
bowel/ileostomy creation). Obesity, diabetes, smoking, ASA, hernia
width >20 cm and biologic mesh were independent predictors of
SSO. SSO/SSI rates were 6%/6% for Grade 1, 16%/12% for Grade
2, and 39%/18% for Grade 3 hernias.
Conclusion: Mesh positioning during complex AWR has significant
impact on wound complications. For the first time, based on a large
cohort of patients, we identified specific patient and wound factors
contributing to SSOs for hernia repairs with retromuscular mesh palcement. Our findings represent an important addition to AWR outcomes data to facilitate patient counseling as well as technique and
mesh selections.
Hernia (2014) 18 (Suppl 1): S11-S14
FP-116
Component separation index (CSI) and width of
diastasis predict complications after open components
separation for abdominal hernias
Goldblatt M, Rettenmaier C, Abston E, Frelich M, Wallace J, Gould J
Medical College of Wisconsin
Background: Components separation is a method of hernia repair
utilized for complex hernias. This technique may have short term
morbidity due to the extensive dissection required. The Component
Separation Index (CSI) is a metric that objectively defines hernia
morphology in relation to body habitus. We hypothesized that a larger
CSI and longer Width of Diastasis (WD) were predictive of shortterm (30-day) postoperative complications.
Methods: This is a retrospective review of patients who underwent
components separation at the Medical College of Wisconsin from
August 2009 to January 2013. Clinical and perioperative information
was collected up to 30 days after surgery. The CSI was calculated
from CT scans by dividing the angle of diastasis, measured from the
aorta to the medial edges of the rectus abdominis muscles, by 360°.
Results: Thirty-nine patients underwent open components separation
during the study period (35 bilateral, 4 unilateral). The majority of
repairs were recurrent (31, 79.5%). A total of 9 patients (23.1%)
experienced complications before discharge. Fourteen patients
(35.9%) experienced complications within 30 days of discharge, of
which 11 (78.6%) were wound complications. According to the ACSNSQIP wound classification system our series presented 23 (59.0%)
clean, 5 (12.8%) clean-contaminated, 9 (23.1%) contaminated, and
2 (5.1%) dirty wounds. No reoperations occurred. The mean followup interval was 17.8 months. There were three hernia recurrences
(7.7%) with a mean interval to known recurrence of 7.0 months. A
smaller CSI correlated with a greater incidence of total complications
(p=0.05), post-discharge complications (p<0.01), and post-discharge
wound complications (p=0.02). A larger CSI predicted hernia recurrence (p=0.05). A larger WD predicted pre-discharge complications
(p=0.04).
Conclusions: CSI is a valid predictor of 30-day complications, but
unexpectedly, patients with lower CSI have more complications.
These findings are not reproduced with WD. Larger CSI does correlate with greater recurrence rate in our cohort.
Hernia (2014) 18 (Suppl 1): S11-S14
FP-207
Short term results of a randomized controlled trial
comparing primary suture with primary glued mesh
augmentation as a means to reduce incisional hernia
Timmermans L, Jeekel J, Lange J
Erasmus MC
Background: Incisional hernia (IH) is one of the most frequent postoperative complications after abdominal surgery. Patients with an
abdominal aortic aneurysm (AAA) or patients with a BMI of 27 or
higher have a risk of developing an IH of more than 30%. Primary
mesh augmentation (PMA) is a method in which the abdominal wall
is strengthened to reduce IH incidence. This paper focuses on the
short-term results of the PRIMA trial, a multicentre double blind randomized controlled trial (RCT) which compared onlay glued mesh
augmentation (OMA) and sublay glued mesh augmentation (SMA)
to primary suture (PS)
Methods: The RCT was performed in 11 hospitals in the
Netherlands, Germany and Austria. Between 2009 and 2012, patients
were included if they were either operated via midline laparotomy
for an AAA or if they had a BMI of 27 or higher. Patients were randomly assigned to either receive PS, OMA or SMA.
Results: A total of 498 patients were selected of which 18 patients
were excluded preoperatively, leaving 480 randomized patients.
During analysis statistically significant (p=0.002) more seromas were
detected after OMA (n=34, 18.1%) compared to PS (n=5, 4.7%) and
SMA (n=13,7%). No other differences were discovered in any of the
other outcomes. During multivariable analysis, seroma formation
after OMA had an odds ratio (OR) of 4.5 (p=0.003) compared to PS
and an OR of 2.9 (p=0.003) compared to SMA.
Conclusion: Based on the short-term results, PMA is a save procedure with only an elevation in seroma formation after OMA, but
without an increased risk of surgical site infection (SSI). The longterm effects of PMA shall be evaluated after conclusion of the follow-up period of this RCT.
S13
FP-109
In vivo evaluation of a novel suture design
for abdominal wall closure
Souza J, Dumanian G
Northwestern University, Feinberg School of Medicine
Purpose: We present a novel suture design aimed at minimizing the
early laparotomy dehiscence that drives ventral hernia formation.
Methods: Incisional hernias were produced in 30 rats according to
an established hernia model. The rat hernias were randomized to
repair with either two 5-0 polypropylene sutures (Group 1) or two
mid-weight polypropylene mesh sutures (Group 2) placed in similar
fashion. Standardized photographs were taken prior to repair and
1 month after repair, with an intra-abdominal sheet of 2 mm grid
graph paper serving as a calibration reference for all photographs.
Edge-detection software was used to define the border of the hernia
defect and calculate the defect area. Histology was performed on all
mesh suture specimens, with in-growth graded according to the
ASTM 4-point scale.
Results: Seventeen hernias were repaired with mesh sutures; 13 hernias were repaired with conventional sutures. Despite randomization,
the defects repaired with mesh suture were significantly larger than
those undergoing conventional suture repair (391.9±33.4 mm2 vs
255.4±23.3 mm2; p<0.0025). The mean area of the recurrent defects
following repair with mesh suture was 177.8±27.1 mm2, compared
to 267.3±34.1 mm2 following conventional suture repair. This correlated to a 57.4% reduction in defect area after mesh suture repair,
compared to a 10.1% increase in defect area following conventional
suture repair (p<0.0007). None (0/34) of the mesh sutures pulledthrough the surrounding tissue, while 65% (17/26) of the conventional sutures demonstrated complete pull-through. Excellent
(ASTM3) in-growth was observed in 13/17 mesh suture specimens;
4 specimens demonstrated Good (ASTM2) in-growth.
Conclusions: The mesh sutures better resisted suture pull-through
than conventional polypropylene sutures. By more evenly distributing
distracting forces and permitting tissue integration into the substance
of the suture, a suture incorporating these design elements may prevent the early laparotomy dehiscence that leads to incisional hernia
formation.
S14
FP-209
Predictors of 30-day readmission after ventral hernia
repair
Oommen B, Kim M, Ross S, Bradley J, Williams K, Walters A,
Lincourt A, Heniford B, Augenstein V
Carolinas Medical Center, Department of Surgery, Division of
Gastrointestinal & Minimally Invasive Surgery
Introduction: Hospital readmission within 30 days of surgery is
associated with negative patient outcomes and increased healthcare
costs. Current data regarding risk factors for readmission after ventral
hernia repair (VHR) are limited. We analyzed basis for readmission
after VHR.
Methods and procedures: The ACS-NSQIP database was queried
for all inpatient VHRs. Inclusion criteria were elective VHR with
30-day readmission data recorded (available since 2011). Bivariate
analysis was performed to determine variables that were potentially
associated with readmission. Multivariate regression, incorporating
significant factors identified on the bivariate analysis, was then performed.
Results: Out of 10,529 elective VHRs (7,987 open; 2,402 laparoscopic), 9,495 met inclusion criteria. The overall 30-day readmission
rate was 9.9%. Mean age was 57.8±13.5 years; 572% were female.
Patients readmitted were more likely to have the following preoperative conditions (p≤0.05): higher mean BMI (34.0±9.1 vs 33.2±8.6
kg/m2), diabetes (12.7% vs 9.2%), smoking (12.5% vs 9.3%), dyspnea (14.5% vs 9.4%), dependent functional status (21.5% vs 9.7%),
COPD (15.9% vs 9.5%), ascites (18.4% vs 9.8%), CHF (31.7% vs
9.8%), hypertension (10.7% vs 8.9%), dialysis (16.8% vs 9.8%),
bleeding disorder (13.0% vs 9.8%), wound class II-IV (12.4% vs
8.5%), ASA class IV/V (17.5% vs 9.6%). Postoperative complications were also associated with readmission (p<0.001): superficial
SSI (36.1% vs 8.8%), deep SSI (62.2% vs 8.8%), organ space SSI
(53.5% vs 9.2%), pneumonia (31.3% vs 9.5%), unplanned intubation
(20.4% vs 9.7%), pulmonary embolism (45.9% vs 9.7%), ventilator
>48 hours (20.2% vs 9.8%), progressive renal insufficiency (38.0%
vs 9.8%), UTI (22.8% vs 9.7%), stroke (53.9% vs 9.8%), MI (43.2%
vs 9.8%), perioperative transfusions (20.0% vs 9.4%), graft/prosthesis failure (66.7% vs 9.9%), DVT (46.9% vs 9.7%), sepsis (50.4%
vs 8.9%), septic shock (36.1% vs 9.7%), reoperation (57.5% vs
7.7%). Readmission was associated with longer mean operative time
(181±111 vs 148±98 min), mean LOS (5.9±12.8 vs 4.4±7.8 days),
and open repair (11.0% vs 6.2%); p<0.001 for all. Multivariate
regression found diabetes, smoking, dyspnea, dependent functional
status, CHF, wound classification, ASA class, open approach, and
operative time to be independent factors associated with readmission
after VHR.
Conclusions: Readmission after ventral hernia surgery is a more
common occurrence that might before have been suspected and correlates with specific preoperative patient factors, operative characteristics, and postoperative complications. By targeting these risk factors
for quality improvement and decreasing operative time, readmission
rates and healthcare costs may be significantly improved. While
laparoscopic VHR has lower readmission rates overall, other factors,
including case complexity, may impact these findings.
Hernia (2014) 18 (Suppl 1): S11-S14
FP-12574
2012 Resident research grant – Synthetic hernia mesh
with nitric oxide induced bacteriacidal properties –
A paradigm shift
Fernandez-Moure J, Van Eps J, Bryan N, Weiner B, Olsen R,
Dunkin B, Tasciotti E
Houston Methodist Hospital
Background: Mesh infection after ventral hernia repair results in
significant morbidity. Management includes re-operation with mesh
excision and antibiotic therapy. Impregnating mesh with antibiotics
may decrease infection but is prone to resistance. Nitric Oxide (NO),
a diatomic free radical with no known resistance mechanism, plays
a key role in the natural immune response to fighting infection and
may overcome these limitations. We sought to create a NO-releasing
mesh and study its antibacterial efficacy in vitro and in vivo, hypothesizing that a NO-releasing polyester mesh would prevent MRSA
colonization and growth.
Methods: NO-Silica (NO-Si) nanoparticles were synthesized via a
co-condensation of tetraethoxysilane with aminoalkoxysilane with
methanol and ammonia under high pressure nitrous oxide. NO release
was measured and confirmed using a chemiluminescence NO analyzer. MRSA bactericidal efficacy of these nanoparticles was quantified in vitro through tryptic soy broth assay. The NO-Si nanoparticles were then bound to a commercially available polyester mesh
and implanted in a rat model of ventral hernia repair and inoculated
with MRSA. Bacterial growth was quantified using colony forming
unit assay.
Results: NO-Si, synthesized at 500nm, was capable of NO release
for up to 12 hours. NO release from the NO-silica polyester mesh
was equivalent to NO-Si alone. MRSA CFUs recovered relative to
treatment demonstrated a dose dependent response to NO-Si with
100% bactericidal effect at 66mg NO-Si in vitro. The in vivo bactericidal effects of the NO-releasing mesh correlated with in vitro
results with 100% bacterial clearance at 66mg NO-Si.
Conclusion: This study created a NO-releasing synthetic mesh and
demonstrated its MRSA bactericidal efficacy both in vitro and in
vivo. Creation of a novel polyester mesh with enhanced non-antibiotic antibacterial activity using nanoparticles may lead to a paradigm
shift in treating not only abdominal wall defects in a contaminated
environment, but perhaps all surgeries that require use of a synthetic
mesh.
Hernia (2014) 18 (Suppl 1): S15-S17
ABSTRACTS
Wednesday, March 12, 2014
Session 2B: Chronic inguinodynia
© Springer-Verlag 2014
IP-12562
Assessment, evaluation and nonoperative treatment of
patients with inguinodynia after inguinal hernia repair
Phillips M
University of Tennessee Health Science Center
Chronic groin pain has been estimated to occur in 15-25% of patients
undergoing inguinal hernia repair. Surgical technique is an important
aspect of prevention of this pain with identification and care to preserve the nerves of the groin playing an essential role. Assessment
of these patients involves detailing the onset and quality of pain as
well as the patterns of radiation and the nature of pain. Initial management entails excluding non-neuropathic pain etiologies such as
recurrent hernia or mesh infection. Imaging studies may be indicated
to further investigate these sources. Pain management in the early
postoperative period will include opioids and NSAIDs, where persistent pain may require the addition of nerve blocks or nerve ablation. Others will address the surgical techniques for management of
chronic inguinodynia including groin exploration, mesh removal, and
neurectomy.
IP-160
Prophylactic neurectomy during inguinal hernia repair
to prevent chronic inguinodynia: does it work?
Greenberg J
University of Wisconsin
The incidence of inguinodynia following inguinal hernia repair
ranges from 0-63% in the literature. While neurectomy is frequently
involved in the treatment of chronic groin pain, the role of prophylactic neurectomy during inguinal hernia repair remains unclear.
Of the three nerves commonly responsible for postoperative inguinodynia, prophylactic ilioinguinal neurectomy has been the most
widely studied. Five separate randomized controlled trials (RCT)
have evaluated the effect of prophylactic ilioinguinal neurectomy
on the incidence of postoperative inguinodynia. A meta-analysis
incorporating four of these trials showed a small but significant
decrease in the degree of pain at 6 months favoring neurectomy
(-0.29 on a 10-point scale) [1]. The fifth and most recent study showed
no significant reduction in the rate of moderate or severe pain intensity beyond the first month of follow-up [2]. One RCT has looked at
ilioinguinal neurectomy in conjunction with subcutaneous transposition of the spermatic cord and found no change in chronic pain at
6 months while at rest. However, neurectomy was associated with
decreased rates of chronic pain while walking (0% vs 41.7%,
p=0.001) and ascending stairs (0% vs 37.5%, p=0.02) [3].
An alternative approach to prophylactic neurectomy is identification
and preservation of all nerves during herniorraphy. One multicenter
prospective study of 973 patients undergoing open mesh inguinal
hernia repair, found that the lack of identification of nerves as well
as the division of nerves were both significantly correlated with the
presence of chronic pain [4]. Another study of 525 patients undergoing
Lichtenstein hernioplasty assessed the value of nerve identification
and resection of nerves “at risk” again found the non-identification
of nerves correlated to the highest level of inguinodynia at
3 months [5].
While prophylactic neurectomy may have some benefit with respect
to inguinodynia, a focus on intraoperative nerve identification and
preservation is likely more beneficial.
References:
1. Johner, A., J. Faulds, and S.M. Wiseman, Planned ilioinguinal nerve excision for prevention of chronic pain after inguinal hernia repair: a metaanalysis. Surgery, 2011. 150 (3): p. 534-41.
2. Crea, N. and G. Pata, Effects of prophylactic ilioinguinal nerve excision
in mesh groin hernia repair: short- and long-term follow-up of a randomized clinical trial. Am Surg, 2010. 76 (11): p. 1275-81.
3. Caliskan, K., et al., A method for the reduction of chronic pain after tension-free repair of inguinal hernia: iliohypogastric neurectomy and subcutaneous transposition of the spermatic cord. Hernia, 2010. 14 (1): p. 51-5.
4. Alfieri, S., et al., Influence of preservation versus division of ilioinguinal,
iliohypogastric, and genital nerves during open mesh herniorrhaphy:
prospective multicentric study of chronic pain. Ann Surg, 2006. 243 (4):
p. 553-8.
5. Smeds, S., L. Lofstrom, and O. Eriksson, Influence of nerve identification
and the resection of nerves “at risk” on postoperative pain in open inguinal
hernia repair. Hernia, 2010. 14 (3): p. 265-70.
S16
IP-12545
Impact of novel mesh technology and fixation methods
in the incidence of chronic inguinodynia
Hope W
New Hanover Regional Medical Center
The traditional outcome measure related to inguinal hernia repair has
been hernia recurrence. With improvements in technique, knowledge
of anatomy, and the use of mesh the hernia recurrence rates have
become quite low. The improvements seen in hernia recurrence have
caused a shift in focus away from hernia recurrence and towards the
understanding and treatment of chronic groin pain. Chronic groin
pain can be a devastating complication following inguinal hernia
repair and one that continues to plague and confuse surgeons and
patients.
Many factors can lead to chronic groin following inguinal hernia
repair. Pain can generally be classified as neuropathic (related to
nerve injury or damage) or non-neuropathic (related to mesh or other
causes) and has been documented after all major types of repair
including tissue based repairs, open anterior and preperitoneal
approaches, and laparoscopic repairs.
Recently, several promising technologies have been developed in
hopes of minimizing chronic groin pain and will be reviewed. The
concept of lightweight mesh has been intriguing for lowering the
incidence of chronic pain as the mesh will incite less of a foreign
body reaction. To date, their does seem to be some improvement in
groin pain with the use of lightweight mesh; however the reports are
conflicting with further studies needed. Newer self-gripping meshes
have also been developed but so far have not shown demonstrable
improvements on the incidence of chronic groin pain. Methods of
fixation have also been a focus with the use of glue fixation showing
improvements in the incidence of chronic groin pain compared to
sutures in some studies.
Chronic groin pain is a challenging problem that is not entirely understood. Although several new technologies such as lightweight mesh,
self-gripping mesh, and sealants/glues have shown some promise in
possibly lowering the incidence of chronic groin pain to date there
is no single technique/mesh that can be promoted or recommended
as there is insufficient data on these newer technologies.
IP-12557
Anterior approach with triple neurectomy for chronic
inguinodynia
Amid P
University of California, Los Angeles
With the rate of recurrence significantly declined due to the use of
mesh and tension free techniques, chronic pain is the main concern
of surgeons around the globe and number one cause of legal liability.
“Triple neurectomy” suggested by our group in 1987, can be performed through an open approach using the groin incision of the
original hernia operation or through a laparoscopic approach particularly for pain after plug repair and open and laparoscopic preperitoneal repair. Advantages of the open approach is the possibility of
performing a single stage operation for triple neurectomy as well as
plug/meshoma removal if any, repair of the resulting defect, resection
of the main trunk of the GFN over psoas muscle, and resection of
paravasal nerves within the lamina propria of the vas in case of associated orchialgia. Disadvantages of the approach is its complexity
and technical difficulty operating within the scarred field. Advantages
Hernia (2014) 18 (Suppl 1): S15-S17
of the laparoscopic approach are the ability of resecting nerves proximal to the mesh material used during the original herniorrhaphy,
working within the untouched retroperitoneum with its uniform neuroanatomy, and its technical simplicity Disadvantages of laporoscopic
approach are not being able to remove plugs if any, not being able
to resect the lamina propria of the vas in case of associated orchialgia
and potential laxity of the abdominal muscles caused from proximal
denervation. Our experience has included over 600 patient utilizing
an open approach with an over 85% success rate and 37 cases using
a laparoscopic retroperitoneal approach with a 92% success rate.
Planning surgical management for remediation of pain largely
depends on the method of the original hernia repair and its success
requires in depth knowledge of groin neuroanatomy (A) in front of
transversalis fascia (i.e. ilioinguinal, the visible and intramuscular
segment of iliohypogastric, and the inguinal segment of the genital
branch of the genitofemoral nerve), (B) behind the transversalis fascia within the preperitoneal space (i.e. the main trunk of the genitofemoral and the preperitoneal segment of genital branch of GFN),
and (C) within the retroperitoneal space (the main trunks of the ilioinguinal, iliohypogastric nerves over the quadratus lumborum and the
main trunk of the GFN over psoas muscle).
IP-165
Posterior laparoscopic approach with triple
neurectomy for chronic inguinodynia
Chen D
University of California, Los Angeles
Due to the technical success of tension-free hernia repairs, chronic
groin pain has far surpassed recurrence as the most common and
important long-term complication after open and laparoscopic
inguinal hernia repair. Triple Neurectomy of the iliohypogastric,
ilioinguinal, and genitofemoral nerves remains the gold standard in
the operative management of refractory inguinodynia. Standard triple
neurectomy does not address neuropathic pain caused by neuropathy
of the preperitoneal nerves after plug and open and laparoscopic hernia repair unless the operation is extended to include retroperitoneal
resection of the main trunk of the genitofemoral nerve. Access to
these nerves proximal to the site of pathology has been the major
limitation in treatment failures. Laparoendoscopic access to the
retroperitoneal lumbar plexus has been utilized for selective and
triple neurectomy to all potential sites of peripheral neuropathic
pathology from all prior open and laparoscopic anterior and posterior
repair techniques. This allows for consistent and reliable nerve identification, avoidance of the previously scarred field, proximal neurectomy, and obviates the need for repair of a resultant defect in the
inguinal floor. The operation is performed using minimally invasive
access the retroperitoneal space overlying the quadratus and psoas
muscles. Surgery involves identification of the subcostal, iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous
nerve trunks with neurectomy of the iliohypogastric, ilioinguinal
nerve, and genitofemoral nerve trunks. Laparoscopic retroperitoneal
triple neurectomy for treatment of inguinodynia after open and
laparoscopic anterior and preperitoneal mesh repair is a safe and
effective procedure overcoming many of the limitations of previous
operative techniques. Utilization of a different operative field allows
for immediate assessment of the efficacy of this operation. In the
absence of recurrence or overt meshoma, it may be the preferred
technique for the definitive management of chronic neuralgia after
all prior types of hernia repair.
Hernia (2014) 18 (Suppl 1): S15-S17
IP-12556
International guidelines for prevention and
management of postoperative chronic pain after
inguinal hernia repair
Roll S
Brazil
S17
Hernia (2014) 18 (Suppl 1): S18
ABSTRACTS
Wednesday, March 12, 2014
Session 3: Americas Hernia Society Quality Collaborative
© Springer-Verlag 2014
IP-12582
Americas Hernia Society Quality Collaborative
Poulose B, Rosen M
Vanderbilt University Medical Center
The Americas Hernia Society Quality Collaborative (AHSQC) mission is to provide health care professionals real-time information for
maximizing value in hernia care. Formed in 2013 by hernia surgeons
in private practice and academic settings, the AHSQC utilizes concepts of continuous quality improvement to improve outcomes and
optimize costs. This is accomplished through patient-centered data
collection, ongoing performance feedback to clinicians, analysis of
collected data and collaborative learning. The AHSQC will provide
critically needed information for patients, surgeons, hospitals, the
FDA, and industry to improve the value of care delivered to hernia
patients. Quality improvement, education, and stakeholder engagement will be important activities that support this effort. Broad publication and dissemination of AHSQC findings and best practices will
increase public awareness of the AHSQC mission while improving
care for patients. We invite all surgeons involved in hernia care to
be an active member of the AHSQC.
Hernia (2014) 18 (Suppl 1): S19-S20
ABSTRACTS
Thursday, March 13, 2014
Session 4: Controversies in open and laparoscopic inguinal hernia repair
© Springer-Verlag 2014
IP-162
Concomitant laparoscopic inguinal hernia repair
during minimally invasive retropubic prostatectomy:
do or don’t?
Goldblatt M
Medical College of Wisconsin
During a robotic assisted retropubic prostatectomy, Urologists take
down the bladder flap in a very similar manner to a Trans-Abdominal
Pre-Peritoneal (TAPP) inguinal hernia repair. It is therefore not
uncommon to find both direct and indirect inguinal hernias that were
not appreciated before surgery. With the growing number of robotic
prostatectomies done in the U.S., the incidence of an intra-operative
consultation for a hernia repair is becoming more common. The
dilemma one is faced with is whether to repair this hernia at the
same setting or to delay and repair at a different time. If you do not
repair it, the pre-peritoneal planes have been disturbed and so a
laparoscopic approach at a later date may be difficult. If you do
choose to repair it can mesh be used since they have entered the
bladder and urethra. In addition, although rare, a urine leak could
spill out onto the mesh. Finally, the patient has not been consented
for this procedure, which has its own set of complications including
chronic pain and recurrence.
In this presentation the argument for both sides of the issue will be
presented. The data supporting the delayed repair vs immediate
reconstruction will be discussed.
IP-12597
Is watchful waiting appropriate for asymptomatic or
minimally symptomatic inguinal hernia?
Boyd C
Memorial Health University Medical Center
IP-12550
Inguinal hernia repair in woman: laparoscopic or open
repair?
Harold K
Mayo Clinic
IP-12572
Over 45 prospective, randomized trials comparing
laparoscopic and open inguinal hernia repair:
what do I offer the patient?
Cavazzola L
Brazil
The repair of an inguinal hernia has more peer-reviewed published
level one evidence than any other surgical disease to guide informed
consent about management. The decision analysis of whether to perform laparoscopic or open inguinal hernia repair is dependant on
many factors. Patient factors, hernia characteristics, surgeon experience and skill, resource utilization and patient-centered outcomes are
variables influencing the technique offered to patients with inguinal
hernias. This lecture will review prospective, randomized controlled
trials comparing laparoscopic and open inguinal hernia repair.
General principles to guide a patient-centered decision will be provided.
S20
IP-12558
Is there a role for tissue-based inguinal hernia repair in
adults?
Voeller G
University of Tennessee Health Science Center
It is ony in recent surgical history (the last 30 years) that the repair
of inguinal hernia has become dominated by the use of mesh. Over
100 years ago Edoardo Bassini proposed his physiologic reconstruction of the inguinal canal. In the USA the classic Bassini repair was
rarely done and was corrupted to an approximation of the transversus
arch to the shelving portion of varying rates of success but the
Shouldice repair, which is a Bassini repair with continuous sutures
rather than interrupted, has predominated. While the Shouldice Clinic
in Canada claimed a very low recurrence rate these excellent results
were not always replicated by other attempting the repair. This discrepancy has been attributed to the fact that the Clinic is solely
focused on hernia repair and has a very standard approach that is
very repeatable.
Mesh based repairs have significant risks including infertility, infection, erosion and chronic, incapacitating pain. These problems are
rarely seen with the Shouldice repair. Some surgeons have a tailored
approach to inguinal hernia repair is ideal and allows the best repair
to be used for each situation. More commonly today however most
believe that each surgeon should learn one technique well and apply
it to the majority of the repairs they do. When one looks at the issues
involved with mesh based repair of inguinal hernia an argument can
be made that there is and should be a role for tissue based repair of
inguinal hernia in certain adult patients.
Hernia (2014) 18 (Suppl 1): S19-S20
IP-12598
Is laparoscopic inguinal hernia repair an advanced
minimally invasive technique? Credentialing, training
and quality assessment
Bittner J
Virginia Commonwealth University School of Medicine
Laparoscopy has an important role to play in the management of
inguinal hernia; however, the laparoscopic approach is used in only
a small fraction of inguinal hernia repairs in the United States. A relatively low utilization rate for laparoscopic inguinal hernia repair is
the result of multiple factors, but learning and mastering the laparoscopic techniques seem to be one of them. The appreciable learning
curve for these advanced laparoscopic procedures may be shortened
by the use of structured curricula, simulation-based training and
assessment, and appropriate proctorship. Credentialing bodies that
grant surgeon privileges for laparoscopic inguinal hernia repair
should ensure competency in the fundamentals of laparoscopic surgery through validated training programs and assessment tools as
well as verify proficiency with each technique through tracking of
clinical outcomes. The goals of this session are to highlight some of
the curricula, simulation-based tools, and assessments used to teach
and validate proficiency in laparoscopic inguinal hernia repair. Also,
the session will discuss qualitative assessment and its potential
impact on credentialing for these challenging procedures.
Hernia (2014) 18 (Suppl 1): S21
ABSTRACTS
Thursday, March 13, 2014
Session 5A: Expert debates: Ventral hernia repair: this is the ideal location for mesh placement
© Springer-Verlag 2014
IP-12559
Onlay repair after primary fascial closure
IP-12571
Underlay retrorectus or preperitoneal repair
Voeller G
University of Tennessee Health Science Center
Poulose B
Vanderbilt University Medical Center
In the 1980s George Wantz brought the Rives retrorectus repair from
France to the United States. We were taught this repair during a visit
by Dr. Wantz at that time and at a time when the majority of repairs
for V/I hernia in the United States were done as an inlay. Like Dr.
Wantz, we became big proponents of the Rives repair. When we
developed and taught our laparoscopic approach for V/I hernia in
1991 we used our experience with the Rives repair as a foundation.
With the explosion of the laparoscopic technique in the 1990s the
Rives open repair became known to American surgeons and over the
past 20 years became the open procedure of choice for many hernia
surgeons.
At the same time Rives was developing his sublay approach in
France, Chevrel, also in France, developed his onlay repair for ventral incisional hernia. Dr. Chevrel had a unique closure of the midline
followed by only use of polypropylene or polyester mesh that was
sutured to the fascia. Dr. Chevrel did subsequent biomechanical studies showing the importance of the linea alba and what he believed
were advantages of the onlay position of the mesh. Also as part of
his repair he later added the use of fibrin glue over the midline closure to prevent disruption of the closure and immediately take stress
off of that closure. Despite Chevrel’s excellent results (which were
equal to Rives), in America his technique never has received much
attention.
Beginning in January 2010 we developed an onlay technique for ventral incisional hernia repair suing fibrin glue alone for mesh fixation.
We will discuss some basic laboratory work performed regarding the
onlay technique of mesh fixation with fibrin glue. In addition, we
will describe the technique and some clinical results.
The optimal position for mesh placement remains to be determined
in ventral hernia repair. Intraperitoneal mesh remains the most common space for the repair of ventral hernias. However, complications
such as adhesions and fistula formation can result from direct interaction between mesh prosthesis and bowel. Retrorectus or preperitoneal mesh placement offer an alternative to intraperitoneal mesh,
potentially minimizing these issues. The advantages and disadvantages of this approach to ventral hernia repair are discussed.
IP-12553
Sublay intraperitoneal repair with barrier coated mesh
Kercher K
Carolinas Medical Center
Hernia (2014) 18 (Suppl 1): S22
ABSTRACTS
Thursday, March 13, 2014
Session 5B: International Hernia Collaboration: hernia consultation through social media
© Springer-Verlag 2014
IP-12595
Distinguished panel – International Hernia
Collaboration: hernia consultation through social
media
Jacob B
Mount Sinai Hospital
Social media platforms are powerful tools that, among many things,
have the potential to help surgeons optimize the care they are delivering to their patients. Launched in late December 2012, the
International Hernia Collaboration (IHC) is an rapidly expanding
online Facebook Group representing just one type of a social media
tool available to surgeons. Designed to help improve collaboration
between all shareholders invested in the care of patients suffering
from the disease of hernia, the IHC is allowing surgeons from over
38 countries to communicate in real time about complicated and routine patient care issues. Through this collaboration, improved is being
delivered.
At AHS 2014, we will demonstrate some of the unique features
offered by the IHC. Through live case presentations, both nationally
and internationally, the audience will be able to witness how the IHC
can potentially improve actual patient care in real time.
Hernia (2014) 18 (Suppl 1): S23-S26
ABSTRACTS
Thursday, March 13, 2014
Session 6A: Scientific session II
© Springer-Verlag 2014
FP-186
A new methodology for abdominal wall biomechanical
strain analysis
Novacek V, Ignotz R, Dunn R, Turquier F
France
The purpose of this video is to demonstrate how Digital Image
Correlation (DIC) system can record and examine biomechanical
abdominal wall (AW) strain. It may serve as a tool to analyze current
and alternative AW closure techniques for hypothetical biomechanical optimization and therefore potential clinical superiority. This
method also offers the possibility of studying hernia repair technique
that may result in optimal functional outcomes as well as the possibility to optimally design hernia closure devices (mesh).
DIC is a 3D non-contact optical technique based on grey value digital
images with a stochastic intensity pattern and can determine the displacements and strains of an object under load. Using two cameras,
each object point is focused on a specific pixel in the image plane
of the cameras. Knowing the orientation of the cameras with respect
to each other, the position of each object point can be calculated by
a correlation algorithm.
In our experimental setup, the cameras on a tripod were placed above
a post-mortem human subject lying in supine position. An insufflation needle and a pressure transducer were inserted to the abdomen.
The needle was connected to a pump delivering air of up to 30 mm
Hg. The transducer was connected to a data acquisition system synchronized with the image acquisition system controlling the cameras.
Skin and fat of the anterior AW were carefully removed. The anterior
AW was then covered with white make-up. A stochastic pattern of
dots was created using a black spray paint. The AW was subsequently
insufflated and its deformation and strain were recorded and analyzed.
This methodology demonstrated reproducible early results in terms
of tissue strain due to pressure load. Application to other AW models
may provide insights leading to clinical advances in management of
AW hernia repair.
FP-12505
Endoscopic assisted mini open transhernial sublay
repair of ventral and incisional hernias – Matched pair
analysis of 300 cases of the German hernia registry
Reinpold W
Department of Surgery and Hernia Centre – Gross Sand Hospital
Hamburg
Introduction: Laparoscopic IPOM repair and open sublay repair are
both established techniques for the cure of ventral and incisional hernias. IPOM meshes have to be fixated thoroughly with transmural
sutures, staples or clips which carry the risk of additional adhesions
and pain. Open sublay repair is associated with higher infection rates.
Material and methods: We developed an endoscopic assisted “miniopen” transhernial technique for the total extraperitoneal repair of
large ventral and incisional hernia: Via a 4 to 6cm incision the hernia
sac is mobilized. Endoscopic assisted dissection of the hernia defect
and extraperitoneal plane allows the implantation of large standard
alloplastic meshes and anatomical reconstruction of the abdominal
wall. The data of all patients were included in the German Hernia
Registry and prospectively analysed. After one year all patients
received a questionnaire and symptomatic patients were re-examined.
A matched pair analysis with open sublay and laparoscopic IPOM
patients of the German Hernia Registry was performed.
Results: We report 300 cases of ventral and incisional hernias with
an average defect size of 72 cm2, an average mesh size of 438 cm2,
and a minimum overlap of 5 cm. The largest mesh was 45x30 cm.
The hernia defect was closed in all operations. There were no bowel
injuries. There were three large retromuscular hematomas which
needed a surgical intervention. There were no infections. One year
follow-up was 90.2%. Pain medication was stopped within a week
in 92% of the patients.
Conclusion: The endoscopic assisted “mini-open” transhernial sublay repair combines the advantages of minimal access surgery and
the open Sublay-Rives-Stoppa operation. The technique allows the
cure of large ventral and incisional hernias with low morbidity.
S24
Hernia (2014) 18 (Suppl 1): S23-S26
FP-182
One-year outcomes in a prospective, multicenter study
of contaminated ventral hernia repairs using a
biosynthetic material
FP-12493
The effect of component separation for large open
ventral hernia repair (OVHR) on post-operative
physical activity
Rosen M, Carbonell A, Cobb W, Bauer J, Jacobsen G, Matthews B,
Poulose B, Selzer D, Goldblatt M, Rosman C
Case Western Reserve
Kim M, Oommen B, Ross S, Bradley J, Tsirline V, Belyansky I,
Colavita P, Sing R, Heniford B, Augenstein V
Department of Surgery, Division of GI and Minimally Invasive
Surgery, Carolinas Medical Center, Charlotte, NC
Purpose: Contaminated ventral hernias (CVH) have increased risk
of postoperative infection and remain challenging to repair. Synthetic
meshes, while durable, are not widely accepted as an option in contamination due to fear of chronic infections. Biologic meshes in CVH
repair have not provided a long term solution. Use of biosynthetic
material in the retro-rectus space with fascial closure may provide a
more durable repair solution. In this study, we evaluated use of
biosynthetic material in single-staged CVH repairs.
Methods: Patients with CVH underwent repair with biosynthetic
material placed in a sublay position following fascial closure. At follow-up, patients underwent examination and responded to health
questionnaires.
Results: Of 104 patients enrolled (42 men; mean age, 58 years; mean
BMI, 28), 23% had clean-contaminated and 77% had contaminated
wounds. Concomitant procedures included bowel surgery (n=65), fistula takedown (n=24), open wound (n=26), or removal of infected
mesh (n=27). Twenty one surgical site infections occurred.
Superficial surgical site infections (9) resolved with antibiotics. Deep
infections (10) required percutaneous drainage (6), minor operative
debridement (3), and wide debridement with partial mesh removal
(1). Organ space infections (2) were from anastomotic leaks. Follow
up is ongoing and was completed at 12 months (67%), and 24 months
(14%), with a mean of 12±6 months. Ten hernia recurrences developed, of which 3 had reoperations. Time to recurrence was statistically earlier for subjects developing infections during the study (logrank p=0.007): 22.2% recurrence with infections versus 7.0% without
infections. Mean 1-year EQ-5D visual analogue and SF-12 physical
component scores improved over baseline values (p < 0.01); mental
scores did not change.
Conclusions: Our findings represent the first prospective multicenter
study with evidence substantiating the efficacy of biosynthetic material for contaminated single stage ventral hernia repairs.
Introduction: Components separation (CS) for repair of ventral hernia defects is believed to restore physiologic function of the abdominal wall, but the implications for postoperative physical activity are
not well known.
Methods: A prospective international hernia database (IHMR) was
queried for patients who underwent OVHR for large hernias from
October 2007 to July 2013 with (CS) and without CS (NoCS).
Defects <200 cm2 were excluded. The Carolinas Comfort Scale was
used to compare eight parameters of pre-operative and post-operative
activity: lying, bending, sitting, performing activities of daily living,
coughing, walking, climbing stairs and exercise. Demographics, operative details, complications and outcomes were evaluated by standard
statistical methods, with significance defined as p<0.05.
Results: Of 52 patients, 22 had CS. Demographics for CS and NoCS
were similar: mean age 54.6±14.5 vs 55.3±13.6 years, male 39% vs
48%, mean BMI 33.4±9.0 vs 31.5±6.1 kg/m2. No differences were
seen in patient comorbidities or hernia characteristics: defect size
(333.3±119.0 vs 413.6±270.0 cm2), incision length (23.8±18 vs
16.5±12.9 cm), recurrent (37% vs 43%), and multiple defects (all
p>0.05). Pre-operative CCS scores for pain and activity limitation
were similar between groups. Mesh placement was similar: intraperitoneal (50% vs 50%); preperitoneal (36.7% vs 31.8%); retrorectus
(13.3% vs 9.1%); mesh size and weight was also similar. Operative
time was longer for CS (280±48 vs 231±38 min; p<0.05) but length
of stay and complications, including wound and major systemic morbidity, were similar. At one-month follow-up, while pain was similar
between groups, CS experienced more movement restriction (93.8%
vs 57.9%; p=0.0221); however, by 6-month follow-up, this was no
longer significant.
Conclusion: Patients who have CS with OVHR experience simlar
surgical outcomes but are more likely to have limitations in movement in the immediate post-operative period when compared to conventional mesh OVHR. Six months after surgery patients with large
VH undergoing CS have equal outcomes to those undergo standard
OVHR.
Hernia (2014) 18 (Suppl 1): S23-S26
FP-12520
Long-term quality of life (QOL) between TEP, TAPP
and modified lichtenstein inguinal hernia repair (IHR):
a two-year follow-up
Ross S, Oommen B, Kim M, Belyansky I, Tsirline V, Colavita P,
Walters A, Augenstein V, Heniford B
Carolinas Medical Center, Dept. of Surgery, Division of
Gastrointestinal and Minimally Invasive Surgery
Introduction: We have extensively studied post-operative outcomes
and QOL in IHR according to operative technique. Herein, we report
long-term follow-up data on QOL compared by surgical approach.
Methods: The International Hernia Mesh Registry was queried for
all IHR from 2007 to 2013. TEP, TAPP, and Modified Lichtenstein
(ML) were included. Bilateral hernias were excluded. QOL at two
years was the primary outcome and was measured by the Carolinas
Comfort Scale, a hernia-specific symptoms index with symptomatic
defined as “minimal but bothersome.” Outcomes were examined
between IHR groups with standard statistical methods and logistic
regression.
Results: There were 1651 IHR included: 969 ML, 362 TAPP, and
320 TEP. Patients were similar between the ML, TAPP and TEP
groups: average age (56.8±15.8 vs 55.8±15.3 vs 52.3±15.2 years),
male (93.0% vs 92.1% vs 94.9%), BMI (26.0±3.7 vs 26.4±4.1 vs
26.8±19.3 kg/m2). Pre-operatively, they differed in the percentage of
recurrent hernia (8.6% vs 9.7% vs 21.6%), inpatients (68.4% vs
54.4% vs 83.8%), local anesthesia (54.5% vs 0% vs 0%), and symptomatic pre-operative pain (54.2% vs 59.5% vs 69.1%); all p<0.05.
There was no significant difference in the rate of post-operative complications (p>0.05). Overall 2-year follow-up was 68.0%. Hernia
recurrence was similar (1.6% vs 1.4% vs 1.6, p>0.05). Symptomatic
discomfort (8.1% vs 9.4% vs 12.3%), mesh sensation (10.5% vs 8.5%
vs 12.1%), and movement limitation (4.5% vs 5.6% vs 7.2%) were
not significantly different at two years (all p>0.05). Bivariate analysis
found age, gender, recurrent hernia, anesthesia type, mesh fixation
with glue, and pre-operative pain to be associated with symptomatic
pain at two years. After controlling for these factors in multivariate
analysis, there was no difference in QOL at 2 years between ML,
TAPP and TEP. The factors that were independently associated with
symptomatic pain at 2 years were surgery for recurrent hernia (OR
2.2, 1.2-3.9; p=0.008) and pre-operative pain (OR 2.1, 1.3-3.5;
p=0.002).
Conclusion: Long-term QOL after IHR is not affected by the surgical
approach. Pre-operative pain and previous recurrence are the most
influential factors to post-operative pain 2-years after IHR. These
facts can be useful in counseling patients concerning choices of operative technique and QOL outcomes.
S25
FP-11345
A new method of follow-up after inguinal hernia repair;
validation of the Pinq-Phone
Heuvel B, van Jarwaarde J, Wichers P, de Lange de Klerk E,
Bonjer H, Dwars B
VUMC, The Netherlands
The most important long-term complications after inguinal hernia
repair are chronic pain and recurrence. Previous follow-up studies
showed that physical examination is the only reliable method of follow-up to detect recurrences. However, physical examination is laborious and time consuming. We designed a telephone questionnaire as
a method of follow-up after inguinal hernia surgery; the PINQPHONE (Post-INguinal-repair-Questionnaire by telePHONE). The
aim of this study is to validate the PINQ-PHONE in detecting both
asymptomatic and symptomatic recurrences.
Methods: This prospective study contained 300 randomly selected
patients after inguinal hernia repair. All patients were contacted by
telephone and the PINQ-PHONE was carried out. The PINQ-PHONE
contains four elements; three questions and a do-it-yourself Valsalva
manoeuvre. Subsequently, all patients were seen in clinic and physical examination (gold standard) was done.
Findings: The majority (96%) was male and the mean age was 66
(range 26-93) years old. The mean interval between surgery and
study inclusion was 58 (range 6-141) months. In five patients a recurrence was found. All of them scored positively for one or more elements of the PINQ-PHONE. Two-hundred-fifty-two patients scored
negatively for all elements and none of them had a recurrence. The
overall sensitivity was 1•00 and the overall specificity 0•86.
Interpretation: This study validated the PINQ-PHONE. It is a reliable, practical and simple method of follow-up after inguinal hernia
repair to detect both symptomatic and asymptomatic recurrences.
S26
FP-178
One year results of prophylactic mesh placement
during formation of an end-colostomy for prevention
of parastomal hernia; The Dutch PREVENT-trial
Brandsma H, Hansson B, Aufenacker T, Bleichrodt R, Rosman C
Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
Background: A parastomal hernia (PSH) is an incisional hernia
related to an enterostomy and is the most frequent complication after
stoma formation; approximately 50% of all patients with a stoma
develop a symptomatic PSH over time. Symptoms may range from
mild abdominal pain to life-threatening obstruction and strangulation.
The treatment of a parastomal hernia is notoriously difficult. Despite
the use of a mesh recurrences up to 20% are published. Due to these
results surgeons focus more and more on prevention.
Methods: We conducted a large multicenter RCT in which augmentation of the abdominal wall with a retromuscular lightweight
polypropylene mesh (treatment group) is compared to the traditional
formation of a colostomy (control group). The incidence of a PSH,
complications, cost-effectiveness and quality of life were measured.
150 patients (1:1 ratio) were included.
Results: There was no difference between groups regarding demographics, predisposing factors and SF-36 Quality of life. Operating
time was 26 minutes longer in the mesh group. There was no significant difference in postoperative infections and other morbidity
and no mesh had to be removed. After one year stomacare problems
did not differ between both groups. The von Korff pain score as well
as the EQ-5D health questionnaire were similar in both groups after
three months and one year. Sixteen patients had a parastomal hernia
of which 12 in the non-mesh group (p=0.03). No difference was
found in concomitant hernias.
Conclusion: After one year of follow-up we can state that placement
of a polypropylene mesh in a sublay position to prevent parastomal
hernia is a save and feasible procedure with no increase in morbidity.
After 12 months it significantly reduces the incidence of parastomal
hernias.
Hernia (2014) 18 (Suppl 1): S23-S26
FP-12213
Laparoscopic repair of a paraduodenal hernia
Cuenca A, Alvarez J, Iqbal A
University of Florida
Paraduodenal hernias are an uncommon to rare form of congenital
malrotation whereby a segment of bowel fails to rotate properly and
becomes trapped either within the mesenteric leaflet of the cecum
(right sided) or the descending colon (left sided) during fixation of
the mesentery to the peritoneum. There have been several published
case reports by investigators that have successfully used laparoscopy
to repair the paraduodenal hernias. We report the diagnosis and
laparoscopic repair of a left sided paraduodenal hernia in a 33 year
old woman that presented in a non-acute setting with 6-8 month history of intermittent severe abdominal pain. The patient received a
CT scan during an episode which clearly demonstrated a left sided
paraduodenal hernia and was referred to us for definitive management. The patient was electively taken to the OR for laparoscopic
repair and was discharged on POD 2. The patient was seen in clinic
3 months after the procedure and was doing well. While a large trial
comparing an open to a laparascopic technique is impossible in this
clinical setting due to the rarity of this defect, there is a collection
of case reports including this study that suggest that laparascopic
repair of paraduodenal hernias is not only feasible but more importantly, safe.
Hernia (2014) 18 (Suppl 1): S27-S28
ABSTRACTS
Thursday, March 13, 2014
Session 6B: Biomaterial science session I – Evidence based literature
© Springer-Verlag 2014
IP-12549
Preclinical evaluation of biomaterials: material
characterization and predictability of clinical
performance
Deeken C
Washington University School of Medicine
The composition of hernia repair materials has evolved over the years
to include not only permanent polymers such as polypropylene, but
also biologically-derived materials, absorbable polymers, and composites with anti-adhesive barrier layers. Surgeons must select an
appropriate material for each hernia repair scenario from dozens of
available materials. Greater mechanical strength is theoretically conferred through the use of high density or tightly knitted polymer
fibers. However, this may result in greater inflammation and foreign
body reaction once implanted. Recent mesh designs have employed
lower density polymers with a more open knit structure in an effort
to reduce inflammation and foreign body reaction, but the effect on
mechanical properties is unknown. Until recently, the literature
lacked a systematic evaluation of the physiomechanical characteristics of each type of hernia repair material and a rationale for the
suitability of these materials for hernia repair applications. Thus, we
determined the physiomechanical characteristics of thirty-eight
(n=38) types of hernia repair materials and compared the results to
theoretical requirements for hernia repair scenarios. Scanning electron microscopy, laser micrometry, suture retention testing, tear
resistance testing, and ball burst testing were performed on all materials. In addition, differential scanning calorimetry and collagenase
digestion assays were performed on all biological materials.
Theoretical calculations dictated at least 20N suture retention and
tear resistance strengths and at least 50N/cm ball burst strength to
support “worst case” hernia repair scenarios. Out of 38 materials
evaluated, 14 met all criteria, 18 failed to meet at least one criterion,
and 6 failed to meet 2 or more criteria.
IP-12547
Barrier coated mesh for laparoscopic ventral hernia
repair
Earle D
Baystate Health
Laparoscopic Ventral Hernia Repair (LVHR) has significant advantages for select patients, but remains underutilized due to both technical factors and the complex nature of the mesh industry. The
intraperitoneal placement of mesh during LVHR has spawned the
development of a variety of products designed to minimize adhesions
between the viscera and the mesh. Not all barrier coated mesh however is the same, and many factors must be considered when choosing a barrier coated mesh for LVHR. These factors include patient
factors, clinical scenario factors, and a working knowledge of the
physical properties of the underlying polymer and architecture of the
mesh. While most surgeons are familiar with the concepts of light
and heavy weight mesh, the lack of standard definitions of mesh
weight and its meaning, as well as the development of a variety of
composite mesh can make this difficult to sort out. This lecture will
specifically address the fundamental principles of determining how
to choose a barrier coated mesh for LVHR, and detail the currently
available products. Real clinical cases, along with manufacturer
information will be used to allow the surgeon to immediately incorporate this information in to practice as appropriate.
S28
IP-12564
Biologic, absorbable synthetic or permanent mesh for
laparoscopic paraesophageal and hiatal hernia repair
Bittner J
Virginia Commonwealth University School of Medicine
Once the decision has been made to reinforce the hiatus during
laparoscopic repair of a hiatus or paraesophageal hernia, the foregut
surgeon must choose between various materials. To that end, the
goals of this session are to discuss in some detail the biologic
(porcine and human acellular dermal matrix, porcine small intestine
submucosa), absorbable synthetic (glycolic acid/trimethylene carbonate, poly-4-hydroxybutyrate), and permanent synthetic mesh options
(polypropylene, polyester composite, expanded polytetrafluoroethylene), currently available for use at the hiatus, elaborate on the potential risks and benefits of each, and review clinical outcomes data that
may facilitate an informed decision.
IP-12566
Lightweight mesh for open inguinal hernia repair:
effect on recurrence, patient-centered outcomes
Conze K, Muschaweck U
Germany
The results of lightweight meshes in inguinal hernia repair are not
always consistent, sometimes even controversial.
What do we consider a “lightweight” mesh? Is it really only a question of weight? In 2011 Coda et al. developed and published a classification for polypropylene meshes according to the mesh weight:
Ultra-light <35 g/m2, Light 35-70 g/m2, Standard 70-140 g/m2 and
Heavy >140 g/m2. The decision on the weight group limits were
never explained and seem arbitrary.
And is weight the only parameter? The terminology of the so called
“lightweight” meshes is a misnomer and has proved to be not sufficient but misleading. Already in 2006 Wehye et al. showed that
there must be more to it than the total weight, when he proved a
significant decrease in biocompatibility for a lightweight but small
pore almost foils-like mesh, compared to a heavyweight mesh. So
there is more to it: we need to consider the pore size, the polymer
and the filament construction. Klinge has introduced and established
the term “porosity” into the mesh world and developed a classification accordingly. It is the effective porosity of meshes that defines
the contact area between mesh surface and host. This is the essential
factor for the degree of foreign body reaction, for the fibrogenous
ingrowth and possible mesh related complications – not the weight!
Therefore it is time to be more precise in evaluating the benefit of
the so called “lightweight” meshes. Their description is misleading
and should be abandoned. Unfortunately most studies and metaanalysis did not take mesh porosity into account. Today we should
look at high porosity – low surface meshes when we want to evaluate
this new mesh generation.
Hernia (2014) 18 (Suppl 1): S27-S28
IP-12551
Biologic mesh for abdominal wall reconstruction
Van Goor H
Radbound University Medical Center, The Netherlands
Biologic grafts have been introduced in ventral hernia repair as an
alternative to synthetic mesh for complex hernia with a contaminated
or infected operation area. Biologic grafts hold promise of a durable
repair with less adhesion formation and lower infection propensity
compared to synthetic mesh due to their biocompatible nature.
However, proper evidence for use of these biologic grafts is scant
and study results vary markedly. Against the background of the high
financial price of biologic grafts proof of safety and efficacy is
needed for surgeons, patients and health care providers.
In this lecture, results are presented of a systematic review summarising and evaluating the use of biologic prostheses for ventral hernia
repair under clean and contaminated conditions, with focus on recurrence and complications.
It appeared that the quality of evidence for use of biologic grafts for
ventral hernia repair was low: many authors grouped different types
of ventral hernias (e.g. primary and incisional) together, along with
varying sizes and locations, and all the studies included in the current
review were of a retrospective nature. It was concluded that the current evidence regarding recurrence and morbidity does not support
the routine use of biologic grafts for clean, contaminated, dirty or
otherwise complicated ventral hernia repair at the moment.
Future research should focus on i) adoption of a universal classification system for ventral hernias helping to decrease the heterogeneity of study groups and on ii) designing proper prospective studies
with well defined and clinically relevant outcomes, to better delineate
the indication (s) for a biological graft in ventral hernia repair.
Hernia (2014) 18 (Suppl 1): S29
ABSTRACTS
Thursday, March 13, 2014
Session 7: AHS Journal Club: articles all hernia surgeons should know
© Springer-Verlag 2014
Paper #1: Long term follow up of a randomized
controlled trial of suture vs mesh repair of incisional
hernia (Annals of Surgery 2004)
Jeekel J
The Netherlands
Paper #2: Effect of stitch length on wound
complications after closure of midline incisions: a
randomized controlled trial (Arch Surg 2009)
Carbonell A
Greenville Health System
Paper #3: Randomized, controlled, blinded trial of
tisseel/tissucol for mesh fixation in patients undergoing
lichtenstein technique for primary inguinal hernia
repair: results of the TIMELI trial (Ann Surg 2012)
Campanelli G
University of Insurbia, Italy
Paper #4: Comparison of laparoscopic and open
repair with mesh for the treatment of ventral
incisional hernia: A randomized trial
(Arch Surg 2010)
Matthews B
Carolinas Medical Center
Paper #5: Randomized clinical trial comparing suture
and mesh repair of umbilical hernia in adults
(Br J Surg 2001)
Pierce R
Duke University
Paper #6: A randomized, double-blind, placebocontrolled trial to determine effectiveness of antibiotic
prophylaxis for tension-free mesh herniorrhaphy
(J Am Coll Surg 2005)
Adrales G
Dartmouth-Hitchcock Medical Center
Hernia (2014) 18 (Suppl 1): S30
ABSTRACTS
Thursday, March 13, 2014
Session 8: Humanitarianism: honoring those who serve others
© Springer-Verlag 2014
IP-12599
Operation hernia
Kingsnorth A
Peninsula College of Medicine & Dentistry, Plymouth, UK
Hernia (2014) 18 (Suppl 1): S31-S32
ABSTRACTS
Friday, March 14, 2014
Session 9: Instruction through video: laparoscopic and open hernia repair
© Springer-Verlag 2014
IP-12563
Myofascial release: Rives-Stoppa and posterior
component separation/TAR
IP-137
Laparoscopic ventral hernia repair: defect closure,
positioning systems, myofascial release
Phillips M
University of Tennessee Health Science Center
Novitsky Y
University Hospitals Case Medical Center
As the patients and hernia characteristics continue to become more
complex, we must as surgeons continue to evolve our techniques to
overcome these growing challenges. Myofascial release techniques
have been described in multiple formats as solid ways to repair both
initial and recurrent hernias. The Rives-Stoppa, or retro-rectus, technique has the option to be the “work horse” for many hernias, providing an easily teachable, reliable repair with a low complication
profile. This technique can be applied to most midline hernias with
transverse fascial defects up to 8cm. In hernias with a transverse fascial defect greater than 8cm, a posterior component separation or
transversus abdominus release (TAR) offers an alternative to the standard anterior component separation or external oblique release. The
TAR has a lower rate of wound complications when compared to
the anterior approach while allowing primary fascial reapproximation
of similar size defects. Additionally, it can be applied to the nonmidline hernia, making it ideal for flank or subcostal needs. The surgical technique as well as pearls of each repair will be detailed in
this video-based session. As no patient’s hernia is identical, it is
important to have multiple technique options so that the repair can
be customized for each individual.
IP-166
Anterior component separation release:
open ramirez and endoscopic techniques
Roth J
University of Kentucky Medical Center
Abdominal wall reconstruction for complex and complicated hernias
is performed with increasing frequency to facilitate apposition of the
rectus abdominis muscles. Benefits of abdominal wall reconstruction
include a functional abdominal wall with reduced laxity and bulging.
The initial descriptions of component separation techniques involved
posterior rectus sheath release, subcutaneous skin flaps, and division
of the external oblique aponeurosis. This traditional technique allows
for rectus abdominis muscle advancement, although wound complications are not infrequent due to devascularization of the ventral
abdominal wall skin. Perforator preserving techniques have been
described in an attempt to reduce wound complications while allowing for comparable abdominal wall advancement. The endoscopic
component separation technique allows for abdominal wall advancement with preservation of all abdominal wall vasculature. The “interoblique” technique is performed by dissecting the space between the
external and internal oblique muscles with subsequent division of the
external oblique muscle. The endoscopic approach allows for comparable advancement to traditional Ramirez component separation
techniques with significantly reduced morbidity.
S32
IP-161
Laparoscopic paraesophageal and type I hiatal hernia
repair
Stoikes N
University of Tennessee Health Science Center
Laparoscopic paraesophageal hernia repair contains many technical
considerations, some of which are controversial. Hallmarks of work
up first include the assessment of symptoms such as: heartburn, dysphagia, chest pain, shortness of breath, and regurgitation. Pertinent
diagnostic tests include barium swallow and manometry. The key
technical steps involve: reduction of the stomach and hernia sack,
mobilization of the greater curve of the stomach, creation of a retroesophageal window, crural repair, and fundoplication.
Controversy within the technique revolves around the use of mesh
for the crural repair and type of fundoplication (or not). There is literature to support the use of mesh as well as not using mesh for hernia repair. Mesh options for repair include biologics or absorbable
synthetics. Fixation when using mesh also varies and includes
sutures, tacks, or fibrin glue depending on what type of mesh is
selected. Fundoplication choice should be determined based on the
results of manometry, which is recommended in all cases. Finally, a
key feature of successful paraesophageal hernia repair is adequate
intrabdominal esophageal length. In some cases collis gastroplasty
or wedge fundectomy may be necessary in select cases.
IP-159
Laparoscopic parastomal hernia repair
LeBlanc K
Surgeons Group of Baton Rouge
Introduction: Parastomal hernias represent a difficult challenge for
both the patient and the surgeons that treat them. The re-location
method and the simple primary closure of these hernias have a significant rate of recurrence. Newer laparoscopic methods appear to
have improved the long-term results of these hernia repairs.
Technique: The current method that I employ involves a three-step
approach during the laparoscopic repair. The initial repair involves
the primary closure of the defect. An onlay of a bioresorbable material is then placed over the closure to reinforce the fascial. The intestine is then lateralized and covered with an ePFTE based prosthetic
material.
Results: Fifteen consecutive patients have undergone this approach
over a three year period. Two patients (5.5%) required a return to
the operating room due to obstruction secondary to an undersized
passageway underneath the onlay mesh. A transfascial suture was
released in each case. One patient (6.67%) developed a late mesh
infection of a prior incisional hernia repair (unrelated to the parastomal hernia repair). This required excision of all of the meshes and
an ultimate recurrence of the hernia. Other than this patient, there
has been one recurrence in these individuals (6.67%). This patient
gained approximately 50 pounds of weight subsequent to the procedure and this appears to have been an inciting factor in the recurrence.
Conclusion: With a recurrence rate of approximately 13%, this
method of repair appears to be an acceptable choice for the repair
of this difficult hernia. More time is needed to assure the success of
this hernioplasty.
Hernia (2014) 18 (Suppl 1): S31-S32
IP-12591
Laparoscopic TAPP and TEP inguinal hernia repair
Abdalla R
University of Sao Paulo, Brazil
Introduction: Since the beginning of inguinal hernia treatment, surgeons are looking forward the ideal solution. Video surgery for
abdominal wall hernias is turning down its controversy; despite it
has been done in specialized institutions of minimally invasive surgery. Brazil had its development restricted because of investments,
but nowadays all the Hospitals are improving it. The tension free
concept was introduced by the method and mesh became an obligation. The mesh could suggest a more aggressive condition but,
because of it, treatment became less traumatic, with better recovery,
without persistent pain. Video surgery could reveal a complex defect
and clarify the way for abdominal wall reconstruction.
Two methods can reach the origin of defect, Trans Abdominal pre
Peritoneal (TAPP) Laparoscopic Hernioplasty and Total Extra
Peritoneal (TEP) Laparoscopic Hernioplasty. Today there is a tendency to indicate TEP.
Consensual conduct or best practice protocols are difficult because
of characteristics multiplicity from hernia presentations. Reviewing
more than 12,000 patients, the Cochrane Collaboration concluded
that regarding TEP vs TAPP, there were NO differences for recurrence rates, vascular injuries, and OR time. TEP led to more conversions overall and might be harder to learn. On the contrary, TAPP
procedures led to slightly more intraabdominal adhesions, trocar site
hernias, and visceral injuries. Today, treatment algorithms remain surgeon dependent. Compared to other techniques, TEP has been associated with quicker return to daily activities, better Quality of Life
outcomes, less acute and chronic pain complaints and less intraabdominal morbidities. TAPP has been shown to be very effective in
experienced hands and is easier to teach.
Conclusion: For all inguinals and recurrences, TEP is an optimal
choice. TAPP should be considered at incarceration or strangulation,
scrotal hernias, inguinodynia, recurrence and in women with
Pfannenstiel incision.
Hernia (2014) 18 (Suppl 1): S33-S35
ABSTRACTS
Friday, March 14, 2014
Session 10A: Scientific session III
© Springer-Verlag 2014
FP-214
Suprapubic hernia repair with a rectus femoris flap
Petro C, Armstrong B, Soltanian H, Rosen M
University Hospitals Case Medical Center
Introduction: A 45-year-old male presents with a large suprapubic
hernia, loss of domain and frequent obstructive symptoms. His history is notable for bladder sarcoma at age 4 requiring neoadjuvant
radiation followed by a cystectomy and ileal conduit. As a consequence of this radiation he developed a rectal cancer requiring further
neoadjuvant radiation and a low anterior resection. After his loop
ileostomy reversal he developed this suprapubic hernia that was
repaired more than four times with biologic and intraperitoneal synthetic mesh which ultimately became infected due to skin breakdown,
required explantation and led to recurrence.
Methods: The plan was made for open incisional hernia repair using
a posterior components separation and transversus abdominis muscle
(TAR) release with permanent synthetic (polypropylene) mesh sublay
and pelvic bone fixation. Due to his history of radiation and thin
subcutaneous tissue, it was felt that a rectus femoris myocutanous
flap would be necessary for anterior coverage of the mesh.
Results: The patient developed a fluid collection post-operatively
which required drainage by interventional radiology and grew
MRSA. For this he remained on antibiotics for 37 days. He has now
been off all antibiotics for two months, his donor site has healed and
100% of his graft has taken. He is very happy with his repair.
Conclusion: TAR with synthetic mesh sublay and pelvic bone mesh
fixation is suitable for suprapubic hernia repair. When soft tissue coverage of mesh cannot be easily obtained, flap coverage is critical and
can lead to a successful outcome.
FP-200
Outcomes of transversus abdominis muscle release
(TAR) with synthetic mesh sublay for abdominal wall
reconstruction
Orenstein S, Petro C, Criss C, Raigani S, Elliott H, Rosen M,
Novitsky Y
University Hospitals Case Medical Center
Introduction: Posterior component separation for complex abdominal wall reconstructions (AWR) is gaining in popularity. Although
our early experience with transversus abdominis muscle release
(TAR) has been promising, long-term outcomes in a large cohort of
patients have not been reported to date. Herein, we aimed to evaluate
the safety and efficacy of TAR with retrorectus synthetic mesh reinforcement in a large series of complex hernia patients.
Methods: From 2006 to 2013, consecutive patients undergoing open
retromuscular AWR utilizing the TAR approach were identified in
the prospectively maintained database and reviewed. Main outcome
measures included demographics, perioperative details, wound complications and recurrences. Typical follow-up assessment includes a
physical exam at 1, 3, 6 and 12 months and computed tomography
at 6-12 months postoperatively.
Results: Two hundred fifty-two consecutive TAR procedures were
analyzed. The mean age was 56; mean BMI was 36 kg/m2 (range:
20-65 kg/m2). Major co-morbidities included diabetes (23%), COPD
(17%), and smoking (7%). Mean hernia defect width was 17 cm
(range: 8-38 cm) and area 416 cm2 (range: 100-1,520 cm2). Mean
mesh size was 1,205cm2 (range: 180-3,600 cm2). The majority of
cases were clean, with 28 (11.1%) being clean-contaminated and 14
(5.6%) being contaminated. Fifty-six patients (22.2%) developed a
surgical site occurrence, 32 (12.7%) of which were surgical site infections. Seven patients required re-operations/debridement but there
were no instances of mesh explantation. At a mean follow-up of 12
months (range: 3-76 months) there have been 11 recurrences (4.4%).
Conclusions: Complex AWR represents a formidable surgical challenge. In this large series we demonstrated that posterior component
separation using transversus abdominis release with wide synthetic
mesh sublay provides a very durable repair with low morbidity, even
in comorbid patients with large defects. We strongly advocate TAR
as a durable addition to the armamentarium of reconstructive surgeons.
S34
FP-133
TEP and Lichtenstein anatomy – Does simulation
accelerate acquisition among interns?
Rowse P, Ruparel R, Abdelsaatar J, AlJamal Y, Farley D
Mayo Clinic
Introduction: The anatomy of the inguinal region is notoriously
challenging to master. We sought to teach open inguinal hernia (OIH)
and total extraperitoneal (TEP) anatomy with simulation models
among general surgery (GS) interns.
Methods: Low-fidelity OIH and TEP models were constructed out
of cardboard, plastic bins, fabric, and yarn. GS interns (n=30) participated in a 3-hour hernia session including a pretest, anatomy lecture, simulated hernia repair with OIH and TEP models, individual
oral exam, and posttest. Pre and posttest scores were based on a difficult 30-point exam. Participants were surveyed anonymously using
a 5-point Likert scale (1= strongly disagree, 5= strongly agree).
Results: Median pretest scores were 13% (range 0-60%). Median
posttest scores improved to 47% (range 20-93%, p<0.001). Median
scores for knowledge of TEP anatomy improved from 2 (range 014) to 11 (range 1-21, p<0.001). Median scores for knowledge of
OIH anatomy improved from 3 (range 0-15) to 7 (range 1-19,
p<0.001). 67% (12/18) demonstrated improvement in knowledge of
abdominal wall layers. 23% (7/30) knew the triangles of pain/doom
and could identify their contents on pretest vs 77% (23/30) on
posttest. Location of hernia recurrence for OIH and TEP was known
in 27% (8/30) and 7% (2/30) on pretest vs 93% (28/30) and 43%
(13/30) on posttest, respectively.
Survey response was 100%. Mean Likert scores for session enjoyability (4.5), improved understanding of TEP and OIH anatomy (4.2,
4.4), and “not a waste of training time” (4.4) rated highest. Trainees
felt deliberate practice with TEP and OIH models would improve
surgical skill (4.5, 4.4). TEP and OIH models were acceptable with
regard to realism (4.1, 3.9).
Conclusion: Low-fidelity simulators can be used to teach and assess
knowledge of TEP and OIH anatomy. While enjoyable and useful,
one three hour session does not create master hernia surgeons out of
novice trainees.
Hernia (2014) 18 (Suppl 1): S33-S35
FP-148
A multicenter randomized controlled trial evaluating
the effect of small stitches on the long-term incidence
of incisional hernia after midline laparotomy
(Stitch-trial)
Deerenberg E, Harlaar J, Lont H, Van Doorn H, Wijnhoven B,
Schouten W, Cense H, Stockmann H, Berends F, Dijkhuizen F
Erasmus University Medical Center
Background: Incisional hernia is one of the most frequent complications after midline laparotomy, associated with morbidity, a
decreased quality of life and high costs.
Methods: We randomly assigned patients who underwent a midline
laparotomy to either a standardized small bites suture technique of
the fascia or to a conventional large bites (mass closure) suture technique. Primary outcome was the clinical and/or radiological occurrence of an incisional hernia after at least one year follow-up.
Results: 560 patients from 9 hospitals (surgical and gynecological
departments) were enrolled in the trial, 549 of whom were included
in the intention-to-treat analysis. In the small bites group the fascia
was sutured with more stitches (45 versus 25), a higher suture length
to wound length ratio (5.03 versus 4.37) and closing took more time
(14 versus 10 minutes; all p<0.001). Short-term postoperative complications, such as surgical site infection, burst abdomen and hospital
stay did not differ in incidence between both groups. During one
year follow-up 11 patients were lost to follow-up, 84 patients needed
a relaparotomy and 65 patients died. The incidence of incisional hernia in the large bites group was 23.6% (66 out of 279) and in the
small bites group 14.4% (39 out of 270)after a mean follow-up of
13.5 months (SD 5.34), log rank test p=0.014. Thecovariate adjusted
hazard ratio was 0.66 (95% Confidence Interval 0.44-0.99, p=0.048).
Conclusion: Suturing the fascia of an abdominal midline incision
with a continuous small bites technique reduces the long-term incidence of the incisional hernia with 34% and merits wide application.
(Funded by a Efficiency Research Grant ErasmusMC and Ethicon
Inc.; Clinicaltrials.gov NCT01132209)
Hernia (2014) 18 (Suppl 1): S33-S35
FP-113
Long acting local anesthesia for groin hernia repair
with a new product: liposomal bupivacaine.
A preliminary study of efficacy for reduction
of post-operative pain
Young J, Gilbert A
Hernia Institute of Florida
Background: Multimodal anesthesia for control of peri-operative
pain during out-patient inguinal hernia repair is increasing in popularity. To date, there has been no effective long acting injectable local
anesthetic preparation to extend pain control through the post-operative period. Bupivacaine liposomal injectable solution - depo-bupivacaine (DB) (Exparel®; Pacira Pharmaceuticals Inc, Parsippany, NJ)
is an injectable preparation of bupivacaine encapsulated in lipid particles which allows for extended release of the anesthetic. DB has
been used successfully for post-operative pain control after other surgical procedures. We present our experience demonstrating efficacy
of DB for pain control after inguinal hernia repair.
Methods. From January to April, 2013, 116 consecutive patients had
open inguinal hernia repairs under local anesthesia with intravenous
sedation, with or without the use of DB. Post-operative VAS pain
scores were recorded at five time periods after the surgery: recovery
room, day of surgery, and 1st, 2nd, and 3rd postoperative days. The
number of opioid pain tablets taken in the three days after surgery
was recorded. The pharmacology and technique for injection is
described.
Results: There were 60 patients in the treatment group and 56
patients in the control group. Pain scores in the treatment group were
significantly reduced (mean - 3.0 vs 4.1: p=0.0002) at all five time
periods. There was a significant reduction in the number of narcotic
pain tablets taken by the DB group (3.7 vs 5.9: p=0.0025) in the
post-operative period.
Conclusion: This study demonstrates the efficacy of a new long lasting local anesthetic product (DB) for controlling post-operative pain
after inguinal hernia repair. The findings are consistent with studies
of the efficacy of DB in other procedures. DB is a new medication
which will have a significant impact in the peri-operative pain management of surgical patients.
S35
FP-220
A novel intervention for augmenting postoperative
urination in patients undergoing laparoscopic inguinal
hernia repair
Wormer B, Ross S, Walters AL, Kuwada T
Carolinas Medical Center
Introduction: Postoperative urinary retention (POUR) following
laparoscopic inguinal hernia (LIH) is a costly and uncomfortable
complication. Rapid bladder filling from excessive intra-op IVF has
been associated with POUR. We hypothesized that filling the bladder
prior to foley removal would augment postoperative voiding and
decrease the time to discharge (TTD) and incidence of POUR.
Methods: Review of a prospective, single surgeon, consecutive
series of LIH (TEP and TAP) from 2010 to 2013. All patients were
catheterized during LIH. Prior to catheter removal, selected patients
had a 200 cc saline “bladder fill” (BF). Patients were required to
void >250 cc prior to discharge. POUR was defined as catheter reinsertion (residual >400 cc). POUR incidence and TTD were compared
between the BF and No-BF groups.
Results: LIH was performed in 175 patients (70% TEP), of those
89 (50%) underwent BF and 86 (49%) No-BF. Demographics, type
of defect and repair, OR IVF and time, narcotics and prostate disease/medications were similar between the BF and No-BF groups
(p>0.05). The BF group had a lower incidence of POUR (10% vs
15% for no-BF), but this was not significant (p=0.32). BF yielded a
significantly shorter TTD (222 min vs 286 min for No-BF; p<0.01).
On univariate analysis, patients with POUR had higher rates of BPH
(36% vs 10%; p<0.01), direct hernias (59% vs 28%; p<0.01), and
were older (65±11 yrs vs 55±14 yrs; p<0.01). However on multivariate analysis, increased odds of POUR was only associated with
BPH medication use (OR 13.2, CI 3.1-56.2; p<0.05) and direct hernia
(OR 6.9, CI 2.0-24.1; p<0.05). The only postoperative UTI was in
the No-BF group.
Conclusion: In our study, postoperative BF reduced the incidence
of POUR and time to discharge by over an hour; challenging the
widely held belief that rapid bladder filling increases the risk of
POUR. To our knowledge, this is the first description of BF in LIH.
BF has the potential to substantially reduce the cost and morbidity
of POUR and warrants further prospective study.
Hernia (2014) 18 (Suppl 1): S36
ABSTRACTS
Friday, March 14, 2014
Session 10B: Athletic pubalgia
© Springer-Verlag 2014
IP-154
Epidemiology and pathoanatomy of athletic pubalgia
Jacobsen G
University of California, San Diego
Groin pain in the athlete is challenging entity which deserves specific
attention to the etiology of the pain as well as specific anatomic considerations. To this end a review of the current data on the epidemiology of athletic pubalgia will be taken with specific attention paid
to individual sporting activities. Attention will also be directed to the
commonly associated pathoanatomic problems encountered in athletes performing at the elite level, and the methods of identifying
these entities.
IP-12573
Examination and imaging characteristics in a patient
with athletic pubalgia
Matthews B
Carolinas Medical Center
Athletic pubalgia (sports hernia) is a syndrome of chronic lower
abdomen and groin pain that typically occurs in athletes. The lower
abdomen and groin area is at extreme risk of chronic overuse injury
caused during sports activities such as hockey, soccer, football and
rugby. Repeated trauma and overuse of the groin area associated with
repeated turning and twisting movements are often responsible to
promote force imbalances of pubic symphysis and pubic bones that
pressurize the posterior wall of inguinal canal. This can cause a disruption of the inguinal canal resulting in tearing and weakness of
abdominal tissues and muscles which also pulls away tendons, ligaments and muscles from pubic bone. Nevertheless, the differential
diagnosis of chronic lower abdomen and groin pain is quit broad in
athletes and nonathletes, respectively. A comprehensive examination
with a focus on the abdomen and groin with appropriate imaging
differentiate athletic pubalgia from other conditions causing lower
abdominal and groin pain. This lecture will review examination techniques and findings as well as imaging charactericstics in patients
with athletic pubalgia.
IP-12552
Nonoperative and operative treatment strategies in a
patient with athletic pubalgia
Brunt L
Washington University School of Medicine
Athletic pubalgia or also known as Sport’s hernia has been an
increasing problem in high performance athletes over the last two
decades. Unlike many athletic groin injuries, these do not often
resolve with conservative management and surgical intervention,
therefore, may be required to get the athlete back to play. Surgery
should be reserved for failure of conservative management which
consists of rest, ice, abdominal core strengthening and stretching and
strengthening exercises for the lower body. Athletes who have failed
conservative management and have appropriate physical exam and
imaging findings are appropriate for surgical repair. A variety of surgical options exist including different open primary tissue repairs,
tension free mesh repairs and laparoscopic approaches. In this talk
the various operative treatment strategies will be discussed and presented as well as conservative management and postoperative physical rehabilitation approaches.
Hernia (2014) 18 (Suppl 1): S37
ABSTRACTS
Friday, March 14, 2014
Session 11: Complication management: morbidity conference at the Americas Hernia Society
© Springer-Verlag 2014
IP-12594
Distinguished panel – Complication management:
morbidity conference at the Americas Hernia Society
Harold K
Mayo Clinic
Hernia operations have known complications. Discuss techniques for
avoiding complications and how to manage them when they occur
with a panel of experts. An array of topics will be covered such as
“Avoiding/ managing enterotomy during laparoscopic ventral hernia
repair”, “Managing Chronic Seroma”, “Managing mesh infection following laparoscopic ventral hernia repair”, “Avoiding and treating
groin pain after inguinal hernia repair”, “Managing enterocutaneous
fistula in the setting of prosthetic biomaterials”.
Hernia (2014) 18 (Suppl 1): S38-S39
ABSTRACTS
Friday, March 14, 2014
Session 12A: Hernia emergencies for the on call general surgeon
© Springer-Verlag 2014
IP-12561
Incarcerated umbilical hernia in a morbidly obese
56 year old male
Doerhoff C
SurgiCare of Missouri
A 56-year old white male, 73 inches in height, weighing 405 pounds,
a BMI of 55, presents with 8-hour history of umbilical pain, nausea
and vomiting: He has a tender non-reducible hernia at the umbilicus.
CT scan shows defect to be 4 cm and contains small bowel. His
white count is 14,000. He has COPD and is on C-Pap. He is an
insulin-dependent diabetic. He’s a smoker. He’s on Coumadin for a
history of DVT/PE.
What are your treatment options? Open repair vs laparoscopic repair?
What additional co-morbidities would change your plan?
Which factors influence your decision for your choice of mesh?
What additional post operative concerns might you anticipate?
Post operative pain management?
IP-135
Strangulated femoral hernia in a 82 year old female
resident of a nursing home
Schuricht A
Perelman School of Medicine, University of Pennsylvania
A discussion of surgical options for the treatment of femoral hernias
will be presented. This will include a discussion of anatomic considerations, hernia incidence and clinical presentation. Imaging will
be discussed as appropriate. A review of historical approaches to
femoral hernia repair will be given, including the risks and benefits
of the various approaches. The discussion will enable the surgeon to
confidently treat a patient with a femoral hernia in an emergency situation.
IP-12580
Incarcerated recurrent ventral incisional hernia in a
55 year old diabetic female with possible mesenteric
ischemia
Greenberg J
University of Wisconsin
This case represents one of the many challenges facing the on-call
general surgeon. As the obesity epidemic continues, recurrent hernias
in diabetic obese patients will likely become increasingly common
occurrences. When intestinal perfusion is compromised in this setting
the decision making becomes even more complex. The utilization of
mesh in this context is fraught with multiple potential complications
yet hernia recurrence without mesh is highly likely. Additionally, the
timing of abdominal closure will factor into the surgical decision
making as well. This presentation will review the treatment options
for patients with mesenteric ischemia complicated by a recurrent incisional hernia.
Hernia (2014) 18 (Suppl 1): S38-S39
S39
IP-138
Incarcerated inguinal hernia in a 62 year-old male with
a small bowel obstruction
IP-163
Internal hernia in a 26 year old female 6 months after
laparoscopic gastric bypass
Tessier D
Kaiser Foundation Hospital Fontana
Goldblatt M
Medical College of Wisconsin
Acute incarceration occurs in approximately 0.29 to 2.9% of all hernia presentations in large retrospective studies. Approximately 1015% of incarcerated hernias will have necrotic bowel requiring resection on exploration. Because males more commonly have inguinal
hernias they comprise the majority of the group. Women, however,
typically present with incarcerated femoral hernias. Strangulated
femoral hernias comprise up to 35% of all strangulated hernias.
Treatment options in the emergency room include manual reduction
with sedation if no evidence of strangulation and then observation.
If unable to be reduced the patient should be emergently taken to
the operating room for hernia repair as duration of incarceration
increase likelihood of strangulation and increases mortality.
Operative strategies were limited prior to mesh and laparoscopy.
Small retrospective studies and non-randomized studies have shown
that even in the presence of strangulation both mesh and laparoscopy
can be used depending on the overall health of the health of the
patient and characteristics of the hernia.
The number of patients who have undergone Roux en Y gastric
bypass continues to grow. One of the most common late surgical
complications in these patients is an internal hernia, where a mesenteric defect allows small bowel to possibly strangulate. These hernias
can range from subtle in both symptoms and radiographic findings
to an acute abdomen with risk to the bowel. In a tertiary center, these
patients are often taken care of by Bariatric surgeons, but at community hospitals, the on-call General Surgeon will need to evaluate
and treat. This presentation will review the work up for a bariatric
patient in the Emergency Department as well as treatment options.
IP-12589
Umbilical hernia with epidermal erosion and ascites
leak in a 44 year old male with cirrhosis
Roth J
University of Kentucky Medical Center
Abdominal wall hernias in the cirrhotic patient represent a significant
challenge. The physiologic derangements of cirrhosis may result in
thrombocytopenia, coagulopathy, portal hypertension, hyperbilirubinemia, encephalopathy, hypo-albuminemia, malnutrition and
ascites. While asymptomatic reducible umbilical hernias in the cirrhotic patient allow the surgeon time for medical optimization, those
with epidermal erosions and ascetic leaks require prompt attention.
Considerations to the all sequelae of cirrhosis and liver dysfunction
are paramount. Perioperative techniques for managing ascites include
paracentesis, abdominal drains, diuretics, and shunting procedures.
The immediacy of the patient presentation directly impacts medical
and surgical options. Incarcerated hernias with threatened intestines
require urgent surgical intervention with careful peri-operative care
as well as postoperative optimization while hernias not involving the
viscera with an associated ascitic leak may allow for either non-operative management or preoperative optimization. An algorithmic
approach to the cirrhotic with a ruptured umbilical hernia will be
presented.
Hernia (2014) 18 (Suppl 1): S40-S41
ABSTRACTS
Friday, March 14, 2014
Session 12B: Expert debates: Fixation for laparoscopic inguinal hernia repair
© Springer-Verlag 2014
IP-164
Mechanical nonabsorbable fixation
IP-12565
Mechanical absorbable fixation
Cobb W
Greenville Health System
Miserez M
University Hospital, Leuven, Belgium
With the recent focus on advances in technique and mesh constructs,
the long-term morbidity following inguinal hernia repair has shifted
from recurrence to inguinodynia. The incidence of post-herniorrhaphy chronic groin pain is poorly defined and underreported.
In meta-analyses, the laparoscopic approach demonstrates a consistent reduction in the incidence of inguinodynia. The posterior preperitoneal approach to the myopectineal orifice avoids the sensory nerves
of the inguinal region. However, the dissection of the preperitoneal
space must be meticulous, and the placement of mechanical fixation
should be judicious to avoid causing potential pain.
The dilemma surrounding fixation of mesh in the inguinal space is
a balance between secure mesh ingrowth to minimize recurrence and
pain from the fixation itself. Mechanical fixation constructs can be
permanent or absorbable. Prospective studies have demonstrated no
improvement in postoperative pain with absorbable vs permanent fixation. The associated trauma from placement of fixation is similar
whether the tack is permanent or absorbable. Most of the absorbable
devices do not resorb for close to one year anyway.
Efforts to avoid the trauma of mechanical fixation have been made.
Fibrin sealants and tissue glues have been utilized. Mesh constructs
have been designed to have self-fixating points, and some authors
argue that no fixation is necessary at all. All of these methods potentially sacrifice secure mesh fixation, particularly with large indirect
and direct defects. Reduction in chronic pain using these methods
has not been well established.
Mechanical nonabsorbable fixation for laparoscopic inguinal hernia
repair provides the most consistent mesh security with minimal longterm pain when used judiciously. The data will be reviewed to support this statement.
Hernia (2014) 18 (Suppl 1): S40-S41
S41
IP-12555
Fibrin sealants
IP-141
Self adherent mesh
Campanelli G
University of Insubria, Italy
Jacob B
Mount Sinai Hospital
Objective: Test the hypothesis that fibrin sealant mesh fixation can
reduce the incidence of postoperative pain/numbness/groin discomfort by up to 50% compared with sutures for repair of inguinal hernias using the Lichtenstein technique.
Background: Inguinal hernia repair is the most common procedure
in general surgery, thus improvements in surgical techniques, which
reduce the burden of undesirable postoperative outcomes, are of clinical importance.
Methods: A randomized, controlled, patient- and evaluator-blinded
study (Tissucol/Tisseel for MEsh fixation in LIchtenstein hernia
repair [TIMELI]) was conducted among patients eligible for
Lichtenstein repair of uncomplicated unilateral primary inguinal
small-medium sized hernia. Patients were subject to mesh fixation
with either fibrin sealant or sutures. Main outcome measures were
visual analogue scale (VAS) assessments for “pain, ” “numbness, ”
and “groin discomfort” on a scale of 0=best and 100=worst outcome.
The primary endpoint was a composite that evaluated the prevalence
of chronic disabling complications (VAS score >30 for pain/numbness/groin discomfort) at 12 months after surgery.
Results: In total, 319 patients were randomized between January
2006 and April 2007 (159 fibrin sealant, 160 sutures). At 12 months,
the prevalence of 1 or more disabling complication was significantly
lower in the fibrin sealant group than in the sutures group (8.1% vs
14.8%; p=0.0344). Less pain was reported in the fibrin sealant group
than in the sutures group at 1 and 6 months (p=0.0132; p=0.0052),
as reflected by a lower proportion of patients using analgesics in the
fibrin group over the study duration (65.2% vs 79.7%; p=0.0009).
Only 3 of 316 patients (0.9%) experienced recurrence. The incidences
of wound-healing complications and other adverse events were comparable between groups.
Conclusions: Fibrin sealant for mesh fixation in Lichtenstein repair
of small- medium sized inguinal hernias is well tolerated and reduces
the rate of pain/numbness/groin discomfort by 45% relative to sutures
without increasing hernia recurrence.
This trial was conducted thanks to the cooperation of six surgeons
in Europe: MH Pascual, A Hoeferlin, J Rosenberg, G Champault, A
Kingsnorth, and M Miserez
Pubblished on Annales of Surgeon 2012; 255: 650-657
IP-153
No fixation is required
Felix E
Marian Hospitals
Fixation during laparoscopic hernia repair has been debated for more
than 20 years. A few maverick surgeons in the early 90s had the gall
to propose that the peritoneum would hold the mesh in place and
that fixation was costly and unnecessary. Although initially thought
to be ludicrous, the debate began and we continue that debate at the
16th Annual Hernia Repair Symposium.
Laparoscopic hernia repair has come a long way since it’s infancy
24 years ago. The techniques have improved, been standardized and
been shown in multiple randomized studies with qualified surgeons
to be equal to or surpass the results of open hernia repairs. These
studies did not address whether fixation was necessary or even potentially detrimental.
A landmark cadaver study however, did demonstrate that the pelvic
nerves are at risk for fixation injury even when fixation is properly
placed. Multiple non-randomized reports appeared that presented data
suggesting that recurrence rate were not dependent on fixation of the
mesh, but rather the expertize of the operator. To completely settle
the debate randomized controlled studies comparing fixation vs no
fixation were performed. The results clearly demonstrated that in the
typical hernia patient, fixation did not improve the already excellent
incidence of recurrence. Lack of fixation did however, decrease pain
scores. Whether there are special patients that require fixation of the
mesh to reduce recurrence still needs to be investigated.
What about newer non-penetrating forms of fixation? Are they superior? Can they further reduce recurrence without adding unnecessary
cost? Let the debate continue!
Hernia (2014) 18 (Suppl 1): S42-S44
ABSTRACTS
Saturday, March 15, 2014
Session 13: The future of hernia surgery
© Springer-Verlag 2014
IP-12570
Prophylactic mesh placement after laparotomy:
primary mesh augmentation to prevent ventral hernia
IP-167
Quality of life metrics for hernia repair: functionality
of abdominal wall reconstruction
Jeekel J
The Netherlands
Roth J
University of Kentucky Medical Center
Prevention of incisional hernia should be the first and foremost focus
of scientific endeavors in the next years, since Incisional hernia following laparotomy is one of the most frequent long-term complications since long, affecting 10 -20% of unselected patients and up to
50% of high-risk (e.g. obesity, AAA, stoma, Hartmann procedures)
patients and lead to significant morbidity including pain, deformity,
emergency re-admission and re- operation.
Incisional hernia repair is highly prone to recurrence, leading to further morbidity and patient dissatisfaction, leading to high costs.
The problem is that the worldwide incidence of incisional hernia has
not changed despite the introduction of new techniques, like continuous sutures, slowly absorbable sutures, small stitches, suture length
to wound length ratio (SL:WL) of 4:1 which did not change the incidence in daily practice.
Continuous, slowly absorbable suture showed in systemic analyses
and meta-analysis the optimum risk reduction of incisional hernia.
Additional measures to further reduce this risk, even following optimum sutured closure, require investigation. Prophylactic mesh reinforcement of midline wounds has the potential to be an effective
intervention in reducing the risk of incisional hernia formation and
does show a benefit in reviews. However, the possibility of adverse
effects of these techniques and increased costs remain. The adverse
particularly regarding the risk of seroma, haematoma and surgical
site infection following mesh implantation are still a concern.
Other new techniques like small stitch techniques for closure of midline wounds show potential to be an effective technique for reducing
the risk of incisional hernia formation. New data show a high potential for the small stitch technique for prevention.
The recent data of new techniques for prevention of incisional hernia
in patients with obesity, AAA, stoma and Hartmann procedures will
be discussed.
The repair of abdominal wall hernias is often judged based on the
presence or absence of a hernia recurrence. Quality of life metrics
are essential to understanding the implications of any procedure.
Techniques for hernia repair include primary closure, bridging mesh,
mesh reinforcement, and myofascial advancement flaps. Operative
strategies are often employed with the primary goal of abdominal
wall closure with a low rate of hernia recurrence. However, improvements in patient quality of life may be more relevant than hernia
recurrence rates. The advantages and disadvantages of midline closure, bridging mesh, and advancement flaps should be considered
preoperatively and measured to understand the functional implications of these techniques. Closure of the abdominal wall in the midline has benefits in rectus abdominis muscular function compared to
bridging mesh. Abdominal wall atrophy and fibrosis associated with
hernias may be reversed with midline apposition. However, the use
of relaxing incisions and advancement flaps may impact function,
stability, and quality of life. Abdominal wall physiology and functionality must be considered when performing abdominal wall reconstruction.
Hernia (2014) 18 (Suppl 1): S42-S44
S43
IP-12546
Biomimetic materials for ventral hernia repair:
eliciting specific cellular responses
IP-158
Routine use of synthetic mesh in clean-contaminated
and contaminated ventral hernia repairs
Franz M
University of Michigan
Carbonell A
Greenville Health System
Biomimetic materials are designed to imitate the structure and function of biological systems. A biomimetic mesh for ventral hernia
repair should optimize repair cell influx while minimizing the foreign
body response. The goal is improved wound healing, normalized
inflammation and restoration of abdominal wall physiology.
Biomimetic materials have used constructs of collagen, glycosaminoglycans, and extra-cellular matrix (ECM) based matrices composed
of poly-caprolactone (PLC) and poly-carbonate/poly-urethane.
Nanotechnologies (electrospinning) introduced constructing biomimetic surfaces with a defined nanopattern, eliciting tissue-specific
cellular responses by stimulating integrin clustering. To improve
upon the biological model, the biomimetic should be equally safe
and effective at equal or less cost.
One mechanism by which biomimetic material works is eliciting specific cellular responses. A biomimietic mesh should signal the influx
of normal tissue repair cells (fibroblasts), mitigate a pathological
inflammatory response (macrophages) and restore normal tendon
function. The fundamental designs for cell influx are; 1) passive,
three-dimensional scaffold, 2) bioactive molecular sequences
attached to a passive, scaffold, and 3) active molecules secreted from
the scaffold. A challenge is to develop such a material with the
mechanical properties to withstand abdominal wall forces.
Nanotechnology allows the production of biocompatible micro- and
nano-structured scaffolds made of ultra- fine and continuous fibre
networks with variable pore-size morphologically similar to the natural ECM. Several materials including synthetic- and natural-origin
polymers and proteins have been successfully electrospun into
nanofibre scaffolds. The structures interact with intercellular communications by sustaining cell adhesion, proliferation and differentiation.
Complex biological systems are hard to “mimic”. It is the goal of
biomimetic science to improve the challenges of tissue and organ
based approaches, mitigating the limitations of the foreign-body, synthetic polymer approach. The bioactive properties of biomimetic
materials may increase regulatory requirements for clinical applications. Clinical studies are needed to prove the potential of biomimetic
materials in ventral hernia repair.
Surgical dictum has long posited that permanent synthetic mesh is
contraindicated in the repair of a hernia in a clean-contaminated or
contaminated field. The origin of this belief arose from scattered
reports of mesh erosions into the viscera, fistula complications, and
chronic draining sinuses which occurred when heavy-weight
polypropylene mesh was being used for the closure of the open
abdomen, allowing the mesh to granulate through, prior to skin grafting. Despite these reports, several investigators have demonstrated
the acceptably low morbidity associated with the use of heavy-weight
polypropylene mesh in clean-contaminated and contaminated fields.
Recently, the development of light-weight polypropylene mesh constructs has provided surgeons with a less dense mesh containing significantly decreased surface area and wide pores. The experience
with using these more modern mesh constructs in contaminated fields
has grown considerably. The time has come to critically reevaluate
the unfounded fear of utilizing permanent synthetic mesh in contaminated fields. We will review the data speaking to the safety of mesh
in these clean-contaminated and contaminated fields.
S44
IP-118
Robotic Abdominal Wall Reconstruction
Abdalla R
University of Sao Paulo, Brazil
Background: The weakness of the linea alba can be caused by congenital and acquired factors. The conventional procedure to correct
these imperfections generally involve large incisions with big detachments of the skin and subcutaneous tissue. The use of video surgery
for the repair of these weaknesses is still controversy. Robot positioning from lower abdomen can show midline almost complete from
inside peritoneal view. Therefore, one can recognize linea alba and
its defects. It is a mirror view of muscular aponeurotic abdominal
wall, exact the same after opening the skin and subcutaneous tissue.
With the exposure of midline the procedure can be done suturing it
and bringing together rectus muscles with minimum dissection.
Aim: To describe a new procedure using robotics in the repair of
the linea alba, associating minimally invasive techniques by
Rives/Stoppa and component separation techniques.
Methods: Five patients undergone surgery in the same hospital, the
same operating team and using the Da Vinci S. robotics equipment.
Retro sheaths were opened and its borders were restored superior
and inferior in its midline. This created a retro muscular envelope
where a mesh is positioned and fixed.
Results: Three women and two men undergone surgery, with no mortality. Two of these patients were re-operated due a recurrent hernia
between muscle and posterior sheath that was closed in the re-access.
Conclusions: The robotic procedure in the reconstruction of the linea
alba showed itself feasible and aesthetically acceptable. Also, in
advantage, the procedure follows the traditional principals reputable
by experts of the abdominal wall trough minimally invasive surgery.
Headings: Ventral hernia. Robotics. Abdominal wall. Umbilical hernia.
Hernia (2014) 18 (Suppl 1): S42-S44
IP-152
Public disclosure of outcomes and cost after hernia
repair: surgeon-centered metrics
Poulose B
Vanderbilt University Medical Center
Hernia repair represents entities with fairly small variation in care
(inguinal hernia) to wide variations in approach and cost (ventral
hernia). As we transition from a health care model of volume-based
care to value-based care in the United States, an increasing focus
must be placed on defining quality of care and costs associated with
hernia management. A framework for public disclosure of outcomes
and costs is presented in the context of continuous quality improvement for individual surgeons.
Hernia (2014) 18 (Suppl 1): S45-S46
ABSTRACTS
Saturday, March 15, 2014
Session 14A: Biomaterial science session II
© Springer-Verlag 2014
IP-12590
Inguinodynia – Causes and prevention
Murphy J
Troy, MI
The incidence of inguinodynia or chronic groin pain has been
reported as 11%. This means that 93,000 patients suffer this complication of inguinal hernia repair each year. Inguinodynia results in an
increased cost of care, loss of work time and productivity, very
unhappy patients and approximately 6,000 malpractice cases/year.
Potential causes of inguinodynia include nerve damage, excessive
use of mesh, and fixation. Nerve damage may be the result of direct
trauma, stretching, vascular injury, as well as fixation. The use of
excessive mesh with its inherent shrinkage and well as required fixation may also be a cause. Fixation may cause pain secondary to
direct entrapment, by tension from shrinkage, or foreign body reaction.
ProFlor is a dynamic implant that has been specifically designed to
address each of these deficiencies and to eliminate them as possible
causes of inguinodynia. Initial studies have shown that the incidence
of chronic groin pain has been reduced by the use of ProFlor in
inguinal hernia repairs.
IP-155
Absorbable synthetic mesh for abdominal wall
reconstruction: clinical value or an inexpensive
alternative to biologic mesh
Jacobson G
University of California, San Diego
Over the past several years there has been an ever increasing array
of bioabsorbable products available for use in the reconstruction of
the complex abdominal wall hernia. Recent data has suggested that
they may provide a more cost effective modality when compared to
traditional biologic grafts in the clean contaminated or contaminated
environments. Consideration will be given to the data in this regards.
However additional consideration is warranted as to the true value
of these products relative to their more costly biologic counterparts.
A review of the clinical performance characteristics of bioabsorbable
materials will be made to assess if there is value outside of the inherent cost differences between the two.
S46
Hernia (2014) 18 (Suppl 1): S45-S46
IP-136
Antimicrobial Mesh as Prophylaxis for Mesh Infection:
Preclinical and Clinical Support for Technology
IP-12600
Mesh selection will be determined by genetic profiling:
Hernia Repair 2030
Belyansky I
Anne Arundel Medical Center
Bachman S
University of Missouri
Prosthesis infection is a serious complication with the incidence as
high as 18%. S. aureus is the most common pathogen responsible
for over 90% of prosthetic infection and develops resistance to
antimicrobial treatment by its ability to produce biofilm. Powerful
intravenous broad-spectrum antibiotics have been used yielding marginal success rate in penetrating biofilm and killing the pathogen.
It has been proposed that mesh hydrophobicity and the presence of
niches in multifilament meshes contribute to increased biofilm
growth. Composite anti-adhesive barrier meshes, and laminar antimicrobial impregnated meshes are not able to clear bacterial contamination as well as monofilament unprotected synthetic meshes.
Presoaking the mesh in vacomycin solution has been shown to
decrease bacterial growth in animal experiments. Recently, naturally
occurring antimicrobial peptides have attracted much attention
because of their high activity, broad antimicrobial spectrum, and low
rate of antimicrobial resistance.
We have investigated the efficacy of several antimicrobial proteins
bound to mesh, and found lysostaphin to be superior in vitro.
Lysostaphin effectively penetrates biofilm, making it an ideal agent
for prevention and treatment of prosthetic-bound infections. In animal models, lysostaphin demonstrated significant in vitro and in vivo
antibacterial efficacy when bound to mesh products. A large animal
trial of lysostaphin-coated biologic mesh for abdominal wall reinforcement in the presence of a lethal inoculum of S. aureus demonstrated 100% animal survival, a significant reduction in the incidence
of positive wound cultures, and complete defense of the mesh
implant. Animal trial examining lysostaphin coated polyester mesh
(concentrations of 100 μg/ml), demonstrated complete bacterial clearance at 7 days. Surface coatings using antibacterial enzymes could
be a groundbreaking addition to the field of hernia repair. Future trials should focus on evaluation of monofilament antimicrobial-coated
meshes in clinical arena.
Hernia (2014) 18 (Suppl 1): S47-S49
ABSTRACTS
Saturday, March 15, 2014
Session 14B: Posters of distinction
© Springer-Verlag 2014
FP-10933
Does normothermia reduce the risk of surgical site
infection in ventral hernia patients?
FP-130
Single-center experience with parastomal hernia repair
using sublay mesh placement
Baucom R, Phillips S, Holzman M, Ehrenfeld J, Martin B, Nealon W,
Sharp K, Kaiser J, Poulose B
Vanderbilt University Medical Center
Raigani S, Criss C, Petro C, Novitsky Y, Rosen M
University Hospitals Case Medical Center
Background: The World Health Organization (WHO) defined perioperative core body temperature above 36 degrees C as a quality
metric (QM) to minimize the risk of surgical site infection (SSI).
Ventral hernia repair (VHR) patients often have higher than expected
rates of SSIs, with no evidence evaluating the benefit of normothermia in this population. This study aims to evaluate the effect of normothermia on postoperative SSI in VHR patients.
Methods: Patients who underwent VHR between 2005-2012 at
Vanderbilt University Hospital were eligible for enrollment.
Temperature data for VHRs with Class I incisions were obtained
from the Perioperative Data Warehouse (PDW) and merged with outcome data for SSIs using National Surgical Quality Improvement
Program data. Patients were divided into normothermic or hypothermic groups based upon the QM. The primary outcome was 30-day
SSI.
Results: 552 VHR patients were identified: 46% women with mean
age 53 years (±13 SD). 79% were open procedures, and all but 1
SSI occurred in open VHRs. 96% received on-time perioperative
antibiotics. The mean intraoperative temperature was 36.1 (±0.8)
degrees C, and 88% met the QM. With an overall SSI rate of 7%,
the rate of SSI was 7% in the normothermic group and 4% in the
hypothermic group (p=0.61). Smoking (OR 3.4, 95% CI 1.5-7.5,
p<0.05), body mass index (OR 1.5, 95% CI 0.99-2.2, p=0.06), and
length of operation (OR 2.1, 95% CI 1.6-2.6, p<0.05) were included
in multivariable analysis. After controlling for these risk factors, there
was no association between hypothermia and SSI (OR 1.4, 95% CI
0.4-5.0, p=0.62).
Conclusions: This study demonstrates that maintenance of normothermia is not associated with decreased 30-day SSI in VHR patients.
Efforts to reduce SSI should focus on surgical technique, total time
spent in the operating room, and patient factors.
Background: Parastomal hernias (PsH) are frequent complications
of enterostomies. While several approaches have been described, the
preferred technique is yet to be defined. We aimed to evaluate our
outcomes of open PsH repair with retromuscular (sublay) mesh reinforcement.
Methods: From 2006 to 2013, 48 consecutive patients undergoing
open retromuscular PsH repair were identified in the prospectively
maintained database and analyzed. Surgical technique included stoma
relocation, retromuscular dissection with transversus abdominis
release, and sublay mesh placement. All stomas were prophylactically
reinforced with cruciate incisions through sublay mesh. Main outcome measures included demographics, perioperative details, wound
complications (classified according to the CDC guidelines) and recurrences.
Results: There were 22 male and 25 female patients with a mean
age of 62.5 and BMI of 31.7kg/m2. 24 patients had recurrent PsH
with an average of 3.8 prior repairs. Ostomies included 19
colostomies, 20 ileostomies, and 10 ileal conduits. Thirty-three
patients had a concurrent repair of a ventral/incisional hernia. All
patients underwent mesh repair with either biologic (n=33), lightweight polypropylene (n=12) or absorbable synthetic mesh (n=2).
There were 13 (28%) occurrences of superficial surgical site infections (SSI); 7 required beside drainage and 6 resolved with antibiotics. There were 8 (17%) deep SSIs; 5 were treated with percutaneous drainage, 2 resolved with antibiotics and 1 required
debridement in the operating room. One patient had mucocutaneous
separation, which was treated conservatively. No mesh grafts
required removal. At a mean follow-up time of 11.1 months, 5
patients (10.6%) developed a recurrence; 3 patients required re-repair.
Conclusion: PsH represent a formidable surgical challenge. In this
largest series of complex open repairs with sublay mesh reinforcement and stoma relocation, we demonstrate that this results in an
effective repair. This technique may be the procedure of choice for
complex parastomal hernia repair.
S48
FP-172
Comparing perioperative outcomes of laparoscopic vs
open inguinal hernia repair using two national large
data bases
Tadaki C, Lomelin D, Simorov A, Jones R, Oleynikov D, Goede M
University of Nebraska Medical Center
Introduction: Studies comparing laparoscopic vs open inguinal hernia repair (IHR) techniques have shown similar recurrence rates, but
have disagreed on perioperative outcomes and costs. The aim of this
study is to compare laparoscopic vs open outcomes and costs.
Method: The National Surgical Quality Improvement Program
(NSQIP) was used to compare length of hospital stay (LOS), operative and anesthesia time. The University Health System Consortium
(UHC), an alliance of more than 300 institutions, was used to review
the overall cost. International Classification of Disease 9TH revision
codes (ICD-9) and Current Procedure Terminology (CPT) for laparoscopic and open IHR was used.
Results: A total of 75,132 patients’ records and perioperative outcomes who underwent an IHR were evaluated through NSQIP. Cost
data was evaluated from a matched group of patients in UHC.
Laparoscopy was performed in 18, 309 patients and open surgery
was performed in 56,823 patients. Though LI patients had a longer
operative time (66.3±36.1 vs 60.6±31.4; p<0.05) and anesthesia time
(88.6±73.1 vs 81.8±64.1; p<0.05); they had a shorter LOS (0.2±1.7
vs 0.3±4.1; p<0.05), and decreased morbidities: wound breakdown
(Odds ratio of 0.321; 95% CI 0.098-1.054) and surgical site infections (OR of 0.727; 95% CI 0.532-0.993).
Overall costs favored open over LI repair (5,226±1,933 vs
3,061±1,289). Analyzing the cost data showed the discrepancy
mainly stemmed from LI supplies ($1,448 vs $340; p<0.05) and OR
services ($1,380 vs $1,080; p<0.05).
Conclusion: This study demonstrates the LOS and perioperative outcomes were superior in the LI group; however, the overall cost was
higher due to the supplies. Advancement in technology as well as a
surgeon’s preference of supplies and skill level are all factors in
decreasing the overall cost of the operation. Though the “price tag”
of a LI inguinal hernia repair appears to be greater, the benefits from
the operation may outweigh the cost.
FP-144
Apples to apples: a validated staging system (I-IV)
for incisional hernias
Petro C, Raigani S, Criss C, Bakaki P, Orenstein S, Soltanian H,
Novitsky Y, Rosen M
University Hospitals Case Medical Center
Introduction: The absence of a standardized classification scheme
for incisional hernias hinders comparisons within the literature, indirectly delaying meaningful discussions regarding technique. We
aimed to create a simple, validated staging system using variables
associated with prognosis.
Methods: Our prospective database of abdominal wall repairs at Case
Medical Center between 2005 and 2012 was reviewed retrospectively
with no filter for technique. Patient demographics, modified Ventral
Hernia Working Group (mVHWG) grade, and hernia width/location
using preoperative CT-scan were reviewed. Predictors of surgical site
occurrence SSO and recurrence would be used to generate a staging
system that groups patients with similar outcome profiles.
Hernia (2014) 18 (Suppl 1): S47-S49
Results: Three hundred thirty-three patients with a minimum of 90day follow-up including 181 patients with at least 1-year follow-up
were reviewed. We found that hernia width (<10 cm, 10-20 cm, >20
cm) was associated with both SSO (p<0.0001) and recurrence
(p=0.0002). Using width and mVHWG grade (G), we grouped permutations with similar morbidity profiles. Stage I patients are healthy
with small defects (G1 <10 cm) and can expect infrequent SSO/recurrence rates [6.7%, 6.7%]. Stage II patients are either healthy with
moderate-sized defects, or have small hernias with comorbidities or
contamination (G1 10-20 cm OR G2-3 <10 cm) and can expect mild
SSO/recurrence rates [12.4%, 11.3%]. Stage III patients are healthy
with large hernias, or have moderate sized hernias with comorbidities
or contamination (G1 >20 cm OR G2-3 10-20 cm) and have a moderate risk for SSO/recurrence [27.1%, 15.1%]. Finally, Stage IV
patient have large hernias with comorbidities or contamination (G23 >20 cm) and are considered highest risk for SSO/recurrence
[42.3%, 34.6%]. Staging trends were significant for both SSO
(p=0.0002) and recurrence (p=0.00015).
Conclusions: Herein we present a validated staging system that ordinally ranks hernias by risk of SSO and recurrence. As there was no
control for technique, this can now serve as the platform for “apples
to apples” comparisons regarding operative approach.
FP-115
A summative assessment of laparoscopic ventral hernia
repair for general surgery residents: perception does
not equal reality
Greenberg J, Cohen E, Maag A, Wiegmann D, Greenberg C, Pugh C
University of Wisconsin
Background: Laparoscopic Ventral Hernia (LVH) repair is a common procedure performed worldwide. Graduating residents should
be competent to perform this procedure independently. We utilized
a LVH simulation to assess differences in resident self-assessment
and faculty evaluation.
Methods: Six graduating Chief Residents, within two weeks of graduation, were given 30 minutes to complete a LVH repair using a
simulator with known evidence of validity. Prior laparoscopic case
experience was reviewed using the ACGME Resident Case Log
System. Residents completed both pre- and post- self-assessments
utilizing a 5 point-Likert scale to assess their pre- and post-procedure
confidence. Faculty assessed resident competency and performance
utilizing a 12-item, task-specific checklist and Objective Structured
Assessment of Technical Skills (OSATS) to assess general technical
skills (1=very poor, 5=clearly superior). All simulations were
recorded using both external and laparoscopic views.
Results: Residents completed an average of 140 basic laparoscopic
cases (Range: 108-175); 150 complex laparoscopic cases (Range:
122-170); and 15 laparoscopic ventral hernia repairs (Range: 13-20)
during the course of their residency. Five out of six residents were
confident or very confident in their ability to complete a LVH repair
while one was moderately confident. After completion of the simulator, resident confidence in overall ability to perform LVH repair
was unchanged (4 vs 4, p=1.0). Despite their confidence, 5 out of 6
residents failed to complete the simulation. Video review revealed a
wide range of critical errors. Faculty checklist scores ranged from
33%-100% of tasks performed correctly. OSATS scores ranged from
2 (poor) to 5 (clearly superior) for general technical skills.
Conclusions: Resident perceptions regarding procedural competence
vary drastically from observer ratings. Earlier assessment followed
by focused teaching may allow for better awareness and a faster progression to competency in LVH repair.
Hernia (2014) 18 (Suppl 1): S47-S49
FP-132
Efficacy of antibiotic pulse lavage irrigation
for contaminated retro-rectus abdominal wall
reconstructions
Wu Y, Peacock J, Criss C, Soltanian H, Rosen M, Novitsky Y
University Hospitals Case Medical Center
Introduction: Contaminated surgical wounds are frequently encountered during abdominal wall reconstruction (AWR). Pulse lavage irrigation (PLI) facilitates the removal of surface contaminants and bacteria. We hypothesized that PLI would help reduce bacterial burden
during complex retro-rectus abdominal wall reconstruction in clean
contaminated and contaminated wounds.
Methods: A retrospective review of prospectively collected data
from our institution was performed for patients undergoing AWR in
the setting of clean contaminated or contaminated wounds. Wound
cultures were obtained from the retro-rectus space prior to and after
3L of antibiotic PLI (cephazolin/gentamycin/bacitracin). Routine
microbiologic analysis was then performed; any detected bacterial
growth was defined as “positive” culture.
Results: From January 2012 to May 2013, 46 consecutive patients
undergoing major AWR were evaluated. The median age was 54
years (31-88) with a mean BMI of 39±27. Seventy-six percent of
patients had recurrent hernias. Twenty-six patients (56%) had a history of wound infection. Pre-operatively, the wounds were classified
as clean-contaminated in 22 (48%) patients and contaminated in 23
(52%) patients. Biologic mesh was used in 46%, synthetic mesh in
48%, bioabsorable mesh in 4%, and primary repair in 2% of cases.
Intra-operatively, 27 (59%) of patients had a negative Pre-PLI (56%
clean-contaminated, 44% contaminated). Of the 19 positive pre-PLI
cases, the majority were contaminated (12) versus clean-contaminated (7). Seventeen positive pre-PLIs cultures became negative for
a conversion rate of 89%. Overall, the rate of culture negative retrorectus space following PLI during clean-contaminated/contaminated
repairs was 95.7%.
Conclusion: We demonstrated that the majority of contaminated
AWR cases had no detectable bacteria in the extraperitoneal space.
Furthermore, the use of antibiotic pulse lavage of the retro-rectus
pocket resulted in near complete elimination of detectable bacteria.
It appears that intra-operative antibiotic pulse lavage is associated
with a significant bacteriologic advantage during contaminated retrorectus repairs.
FP-12503
Do patients follow-up with their original surgeon when
ventral hernia repairs (VHR) fail?
Oommen B, Kim M, Ross S, Augenstein V, Heniford B
Carolinas Medical Center, Department of Surgery, Division of
Gastrointestinal and Minimally Invasive Surgery
Introduction: VHR are one of the most common procedures in
General Surgery. Without formal follow-up, surgeons may underestimate recurrence rates. Our aim was to determine the rate at which
patients do not return to their original surgeon and why. An examination of the factors influencing patients to seek new surgeons for
repair of recurrent hernias was undertaken.
Methods: Recurrent ventral hernia patients who presented from
December 2012 to September 2013 were surveyed. Responses
regarding their original VHR, recurrence and factors influencing their
change in surgeon were collected.
S49
Results: Eight-seven patients completed surveys. The majority
(84.5%) identified their own recurrence; 71.2% had imaging /labs
since surgery. Over one-third (35.8%) had three or more hernia
repairs; 43.5% had two or more surgeons. Only 44.2% of patients’
surgeons were aware their patient was seeing another surgeon for
VHR recurrence. The most common reasons for not returning to the
last surgeon were that the surgeon “failed to repair my hernia”
(51.6%), distant location (29.0%): 54.9% lived 25-100 miles from
their previous surgeon; 22% lived >100 miles. There was a 75.9%
satisfaction rate with pre-operative experience and less post-operatively (67%). 76.8% were satisfied with surgeon demeanor, 69.9%
with timeliness, 70.4% at discharge, 69.1% at follow-up. Sixty percent reported complications related to previous repair; 12% were readmitted within thirty days of surgery. Two-thirds of these patients
rated their previous surgeon’s skill level at 4 or 5 on a 5-point scale.
Conclusions: The majority of patients with recurrent ventral hernias
do not return to their last surgeon. This number is influenced by failure of the operation and distance from the surgeon. Most patients
had complications but were satisfied with their surgeon demeanor
and skill level. Surgeon without particular follow-up regimen should
be careful in quoting their recurrence rates.
FP-121
The impact of developing a comprehensive hernia
center on referral patterns and cost of hernia care
Raigani S, De Silva G, Novitsky Y, Rosen M
University Hospitals Case Medical Center
Background: Complex hernia repairs represent a formidable surgical
challenge. Several comprehensive hernia centers, including ours, with
advanced expertise have recently emerged across the country.
However, the effects of tertiary specialization remain largely unclear.
We aimed to evaluate the impact of developing a comprehensive hernia center on the referral patterns and costs of patients with complex
hernias.
Methods: A prospectively maintained database was used to identify
all patients undergoing open ventral hernia repair (VHR) between
2006-2013 at the Case Comprehensive Hernia Center. Patients were
separated into two groups by zip code: those traveling either <25
miles or >100 miles. Demographics, operative characteristics, length
of stay (LOS), and costs data were analyzed.
Results: Of all patients who underwent open VHR during the study
period, 287 met the inclusion criteria. Hernia length, width and area
were all significantly larger for patients traveling >100 miles (p<0.01
for all). These patients were also more likely to have active mesh
infections (OR 3.57) and non-healing wounds (OR 5.00) when compared to local patients. Length of hospital stay was significantly
longer for patients traveling >100 miles compared to those traveling
<25 miles (9.7 vs 6.8; p<0.0001). Surgical site occurrence, infection
and hernia recurrence rates were similar between the two groups during the follow-up period. Patients who traveled >100 miles incurred
significantly higher fixed direct and variable direct costs compared
to those traveled <25 miles (p<0.05 for both).
Conclusion: The development of a comprehensive hernia center
results in centralization of complex hernia care. Patients traveling
>100 miles for ventral hernia repair have significantly larger and
more complex hernias. The implications for improved patient outcomes and potential reimbursement issues for providing this care
should be carefully evaluated.
Hernia (2014) 18 (Suppl 1): S50-S97
ABSTRACTS
Posters
© Springer-Verlag 2014
P-100
Abdominal wall reconstruction, what have we learned?
Clarke J
Palms of Pasadena Hospital
This presentation will review lessons learned during the evolution of
surgical techniques for repair of abdominal wall defects, with focus
on those related to previous abdominal surgery: ventral incisional
hernia. Progress and improvement in results for this challenging surgical problem continue to develop, based in part on a better understanding of certain anatomical and physiological characteristics of
the abdominal wall. Examples of what we have learned from shortcomings of various operations will be discussed as well as contributions and experience from some of the many surgeons who have
described new techniques or have modified existing ones. Despite
individual variation in methods, there now seems to be a trend toward
general agreement on the basic surgical principles for incisional hernia repair. Prevention, however, remains elusive. As surgeons, the
only variable under our control is technique. Some newer thoughts
in the area of prevention, especially focused on techniques of abdominal wall closure, will be introduced.
P-101
Laparoscopic midline incisional hernia repair: new
technique based on trans peritoneal retro-muscular
mesh placement
Copsta T, Abdalla R, Santo M, Ceconnello I
Clinics Hospital of the University of Sao Paulo
Background: The minimally invasive approach changed the way to
dissect and prepare the anatomy of the abdominal wall. Former evidences showed defect closure benefits with mesh reinforcement.
Therefore, we designed a study to demonstrate a new technique for
laparoscopic correction of incisional hernias with defect closure and
retro-muscular mesh placement.
Methods: Between October 2012 and August 2013, a total of 13
patients were submitted to laparoscopic correction of incisional hernias. Access to the cavity was obtained through a suprapubic incision,
two ports were placed in the lower inferior quadrants for dissection.
The defect was closed with endo-stapler. A pouch was created, in
which a retro-muscular mesh was placed. Fixation was completed
using a trans-aponeurotic hernia stapler.
Selection was based on supra umbilical midline hernias post open
bariatric surgery. Pregnant women, patients in the presence of cancer
or clinical contraindications were excluded.
Results: The patients mean age was 52.3 (range 39-65). 85% (n: 11)
were women. Two patients had Fibromyalgia, four had Diabetes and
Hypertension. The mean BMI was 28.36 kg/m2 (range 23.1-31.6).
Surgery was performed successfully through the three ports; mean
number of incisional hernias was 3 (range 1-5), with a mean maximum length of 3.97 cm (range 2.1-5.4). The mean surgical time was
115.8 min (range 90-170), and the median hospital stay was 1 day.
No intraoperative or immediate postoperative complications
occurred. One patient had a seroma treated conservatively one week
after surgery.
CT-Findings, made before and after the procedure, showed total closure of the defect. QOL showed satisfaction, acceptance and no complains.
Conclusion: Although it is a small number of patients we showed
it is a feasible technique, easy to do, with the laparoscopic benefits,
with acceptable results showed by CT-scan, peri-operative and QOL
findings.
Hernia (2014) 18 (Suppl 1): S50-S97
P-102
Extreme single-stage reconstruction of the abdominal
wall: A prospective series of patients presenting with
enteric fistulas, mesh infection and ventral hernias
Birolini C, Utiyama E, Rasslan S
University of São Paulo, School of Medicine
The reconstruction of the abdominal wall in patients presenting with
enteric fistulas is a formidable challenge. The recommended
approaches are component separation techniques or staged operations
using absorbable or biological meshes despite high recurrence and
mesh infection rates, and the risk of two operations in this complicated group of patients. Moreover, the coexistence of an infected
mesh is usually considered an absolute contra-indication to perform
a primary reinforcement using a new synthetic mesh.
From 2008 until 2013, twelve patients presenting with severe destruction of the abdominal wall were submitted to a single stage repair
with simultaneous treatment of enteric fistulas. In eight patients, fistulas were associated to mesh erosion into the bowel. In all patients,
we used an onlay polypropylene mesh to reinforce the reconstruction
of the midline. There were 8 males and 4 females, and the mean age
was 53 years. Mean BMI was 27 and five patients were ASA 2. The
number of previous abdominal operations ranged between 1 and 20,
and the onset of symptoms, between 1 month and 26 years. Pre-operative cultures were positive in 8 patients.
Surgical complications included two minor wound infections, two
seromas and one patient with localized skin necrosis. One patient
presented a suspicious discharge of enteric fluid through the drain
that healed on medical therapy. All patients were discharged with no
signs of wound infection. Nine patients have a follow-up of more
than one year and no re-infection or hernia recurrence, were observed
in this series. These results reinforce the fact that the use of synthetic
mesh is safe in contaminated and infected surgical fields.
P-106
Abdominoscrotal hydrocele presenting as abdominal
pain and mass after trans scrotal hydrocelectomy
Megison S, Soeken T, Hodgman E
Children’s Medical Center Dallas/ UT Southwestern Medical School
Purpose: Describe previously unreported presentation of
Abdominoscrotal hydrocele
Methods: Abdominoscrotal hydrocele (ASH) is an uncommon form
of hydrocele that extends from the scrotum through the inguinal ring
into the abdomen. Modern imaging capabilities with ultrasonography
or computed tomography (CT) may identify a cystic abdominal mass,
which when combined with physical exam findings, may suggest the
diagnosis of ASH and permit appropriate operative planning.
However, the diagnosis is often made only upon surgical exploration,
prompting an alteration of the surgeon’s initial plan for repair.
Results: We present the case of a 7-year-old child who underwent
hydrocele repair 5 years ago via a trans-scrotal approach. He presented to the ED with complaints of right lower quadrant (RLQ)
pain. Ultrasound revealed a cystic mass in the RLQ; a CT was
obtained which confirmed the diagnosis of ASH. Repair was initially
approached via laparoscopy; however, inflammation around the internal inguinal ring made identification of the vas deferens and spermatic vessels difficult, and the procedure was converted to a minilaparotomy, with successful excision of the hydrocele and drainage
of the inguinal portion.
S51
Conclusions: ASH is a rare form of hydrocele, and is best diagnosed
through a combination of thorough physical examination and judicious use of imaging. It is unclear whether this case represents a
recurrence of the hydrocele with conversion to an ASH, or whether
this patient’s ASH went undiagnosed at the time of his prior procedure. Pre-operative identification of ASH will allow selection of the
most appropriate approach, whether through a conventional inguinal
incision, or via a trans-scrotal, laparoscopic, or open abdominal technique. The surgeon must remain alert to the potential for an abdominal component to any hydrocele, as the diagnosis of ASH may be
made only intra-operatively, and require an adjustment in the operative plan.
P-107
New indication of surgical glue in preperitoneal
approach: Nyhus modified technique
Carreño-Saenz O, García Pastor P, Aguilar Martí M, Barber Millet S,
Montilla Navarro E, Iserte Hernández J, Bonafé Diana S,
Carbonell Tatay F, Salvador P
Valencia, Spain
Introduction: Cyanoacrylate glues are tissue adhesive with high
adherent and hemostatic properties. In recent years, the use of synthetic glues has become an established practice in several areas of
surgical treatment. For example, they are used in open and laparoscopic surgery and in digestive tract endoscopy and interventional
radiology. In this case, we use the glue for mesh fixation in modified
Nyhus technique for hernia repair.
Methods: By modified Nyhus technique, once identified the preperitoneal space, place a polypropylene mesh coated with bioabsorbable
oil 4.1 “x 6.3” (C-qur CentrifiFX Atrium) fastening the cooper ligament and pubis with cyanoacrylate glue.
Results: The use of glue in this technique decreased operative time,
postoperative pain and early recovery to perform activities of daily
living. Although, there are still serious studies that reveal the effectiveness of the glue over other fastening means, is setting a good
option.
Conclusions: The preperitoneal approach (Nyhus modified) for hernia repair is easier to perform and faster. The use of a synthetic tissue
adhesive (n-hexyl-α-cyanoacrylate) is safe as fastening in patients
without comorbidity hernioplasties with good postoperative results.
S52
P-108
Supra pubic ventral hernias treatment:
modified Stoppa technique
Carreño-Saenz O, Barber Millet S, Aguilar Martí M, García Pastor P,
Vergara Suarez F, Montilla Navarro E, Iserte Hernández J,
Bonafé Diana S, Carbonell Tatay F, Salvador P
Valencia, Spain
Introduction: The suprapubic hernia, has its own characteristics that
define and differentiate. It belongs to the hernias that have a ring
party formed by a bony ridge, is located immediately above the pubic
bone in the midline and lower abdominal wall and according to the
classification of the European Hernia Society is nominated with
acronyms M5.
Our team has developed a technique that is based on the methods
described by Stoppa, Rives, Zavaleta, Wantz and Bendavid, among
others, but was the first, René Stoppa who provided the fundamental
idea of the “complete reinforcement of the visceral sac” placing a
prosthesis hosted pre peritoneal space and adapted to the anatomy
of the area, technique designed to solve recurrent or bilateral inguinal
hernias. Our modification is adapted to correct defects supra pubic
and effectively strengthen the entire lower abdominal wall.
Methods: We have created a new technique based on the placement
of an open prosthesis extended “butterfly wings” and preperitoneal
retropubic space, and above exceeds the umbilical region. The series
consisted of 50 consecutive patients operated on between 2003 and
2011, following a surgical protocol similiar for all the patients.
Results: There were no significant complications the most frequent
was a seroma (6%) followed by wound infection (2%) and
Haematoma (1%). During the follow (between 4 and 80 months),
there has been one recurrence of the incisional hernia.
Conclusions: The modified Stoppa technique achieved good results
in our hands, from the surgical point of view (reproducibility, recurrence), and for the patient, with minimal discomfort and recovery of
quality of life.
P-110
Recurrent Inguinal Hernias. How to face them?
Goderich Lalán J, Alfonso J, Fernández E, Fajardo M
Hospital Universitario de Santiago de Cuba
Operated hernias always have recurrence possibilities. Inguinal hernia relapse oscillates between 11-20% using tension techniques and
0.5-5% with open or laparoscopic techniques without tension.
Recurrence with open or laparoscopic techniques without tension is
smaller than 1% in primary hernias and up to 5% in relapsing hernias,
independently from the access path, as reported in 37 publications
in the last 5 years. Classification is important. We use that of Nyhus:
Iva direct hernia, IVb indirect hernia, IVc femoral hernia and IVd
combination of anyone of the above mentioned.
Objective: To evaluate the result of the surgical treatment: Shortterm: before the 2 years; Mid-term: up to 14 years.
Method: Clinical observational study from January 1, 1996 to
December 31, 2010, at the University Hospitals Dr. Juan Bruno
Zayas Alfonso, in Santiago de Cuba and Dr. Manuel Fajardo, in
Havana. Each patient requires individual evaluation of nutritional
state, antecedents of respiratory, urinary obstruction, cardiovascular
diseases, other abdominal operations, other hernias, time from last
operation, technique used, bilateralism, age. Treatment Principles:
individual assessment, antibiotic prevention, short hospital stay sur-
Hernia (2014) 18 (Suppl 1): S50-S97
gery, systematic specialized consultation follow up. One hundred and
eighty nine patients were operated; from them, 23 Iva direct hernias,
31 Ivc femoral hernias, 45 IVb indirect hernias and 102 IVd combined.
Results: No relapse in 23 recurrent direct hernias with Lichtenstein’s
technique; one relapse (0.5%) in 45 direct hernias with Lichtenstein’s
and Rives’s. In femoral hernias, if absolute certainty of its femoral
nature, application of laparoscopic or pre peritoneal prosthetic techniques through inguinal approach is valued; thirty-one of them did
not relapse and two relapsed (2%) from 102 hernias combined with
the Jean Rives’s technique. From a total of 189 hernioplasties in
reproduced hernias, 3 relapsed (3.5%). Complications: 2 seromas
(1.1%), operation site infections: 4 (2.2%); haematoma: only 1
(0.6%).
Conclusions: Lichtenstein’s and Jean Rives’s techniques offer excellent results in mesh repairs of hernias recurrence, with correct individualized pre-operatory evaluation by trained personnel.
P-112
Adhesive mesh utility in the treatment of hernia groin,
comparison with polypropylene mesh
Montilla-Navarro E, Carreño-Sáenz O, García Pastor P,
Aguilar Martí M, Bonafé Diana S, Iserte Hernandez J,
Carbonell Tatay F
Valencia, Spain
Background: Certainly since these biomaterials way meshes were
first used to treat inguinal hernias has been increased not only the
type of material used (Polyester, poliproplineo, expanded polytetrafluoroethylene (e- PTFE), but the shape and configuration of the
same. currently the appearance of absorbable materials, biological
glue to attach the mesh and use self-adhesive mesh has diverted
attention from the research, since they are aspects that have yet to
show their true value.
Materials and methods: We performed a retrospective study by
reviewing medical records of patients from our unit between 2009
and 2012. We included 120 patients treated for inguinal hernia. Sixty
patients (60) were in the group of self-adhesive mesh (Parietene
Progrip®) and 60 patients were in the group of conventional mesh
PPL. Were measured intraoperative and postoperative results in both
groups. We excluded patients with bilateral hernias, recurrent and
emergency surgeries.
Results: A total of 120 patients were included in the series, were
divided into 2 groups (Mesh Adhesive / conventional mesh) of 60
each. The demographic characteristics of both groups were similar
in age, sex, type and size of inguinal hernia. From the analyzed data,
which identifies the only difference is the operating time in both
groups, being lower in the sticky mesh. No differences in postoperative outcomes such as pain, hospital stay, complications and hernia
recurrence.
Conclusion: In our series, the use of self-adhesive mesh in inguinal
hernia treatment reduced surgical time, no differences were found in
terms of postoperative pain, hospital stay, complications and hernia
recurrence.
Hernia (2014) 18 (Suppl 1): S50-S97
P-117
Reconstruction of giant incisional hernia with Chevrel’s
technique
Mladenovik D, Shenol T, Nikolo vs ki A, Devaja A
University Surgical Clinic St. Naum Ohridski
Reconstruction of giant incisional hernias (diameter > 10 cm) represents a serious surgical problem, accompanied with high rate of
recurrence, postoperative complications and mortality. The application of Chevrel technique which is based on dynamic reconstruction
of the anterior abdominal wall supported with onlay application of
mesh, sublimates anatomical and functional assumptions for successful reconstruction of the anterior abdominal wall defects.
Method and material: In the 16 year period (1996-2012), 125
patients have undergone elective surgery because of giant incisional
hernia M4-W4R according to Chevrel classification. The female/male
ratio was 88/37 with average BMI 31.2. Only 21 patients had normal
weight. The patients were operated in general endotracheal anesthesia
using Chevrel technique.We used polypropylene to onlay position,
double suction drainage, low weight heparin prophylaxis and epidural
analgesia in all cases.
Results: The used technique did not cause any intraoperative complications and there was one death (perforated ulcer). Operative time
was 60-80 minutes. Postoperative hospitalization was 8.8 days (721). The following complications were noted: skin necrosis - 1
patient, hematoma - 8 patients, seroma 22 patients. We had recurrence in three patients because mesh was shrinking on the anterior
aponeurosis m. recti abdominis defect.
Conclusion: The original Chevrel technique sublimates from the tissue reconstruction on the linea alba and approximatio of the rectus
muscles strengthened with onlay application of the mesh, represents
acceptable method. The low rate of recurrence and complications, as
well as good cosmetic results, kindly recommend Chevrel technique
as dynamic support of anterior abdominal wall.
P-122
30-day postoperative mortality risk score for emergent
anterior abdominal wall hernia repair using the
american college of surgeons national surgical quality
improvement database
Chung P, Tam S, Schwartzman A, Bernstein M, Sugiyama G
SUNY Downstate Medical Center
Background: No risk score for short term mortality after emergent
anterior abdominal wall hernia repair yet exists in the literature.
Study design: NSQIP Participant Use Files (2005-2010) were the
primary data source. Patients that had incarcerated, irreducible,
obstructed, or gangrenous ventral, umbilical, or epigastric hernias
(identified by ICD9 codes), undergoing either open or laparoscopic
repair with or without mesh (identified by CPT codes), undergoing
emergent surgery were selected. 76 variables were used as potential
predictors. Multiple logistic regression analysis was used to create a
model predicting short-term mortality. The Receiver Operating
Characteristic Area Under Curve (AUC) and the Hosmer-Lemeshow
goodness-of-fit test were used to evaluate the model. Bootstrap-validated AUC was calculated.
Results: 5120 cases met the selection criteria. 145 patients (2.83%)
died within 30 days. Ten independent variables correlated to short-
S53
term mortality: age (OR 3.47, 95% CI [2.47, 4.87], p<0.0001), anesthesia time (OR 1.28, 95% CI [1.09, 1.50], p=0.0022), preoperative
creatinine levels (OR 1.15, 95% CI [1.10, 1.19], p<0.0001), preoperative elevated WBC (OR 1.23, 95% CI [1.03, 1.46], p=0.0189),
preoperative platelet levels (OR 0.61, 95% CI [0.48, 0.78],
p<0.0001), ascites (OR 5.08, 95% CI [3.14, 8.24], p<0.0001), CHF
(OR 2.71, 95% CI [1.30, 5.65], p=0.008), PVD (OR 4.55, 95% CI
[2.27, 9.12], p<0.0001), disseminated cancer (OR 4.57, 95% CI
[1.55, 13.45], p=0.0058), preoperative sepsis (OR 18.09, 95% CI
[9.89, 33.12], p<0.0001), and preoperative septic shock (OR 2.49,
95% CI [1.60, 3.87], p<0.0001). The AUC was 0.896, the bootstrapvalidated AUC was 0.878, suggesting excellent discriminative ability.
The Hosmer-Lemeshow test had a p-value of 0.453, suggesting that
the model does not overfit.
Conclusion: The risk model developed has good-to-excellent ability
to predict 30-day mortality after emergent hernia repair for incarcerated, irreducible, obstructed, or gangrenous hernias. A nomogram was
also created.
P-123
Inguinal neuritis in recurrent inguinal hernia
Wright R
Cascade Hernia Institute
Purpose: Investigate the pattern of occurrence of inguinal neuritis
in recurrent inguinal hernia. We hypothesize neuritis will occur in
more nerves and with a wider distribution than in primary repair.
Methods: Retrospective chart review of thirty consecutive recurrent
inguinal hernia repairs concentrating on the occurrence of inguinal
neuritis. These are not chronic pain patients. Nerves suspected of
containing inguinal neuritis were sent for histologic examination.
Operative parameters and nerve pathology reports were reviewed.
This data was compared with a recent series of one hundred consecutive primary inguinal hernia repairs. An independent statistician
from Whitman University reviewed the data.
Results: 20 patients were found to have inguinal neuritis among
thirty recurrent open inguinal hernia repairs (66%). This compares
to 34% among primary repairs, but is a similar rate (p>.886) assuming the damaged nerve was left intact in 34% of these recurrences
during the primary repair.
Two separate nerves were found to exhibit neuritis in six patients,
(20%), significantly higher than 1% among primary hernias, (p<0.01)
In recurrent inguinal hernia, 89% of neuritis occurred in the
Ilioinguinal nerve compared to 88% of damaged Ilioinguinal nerves
in the primary hernia. A test for the difference in proportions gives
Z=0.1522 with P (|Z|>.1522)=0.879.
The most common site of neuritis occurrence in recurrent hernias
with nerve damage to the Ilioinguinal nerve was at the external
oblique Neuroperforatum among 70% of the patients, compared to
83% in primary cases. A test for difference in proportions gives
Z=1.4175 with P (|Z|>1.4175)=0.156.
Conclusion: The overall incidence of inguinal neuritis was 66% in
recurrent inguinal hernia repairs. The Ilioinguinal nerve was most
commonly affected in these recurrent hernias. Inguinal neuritis occurs
more commonly in recurrent hernia repair compared with primary
inguinal hernia; however, it has a similar distribution. Neuritis occurs
in two nerves with a 20% frequency (p<0.01), so all nerves should
be assessed during recurrent herniorrhaphy.
S54
P-124
Original technique description: treatment of mid-line
abdominal wall hernias with the use of endo-stapler for
mid-line closure
Garcia R, Abdalla R, Costa R, Abdalla B
Hospital Sirio Libanes
Introduction: Minimally invasive video surgery has modified
anatomy dissection of diseases that are treated operatively. However,
the benefit of this method has been delayed due to the lack of development of technologies and articulated movements for the abdominal
wall; demanding the need for investments and time for solidification.
Our operative approach to repair the abdominal wall is based on the
Rives-Stoppa principles.
Objectives: Case report of an original technique, approximating the
retro sheaths of the rectus abdominal muscles together with its suturing, using linear endo staplers for incisional supra umbilical medial
ventral hernia treatment.
Methods: As the recognition of the stability and safety of the suture
was identified we proposed the laparoscopic technique for the midline ventral hernia treatment for a patient after consenting agreement
was signed.
Discussion: The procedure was able to achieve better results of the
rectus muscle function with approximation comparing to the laparoscopic bridging maneuver. The use of liner stapling is more appealing
than endoscopic suture, due to a safer approach for the patient and
better management of time for the surgeon.
Conclusion: The method is feasible, easier to perform, reproducible
and saves time.
P-125
Quality of life study of patients submitted to anterior
abdominal wall laparoscopic hernioplasty
Garcia R, Abdalla R, Said D, Costa R
Hospital Sírio Libanes
Background: The laparoscopic ventral hernia repair techinique,
introduced by Leblanc and Booth, in the 90`s, made possible surgeries
with smaller skin incisions and smaller dissection of the soft tissue
around the hernia, therefore a better wound, a quicker postoperative
with a recent return to activities, and a lower complications rate.
Aim: We intend, with this study, to evaluate the applicability of a
quality of life questionnary based on the molds of the American
Hernia Society, European Hernia Society e Carolinas Equation for
Quality of Life, in patients that have been throw an anterior abdominal wall laparoscopic hernioplasty (incisional/ epigastric/ umbilical).
Methods: Retrospective cohort study. A total of 21 patients in the
postoperative period of 12 months after an anterior abdominal wall
laparoscopic hernioplasty by the Intraperitoneal Onlay Mesh
techinique between November 11, 2005 and May 21, 2012, by the
same surgeon in a private clinic in São Paulo, were submitted by
telephone, to the quality of life questionnary.
Results: Of the 21 patients 19% experienced recurrence of the hernia
and 81% reported that nothing happened. Futhermore 19% underwent
other abdominal surgery, and among these, 75% related to previously
hernia correction and 81% haven’t undergone any other abdominal
surgey.
Conclusion: It was possible to apply the quality of life questionnary
by telephone on patients who underwent an anterior abdominal wall
hernia by Intraperitoneal Onlay Mesh through laparoscopic approach.
The results, in its turn, were satisfactory and showed that patients,
in general, were satisfied with the surgical procedure.
Hernia (2014) 18 (Suppl 1): S50-S97
P-127
Parastomal hernia containing stomach
Barber S
Valencia, Spain
Introduction: Parastomal hernia is the most common late stoma
complications. Its appearance is usually asymptomatic. We report a
parastomal hernia containing stomach.
Clinic case: A 69-years-old patient with end colostomy arrived at
the emergency room presenting abdominal pain associated with vomits and functioning stoma. She had a distended and painful abdomen
without signs of peritoneal irritation and pericolostomic eventration
in the left iliac fossa.
X-ray visualized gastric fornix dilatation without dilated intestine
bowels, and computed tomography showed parastomal incarcerated
gastric herniation.
Gastrografin®was administered, showing no passage to duodenum.
She undergone surgery, with stomal transposition and placement of
onlay polypropylene mesh around the new stoma.
Summary: Parastomal hernias are a frequent late complication of
colostomy. Only 4 gastric parastomal hernia cases are reported in the
literature. 3 of these 4 cases have needed surgery. The placement of
prosthetic mesh in the moment of stoma elaboration should be considered as a potential preventive measure.
P-129
Posherpetic abdominal wall pseudohernia
Real-Romo Z, Gil-Gallardo G, Villegas-Cabelllo O,
Guajardo-Nieto D, Diaz-Elizondo A, Peralta-Castillo G,
Palomo-Hoil R, Martínez-Sánchez D
TEC Salud
Introduction: Herpes Zoster disease affects approximately 10-20%
of population. It can cause either sensitive or motor complications,
when these occur, the sensitive dermatome affected during the infectious episode presents protrusion in the abdominal wall that can be
confused with a true hernia of the abdominal wall.
Material and methods (Case Presentation): A 44 year old male
with past history of Herpes Zoster presented a protrusion in the
abdominal wall at the level of the Spigelian line, it was painless and
no palpable defect was detected through the physical examination.
A CT scan revealed dissociation and thinning of the muscles without
evidence of a true abdominal wall hernia.
Discussion: Herpes Zoster occurs when a Varicela Zoster virus is
reactivated, characterized by a painful skin rash limited to the skin
corresponding dermatome. The incidence of complications are
reported in 0-2% of the cases. The difference with a true hernia of
the abdominal wall is that pseudohernia do not have a sac, neither
sac contents nor a wall defect. The neurological examination provided evidence of paralysis of the muscles in the affected area. An
electromyography demonstrated denervation of the affected dermatomes with fibrillation of damaged muscles. A CT scan shows
diastasis of affected muscles and the absence of a true sac or defect
of the abdominal wall. The physiopathology behind this complication
has not been well described, although some studies have shown ganglionic lesion with denervation of sensory and motor roots that
explain the signs and symptoms of the disease.
Conclusion: A post herpetic pseudohernia of the abdominal wall is
a rare complication and must be considered when history of Herpes
Zoster is present. It is very important to identify signs and symptoms
of motor dysfunction in the abdominal wall musculature, in order to
achieve an accurate diagnosis and avoid unnecessary surgical procedures.
Hernia (2014) 18 (Suppl 1): S50-S97
S55
P-134
The future of stem cell therapy for abdominal wall
defects
P-145
Earlier experience of innovation in modified LPEC
method to adult inguinal hernias
Petter-Puchner A, Gruber-Blum S, Wittmann J, Redl H
Ludwig Boltzmann Institute for Experimental and Clinical
Traumatology
Takehara H, Nishihara M, Miyahira T, Hanashiro N, Takushi Y,
Aka H, Kuniyoshi F, Uehara H, Tajima K, Okushima N
Okinawa Heartlife Hospital
Introduction: In the past two decades stem cell therapy has evoked
high hopes in many fields of regenerative medicine and today still
appears as a promise not kept in most areas. In abdominal wall repair
the idea of actually “healing” large defects by host´s own functional
tissue is intriguing. This presentation will give an overview of recent
literature and own research with emphasis of potential benefits of
stromal vascular fraction SVF. The benefits are clear at hand: The
processing of SVF does not require lengthy purification and cultivation and can be re-administered within a few hours after bedside
preparation.
Methods: Our study group has focused on the advantages of SVF
for abdominal wall repair over adipose tissue derived stem cells
(ASC). In sprague dawley rats SVF was gained by harvesting fatty
tissue by an original minimally ina vs isv method. SVF was embedded in various scaffold materials and applied to abdominal wall
defects of the same animal.
Results: SVF shows the potential to be used for coverage and restorage of abdominal wall defects. In contrast to most other stem cell
approaches, SVF can be easily obtained in large quantity and excellent quality.
Conclusion: Bearing later translation to clinics in mind, SVF
research should have high priority in the field. Other methods, including own work with vital human amnion, shall also be discussed.
Background: LPEC method is introduced by Takehara for inguinal
hernias in children, and is widely performed as standard surgery for
the children with inguinal hernias in Japan.
Purpose: The purpose of this study is to present an innovated method
to adult inguinal hernias, which insert cone mesh prosthesis laparoscopically into the hernia sac via the internal inguinal ring and close
the hernia orifice by LPEC method.
Materials and methods: Thirteen men with inguinal hernias less
than 45-year-old were treated by the modified LPEC method. The
sizes of hernia orifice of these cases were less than 3 cm that were
Hernia type I-1 and I-2 by classification of Japanese Hernia Society.
Under 2-port technique (5mm and 2mm) by needlescopic surgery,
the cone mesh prosthesis was inserted laparoscopically into the hernia sac and was fixed to the internal inguinal ring by using LPEC
needle. And then the hernia orifice was closed completely by double
LPEC suturing. The operation time was 45 to 60 minutes. There were
no complications during or after surgery.
Results and conclusion: There were no recurrences between 3 to
13 months after surgery. The advantages of the modified LPEC
method are not only cosmetic due to the minimally invasive nature
of the repair, but also a simplified technique and easier than other
laparoscopic hernia surgery.
P-142
Bilayer connected mesh device-15-year experience from
surgical peer reviewed literature
Gilbert A
Hernia Institute of Florida
The Bilayer connected Mesh Device (BCMD) (Ethicon, J&J) was
introduced in April 1998 for the repair of groin hernias in male and
female patients. In its fifteen years availability the manufacturing
company has sold approximately two million devices to the worldwide market. It is assumed that the majority of those devices have
been used to repair groin hernias.
The three components of the original device (underlay patch, connector, onlay patch} were made of heavy weight polypropylene
mesh. The first iteration of the BCMD was the Ultrapro Hernia
System. Its newer construct combines lightweight mesh as the onlay
patch with heavy weight mesh in the connector and underlay patch.
A search of the peer-reviewed literature was done to collect information on the performance information of these two BCMDs. Some
reports were of single product use in personal series. Others were
comparative studies to other devices, materials and techniques.
In evaluating the quality of outcomes in these reports information
pertaining to hernia repair failures, short and long-term postoperative
pain, ease of technique, time needed in OR for the procedure and
other related factors noted in reports will be discussed.
S56
P-146
Reduction of the chronic pain and recurrence rate. A
three-year experiences using a self-adhesive mesh in
TAPP – hernia repair for inguinal hernia
Klobusicky P, Feyerherd P
St. Elisabeth Hospital
Introduction: It is commonly considered that laparoscopic hernia
repairs (LIHR) are comparable to the conventional surgical methods
as an equal treatment method in management of the inguinal hernias.The advantages of LIHR are supported by a clearer view of the
spermatic cord content presenting a safer method in preservation of
testicular function with lower incidence of an acute and chronic pain
and a significantly better quality of life postoperatively in comparison
to OMR. One of the last unexplained questions regarding laparoscopic inguinal hernia repair techniques was a fixation of the mesh.
Materials and methods: 260 patients were operated on using the
TAPP technique with a self-adhesive mesh from 07/2010 till 07/2013
in our medical facility. Complications, pain score true numeric rating
scale (NRS), patient satisfaction and hernia recurrence were assessed.
All patients were managed in compliance with a standard protocol
and were then reevaluated 1, 6 and 12 months after the surgery using
a standardized questionnaire. Patients with a fixed scrotal hernia or
an ASA-Stage IV were excluded from the study.
Results: 398 inguinal hernia surgeries were performed on 260
patients using the TAPP-Technique with a self-adhesive mesh during
the above mentioned time frame. 138 (53%) of those, were bilateral
hernias and 66 (16.6%) were cases of recurrent hernias. The average
duration of surgery was 36 minutes (27-45). There was only one
report of hernia recurrence (0.3%) and only one patient suffered from
the chronic inguinal pain (NRS 7-10) during the mean follow-up of
24 months.
Summary: Using the author´s own surgical technique incorporating
also standard pre and post-operative management, the self-adhesive
mesh has proven to be extremely reliable. As no specific materials
to fix the mesh were needed, the method was fast, simple and economical. We could also reduce the incidence of the chronic inguinal
pain.
P-147
Evaluation of an innovative device (Parietex™
Composite Ventral Patch) for umbilical hernia repair
García-Moreno F, Sotomayor S, Pérez-López P, Pérez-Köhler B,
Bayon Y, Pascual G, Bellón J
University of Alcalá
Introduction: The most common treatment option for ventral and
umbilical hernias continues to be the implant of a prosthetic mesh.
This study compares the behaviour of a new device Parietex™
Composite Ventral Patch (Ptx) vs two devices currently used for this
purpose.
Materials and methods: The following materials were tested in a
rabbit model of umbilical hernia repair: Ventralex™ ST Hernia Patch
(Vent) (Bard Davol Inc) (n=18); Proceed™ Ventral Patch (PVP)
(Ethicon) (n=18); and Ptx (Covidien) (n=18). At 3, 7 and 14 days
postimplant, peritoneal behaviour and adhesion formation were
assessed by sequential laparoscopy. Adhesions were scored for consistency and quantified by image analysis. The animals were euthanized at 2 and 6 weeks postsurgery. Neoperitoneum cover of materials and tissue ingrowth were determined by scanning and light
microscopy.
Hernia (2014) 18 (Suppl 1): S50-S97
Results: Seroma was observed in 1/18 Vent, 7/18 PVP and 4/18 Ptx,
mainly between the implant and subcutaneous tissue. Firm omental
adhesions between the mesh and parietal peritoneum were observed
in 2/9 Vent, 6/9 PVP and 3/9 Ptx at 2 weeks and in 3/9 Vent, 5/9
PVP and 1/9 Ptx at 6 weeks. Three encapsulated PVP implants (3/9)
showed “tissue-integrated” adhesions affecting intestinal loops. No
differences between implants were detected in the percentage surface
occupied by adhesions at 14 days, though at 6 weeks, percentages
were significantly higher (p<0.01; Mann-Whitney U test) for PVP
versus Ptx or Vent. At 6 weeks, Ptx and Vent showed satisfying tissue
repair, but contrary to Vent, Ptx was integrated in its entire surface.
Conclusions: The PVP implants showed the greatest adhesion formation. Postimplant behaviour was comparable for Ptx and Vent
including scarce adhesion formation accompanied by continuous
neoperitoneum formation. The Ptx meshes nevertheless showed best
host tissue incorporation at the intraperitoneal surface due to the initial tighter conformability of Ptx to the abdominal wall as evidenced
by laparoscopy.
P-150
Use of the biological mesh Permacol™ in complex
abdominal wall hernia repair in the Netherlands
Kaufmann R, Timmermans L, Jeekel J, Lange J
Erasmus Medical Center
Introduction: Complex abdominal wall hernia repair (CAWHR) is
a surgical challenge. Mesh prosthesis is often indicated, but use of
conventional mesh in a contaminated area is controversial. Biological
meshes may provide a solution, but since these meshes are expensive
and rarely used, little is known about long-term results. The aim of
our study was to evaluate clinical efficacy and patient satisfaction
following Permacol™ placement.
Methods: In this cohort study, we included all patients operated for
CAWHR with Permacol™ mesh in the Netherlands between 2009
and 2012. Patients underwent abdominal examination to assess hernia
recurrence and bulging and completed Quality of Life questionnaires
to assess patient satisfaction.
Results: One hundred four patients met the inclusion criteria, of
whom 62 have so far been seen in the outpatient clinic (33 male,
mean age 60 years, median follow-up 19.8 months). With regard to
the surgical intervention, the most frequently used mesh size was
600 cm2 and the most frequent postoperative complication was
wound infection (n=13). Permacol™ had to be removed in 6 patients.
By the time of outpatient clinic visit, 16 patients (25.8%) had had a
recurrence of hernia, of whom 10 (16.1%) had undergone reoperation. Twenty-seven patients (43.5%) had bulging of the abdominal
wall. When asked, 21 patients (34.0%) were satisfied with the cosmetic result. Quality of Life questionnaires revealed that patients
judged their scar with a median 6.0 out of 10.0 points (IQR 4.5-8.0)
and graded their health status at the outpatient clinic visit with a
median 7.0 out of 10.0 (10.0 is best; IQR 6.0-8.0).
Conclusion: These preliminary results show that although bulging
is seen in many patients and patients are often dissatisfied with the
cosmetic result, the recurrence rate and infection rates are acceptable
in these complicated hernias. Permacol™ seems therefore to be an
appropriate option for CAWHR.
Hernia (2014) 18 (Suppl 1): S50-S97
P-168
Risk factors for inguinal hernia in middle-aged and
elderly men: Results from the Rotterdam study
de Goede B, Timmermans L, van Kempen B, van Rooji F, Hofman A,
Kazemier G, Lange J, Jeekel J
Erasmus University Medical Center
Background: Prospective data on the incidence of inguinal hernia
and its risk factors are sparse, especially in the elderly. The aim of
this study was to determine the incidence of inguinal hernia in middle-aged and elderly men and to identify its potential risk factors.
Methods: Data from the Rotterdam Study, a prospective cohort study
of the general population aged 45 years and over of Ommoord, a
district in Rotterdam, followed up from 1990 onwards for a period
of now more than 20 years (n=5,780), were analysed. Diagnoses of
inguinal hernia were obtained from hospital discharge records and
general practitioners. Multivariate Cox-regression analyses were performed to determine risk factors for inguinal hernia.
Results: A total of 416 cases of inguinal hernia were identified. The
risk among male participants to develop an inguinal hernia over 20
years was 14.0%. Age-adjusted hazard ratio (HR) for inguinal hernia
for men relative to women was 12.4 (95% confidence interval (CI)
9.5 to 16.3; p<0.001). In multivariate analysis, the risk of inguinal
hernia increased with advancing age (HR 1.3, 95% CI 1.02 to 1.04;
p<0.001). An elevated body mass index (BMI) decreased the risk of
inguinal hernia: a BMI of 25 to 30 had an HR of 0.72 (95% CI 0.58
to 0.89; p=0.003) and participants with a BMI over 30 an HR of
0.63 (95% CI 0.42 to 0.94; p=0.025).
Conclusion: This study shows an increased risk of inguinal hernia
with advancing age and a potential protective effect of increased
body mass index in the middle-aged and elderly population.
P-169
A Comparison of Endoscopic Component Separation in
Patients Undergoing Laparoscopic and Open Hernia
Repair
Azoury S, Dhanasopon A, Hui X, De La Cruz C, Liao C, Lovins M,
Nguyen H
The Johns Hopkins Hospital, Department of Surgery
Background: Endoscopic component separation (ECS) can be followed by open hernia repair (OHR) or laparoscopic hernia repair
(LHR). We analyzed surgical factors and outcomes data to compare
patients undergoing laparoscopic versus open ventral hernia repair
after endoscopic component separation.
Methods: Forty-two ECS patients who underwent ventral hernia
repair with mesh were identified from a prospectively maintained
database (October 2010 to July 2013). All cases were performed by
the same surgeon: 25 underwent laparoscopic hernia repair, and 17
open hernia repair. Demographics and surgical factors were analyzed.
Wound complications and hernia occurrences were reviewed.
Results: Surgical factors and patient demographics of the two groups
were not statistically different. All 42 patients achieved primary fascial closure. Operative time for the laparoscopic hernia repair group
was significantly shorter than with open hernia repair (278 vs 378
min; p=0.0022). Estimated blood loss per ECS case with LHR was
significantly lower than with OHR (63 vs 147 cc; p<0.0017).
Hospital stay was significantly shorter for the laparoscopic group
than the open hernia repair group (LHR: 4 days, OHR: 5 days,
S57
p=0.0022). In both groups, wound complications occurred in 5
patients (LHR: 20%, OHR: 29%), 4 of which necessitated intervention. There was 1 midline hernia recurrence (4%) and 2 lateral
abdominal wall hernia occurrences post-operatively in the laparoscopic group (mean follow-up 8 months), whereas there were no
midline and 1 lateral wall hernia occurrence in the open hernia repair
group (mean follow-up 11 months).
Conclusion: Patients undergoing endoscopic component separation
with laparoscopic hernia repair had a significantly shorter operative
time and length of stay than open repair. Estimated blood loss was
significantly lower in the laparoscopic cases. Wound complications
were similar in both groups. There were a greater number of hernia
occurrences post-operatively in the laparoscopic group, though not
statistically significant.
P-170
Cadaveric abdominal wall biomechanical strain
analysis: supportive evidence for small bite
Laparotomy Closure
Dunn R, Novacek V, Ignotz R, Turquier F
UMass-Memorial Health Center
Size of suture stitches (distance from incised fascial margin) and
suture distance between adjacent sutures have recently been shown
to play a significant role in the risk of future ventral hernia. The purpose of our study was to perform cadaveric abdominal wall biomechanical strain analysis (AWSA) of different laparotomy closure techniques in an attempt to lend an objective assessment of rationale for
such closure considerations.
AWSA of several closure modalities were studied on unembalmed
post-mortem human subjects (PMHS) (n=3). Digital image correlation was used to record strain pattern of the abdominal wall under
pressure load. AW skin and fat were removed and an intact AW was
loaded by internal expansion insufflation. A midline incision was created and closed. Running suture and separate stitches were compared
with 5x5 and 10x10 mm for stitch interval and tissue bite size respectively.
Transverse strain was selected as an indicator differentiating closure
techniques. Averaged transverse strain was 1.3-1.8 times higher in
5x5 mm closure compared to intact wall and 1.2-1.5 times higher in
10x10 mm closure compared to 5x5 mm closure. Maximum transverse strain showed similar trends. No significant difference was
found between continuous and discontinuous suture in 5x5 mm closure. In 10x10 mm closure, averaged transverse strain was 1.2 times
higher and maximum transverse strain was 1.2 times lower in separate stitches compared to running suture.
Running suture and separate stitches were equivalent in terms of tissue strain in 5x5 mm closure. Both continuous and discontinuous
sutures showed high local tissue strains over 80% in 10x10 mm closure. 5x5 mm closure resulted in a strain pattern closer to the intact
wall than 10x10 mm closure.
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P-173
Prospective evaluation of self-gripping mesh (Parietex
Progrip™) without additional fixation during
laparoscopic total extraperitoneal (TEP) inguinal
hernia repair: one year results in over 100 hernias
Bates A, Wu A, Reiner M, Jacob B
Mount Sinai Medical Center
Background: The use of self-gripping mesh during laparoscopic
TEP inguinal hernia repairs may eliminate the need for any additional
fixation without added concern for mesh migration. Long term outcomes are not yet prospectively studied in a controlled fashion.
Methods: Under IRB approval, from July 2011-Sept 2012, 102 hernias were repaired laparoscopically with self-gripping mesh without
additional fixation. Patients were followed for at least one year.
Demographics and intraoperative data (defect location, size, mesh
deployment time) are recorded. Carolinas Comfort Scale ™ (CCS),
a validated 0-5 pain/quality of life (QoL) score where a mean score
of >1.0 means symptomatic pain, is employed in the recovery room
(RR), at 2 wks, and at 1 year. Morbidities, narcotic usage, days to
full activity and return to work, and CCS scores are reported.
Results: 64 patients with 102 hernias completed a mean 15.1 months
follow up. 20 hernias were direct defects (average size 2.8cm). Mesh
deployment time was 198 seconds. RR pain was 1.1 / 5. Total average
oxycodone/acetaminophen (5 mg/325 mg) usage = 5.4 tablets, days
to full activity was 1.7, and return to work was 4.5 days. 12 small
asymptomatic seromas were palpated without any recurrences or
groin numbness. All seromas resolved by the 6 month visit. Transient
testis discomfort was reported in 8 patients. Urinary retention was
3%. Mean CCS™ scores for groin pain laying, bending, sitting, walking, and step-climbing were 0.2, 0.6, 0.3, 0.5, and 0.07 respectively.
At the first postop visit, 6% had symptomatic pain (CCS >1). At
15.1 months, no patients had symptomatic pain (CCS scores = 0.05,
range 0-0.8). There are no recurrences.
Conclusions: Self-gripping mesh can be safely used during laparoscopic TEP inguinal hernia repairs. Recovery was rapid. In this
cohort, there were no reports of chronic pain or recurrences.
P-174
Post prevention eventroplasty seroma mans? Talc?
Gorganchian F, Santa María V, Beltrame M, Montes de Oca J,
Giunippero A, Anania S
Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de
Buenos Aires
Eventropalstía performing component separation and placement of
mesh is a long-established technique for incisional hernia repair. At
large dissections performed one of the most common complications
is seroma. The use of talc pleurodesis is used daily to great effect,
but its use is still debated eventroplasties.
Are 2 cases in which large eventrations technique was conducted
components sepaeacion
Eventration secondary median aortic surgery. Ventral hernia repair
with polypropylene mesh placement sublay.
Gibson incision hernia (kidney transplant). Ventral hernia repair with
mesh placement sublay made.
In both cases sprinkled talcum 8gr subcutaneous plane. The patient
in case 1 evolves dehiscence of skin and non-adherence to the muscular fat plane. The case 2, fever in the first 24 hours and uncontrolled pain.
Hernia (2014) 18 (Suppl 1): S50-S97
In literature the use of talc in the treatment of relapsing-eventroplasties seroma with preperitoneal mesh placement has been positive, but
the evidence is of low grade. In our study, both patients had minor
complications secondary to this treatment and even did the opposite
effect to that intended, so preliminarily do not recommend the use
of talcum powder to prevent seroma in conducting eventroplasties.
P-175
Use of barbed suture for peritoneal closure in
transabdominal preperitoneal hernia repair –
Experience after more than 1,000 procedures
Wilke R
Germany
Introduction: The laparoscopic transabdominal preperitoneal patch
plastic (TAPP) requires peritoneal closure with technical difficult
intracorporeal suturing and knotting. To address this problem, we
investigated the use of the Quill™ absorbable wound closure device
(Angiotech, USA), which is a skin closure device with self-anchoring
barbs and loops that obviate the need for knot tying.
Materials: We performed TAPP within March 2011 to September
2013 in 538 unilateral and 311 bilateral routinely inguinal hernia
repairs (646 males, 293 females) and investigated retrospectively.
Every patient with different size (L 1-3, M 1-3, S 1-2) of hernia was
included in this study. Where was no excluding factors. After adequate preperitoneal dissection, lightweight polypropylene mesh was
fixed in the preperitoneal region using Fibrin glue Evicel or
Securestrap™. After that, barbed suture was used for peritoneum closure.
Results: The mean age was 48.6 years (range 36 to 81 years), mean
BMI was 23.8 (range 16.9 to 30.1) and mean operative time was
39.5 min (range 19 to 117 min). The unilateral cases consisted of
267 indirect, 203 direct and 68 supravesical hernias, bilateral hernias
shows all indirect cases and 155 direct hernias. After operation, no
relevant complications were observed prior to discharge in any cases.
The morbidity rate was 3.2%, and the recurrence rate was 0.4% during the follow-up of up to 2 years maximum.
Discussion: Using barbed suture, we found that the peritoneal flaps
can be maintained tautly, thus minimizing the distance between the
upper and lower peritoneal edges, which enables placement of the
next single twist suture. In addition, a significant advantage is that
there is no need to tie knots at any point. Hence, barbed sutures are
more advantageous, the technique can be learned quickly, skillfully,
and safely. In our experience, the technical difficulty and operative
time was reduced using barbed suture.
Hernia (2014) 18 (Suppl 1): S50-S97
P-176
A prospective outcome study of condensed fenestrated
PTFE mesh (MotifMesh) in non-sterile abdominal wall
defects
Cheesborough J, Liu J, Dumanian G
Northwestern University
Introduction: Prosthetic mesh is typically avoided for hernia repairs
with mild contamination (VHWG Type 3) due to the increased risk
of infection and the presumed difficulty of removal if the mesh were
to become infected. Condensed fenestrated polytetrafluoroethylene
(cPTFE) MotifMesh has several unique properties including resistance to bacterial anchorage and infection, macroporosity, and bowel
compatibility that may warrant its use in minimally contaminated
and potentially contaminated patients.
Methods: Ten patients with non-sterile abdominal incisional hernias
were prospectively enrolled in this study and followed at set intervals
for one year after direct supported ventral hernia repair with
MotifMesh. All patients were evaluated for hernia recurrence, infection requiring mesh removal, and quality of life as measured by
patient-reported outcomes of pain, fatigue, and mobility.
Results: Nine of ten patients had no signs or symptoms of hernia
recurrence at one complete year of follow up. One patient underwent
MotifMesh removal for infection and as anticipated the mesh
removal was straightforward and without bowel manipulation. The
infection was thought to be caused by a retained remnant of infected
polypropylene mesh. There were no other mesh related problems in
the remaining patients. As measured by the Visual Analog Scale,
patients experienced an average 50% decrease in pain after hernia
repair with MotifMesh (5.7 preoperative, 2.9 one year postoperative).
On the same scale, fatigue decreased by 46% (5.7 preoperative, 3.1
postoperative) and average movement improved by 62% (6 preoperative, 2.3 postoperative).
Conclusions: MotifMesh was successfully utilized for contaminated
or potentially contaminated ventral hernia repairs. Combining the
durability of traditional synthetic mesh, efficient tissue integration,
and minimal adhesion formation/ease of removal, fenestrated cPTFE
may provide the optimal material characteristics for hernia repair in
non-sterile settings that would otherwise require bioprosthetic mesh
or staged/delayed reconstructions.
P-177
A PROMISing study: open ventral hernia repair leads
to decreased pain intensity and pain interference
Cheesborough J, Park E, Souza J, Dumanian G
Northwestern University
Purpose: PROMIS is a tool developed by the NIH to provide precise
measurement of patient pain. Unlike historical methods that only
measure pain intensity and quality, the PROMIS Pain Survey directly
assesses the impact of pain on patient behavior and the interference
of pain on physical, mental and social activities. This assessment tool
generates individual scores that can be compared over time and
against population averages. PROMIS was utilized to prospectively
measure the effect of open midline hernia repair on pain as a patient
reported outcomes measure.
Methods: All 57 patients who underwent midline hernia repair by
the senior author between August 2010 and October 2012 with preoperative and postoperative PROMIS data were included in this
study. To provide a legacy control of pain intensity, the patients were
also assessed on the 11-point Comparative Pain Scale.
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Results: A statistically significant improvement in both pain intensity
(p=0.015) and pain interference (p=0.016) over an average follow up
period of 7.1 months was measured using Wilcoxon signed ranks
testing. Pain-related behavior did not change significantly (p=0.268).
Improvement did not vary with age, BMI, diabetes, smoking, gender,
or previous hernia repair. Critical analysis of the data demonstrates
that pain interference with physical, mental and social activities continues to decline with increasing time after surgery.
Conclusions: PROMIS Pain Survey provides a precise, multifaceted
evaluation of pain and demonstrates in a novel manner the benefit
of abdominal wall reconstruction-significant improvements in both
pain intensity and pain interference following open midline hernia
repair. The scores improve with length of time since surgery, and,
although behavior did not change significantly, the trend is towards
improvement. While not possible in a single surgeon study, PROMIS
may be the ideal tool to compare patient reported outcomes across
various types of abdominal wall reconstruction.
P-179
Eventraciones post-trasplante renal: análisis de
factores de riesgo y técnica quirúrgica
Gorganchian F, Santamaría V, Beltrame M, Montes de Oca J
Instituto de Investigaciones Médicas Alfredo Lanari, Universidad de
Buenos Aires
Diferentes factores aumentan el riesgo de eventraciones post
trasplante renal, y existen para su resolución diferentes técnicas
quirúrgicas.En este trabajo se intenta analizar la experiencia en eventraciones post trasplante renal realizada en nuestra institución. Se
realizó un estudio retrospectivo analizando los trasplantes renales
realizados entre 2006-2013. Se analizó la tasa de eventración post
trasplante renal, las comorbilidades asociadas, las complicaciones
postoperatorias y la tasa de reoperación. De aquellos que fueron
sometidos a eventroplastía se analizó la técnica quirúrgica utilizada
y sus complicaciones. Se realizaron test de Chi cuadrado e IrwinFisher.Se realizaron 62 trasplantes renales por incisión de Gibson.
La incidencia de eventraciones fue de 12.7%. Se analizaron como
factores de riesgo: Diabetes, hipertensión arterial, tiempo de diálisis,
cirugías previas, complicaciones post trasplante inmediato y terapia
inmunosupresora. Todos ellos resultaron estadísticamente independientes de la aparición de eventraciones, probablemente por influir al
combinarse entre sí y no cada uno por separado. Siete pacientes
fueron sometidos a eventroplastía. Un paciente presentó infección del
sitio quirúrgico que resolvió con tratamiento antibiótico.En concordancia con la bibliografía aquellos pacientes en lo que no se utilizó
malla o se usó una malla reabsorbible tuvieron una recidiva del
100%. Se debe estudiar más ampliamente los factores de riesgo que
influyen en el desarrollo de eventraciones post-trasplante debido a
las contradicciones que surgen de la bibliografía. La eventroplastía
post-trasplante renal es segura y efectiva siempre y cuando se realice
con malla no reabsorbible. El riesgo de infecciones post-quirúrgicas
no parece verse afectado por la utilización de malla cuando se toman
los recaudos necesarios, y si sucede no modifica el pronóstico.
Respecto a la utilización de mallas separadoras de componentes es
extremadamente útil dado que pueden estar en contacto libremente
con el riñón injertado y recomponen la pared abdominal libre de tensión.
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P-180
Retrospective comparison of 3d mesh devices (uhs and
phs) in inguinal hernia repair
Premnath R
Association of Surgeons of India (ASI)
Introduction: Inguinal hernia is a common condition and there is
today a trend towards lightweight meshe repairs. Achieving a low
recurrence rate with lower incidence of chronic groin pain is one of
the primary aims. We retrospectively compare the 3d mesh devices,
ultrapro hernia system (UHSOV1) and prolene hernia system (PHSE)
in the management of inguinal hernia. 3D mesh devices consist of
onlay and underlay patch which are connected together. They have
the benefit of a posterior and anterior repair via an anterior approach.
Methods: PHS hernia repairs performed between January 2005 and
June 2009 were compared with UHS mesh hernia repairs performed
between August 2008 and June 2012. Demographic data such as age,
gender as well as comorbid conditions such as COPD, heart disease,
diabetes, hypertension, prostatism, and chronic cough were collected.
Complications such as seroma, hematoma, urinary retention, orchitis
and wound infection were recorded. Recurrences in each group were
also recorded. A student t test and chi-square analysis were used for
statistical analysis.
Results: 210 valid cases entered the study. UHS 127 & PHS 83. All
patients were followed upto February 2013. There was no significant
difference with regards to age, gender or comorbidities. In general
the trend for chronic pain and recurrence appeared to be decreasing
with UHS. When we measured satisfaction ratio as being pain free,
recurrence or discomfort, then the PHS group shows 74.7% satisfaction as opposed to 85.5% with the UHS group.
Conclusion: Our study shows, UHS is significantly better when compared to PHS in terms of recurrence and chronic groin pain. UHS
may be better alternative to PHS in inguinal hernia repair suggesting
that light weight mesh may be the way ahead.
P-181
Pre-operative groin discomfort can predict persistent
post-operative groin pain despite a successful
laparoscopic inguinal hernia repair
Carter J, Jenkins M, Coombs N
Great Western Hospital
Introduction: Laparoscopic hernia total extra-peritoneal (TEP)
repair, performed by appropriately experienced surgeons, is the standard repair for recurrent or bilateral inguinal herniae. Potential benefits include reduced post-operative pain, earlier recovery and reduction in long-term pain. This study determines factors that may predict
risk of developing long term complications.
Method: A retrospective review of male patients undergoing TEP
repair of all hernias was performed. Operations were performed by
a single consultant surgeon. Comparison was made of pre-operative
symptoms and signs, operative findings and post-operative patient
reported symptoms.
Results: Between 2009 and 2012, 91 patients required TEP repair
(mean age 54.7 years, range 25-78) fifteen (16.5%) had been referred
with recurrence after previous open repair. Patients with recurrence
were more likely to present with pain than those with primary hernias
(86.6% vs 51.7%, p=0.02, χ2=5.05). At consultation 35 (38.4%) had
bilateral symptoms or signs. At operation 127 herniae were repaired
(14 direct, 104 indirect, 9 pantaloon). Of the four (3.2%) converted
Hernia (2014) 18 (Suppl 1): S50-S97
to open repair, two (1.6%) were irreducible inguino-scrotal herniae.
One (0.8%) developed a recurrence. Mean time to follow up was 22
days. Mild post-operative discomfort was more frequently reported
in patients with pre-operative groin pain (10.2% vs 2.2%, p=0.1,
Fisher’s exact test). Only two patients (both with significant preoperative pain) required referral to a chronic pain specialist.
Discussion: Patients with pre-operative groin discomfort need to be
warned of the potential risk of persistent groin pain despite successful
TEP hernia repair. Laparoscopic TEP repair by an experienced surgeon carries a very low risk of recurrence, conversion to open procedure or long-term complications yet, while the frequency of these
complications was universally low, patients need to be informed of
these risks. However, TEP repair remains the treatment of choice for
most patients with reducible inguinal herniae.
P-183
Midline hernia closure
Ross N
Shouldice Hospital
Primary suture technique in 747 midline hernia repair
Nagui A. Ross, MD, MSc Surgery, FCFP
Department of Surgery, Shouldice clinic, Thornhill, Ontario, Canada
Introduction: The Shouldice hospital remains one of the last battle
grounds to champion the pure tissue repair for all kinds of abdominal
wall hernias. Although general surgeons operate on a great number
of these hernias, large series are absent from the literature with the
largest series studied 146 of such patients. We carried a review of a
series of 747 midline abdominal wall hernias performed between
2003 and 2013, at the Shouldice hospital by one of the surgeons (the
author).
Method: Those cases reviewed were divided into 430 umbilical
repair, 74 Paraumbilical, 137 epigastric, and 106 trocar site incisional
hernias. Using primary suturing technique with double breasting with
continuous layers of 2/0 polypropylene as the first two layers, and
32 gauges stainless steel wire suture material for the second, we followed these patients five weeks, one year, and annually afterwards.
Results: Only 2 reported recurrences over 10 years period were
found, representing a 0.003% rate, surgical site infection in only 3
cases with the same rate of 0.004%. The size of the defects ranges
between 0.5 cm-6 cm with a mean of 2.6 cm. The age group ranges
between 16-83 years old, with mean of 44 years old. The mean BMI
was 24.9 with 80% male predominance.
Conclusion: We believe that primary suturing technique using these
two materials with double breasting proofs to be the near to the ideal
method of closure of such midline hernias.
A video presentation is enclosed with this abstract to elucidate the
technique described.
Hernia (2014) 18 (Suppl 1): S50-S97
P-184
Comparison of Polysoft patch with Modified Kugel
patch on postoperative pain in inguinal hernia repair:
a randomized controlled trial for assessing noninferiority
Okinaga K, Hori T, Inaba T, Yamaoka K
Okinaga Clinic
Background: Preperitoneal patch placement has some advantage: the
patch is applied to the deep surface of the posterior abdominal wall
and it is not contact with the nerves in the inguinal canal. Although
Polysoft patch (P) and Modified Kugel patch (K) are available for
the preperitoneal repair in Japan, P is lightweight and K is heavyweight. Both patches have permanent memory ring and each has a
different configuration. The aim of this prospective study is to show
that P is non-inferior to K with respect to strength of postoperative
chronic pain. This presentation shows the design of a randomized
controlled trial for assessing non-inferiority study.
Methods: Primary inguinal hernia patients were included in this
study. Inguinal hernia repair was performed at three different hospitals (O, F, & T). In total 431 patients were allocated randomly either
to P or K from November, 2010 to December, 2012. Surgical technique includes the recommended procedure of preperitoneal blunt
dissection and placement of the patch after the inguinal canal opening. At O clinic 1% lidocaine was administered locally supplemented
with intravenous midazolam sedation, at F hospital and T hospital
laryngeal mask anesthesia was employed. A questionnaire including
pain visual analogue scale (VAS) was sent to patients by mail one
month, six months, and one year after surgery. The study was conducted as an unblinded randomized controlled trial for assessing noninferiority of P comparing to K with 5% non-inferiority margin.
Discussion: The proposed study will provide practical information
about the usefulness of the Polysoft patch in inguinal hernia repair.
Data on the effect evaluation will be available in 2014. Trial
Registration: UMIN R000013636.
P-185
Laparoscopic hernioplasty and multiple surgery,
preliminary results Clinical Hospital University of
Chile
Alban M, Carrasco J, Dominguez C, Rappoport J, Silva J, Palacios F,
Salazar V
Hospital Clinico Universidad de Chile
Introduction: Laparoscopic surgery is an alternative for the treatment of hernias and multiple surgery. Advances in prosthesis, mesh
fixation and instruments with early return to work and less postoperative pain under this method has enabled progress in perfecting
this technique.
Materials And Methods: We evaluate our digital database of the
Hernia Unit of the Clinical Hospital of the University of Chile, made
in File Maker Pro including 46 variables.
From January 2011 to June 2013, 102 patients were operated for a
total of 164 hernias by this method, 16 of these cases also had other
pathology of surgical resolution.
Results: 50 (49%) women and 52 (51%) men have been operated
by this technique, the average age was 52 years, with a BMI of 28
(17-41). Surgery time: 104 minutes (30-250), with three days hospitalization (1-5). 47 (46%) showed only one hernia, the remaining
cases have multiple hernias (2 rings: 39 patients, three rings: 14
patients, 4 rings: 2 patients). The surgery was elective in 100%.
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Hernia type: Inguinal 57%, incisional 19.5%, other 23.5%. In 100%
prosthesis was used, light polypropylene for inguinal (TAPP) and
composite mesh for incisional hernias. In 16 cases other surgical
pathology resolved in the same surgery without requiring conversion
to open surgery procedure; installation of peritoneal dialysis catheter
3 patients, cholecystectomy 11 cases, sleeve gastrectomy 1 case,
transurethral prostatectomy 1 case. There was no mortality in this
series.
Conclusions: Laparoscopic surgery appears to be a safe technique
for the treatment of hernia associated with other diseases. We need
more studies and monitoring to recommend this technique.
P-187
Lichtenstein’s hernioplasty with long-term resorbable
mesh: preliminary pain results at 4-year follow up
Ruiz-Jasbon F, Norrby J, Ivarsson M, Björk S
Hallands Hospital, Kungsbacka
Background: Pain and recurrence are the most common long-term
complication after hernia repair. Conventional nonabsorbable synthetic implants for hernia surgery may lead to chronic pain probably
due to foreign body reaction with subsequent chronic inflammation.
TIGR Matrix Surgical Mesh, a long-term resorbable mesh, has in
pre-clinical studies been shown to stimulate the formation of new
tissue capable of carrying the abdominal loads and theoretically could
get less chronic pain after hernia surgery.
Methods: This was a prospective study in 40 patients with primary
inguinal hernias in Sweden. Patients were enrolled for Lichtenstein
repair using TIGR Matrix. The primary endpoint was safety as
assessed by monitoring the incidence of Adverse Events (AE) and
Serious Adverse Events (SAE) related and unrelated to the mesh and
rehabilitation. The secondary endpoint was the performance of the
mesh with respect to pain and discomfort.
Patients have been followed up at 0.5, 1, 3, 6 and 12, 24, 36 months.
The 48 follow-up is currently ongoing. Pain assessment has been
performed using a visual analogue scale (VAS 0-100) and the
Inguinal Pain Questionnaire, (IPQ); another questionnaire was used
in order to follow up different factors affecting the patients’ QOL.
Recurrences are included in the follow up of AE.
Results: All patients followed a normal postoperative course. After
24 months, no Serious Adverse Events were reported, two patients
experienced mild pain (VAS<10) and only four patients could feel
the sensation of a mesh in their groin. This compares favorably with
previously published data. A total of 4 hernia recurrences were found
at 24 months follow up.
Preliminary results up until 4-year follow up will be presented.
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P-188
Crossing the tails of the mesh or not: a prospective
randomized study for repair of direct inguinal hernias
Kulacoglu H, Yazgan A, Olcucuoglu E
Ankara Diskapi Teaching and Research Hospital
Parviz Amid, the director of the Lichtenstein Hernia Institute, stated
in his paper in 2004 that suturing the tails of the mesh together in
a parallel position is a known cause of recurrence lateral to the internal ring, therefore the tails of the mesh should be crossed behind the
spermatic cord. However, there has been no study to test this principle clinically. This technical modification is probably very important for indirect hernias however its effect in repair of direct hernias
is rather questionable. Besides, crossing the tails to create a doublebreasted mesh lateral to the ring may create a heavier part for the
prosthesis and discomfort postoperatively. Method: We conducted a
prospective randomized study to search if the crossing provides more
secure repair and causes postoperative discomfort. 100 consecutive
patients with direct hernia were allocated in 2 groups with crossing
(gC) or not (gN). Crossing was done by suturing cranial and caudal
tails of the mesh together at the inguinal ligament. Results: Mean
follow-up times were 594 and 564 days. No recurrences were
recorded in either group. Two patients in gC developed severe
chronic pain and underwent reoperations. VAS scores at day 1, 7,
30, 90 and 365 were significantly higher in gC. Median SF-36 score
was 1±2.5 in gC and 0±1.0 in GN at day-30 (p<0.001). Both groups
displayed very low SF-36 scores after one year although the median
score was still higher in gC (0±2.50 vs 0±0.95, p<0.001). Comment:
Lichtenstein repair provide very good results, however crossing the
tails of the mesh may cause postoperative discomfort. Suturing the
tails together in parallel position does not seem to be resulted in
recurrence in mesh repair of direct inguinal hernias.
P-189
Early complications after cyanoacrylate glue mesh
fixation in incisional hernia repair
Kumar S
The Royal Infirmary
Background: Very little is known about use of cyanoacrylate glue
in mesh fixation at open ventral hernia repair though its use has been
widely reported in groin hernia surgery.
Aim: To assess early complications and effectiveness of cyanoacrylate glue in mesh fixation at open incisional hernia repair.
Patients and methods: 15 patients with a median age of 66 years
(range 28-3), including10 males had incisional hernia repair between
May 2012 and Sept 2013. After dealing with the hernia sac, a
polypropylene mesh was secured in the retro-muscular plane. One to
two ml of cyanoacrylate glue was used to fix either part or whole
of the mesh by spot welding technique. The wound was drained if
considered appropriate. All patients received a single prophylactic
dose of antibiotic. Data on size of the hernia defect and size of the
mesh used was recorded prospectively. Patients were reviewed in the
outpatient clinic 6-8 weeks after surgery.
Results: Of the 15 patients, 3 (20%) had recurrent incisional hernias.
Median hospital stay was 1 day (range 0-6). The hernia defect was
a median of 6 cm (range 4.5-12 cm). Polypropylene mesh used was
a median 275 square cm (range 63-420). Post op complications
developed in 5 (33%) patients: seroma 2 (one drained spontaneously),
Hernia (2014) 18 (Suppl 1): S50-S97
wound infection requiring oral antibiotics in 2, and one patient
required hospital admission for abdominal pain but settled spontaneously. No patient with chronic pain or recurrence till date. No
patient developed mesh infection.
Conclusion: Cyanoacrylate glue may be safe and effective in mesh
fixation at incisional hernia repair.
P-190
Metachronous contra-lateral inguinal hernia
Nagahama T, Ando M, Ami K, Ganno H, Arai K
Toshima Hospital
Introduction: Development of contra-lateral inguinal hernia after
unilateral hernioplasty is not rare condition. Most of the etiology for
those lesions was supposed to be subclinical hernia already present
at initial surgery. But in a few cases development of another primary
hernia can be observed. We have evaluated herniographic finding and
the etiology of metachronous bilateral inguinal hernia.
Object and results: From 2004, 653 patients (unilateral 504, bilateral 149) received preoperative herniography and subsequent surgery.
Radiographically apparent hernias were treated simultaneously even
if subclinical. During follow up (5-82months) after initial surgery,
17 patients developed contra-lateral hernia. Retrospective evaluation
of initial herniography revealed that 7 cases demonstrated patent
processus vaginalis, 9 cases demonstrated dilatation of internal ring
while 2 cases have no radiographic finding. Among 59 patients with
history of surgery for prostate cancer 7 patients developed metachronous lesion, which was statistically higher than those without prostate
cancer surgery (p<0.01 7/59 11.9% vs 10/445 2.2%)
Discussion: In our series 17 patients among 504 patients who has
no radiographically proven hernia at initial diagnosis developed contra-lateral lesion during follow up. Patients who had history of
prostate cancer surgery demonstrate higher incidence of metachronous contra-lateral lesion than who had no history of prostate cancer.
Retrospective evaluation of herniography finding demonstrated that
most patients who developed contra-lateral lesion had some minimal
radiographic finding such as patent processus vaginalis or dilatation
of internal ring. These results support the fact that inguinal hernia is
common for the patients who have previously history for prostate
cancer, and that unilateral hernioplasty may enhances development
of inguinal hernia on the contra-lateral side.
Conclusion: Another primary contra-lateral inguinal hernia is rare
condition but can be developed from minimal change of abdominal
wall. For the patients after prostate cancer surgery the incidence of
metachronous lesion is particularly higher.
Hernia (2014) 18 (Suppl 1): S50-S97
P-191
Laparoscopic ventral hernia repair, a modified
technique combined with trans-fascial sutures and
peripheral stapled fixation
Hata T, Hasegawa T, Yoshida K, Yanaga K
The Jikei University School of Medicine
Background: Even though laparoscopic ventral hernia repair (LVHR)
has proved to be an efficient and safe procedure, its recurrence rate
remains high. There is a criticism that the trans-fascial sutures induce
pain.
Aim: Diminishing postoperative recurrence and pain in LVHR with
combined technique with trans-fascial sutures and peripheral stapled
fixation.
Patients and methods: Six consecutive patients with ventral hernia
defect up to 15cm in diameter underwent LVHR. After standard adhesiolysis, a composite mesh overlapping the hernia defect at least 5cm
on each side was fixed with 4 point trans-fascial sutures by rather
loose knotting and peripherally placed tacks. No drains were used and
abdominal binding was recommended.
Results: No patient complained pain regarding trans-fascial sutures.
At 20 months follow-up no recurrence and complication was observed.
Conclusion: Despite of a small sample, the study suggested that
LVHR with trans-fascial suturing and peripheral stapling is an effective procedure.
P-192
Abdominal wall reconstruction in the octagenarian
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health System
Many patients have large ventral hernias. These hernias may get larger
if not repaired in a timely fashion. Elderly patients are often denied
elective treatment of large ventral hernias due to co-morbid risks. Many
patients present with emergent complications from their ventral hernia
which require surgery. We feel that elective treatment of complicated
ventral hernias is favorable to emergent treatment. We have routinely
considered elderly patients with large ventral hernias for elective open
ventral hernia (OVH) repair with component muscle separation (CMS).
We retrospective reviewed our prospectively maintained data-base for
patients with age greater than or equal to 80 years who underwent
elective OVH repair with CMS and placement of polypropylene mesh
in the retro-rectus or pre-peritoneal space. Outcome parameters
included hospital length of stay, surgical site occurrence and hernia
recurrence.
We identified 6 patients with follow-up 9-36 months (mean 16). Patient
demographics showed age 80-95 (mean 85), BMI 26-30 (mean 29),
and hernia width 7-12 cm (mean 9). All patients had failed at least 2
hernia repairs prior. All patients had rectus muscle closure assisted by
an open external oblique component separation. Two patients had retrorectus polypropylene mesh placement and the others had 1,500 cm2
placement of the same mesh in the pre-peritoneal space. Five patients
were clean and 1 patient was contaminated. No patients had surgical
site occurrences or wound dehiscence. Hospital length of stay was 386 days (mean 23). No hernia recurrences were noted. One patient represented a prolonged length of stay complicated by alcohol withdrawal.
There’s very little published about the outcome of complicated OVH
repair in the elderly. As our patient population ages, and more individuals demand active lifestyle, we feel that octogenarian patients
should not be denied treatment for their abdominal wall dysfunction
secondary to hernias.
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P-193
Abdominal wall reconstruction in the massively
morbidly obese patient
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health Systems
Obesity may be a contributing factor for patients with a large ventral
hernia. Standard repairs have a high recurrence rate. Open ventral
hernia (OVH) repair with component muscle separation (CMS) is
not often performed in the obese patient because of the potential for
poor outcome. Many centers refuse this type of repair in patients
with a body mass index (BMI) over 45 kg/cm2.
We retrospectively reviewed our prospectively maintained data-base
for patients with BMI greater than 50 kg/cm2 who underwent elective
OVH repair with CMS and placement of polypropylene mesh in the
pre-peritoneal space. Outcome parameters included hospital length
of stay, surgical site occurrence, and hernia recurrence.
Fifteen patients with follow-up 6-42 months (mean 21), age 32-63
years (mean 51), BMI 50-76 (mean 55), and hernia width 5-24 cm
(mean 13) were included. One patient did not have complete rectus
re-approximation. All patients had pre-peritoneal placement of at
least 1500 cm2 light weight polypropylene mesh. Eleven patients
were clean and four patients were clean contaminated. Eleven surgical site occurrences occurred and eight were managed with a return
to the OR. One patient developed an enterocutaneous fistula which
led to a prolonged hospital stay. Hospital length of stay was 3- 88
days (mean 18). No hernia recurrences were noted. No mesh was
removed.
Little is published about the outcome of complicated OVH with CMS
in the massively morbidly obese patient. Although patient optimization with weight loss is encouraged in our patients, realistic expectations for patients can push the need to have this surgical procedure.
Although hernia recurrences were zero, wound complications were
high. Interestingly, after we adopted a perforator sparing mid transverse incision to our patient population, the wound morbidity diminished as evidence by our patient with a BMI of 76 kg/cm2 who had
no surgical site occurrence.
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P-194
Hybrid Laparoscopic Open-Assisted Repair (HLOAR)
for complex incisional hernias: A review of the hybrid
technique in comparison to an initial experience
Miller K, Raval M, Nagle A
Northwestern University
The ideal surgical approach to large, complex incisional hernias
remains controversial, but typically involves an open approach with
creation of large soft tissue flaps. We describe a novel hybrid technique which the combines the benefits of both the open and laparoscopic approach. The Hybrid Laparoscopic Open-Assisted Repair
(HLOAR) consists of an initial targeted open incision with adhesiolysis and resection of the hernia sac. A large mesh is placed in the
intra-peritoneal position and under direct vision four trans-fascial
sutures are placed. Additionally, under direct vision, the initial 5-mm
trocar is placed lateral to the mesh. The fascia is then closed primarily
above the mesh. If required, a separation of components can be added
via separate flank incisions. Pneumoperitoneum is established and the
mesh is laparoscopically secured to anterior abdominal wall with fixation tacks and additional trans-fascial sutures. A total of three
patients underwent HLOAR with average age of 55, operative time
290 minutes, mesh size of 20x25 cm, and LOS 3.4 days. There were
no hernia recurrences with average follow-up of 9 months. A review
of the literature yielded only six similar case reports. We compare
our results to the limited available data. Long-term results of the
HLOAR technique are not available. The HLOAR technique maintains the principles of a tensions-free mesh repair with adequate mesh
coverage and restoration of the rectus muscles to the midline. In addition, HLOAR has the potential for improved outcomes by combining
the advantages of the both the open and the laparoscopic approaches.
Specifically, compared to an open approach, HLOAR avoids the need
for a large soft tissue dissection and its associated morbidity.
Additionally compared to a laparoscopic approach, HLOAR may provide decreased operative times, decreased potential for enterotomies
or missed enterotomies and allows closure of the hernia defect.
P-195
Obturator hernia: diagnosis and treatment
Ross S, Oommen B, Kim M, Mckinney W, Criss CR, Heniford B,
Augenstein V
Carolinas Medical Center, Dept. of Surgery, Division of
Gastrointestinal and Minimally Invasive Surgery
Introduction: Obturator hernias (OH) are rare and can be difficult
to diagnose by physical exam or radiographic imaging. While an
open inguinal approach does not allow for visualization of the obturator space, laparoscopy is an excellent approach for diagnosis and
repair of OH. We describe our experience with the diagnosis and
management of OH.
Methods: A prospectively maintained, institutional, hernia-specific
database was queried from 2004-2013 for all OH. Demographics,
pre-operative imaging, operative details, and outcomes were collected and analyzed by standard statistical methods.
Results: There were 15 OH in 14 patients: 13 unilateral and one
bilateral. All OH were diagnosed intraoperatively. Inguinal hernia
was the most common preoperative diagnosis (85.7%). Two patients
had no hernia on exam but had intractable pelvic pain and had diagnostic laparoscopy. 78.6% of OH were incarcerated, 14.3% were
Hernia (2014) 18 (Suppl 1): S50-S97
recurrent. Concomitant inguinal hernias were present in 78.5% of
cases; three patients had an associated femoral defect (21.4%). Six
patients (42.9%) had a CT or MRI preoperatively, but OH wan not
diagnosed radiographically. All hernias were repaired laparoscopically with a light weight polypropylene mesh by TAPP. Mean follow
up was nearly 2.5 years (28.7±23.9months). The vast majority of
patients (90.9%) had complete symptom resolution by their first follow up. Interestingly, the two patients undergoing diagnostic
laparoscopy due to chronic pelvic pain had complete resolution of
pain by their first visit. Post-operative pain scores were significantly
lower than pre-operative pain score (0.5±1.2 vs 3.8±4.0, p=0.017).
There have been no hernia recurrences or recurrence of symptoms.
Conclusions: Obturator hernias are difficult to diagnose by history,
physical exam, or by radiologic imaging, and are likely to occur with
other groin hernias which can obscure their diagnosis. Laparoscopy
is the ideal modality for both diagnosis and treatment of OH. Repair
of OH results in decreased pain and complete resolution of symptoms
in a high percentage of patients.
P-196
A novel reinforcing approach for abdominal wall
reconstruction with 2,400 cm2 mesh
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health Systems
Open ventral hernia (OVH) with component muscle separation
(CMS) is utilized in complex, large ventral hernia repairs. Data has
suggested that utilizing a reinforcing material improves outcomes
with this open technique. Hernia recurrence after successful placement of reinforcing material usually occurs beyond the limits of the
reinforcing mesh. Placement of larger reinforcing mesh is appealing
in order to minimize recurrence. The size of the reinforcing material
is anatomically restricted in all planes except the pre-peritoneal
space. After a flank hernia recurrence in our series of 168 patients
with 1,500 cm2 of barrier coated large pore low surface area
polypropylene mesh in the pre-peritoneal space, we introduce a technique for essentially wrapping the three-dimensional contours of the
entire abdominal cavity with 2,400 cm2 of barrier coated mesh along
the mid-line and non-barrier coated mesh along the posterior-lateral
abdominal wall.
We retrospectively reviewed our prospectively maintained data-base
for patients that had an abdominal wall reconstruction with 2,400
cm2 of light weight polypropylene mesh. Outcome parameters include
surgical site occurence, hernia recurrence and hospital length of stay.
Twenty four patients age 37-80 years (mean 55), BMI 26-56 kg/cm2
(mean 41) with a hernia width 5-22 cm (mean 10) were included.
There were eight surgical site occurences (33%), four of which were
managed with operative intervention. Hospital length of stay was 526 days (mean 10). Follow-up from 6-23 months (mean 13) with no
hernia recurrence.
Historical recurrence rates of more than 25% for complex, open ventral hernia repairs are no longer acceptable. Placement of a large,
durable, strong, predictable and tolerable mesh at the time of repair
should improve outcomes even further. To our knowledge, and
review of the literature, this represents the largest surface area mesh
reinforcement placed in the abdomen. Early results demonstrate it is
well tolerated with low recurrence rates.
Hernia (2014) 18 (Suppl 1): S50-S97
P-197
Hybrid operation (laparoscope assisted hernioplasty:
LAH) for reduction of the pain and shortening of
incision in a ambulatory groin hernia under the local or
epidural anesthesia
Imazu H, Imazu Y
Imazu Surgical Clinic
Introduction: I perform a hybrid operation to use a laparoscope with
local or epidural anesthesia for a ambulatory groin hernia operation
(laparoscope assisted hernioplasty: LAH) from 2012. This operation
has the following merits.1, shortening of the wound, 2. It is more
exact than the naked eye, because of expansion.3.post operative pain
is slight. 4.can go home in a short time.
Method: I perform the Direct Kugel method for indirect hernia and
perform the Kugel method in direct hernia from 1.5-2cm length
wound. Until the handling of hernia sac, I perform both methods by
this method. After this processing, I perform the detachment of
prepetitoneal fat tissue layer from a wound using laparoscopy. I
detached as much as possible between peritoneum and prepetitoneal
fat tissue layer. After detachment, I measure a detachment range and
insert mesh of size as big as possible. The mesh which I insert it in
prepetitoneal fat tissue layer, and unfolded enough using laparoscope.
Result: I was operated on to 165 patients (175 lesions). Their sex
ratio were 90:10 (males: females), with mean age of 57 years (range
22-88). The type of hernia was indirect hernia 143 lesions, direct
hernia 34 lesions, and combine type 2 lesions. Right side hernia 85
cases left 70 cases and bilateral 10 cases. All cases average operation
time were 49min. In time of operation, all cases. All cases came
home on same day and no recurrence and no severe complications.
Conclusions: There was not the case that a day surgery was not possible, but, as for an operative time having become long. The severe
complications are not seen after operation, and the inguinal hernia
day surgery is basically possible in all cases by LAH.
P-198
Laparostomy in tuberculous peritonitis
Reddy A, Cunnigaiper N, Narayanan M, Jagan B
Sri Ramachandra University
Laparostomy is a valuable procedure in fulminant peritonitis, often
saving lives. It helps in free drainage, prevents abdominal compartment syndrome and allows inspection of viscera in doubtful viability.
Tuberculous peritonitis caused by perforation is common in the
Indian subcontinent posing a challenge to the surgeon as the bowel
loops are plastered.
The management of laparostomy wound poses a technical challenge
testing the ingenuity of the Surgeon. Limited literature is available
on the use of composite mesh in the management of laparostomy
wounds, more so in tuberculous patients.
Herein, we present a case of a twenty year male with features of
Tuberculous Abdomen, for whom an Ultrasound Abdomen and diagnostic Laparoscopy was done. Biopsy revealed a necrotizing granulomatous lesion and patient was subsequently started on Anti
Tuberculous Therapy.
At Laparotomy, we could not identify the site of perforation, there
was gross faecal contamination of the peritoneal cavity and no loop
of bowel could be exteriorized as a controlled fistula. We chose to
perform a laparostomy and placed drains to have access to the peri-
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toneal cavity. A composite mesh was sutured to the edges of the rectus sheath. The composite mesh placement is useful in that it helps
in early ambulation of the patient, prevents the rectus from moving
away from the midline, protects the bowel and helps in free drainage
of contaminated fluid through the peritoneal cavity. Anti Tuberculous
Treatment was continued and patient began to improve symptomatically. Two months later, there was a healthy layer of granulation tissue. This was subsequently grafted. Patient remains healthy at the
end of eight months. Thus, we find that the use of composite mesh
acts as a media between laparostomy and definite closure.
P-199
Laparoscopic repair of ventral hernia: Can we make it
a less painful surgery
Rahman S, Kanth R
al ain ahospital
Laparoscopic ventral hernia repair is now an established operation.
The advantage is prevention of wound infection and the use of large
size mesh to reduce the recurrence rate. However the pain in ventral
hernia repair is a disadvantage and concern.
Different techniques have been used to reduce pain in ventral hernia
like use of absorbable tacker, avoiding transfacial sutures, use of local
anesthetic agents etc. All these technique have failed in reducing pain.
We, at Alain Hospital are presently developing a technique to suture
the mesh intra-peritonealy with minimal use of tackers. We started
this technique in May 2013. Patients are followed up regularly with
regards to pain and recurrence rate.
So, far we operated on 12 patients. Our initial result with regards to
pain is very encouraging. Both acute and chronic post-operative pain
was less, which was evident by the patient’s requirement of analgesics and outpatient visit.
The purpose of this presentation is to show the technique and thereby
put this into discussion ’how the post-operative pain in ventral hernia
repair can be lessened by simple technique’.
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P-202
Contaminated ventral hernia repair using Component
Separation Technique with synthetic mesh is safe
Slater N, van Goor H
Radboud University Nijmegen Medical Centre
Background: Large ventral hernia repair represents a major surgical
challenge, especially under contaminated conditions. Synthetic mesh
placement is often deferred from due to fear of mesh-related complications necessitating its removal. The aim of the current study was
to evaluate the safety of contaminated large ventral hernia repair
using Component Separation Technique (CST) with non-absorbable
synthetic mesh placement, focusing on infectious complications and
mesh removal.
Methods: Retrospective chart review took place of consecutive
patients that underwent CST with synthetic mesh placement for ventral hernia repair between 2000 and 2013. The primary outcome was
early (< 30 days postoperative) or late Surgical Site Infection (SSI)
with a focus on mesh infection and mesh removal. Patients groups
were formed based on Surgical Wound Class (SWC); 1: ’clean’, 2:
’clean-contaminated’, 3: ’contaminated’ and 4: ’dirty/infected’.
Outcomes were compared between groups.
Results: One hundred thirty-seven patients were included in analysis.
Mean age, BMI and size of defect were respectively 58.6 (range 2179) years, 26.6 (17.9-45.9) kg/m2, and 361.2 (24-1,050) cm2. SSI’s
occurred in 6/56 (10.7%) patients in SWC 1. In the non-clean wound
settings SSI’s occurred in 10/34 (29.4%, SWC 2), 4/19 (21.2%, SWC
3), and 9/28 (32.1%, SWC 4) patients (p=0.034). Six SSI’s (4.4%)
involved the mesh resulting in explantation: 2 in both SWC 1 (3.6%)
and SWC 2 (5.9%) and 2 in SWC 4 (7.1%). Twenty-four (17.5%)
hernias recurred after 15 months mean follow-up and was not
dependent upon SWC (p=0.629).
Conclusion: Two to three out of ten repairs of large contaminated
ventral hernias with synthetic mesh become infected, however with
low risk of mesh loss.
P-203
Quantitative evaluation of abdominal wall hernias
using anatomical labeling
Baucom R, Xu Z, Allen W, Asman A, Landman B, Poulose B
Vanderbilt University Medical Center
Background: Classification of ventral hernias (VHs) remains cumbersome and is not well standardized. The European Hernia Society
(EHS) classification is the most widely accepted system; however,
it lacks quantitative metrics. We hypothesize that computed tomography (CT) offers a wealth of underutilized information that can be
used to precisely characterize VHs. We developed an image labeling
protocol to segment hernia-related anatomic structures and identify
metrics that might be useful for predicting clinical outcomes, including loss of domain.
Methods: CT images for 47 general surgery patients were viewed
using image-processing software. A labeling protocol was developed
to identify key layers of the abdominal wall, fascial defects, hernia
volume, and skeletal landmarks. Intra- and inter-rater reproducibilities were tested, and the ratio of hernia to intraabdominal volume
was calculated. This ratio was then correlated with primary fascial
closure.
Hernia (2014) 18 (Suppl 1): S50-S97
Results: The intra- and inter-rater reproducibilities of the protocol
were tested, and mean surface distance tolerances of 2-5mm were
achieved for all labels. The prevalence of VH for our population was
64%, and the mean ratio of hernia volume to intraabdominal volume
was 0.09 (range 0.0006-0.41). Twelve patients underwent VH repair
with intent for primary fascial closure and mesh sublay. Six patients
required a bridge for closure and 6 did not. The mean ratio of hernia
to abdominal volume in patients who required a bridge was 0.14
(range 0.08-0.30), whereas the mean ratio for the patients who underwent primary fascial closure was 0.008 (range 0.002-0.02). The mean
ratio was significantly different between groups (p=0.01).
Conclusions: CT image labeling for VHs is reproducible and offers
promising metrics that could be used to better describe hernias and
help determine optimal individualized techniques for repair, especially in the setting of loss of domain.
P-204
Improved outcomes in the management of high-risk
incisional hernias: A single centre experience
Skipworth J, Vyas S, Uppal L, Floyd D, Shankar A
Royal Free and University College London Hospital Complex Hernia
Unit
Introduction: Incisional hernia repair (IHR) is complex in the setting
of previous/current infection, loss of domain and bowel involvement:
often on the background of co-morbidities such as obesity, diabetes
and malignancy. Repair methodologies previously described are associated with significant morbidity, leading our unit to develop a novel
technique for complex IHRs.
Methods: A retrospective review of IHRs performed as a combined,
single-stage procedure, by a general and plastic surgeon, was undertaken (Feb 2009-Sep 2013). Standardised repair involved radical
resection of soft tissue with hernia-sac, component separation (where
necessary), intra-peritoneal mesh-insertion (Bard™ composite for
ventral hernia working group (VHWG) grades 1 and 2; Strattice™
biological for grades 3 and 4, and high-risk grade 2), midline fascial
closure, and abdominal wall reconstruction (with soft-tissue flaps
where necessary).
Results: 95 (69 biological/26 composite) patients underwent IHR
(64% female; median age 59 years; BMI 31.5 kg/m2; length of stay
8 nights; follow-up 22 months). 9 (9%) patients were VHWG grade
4, 47 (49%) grade 3, 28 (29%) grade 2 and 11 (12%) grade 1. 27
(28%) were recurrent hernias, 19 (20%) had diabetes and 31 (33%)
had malignancy. 25 (26%) patients developed complications including 18 (19%) surgical-site occurrences; 3 (3%) returning to theatre;
7 (7%) respiratory and 3 (3%) cardiac complications. Clinical follow-up revealed 4 (4%) hernia recurrences: 1 has undergone further
repair and 3 are asymptomatic and undergoing active follow-up.
None of the patients have required mesh-removal.
Conclusions: Despite the high-risk cohort, this technique is associated with a low incidence of recurrence and a low risk of surgicalsite occurrences (including 0% mesh-explantation), a finding that
may be dependent upon comprehensive resection of poorly-vascularised soft-tissue (bioburden reduction) and abdominal wall reconstruction utilising healthy tissue. Furthermore, the low incidence of
surgical-site events in grade 2 patients repaired with synthetic mesh
has led to a change in our unit’s practice, with biological mesh now
exclusively reserved for grade 3/4 IHRs.
Hernia (2014) 18 (Suppl 1): S50-S97
P-205
Rives-Stoppa, endoscopic and anterior components
separation for hernia repair: does technique influence
outcomes?
Muse T, Zwischenberger B, Miller M, Davenport D, Roth J
Department of Surgery, University of Kentucky College of Medicine
Introduction: The Rives-Stoppa repair is considered the gold standard for repair of complex abdominal hernia defects. Open and endoscopic anterior components separation are alternative options for a
ventral hernia repair. The aim of this study is to evaluate wound
complications, hospital readmission, and hernia recurrence after
Rives-Stoppa repair compared to open and endoscopic components
separation.
Methods: A retrospective review of patient demographics and outcome measures was conducted of patients who underwent an open
ventral hernia repair between 2006 and 2011. The search was limited
to the following repairs: endoscopic components separation with
mesh (Endo CS), open components separation (CS) with mesh, open
components separation without mesh, and Rives-Stoppa repair.
Characteristics were compared between the groups using chi-square
tests or analyses of variance as appropriate. Significance was set at
p<0.05. SPSS™ version 21 (IBM Corp., NY, New York) statistical
software was used.
Results: A total of 362 patients underwent a ventral hernia repair
with Endo CS (53 patients), CS with mesh (126 patients), CS without
mesh (117 patients), and Rives-Stoppa (66 patients) techniques. No
differences were found between groups in terms of demographics
and co-morbidities. Average follow-up was 392 days. The previous
number of repairs varied significantly (p<0.001) between groups with
Endo CS used to treat patients with the greatest number of previous
repairs. There were no significant differences between groups for
wound complications (p=0.57), hospital 30-day readmission rate
(p=0.898), or hernia recurrence (p=0.137).
Conclusion: Open and endoscopic anterior components separation
have comparable outcomes to the Rives-Stoppa technique alone.
Endoscopic components separation is a viable option for complex
ventral hernia repairs, particularly multi-recurrence hernias, without
added morbidity.
P-206
Incarcerated diaphragmatic hernia in pregnant with
intrathoracic bowel obstruction after right liver
donation
Bardella R, Fernandes V, Garcia D, Ripardo J, Ushinohama A
Hospital da Luz, Vila Mariana
Patient 29 years old female, 31 weeks of pregnancy, presenting the
last four days with chest pain, dyspnea and vomiting.
Past medical records: Right liver lobe donor in 2005. Previous medical history unremarkable.
CT scan was performed and shows right pleural effusion and right
diaphragmatic hernia (small bowel herniated with no signs of
ischemia). Steroid was administered for lung maturation 24 hours
before delivery. Due to clinical worsening, surgical treatment was
indicated.
First cesarean section was performed and followed by laparotomy in
the same surgical procedure.
The child was born without complications.
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Findings: Strangulated Segment of 25 cm of the terminal ileum with
enteric fluid in thoracic cavity and large amount of omentum also
ischemic.
Treatment: Enterectomy and primary anastomosis; right hemithorax
drainage and diafragmatic suture.
In the ICU, the patient developed drug-induced acute renal insufficiency (vancomycin) which resolved with dose adjustment and
hydration. Oral intake was started on the fourth day post surgery,
with good acceptance and normal bowel movements. The chest tube
was removed on the 7th pos operative day. On the 25th pos operative
day, mother and child were discharged without complaints.
Right-sided diaphragmatic hernia in pregnant patient (previous liver
transplant donor) has not been described before.
There has been a few reports of right-sided diaphragmatic hernia in
pediatric living donor liver transplant recipients, and in right lobe
donor hepatectomy patients.
So, the aim of this case report is show an extremely rare complication
of a living liver transplant donor patient in a very especial situation,
that was not described before.
P-208
Meta-analysis of sublay versus onlay mesh repair in
incisional hernia surgery
Timmermans L, Goede B, Dijk SM, Kleinrensink G, Jeekel J,
Lange J
Erasmus MC
Background: Incisional hernia (IH) remains the most frequent postoperative complication after abdominal surgery. The treatment of
choice for IH surgery is mesh repair. The two techniques most frequently used are the onlay repair (OR) and sublay repair (SR). Both
techniques have their merits; however it remains unclear which is
superior with regards to IH recurrence, operation time and postoperative complications.
Methods: A meta-analysis was conducted according to the PRISMA
guidelines. A systematic search of MEDLINE, Embase, Web of
Science, Scopus, PubMed publisher and Cochrane library was performed. The quality of the non-randomized studies was assessed
using the Newcastle-Ottawa scale (NOS).
Results: Out of 178 papers, 10 studies (2 randomized controlled trials, 1 prospective study and 7 retrospective studies) were selected
comprising 1948 patients. Two of the studies scored below 5 points
on the NOS and were not selected for meta-analysis. A trend was
observed for IH recurrence in favour of SR (OR 2.41, 95% CI 0.99
to 5.88, I2 70%, p=0.05). SSI occurred significantly less after SR
(OR 2.42, 95% CI 1.02 to 5.74, I2 16%, p=0.05). No difference with
regards to seroma and hematoma could be discovered. Data regarding
operation time, postoperative pain and fistula could not be pooled.
Conclusion: Although the majority of included studies were of retrospective nature, SR seems the preferred technique for IH repair
compared to OR.
S68
P-212
Giant inguinal hernia: pneumoperitonium + Stoppa
technique
Marins C, Loss A, Oliveria P, Rosa R, Gitahy A, de Freitas L
Brazilian
Giant inguial hernia is a not so frequente pathology, defined when
the hernia reaches below the middle of the tights. Several methods
are usually employed attempting to reduce the hérnia contente without respiratory difficults.
The authors present a case of a midde-aged man with a giant inguinal
hernia submitted to a 12 liters pneumoperitoneum during 14 days
and then operated with a pre-peritoneal mesh reinforcement (Stoppa
technique) and no organ resection.
P-215
Evaluation of a novel antimicrobial coated
non-crosslinked acellular porcine dermal matrix
Novitsky Y, Liese R, Scott J
University Hospitals Case Medical Center
Introduction: Biologic graft bacterial colonization may result in
accelerated degradation and diminished performance. Antimicrobial
coating of biologic grafts may resist bacterial adherence and improve
bacterial clearance. We aimed to evaluate the antimicrobial efficacy
of a novel rifampin/minocycline polymer-coated non-crosslinked
acellular porcine dermal matrix device (ABX-ADM) in vitro and in
vivo after inoculation with Methicillin-resistant Staphyloccus aureus
(MRSA) or Escherichia coli (E.coli) in a rabbit model.
Methods: ABX-ADM was compared to 5 biologic/biodegradable
grafts (Strattice, Permacol, Surgimend, XCM and Bio-A). For the in
vitro evaluation: 5 samples of each device were placed onto MuellerHinton agar plates, inoculated with MRSA or E.coli., and Zone of
Inhibition (ZOI) was calculated post-incubation. For the in vivo evaluation: 60 male New Zealand White Rabbits were implanted with
two 3.8cm diameter samples (n=10 per group), and randomized for
inoculation with either MRSA or E.coli. After 7 days, each device
underwent quantitative analysis for viable colony forming units
(CFU). Both ZOI and CFU data were evaluated by Mann-Whitney
test, with p<0.05 considered significant.
Results: ABX-ADM demonstrated significantly greater ZOI, as compared to all other devices. After explantation, ABX-ADM demonstrated complete inhibition of MRSA colonization, as compared to
significantly greater MRSA colonization of Strattice and Bio-A.
Premature euthanasia was required for all MRSA-inoculated
Surgimend and XCM animals. ABX-ADM also demonstrated complete inhibition of E.coli colonization, as compared to significantly
greater colonization in the Strattice, Permacol, Surgimend and XCM
groups.
Hernia (2014) 18 (Suppl 1): S50-S97
P-216
Evaluation of an experimental model of onlay
polypropylene mesh versus light composite
monocryl/polypropilene mesh
Grossi J, Cavazzola LT, Manna B, Nery LA, Montes JHM, Bau R,
Roll S
PUCRS
Background: Adhesions are due to the exposure of prosthesis to the
intra-abdominal contents and it is an important factor to its importance in surgical complications clinic.
Objective: To evaluate an experimental model of hernioplasty with
the placement of an onlay polypropylene mesh (PP) or a composite
lightweight polypropylene and monocryl mesh (UP).
Materials and methods: An experimental study, with a sample of
28 female Wistar rats. They were randomized into 3 group (1 with
8 animals - control and 2 groups with 10 animals). In all three group
a 1 cm diameter defect was created in the rectus muscle. The 3
groups were divide as: skin closure (sham - 8 animals), PP mesh and
UP (10 animals each). Samples were analyzed for the presence of
adhesions, it’s extent, the strength necessary for their rupture and
involved organs. Retraction of the mesh was analyzed. All animals
were killed 21 days after the procedure.
Results: All groups showed adhesions. PP group had worst extension
of adhesions when compared to UP and sham group. The force for
adhesion rupture did not differ between meshes studied. Adhesions
involved mostly the omentum and only in the PP group there were
adhesions with the round ligament (liver) in 50% and small bowel
in 20% of the animals, p=0.004. Exposed area of the defect was
0.83±0.18 cm2 in the sham group; 0.90±0.09 cm2 in the PP group
and 0.60±0.18 cm2 in UP; p<0.001.
Conclusion: All groups showed some degree of adhesions. One of
the explanations for the lowest percentage of adhesions in the UP
group is the smaller exposed area (with the greatest retraction of the
mesh) compared to the other groups.
Keywords: Hernia, Monocryl
Hernia (2014) 18 (Suppl 1): S50-S97
P-217
Wound and mesh complications after ventral hernia
repair are expensive: the cost is more than just money
Colavita P, Zemlyak A, Tsirline V, Burton P, Dacey K, Walters A,
Lincourt A, Augenstein V, Kercher K, Heniford B
Carolinas Medical Center
Introduction: Wound complications, including wound and mesh
infections, following ventral hernia repair (VHR) are expensive, but
the price is more than money alone.
Methods: Prospective, consecutive, open VHRs from 2008-2011
were analyzed with extensive 1 year follow-up. Wound infections,
wound complications (breakdown, seroma requiring intervention,
abscess), and mesh infections were examined. Charges incorporated
all hernia-related visits, interventions, and readmissions within one
year.
Results: Five hundred consecutive open VHRs were analyzed.
Patients were 57.2% female, mean age 56.4 years, BMI of 33.1, and
60.6% had recurrent hernias. Defect and mesh sizes were 198.3 cm2
and 784 cm2. 27.0% had a previous wound infection, and 6.6% had
an active infection at the time of VHR. Panniculectomy and component separation were performed in 31.8% and 25.6% of cases. 293
patients had no infections or complications (NC), 21.8% had noninfectious wound complications (WC), 17.4% had wound infections
without mesh infections (WI), and 2.2% developed mesh infections
(MI). Mean hospital charges were: NC- $38,677, WC- $51,843; WI$65,240, and MI- $82,779 (p<0.0001). Mean follow-up charges were:
NC- $1,393, WC- $6,213, WI- $20,232, and MI- $63,389 (p<0.0001).
NC had 2.4 average post-operative visits, WC had 4.3, WI required
6.7, and MI averaged 9.2. Readmission was necessary for 57.5% of
WI and 90.9% of MI. At 2 and 4 week follow-up, there were no differences in patient QOL with and without complications/infections.
At 6-months, 57.6% of patients with complications/infection had discomfort/pain versus 35.4% without complications (p=0.01), 58.6%
versus 29.9% (p<0.001) had activity limitations, and 52.5% versus
34.2% reported mesh sensation (p=0.031).
Conclusion: VHR wound-related complications yield significant cost
on many levels: financial impact during and after hospitalization,
increased patient and physician time investment, and reduction in
patient QOL. Efforts to reduce VHR wound-related complications
should be strongly pursued.
P-219
Reasons for readmission following repair of primary
and recurrent ventral hernias
Elegbede A, Tevis S, Greenberg J
University of Wisconsin
Introduction: Readmission to the hospital following ventral hernia
repair is a common and costly problem. The goal of this study was
to evaluate which factors influence 30-day re-admission rates following ventral hernia repair.
Methods: We performed a retrospective review of NSQIP data on
ventral hernia repairs performed at our institution between 2006 and
2012. Patients were divided into two groups based on whether their
hernia was primary or recurrent. Groups were then compared based
on demographic information, operative intervention, co-morbidities,
and reason for readmission. Student’s t-test was used for continuous
variables and Chi-square test was used for categorical data.
S69
Results: 468 ventral hernia repairs were performed during the study
time period. 407 (86.9%) were primary hernia repairs and 61 (13.0%)
were recurrent hernia repairs. Additionally, 68 (14.5%) were performed laparoscopically while 400 (85.5%) were performed open.
Baseline demographics were similar between the two groups expect
for BMI which was significantly higher in the recurrent group (31.5
vs 37.4, p=0.0001). Thirty-day re-admission occurred in 4.4% of primary and 1.5% of recurrent hernias. Surgical Site Infection was the
most common reason for readmission in both groups (55% of readmitted primary patients and 67% of readmitted recurrent patients).
While laparoscopic repair was associated with fewer readmissions in
both the primary (OR=0.76, p=0.71) and the recurrent groups
(OR=0.19, p=0.26), neither reached statistical significance. Other
common reasons for readmission were failure to thrive (4 after primary repair and 1 after recurrent repair) and exacerbation of baseline
illness (3 after primary repair and 1 after recurrent repair).
Conclusions: Surgical Site Infection is the most common cause for
readmission after ventral hernia repair. Patients who underwent open
repair were more likely to be readmitted than those who were
repaired laparoscopically. As reimbursement for readmissions falls,
further work is needed to identify high-risk patient populations.
P-222
Evolution of component separation technique; a
systematic literature review
Bökkerink W, Slater N, van Goor H
Dept. of Surgery, Radboud University Nijmegen Medical Centre
Background: Component Separation technique (CST) is a widely
used method for fascial closure in patients with large incisional ventral hernias. Since its description by Ramirez in 1990 surgeons tried
to find solutions to decrease the high rate of wound complications
and reherniation associated with CST. The aim of this study was to
systematically review all papers on CST and compare the results of
CST modifications.
Methods: Medline, EMBASE and the Cochrane database were
searched systematically for studies on CST and incisional ventral
hernia. Quality of papers was assessed by the modified MINORS
score. Data on surgical technique, short and long term outcomes were
extracted. Subgroup descriptives and comparative analyses were performed. Outcomes are presented as weighted pooled proportions.
Results: 56 studies were included, all but one retrospective, describing 2885 patients. Mean wound complications and recurrence rates
were 24.7% (95% confidence interval [CI] 19.9-29.9) and 11.2%
(7.8-15.1) after CST without mesh; 29.0% (4.0-66.0) and 18.8%
(10.2-29.4) after CST with absorbable mesh; 25.0% (18.0-32.0) and
14.9% (4.1-30.9) after CST with non-absorbable mesh; and 37%
(25.0-50.0) and 10.5% (5.7-16.6) after CST with biological mesh.
Subgroup comparison showed that CST with biological mesh had a
higher wound complication rate (compared to all other subgroups,
p<0.001). Long-term outcomes showed no differences between CST
with or without mesh. Wound complications occurred less after posterior CST and endoscopic CST (compared to classic CST, p=0.0005
and p<0.0001, respectively). Furthermore, fewer recurrences were
reported after posterior CST (p=0.0166).
Conclusion: There is an abundance of literature on CST, however,
most studies are of poor quality. There are significant differences in
study outcomes between the mesh materials used in conjunction with
CST. Based on the current literature, biological mesh is inferior
regarding short-term outcome. New modifications including posterior
CST and endoscopic CST show promising results.
S70
P-223
Abdominal wall tension: a new vital sign for ventral
hernias
Hope W, Christian D, Hooks W, Clancy T
New Hanover Regional Medical Center
Hernia size and mesh size remain the standard reporting metrics
when discussing ventral hernia repair. When evaluating success of
components separation techniques length of fascial advance has traditionally been used. Very little is known regarding the impact
abdominal tension has on hernia formation and its impact on hernia
repair. The purpose of this project was to evaluate a novel method
for evaluating abdominal wall tension to its effect on abdominal wall
closure.
Following IRB approval, a prospective study of patients undergoing
hernia repair or laparotomy was performed. Patient demographics,
operative information, and outcomes were documented. Abdominal
wall tension measurements were obtained in the operating room by
placing two Kocher clamps on the fascia at the mid portion of the
incision. Two separate scales were then were hooked onto the handle
of the Kocher clamps. The clamps were then pulled until the fascial
edges met in the midline. Measurements on the scales were then
recorded.
Five patients have undergone tension measurements during hernia
repair. Average age was 63 years with all patients being Caucasian
and 80% males. All patients underwent open repair of incisional hernia with either incision of the posterior rectus sheath or a transversus
abdominus release. Average length of the incision was 22cm. Average
total pounds of tension for hernia patients at the midportion of the
wound was 12.2 lbs (range 2.6-22.1 lbs). Average total pounds of
tension following transversus abdominus release in 4 of the patients
was 5.7 lbs. All patients had a decrease in the total amount of tension
following retrorectus and transversus abdominus release.
This preliminary study shows the feasibility of measuring abdominal
wall tension and suggests a potential for its use during complex ventral hernia repair. The implication of these tension measurements and
their impact on clinical decision making and outcomes requires further study.
P-224
Series of 169 cases of hernioplasty retro muscle
Grossi J, Mottin C, Padoin A, Alves L, Ramos R, Monteiro P, Agra A
PUCRS
Background: The ventral incisional hernias represent a complication
of a surgical procedure performed previously. Present in large numbers, with an incidence of approximately 10-15% of all laparotomies,
and in series there recurrence after repair of up to 67% without mesh
insert.
Objective: To evaluate the mesh in incisional hernioplastias position
retro-muscular performed at the Hospital São Lucas-PUCRS, Brazil.
Methods: Retrospective study selected repair retro-muscular mesh
in ventral hernioplasty. From January 2006 to December 2012.
Performed by the team of COM (center of morbid obesity) in hospital
São Lucas.
Results: We selected 169 patients with a mean age of 52±12.9 years,
of both sexes, with a predominance of females with 118 (69.8%) and
male 51 (30.1%). The initial surgery was the most common gastric
bypass (bariatric) with 126 (74.5%), followed by laparotomy 34
Hernia (2014) 18 (Suppl 1): S50-S97
(20.1%), subcostal cholecystectomy and cesarean section with 3
(1.7%) cases each, plus a case aortic aneurysm, prostatectomy, appendectomy (open). The location of the hernia was more frequent in the
epigastric region with 108 (63.9%), umbilical 52 (30.7), infra-umbilical 6 (3.5%) and subcostal with 3 (1.7%) cases. The time between
initial surgery and hernioplasty was 3.7 years. The mean duration of
surgery was 2 hours and 16 minutes. The length of stay was 4 days.
The number of recurrences reoperated the period was 19 cases
(11.2%), 10 (5.9%) in the epigastric region. The correction time
between hernioplasty and recurrence was 1.7 years.
Conclusion: The surgical repair mesh retro-muscular position is considered an option for treatment of ventral incisional hernia mainly
in the epigastric region after bariatric surgery.
P-225
Quality improvement through social media:
an initial look at the international hernia collaboration
facebook group
Chui P, Jacob B
Mount Sinai Hospital
The widespread accessibility to social media platforms, such as
Facebook™, affords the surgical community an extraordinary opportunity to participate in the rapid global exchange of education and
ideas. Made up of surgeons, healthcare providers, and vetted medical
device industry partners, The International Hernia Collaboration
Facebook™ group is a new example of a professional-to-professional-to-industry group where exchange of information is centered
on the concept of improving patient outcomes. As its founders, we
wanted to review the initial statistics surrounding its growth during
the first 9 months of its use.
Since its inception in December 2012, the group has expanded to
302 individually vetted members. 102 members are located internationally and represent 36 individual countries, including Saudi
Arabia, Egypt, Algeria, Syria, Russia, Brazil, Japan, Colombia,
Guatemala, and Mauritius. 260 members are either surgeons or members of an academic institution, while 42 members work within
industry. Of the nearly 200 unique posts made to this forum since
its creation, 40.9% of the posts involved questions about individual
case presentations; 39.8% sought technical expertise in some aspect
of hernia repair; 10.2% involved questions about materials used in
hernia repair; and 7.8% discussed pain after hernia procedures. 27.3%
of the posts used de-identified images, including CT scans and
videos. Remarkably, the vast majority of the posts garnered a substantial number of responses from other members, ranging from 4 to
46 responses per post.
Our initial review of The International Hernia Collaboration
Facebook™ group demonstrates that social media can be used professionally as an effective tool that provides rapid global collaboration with limitless possibilities, all designed to optimize patient care.
Whether providing education to students and residents, market feedback to industry partners, or technical advice and opinions to colleagues, this group, and other groups like it, are revolutionizing the
way the medical community collaborates.
Hernia (2014) 18 (Suppl 1): S50-S97
P-8224
Histological profile of a porcine acellular dermal matrix
(Strattice™) 31 and 36 months after implantation:
two clinical case reports
Sawyer M, De Deyne P
Comanche County Hospital
Use of mesh reinforcement in incisional herniorrhaphy is the standard
of care; however, an unresolved question centers on the durability
of a biological scaffold in humans. We present the histological profile
of Strattice™ Reconstructive Tissue Matrix (LifeCell Corporation,
Branchburg, NJ) more than 30 months after initial placement in
humans. A biopsy of the abdominal wall was obtained and standard
histopathology and immunohistochemistry was performed in 2
patients: Patient #1, an 82-year-old male, presented with a ventral
hernia (class III) resulting from rectal cancer surgery 3.5 years prior.
The cancer and a portion of the abdominal wall were resected and
Strattice was used to repair the defect. Thirty-one months later, he
experienced a third manifestation of rectal cancer and was re-operated; a biopsy was obtained. Patient #2, a 54-year-old male, presented
with a ventral hernia (class III) which was surgically repaired using
Strattice. Subsequently, he gained 80 lbs, leading to a minor recurrence repaired with Parietex™ (Covidien, Mansfield, MA). Twentyeight months later he had MVA-related abdominal trauma, which was
repaired with Parietex (a biopsy was obtained). Histopathology for
patient #1 showed robust recellurization, and remnants of Strattice
were visible; immunohistochemistry (against laminin) showed mature
arterioles inside the composite of host-Strattice tissue. The tissue
sample of patient #2, while showing some fibroblast infiltration in
the Strattice material, also had pronounced foreign-body response
and chronic inflammation in the tissue around the synthetic material.
Immunohistochemistry showed myofibroblasts and macrophages
around the Parietex mesh but not in the Strattice material. These
observations support the durability of a biological mesh and support
the findings from others that synthetic materials may lead to persistent chronic inflammation and scarring. Biological scaffolds supporting fibroblast infiltration and graft acceptance should be considered
in surgical reconstruction of the abdomen where the goal is restoration of functional tissue.
P-9207
Management of incarcerated inguinal hernias
in the era of laparoscopy
Nakata R, Suzuki H, Chihara N, Watanabe M, Uchida E
Institute of Gastroenterology, Nippon Medical School, Musashikosugi
Hospital
Background: The transabdominal pre-peritoneal (TAPP) approach
has been the first choice for adult inguinal hernias in our department
since 2009. TAPP technique offers the following advantages:
1. Diagnostic accuracy; 2. The bilateral groin can be checked and
immediately repaired; 3. Relief of postoperative pain and wound
discomfort; and 4. Earlier rehabilitation. We have expanded our indication to incarcerated cases with the advancement of our technical
stability and safety.
Methods: In our strategy for incarcerated inguinal hernia, we first
verify the viability and peristalsis of the incarcerated bowel with
enhanced computed tomography and abdominal ultrasonography followed by reduction. Even if reduction is possible, we perform surgery
within 24 hours to avoid false reduction or late perforation. If reduc-
S71
tion is impossible, we determine the viability of the incarcerated
bowel segment based on color, peristalsis, and venous congestion by
laparoscopy. When the bowel resection is not required, TAPP is performed in the usual manner. If bowel resection is required or the
bacterial contamination is suspected, we postpone TAPP for the protection of the prosthesis infection.
Results: We experienced 13 cases (14 hernias: 1 direct, 11 indirect,
2 femoral) between 2009 and 2013. In 9 cases TAPP was simultaneously performed after laparoscopic observation confirming the viability of the incarceration bowel segment. TAPP was performed in
3 cases within 24 hours after undergoing reduction and postpone
TAPP was performed in the remaining cases because the incarcerated
bowel was perforated by strangulation. No conversion to open surgery occurred. The median operative time was 107 minutes (53-221)
including a bilateral case. The median postoperative hospital stay
was 4 days (2-8). Recurrence has not been seen nor any adverse
event exceeding Grade 3.
Conclusion: It can be considered that TAPP can offer benefits in
reliable therapy and minimally invasive not only for elective cases,
but also incarcerated cases.
P-9667
Posterior component separation safely addresses
recurrences after external oblique release herniorraphy
Juza R, Jackson T, Haluck R, Soybel D, Pauli E
Penn State Milton S. Hershey Medical Center
Introduction: Anterior component separation (ACS) with external
oblique release for ventral hernia repair has a reported 20% recurrence rate. Managing recurrent hernias after ACS is challenging
because of iatrogenically-altered myofascial planes and perceived
loss of abdominal wall integrity. We report our experience and short
term follow-up of four patients who were successfully managed with
posterior component separation (PCS) and transversus abdominis
release (TAR).
Methods: Patients with recurrent ventral hernia after ACS were retrospectively identified from a prospectively-collected hernia database. All patients were symptomatic and were not acceptable candidates for laparoscopic repair. Open PCS herniorraphy with sublay
lightweight polypropylene mesh was performed under general anesthesia. When defect size was sufficiently large, TAR (as described
by Novitsky) was added to permit primary midline fascial closure.
Results: Four patients (3 female, mean age 53) underwent PCS after
ACS for midline hernia recurrence. There was an average 2.3 prior
ventral herniorraphies. All patients had undergone previous external
oblique release. Average Body Mass Index was 37 with an American
Society of Anesthesia class of 3. Two patients had controlled diabetes
mellitus and 2 patients had prior methicillin resistant S. aureus wound
infections. Mean operative time was 357 minutes and mean defect
size was 309 cm2. Two patients (50%) required TAR for adequate
mesh overlap and midline defect closure. Mean length of hospital
stay was 7 days. There were no surgical site occurrences or recurrent
hernias at a mean of 6 months follow up.
Conclusions: This is the first report of PCS with TAR for ventral
hernia recurrence after ACS. Despite multiple comorbidities, the
patients had no wound morbidity and no evidence of early recurrences. All have resumed normal activity with no perceived functional limits. Although longer term follow-up is necessary, PCS with
TAR appears to be a safe option for abdominal wall reconstruction
following failed ACS.
S72
Hernia (2014) 18 (Suppl 1): S50-S97
P-9733
Laparoscopic ventral hernia repair – How we do it
P-10469
Results from the first HRFU-Mission in Paraguay
Solecki R, Szura M, Matyja A, Kulig J
Department of General Surgery, Jagiellonian University
Reinpold W, Schroeder A, Torres O
Wilhelmsburg Gross Sand Hospital
Incisional hernia is a complication following laparotomy, with an
estimated incidence of 10% compared to about 20% after conservative procedures. The prosthetic herniorrhaphy, and especially sub-lay
technique, decreased reccurence rate of hernias to 10%. Laparoscopic
repairs of incisional hernia reduced reccurence rate still further to
below 5% and were accompanied by a low rate of postoperative complications (wound infection, seroma or haematoma formation, urinary
retention or pneumonia).
According to the Polish National Health Fund data, about 6000 incisional hernia repairs are performed in Poland each year. Of 6000
incisional hernias, only about 10% laparoscopically, and the remaining with conservative methods. Most frequently used laparoscopic
technique is IPOM (Intraperitoneal On-lay Mesh). The major limitation for laparoscopic incisional hernia surgery in Poland is cost of
the procedure. The IPOM procedures have been performed at the Ist
Department of General, Oncological and Gastrointestinal Surgery,
Jagiellonian University Medical College since 2007, and the authors
are presenting possibilities and limitations of this technique. Having
in mind benefits of the laparoscopic ventral hernia repairs we hope
to perform more such procedures in future as soon as the financing
system of medical procedures changes in Poland.
Currently 78% of the Paraguayan population has no health insurance.
Access to health care is difficult and government funding is limited.
For most patients, mesh repair of inguinal and ventral hernias is too
expensive due to high mesh costs. This presentation shows results of
the first Hernia Repair for the Underserved (HRFU)-Mission in
Asuncion, Paraguay. HRFU is a non-profit organization performing
charitable hernia surgery in the United States, the Dominican
Republic, Haiti, Guatemala, Ecuador and now Paraguay. The Mission
was coordinated by Prof. Charles Filipi, founder of HRFU from
Creighton University. The surgeries and education were carried out
by lead surgeon Dr. Wolfgang Reinpold and our team. During an 8day period, we provided free hernia repair for 76 patients at the
Hospital Nacional and Luque District Hospital in Asuncion. We
repaired 86 inguinal, ventral and incisional hernias (71% inguinal hernias) by using primarily the Lichtenstein technique. Following the
EHS-Classification for size of inguinal hernias, 54% of inguinal hernias were considered large with a mean diameter of 3.6 cm (range
1.0-5.0 cm). The mean operating time was 66 min (range 35-210 min).
There were no acute perioperative or immediate postoperative complications. As education and capacity building is an important part of
HRFU-Missions, Dr. Reinpold successfully educated three Paraguayan
surgeons using the HRFU Lichtenstein hernia rating form system. In
conclusion, we consider the first HRFU-Mission in Paraguay to be a
great success with high potential for subsequent missions in order to
make a difference for thousands of patients in the coming years.
P-9903
Sutureless Lichtenstein repair for inguinal hernia:
short- to mid-term outcomes
Wada N, Furukawa T, Kitagawa Y
Department of Surgery, Keio University School of Medicine
Introduction: Lichtenstein repair is recommended for the treatment
of many types of adult inguinal hernia in European Hernia Society
Guidelines published in 2009. Recently, a self-fixating mesh with
advanced microgrip technology is commercially available. With this
mesh, fixation with the entire mesh surface may reduce the tension
at the suture points and potential risk of chronic pain. Here we present our current technique and short- to mid-term clinical results of
Lichtenstein repair for inguinal hernia.
Methods: Surgical repair for inguinal hernia was performed for 460
patients in our institution from December 2009 to June 2013. Of
these patients, a total of 393 patients (85.4%) were treated with
Lichtenstein method using self-fixating mesh. A skin incision of 3.5
cm was made under local anesthesia with 0.5% lidocaine.
Intravenous administration of 35 mg of pethidine and 0.4 mg of flunitrazepam was the standard protocol for conscious sedation.
Prophylactic antibiotic was given once within 30 minutes prior to
surgery. Pre-shaped polyester mesh with microgrip was placed as an
onlay mesh and overlapped onto the pubic tubercle.
Results: Mean age was 68.4 +/- 11.4 years. Median duration of surgery was 96 minutes and estimated blood loss was less than 10 mL.
Median hospital stay after surgery was 1 day. We observed 16 cases
(4.1%) with post-operative minor complications (10 hematomas and
6 seromas) which were treated conservatively without aspiration.
During a media follow-up period of 24 months, one patient (0.25%)
developed recurrent hernia at 3 years (a direct recurrence after direct
hernia). No patient needed medication for chronic pain.
Conclusions: Sutureless Lichtenstein repair using self-fixating mesh
could be a feasible and safe method for inguinal hernia patients in
Japan.
P-10550
Chronic postoperative pain & discomfort classification:
through dermatome mapping
Alvarez R
PROBEN
Chronic post operative pain following a surgical procedures oriented to
repair a defect of the inguinal or abdominal area or in some cases
related to a kidney intervention, cesarean procedure or thoracotomy
with the result of lumbar or thoracic nerve injury is a non pleasant situation for any surgeon and frequently a devastating event for the
patient, therefore these situations demand a diligent analysis and especially an accurate classification which provides the closest idea of the
clinical status with a accurate and homologous language.
This classification should include all different descriptions of pain and
its location and level of intensity, also should determine the structure
or structures involved.
Currently is not enough to refer to these complex events with ambiguous terms or just call it a “painful groin”.
Dermatome mapping is the most frequent clinical test used by neurologist and physicians in general and it´s classification allows us to
assess, classify and mainly refer with a specific language those broad
manifestations that unfortunately come with these events.
This tool not only evaluates pain but also the discomfort associated with
foreign body such as meshomas, granulomas & denervation either incidental or therapeutic. The signs & symptoms expressed by every patient
vary since not all events have the same source and therefore not all
post operative pain should have the same approach and treatment.
The dermatome mapping classification provides a test to evaluate postoperative pain & discomfort and objective criteria for its proper diagnosis and treatment.
Hernia (2014) 18 (Suppl 1): S50-S97
P-10824
Laparomesh hernia repair: five years in cubans patient.
Molina E, Lalán J, Mora O, Larios L, Tamayo J
Cuba
Objective: Report our experience in the Laparomesh mesh use for
the treatmen of many hernias the medline and incisional hernia prevention.
Methods: A total of 47 patients that underwent surgery at Manuel
Fajardo and Juan Bruno Zayas Teaching Hospitals, from November
2008 to May 2013, with incisional hernias of the midline or risk to
develovent incisional hernias were presented, with repair by
Laparomesh mesh. In our series a careful preoperative arrangement
was made that included the local preparation of the skin. Cefazolin
was used as a prophylactic antibiotic in all cases. Follow-up times
were: monthly for the first year, each 3 months four for the second.
Results: There was no trans-operative complications, no found sepsis. There have been no manifestations of rejection to the prosthetic
material up to now. No immediate complications as seroma or
hematoma of the surgical found were reported. No hernial relapse
was observed with an average follow-up of 3 years.
Conclusion: Our experience showed that Laparomesh mesh was a
good option to the treatmen and prevention of incisional hernia.
P-11073
The role of pure tissue repairs in a tailored concept for
inguinal hernia repair
Koch A, Lorenz R
Center for Hernia Surgery
The Guidelines of the EHS set a clear recommendation that a mesh
should be used in every male Patient above the age of 18. But is
there a strong evidence fort hat? A Cochrane Review shows that the
use of mesh is associated with a lower rate of recurrence but the
quality of included studies, assessed with jaded scale, were low. The
Guidelines don´t respect the Classification of the EHS. In clinical
praxis it is necessary to include the Hernia size in to the decision
process for an individualized concept in inguinal Hernia repair. The
critical Analysis of the available studies and the results of a prospective study of 1,500 consecutive cases with a minimal follow up of
12 month will discuss the role of Suture Repairs yet.
The current study shows the results of 1,500 inguinal hernia repairs
from 2006 to 2013.
The median age was 48 years. 30% Suture Repairs and 70% Mesh
Repairs. There is an minimum 1 year follow up. Recurrence Rates:
overall 0.8%, Suture Repair 0.6% and Mesh Repair 0.8%.
There were no major complications. The infection rate was 0.4% in
the mesh and 0.3% in the suture group.
Conclusion: In opposite to the EHS Guidelines we can show the
place for suture repair in an tailored concept. For EHS I Hernias the
suture repair is a good choice with low recurrence rates, especially
in young males. The failure of the guidelines ist hat they don´t discriminate between the different hernia sizes.
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P-11228
Mesh ingrowth with concomitant bacterial infection
resulting in inability to explant: A case series of
Parietex mesh repairs
Hanna M, Dissanaike S
Texas Tech University Health Sciences Center
Purpose: Removal is the standard treatment for mesh infection following prosthetic hernia repair. However certain types of mesh may
be less amenable to removal even in the setting of active infection;
we present four such cases, all involving the same composite mesh.
Methods: Four high-risk patients underwent Parietex mesh implantation for large ventral wall hernias and developed subsequent staphylococcus infections with attempted explantation of infected mesh and
wound care.
Results: There was inability to completely explant mesh in all four
cases, leading to chronic purulent wounds and long term complications.
Conclusions: While mesh infection is a recognized complication of
prosthetic hernia repair, many synthetic meshes form a slimy biofilm
and thus can be removed relatively easily. However the structural
qualities of certain types of mesh create ingrowth into tissues even
in the setting of infection, resulting in inability to explant with subsequent long-term chronic wound complications.
P-11555
Laparoscopic repair of a canal of nuck cyst and indirect
inguinal hernia
Gustafson M, Pellini B, Daoud I
St. Francis Hospital and Medical Center
The canal of Nuck is a peritoneal evagination accompanying the
round ligament into the inguinal canal in females. The equivalent of
the processus vaginalis in males, it typically obliterates early in life.
A patent canal can lead to an indirect inguinal hernia or hydrocele.
A noncommunicating hydrocele of the canal may be termed a canal
of Nuck cyst. This is rare and typically presents as a painless, cystic
mass above the labia majora. Traditionally, treatment of a canal of
Nuck hydrocele has been surgical excision via an open anterior
approach. Reviews of the literature suggest an incidence of contralateral inguinal hernia of 2.6%. We report laparoscopic repair of a canal
of Nuck cyst and ipsilateral indirect inguinal hernia.
A 41 year old female with a past surgical history of Cesarean section
presented with a painful mass of the left labia majora that was
increasing in size. Exam revealed a palpable mass that was more
prominent upon standing. Ultrasound demonstrated a well-circumscribed, nonseptated, cystic, avascular mass. Hydrocele of the canal
of Nuck and possible inguinal hernia was suspected. A laparoscopic
approach was decided upon to allow diagnosis and treatment of
inguinal hernia if present. Because of the previous Pfannenstiel incision, we opted for a transabdominal approach. A canal of Nuck cyst
and ipsilateral indirect inguinal hernia were found without a contralateral defect. The hyrocele was excised and a transabdominal
preperitoneal repair of the hernia performed. She recovered without
incident. Pathology was consistent with a hydrocele.
Hydrocele of the canal of Nuck is an uncommon occurrence. To our
knowledge, laparoscopic repair has not previously been reported. We
demonstrate that laparoscopy is a viable approach for treating a canal
of Nuck hydrocele and offers the additional benefit of identifying
and treating concomitant inguinal hernias.
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P-11732
Outcome analysis in complex open ventral hernia
repair with large pore low surface area polypropylene
mesh in the retro-rectus and pre-peritoneal space
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health Systems
Open ventral hernia (OVH) repairs have had historically high recurrence rates. The type of reinforcing material, the layer of reinforcement and the extent of mesh placement is debatable. We propose
mesh placement from xiphoid to pubis. We present our outcome data
of large OVH repair with component muscle separation (CMS) utilizing a large pore low surface area (LPLSA) polypropylene mesh
in the pre-peritoneal or retrorectus placement.
We retrospectively reviewed our prospectively maintained single
institution data base of 208 consecutive patients. Patient demographics were identified and outcome variables including surgical site
occurrences, length of hospital stay and hernia recurrence were evaluated.
Patient follow-up of 6-42 months (mean 28), 144 females and 72
males, age 23-95 years (mean 56), with BMI 23-78 kg/m2 (mean
36), and hernia width 5-28 cm (mean 10) were evaluated. Ninety
eight percent of patients had re-approximation of the rectus muscles
in the midline utilizing an external oblique or transversalis component muscle release. Mesh was placed in the pre-peritoneal space in
164 patients (79%) and retro-rectus space in 44 (21%) patients. Sixty
six surgical site occurrences (31%), including 5 mesh infections
occurred which were successfully managed without mesh removal.
Mean hospital stay was 9.4±6.2 days. One patient developed an enterocutaneous fistula and stayed in the hospital 121 days. Two hernia
recurrences (1%) were noted, both under 6 months from time of operation.
Larger reinforcement of the abdominal wall is appealing to prevent
future hernia recurrence and we feel that reinforcement from xiphoid
to pubis is helpful to minimize recurrence. LPLSA mesh can safely
be placed in this space and infections may be treated without mesh
removal. Patient satisfaction is acceptable. One sub-xiphoid recurrence and one flank recurrence were thought to be secondary to technical aspects of mesh anchoring.
P-11928
Umbilical hernia.
Implementation of a digital data base
Rappoport J, Dominguez C, Carrasco J, Alban M, Silva J,
Rappoport D, Salazar V, Bencina F, Palacios F
Clinical Hospital, University of Chile
Introduction: The implementation of a digital database, will optimize the evaluation of the treatment of this disease.
Methods: We present a digital database, based on FileMaker Pro
program, used in Hernia Unit, Department of Surgery, Clinic
Hospital, University of Chile, which includes 46 variables.
From January 2009 to June 2013, 1,799 patients have been entered
into the database, of which 188 (10.45%), corresponding to umbilical
hernias, 94 females (50%) and 94 male (50%). Mean age 54±13.6
years.
Results: The average BMI was 24.76. Operative time 93 mins.
(Range 20-220). Elective Surgery 168 (89%). Emergency 20 (11%).
Two of them were presented as strangulated hernia, and required
bowel resection. 107 presented a single ring deffect and 81 (53%)
Hernia (2014) 18 (Suppl 1): S50-S97
presented two or more defects. Mesh repair was performed in 169
cases, (90%) and simple repair in19 (10%), mainly in emergency
cases. Open onlay mesh was performed in 111 patients (65.6%),
preperitoneal or retromuscular in 42 cases (24.8%), and laparoscopic
approach in 16 cases (8.5%). Drainage was used in 55 cases (29.2%).
Hevy weight polypropylene mesh was implanted in 120 patients
(71%), composite mesh for intraperitoneal position 16 (9.5%), light
weight polypropylene in 16 (9.5%), polyester autoadhesive in 16
(9.5%), and absorbable polyglactin mesh in 1 case (0.59%). 124
patients, (66%), presented as primary hernia, 34% had one or more
recidives.
Postoperative morbidity occurred in 21 patients, 2 (1.06%) in elective
and 19 (10.1%) in emergency. p <0.05. There was no mortality in
this series. The average hospital stay was 3 days.
Comment: The implementation of a digital record, will more accurately assess the results of treatment of umbilical hernias. Long term
follow up, will let us to evaluate the real utility of the techniques
described in this serie.
P-12180
Mid-transverse epigastric perforator sparing skin flaps
minimize wound morbidity in open ventral hernia
repair
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health Systems
Open ventral hernia (OVH) repair with component muscle separation
(CMS) may devascularize the abdominal wall and lead to dehiscence,
infection, fat necrosis and seroma formation. Numerous approaches
to maintain blood supply to the abdominal wall have been proposed
including an endoscopic muscle release, vertical incision with umbilical perforator sparing and lateral transversalis release without skin
undermining. We present a transverse skin incision with epigastric
perforating skin flaps for OVH repair that maintains skin blood supply and allows access for an external oblique CMS and placement
of trans-muscular sutures.
We retrospectively reviewed our prospectively maintained single
institution data-base of OVH repair with CMS and placement of preperitoneal or retro-muscular polypropylene mesh with 13 consecutive
patients with a transverse incisional epigastric perforator sparing
approach to 13 consecutive previous patients with a traditional transverse incisional approach. Outcome data included seroma, fat necrosis, dehiscence, infection and return to operating room for wound
complications.
In the epigastric perforator sparing group, there was 1 (8%) seroma,
1 (8%) fat necrosis, 0 dehiscence and no return to the operating room
as compared to the same incision with undermining there was 3
(23%) seromas, 2 (15%) fat necrosis, 2 (15%) dehiscences and 3
(23%)return to the operating room for wound complications. Total
surgical site occurrences for the perforator sparing group was 2
(15%) vs 5 (38%) for the undermined group (p<0.05). No mesh was
removed in either group.
OVH repair techniques for abdominal wall reconstruction are important to minimizing recurrence rates. Surgical sight occurrences and
surgical site infections have consistently been reported over 25%.
Consensus opinions agree that preserving blood supply to the adipofascial-cutaneous flaps is important to minimizing wound complications. The perforator sparing mid-transverse incision shows promise
for meeting these demands, and provides ease of anchoring with large
mesh reinforcements.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12208
Pure tissue repair with biological mesh.
A ten-year follow-up
Ravo B, Falasco G
Rome American Hospital
The aetiology of inguinal hernia (IH) is by multifactorial causes
which remain after surgery The use of non biological meshes can be
cause of infections, migration, adhesions, granulomas, fistula formation, erosions to adjacent organs, etc. Biological materials (BM) of
various human and animal origin have been proposed for hernia surgery A study evaluating complications associated with the use of biological mesh for inguinal hernia surgery has started in 2003.
Patients and methods: from April 2003 to June 2013. 104 IH have
being repaired in 101 patients (pts), using a BM (Surgisis-Cook).
There were 87 male (86%) and 14 female (13%) pts, with a mean
age of 59.4 yrs. (range 19-89). Three male pts had bilateral IH, two
male had incarcerated IH, 11 pts (10%) were on anticoagulants, 12
pts (11%) had recurrent IH. 80 pts (79%) had spinal anaesthesia, 21
pts (21%) had general anaesthesia. All received pre- and post-operative i.v. antibiotics. Surgical Technique:The BM is placed under the
transversalis fascia. A tissue repair is carried out with a continuous
suture of prolene, taking transversalis fascia to transversalis fascia.
Results: In all IH (elective 90, emergency 2, recurrent 12) 33 indirect
hernias, 39 direct and 32 direct+indirect. Follow-up ranges from 79
to 122 months, with a median of 8.4 yrs in 94% of pts. Recurrence
2/104 (1.9%) One in a patient with bilateral IH in the first week, in
another pt at six yrs. Mortality 0. Dermal haematic infiltration to the
scrotum 6, to the vulva 1, all resolved spontaneously. Mean recovery
time was 1.2 days (range 1-5 days).Wound infection 0 Urinary retention 11/101 (11%). Inguinal scrotal hypoesthesia 7/101 (7%), which
improved after 4 to 6 months. Fever (39°C) 2/101 (2%), which
responded to single dose of 4 mg betametasone.
Conclusions: The use of BM to reinforce IH tissue repair is safe
and effective.
P-12209
Femoral hernia, results and quality of life
Carrasco J, Muñoz A, Dominquez M, Alban M, Rappoport J,
Rappoport D, Norambuena M, Huerta C, Torres R
Hospital Clinico Universidad de Chile
Introduction: Femoral Hernia (FH) represent only 2 to 5% of hernia
surgery and a high risk of strangulation. Emergency bowel resection
is associated with 6 to 25% of mortality.
The purpose of the present study is to evaluate demographic issues,
surgical treatment and quality of life of FH patients.
Materials and methods: Computed data base was used to register
46 variables, like age, sex, elective (ElS) or emergency surgery
(EmS). and postoperative morbility.
Quality of life was assessed with a telephonic follow up of a previous
validated test T student was performed for statistical analysis and a
p<0.05 was considered significative.
Results: Since January 2002 to June 2013, 211 patients were
included. 48 men (22.75%), female 163 (77.25%).
Elective Surgery (ElS) was performed in 157 patients (74.41%) and
emergency surgery (EmS) in 54 (29.9%).
Mean age of 55.3 years for ElS and 72.8 years for EmS. p <0.007.
Length of hospital stay, 2.37 days for ElS and 7.02 days for Ems.
p<0.002.
S75
Postoperatory morbility 3.82% EmS and 32.65% for Em. p< 0.0001
Postoperatory mortality 0% ElS and 3.7% Em. p<0.002.
Quality of life assesed in 86 patients (37.9%) revealed: Excelent 44
patients (51.16%). Very good 20 (23.26%), good 13 (15.12%), bad
6 (6.98%) and very bad 3 (3.49%).
Comments: FH had a low frequency but a high risk of emergency
surgery. Mortality after bowel resection was 18.18% in this series.
Female incidence is accord with other series.
Mean age of emergency cases was 20 years older than elective cases,
suggest that EmS was in patients with FH of longer evolution and
efforts for early diagnosis and elective surgery may improve the
results of surgical treatment in this pathology.
P-12211
Management considerations in the contaminated
abdominal wall
Fernando I
Hospital Universitario Austral
The management of contaminated abdominal wall provides a complex challenge for any surgical team. the use of biological or not
biological mesh is until controversial in this type of patient. We could
find many options of management of the abdominal wall in the face
of contamination, but in this opportunity we will discuss our way to
achieve better outcomes in the complex patient.
A suitable patient selection, management of nutritional state, control
of local infection, antibiotic therapy, and the use of the adequated
material in the correct place have allowed to take a stance to treat
these patients.
In our hospital, these type of patients are treated in a multidisciplinary way, endured a good nutritional status will allow to get better
local control. The vacuum system is mandatory in these phase of
treatment. Once, local infection has been under control, surgery have
a protagonic place to solve these pathology in one step. First of all
we begin the dirty time ensured a minimum dissection of the abdominal wall (infectious focal control with or without bowel resection)
to continue with the second time where with a meticulous dissection
of the abdominal wall, we can see where is the best place where we
leave the mesh. It could be inlay (flexible composited mesh) or sublay if we can close the posterior wall, using the adequated mesh
material (light macropourus mesh)
S76
P-12212
“Sportsmans Hernia” – The difference between
pubalgia and inguinal pain
Hernia (2014) 18 (Suppl 1): S50-S97
Conclusion: In conclusion, this study demonstrated that hernia surgery with with Gilbert Repair is associated with low rates of recurrence and chronic pain. The rate of satisfied patients is high.
Koch A, Lorenz R
Center for Hernia Surgery
Recent publicity and some scientific reports suggest increasing success in treating an entity called “sports hernia” – more accurately
named athletic pubalgia.
The former concepts do not take into account the likely mechanisms
of injury or various patterns of pain that these athletes exhibit. The
author believes that the concept of a “pubic joint” or “pubic dynamic
complex” is fundamental to understanding the anatomy and pertinent
pathophysiology in these patients. Many injuries can now be treated
successfully. Some of the injuries require surgery and others do not.
We have to look for the Symphyseal bones and the entire anterior
pelvic musculo-sceleton complex around these bones, this is the
“dynamic pubic complex”.
The Approach to to the right therapy is the understanding of this
Complex. Most of the athlets can be cured by a conservative treatment some needs an anterior pelvic floor repair.
The decision to an operative treatment is highly selective, in case of
pubalgia the Revision of the inguinal canal is not enough. The first
choice of treatment is conservative! The discrimination between
inguinal pain and pubalgia is essential to find out the right strategy!
Inguinal pain (bulging with nerve entrapment) ist the domain of operative treatment (minimal repair)
In case of pubalgia anterior pelvic floor repair is the most effective
method with the lowest recurrence rate if the conservative treatment
fails.
P-12215
Knotless tissue control device suture for minimally
invasive closure of abdominal wall defects
Ortiz-Ortiz C
Florida Hospital
Minimally invasive ventral hernia repairs has gained more acceptance
during the past few years. Guidelines for hernia repairs has been
described in order to minimize the risk of recurrence. Laparoscopic
closure of Abdominal Wall defects is quite a challenge due to angles,
size and intrabdominal pressure.
Knotless tissue control device suture for laparoscopic and robotic
closure of defects makes repairs more amenable and easier to performed in situations where closing the hernia defect and deploying
the mesh is a real challenge.
P-12216
Inicial brazilian experience using 3d mesh in
laparoscopic inguinal hernia repair
Morrell A, Cavazolla L, Malcher F, Furtado M, Meyer A, Farah F,
Costas M
Brazil
P-12214
Gilbert repair for inguinal hernia – CCS Evaluation of
more than 6,000 patients
Koch A, Lorenz R, Wiese M, Born H, Cejnar S
Center for Hernia Surgery
Background: With the use of mesh shown to considerably reduce
recurrence rates for hernia repair and the subsequent improvement
in clinical outcomes, focus has now been placed on quality-of-life
outcomes in patients undergoing these repairs, specifically, as they
relate to the mesh prosthesis. In 2007 Heniford et al. propose a new
quality-of-life survey, the Carolinas Comfort Scale (CCS), pertaining
specifically to patients undergoing hernia repair with mesh. (J Am
Coll Surg 2008; 206: 638-644. © 2008 by the American College of
Surgeons)
Methods: 35 ambulant hernia centers in Germany carry on a large
multicenter study on hernia repair using the Gilbert Repair since the
1st of October, 2009. The CCS questionnaire was mailed to all
patients 4 and 12 weeks after surgery. A clinical examination by the
surgeon was also made 4 and 12 weeks postoperatively There are 3
main points in the questionnare: sensation of mesh, movement limitations and pain. For each point, 8 questions (eg. Laying down,
bending over, sitting down, walking etc.) and for every question a
maximum of 5 points is possible.
Results: Between 1st of October 2009 and 31st of August 2013 in
total 6.021 patients were enrolled (median age 54 years).The postoperative morbidity was 1.5% and the recurrence rate after 52 weeks
was 0.4%. Inguinal chronic pain was found in 2.2% The patient satisfaction rate was 98%. The sum score for the satisfied patients is
in correlation with the score published by Heniford in 2008.
Background: Several surgical techniques have been developed over
the past years, and total extraperitoneal (TEP) and transabdominal
preperitoneal inguinal hernia repair (TAPP) are the endoscopic techniques that are most commonly used. The purposes of this study
were to describe and discuss the modifications of using 3-D mesh
in inguinal hernia repair.
Methods: 169 patients who underwent an elective inguinal hernia
repair at a five hospitals in Brazil (Professor Edmundo Vasconcelos
Hospital, São Paulo; Albert Einstein Hospital, São Paulo; Soban
Hospirtal, Jundiai; Anchieta Hospital, Fundação ABC, Santo André;
Graffe Guinle Hospital, Rio de Janeiro) between May 2012 and July
2013 were enrolled prospectively in this study. Operative and postoperative course were studied.
Results: A total of 225 hernia repairs were included in the study.
The hernias were repaired by TEP and TAPP technique; Mean operative time was 32 min in unilateral hernia and 42 min in bilateral
hernia. Most of the patients (95%) were discharged at the same day
of the surgery. The overall postoperative morbidity rate was 0,1%.
The incidence of recurrence rate was 0% in this short period.
Conclusion: Endoscopic hernioplasty is a very effective and safe procedure in the hands of experienced surgeons with specific training.
It is an interesting option in bliateral and recurrent hernia as it obtains
satisfactory results in terms of postoperative pain and morbidity.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12217
Subtotal colectomy and omentectomy for loss of
domain in giant ventral hernias
Ortiz-Ortiz C, Parra-Davila E, Diaz-Hernandez J, Amarante G,
Rojas A
Florida Hospital
Complex Ventral Hernias with loss of domain are challenging cases
for surgeons. Techniques like component Separation have been
describe to allow medialization of the rectus muscle and stabilization
of the abdominal wall.
Giant Hernias with loss of domain precludes medialization of the
abdominal wall even after component separation technique. Due to
lack of space and high intrabdominal pressures, compartment syndrome is a threathening complicaton. Techniques to allow closure
while preventing compartment syndrome includes omentectomy and
bowel resection.
A series of 25 subtotal colectomies with omentectomies have been
done in the last 3 years. Complications including recurrence, mesh
infection, wound infetion, anastomotic leaks and bowel obstructions
where consider.
P-12218
Outcome of abdominal wall hernia repair with biologic
mesh: Permacol vs Strattice
Cheng A, Abbas M, Tejirian T
Kaiser Permanente, Los Angeles Medical Center
The use of biologic mesh in abdominal wall operations has gained
popularity despite a paucity of outcome data. Numerous biologic
products are available with virtually no clinical comparison studies.
We reviewed and compared the experience of a large healthcare
organization with Permacol™ and Strattice™ biologic mesh.
A retrospective study was conducted of patients who underwent
abdominal wall hernia repair with Permacol™ (cross-linked porcine
dermis) and Strattice™ (non-cross-linked porcine dermis) in 14
Southern California hospitals.
270 patient charts were analyzed; 195 Permacol™ and 75 Strattice™.
Operations included ventral/incisional, parastomal, and inguinal hernia repairs. Short-term complications including infection, seroma,
hematoma, and dehiscence were statistically less in the Strattice™
group compared to the Permacol™ group (13% vs 38%, p<0.05). In
Permacol™ patients complication rates were significantly higher in
patients with infected versus clean wounds, BMI>40 kg/m2 versus
BMI<40 kg/m2, and in patients with prior mesh repair. These were
not seen in the Strattice™ group. Both mesh groups had significantly
higher short-term complication and recurrence rates when mesh was
used as a fascial bridge (51% Permacol™, 58% Strattice™). Overall
hernia recurrence was not different between the two groups. In
patients with a history of prior mesh repair, recurrence rates were
significantly higher in those who subsequently underwent Strattice™
repair (50%) versus Permacol™ repair (19.7%) with a mean follow
up of 1.6 years for Strattice™ and 2.1 years for Permacol™.
To date, this is the largest study comparing two types of commonly
used biologic products in abdominal wall hernia repair. In our patient
population undergoing heterogeneous operations, the Strattice™
group has lower short-term complications compared to Permacol™.
However, there was a higher rate of recurrence for Strattice™ in
patients with a prior history of mesh repair. The cross-linked nature
of the mesh material might be contributing to the difference of outcomes with these biologic products.
S77
P-12219
Outcomes analysis of biologic mesh use for abdominal
wall reconstruction in clean-contaminated and
contaminated ventral hernia repair
Kwon E, Piper M, Sbitany H
University of California San Francisco
Background: Repair of grade 3 and grade 4 ventral hernias is a distinct challenge, given the potential for infection, and the comorbid
nature of the patient population. This study evaluates our institutional
outcomes when performing single-stage repair of these hernias, with
biologic mesh for abdominal wall reinforcement.
Methods: A prospectively maintained database was reviewed for all
patients undergoing repair of grade 3 (potentially contaminated) or
grade 4 (infected) hernias, as classified by the Ventral Hernia
Working Group. All those patients undergoing repair with component
separation techniques and biologic mesh reinforcement were
included. Patient demographics, comorbidities, and postoperative
complications were analyzed. Univariate analysis was performed to
define factors predictive of hernia recurrence and wound complications.
Results: A total of 41 patients underwent single-stage repair of grade
3 and grade 4 hernias over a 4-year period. The overall postoperative
wound infection rate was 15%, and hernia recurrence rate was 12%.
Almost all recurrences were seen in grade 4 hernia repairs, and in
those patients undergoing bridging repair of the hernia. One patient
required removal of the biologic mesh. Those factors predicting hernia recurrence were smoking (p=0.023), increasing BMI (p=0.012),
increasing defect size (p=0.010), and bridging repair (p=0.042). No
mesh was removed due to perioperative infection.
Conclusion: Single-stage repair of grade 3 hernias performed with
component separation and biologic mesh reinforcement is effective
and offers a low recurrence rate. Furthermore, the use of biologic
mesh allows for avoidance of mesh explantation in instances of
wound breakdown or infection. Bridging repairs are associated with
a high recurrence rate, as is single-stage repair of grade 4 hernias.
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P-12220
Permissive abdominal hypertension following open
incisional hernia repair: a novel concept
Petro C, Raigani S, Orenstein S, Klick J, Rowbottom J, Novitsky Y,
Rosen M
University Hospitals Case Medical Center
Introduction: Intra-abdominal hypertension (IAH, >12 mmHg) leading to abdominal compartment syndrome (ACS, >20 mmHg with
associated organ dysfuction) can indicate the need for a decompressive laparotomy. However, the physiology and sequelae of primary
IAH/ACS following abdominal wall reconstruction are unknown.
Methods: Bladder pressure (BP) and plateau pressure (PP) were
measured before incision and immediately after fascial closure for
patients undergoing complex open ventral hernia repairs at Case
Medical Center. Measurements were obtained again on post-operative
day (POD)1 and 2 if a bladder catheter remained or the patient
remained intubated. Outcome measures were changes in BP and PP.
Secondary outcomes were incidence of end organ dysfunction such
as respiratory events or acute kidney injury (AKI).
Results: Four men and ten women with an average age of 60 and
body mass index of 33.4 kg/m2 undergoing open repair of incisional
hernias with an average hernia width of 13.2 cm were followed
prospectively. Mean increase in PP after repair was 3 (range -2 to
7) cmH2O. Mean BP was 13 (range 7-21) mmHg preoperatively and
20.4 (12-34) mmHg postoperatively, with 8/14 patients measuring
>20 mmHg following closure. Only one patient remained intubated
post procedure (PP 17->27, BP 11->24) and these values decreased
by the following morning at which time she was extubated (PP 24,
BP 12). All remaining patients were extubated postoperatively and
did not require reintubation (mean BP 20.1) BP decreased in 12/14
patients on POD1 with an average value of 15.1mmHg (range 1-11).
In the 2/14 instances where BP increased on POD1, one patient was
nauseated and vomiting, the other was having significant pain.
Conclusion: Primary IAH and potentially ACS is a predictable outcome following abdominal wall reconstruction. Marked improvement
by POD1 can be expected and is likely attributed to musculofascial
releases that allow the abdominal wall to expand allowing physiologic compensation for the intra-abdominal hypertension.
P-12221
Outcome analysis of light weight large pore
polypropylene mesh in complex open ventral hernia in
clean contaminated and contaminated fields
Zabel D, Conway M, Kalish E, Belgrade J
Christiana Care Health Systems
There is no consensus for a reinforcing mesh material in complicated
open ventral hernia (OVH) repair. Use of synthetic mesh in clean
contaminated and contaminated fields has not been routinely recommended because of poor infection resistance. Recent studies have
suggested that open ventral hernia repairs utilizing bio-prosthetic
mesh in clean contaminated and contaminated fields may have hernia
recurrence rates of more than 30%. The use of light weight, large
pore (LWLP) polypropylene mesh may be considered an alternative
to bio-prosthetic mesh. We aimed to analyze the outcome of implanting LWLP mesh in the pre-peritoneal space for OVH repairs in clean
contaminated and contaminated fields.
Hernia (2014) 18 (Suppl 1): S50-S97
We retrospectively examined our single institution hernia center data
base. Patients with OVH repair and component muscle separation
with at least 1,500 cm2 of LWLP polypropylene mesh in the preperitoneal space that were clean contaminated and contaminated were
included. Outcome parameters included length of hospital stay, surgical site occurrence, mesh removal, and hernia recurrence.
68 patients (28 male, 40 female) with a mean age of 60±14 years
and a body mass index (BMI) of 38±14 kg/m2 were evaluated. There
were 40 clean contaminated and 28 contaminated patients. Mean hospital stay was 7±4 and 9±11 days respectively. There were a total of
29 (42%) surgical site occurrences in the 30 day post-operative
period for the clean contaminated group and 12 (33%) for the contaminated group. No mesh removal and no hernia recurrences were
noted during the follow up of 32±12 months for both groups.
Interestingly, BMI was more predictive of surgical site occurrence
than mesh placement in a contaminated field, p<0.05.
Early analysis of LWLP polypropylene mesh is favorable. The cost
of bio-prosthetic mesh may not justify its use when compared to
LWLP synthetic mesh in OVH repair with CMS if further data support an acceptable risk profile.
P-12222
Initial experience of TEP technique without fixation in
Sao Paulo, Brazil
Meyer A
USP
Background: Several surgical techniques have been developed over
the past years, and total extraperitoneal and transabdominal preperitoneal inguinal hernia repair are the endoscopic techniques that are
most commonly used. The purposes of this study were to describe
and discuss the initial experience of TEP technique (total extraperitoneal inguinal hernia repair) without fixation in São Paulo, Brazil.
Methods: Patients who underwent an elective inguinal hernia repair
were enrolled prospectively in this study. Operative and postoperative
course were studied.
Results: Between May 2009 and May 2013 a total of 381 hernia
repairs were included in the study. The hernias were repaired by total
extraperitoneal technique; three hernias (0.7%) were converted to
open anterior Liechtenstein technique. Mean operative time was 36.2
min in unilateral hernia and 45.36 min in bilateral hernia. Most of
the patients (96%) were discharged at the same day of the surgery.
The overall postoperative morbidity rate was 4.8%. The incidence of
recurrence rate was 0.0% in this short period.
Conclusion: Total extraperitoneal hernioplasty is a very effective and
safe procedure in the hands of experienced surgeons with specific
training. It is an interesting option in bilateral and recurrent hernia
as it obtains satisfactory results in terms of postoperative pain and
morbidity.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12223
The use of bioresorbable polymer mesh in open
inguinal hernia repair reduces post-operative pain and
dysfunction: A pilot investigation.
Rose B, Morfesis A
Owen Drive Surgical Clinic of Fayetteville
Introduction: Currently, the use of bioresorbable polymers in mesh
for open inguinal hernia repair is not completely understood. To date,
four such products exist, all with variable rates of degradation in
vivo. Here we report on the long-term efficacy of a lightweight, polyester plug mesh with 50% degradation at 6 months.
Methods: A prospective cohort was designed and IRB approval was
granted. Patients were offered plug-and-patch repair for their hernias.
They were asked at the time of consultation to complete a pain and
quality of life survey. This assessment was again given at 1 month
and 3 months post-repair. The survey consisted of questions related
to physical activity (lying down, bending, coughing, standing, sitting,
walking flat, and walking on a slope), work-relatedness of their hernia, and patient satisfaction of the repair. The Covidien Parietex plugand-patch hernia system was selected for repair. This mesh is composed of 50% Poly-L-Lactic acid which is resorbed in vivo 6 months
after implantation.
Results: A total of n=26 patients were repaired. 10/26 had an RIH,
10/26 had an LIH, and 6/26 had bilateral inguinal hernias. The mean
age was 55.4 years (26-78) with a mean body weight of 198 pounds
(138-291). At pre-operative evaluation, 17/26 indicated they had at
least one significant physical limitation. At 1 month post-repair 6/26
indicated they had at least one significant physical limitation. And
finally, at 3 months post-repair, 2/26 indicated significant physical
limitation. The were no wound seromas or recurrences. Only 2/26
participants reported persistent chronic groin pain at 3 months. With
the exception of one participant, 25/26 reported that they were either
“satisfied” or “very satisfied” with the outcome of their hernia repair.
Conclusion: This brief pilot investigation demonstrates that the use
of a PLLA-lightweigh polyester mesh for open inguinal hernia repair
is a suitable option.
P-12224
Revision of failed transoral incisionless fundoplication
by subsequent laparoscopic nissen fundoplication
Ashfaq A, Harold K
Mayo Clinic, Arizona
Background: Transoral incisionless fundoplication (TIF) is a new
endoscopic approach for treating gastroesophageal reflux disease
(GERD). In cases of TIF failure, subsequent laparoscopic fundoplication may be required. This study aimed to evaluate the feasibility
and outcomes of laparoscopic nissen fundoplication after failed TIF.
Methods: All patients from 2010 to 2013 who had persistence and
objective evidence of recurrent gastroesophageal reflux after TIF
underwent laparoscopic Nissen fundoplication. Primary outcome
measures included operative time, blood loss, length of hospital stay
and complications encountered.
Results: A total of 5 patients underwent revisional laparoscopic
Nissen fundoplication for recurrent GERD at a median interval of
24 months (range, 16-30) after TIF. Patients had recurrent reflux
symptoms at an average of 1 month following TIF (range, 1-9
months). Average operative time for revisional fundoplication was
S79
94 minutes (range, 65-240) and all surgeries were performed with a
minimal blood loss (<30 ml). There were no cases of gastric or
esophageal perforation. Three patients had additional finding of a
significant hiatal hernia that was fixed simultaneously. Median length
of hospitalization was 2 days (range, 1-3 days). All patients had resolution of symptoms at the last follow up.
Conclusion: Laparoscopic Nissen fundoplication is a feasible and
safe option in a patient who has persistent GERD after a TIF.
Previous TIF did not result in additional operative morbidity.
P-12225
Utilization of biologic mesh materials in repair of
incisional hernias among peritoneal dialysis patients:
The comparison of crosslinked versus non-cross linked
porcine dermis scaffolds
Rose B, Morfesis A
Owen Drive Surgical Clinic of Fayetteville
Introduction: The use of mesh in ventral/incisional hernia repair has
been well described. Currently, there are a number of mesh materials
available for implantation, including those that are purely synthetic,
partially biodegradable, full biodegradable, and biologic scaffold. The
later lacks widespread consensus among its exclusive utilization in
complex, often contaminated abdominal scenarios. Our group has
found that using biologic materials to repair ventral/incisional hernias
among peritoneal dialysis (PD) patients allows for optimum outcomes. It is well known that PD patients have higher intraabdominal
wall pressures, thus putting them at higher risk for the development
of abdominal wall hernias at prior incision sites. This abstract seeks
to explore our institution’s experience with several biologic mesh
products used in PD patients.
Methods: PD patients who presented with a primary or incisional
(trocar site) defect were offered elective open repair using a biologic
graft. The biologic grafts utilized include Strattice (acellular porcine
dermis), Permacol (cross-linked porcine dermis), and XenMatrix
(non cross-linked porcine dermis). Upon repair of the abdominal wall
defect, patients were placed on hemodialysis for variable periods.
Retrospective chart review was then conducted to assess for pertinent
clinical predictors and outcomes at follow up.
Results: n=2 patients underwent repair with acellular procine dermis,
both of which returning to peritoneal dialysis post-repair. n=1 patients
underwent repair using a heavily cross-linked porcine dermis without
complication and also was able to resume peritoneal dialysis readily.
Lastly, n=1 patient underwent repair utilizing a moderately crosslinked porcine dermis and developed an enterocutaneous fistula (EC),
however this only required minimal operative repair and bowel rest,
not explantation of the allograft.
Conclusions: We report this small, long-term case series in efforts
to understand the efficacy of biologic mesh in treating abdominal
wall hernias in PD patients. We believe this is the preferred method
to be applied widely among surgeons.
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P-12226
Utilizing innovative analysis methods to define and
measure optimal technique for fascial closure
Soto-Edwards A, Ursu D, Suchoski J, Russomanno A, Kasten S,
Gillespie B, Minter R
University of Michigan Department of Surgery
Introduction: Incisional hernia is the most common complication in
general surgery with an estimated cost of $2.5 billion/year (USA).
Validated standards support a running suture closure of 5-10mm bites
and 5-10mm travel between bites. Despite these established metrics,
there are few if any simulators for teaching abdominal fascial closure.
Methods: A surgical simulator and iPhone application were developed to allow trainees to perform a 3-D laparotomy closure on artificial human abdominal fascia [AHAF] utilizing standard surgical
equipment and to receive feedback on their performance. The app
uses a photo of their final closure with a client-server architecture
and computer image-processing algorithm to measure the geometries
of their sutures, and longitudinally tracks their performance. Trainee’s
closure attempts are measured against expert surgeons’ closures performed on pre-marked AHAF with 0.5 and 1 cm bites and travel
suture entry points defined.
Results: Utilizing porcine and cadaver laboratory studies of fascia,
along with published experimental data, and the Cambridge
Engineering Selector, AHAF was designed with a neoprene polymer.
This allowed for simulator properties of similar feel on suturing, size
of gap after incision, and force required to pull cut edges to midline
as human fascia. After a closure is performed, the algorithm identifies
the incision, pixel/distance ratio, and stores suture properties to a
database. Feedback via the iPhone application from quantitative values such as stitch count, travel, and bite-size, in reference to the
expert closures instructs students in modifying their technique (e.g.
take smaller bites or travel more).
Conclusions: This mobile surgical simulator for fascial closure will
allow trainees to train to automaticity utilizing clinically established
optimal technique on a realistic 3-D laparotomy model prior to performing fascial closure in patients. Prospective trials are needed to
determine if this training will translate into decreased incisional hernia rates.
P-12227
Totally Laparoscopic management of acute hernia with
prosthetic mesh
Hernandez M, Franklin M, Romo Z, Castillo G
Texas Endosurgery Institute
Background: The indications for minimal access surgery in the
emergency situations have been expanded in the last decade. The
laparoscopic treatment of acutely incarcerated or strangulated hernia
is uncommon and still controversial either inguinal, incisional or any
type of hernia. Recent development of new biologic materials and
technologies in laparoscopy has led to improved results. This
approach allows hernia correction and treatment of the hernia content
leading to swift patient recovery and discharge.
Methods: A prospective database of consecutive series of patients
with any type of acute hernia who underwent laparoscopic repair
with mesh placement was identified. We collected the results of
patients admitted between January 2007 and August 2013.
Demographic characteristics, mode of presentation, type of hernia,
intraoperative findings, postoperative course and complications were
analyzed.
Hernia (2014) 18 (Suppl 1): S50-S97
We practice closure of large defects with nonabsorbable suture, even
if only a limited closure is possible. In our practice, this is usually
accomplished percutaneously, as individual sutures. Any incarceration was reduced and a prosthetic material was used to reinforce the
defect closure.
Results: A total of 644 patients with emergency hernia were analyzed
[Female: 271 (42.1%), Male: 373 (57.9%), the preoperative morbidity heart disease 7%, COPD: 3.95%, diabetes: 6%, obesity: 11%, all
patients underwent emergent laparoscopic procedure for
inguinal/femoral hernia 54%, ventral hernia 20%, incisional hernia
26%, the acute hernia were complicated by incarcerated omentum
64%, incarcerated bowel 16%, strangulated bowel 20%. The rate of
bowel resection was 7% and a conversion rate 2.4%.
Conclusions: The emergency treatment for acutely incarcerated hernia is increasingly tackled using laparoscopic approach and it can be
used without hesitation. The minimal access surgery has a lower
recurrence rates, is associated with a less physiological insult, quicker
recovery, and has a shorter hospital stay, lower postoperative complications such as infections, hernias, and scarring compared with
open techniques.
P-12229
Initial outcomes with an absorbable fixation device for
mesh fixation
Doerhoff C, Bringman S, Bringman J, Hammond J, Romanowski C,
Jones P
SurgiCare of Missouri
Surgeons utilize different methods of mesh fixation including sutures,
mechanical fixation devices, tackers and combinations thereof. An
absorbable fixation device, consisting of polydioxanone and L (-)lactide/glycolide copolymer, was developed for mesh fixation during
hernia repairs. Here we report initial outcomes related to pain and
limitation of movement.
Methods and procedures: The International Hernia Mesh Registry,
a prospective international multi-center registry, collects longitudinal
data on hernia mesh products including fixation methods. Data collection includes baseline characteristics, peri-operative details and
complications. Patients complete the Carolinas Comfort Scale™, a
quality of life questionnaire specific to herniorrhaphy, at baseline and
intervals post-operatively up to 12 months. Symptomatic is defined
as a score > 1 for at least one question. The database was analyzed
to include all patients who received absorbable fixation device straps
(Ethicon Securestrap™ Absorbable Fixation Device, Ethicon,
Somerville, NJ) during hernia mesh repair.
Results: Data on 115 patients across 13 centers with 1, 6 and 12
month data on 60, 34 and 33 patients, respectively was available.
Mean age and Mean BMI were 54.7 years (13.8SD) and 33.7
(15.9SD). Overall hernia types/characteristics were; 83
incisional/ventral; 18 umbilical; 7 trocar and 7 epigastric; 92 primary/initial repairs and 112 laparoscopic repairs. Overall fixation
methods (n): tackers only (42); tackers and sutures (71); tackers,
sutures and fibrin sealant (2). Symptomatic patients with pain and
movement limitations improved from baseline to 12 months (pain
71.8% to 31.3%; movement limitation 59.2% to 19.4%). Most common adverse events reported were 8 (7.0%) seromas and 3 (2.6%)
urinary retentions. 6 (5.2%) patients had self-reported recurrences
(though have not been medically confirmed).
Conclusions: These results provide data on the use of Securestrap™
fixation device across a variety of different hernia surgeries. By 12
months, pain and movement limitations improved compared to baseline.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12234
Long acting local anesthesia – will it have an impact on
the practice of surgery?
Young J, Gilbert A
Hernia Institute of florida
The selection of anesthetic technique for all surgical procedures is
based on the requirements for the specific procedure, and the personal preference of the surgeon and anesthesiologist. Multimodal
anesthesia, which combines the use of general, spinal, or regional
anesthesia with local anesthetic infiltration by the surgeon, has been
increasing in popularity. The control of pain in the post-operative
period has been classically done with opioids, but anti-inflammatories given in the operating room and after surgery have become a
part of the armentarium of the surgical-anesthesia team. This may
have some prolonged effect beyond the period where local injection
of bupivacaine helps to control pain. Up until recently, there has been
no effective long acting injectable local anesthetic preparation to
extend pain control through this post-operative period.
Bupivacaine liposomal injectable solution - depo-bupivacaine (Pacira
Pharmaceuticals Inc, Parsippany, NJ) is a newly FDA approved
injectable preparation of bupivacaine encapsulated in lipid particles
which allows for extended release of the anesthetic. The product has
been used successfully for post-operative pain control after several
different types of surgical procedures, both for in-patients and outpatients. There is evidence that pain after surgical procedures may
lead to over-use of opioids, which can have serious consequences in
the immediate post-operative period including adverse events that
lead to prolonged hospital stay and increased costs. Prolonged postoperative pain can lead to increased opioid usage and even addiction,
as well as an increased risk for chronic pan.
A review of the pharmacology, safety and efficacy of injectable liposomal bupivacaine will be presented. An up-to-date summary of the
methodology for injection for different procedures, including
inguinal, umbilical and incisional hernias, will be described. This
new product has the potential to change the way surgeons from all
disciplines help patients to control post-operative pain.
P-12235
A national evaluation of laparoscopic versus open
ventral hernia repair in the cirrhotic patient
Wormer B, Colavita P, Bradley J, Williams K, Walters A, Heniford B,
Augenstein V
Carolinas Medical Center
Introduction: Ventral hernias commonly arise in the cirrhotic patient
and have poor outcomes when they are repaired in the emergent setting; however few studies have evaluated the outcomes in laparoscopic versus open repair. The objective of this study was to perform
a national analysis of the outcomes of laparoscopic (LVHR) versus
open ventral hernia repair (OVHR) in cirrhotic patients in the elective
and non-elective settings.
Methods: The National Inpatient Sample, which captures approximately 20% of all US inpatient admissions, was queried for adults
undergoing elective and non-elective LVHR or OVHR from 1/200912/2010 using ICD-9-CM coding. Patients were grouped based on a
diagnosis of cirrhosis, with (PORT) or without (CIRR) signs of portal
hypertension (ascites, varices, or encephalopathy). Standard statistical methods were used.
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Results: During the study period, 25,368 patients underwent OVHR,
150 (0.6%) had CIRR and 123 (0.5%) had PORT. 9,419 patients
underwent LVHR, 49 (0.5%) had CIRR and 27 (0.3%) had PORT.
CIRR and PORT had equal rates of incarcerated hernias undergoing
LVHR and OVHR, along with no difference in gender, race, or
Charlson Comorbidity Index. In CIRR, admissions were more commonly elective in LVHR vs OVHR (87.8% vs 63.3%; p<0.05).
Length of stay was shorter in CIRR undergoing LVHR vs OVHR
(4.1±4.4 vs 5.1±4.5 days; p<0.05). For CIRR and PORT, there was
no difference in postoperative wound infection or mortality between
OVHR and LVHR (p>0.05). Mortality was higher for PORT vs CIRR
for OVHR (9.76% vs 1.33%; p<0.05), but not LVHR (7.41% vs
2.04%; p>0.05). Despite repair type, mortality was higher in nonelective vs elective setting in PORT (14.3% vs 3.0%; p<0.05) and
all cirrhotics (9.7% vs 1.5%; p<0.05).
Conclusion: Severity of liver disease influences mortality more in
OVHR than in LVHR, which is associated with decreased LOS in
CIRR patients. Elective VHR should be considered in cirrhotic
patients to improve mortality regardless of the repair type.
P-12483
Glue for mesh fixation in laparoscopic ventral hernia
repair. An experimental comparison with conventional
fixation.
Reynvoet E, Cleven S, Vanlander A, Van Overbeke I, Troisi R,
Berrevoet F
University of Ghent, Department of General and Hepatobiliairy
Surgery
Introduction: The use of glue for mesh fixation in laparoscopic ventral hernia repair is gaining popularity as it is atraumatic to the peritoneum and results in less postoperative pain compared to penetrating
fixation.
Methods: A total of 21 sheep were operated using a hernia model
with two fascial defects of 2 cm2 at the linea alba. One week later
two polypropylene meshes (Dynamesh®) were implanted laparoscopically, using cyanoacrylate glue (Ifabond®) or conventional fixation
(Securestrap®). In half of the animals the fascial defect was closed
before mesh placement. After 1 day (n=6), 2 weeks (n=8) and 6
months (n=6) a second laparoscopy was performed at which hernia
recurrence, mesh integration and adhesion formation were evaluated.
After euthanasia, meshes and abdominal wall were excised to perform burst strength testing and to prepare samples for histopathological evaluation.
Results: One animal died because of intestinal incarceration and was
not used in the analysis. No recurrences were diagnosed in all 20
animals. Mesh placement was satisfying with good incorporation in
both groups. Adhesions could hardly be observed after one day but
were omnipresent at two weeks and six months. No significant difference in adhesion formation was seen between straps and glue.
Burst strength testing exceeded 100N in all samples, independent of
the fixation device used. Not after 1 day, but after 2 weeks the inflammatory cell response was significantly higher in the glue group.
Foreign body reaction (FBR) was most pronounced at two weeks but
no difference was seen between both fixation groups.
Discussion: Using a standardized biomechanical testing system, synthetic glue can be considered an effective fixation in laparoscopic
ventral hernia repair for relatively small mesh sizes. The possible tissue toxicity of cyanoacrylates does not lead to an increased FBR.
No difference in burst strength was observed for closing or not closing the defect.
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P-12484
Recycling the selfexpandable mesh in the laparoscopic
repair of small ventral hernias: a series of
25 consecutive patients
Reynvoet E, Cauwenberge S, Van Der Fraenen D, Feryn T,
Dillemans B
AZ Sint Jan
Introduction: Nowadays the use of a mesh is mandatory, even for
small ventral hernias. To avoid wide tissue dissection for this small
defects, selfexpandable patches for intraperitoneal placement were
launched on the market. However, recent reports describe failure of
this technique as this implies blind placement and good deployment
cannot be controlled. We present an adapted approach, using these
patches in laparoscopic ventral hernia repair.
Methods: This is a retrospective review of all patients in which a
selfexpandable mesh was used to repair small ventral hernia. It concerns a polypropylene mesh with an ePTFE layer and a polyethylene
terephthalate (PET) polymer ring as memory system, developed for
open intraperitoneal placement. In our series the patch was placed
laparoscopically over the fascial defect and fixed with resorbable
tacks. A standardized technique was performed in all cases.
Results: A series of 35 patients was operated from July 2011 to
August 2013. In 10 cases, the mesh was placed by open repair. Of
the 25 hernias treated laparoscopically, 12 were incisional hernias,
12 were primary ventral hernias and one Spighelian hernia. There
were no conversions. The mean operative time was 59.26 min. and
hospital stay was 2.9 days. Postoperative follow-up was complete for
18 patients (72%) with a mean follow-up of 19.7 months. Early postoperative complications consist of 5 seromas, all resolved spontaneously. Wound infection rate was zero. At long-term, no recurrences
were seen. Mean VAS score is 1.18/10 at long-term. Three patients
(12%) describe discomfort while bending and moving with foreign
body sensation.
Discussion: Laparoscopic placement of selfexpandable patches guarantees excellent visualization and correct mesh deployment. This
approach should be considered as a valid alternative for the open
technique in small ventral hernia repair.
P-12486
Mayo health system analysis of endoscopic inguinal
hernia repair mesh fixation
AlJamal Y, Farley D, Paley K
Mayo Clinic
Background: While endoscopic totally extraperitoneal inguinal hernia repair (TEP IHR) offers favorable advantages over conventional
repair, the need for general anesthesia and increased possibility of
urinary retention may be troublesome. Urinary retention and subsequent overnight hospitalization frustrate hernia surgeons and their
patients. Some mesh fixation options may lead to less pain, decrease
use of narcotics and infrequent urinary retention.
Methods: This retrospective study compares TEP-IHR within the
Mayo Health System. While anesthesia, fluid management, and operative technique was consistent, fixation of mesh by titanium tacking
clips (Rochester =21 surgeons) or glue (Owatonna = 3 surgeons) was
varied.
Results: A total of 1944 patients underwent a TEP-IHR: 343 patients
(508 repairs) in Owatonna (O) and 1601 patients (2409 repairs) in
Rochester (R). Patient demographics were similar between groups:
median patient age (O=52, R=56), mean ASA (O=1.9, R=1.8), mean
Hernia (2014) 18 (Suppl 1): S50-S97
BMI (O=28, R=27), etc. Operative times were similar (O=84 min,
R=87 min). The rate of intraoperative issues (peritoneal tear, bladder
injury, conversion to open, etc) was increased for O compared to R
(p<0.05). Among numerous postoperative variables assessed, Groups
O and R differed for urinary retention (2% vs 10%, p<0.05), postoperative pain (0.8% vs 1.6%, p<0.05), and need for hospital admission (6% vs 20%, p<0.05).
Conclusion: Patients undergoing endoscopic inguinal hernioplasty
using glue fixation of mesh had less urinary retention and less need
for overnight hospitalization.
P-12487
Laparoscopic repair of traumatic diaphragmatic hernia
Alaedeen D, Raj N
Cleveland Clinic
Introduction: Diaphragmatic rupture is a rare but serious complication of blunt thoracoabdominal trauma. Pulmonary or intestinal
symptoms may aid in identifying the diagnosis and further aided by
imaging studies.
Methods: We present a case of a 56-year-old man with epilepsy who
had sustained multiple falls presenting with an incarcerated traumatic
diaphragmatic hernia.
Case: At the time of laparoscopy the entire stomach, as well as the
superior aspect of the spleen was seen herniating through the defect,
which measured approximately 12 cm in length. The contents were
reduced laparoscopically. The diaphragmatic defect was repaired
using a running # 1 polyester suture and a left thoracostomy tube
was placed. An intraoperative EGD showed a bezoar in the stomach
with slight superficial ulcerations likely secondary to the gastric
incarceration. Post operatively, he was managed on the regular nursing floor. The chest tube was removed post-operative day 2. He was
tolerating a regular diet by post-perative day 3, and was discharged
from the hospital on postoperative day seven.
Summary: The surgical approach for repair of a diaphragmatic
injury can be either through the chest or abdomen. In the acute setting, an abdominal approach is preferred as this allows examination
of other abdominal contents that are at risk of injury. In the chronic
setting, a combined approach should be entertained, as the surgeon
should anticipate extensive adhesions.
In this case report, we present a minimally invasive approach to a
acute diaphragmatic injury. The laparoscope served as a diagnostic
modality to evaluate for other abdominal injuries as well as reduction
of the contents and repair of the hernia. The defect was repaired primarily using running sutures. The patient did well in the immediate
postoperative period. In stable patients, the laparoscopic approach is
safe and provides the advantages of minimal trauma, earlier recovery,
and decreased hospital stay.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12489
The use of porcine small intestinal submucosa surgisisr
now as biodesigntm as prosthetic material in abdominal
laparoscopic hernia repair: long-term follow-up at
Texas Endosurgery Institute
Hernandez M
Texas Endosurgery Institute
Introduction: Since their introduction in 1995, acellular dermal
matrices (ADMs) have been preferable over synthetic mesh because
they incorporate into host tissue and are relatively resistant to infection. In the event of incarcerated/strangulated hernias and other
potentially contaminated fields, the placement of prosthetic material
remains controversial because of increased risk of recurrence and
infection. Porcine small intestine submucosa mesh (Biodesign by
Cook) has been demonstrated safe and feasible in laparoscopic hernia
repairs in this scenario. We present our 13 year experience, with
placement of Biodesign mesh in potentially or grossly contaminated
fields.
Methods: From May 2000 to June 2013, 304 patients (187 male,
117 female) with 344 procedures were performed. Placement of
Biodesign for either incisional, umbilical, inguinal, femoral or parastomal hernia repair in an infected or potentially contaminated setting
were achieved and studied in a prospective fashion.
Results: All procedures were done laparoscopically. Mean Follow
up was 120 +/- 28.2 months. 233 procedures were performed concurrently with a contaminated procedure. 132 incarcerated hernias,
34 required small intestinal resection; 55 were left inguinal hernia,
83 right inguinal hernia, 81 incisional hernia, 65 umbilical hernia,
17 femoral hernia, 43 multiple defects, 27 seromas (all resolved), 17
recurrences, 34 patients report mild pain and two wound infection.
Conclusion: In our experience the use of Biodesign small intestine
submucosa mesh in contaminated or potentially contaminated fields
is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow up.
P-12490
Seroma after IPOM hernia repair of giant incisional
hernias
Szura M, Solecki R, Matyja A, Kulig J
Jagiellonian University
Incisional hernias after open surgical procedures occur in several percent of operated patients. Most common causes include wound infection, obesity, earlier operations, coexisting diseases, immunosuppresion, and age. One of the treatment methods used to treat incisional
hernia is laparoscopic implantation of intraperitoneal onlay mesh to
close hernia gate and enhance abdominal wall. Seroma is frequently
observed complication of hernia mesh implantation. It is either
asymptomatic or may suggest hernia recurrence. Seromas are localized between the implemented mesh and inner surface of abdominal
wall. Ultrasonographic examination or CT are basic methods used to
confirm these postoperative complications.
The authors evaluated the association between hernia repair and the
incidence of seromas after laparoscopic hernia repair of incisional
hernias.
Material and methods: One hundred fifty eight patients undergoing
laparoscopic hernia repair of incisional hernias between 2008 and
2012 were evaluated retrospectively. A study group consisted of 82
women and 76 men, at the mean age of 59, 3 years. The average
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surface of hernia gate was 193 cm2. Group I consisted of 75 patients
in whom hernia sac was removed, and group II of 83 patients in
whom hernia sac was left. In both groups mesh was fixed by transfascial sutures and tacks.
Results: In group I, there were 6 asymptomatic and 3 symptomatic
seromas. In group II there were 6 asymptomatic and 5 symptomatic
seromas. The average diameter of asymptomatic seromas was 25 cm3,
and 58 cm3 in case of symptomatic seromas. After three-months follow-up, asymptomatic seromas were detected in 3 patients of group
I, and in 4 of group II.
Conclusions: Removal of hernia sac during laparoscopic IPOM hernia repair of incisional hernias lowers the frequency of seromas in
the early postoperative period. In the long-term observation time no
associations were found between removal of hernia sac and frequency of residual seromas.
P-12492
Laparoscopic vs open inguinal hernia repair in
octogenarians: results of a prospective international
study
Kim M, Oommen B, Ross S, Bradley J, Lincourt A, Sing R,
Augenstein V
Department of Surgery, Division of GI and Minimally Invasive
Surgery, Carolinas Medical Center
Introduction: With improvements in medical care, advanced age is
less often a contraindication for elective surgery. Both laparoscopic
and open approaches for repair of inguinal hernias are used for octogenarians, but little is known about the differences in post-operative
outcomes or quality of life (QOL) by operative approach in this population.
Methods: A prospective, international hernia database was queried
for all patients age 80-90 years old that underwent inguinal hernia
repair between 2007 and 2011. Laparoscopic (LIHR) and open
(OIHR) approaches were compared for demographics, comorbidities,
operative details and outcomes, including quality of life (QOL). Data
were examined by standard statistical methods, with significance at
p<0.05.
Results: Of 116 cases, 32 LIHR and 84 OIHR were performed.
Patients were 94% Caucasian, with no differences in gender. The
LIHR group was slightly younger (82±2.5 vs 83±2.4 years; p=0.02),
but groups were similar for major comorbidities. Preoperative QOL
was similar for pain and movement limitation. LIHR had more bilateral repairs (31.3% vs 8.3%; p=0.006) and all were performed under
general anesthesia; OIHR was divided between general (44.1%),
spinal (26.2%) and local (29.8%) anesthesia. LIHR were 68.8%
transabdominal preperitoneal and 28.1% totally extraperitoneal.
Mean OR time, inpatient stay, postoperative urinary complications
and hematoma rates were similar between groups (all p>0.05). There
were no infections, DVT, cardiac issues, reoperation or recurrence
in either group. A subanalysis of OIHR by anesthesia type yielded
similar patient characteristics and postoperative outcomes. No significant differences in pain, activity restriction or mesh sensation
were present for follow-up at 1, 6, 12 or 24-month follow-up; p>0.05.
Conclusion: LIHR and OIHR have similar safety, surgical and QOL
outcomes in patients with advanced age. Octogenarians should not
be excluded from consideration of a minimally invasive repair.
S84
P-12494
Hernia is a mechanical disease
Nicolo E
Jefferson Regional Medical Center
Modern authors are attaching more and more importance to the
Transversalis Fascia as the most solid element of resistance to the
Intra-Abdominal Pressure.
So it is common view today that inguinal hernia is not just a local
disease, but a local manifestation of a systemic disorder of collagen
metabolism affecting the Transversalis Fascia.
This study aims to demonstrate the fact that the true barrier to resist
the Intra-Abdominal Pressure is the contraction of the Internal
Oblique Muscle. The resistance of the Transversalis Fascia, although
fused with the posterior aspect of the aponeurosis of the Transversus
Abdominis Muscle, is limited when non-protected by the contracted
Internal Oblique Muscle.
Inguinal hernia is therefore a mechanical disease, due to the insufficiency and failure of the Internal Oblique Muscle; the anomalies
in collagen metabolism and changed ratio of collagen types are secondary to the mechanical influences, according to the Hooke’s Law
of Physics.
The Physiopathology of inguinal hernia, as a mechanical disease, is
explained as follows:
1. Abnormal function of the Internal Oblique Muscle.
2. The Transversalis Fascia remains unprotected and so, vulnerable
to the increase of the Intra-Abdominal Pressure.
3. It stretches, decompensate and finally gives up and breaks.
4. Hernia.
Inguinal Hernia is a mechanical disease due to the insufficiency and
failure of the Internal Oblique Muscle. The anomalies of the collagen
metabolism, as well as the breaking down of the Transversalis, are
events secondary only to mechanical influences.
P-12495
Quality of life (QOL) outcomes among elderly hernia
patients – Repair or wait?
Hammond J, Romanowski C, Jones P, Lombard J
Ethicon, Inc
Introduction: The so-called “old-old” elderly population (age 80
plus) is the fastest growing demographic in the US. Inguinal herniorrhaphy in this population may have increased risks, however the
potential benefits have not been fully characterized. The objective of
this study is to evaluate hernia repair outcomes on QOL within an
advanced elderly population.
Methods and procedures: The International Hernia Mesh Registry,
a prospective multi-center registry collects longitudinal data on hernia mesh products and fixation methods. Data collection includes
baseline characteristics, peri-operative details and complications.
Patients complete the Carolinas Comfort Scale™ (CCS), QOL questionnaire specific to herniorrhaphy at baseline and intervals postoperatively up to 24 months.
The database was analyzed to include all patients > 80 years old
(making up 4% of the Registry), with 12 month patient reported outcomes. P-values were obtained using McNemar test.
Results: 127 patients from 20 centers in 8 countries, ranging in age
from 80-95 years, were identified. 12 month data on 91 (71.7%)
patients was available. Mean age; 82.9 (3.1SD); Mean BMI; 25.1
(3.6SD). Hernia types (n); 99 inguinal, 17 incisional/ventral; 8 umbilical; 1 trocar, 1 epigastric and 1 femoral. 109 were primary repairs;
98 patients underwent an open repair. Fixation methods included
Hernia (2014) 18 (Suppl 1): S50-S97
sutures only (87); tackers only (22); no fixation method (13); tackers
and sutures (2); glue (1). 74.3% patients returned to normal daily
activities by 1 month postoperatively. 52.0% reported symptomatic
pain pre-operative; reduced to 2.5% still reporting pain at one year
(p<0.001). Symptomatic limitation of movement improved from
40.7% at baseline to 6.5% at one year (p<0.001). Most common
adverse events reported: 3.9% hematoma and 3.9% urinary retention.
3 patients (2.4%) reported recurrences (medically unconfirmed).
Conclusions: These observational results show herniorrhaphy in
octogenarians is safe and can significantly improve their QOL in lieu
of watchful waiting.
P-12496
The original operation of edoardo bassini for the
radical cure of inguinal hernia
Nicolo E
Department of General SurgeryDepartment of General Surgery,
Jefferson Regional Medical Center, Pittsburgh, PA
The original operation of Edoardo Bassini for the radical cure of
inguinal hernia as intended and reported by the “Maestro” in his
monograph (1889), is a milestone in the surgical literature (the socalled North America Bassini operation is an incomplete and simplified edition of the original one.) The obliquity and the length characterize the sphinceter and shutter mechanisms of the inguinal canal.
They are lost in a patient with inguinal hernia.
The obliquity and the length of the inguinal canal with their physicologic mechanisms are re-established reconstructioning the posterior
wall, (reapproximating the triple layer – internal oblique muscle,
transverses muscle and transversalis fascia – to the inguinal ligament)
and the internal inguinal ring, using the original “filzetta” stitch; and
reconstructing the anterior wall and the external inguinal ring.
The original operation of Bassini is a valid and strong method for
the radical cure of inguinal hernia as demonstrated by numerous
reports and our won experience of recurrence rate of less than one
percent.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12497
Indirect inguinal hernia repair using the Ultrapro Plug
and the “double slit” technique, our initial experience
Haggerty S, Sobacki J
NorthShore University Healthsystem
For open inguinal hernia repair, flat mesh, Perfix ™ plug and patch,
Kugal ™ patch, and Prolene Hernia System ™ offer low recurrence
rates. However, there is growing concern about scar tissue, shrinkage
and chronic pain associated with “heavy mesh”. Therefore, we began
using the Ultrapro ™ Plug and Patch in 2007. This is a light weight,
macroporous, partially absorbable mesh plug with a flat preperitoneal
portion. We used a “double slit” technique where the onlay portion
of the plug was slit and placed around the spermatic cord and sewn
to the inguinal ligament medial to the internal ring. The patch was
also slit and sewn around the spermatic cord to the inguinal ligament
lateral to the internal ring. This is a retrospective study to verify this
technique.
Methods: Retrospective data was collected on male patients above
the age of 18 who had repair of indirect inguinal hernia with
Ultrapro™ mesh and the “double slit” technique between June 1,
2007 and December 30, 2012. Long term data was collected by office
visit and examination by the attending surgeon.
Results: A total of 24 patients qualified and consented to follow-up.
The average hernia size was 1.9 cm and the Large Ultrapro plug was
used in all patients. Over an average follow-up of 21 months, recurrence was zero. Groin pain on a scale from 1 to 10, was either a
zero or one in 23 patients (96%) while one 4% had moderate (4/10)
pain. No patients had testicular pain.
Conclusion: Indirect inguinal hernia repair using the Ultrapro Plug
and the “double slit” technique is very effective with low rates of
recurrence and significant chronic pain.
P-12498
Hybrid ventral hernia repair: A novel approach to
abdominal wall reconstruction
Podolsky E, Yoo J
Duke University
Although ventral hernia repair is one of the most common general
surgeries performed, no consensus exists on proper technique.
Historically, open primary fascial approximation repairs were performed but were plagued by high recurrence rates. Advances in technology offered laparoscopic approaches with pliable meshes.
Advantages of laparoscopy including decreased postoperative pain
and ileus, and shorter length of stay were realized. This repair abandoned the dictum of hernia sac excision and primary fascial approximation instead using a mesh for bridging which can result in seroma
formation leaving a visible bulge and nidus for infection. The hybrid
technique combines the open and laparoscopic approach, optimizing
the approach to ventral hernia repair.
22 patients underwent hybrid ventral hernia repair. Laparoscopic
entry was performed first, allowing lysis of adhesions and inspection
of the abdominal wall and defect measurement. An incision was then
made directly over the defect permitting hernia sac excision.
Endoscopic component separation was performed if necessary. Mesh
was inserted into the abdomen, fascia primarily closed, and the
abdomen reinsufflated. Four quadrant transfascial sutures were used
to prevent mesh migration and numerous absorbable tacks were used
to achieve maximum mesh-to-abdominal wall co-aptation
S85
Six males and sixteen females underwent hybrid repair. Umbilical,
incisional, and recurrent hernias were included, emergent and elective. Average age was 47 years (29-66). Average BMI was 32 kg/m2
(22-49). Average mesh size was 242 cm2 (48-600 cm2). Average
length of stay was less than 24 hours.
The hybrid technique combines laparoscopy with mini-laparotomy to
maximize the advantages of both approaches. It allows for excision
of hernia sac and primary approximation of fascia re-creating a more
physiologic abdominal wall with more equal distribution of abdominal wall tension. It permits placement of large meshes while limiting
incision size and undermining flaps. Laparoscopy decreases bowel
manipulation, post-operative pain, and length of stay.
P-12499
Recurrence rates of laparoscopic intraperitoneal onlay
mesh (IPOM) technique inguinal hernia repairs when
performed alone vs at the time of robotic assisted
laparoscopic prostatectomy
Keating J, Schuricht A
Hospital of the University of Pennsylvania
Background: The association between inguinal hernias and prostatectomy has been well documented. Concomitant repair of inguinal
hernias at the time of open, laparoscopic and robotic prostatectomy
has been well described and the procedures are well tolerated.
Methods: Between July 2006 and December 2011, 137 consecutive
inguinal hernia repairs were performed by a single surgeon at one
institution. These procedures were performed using a laparoscopic
intraperitoneal onlay of mesh (IPOM) technique both as a singular
procedure or concomitantly with robotic-assisted laparoscopic prostatectomy (RALP). All repairs were enacted by using a 3 by 6 inch
piece of Omega 3 FA coated mesh (Atrium C-QUR) fixated with
spiral tacks. A retrospective chart review and telephone survey was
conducted to assess adverse outcomes in this patient population.
Results: A total of 63 IPOM procedures without prostatectomy and
74 IPOM procedures during RALP were performed. There were four
recurrences in these 127 consecutive implants (2.92%) with follow
up time ranging between 1. 7 and 7 years. All four recurrences
occurred when IPOM was performed as a lone procedure (4/63;
6.35%), as opposed to at the time of RALP (0/73,0%).
Conclusion: Inguinal hernia repairs using the IPOM technique both
as a singular procedure and concomitantly during RALP have an
acceptably low rate of recurrence. In our experience, there was a
lower rate of recurrence when performed at the time of prostatectomy. During the robotic prostatectomy, the lower abdominal wall
fascia is partially denuded of its peritoneal covering, allowing mesh
apposition directly to the fascia. Conversely, primary IPOM procedures, by definition and in practice, oppose the mesh to intact peritoneum. The placement of coated mesh against intact peritoneum, as
opposed to against bare fascia, may result in decreased tissue
ingrowth and therefore higher rates of recurrence.
S86
P-12500
Use of narrow mesh for the repair of inguinal hernia
Nicolo E
Department of General Surgery, Jefferson Regional Medical Center,
Pittsburgh, PA, USA
Introduction: The aim of this study was to evaluate the feasibility
and efficacy of open anterior mesh repair of inguinal hernia by using
a new narrow preshaped mesh (indian canoa shaped, wide 2 cm, long
5 cm, lateral to the spermatic cord) on postsurgical pain and recurrence.
Materials and methods: A double-blind randomized clinical trial
was performed on 261 patients undergoing open anterior mesh repair
of inguinal hernia from January 2008 through June 2009. Pain at
POD 1, 1 and 6 months after surgery, and 1 year after surgery was
evaluated in both groups using a visual analog scale. Results were
compared using chi-square analysis.
Results: Of the total number of patients enrolled in the study (median
age 51, range 27-86; 94% males) 134 were in the Lichtenstein group
(LG), and 127 were in the narrow mesh group (NMG). Using the
visual analog scale to detect severity of pain on postsurgical day 1,
median scores in the LG and NMG were 3.2 (range 1 to 4) versus
2.8 (range 2 to 4.5). At 1 month after surgery, these scores were 0.9
(range 0 to 3.7) in the LG versus 4 (range 0 to 1.2) in the NMG.
Between 6 months and 1 year after surgery, median scores in the LG
and NMG were 0.4 (range 1 to 3.4) versus 0 (range 0-0.2). At 1 year
chronic inguinodynia post-hernioplasty was seen in 0 (0%) of
patients in the NMG and 12 (9%) patients in the LG (p<0.001). There
were no deaths and no wound infections. There was 1 (0.7%) recurrence in the LG (p<0.97).
Conclusions: In this study we propose a new shaped mesh and
demonstrate it achieves the following:
1. the presence in the inguinal canal of a minimal mesh volume
2. does not bridge the defect but at the same time retains the tension-free status
3. does not encircle the cord at all
4. the cord is almost completely surrounded by the internal oblique
muscle
5. brings the IOM close to the inguinal ligament reconstituting the
function of the muscle and restricting the inguinal area and makes
it more resistant to the abdominal pressure
P-12501
Reinforced dermis graft for ventral hernia repair
Sahoo S, DeLozier K, Derwin K
Cleveland Clinic
Poor long-term durability of biologic grafts often results in bulging,
dehiscence and recurrence after VHR. There is an unmet need for a
graft that possesses both the adequate biologic and long-term
mechanical properties to prevent complications and improve outcomes following VHR. We propose the novel concept of stitching
small amounts of non-resorbable fiber into biologic grafts to develop
a mechanically durable, yet largely natural biologic graft that is both
safe and effective for VHR. The objective of this work is to investigate fiber-reinforcement as a means to improve and maintain the
mechanical properties of HADM during simulated in vivo conditions.
5x5cm HADM grafts were reinforced with 4wt% of 2-0 Prolene.
Native and reinforced (r-HADM) grafts were treated with 21U/ml
collagenase for 8h using an in vitro enzymatic degradation assay
Hernia (2014) 18 (Suppl 1): S50-S97
intended to simulate in vivo degradation. Test constructs were
mechanically tested before and after enzymatic degradation
(n≥6/group/condition) in ball-burst and planar biaxial test setups.
Grafts were tested by both load-to-failure and cyclic fatigue tests.
Biaxial test images were analyzed using videometric strain analysis
to compute the strain distribution within the graft. Failure load, burst
strength, stiffness and cyclic dilatational strain (percent change in
area) of the grafts were reported.
Fiber reinforcement improved failure load, burst strength and stiffness of HADM, both before and after enzymatic degradation. All
grafts underwent significant elongation during cyclic loading. 0h
HADM and both 0h and 8h r-HADM patches showed similar cyclic
fatigue behavior (25%−40% dilatational strain after 1000 cycles).
Enzymatic degradation resulted in significantly higher rate and
amount of strain (52%−65% strain at 1000 cycles) of 8h HADM
patches, with only a fraction of specimens surviving the 1000 cycles.
These results show that fiber reinforcement imparts mechanical durability to r-HADM during enzymatic degradation. We are currently
validating r-HADM durability in a pre-clinical VHR model.
P-12502
Repari of abdominal incisional hernia by
reconstructing the midline and with the onlay use of
biological material
Nicolo E
Department of General Surgery, Jefferson Regional Medical Center,
Pittsburgh, PA, USA
Background: The aim of this study is to describe the feasibility and
efficacy of a new operative technique that reconstitutes the midline
with the onlay use of biologic material as adjuvant for the treatment
of large abdominal incisional hernia.
Materials and methods: Between January 2002 and December 2008
a total of 71 patients underwent repair of a large incisional hernia
with the onlay placement of biological material after the reconstitution of the midline.
Results: The median size of the defect was 195 cm2 (range, 150420). The median operative time was 125 minutes. No intraoperative
complications occurred. The median length of hospital stay was 6
days. Mortality was nil. Wound seroma was the most frequent and
annoying postoperative complication observed in 51 (71%) patients.
There was 1 (1.4%) recurrence.
Conclusions: This study demonstrates the importance of the reconstitution of the midline for the repair of incisional hernia. The success
of the procedure is achieved by the onlay use of biological material
as an adjunctive that provides the conditions for the complete and
definitive healing of the midline.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12507
Outcomes of 157 v-patch implants in the repair of
umbilical, epigastric, and incisional hernias
Keating J, Schuricht A, Data J
Hospital of the University of Pennsylvania
Background: Umbilical and epigastric hernias have traditionally
been repaired using a Mayo or tensioned suture technique, resulting
in recurrence rates as high as 40% and 54%, respectively. Recent
studies have shown that a tension-free repair using mesh can drastically decrease recurrence rates. Wound complication rates associated with onlay prosthetic placement have led physicians to favor a
retrofascial prosthetic placement. Reinforced deployment prostheses
enable retrofascial placement through a small incision, thus avoiding
both the potential morbidity of a larger incision and the costs associated with a laparoscopic approach.
Methods: A retrospective chart review and telephone survey of all
umbilical, epigastric and incisional hernias repaired with V-Patch, a
reinforced deployment prosthesis, by a single surgeon. Data analysis
included: patient characteristics, operative and post-operative metrics,
hernia recurrence and complication rates.
Results: 156 procedures were performed. Implants were performed
from 12/08/09 through 1/28/13. Patient age ranged from 20 to 85
(mean 48). There were 88 females (57.9%) and 64 males (42.1%).
The average BMI was 30.6 (range 16.6-58.5). Patch size distribution
was 78 small (49.7%), 55 medium (35.0%), and 24 large (15.3%).
There were 81 umbilical hernias (51.6%), 36 epigastric hernias
(22.9%), 39 incisional hernias (24.8%) and 1 multiply recurrent
inguinal hernia (0.6%) repaired. Follow-up time ranged from 8
months to 3.8 years. There were 6 hernia recurrences (3.8%).
Complications included 3 patients (1.9%) with mesh infection, 1 with
an enterocutaneous fistula (0.6%), and 1 patient with small bowel
obstruction (0.6%). Four patients required patch explantation (2.5%).
Conclusion: The use of the V-Patch reinforced deployment prosthesis is effective in treatment of umbilical, epigastric, and incisional
hernias. Its use is associated with a low rate of complications.
P-12508
Ventral hernia repair with component separation
technique: the impact of drain duration on wound
complications
Levy S, Plymale M, Davenport D, Smith N, Whittington H, Roth J
University of Kentucky
Background: In order to evacuate accumulating fluid, closed suction
silastic drainage tubes are placed between the mesh and the abdominal wall during ventral hernia repair with abdominal wall reconstruction. Recent literature does not define best practice for timing
of drain removal. We are interested in the impact on the incidence
of wound complications of the length of time drains are left in place.
Methods: After receiving IRB approval, we queried our surgical
database for component separation cases from 2009-2012. Number
of drains, days post-operatively that last drain was removed, and days
postoperatively that wound complication presented were recorded.
Wound complications were defined as superficial cellulitis,
seroma/hematoma, superficial infection, and deep infection.
Results: A total of 117 component separation cases were found; only
cases with CDC Class I wound were included (n=64). Longest drain
duration varied widely (2-171 days post-operatively; mean=22 days).
Cases were divided into four groups based on number of days post-
S87
operative of last drain removal: ≤ 7 days (n=18), 8-14 days (n=16),
15-21 days (n=14), or ≥ 22 days (n=16). No significant relationship
was found between incidence of seroma/hematoma and days postoperatively of last drain removal. Wound complications increased linearly with drain time (chi-square p=0.038, test for linear trend
p=0.006). Using logistic regression to adjust for obesity, patients with
drains in for 29+ days had a 10.4 odds ratio for wound occurrence
relative to drains in ≤ 1 week (95% CI 1.9-58.6, p=0.008).
Conclusions: Wound complications occur frequently following this
procedure. Although many factors are involved in development of
wound complications, we found an increased incidence of wound
infection for patients with drains remaining more than three weeks
post-operatively compared to patients that had drains removed earlier.
In order to define best practice of timing of drain removal a prospective study would be beneficial.
P-12509
Effects of administration of Celecoxib and Ibuprofen
on reducing postoperative intra-abdominal adhesion in
an experimental rat model
Gónzalez-Ojeda A, Álvarez-Villaseñor A, Fuentes-Orozco C,
Chávez-Tostado M, Macías-Amezcua M, García-Rentería J,
Agredano-Jiménez R
Research Unit in Clinical Epidemiology, Specialties Hospital,
Western Medical Center, Mexican Institute of Social Security.
Background: Intraperitoneal adhesion is a major consequence after
abdominal surgery, and its prevention is an important goal. Adhesion
formation depends on angiogenesis. The COX-2 selective inhibitors
are the only approved drugs, which presumably could selectively
inhibit angiogenesis associated with new adhesion formation.
Objective: To evaluate the effectiveness of Celecoxib and Ibuprofen
in reducing or preventing postoperative adhesion formation in an
experimental rat model.
Materials and methods: Wistar rats were used as the experimental
model to study adhesion formation after a median laparotomy to
remove an area of the abdominal wall, replaced with polypropylene
mesh. They were divided into three groups of 10 rats: Control (no
medication), Celecoxib (68 mg/kg/day) and Ibuprofen (30
mg/kg/12hrs). Drugs were administered orally 12 hours and for eight
days after mesh implantation. On day 9, rats were reoperated to evaluate their intra-abdominal adhesions macroscopically. The mesh area
was resected and fixed in 10% formalin for microscopic evaluation.
All animals were euthanized under general anesthesia.
The results are expressed as means and standard deviations.
Differences between groups were evaluated with the Mann-Whitney
U test and were considered statistically significant when p<0.05,
using the statistical software IBM SPSS for Windows (version 20),
property of IBM corporation. The protocol was approved by the local
research committee (Code 2011-1301-69) and all animals were
treated in compliance with Institutional and Mexican Federal
Regulations (NOM-062-ZOO-1999).
Results: Macroscopic scores, using the Adhesion Scoring Group
System for severity and extension, were 2.9±0.52 for Control group,
2.4±0.38 for Ibuprofen group, and 1.1±0.15 Celecoxib group. The
differences were statistically significant between the control group
and Ibuprofen group (p=0.001) and Celecoxib group (p=0.000).
Celecoxib and Ibuprofen groups were compared, the results favored
the Celecoxib treated group (p=0.000).
Conclusions: Celecoxib reduces intraperitoneal adhesions, making
them laxer, softer and with less vascularity.
S88
P-12510
Long term of totally laparoscopic treatment of
Spigelian hernias
Peralta G, Franklin M, Hernandez M, Palomo R, Real Romo Z
Tec Salud
Introduction: Spigelian hernias are formed by a protrusion through
the Spigelian aponeurosis. They often present with vague signs and
symptoms, and the diagnosis can be problematic or elusive. It´s incidence varies from 0.12%-2% of all abdominal wall hernias. Most
Spigelian hernias are treated with open surgery and without mesh;
little is known of the laparoscopic treatment and the long-term follow-up with mesh. The aim of this study was to prospectively evaluate the safety and effectiveness of the laparoscopic treatment of
Spigelian hernias with mesh at the Texas Endosurgery Institute.
Methods: From February 1991 through December 2012, all
Spigelian hernias treated laparoscopically with mesh were prospectively followed. The technique was essentially the same for each procedure and involved (1) lysis of adhesions, (2) reduction of hernia
contents, (3) closure of the defect, (4) 3-5 cm circumferential mesh
coverage beyond the original edges, and (5) trans-fascial fixation of
the mesh.
Results: Twenty five patients were analyzed, all of them having
Spigelian hernia. The subjects included 15 women (60%) and 10 men
(40%), with an age of 62.5±26.5 years. The height of patients was
171±27cm, with a weight of 85.7±32.2 kg. The operative time was
80±40 min. The estimated blood loss was 15±15 ml. The overall
postoperative complication rate was 12%. No conversions to open
approach were required. The mean postoperative hospital stay was
2 days (range from same-day discharge to 5 days). The mean follow
up was 84.6 months (range 13-176 months); no recurrence has been
observed.
Conclusion: The laparoscopic treatment is efficient for repairing
Spigelian hernias, as it offers advantages such as excellent visibility,
minimal morbidity and sometimes, with no hospital admission.
P-12511
Evaluation of absorbable mesh fixation devices at
various deployment angles
Zihni A, Cavallo J, Thompson D, Chowdhury N, Frisella M,
Matthews B, Deeken C
Washington University in St Louis, Department of Surgery, Section of
Minimally Invasive Surgery
Hernia repair failure may occur due to suboptimal mesh fixation by
mechanical constructs before mesh integration. Construct design and
acute penetration angle may alter mesh-tissue fixation strength. We
compared acute fixation strengths of absorbable fixation devices at
various deployment angles, directions of loading, and construct orientations.
Methods: Porcine abdominal walls were sectioned. Constructs were
deployed at 30, 45, 60, and 90 degree angles to fix mesh to the tissue
specimens. Lap-shear testing was performed in upward, downward,
and lateral directions in relation to the abdominal wall cranial-caudal
axis to evaluate fixation. Absorbatack™ (AT), SorbaFix™ (SF), and
SecureStrap™ in vertical (SSV) and horizontal (SSH) orientations in
relation to the abdominal wall cranial-caudal axis were tested. Ten
tests were performed for each combination of device, angle, and loading direction. Failure types and strength data were recorded. Mean
fixation strengths were compared with two-tailed unpaired student’s
t-tests (p<0.05 considered significant). Tukey-Kramer adjustments
were applied to correct for multiple comparisons.
Hernia (2014) 18 (Suppl 1): S50-S97
Results: At 30 degrees, SSH and SSV had greater fixation strengths
(12.95 N, 12.98 N, respectively) than SF (5.70 N; p=0.0057,
p=0.0053, respectively). At 45 degrees, mean fixation strength of
SSH was significantly greater than SF (18.14 N, 11.40 N; p=0.0002).
No differences in strength were identified at 60 or 90 degrees. No
differences in strength were noted between SSV and SSH with different directions of loading. No differences were noted between SS
and AT at any angle. Immediate failure was associated with SF fixation (p<0.0001) and the 30 degree tacking angle (p<0.01).
Conclusions: Mesh-tissue fixation was stronger at acute deployment
angles with SS compared to SF constructs. The 30 degree angle and
the SF device were associated with increased immediate failures.
Varying construct and loading direction did not generate significant
differences in the fixation strength of absorbable fixation devices in
this study.
P-12512
A cellular dermal matrix in recurrent infected ventral
hernia repair. A case report
Levy S, Plymale M, Roth J
University of Kentucky
Introduction: The management of infected ventral hernias is a challenging problem. The use of a synthetic material carries significant
risk of mesh infection. Component separation techniques allow for
tissue advancement for primary defect closure. The adjunct of a biologic mesh may serve to reinforce the repair. The role of acellular
dermal matrices has been recently challenged in the repair of ventral
hernias largely due to cost concerns. However, infected contaminated
hernias represent an area in which dermal tissue offers advantages
over many other synthetic materials. This case highlights a case of
a recurrent infected hernia repair with a human acellular dermal
matrix.
Case description: A 46 y.o. Gentleman with h/o perforated diverticulitis and Hartman procedure presented with a third time recurrent
ventral incisional hernia. The two prior repairs both resulted in mesh
infection and explants. The most recent repair with a porcine dermal
matrix resulted in a postoperative wound complication and the need
for a skin graft. Months following skin grafting, the wound remained
contaminated. Hernia repair was performed in an extraperitoneal
manner with bilateral transversus abdominal muscle release and
placement of a HADM in the retro-rectus space. Postoperative wound
complications ensued requiring two additional re-admissions but the
hernia was ultimately repaired without evidence of recurrence as of
this time.
Discussion: Patients with recurrent hernias in the setting of active
contamination and prior infection represent a unique challenge. This
patient with 3 prior mesh infections and a recurrent contaminated
hernia has done well to date with a biologic mesh reinforcement to
a transverses abdominis release.
Conclusion: The use of biologic meshes such as a HADM should
be considered as an adjunct to abdominal wall reconstruction in challenging infected abdominal wall hernia repairs. Although the use of
biologic meshes has been contested, when utilized appropriately,
good results can be anticipated.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12513
TAPP in inguinoscrotal hernias
Cingolani P, Fernando I
Hospital Universitario Austral
There are two main problems in this type of hernias which make
this procedure more complex. First the size of the hernia sac which
could require a very complicated dissection and secondly a large
defect needs an extensive reconstruction of the abdominal wall with
a large mesh to avoid recurrences. The treatment for this type of hernias by laparoscopy demands a careful selection of patients.
We believe that this type of procedure needs surgeons who work in
teams, in high volume laparoscopic centers, with solid knowledge of
abdominal wall anatomy.
Several technical aspects of this surgery should be known in order
to achieve better outcomes the reduction of large indirect sacs is the
greatest difficulty in this type of hernias. Whenever possible, a complete reduction of the peritoneal sac is attempted; and it is easier to
identify the elements of the cord and avoid injuries.
If not possible, the peritoneal sac is sectioned as high as possible.
The epigastric vessels do not need to be sectioned routinely.
We use a ligthweigth composite mesh of 15 x 15 cm.
In large indirect defects the overlapping of the mesh has to reach
approximately 1-3 cm lateral to ASIS with a stapled fixation.
We don’t usually use drainage.
The rate of complications is higher than normal hernias.
The recurrence rate in these types of hernias could be related to the
small size of the mesh.
In this type of hernias, a mesh with insufficient overlapping may be
pushed into the defect.
For this procedure a larger mesh (15 x 15 cm) should be used and
always with adequated fixation in conclusion under some conditions
wich are a careful selection of patients, trained surgical teams and
some special technical considerations we can have acceptable outcomes compared to normal laparoscopic hernias.
P-12514
Closure of the defect in LVHR
Cingolani P
Hospital Universitario Austral
Laparoscopic approach for ventral hernias in any locations can be a
safe and effective repair technique. The benefits of minimal access
are well known. The repair of the ventral hernia with bridging the
defect with mesh leads to bulging and seromas and doesn’t restore
the physiology of the abdominal wall. We present different techniques to close the defect prior to mesh placement. LVHR with defect
closure confers more advantage in the repair with a more physiologic
abdominal wall reconstruction and reduction in postoperative seromas. Special attention can be focused in postoperative pain who represents the most important complication of this procedure. We present
our experience in 50 cases with this technique in a university hospital.
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P-12515
Initial experience with novel large-pore polypropylene
mesh in complex open ventral hernia
Cobb W, Vargas K, Warren J, Carbonell A
Hernia Center, Greenville Health Center
Background: The open repair of complex incisional hernias utilizing
a large-pore polypropylene mesh in the retrorectus space is becoming
the preferred approach. Wound morbidity remains a concern; however, mesh infection is rare with the larger pore polypropylene constructs. We report our initial series using a novel, large-pore
polypropylene mesh in the retrorectus space for complex abdominal
wall defects.
Methods: A retrospective review of a prospectively maintained hernia database was performed at our center. The initial experience with
a macroporous, condensed polypropylene mesh (Vitamesh, Proxy
Biomedical, Galwin, Ireland) was reviewed. Data on all patients
undergoing complex open incisional hernia repair was included.
Results: Eleven patients underwent open repair of their ventral wall
defect utilizing a retrorectus placement of Vitamesh. Fascial closure
was achieved in all but one case. The mean BMI was 33.3 (range
27-50.1). Of this complex patient population, 5/11 patients had previous failed mesh repairs, 5/11 were diabetic, and 5/11 were active
or previous tobacco smokers. Wound classification was clean in 7
cases; clean-contaminated in 2 and contaminated in 2. Mean defect
size was 174 cm2, requiring an average mesh size of 517 cm2. Minor
wound events occurred in two patients: one with serous drainage and
another with a hematoma. No overt mesh infections have developed.
Conclusion: In this complex patient population, Vitamesh appears
to function well for abdominal wall reconstruction. Initial results are
promising; however, longer follow-up data will be required to make
any conclusive recommendations.
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P-12516
The principles of complexity science applied to the care
of patients with a ventral hernia
Peters C, Ramshaw B
Halifax Health
Introduction: A complexity science approach for healthcare allows
simplification of patient care by designing care around definable
groups, diseases, and/or problems. The information generated by
these care processes can be used to improve value-based outcomes
of care over time.
Methods: Approximately 100 patients presenting with ventral hernias have been evaluated under this model. A subgroup of 49 patients
who underwent attempted laparoscopic approach for ventral hernia
repair with an all PTFE mesh has been statistically analyzed and the
data has been compared with published data to evaluate effectiveness
of this model. Outcomes that define value for this process include
quality measures, like recurrence and pain, patient satisfaction, and
costs for the entire cycle of care. Statistical analyses included factor
analysis, which evaluates complex interactions of many variables and
determines which factors correlate most highly with outcomes.
Results: Patients treated in this model experienced hernia recurrence
rate of 0%, a readmission rate of 2.2% (1 patient), a re-operation
rate of 0%, and a 4.3% incidence of chronic pain (pain persisting
longer than 3 months-2 patients). Using complex data analytics, the
factors which correlated most strongly with patient outcomes are
emotional complexity (depression, anxiety, symptoms of PTSD, etc.),
surgical complexity (size and location of hernia, number of prior
abdominal operations, etc.), and number of hernia recurrences.
Factors often associated with surgical outcomes, such as BMI, smoking and diabetes had no significant influence on the outcomes for
this care process.
Conclusion: A complexity science model for the care of patients
with ventral hernia has the potential to improve the value of care for
this group of patients. The use of a laparoscopic approach using
PTFE mesh has value for a complex group of patients with a ventral
hernia.
P-12517
Value-based clinical quality improvement for
abdominal wall reconstruction
Mirmehdi I, Ramshaw B
Halifax Health
Introduction: Patients considering an abdominal wall reconstruction
procedure often have very complex abdominal wall pathology. The
principles of complex systems science can help to understand how
to define, measure and improve the value of the entire cycle of care
for patients who undergo an abdominal wall reconstruction.
Methods: A multidisciplinary hernia team has defined the process
of care for patients with complex abdominal wall hernias who chose
to undergo an abdominal wall reconstruction. Over the past 18
months, several attempts at process improvement have been instituted
in an attempt to improve the outcomes that measure value- quality,
cost and patient satisfaction measures. Process improvement initiatives include implementing a person-centered, team approach for
patient care, using a long-term resorbable mesh (TIGR Matrix) and
adapting a Transversus Abdominus Release (TAR) approach for
abdominal wall reconstruction.
Results: There were 34 patients cared for after the initial process
improvement (use of TIGR Matrix) and 10 patients who underwent
the TAR approach. Value-based outcomes included length of stay,
Hernia (2014) 18 (Suppl 1): S50-S97
return to activities, recurrent hernias, costs and satisfaction with the
cycle of care. The most difficult measure has been determining accurate costs for the entire cycle of care. The most significant cost reduction in materials costs has been the use of a long-term resorbable
mesh (30 x 20 cm costing $3900) in place of a biologic mesh (30
x 20 costing $13,200 - xenograft or $17,626 - two allografts sewn
together) and the use of the TAR approach in place of an endoscopic
component separation approach.
Conclusion: Value-based outcomes measures including costs, quality
and patient satisfaction should be defined and measured to allow for
sustainable improvement of value. We found that long-term
resorbable mesh used in place of a biologic mesh contributes to
improved value in abdominal wall reconstruction.
P-12518
Pure single incision versus plus one punctured single
incision for TAPP
Chihara N, Suzuki H, Watanabe M, Nakata R, Uchida E
Institute of Gastroenterology, Nippon Medical School, Musashikosugi
Hospital
Single incision laparoscopic surgery has been reported for a repair
of groin hernia. We experienced pure-single incision (P-SI) TAPP.
As a result, we considered that the surgeon-camera assistant coordination was essential to avoid clashing of the instruments and the
laparoscope during the whole procedure. Consequently we reached
the conclusion that the plus one puncture helped to solve these problems. Herein, we report the plus one puncture- single incision (POPSI) TAPP method. This technique aimed to reduce an opportunity to
clash and gain less invasive umbilical incision and cosmetic merit
equivalent to P-SI. Plus one puncture was applied through thin caliber trocar (2-mm minimal port) with needle forceps which is thin
caliber grasper. The puncture was placed at the left lower abdominal
area on the midclavicular line. The surgical procedure was the same
as for standard laparoscopic TAPP. We experienced single incision
TAPP in 45 patients (23 P-SI, 22 POP-SI). The mean age was
51.0±15.6 and 54.3±16.9, BMI was 22.2±2.6 and 20.7±2.1, respectively. We evaluated postoperative pain using 100-mm visual analogue scale (VAS) score on 1st and 2nd, 7th postoperative day and
the degree of postoperative cosmetic satisfaction in ten steps.10
points meant excellent wound. VAS scores for postoperative pain
were no significant differences between P-SI and POP-SI. From the
personal cosmetic point of view, POP-SI was obtained higher satisfaction than P-SI, because of gaining scarless on the one puncture
and umbilical site. Our new technique with plus one puncture enabled
us to reduce the instrumental clash, and obtained the similar quality
of the triangulation as the conventional 3-port TAPP. In addition, this
procedure provided more excellent satisfaction.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12521
Cosmetic mesh repair of severe rectus diastasis
Cheesborough J, Workman C, Dumanian G
Northwestern University
Introduction: Standard abdominoplasty rectus plication techniques
may not suffice for the most severe cases of rectus diastasis. In our
experience, prosthetic mesh facilitates the repair of severe female
pattern rectus diastasis and male pattern epigastric rectus diastasis
with or without concomitant ventral hernias.
Technique: After skin elevation and exposure of the anterior rectus
fascia, the retrorectus space is developed just lateral to the linea alba.
Soft polypropylene uncoated mesh, 7 cm in transverse dimension, is
anchored with transrectus polypropylene sutures with bites taken 4
cm from the incised edge of fascia. The rectus muscles are then
approximated in the midline with interrupted permanent suture. Skin
tailoring via horizontal or vertical pattern abdominoplasty can be
safely performed simultaneously.
Methods: A retrospective review of all abdominal wall surgery
patients treated in the last four years by the senior author was performed. Those patients with either an isolated rectus diastasis repair
with mesh or a combined ventral hernia repair with abdominoplasty
were analyzed.
Results: Five patients, four female and one male, underwent mesh
reinforced midline repair with horizontal or vertical abdominoplasty.
Patient characteristics include: average age 41 years, average BMI
25.9, all nonsmokers, average width of diastasis 7.1 cm, and average
surgery time 166 minutes. After an average of 20 months of follow
up, none of the patients had recurrence of either a bulge or a hernia
by physical examination.
Conclusions: For male and female patients with significant rectus
diastasis, with or without concomitant hernias, the described mesh
repair is both safe and durable. Although this is a larger operation
than plication alone, it may be safely combined with standard horizontal or vertical abdominoplasty skin excision techniques to provide
an aesthetically pleasing overall result.
P-12522
Predicting poor post-operative quality of life (QOL)
following inguinal hernia repair (IHR)
Williams K, Bradley J, Wormer B, Walters A, Lincourt A,
Augenstein V, Heniford B
Carolinas Medical Center
Introduction: IHR is the most common operation performed in the
world with the most common complication being chronic discomfort.
Predictors of QOL outcomes are rarely discussed. This study examines factors forecasting a poor post-operative QOL.
Methods: The prospective International Hernia Mesh Registry
(IHMR) was queried for patients undergoing IHR (2007-2012).
Demographics, operations, outcomes were analyzed. Using the
Carolinas Comfort Scale (CCS), the worst QOL outcomes (post-operative CCS≥3) at 1-year were evaluated. Standard statistical analysis
was applied; p<0.05 was significant.
Results: 1904 IHR were examined. One year follow-up was 83.3%.
Demographics included: age-56±14.7 years, BMI-26.1±4.9 kg/m2,
94% male. Pre-operatively, moderate to debilitating (CCS≥3) pain
and movement limitation were seen in 36.3% and 29.5% of the population. The majority of IHR were outpatient (57.8%), open (58.9%)
under general anesthesia (62.7%) for primary (89.1%), unilateral
(80.0%) hernias. Mesh used was polypropylene (99.8%), lightweight
(61.1%) with suture (56.3%), tack (29.9%) or glue (6.8%) fixation.
Postoperative complications included seroma (3.3%), recurrence
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(1.9%) and hematoma (1.8%). Pre-op pain and movement limitation,
anesthesia type, recurrent, bilateral, hematoma, recurrence, and reoperation were all significant factors in poor post-operative QOL
(CCS≥3). Odds of equivalent or worse post-operative symptoms were
significantly increased for pre-operative CCS≥3, increased with preoperative severity and remained significant when patients with complications were excluded. Odds ratios (95% CI) for post-operative
pain: 3.5 (2.1-5.7) for pre-op CCS≥3, 4.1 (1.8-9.3) for pre-op CCS≥4,
19.5 (4.8-79.6) for pre-op CCS=5. Odds ratios (95% CI) for postoperative movement limitation: 3.3 (1.8-5.8) for pre-op CCS≥3, 7.0
(2.9-16.9) pre-op CCS≥4, 9.6 (2.3-38.9) for pre-op CCS=5. Odds
ratios (95% CI) for post-operative mesh sensation: 2.6 (1.6-4.3) for
pre-op CCS≥3, 3.5 (1.5-7.9) for pre-op CCS≥4, 8.0 (1.9-33.9) for
pre-op CCS=5.
Conclusions: IHR factors impacting poor QOL outcomes include
recurrent or bilateral hernias, postoperative hematoma, or reoperation. Preoperative symptoms significantly predict equivalent or worse
postoperative QOL. Surgeons should stress to patients that significant
preoperative pain and movement limitation may not be improved
postoperatively despite adequate surgical repair.
P-12523
Risk and outcomes of appendectomy with laparoscopic
ventral hernia repair (LVHR)
Kim M, Ross S, Oommen B, Walters A, Augenstein V, Heniford B
Department of Surgery, Division of GI and Minimally Invasive
Surgery, Carolinas Medical Center, Charlotte, NC
Introduction: Appendectomy performed at the time of other procedures has long been a point of controversy among surgeons. We
hypothesize that appendectomy at the time of LVHR (LVHR-A)
results in worse outcomes than with hernia repair alone (LVHR).
Methods: The American College of Surgeons-NSQIP database was
queried from 2005-2011 for all LVHR and LVHR-A. Patients with
age <18 years, emergency procedures, ruptured appendicitis and
abscess were excluded. Demographics, patient characteristics, operative details and outcomes were analyzed with standard statistical
methods, with significance set at p<0.05.
Results: 49606 LVHR and 101 LVHR-A were performed. Groups
varied significantly by age (54.1±14.7 vs 50.8±16.1 years), BMI
(30.7±8.0 vs 29.5±6.6 kg/m2), gender (male: 54.7% vs 46.4%), and
inpatient status (28.9% vs 52.8%); p<0.05. LVHR had more hypertension (40.7% vs 27.4%), smokers (18.1% vs 16.0%), dyspnea with
moderate exertion (6.2% vs 4.7%), and ASA Class III or IV (30.1%
vs 19.8%), but less ETOH use (>2 drinks/day, 2.8% vs 6.7%), severe
COPD (2.8% vs 4.7%), bleeding disorders (2.0% vs 3.8%) and overall lower modified CCI (0.24±0.68 vs 0.32±0.75); all p<0.05. LVHRA had higher rates of sepsis (0.05% vs 16.4%) and contaminated or
dirty wounds (0.8% vs 39.6%). LVHR had longer operative time
(83.9±52.5 vs 65.3±32.1 min) but shorter length of stay (1.1±2.9 vs
1.7±3.5 days). Additionally, LVHR had with fewer wound (0.9 vs
1.9%) and minor (2.3% vs 4.7%) complications; however, major
complications (1.3% vs 0.9%) and 30-day mortality (0.1% vs 0%)
were increased in LVHR; all p<0.001. After multivariate analysis was
performed to control for age, ASA, CCI and exertional dyspnea, only
minor complications were found to be higher in LVHR-A (OR=3.02,
CI 1.25-7.27; p<0.05), with no significant differences in wound complications, major complications, or mortality; all p>0.05.
Conclusion: In selected patients appendectomy may be safely performed at the time of non-emergent LVHR with minimal additional
risk of short-term major morbidity. However, careful consideration
must be given to the specific clinical indications and advantages to
the individual patient.
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P-12525
Laparoscopic repair of suprapubic ventral hernias:
a retrospective comparison with other laparoscopic
ventral hernia repairs
Ray S, Aihni A, Baalman S, Frisells M, Deeken C, Matthews B
Washington University School of Medicine
Introduction: Laparoscopic suprapubic hernia repairs (LSPHR) are
technically difficult due to dissection near important neurovascular
and bony structures, the bladder, and are often in areas of multiple
previous operations. Due to increased rates of recurrence in LSPHRs
in previous studies, the use of transabdominal suture fixation to the
pubic bone, Cooper’s ligament, and above the iliopubic tract has been
recommended. This study retrospectively evaluates outcomes of
LSPHR.
Methods: A retrospective review of 352 patients undergoing laparoscopic ventral hernia repair was conducted between 2004 and 2011
at an academic surgery center for a single surgeon. Suprapubic hernias were identified as those occurring within four centimeters of the
pubic symphysis. Patient data, including demographics, operative
time, length-of-stay, hernia size, and recurrences were reviewed. Data
were compared using Student’s T-test and Chi-square or Fisher’s
Exact Test where appropriate.
Results: 365 patients were reviewed. Eighty-four had LSPHR, 281
had other ventral hernia repairs (OVHR). LSPHRs included 17 males
and 67 females. OVHRs had 143 males and 139 females. Mean age
for LSPHRs was 51.9 years and 57.1 years for OVHR (p<0.05).
Mean BMI for LSPHR and OVHR were 34.1 and 34.0 (p=0.91),
respectively. Average hernia defect was 216.7 cm2 for LSPHR and
148.9 cm2 for OVHR (p<0.05). Mean operative times were 182.6
minutes and 157.0 minutes (p<0.05) for LSPHR and OVHR. Length
of stay for LSPHR was 4.3 days and 4.7 days for OVHR (p=0.28).
Mean follow-up was 18.1 months for LSPHR, and 13.2 months for
OVHR (p<0.001). There were 5 recurrences in the LSPHR group
(6.0%), and 11 in the OVHR group (3.9%) (p=0.16).
Conclusions: Despite larger defect sizes and longer operative times,
suprapubic hernias had similar recurrence rates and perioperative outcomes when compared to other ventral hernias repaired laparoscopically. Technical alterations in mesh fixation have limited recurrences
to a clinically acceptable level.
P-12527
Laparoscopic inguinal hernia repair in high volume
versus low volume centers: does case mix affect patient
outcomes?
Ross S, Kim M, Oommen B, Bradley J, Williams K, Tsirline V,
Zemlyak A, Augenstein V, Heniford B
Carolinas Medical Center, Dept. of Surgery, Division of
Gastrointestinal and Minimally Invasive Surgery
Introduction: Although inguinal hernia repair is one of the most
common General Surgery procedures, debate regarding the operative
approach continues. We examined the institutional volume of laparoscopic (LIHR) and open inguinal hernia repairs (OIHR) and their
corresponding outcomes.
Methods: The International Hernia Mesh Registry was queried for
all IHR. Institutions reporting less than 50 cases were excluded. High
volume laparoscopic centers (HVLC) were defined as centers that
performed >60% LIHR. The Carolinas Comfort Scale was used to
measure quality of life (QOL). Surgical outcomes and QOL were
analyzed using standard statistical methods.
Hernia (2014) 18 (Suppl 1): S50-S97
Results: There were 2,224 IHRs performed at thirteen centers. There
were 7 HVLC and 6 low volume laparoscopic centers (LVLC). A
total of only 7 LIHR were reported by all LVLC. Four of the LVLC
performed no LIHR (67.7%). On average, HVLC performed 81.9%
LIHR. At HVLC, there was a 0.7% rate of hematoma, 4.6% rate of
seroma, 1.9% rate of recurrence and 0.1% rate of surgical site infections (SSI) reported for LIHR. No differences were found in the rate
of surgical complications for OIHR between HVLC and LVLC
(hematoma 2.6% vs 2.3%; seroma 2.6% vs 1.6%; recurrence 0.7%
vs 1.8%; SSI 0% vs 0.9%; all p>0.05). There was no difference in
QOL at 1 year after IHR between HVLC and LVLC (pain 11.4% vs
11.4%; activity limitation 4.0% vs 6.8%; mesh sensation 13.9% vs
12.4%; all p>0.05). At the HVLC, LIHR was associated with a
decreased rate of hematoma formation when compared to OIHR (0.7
vs 2.6%, p=0.01), but there was no difference in seroma, recurrence,
or SSI. Laparoscopic and open techniques demonstrated equal QOL
at HVLC.
Conclusions: LIHR at HVLC is associated with decreased early
post-operative complications, but no significant differences exist in
long-term complications or QOL. The QOL outcomes of open IHR
in HVLC are equal to centers that perform essentially only OIHR;
furthermore, the low volume of laparoscopic cases does not negatively impact the outcomes of OIHR.
P-12528
Mesh reinforcement at time of ostomy reversal
Warren J, Quigley L, Cobb W, Carbonell A
Greenville Health System
The fascial defect resulting from ostomy reversal is associated with
a high incidence of hernia formation. We report an experience of
mesh reinforcement of the stoma site fascial defect at the time of
ostomy closure.
Methods: A retrospective review of a prospectively maintained database was performed for all patients undergoing mesh placement at
the time of ostomy reversal, which is classified as a contaminated
operation. A matched cohort of contaminated hernia repairs not
including ostomy reversal was selected for outcomes comparison.
Results: Fifty four patients underwent hernia repair at time of ostomy
closure (13 Ileostomy, 41 colostomy). Midline incisional hernia was
present in 57.4% of cases. Average defect area was 98.1 cm2, with
a mean width of 8.8 cm. Retromuscular repair was performed in 95%
of cases, with component separation in 57%. Mesh used included
polypropylene (50%), bioabsorbable (39%) and biologic (11%).
Surgical site occurrence (SSO) was 51.9%, and surgical site infection
(SSI) 25.9%. There was no difference in SSO or SSI between the
ostomy reversal group and the matched cohort (51.9% vs 52.8%;
p=0.719). Interestingly, there was no difference in SSI with synthetic
mesh compared to biologic or bioabsorbable mesh (29.6% vs 21.4%;
p=0.547), closure of ileostomy vs colostomy (46.2% vs 19.5%; p=
0.075), or when midline incisional hernia repair was included (25.8%
vs 26.1%; p=1.000). No mesh was removed for infection. Mean follow-up was 11.8 months. Overall recurrence was 7.4%, and no different between synthetic and bioabsorbable/biologic mesh (7.4 vs
7.1%; p=1) or when midline hernia was included (9.7 vs 4.3%;
p=0.618).
Conclusion: Mesh reinforcement of defects at time of ostomy reversal is associated with a low incidence of hernia recurrence. Despite
contamination, synthetic mesh is associated with wound complications comparable to biologic and bioabsorbable meshes.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12529
A prospective international analysis of the quality
of life (QOL) outcomes for the treatment of flank
hernias
Bradley J, Williams K, Walters A, Wormer B, Augenstein V,
Heniford B
Carolinas Medical Center
Background: Flank hernias are uncommon and challenging, and
post-operative QOL has not been studied. Generally, FH are often
painful pre-op and post-op. This study aims to identify the QOL outcomes for laparoscopic (LAP) and open (OPEN) flank hernia repair.
Methods: The prospective International Hernia Mesh Registry was
queried for patients undergoing flank hernia repair from 2007-2013.
Demographics, comorbidities, operative details, complications and
Carolinas Comfort Scale (CCS) measuring QOL were recorded.
Results: Of the 54 total flank hernias, LAP was performed less often
19 (35%) than OPEN 35 (65%) OPEN. Age (57.5±13.1 vs 60.1±4.6),
BMI (29.7±5.9 vs 31.4±5.9), recurrent hernias (36.8% vs 22.9%),
defect size (48.5±37.4 vs 150.3±281.4 cm2) and comorbidities were
similar between LAP and OPEN (p>0.05). There was no difference
in preoperative pain (72.2% vs 56.2%) or movement limitation
(70.6% vs 56.2%). Operative time (100.9±43.8 vs 120.9±61.6 minutes) was similar (p>0.05). Complications for LAP vs OPEN were
equal for seromas (5.3% vs 2.9%; p=1.00) and reoperation (8.6% vs
3.2%; p=0.62). There were no pulmonary or cardiac complications,
surgical site infections, bleeding, or mortality in either group. Length
of stay was shorter for LAP (3.0±1.6 vs 6.4±4.6 days; p=0.0003).
Mean follow up was 18 months. Recurrence rates were 15.8% (LAP)
and 5.7% (OPEN, p=0.33). CCS scores for LAP vs OPEN were no
different for pain, movement limitation or mesh sensation at any time
point (all p>0.05). The number of patients with post-op pain, even at
a year (31.2%), was surprising. Preoperative pain was predictive of
postoperative pain at 1 (p=0.046), 6 (p=0.04), and 12 months (0.003).
Conclusion: Laparoscopic and open flank hernia repair have similar
outcomes and low perioperative morbidity but have recurrence rates
of 6-16%. A moderate number of patients (24%-34%) have discomfort or movement limitations longterm. Preoperative pain predicts
postoperative pain in these patients. Flank hernias remain a challenge
and need further investigation.
P-12530
Risk for venous thromboembolism after ventral
hernia repair
Oommen B, Kim M, Ross S, Bradley J, Walters A, Dacey K,
Heniford B, Augenstein V
Carolinas Medical Center, Department of Surgery, Division of
Gastrointestinal & Minimally Invasive Surgery
Venous thromboembolism (VTE) is a rare, but potentially lethal complication. Our aim was to investigate the incidence of and risk factors
for VTE in ventral hernia patients.
Methods: We queried the ACS-NSQIP database (2005-2011) for
non-emergent, inpatient, ventral hernia repairs (VHR).
Demographics, comorbidities, perioperative details, and outcomes
were analyzed for those with deep vein thrombosis (DVT) or pulmonary embolism (PE) after VHR. Standard statistical methods were
used; p <0.05 was statistically significant.
Results: Of 60,440 VHR, 87% were open. The overall VTE rate was
1.2%: 734 cases total (VTE) including 392 DVT, 259 PE, and 83
with both. Of VTE events, 59.1% occurred prior to discharge (median
S93
5.0±5.5 days from operation) and 40.9% after discharge (median
16.0±7.2 days from surgery); p<0.05. Patients with VTE were older
(62.1±13.1 vs 57.8±14.0 years) and had higher BMI (34.6±9.2 vs
33.4±9.1 kg/m2); both p<0.001. The following preoperative variables
were associated with VTE (p≤0.05): diabetes (1.5% vs 1.2%), severe
dyspnea (3.2% vs 1.1%), dependent functional status (3.7% vs 1.1%),
ventilator dependence (6.6% vs 1.2%), COPD (1.9% vs 1.2%), pneumonia (5.6% vs 1.2%), CHF (3.6% vs 1.2%), hypertension (1.4% vs
1.1%), peripheral vascular disease (2.3% vs 1.2%), hemiplegia (2.7%
vs 1.2%), stroke (3.0% vs 1.2%), cancer (2.6% vs 1.2%), open
wound/infection (2.2% vs 1.2%), >10% loss of body weight (2.7%
vs 1.2%), bleeding disorders (2.3% vs 1.2%), chemotherapy (2.4%
vs 1.2%), radiotherapy (3.6% vs 1.2%), SIRS/sepsis (3.2% vs 1.2%),
prior operation within 30 days (3.5% vs 1.2%), wound class ≥2 (1.9%
vs 0.8%), ASA class IV/V (2.5% vs 1.2%), return to OR (4.5% vs
1.1%). Patients with VTE had longer operative and anesthesia time
and an increased hospital stay, time from surgery to discharge, and
30-day mortality; all p<0.001. Multivariate regression demonstrated
that prior stroke with neurologic deficit (OR 2.2; 95% CI: 1.5-3.3),
bleeding disorder (OR 1.5; 95% CI: 1.1-2.0), sepsis (OR 1.8; 95%
CI: 1.3-2.4), and wound classification (OR:1.3; 95% CI: 1.1-1.5)
were associated independently with development of VTE; p<0.01.
Conclusion: While the overall incidence of VTE in ventral hernia
patients is low, patients at high risk for developing VTE may be
anticipated pre- and post-operatively. High-risk patients may benefit
from aggressive prophylactic measures, including post-discharge
anti-coagulation, for prevention.
P-12533
A large single center experience of lateral abdominal
wall hernia repairs
Warren J, Quigley L, Carbonell A, Cobb W
Greenville Health System
Lateral abdominal wall hernias may occur following a variety of procedures, including anterior spine exposure, urologic procedures,
ostomy closures, or following trauma. Anatomically, these hernias
are challenging and require a complete understanding of abdominal
wall, interparietal and retroperitoneal anatomy for successful repair.
Mesh placement requires extensive dissection of often unfamiliar
planes, and fixation is difficult. We report our experience with open
mesh repair of lateral abdominal wall hernias.
Methods: A retrospective review of a prospectively maintained database was performed to identify patients with a classification of lateral
abdominal wall hernia. Review included patients which may have
had a midline hernia component as well.
Results: A total of 63 patients underwent 66 repairs. Defects were
located subcostal (10), flank/iliac (32), and combined flank and midline incisional (23). Mean patient age was 57 years (range 13-78),
with a mean BMI of 32 kg/m2 (range 19.0-59.1). Mean defect size
was 80.4 cm2, with a mean greatest single dimension of 9.3 cm
(range 2-25 cm). Retromuscular or interparietal repair was performed
in 45.5%, preperitoneal in 33.3%, intraperitoneal in 12.1%, onlay in
6.1% and primary suture repair in 3%. A component separation was
also performed on 28.8% of patients. The rate of surgical site occurrence was 50%, primarily seroma, while the surgical site infection
rate was 15.2%. With a mean follow up of 10.7 months, 6 patients
(9.1%) have documented recurrence.
Conclusion: Synthetic mesh reconstruction of lateral wall hernias is
challenging. Our experience demonstrates the safety and success of
repair using synthetic mesh primarily in the retromuscular, interparietal or preperitoneal planes.
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P-12536
Predicting post-operative wound complications using
data and mathematical modeling
Bradley J, Walters A, Colavita P, Williams K, Dacey K, Lincourt A,
Augenstein V, Heniford B
Carolinas Medical Center
Introduction: Post-operative wound complications represent significant cost to individual patients and the healthcare system as a whole.
Our aim was to develop an algorithm that mathematically identifies
patients at risk for developing wound complications after open ventral hernia repair.
Methods: Prospective, consecutive open ventral hernia repair data
from 2007-2012, including demographics, comorbidities, operative
details, complications, follow-up, and charges were analyzed. Wound
complications included: cellulitis, wound separation, intra-abdominal
abscess, wound and mesh infection. Multivariate logistic regression
(MVR) model was used to calculate adjusted odds ratios of factors
contributing to wound complications and develop a predictive mathematical algorithm.
Results: A total of 531 OVHR were performed. Patients were 58%
female with mean age of 56 years and BMI of 33.6kg/m2. Recurrent
repairs represented 69%. Average defect and mesh size was 158 cm2
and 691 cm2, respectively. Concomitant panniculectomy, component
separation, and advancement flaps were performed in 30%, 24%, and
46% of cases, respectively. Overall wound complication rate was
38.4%. Cellulitis (23.2%) was the most common, followed by wound
infection (22.7%), wound separation (18.9%), mesh infection (2.7%),
and intra-abdominal abscess (2.3%). MVR yielded the following risk
factors for wound complications (with associated odds ratios and
confidence intervals): diabetes 1.46 (0.90-2.37), smoking 1.20 (1.153.20), BMI per unit 1.07 (1.04-1.10), previous hernia repair 2.07
(1.29-3.32), infection at time of surgery 2.62 (1.13-6.10), advancement flaps 2.29 (1.49-3.51), and component separation 1.91 (1.193.08). A predictive, mathematical algorithm calculating percent risk
of wound complications was developed with sensitivity and specificity exceeding 65%. This complex and lengthy algorithm is not
included due to word limitation.
Conclusion: Through the use of vast amounts of data, we have developed a predictive instrument to calculate the risk of wound complications after OVHR. This powerful tool will enable surgeons and
patients to better assess preoperative risk and modify factors preoperatively to improve outcomes.
P-12537
Surgical site occurrences of simultaneous
panniculectomy and incisional hernia repair
Warren J, Quigley L, Cobb W, Carbonell A
Greenville Health System
Background: Horizontal panniculectomy offers the advantage of
wide exposure for hernia repair with elimination of excess skin and
adiposity, yet at the expense of massive subcutaneous flap creation
with its attendant risks. We report our experience of simultaneous
panniculectomy and incisional hernia repair compared to a group of
similar patients with hernia repair alone.
Methods: A retrospective review of a prospectively maintained database was performed for all patients undergoing open incisional hernia
repair with simultaneous panniculectomy. A comparison was made
to a matched cohort of hernia repairs without panniculectomy.
Outcomes, including surgical site occurrences (SSO), surgical site
infection (SSI) and recurrence were analyzed.
Hernia (2014) 18 (Suppl 1): S50-S97
Results: A total of 48 patients underwent simultaneous panniculectomy and incisional hernia repair with mesh. Mean BMI was 34.3
kg/m2 (range 15.0-57.8), with 35% having undergone prior bariatric
surgery. Repair techniques included retromuscular (76%), preperitoneal (10%), intraperitoneal (6%), onlay (6%) and suture (2%) of
patients. Mesh used was polypropylene (86%), biologic/bioabsorbable (12%), and polyester (2%). Component separation was performed in 29.6% of patients. There was no difference in surgical site
occurrence (38.5% vs 38%; p =1.0) or surgical site infection (18.7%
vs 12.4%; p=0.250) between the panniculectomy and non-panniculectomy group. With a mean follow up of 11.4 months, the recurrence rate was 4.2% in the panniculectomy group and 9.3% without
panniculectomy (p=1.0).
Conclusion: The addition of panniculectomy at the time of incisional
hernia repair does not increase the incidence of wound complications,
nor does it affect the likelihood of recurrence and thus should be
strongly considered for patients with excessive abdominal pannus
and incisional hernia.
P-12538
Ventral hernia repair (vhr) in europe and the usa have
similar surgical outcomes: an international prospective
hernia study
Oommen B, Wormer B, Kim M, Ross S, Walters A, Bradley J,
Williams K, Augenstein V, Heniford B
Carolinas Medical Center, Department of Surgery, Division of
Gastrointestinal & Minimally Invasive Surgery
Introduction: Globalization has dramatically increased the exchange
of information around the world, and distribution of medical information has been at the forefront. We compare surgical technique and
outcomes of VHR between the USA and Europe.
Methods: A multinational, prospective database including 41 centers
from the USA and Europe was queried for all VHR performed from
October 2007 to June 2012. Demographics, operative details and outcomes were compared, including quality of life (QOL), which was
measured using the Carolinas Comfort Scale (CCS). Standard statistical methods were used; a p<0.05 was significant.
Results: There were 855 VHRs: 452 (53%) from Europe and 403
(47%) from the USA. In the USA there were more men (55% vs
47%), younger patients (55±13 vs 58±13 years), and laparoscopic
repair (57% vs 36%); all p<0.05. Defects were larger in the USA for
both OVHR (95±203 cm2 vs 85±104 cm2) and LVHR (102±103 cm2
vs 36±38cm2); all p<0.001. Fixation sutures (OVHR: 98% vs 93%;
LVHR: 94% vs 53%), fixation glue (OVHR: 12% vs 4%; LVHR:
17% vs 1%), and fixation tacks (LVHR: 96% vs 90%) were all used
more frequently in the USA (all p<0.001).
When comparing outcomes of open VHR (OVHR) to laparoscopic
VHR (LVHR), the USA and Europe were not statistically different
in preoperative discomfort, postoperative pain medication, antibiotic
use, DVT, pneumonia, surgical site infection, reoperation, recurrence,
or mortality. At 1-month follow-up, the USA reported more postoperative discomfort (OVHR: 53% vs 26%; LVHR: 69% vs 31%) and
movement limitation (OVHR: 46% vs 24%; LVHR: 59% vs 20%)
compared to Europe (p<0.001). However, there were no differences
in QOL between USA and Europe for both OVHR and LVHR at 6,
12, and 24 month follow-up.
Conclusions: Patients undergoing VHR in the USA report more early
post-operative pain and movement limitation and this may be due to
differences in surgical repair techniques; however, long-term outcomes following VHR are similar in Europe and the USA.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12540
Open retromuscular repair of parastomal hernias
Warren J, Quigley L, Carbonell A, Cobb W
Greenville Hospital System
Background: A variety of techniques have been described for the
repair of parastomal hernias, including re-siting with our without
reinforcement, retromuscular open repair, and intraperitoneal mesh
reinforcement using a key-hole or Sugarbaker technique. We report
our experience with the open retromuscular repair of parastomal hernias.
Methods: A retrospective review of a prospectively maintained database was performed to identify patients undergoing parastomal hernia
repair with or without concomitant midline incisional hernia repair
as well.
Results: Forty-eight patients underwent 49 hernia repairs. Mean age
was 62 years (range 16-87) and mean BMI was 30.5 kg/m2 (range
14-51.4). Patients with ASA class 3 comprised 75% of the study population. Mean hernia area was 77.8 cm2 (range, 6.3-351.7) with a
mean defect width of 7.6 cm (range, 2-16). The ostomy was resited
through the mesh in 31 patients left in situ in 18. Thirteen patients
had a concomitant midline incisional hernia and eight patients underwent prophylactic mesh reinforcement at the time of permanent
stoma creation. Retromuscular repair was performed in 85.7% of
patients, 42.9% included a component separation, and polypropylene
mesh was utilized in 71.4% of cases. Surgical site occurrence was
43%, and surgical site infection (SSI) was 22.4%, including 3 patients
with exposed mesh. None of the patients with exposed mesh required
mesh removal. One patient in whom a colostomy was resited through
the mesh developed an early SSI, and later went on to develop a
colocutaneous fistula one year after surgery. This mesh was removed
at the time of reoperation. With a mean follow up of 10.7 months,
the hernia recurrence rate was 12.2%.
Conclusion: Open retromuscular repair of parastomal hernias is a
viable option with an acceptable recurrence rate and wound complications commensurate with the level of contamination of the surgery.
P-12542
Large pore size and controlled mesh elongation,
relevant predictors for mesh integration quality and
shrinkage reduction
Cobb W, Lomanto D, Alves A, Lecuivre J, Ladet S, Bayon Y,
Weyhe D
Hernia Center, Greenville Health Center
Introduction: Macroporous meshes, as defined by a pore size >1mm, are preferred for abdominal wall hernia repair. Whether the
improved tissue integration of meshes is more dependent on density
versus porosity of the material has not been conclusively determined.
The purpose of this study was to assess the comparative tissue integration based on quantitative histology of monofilament meshes in
a minipig hernia model, mimicking a retromuscular mesh placement.
Methods: Five, monofilament, polyester (polyethylene terephthlate;
PET) meshes were implanted in an intramuscular position in minipigs. They differed in terms of weight (40 [LW] vs 90 [HW] g/m2),
porosity (1x1-mm [small pores; SP] vs 2x3-mm [large pores; LP])
and structure (2D vs 3D): 2D-HW-SP; 2D-HW-LP; 2D-LW-SP; 2DLW-LP; 3D-HW-LP. Meshes were explanted at 3 and 21 weeks.
Histologic analyses were performed on explanted specimens using a
series of stainings, for quantitative evaluations of collagen, cell colonization and tissue ingrowth.
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Results: At 3 and 21 weeks, 3D-HW-LP had statistically higher
quantitative collagen counts than the other mesh constructs
(p<0.001). Maturation of newly formed collagen was seen in all constructs, except 2D-LW-SP, with significant increase (p<0.05) in collagen I:III ratios at 21 weeks vs 3 weeks. Quantitative tissue ingrowth
was statistically higher in the 3D-HW-LP and 2D-HW-LP constucts
at both 3 and 21 weeks (p<0.001). The more stretchable - at 50 N
prior to implantation-constructs (e.g. 2D-LW) showed a higher
degree of shrinkage.
Conclusion: Mesh integration into tissue is more dependent on
increasing the porosity of meshes as opposed to reducing their density and appears to be optimal with three-dimensional meshes vs their
two-dimensional counterparts. There is no benefit of mesh weight
reduction in regards of tissue ingrowth. On the contrary a light weight
mesh with high stretchability sounds at higher risk of shrinkage while
not providing the adequate mechanical support.
P-12543
Primary fascial closure with laparoscopic ventral
hernia repair: a systematic review and meta-analysis
Nguyen D, Liang M, Nguyen M, Wilson T, Hicks S, Kao L
University of Texas Health Sciences Center at Houston
Background: Laparoscopic repair of ventral hernias has grown in
popularity. Typically this repair is done with mesh bridge technique
that results in high rates of seroma, eventration (bulging), and patient
dissatisfaction. In effort to reduce these complications, there is growing interest in the role of laparoscopic primary fascial closure with
intra-peritoneal mesh placement. This systematic review seeks to
evaluate the outcomes of closure of the central defect in laparoscopic
ventral hernia repair.
Methods: A literature search of PubMed, Cochrane databases and
Embase was conducted using PRISMA guidelines. MINORS was
used to assess the methodological quality. Primary outcome was hernia recurrence. Secondary outcomes were surgical site infection
(SSI), seroma formation, bulging, and patient centered outcomes
(patient satisfaction, chronic pain and functional status).
Results: Pooled results from the non-closure studies (n=3) were compared to studies reporting closure (n=11). The closure group (n=1849)
had a mean (range) age of 56 (19-100) and the follow-up period was
40 (0-141) months. For the non-closure group (n=255), the mean
(range) age was 56 (26-91) and the follow-up period was 18 (0-108)
months. Recurrences were reduced with closure (1.4% vs 10.2%).
The pooled bulging rate was lower in the closure group (2.1% vs
69.4%). There was less SSI in the closure than non-closure group
(1.8% vs 13.9%). Closure also had a decreased rate of seroma formation (4.6% vs 10.9%) when compared with non-closure. Patient
satisfaction and functional status was higher in closure group than
non-closure (8.8±0.4 vs 7.1±0.5 and 79±2 vs 71±2 [mean±SEM]).
Conclusions: Closure of the central defect results in less recurrence,
bulging, seroma and SSI. Patients with closure are also more satisfied
with the results and have improved functional status. A randomized
controlled trial to evaluate the role of closure of the central defect
in laparoscopic ventral hernia repair is warranted.
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P-12544
Ventral hernia risk score: a stratification score for
evaluation of surgical site infection following open
ventral hernia repair
Liang M, Berger R, Li L, Nguyen M, Hicks S, Kao L
University of Texas Health Sciences Center at Houston
Background: Assessment of patient risk for surgical site infection
(SSI) following open ventral hernia repair is challenging. Most
indices are based on expert opinion, have not been validated, or are
cumbersome. Herein, we aimed to develop a bedside tool to assess
patient risk for SSI following open ventral hernia repair.
Study design: A retrospective study of consecutive open ventral hernia repairs (n=888) at a single institution from 2000-2010 was performed. Rate of SSI were determined by chart review using strict
CDC definition. Stepwise regression models were built to identify
predictors of SSI and internally validated using bootstrapping. Odds
ratios were converted to a point system and summed to create the
Ventral Hernia Risk Score (VHRS) for SSI. Area under the receiver
operating characteristic curve was used to compare the accuracy of
the VHRS models against the National Nosocomial Infection
Surveillance Risk Index and Ventral Hernia Working Group (VHWG)
grade.
Results: The rate of SSI was 22%. Predictors of SSI included concomitant procedures, dissection of skin flaps, American Society of
Anesthesiologists class ≥3, wound class 4, and body mass index ≥40.
The accuracy of the VHRS in predicting SSI exceeded National
Nosocomial Infection Surveillance and VHWG grade.
Conclusions: The VHRS identified patients at increased risk for SSI
more accurately than the National Nosocomial Infection Surveillance
scores and VHWG grade, and can be used to guide clinical decisions
and patient counseling.
P-12577
Is the use an intraperitoneal phisiomesh mesh using the
Sugarbaker tecnique advisable to prevent of
parastomal hernias?
Barreiro J, Bear I, Abaitua G, Diez J, Florez L, Pachero R
Hospital San Agustin
Introduction: Parastomal hernias are a very common complication,
ocurring in excess of 50%. Only a few studies deal with the prophylactic use the mesh to prevent parastomal hernia and show promising
results.
Methods: Twenty-nine patients undergoing elective rectal surgery
with a permanet colostomy, one with an ileostomy and two needing
surgical correction of pre -existing colostomy were enrolled in a
prospective study. A specially designed mesh was implanted prophylactically using a physiomesh intraperitoneal mesh as described.
Patients were followed for a median of 16 months, range 2-28,
months through clinical examination every 3 months.
Results: No infection or any other adverse effect was observed and
no parastomal hernia or stoma protrusión were detected clinicaly.
Twenty five patients had a rutine computed tomography after 12
months, which also confirmed the absence of hernia formation.
Conclusions: The prophylactic use of a physiomesh mesh is a safe
and effective procedure preventing stoma complications such as hernia formation or prolapse, at least in the short term.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12579
Prevention strategy for abdominal wall hernia
formation during open abdominal therapy
Auer T
Medical University Graz, Department of General Surgery
Purpose: Open abdominal therapy (OAT) is mainly used for surgical
treatments of peritonitis, damage control surgery after trauma and
prevention from MOF for the abdominal compartment syndrome.
Different methods have been used for temporary closing of the
abdominal wall. Most of them do not prevent the muscular wall from
shrinking, and after longer OAT-periods, only skin or mesh-graft closure remains as option.
Methods: 2 commercial systems for abdominal negative pressure
therapy (NPT) were used treating 40 patients. A lateral to medial
musculo-fascial tension was created with application of flexible single stiches (by using “Vessel loops”) for temporary adaption of the
abdominal wall. A vessel-loop running suture stapled to the skin
edges was added for skin adaption.
Findings: The wound sizes were mean L 26,5/W 15/D 4,7 cm. The
mean duration of OAT was 17,5 days. Overall abdominal wall closure
rate was 80%, encountered 2 of these patients needed bridging material due to traumatic destruction of large parts of the rectus muscles,
the rate was 85%. 22 of these patients have reached the first postoperative year, 95% of them remained hernia free. 10 patients have
actually reached the second post-operative year; all of them remained
still hernia free.
Conclusions: Musculo-fascial closure rates after OAT are published
ranking from 12 to 24% before using NPT, 50 to 72% with NPT.
Our data have reached a closure rate of 80% (85, 3%), and a stable
result can be observed after 2 years follow up. Since long term results
are very rarely published, this data can be used as a benchmark.
Hernia (2014) 18 (Suppl 1): S50-S97
P-12592
Evaluation of postoperative pain following laparoscopic
ventral hernia repair: a prospective randomized
comparison of absorbable fixation versus conventional
fixation
Lepère M, Cobb W, Barthes T, Edwards C, Narula V, Scheuerlein H,
Becker P
Clinique St. Charles, La Roche Sur Yon, France
Background: Chronic pain after laparoscopic ventral hernia repair
is of concern to every parietal surgeon and may be related to the
mesh fixation method. Absorbable fixation may reduce postoperative
pain compared to metallic fixation. The resorbable AbsorbaTack™
fixation device (Covidien, Mansfield, MA) is intended to allow mesh
stabilization until tissue ingrowth is achieved.
Methods: This post-market, randomized, multicenter study assessed
postoperative pain following hernia repair with either absorbable
(AbsorbaTack™ fixation device) or conventional fixation (ProTack™
fixation device, Covidien). Primary measures included the 11-point
Pain Intensity Numeric Rating Scale (PI-NRS), analgesic consumption, and the McGill Pain Questionnaire (MPQ). Secondary measures
included functional activity and hernia recurrence.
Results: The intent-to-treat analysis included 110 ventral hernia
patients (56 absorbable, 54 conventional). Baseline demographics
were similar between groups. The median number of tacks used was
20 [range 10-90] and 21.5 [6-88] in the absorbable and conventional
arms, respectively. Preoperative PI-NRS score was approximately 1
point higher (p=0.005) in ventral hernia patients receiving absorbable
versus conventional; postoperative pain scores were similar between
fixation methods. Twelve-month follow-up was completed in 74
patients (37 per group). There was a significant correlation between
preoperative and postoperative pain at 1, 6, and 12-month followup; thus, pain data were expressed as change from baseline.
Postoperative pain decrease from baseline was greater in the
absorbable arm by the PI-NRS (p=0.01, 0.02, and 0.12) and MPQ
(p=0.04, 0.03, 0.03) at 1, 6, and 12 months, respectively. There were
no between-group differences in analgesic consumption. The cumulative 12-month hernia rate was 9% (absorbable) versus 4% (conventional; p=0.29).
Conclusions: In patients undergoing ventral hernia repair, results
show a better relief of postoperative pain and discomfort with the
use of resorbable compared to conventional fixation while maintaining a comparable fixation safety. These findings will need to be confirmed in a larger study.
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Hernia (2014) 18 (Suppl 1): S98-S104
VIDEO ABSTRACTS
Videos
© Springer-Verlag 2014
V-103
Mesh cancer: Single-stage reconstruction of the
abdominal wall in a patient presenting with mesh
infection leading to squamous-cell carcinoma of the
skin with bowel invasion and enteric fistula
Birolini C, Utiyama E, Rasslan S
University of São Paulo, School of Medicine
Chronic mesh infection and enteric fistulas are serious complications
of mesh repair; the reconstruction of the abdominal wall in patients
presenting with enteric fistulas is a formidable challenge. The recommended surgical strategies include component separation techniques or staged approaches using absorbable or biological meshes
despite its high recurrence rates and increased surgical site infection
risks. Moreover, the coexistence of an infected mesh is usually seen
as an absolute contra-indication to perform a primary reinforcement
using synthetic mesh.
In this video, we recorded the reconstruction of the abdominal wall
with simultaneous onlay polypropylene mesh reinforcement on a 59
years old white male, presenting with a twenty-four years history of
mesh infection degenerating into squamous cell carcinoma and bowel
invasion, causing a high output entero-atmospheric fistula. On presentation, he had an impaired status; he had a large ulcer with exposed
pieces of polyester mesh and open bowel in his anterior abdominal
wall. There was Staphylococcus aureus growth in the cultures taken
from a sinus.
The operation included a complete resection of the tumor with
removal of the infected mesh including an enterectomy, a partial
colectomy and the tactical removal of the appendix. The midline was
restored by primary approximation of the rectus muscles. The repair
was reinforced using an onlay polypropylene mesh. The post-operative was uneventful, except for a minor skin breakdown. He was
referred for adjuvant chemotherapy. He is followed since June 2012
and he has an anatomically normal and continent abdominal wall,
without infection or tumor recurrence.
V-104
Visceral resection and preoperative pneumoperitoneum
as adjunctive maneuvers to hernia repair:
Giant inguinal hernia
Birolini C, Utiyama E, Rasslan S
University of São Paulo, School of Medicine
Giant ventral hernias are the ultimate challenge in hernia surgery.
The treatment of hernias with loss of domicile has a considerable
risk of abdominal compartment syndrome and high mortality. The
adjunctive maneuvers to treat giant hernias include weight loss, progressive preoperative pneumoperitoneum (PPP) and component separation techniques, to increase the abdominal volume. Visceral resection, although controversial, is a valuable maneuver to consider in
patients with massive hernias.
In this video, we recorded the operation performed on a 63 years
old white male, presenting with a giant right inguinal hernia. He had
multiple comorbidities, including diabetes, hypertension, atrial fibrillation and a heart ejection fraction of 30%. The whole small bowel
and the right and transverse colon were within the hernia sac, and
the volume ratio was 44%. He was included in our PPP protocol and
prepared during 20 days, to reach an 8,000 ml volume of inflated
CO2.
The operation included an extended right colectomy with ileum transverse anastomosis, a right orchiectomy and the resection of the
exceeding scrotal skin. The inguinal hernia was treated by a double
mesh reinforcement - Rives / Onlay repair using standard polypropylene mesh. The post-operative was uneventful, except for a reversible
renal failure and urinary infection. He was discharged on the postoperative day 20 and he is being followed since May 2013.
Hernia (2014) 18 (Suppl 1): S98-S104
V-105
Visceral resection and preoperative pneumoperitoneum
as adjunctive maneuvers to hernia repair:
Giant ventral hernia
Birolini C, Utiyama E, Rasslan S
University of são Paulo, School of Medicine
Giant ventral hernias are the ultimate challenge in hernia surgery.
The treatment of hernias with loss of domicile has a considerable
risk of abdominal compartment syndrome and high mortality. The
adjunctive maneuvers to treat giant hernias include weight loss, progressive preoperative pneumoperitoneum (PPP) and component separation techniques, to increase the abdominal volume. Visceral resection, although controversial, is a valuable maneuver to consider in
patients with massive hernias.
In this video, we recorded the operation performed on a 54 years
old white female, with a BMI of 41, presenting with a giant ventral
hernia. She had multiple comorbidities, including diabetes, hypertension and chronic obstructive lung disease. The volume ratio was 30%.
She was included in our PPP protocol and prepared during 15 days,
to reach a 6,000 ml volume of inflated CO2.
The operation included an extended right colectomy with ileum transverse anastomosis, a hysterectomy and a dermolipectomy. The
abdominal wall was treated by primary closure of the main defect
and reconstruction of the midline since she had other smaller defects
along a previous laparotomy incision. A large onlay standard
polypropylene mesh was used to reinforce the repair. Despite PPP
and visceral resection, she developed SIRS, acute renal failure and
pulmonary embolism, requiring ICU stay for hemodialysis and respiratory support during 10 days. She was discharged on the postoperative day 30, and she is being followed since March 2013.
V-111
Ileal conduit and colostomy revision with two
parastomal hernia repairs using synthetic mesh
Petro C, Rosen M, Novitsky Y
University Hospitals Case Medical Center
Introduction: A 46-year-old male with a history of rectal cancer status-post neoadjuvant radiation and pelvic exenteration presented two
years later with painful bulges adjacent to his end colostomy and
ileal conduit. A CT scan confirmed bilateral parastomal hernias which
were irreducible in clinic.
Methods: The patient underwent revision of both stomas and repair
of the parastomal defects using a posterior component separation,
transversus abdominis muscle release (TAR) and retromuscular mesh
sublay using synthetic mesh (polypropylene). The colostomy was
fashioned at a new site in the left upper quadrant and the ileal conduit
was revised at its original location, as it was not able to reach a new
site.
Results: The patient developed a superficial wound infection that
required opening 6cm of his midline incision, 14 days of antibiotics
and wet-to-dry dressing changes. At 3 and 6-month follow-up, his
incisions have healed well and there are no signs of infection or
recurrence. He reports significant improvement in his quality of life.
Conclusion: This case highlights technical aspects important to successful stoma revision in the context of a posterior component separation and TAR. The use of synthetic mesh in contaminated surgical
fields continues to be controversial.
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V-114
Evolution of robotic ventral hernia repair
Ballecer C, Prebil B
Center for Minimally Invasive and Robotic Surgery
My presentation will provide a video evolution of robotic ventral
hernia repair in our general surgery practice. We started performing
robotic ventral hernia bridging mesh repairs similar to conventional
laparoscopic technique. We evolved into closing defects starting from
small umbilical hernias to larger ventral and incisional hernias.
Armed with the ability to close defects with relative ease and fearful
of visceral adhesion to intraperitoneal onlay mesh, we can now place
our mesh in a preperitoneal or retrorectus position as described by
Rives−Stoppa. We can now also perform posterior component separation as described by A Carbonell et al for large incisional hernias
as well as hernias with loss of domain. We believe that with the
robot we can now do repairs that were traditionally reserved for open
cases which results in not only a durable repair but most importantly
our patients enjoy the well described benefits of minimal access surgery. The da Vinci robot is a tool we believe will transform minimally
invasive surgery as we know it. The evolution of our technique for
hernia repair provides the evidence.
V-120
The use of ProGrip™ laparoscopic self-fixating mesh in
TEP repair of inguinal hernia
Boyd C
Memorial Health University Medical Center
The use of self-fixating mesh has been used extensively with great
success in open inguinal hernia repair and offers the advantages of
ease of use and the potential for less postoperative pain and decreased
incidence of sensory nerve damage. A new self-fixating mesh
designed for use in the laparoscopic repair of inguinal hernia adds
the advantage of eliminating the pain and costs associated with tack
fixation. One surface of Laparoscopic ProGrip™ Mesh is covered
with a fine collagen film that facilitates insertion, placement and
positioning of the mesh. Secure fixation is assured by the five thousand absorbable microgrips. The self-fixating mesh eliminates the
potential for recurrence under the inferior edge of the mesh posterior
to the iliopubic tract. The video demonstrates a technique for mesh
preparation and placement. The technique is simple, easy to use, and
rapid. Two cases of laparoscopic TEP repair of inguinal hernia are
presented that exhibit the details of the technique as well as the
unique properties of the new mesh.
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V-128
Laporascopic revisional repair of inguinal hernia
Sadek R, Wassef A
Rutgers University
We present the case of a 65 year old male with a prior history of
right inguinal hernia repair. Upon examination it was discovered that
the patient had a recurrent right inguinal hernia. The normal course
of action, according to medical literature, is to repair the inguinal
hernia with an Open surgical approach. Entrance into a previously
operated laparoscopic space is known for its difficulty due to
obstructed surgical field of view caused by increases in adhesion and
slight distortion of anatomy tissues during dissection. Yet, due to the
patients concerns of scarring, the option of laparoscopic repair with
a possible conversion to open procedure was made available. The
Laparoscopic inguinal hernia repair procedure proved successful, one
year with no recurrence to date. The following video describes a new
surgical technique to avoid obstructions of view, and ensure a safe
efficient method of laparoscopic revisional hernia repair.
V-143
Single port TEP without balloon and tacks performed
under local anesthesia
Wada N, Furukawa T, Kitagawa Y
Department of Surgery, Keio University School of Medicine
Introduction: Laparoscopic hernia repair is considered to be minimally invasive. Pneumoperitoneum, however, usually requires muscle relaxation and general anesthesia. We have developed a novel
technique for single-incision endoscopic totally extraperitoneal (TEP)
hernia surgery which is feasible even under local anesthesia. This
procedure does not require the use of dissecting balloon or tacks for
mesh fixation.
Methods: From January 2012 to August 2013, a consecutive group
of 44 patients with bilateral inguinal hernia was included. We used
0.5% lidocaine with epinephrine (1:100,000) as a local anesthetic.
An incision of 30 mm in the lower abdomen was made and a wound
protector with sealing silicon cap was placed. Three 5 mm trocars
were inserted through the cap. A 5 mm flexible laparoscope was
employed. A flat self-fixating mesh with resorbable microgrip was
installed and spread over the entire myopectineal orifice of Fruchaud
with enough overlap.
Results: The age (mean±SD) was 67±10 and male sex was 91%.
The operating time was 166±32 min. Total lidocaine dose was
114±27 mg. All patients were awake but sedated with intermittent
intravenous pethidine (54±18 mg) and flunitrazepam (0.4±0.3 mg).
Surgical complications were not observed except for 13 cases
(29.5%) of minor seromas. Pneumoperitoneum due to peritoneal tear
was occurred in 3 cases (6.8%) and managed with laparoscopic suturing devices. During median follow-up of 9 months, we observed no
hernia recurrence.
Conclusions: Short term outcomes were similar to those of conventional TEP or open hernia repair. Surgical invasiveness would have
been reduced because the area of preperitoneal dissection is smaller
in this procedure than in the umbilical approach. Postoperative recovery was rapid and patients can walk soon after surgery. This novel
procedure may be a promising strategy to reduce the invasiveness of
hernia repair.
Hernia (2014) 18 (Suppl 1): S98-S104
V-149
Laparoscopic inguinal hernia repair with ProGrip
Laparoscopic self-fixating mesh
Kenler A
Yale New Haven Health
The 15 x 10 cm ProGrip™ laparoscopic self-fixating mesh is brought
onto the field. It is furled in such a manner that the anterior and posterior limbs are approximately the same length. The midline is
marked with a blue marking pen as is the posterior limb. The mesh
is then hydrated and placed through the camera port into the
extraperitoneal space as it is pushed away from the surgical operator.
It is fixed against the musculoskeletal compartment of the extraperitoneal space post mesh placement dissection of the lateral space is
employed to allow the mesh to be unfurled posteriorly first.
Employing the 5,000 microgrip technology, allowing fixation posterior to the iliopubic tract. The indirect hernia sac is noted proximal
to the posterior limb of the mesh.
Subsequently, using a curved dissecting instrument and a raking
motion, the anterior limb of the mesh is unfurled. Complete coverage
of the potential direct space, femoral space, and internal ring is
achieved with coverage and fixation posterior to the iliopubic tract.
The indirect hernia sac is reduced proximal to the mesh. The pneumoretroperitoneum is released. Nothing is allowed to go underneath
or to the side of the mesh. The bulb insufflator is used to release
the structural balloon. The anterior fascial defect at the level of the
umbilicus is closed with a running 0 Polysorb suture. A 4-0 Biosyn
subcuticular suture is used to reapproximate the skin edges. Indermil
and Steri-Strips are used for the skin edges and to seal the wounds.
Tegaderm™ dressings are placed on all of the incisions.
Hernia (2014) 18 (Suppl 1): S98-S104
V-151
Laparo-endoscopic single-site surgery (LESS)
for epigastric hernia and rectus abdominis diastasis
repair: a novel technique
Arias F, Herrera G, Cortés N, Pozo M, Arango J
University Hospital Fundación Santa Fé de Bogotá
Introduction: Diastasis recti presents commonly in childbearing
women and can persist after delivery, becoming symptomatic even
years later with disability to perform physical activity and altered
cosmesis. Traditionally surgical repair has been controversial and
approached through abdominoplasty. Laparoscopic surgery has
become a widely used technique for the management of abdominal
wall defects. We describe a novel technique for repair of diastasis
recti through Laparo-Endoscopic Single-site Surgery (LESS).
Methods and procedures: A 44-year-old woman with two prior
pregnancies presented with a painful abdominal mass without
obstructive symptoms. A 6 cm non-incarcerated epigastric hernia was
diagnosed and manually reduced. An abdominal ultrasonography
showed a 31 mm epigastric hernia and diastasis recti of 7 cm. Three
years prior she had undergone an umbilical hernia repair which
failed.
Results: A 2 cm epigastric defect was identified with a 7 cm diastasis
recti extending from the xiphoid process to the umbilicus. A hybrid
LESS device (wound retractor and latex glove) was used. After lysing
omental adhesions to the abdominal wall, pre-peritoneal space was
dissected until the posterior rectus sheath was identified bilaterally.
Plication of the posterior rectus sheath was achieved using continuous non-absorbable 2-0 barbed-suture. A 15 x 10 cm polyester collagen-covered mesh was placed and secured using Covidien
AbsorbaTacks™. Complete overlap of ventral hernia and entry port
was achieved. The patient had an uneventful postoperative recovery
and was successfully discharged.
Conclusion (S): Diastasis recti is common specially after pregnancy,
and frequently occurs in association with other wall defects. Open
techniques have been recommended for this condition when surgery
is indicated with potential increased wound morbidity. We describe
a novel LESS technique for the management of diastasis recti with
improved cosmesis. Further studies should determine long-term outcomes of this approach.
V-171
Robot assisted incisional diaphragmatic hernia repair
from lvad explantation: a video presentation
Srinivasa D, Wilson T
UT Houston Department of Surgery
Purpose: Diaphragmatic hernia after Left Ventricular Assist Device
(LVAD) explantation and orthotopic heart transplant has an incidence
of between 5 and 15%1. Although primary diaphragmatic closure at
the time of initial surgery has reduced the incidence, incisional
diaphragmatic hernias remain a morbid complication, oftentimes
requiring further surgery for definitive repair2. Current standard of
care includes laparoscopic repair with a polytetrafluoroethylene
(ePTFE) mesh and interrupted sutures with tacking reinforcement as
necessary3. Outcomes are favorable but there is little long-term data
on recurrence. Furthermore, tacking reinforcement carries risks since
structures behind the diaphragm cannot be visualized. Here, we
describe robotic assisted primary closure of the diaphragmatic defect
with Goretex mesh reinforcement.
S101
Methods: We performed a robotic assisted diaphragmatic hernia
repair in a patient with an incisional hernia from LVAD explantation
and orthotopic heart transplant. 5 port sites were used and the robot
was utilized for the entirety of the case. After careful lysis of adhesions, the hernia sac was dissected and the diaphragmatic defect isolated. This was primarily repaired with 0-Ethibond interrupted
sutures. A Gore-Tex mesh was then sutured in an overlay fashion
with running 0-Gore-Tex suture.
Results: The patient tolerated the procedure well and there were no
complications. The patient is currently free of recurrence.
Conclusion: Primary repair of incisional diaphragmatic hernias with
mesh reinforcement can be safely performed with robot assisted surgery.
V-210
Abdominal wall reconstruction with bilateral
parastomal hernia repairs
Petro C, Criss C, Novitsky Y
University Hospitals Case Medical Center
Introduction: 74M with a history of T4 rectal cancer in the setting
of ulcerative colitis now 5 years status-post neoadjuvant chemotherapy and radiation followed by a pelvic exenteration and total abdominal colectomy. He has since developed bulges adjacent to his ileal
conduit and end ileostomy which are painful and cause intermittent
obstructive symptoms. CT scan demonstrates bilateral parastomal
hernias.
Methods: The plan was to complete an open abdominal wall reconstruction with a posterior components separation, transversus abdominis muscle release (TAR), biological mesh (porcine dermis) sublay,
and revision of both ostomies. The main teaching point involves careful alignment of the ostomy defects in the posterior fascial layer,
mesh, and anterior fascial layer so as not to compromise the ostomy
or conduit.
Results: The post-operative course was notable for extubation on
post-operative day 1, Foley removal from the ileal conduit on day
14, and normal stoma function bilaterally by discharge at day 16.
There was a portion of wound necrosis with a subcutaneous
hematoma that required packing and daily dressing changes. This has
now entirely healed and he continues to increase his activity level
after 6 months.
Conclusion: Bilateral parastomal hernias in the context of a previous
pelvic exenteration are a difficult problem. Revision of both stomas
with TAR and mesh sublay is our recommended approach for longterm durability.
S102
Hernia (2014) 18 (Suppl 1): S98-S104
V-213
New technique for laparoscopic closure of incisional
hernias using unidirectional barbed suture
V-11182
Reconstruction of a large hiatal hernia after gastric
bypass with a Gore BioA matrix
Betancourt A, Rosales-Velderrain A, Lo Menzo E, Szomstein S,
Rosenthal R
Cleveland Clinic Florida
Birk D
Surgical Department, Protestant Hospital Zweibruecken
Introduction: Incisional hernia is a common long-term complication
of abdominal surgery and is estimated to occur in 3% to 13% of
laparotomy incisions. Laparoscopic incisional hernia repair (LIHR)
is fast becoming the standard approach in the repair of abdominal
wall hernias. Primary closure of the hernia defects is recommended
with no absorbable sutures. This practice may improve cosmesis and
prevent undesirable complications, such as seroma formation. We
present a new technique of laparoscopic insicional hernia primary
closure using a unidirectional barded suture.
Material: A new type of suture material that was originally developed to be used for wound closure in orthopedic and plastic surgery
was utilized. Unidirectional suture contains barbs along its length.
This feature makes possible bidirectional fixation that provides distribution of the tension across the two edges of the tissue and eliminates the need to tie knots maintaining tight tissue approximation.
Method: A 58 years old man, with surgical history of laparocopic
cholecystectomy in 2001, presenting an incisional which has progressivelly grown in size. A laparoscopic repair was perfromed, the
hernia defect was closed laparoscopically with the aid of running
unidirectional barbed suture and reinforced with the use of 15 cm
composite polyester mesh (polyester and porcine collegen) which
was secured with 4 transfascial sutures PDS 0 placed at equal distance from each other. Finally the perimeter of the mesh between
sutures was fiexed to the under surface of the abdominal wall utilizing the titanium tacking device. The recovery of the patient was
uneventful and was discharge at the postoperative day 1, without
complications.
V-218
Mini laparoscopic TAPP herniorraphy with 3D mesh
and cyanoacrylate
Loss A, Marins C, Vinhas L, Silveira P, Kanaan E, Magalhães S
Brazilian
The videolaparoscopic technique has become more popular among
patients and surgeons. Tecnology is beeing used to perform surgeries
even more complex with less agressiveness. The MILS technique
(mini incision lapaoscopic surgery) uses trocars of 2 and 3 mm.
The authors present a video of TAPP inguinal herniorraphy performed by the MILS technique using a 3D light mesh, and its fixation
with a synthetic glue n-butyl cyanoacrylate (Glubran), wich polimerizes very quickly. These materials make the surgery easier, faster and
safer, with less pain and less chances of neural lesions, besides the
cosmetic advantages of the MILS technique
With the increase of obesity the number of bariatric operations is
also rising. Obesity being a risk factor, many of those patients also
suffer from a hiatal hernia.
Either during or in the course of the treatment it may become necessary to repair the hiatal defect. Therefore further interest should be
given to this special patient group.
The submitted video shows the operation of a 45 year old male who
had received a Roux-en-Y gastric bypass 2 years prior to this operation. In this time period he lost 80 kg body weight and reduced the
BMI from 52 to 29.
However, he developed increasing symptoms of regurgitation and
retrosternal pain. Upper GI Endoscopy revealed a large hiatal hernia
with enlargement and dislocation of the gastric pouch into the thorax.
The laparoscopic operation describes the reduction of the hernia sack,
the excision of a large mediastinal lipoma followed by the closure
of the crura with sutures.
Since augmentation of the hiatal closure is strongly advocated in
large hiatal defects a U-shaped Gore BioA matrix was deployed and
sutured ventral onto the diaphragm. This three dimensional
resorbable matrix allows rapid ingrowth of collagen but does not lead
to penetration or ingrowth like permanent meshes may. At end of
the hiatal reconstruction the gastric pouch is trimmed to allow better
passage into the jejunal loop.
Hiatal surgery after bariatric procedures will increase. Understanding
the altered anatomy and the underlying problems of obesity thus
offering successful treatment concepts will become more important
to hernia surgeons.
V-12210
TEP repair in large scrotal hernia
Meyer A
USP
Background: Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of
these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the
hernia arduous and subsequent reinforcement of the parietal sac difficult. Here, we describe techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias and to
achieve a robust preperitoneal repair of incarcerated scrotal hernias.
Patient and method: Male, 59 years, body mass index of 28 kg/m
(2), 2 years after undergoing right open hernia repair and bilateral
varicocele surgery. Left Large incarcerated scrotal hernia. The
Retzius space was developed early in the procedure and hernia sac
contents were reduced using a maneuver with the hands.
Results: The operative time was 50 minutes without drainage. The
postoperative hospital stay was less than 12 hours. There were no
complications.
Conclusion: In cases where a large scrotal hernia may be difficult
or dangerous to reduce laparoscopically, immediate conversion to an
open repair may not be necessary. Laparoscopic TEP repair was successful with excellent outcome in the management of massive incarcerated groin hernia in the hands of an experienced laparoscopic surgeon.
Hernia (2014) 18 (Suppl 1): S98-S104
S103
V-12231
Laparoscopic repair of suprapubic ventral hernia after
prior operative fixation of pubic symphysis disruption
V-12488
Totally laparoscopic vesico cutaneus fistula resection as
a rare complication of ipom incisional hernia repair
Admire J, Van Sickle K
UTHSC San Antonio
Real Romo Z, Moreno M, Castillo G, Franklin M
Texas Endosurgery Institute
The patient is a 33 year old male who was treated for a traumatic
pubic bone disruption in October of 2012. He subsequently developed a suprapubic ventral hernia through his Pfannenstiel incision
site. He was referred to the General Surgery clinic for his hernia that
was causing him discomfort, dysuria and urinary urgency. Given the
location and size of the hernia (11 cm x 18 cm) and possibility of
orthopedic hardware obstructing targets for potential sutures and
tacks, this was felt to be a difficult case. An open separation of components repair was considered but was not felt to be the best option,
and a laparoscopic pre-peritoneal approach was performed. Four trocars were placed and the peritoneal cavity was entered. The pelvic
preperitoneal space was then created with sharp dissection in a manner identical to a Transabdominal Preperitoneal (TAPP) inguinal
herniorraphy. In the course of this dissection, a metallic plate from
the previous operation was noted reinforcing the pubic bone. A large
parietex mesh was then affixed with at least 4cm overlap on each
edge, with the superior and lateral edges secured to the ventral
abdominal wall with PTFE suture and reinforced with tacks. A vicryl
suture was placed in the center of the mesh to prevent sagging and
improve visualization at the inferior aspect for fixation. Consistent
with pre-operative concerns, the metal hardware in the pelvis prevented the feasibility of tack or suture fixation at the inferior margin
of the defect. Fixation in the pelvis was secured with fibrin glue (off
label use). The patient ultimately did well post-operatively although
he did develop a small abdominal wall seroma, which resolved spontaneously. At 11 day and 2 month follow-up, no recurrence was
appreciated and his abdominal wall function is intact.
Introduction: A vesico-cutaneous fistula is an abnormal congenital
or acquired opening that connects the urinary tract to the skin surface.
They usually appear after prolonged suprapubic catheterization or
any other procedure on the anterior vesical wall.
Case report: A 62 year old male with history of sigmoidectomy and
Hartmann’s procedure for complicated diverticulitis, and latter incisional hernia which was repaired laparoscopically with polypropylene mesh, three years ago. He was admitted with urine draining
from the stoma scar. A fistulogram and a CT scan were completed,
they revealed a 7cm length path connecting the stoma scar on the
left inferior quadrant of the abdomen to the bladder. Cystoscopy was
normal. The fistula was canalized with a Franklin® colangiography
catheter, the fistulous path was identified by careful dissection of
preperitoneum space, and then totally removed. In the same procedure the prosthetic material (meshoma) was identified proximal to
the bladder and it was removed.
Discussion: Usually the etiological factors include trauma, radiation,
vesical diverticula, obstetric complications, orthopedic surgery, radiation among others. Enterocutaneous fistula is a known late complication of prosthetic mesh repair of incisional hernia and is usually
due to chronic erosion of bowel by mesh placed in direct contact
with intestinal loops both in open and laparoscopic procedures, nevertheless, vesico-cutaneous fistula associated to mesh repair has not
been widely described in literature.
Conclusions: Meshoma and complications related to the migration
of the plug and mesh are a problem, but their incidence is very low.
These are more frequently encountered after laparoscopic hernia
repair. Laparoscopic approach offers a minimally invasive procedure
with low morbidity and favorable outcome. Nevertheless, a vesicocutaneus fistula secondary to a laparoscopic mesh repair is, to our
knowledge, never been reported in literature.
V-12485
Prevention of the Stoma Site Hernia After
Laparoscopic Reversal Procedure
Hernandez M, Franklin M, Romo Z, Castillo G
Texas Endosurgery Institute
Background and objectives: Stomas represent an important cause
of morbidity. Studies show that the incidence of incisional hernia at
the site of the stoma closure is up to 30% at a mean time of 7 months
after stoma closure. Currently, there are no studies regarding the prevention of an incisional hernia after stoma closure. The aim of this
study is to demonstrate that laparoscopic placement of mesh at the
time of a stoma closure is feasible, safe and is associated with
decreased incidence.
Methods: We performed a prospective study at the Texas
Endosurgery Institute between January 2007 and September 2013 of
all the patients that underwent laparoscopic assisted stoma closure.
Results: A total of 114 patients underwent elective laparoscopic
assisted closure of a stoma with placement mesh at stoma site.
Population included was 70 males and 44 females with a mean age
63.5 years (38-88 years) and a mean BMI of 28.2 kg/m2 (19.3-44.5).
71 of the patients had a loop ileostomy and 43 colostomy. Surgeries
were performed with no conversions in a mean operative time of
102 minutes (35-260) and an estimated blood loss of 53 cc (10-300).
Polyester, polypropylene and biologic meshes were place intraperitoneally. Mean length of hospital stay was 6.9 days.
Conclusion: We have demonstrated that mesh can be safely and successfully placed to reinforce the stoma site after closure. We had no
major full thickness wound issues, no mesh complications and zero
occurrence rate at follow up of 19 months.
S104
Hernia (2014) 18 (Suppl 1): S98-S104
V-12491
Primary suture technique in 758 midline hernia repair
V-12567
Laparoscopic Repair of a Spiegel Hernia
Ross N
Shouldice Clinic
De Luca C, Franca F, Marques T
Brazil
Introduction: The Shouldice hospital remains one of the last battle
grounds to champion the pure tissue repair for all kinds of abdominal
wall hernias. Although general surgeons operate on a great number
of these hernias, large series are absent from the literature with the
largest series studied 146 of such patients. We carried a review of a
series of 758 midline abdominal wall hernias performed between
2003 and 2013, at the Shouldice hospital by one of the surgeons (the
author).
Method: Those cases reviewed were divided into 430 umbilical
repair, 74 Paraumbilical, 137 epigastric, and 106 trocar site incisional
hernias. Using primary suturing technique with double breasting with
continuous layers of 2/0 polypropylene as the first two layers, and
32 gauges stainless steel wire suture material for the second, we followed these patients five weeks, one year, and annually afterwards.
Results: Only 3 reported recurrences over 10 years period were
found, representing a 0.003% rate, surgical site infection in only 3
cases with the same rate of 0.003%. The size of the defects ranges
between 0.5 cm-6 cm with a mean of 2.6 cm. The age group ranges
between 16-83 years old, with mean of 44 years old. The mean BMI
was 24.9 with 80% male predominance.
Conclusion: We believe that primary suturing technique using these
two materials with double breasting proofs to be the near to the ideal
method of closure of such midline hernias.
A video presentation is enclosed with this abstract to elucidate the
technique described.
Spigelian Hernias are rare abdominal wall hernias. Approximately
1.000 cases have been reported in the literature and their incidence
is estimated to be less then 2% off all abdominal wall hernias. These
hernias occur through the spigelian aponeuroses which is composed
of the aponeuroses of the transverse abdominal muscle that lies
between the lateral edge of the rectus muscle and the linea semilunaris.
We present the case of a 47 years old male patient with pain in the
right side for a year without a wall bulge and the ultrasound can
identify the defect about 1,8 cm in the semilunar line. A laparoscopic
approach of this case was decided. We reduced the sac and its contents. We closed the defect using a Phisiomesh and fixed with
absorbable tackers (Securestrap). The surgical time was 30minutes
and the patient was discharged the next day. We concluded that the
Laparoscopic approach is safe and with goods result and great acceptance.
V-12524
Strangulated inguinal hernia repair by trans abdominal
pre peritoneal laparoscopic approach
Morrell A, Cavazolla L, Furtado M, Malcher F, Farah F, Meyer A,
Costas M
Brazil
Laparoscopic inguinal hernia repair have become a popular procedure
for not only bilateral and recurrent hernia but also for unilateral
inguinal hernia.
Recent studies have reported successful reduction and repair of
chronic and/or even acute incarcerated inguinal hernias by the laparoscopic approach, yet this procedure is still controversial and strangulated inguinal hernias has traditionally been considered a contraindication for the laparoscopic approach.
We present a case of a patient who underwent laparoscopic transperitoreal (TAPP) repair for a strangulated inguinal hernia showing that
this technique it’s possible in acute cases and has some advantages.
Hernia (2014) 18 (Suppl 1): S105-S110
ABSTRACTS
Author Index
© Springer-Verlag 2014
Abaitua G, P-12577, S96
Abbas M, P-12218, S77
Abdalla B, P-124, S54
Abdalla R, IP-12591, S32, IP-118, S44, P-101, S50,
P-124, S54, P-125, S54
Abdelsaatar J, FP-133, S34
Abston E, FP-116, S12
Admire J, V-12231, S103
Agra A, P-224, S70
Agredano-Jiménez R, P-12509, S87
Aguilar Martí M, P-107, S51, P-108, S52,
P-112, S52
Aihni A, P-12525, S92
Aka H, P-145, S55
Alaedeen D, P-12487, S82
Alban M, P-185, S61, P-11928, S74, P-12209, S75
Alfonso J, P-110, S52
AlJamal Y, FP-133, S34, P-12486, S82
Allen W, P-203, S66
Alvarez J, FP-12213, S26
Alvarez R, P-10550, S72
Álvarez-Villaseñor A, P-12509, S87
Alves A, P-12542, S95
Alves L, P-224, S70
Amarante G, P-12217, S77
Ami K, P-190, S62
Amid P, IP-12557, S16
Anania S, P-174, S58
Ando M, P-190, S62
Arai K, P-190, S62
Arango J, V-151, S101
Arias F, V-151, S101
Armstrong B, FP-214, S33
Ashfaq A, P-12224, S79
Asman A, P-203, S66
Auer T, P-12579, S96
Aufenacker T, FP-178, S26
Augenstein V, IP-140, S9, FP-209, S14, FP-12493, S24,
FP-12520, S25, FP-12503, S49, P-195, S64,
P-217, S69, P-12235, S81, P-12492, S83,
P-12522, S91, P-12523, S91, P-12527, S92,
P-12529, S93, P-12530, S93, P-12536, S94,
P-12538, S94
Avci M, FP-126, S11
Azoury S, P-169, S57
Baalman S, P-12525, S92
Bakaki P, FP-144, S48
Ballecer C, V-114, S99
Barber Millet S, P-107, S51, P-108, S52
Barber S, P-127, S54
Bardella R, P-206, S67
Barreiro J, P-12577, S96
Barthes T, P-12592, S97
Bates A, P-173, S58
Bau R, P-216, S68
Baucom R, FP-10933, S47, P-203, S66
Bauer J, FP-182, S24
Bayon Y, P-147, S56, P-12542, S95
Bear I, P-12577, S96
Becker P, P-12592, S97
Belgrade J, P-192, S63, P-193, S63, P-196, S64,
P-11732, S74, P-12180, S74, P-12221, S78
Bellón J, P-147, S56
Beltrame M, P-174, S58, P-179, S59
Belyansky I, FP-12493, S24, FP-12520, S25,
IP-136, S46
Bencina F, P-11928, S74
Berends F, FP-148, S34
Berger R, P-12544, S96
Bernstein M, P-122, S53
Berrevoet F, P-12483, S81
Betancourt A, V-213, S102
Bhanot P, IP-12548, S9
Birk D, V-11182, S102
S106
Birolini C, P-102, S51, V-103, S98, V-104, S98,
V-105, S99
Bittner J, IP-12598, S20, IP-12564, S28
Björk S, P-187, S61
Bleichrodt R, FP-178, S26
Bökkerink W, P-222, S69
Bonafé Diana S, P-107, S51, P-108, S52, P-112, S52
Bonjer H, FP-11345, S25
Born H, P-12214, S76
Boyd C, IP-12597, S19, V-120, S99
Bradley J, FP-209, S14, FP-12493, S24, P-12235, S81,
P-12492, S83, P-12522, S91, P-12527, S92,
P-12529, S93, P-12530, S93, P-12536, S94,
P-12538, S94
Brandsma H, FP-178, S26
Bringman J, P-12229, S80
Bringman S, P-12229, S80
Brunt L, IP-12552, S36
Bryan N, FP-12574, S14
Burton P, P-217, S69
Campanelli G, IP-12555, S41
Carbonell A, IP-156, S9, FP-182, S24, IP-158, S43,
P-12515, S89, P-12528, S92, P-12533, S93,
P-12537, S94, P-12540, S95
Carbonell Tatay F, P-107, S51, P-108, S52, P-112, S52
Carrasco J, P-185, S61, P-11928, S74, P-12209, S75
Carreño-Saenz O, P-107, S51, P-108, S52, P-112, S52
Carter J, P-181, S60
Castillo G, P-12227, S80, V-12485, S103,
V-12488, S103
Cauwenberge S, P-12484, S82
Cavallo J, FP-12596, S10, P-12511, S88
Cavazolla L, P-12216, S76, V-12524, S104
Cavazzola L, FP-12504, S11, IP-12572, S19
Cavazzola LT, P-216, S68
Ceconnello I, P-101, S50
Cejnar S, P-12214, S76
Cense H, FP-148, S34
Chávez-Tostado M, P-12509, S87
Cheesborough J, P-176, S59, P-177, S59,
P-12521, S91
Chen D, IP-165, S15
Cheng A, P-12218, S77
Cheung C, FP-126, S11
Chihara N, P-9207, S71, P-12518, S90
Chowdhury N, P-12511, S88
Christian D, P-223, S70
Chui P, P-225, S70
Chung P, P-122, S53
Cingolani P, P-12513, S89, P-12514, S89
Clancy T, P-223, S70
Clarke J, P-100, S50
Cleven S, P-12483, S81
Cobb W, FP-182, S24, IP-164, S40, P-12515, S89,
P-12528, S92, P-12533, S93, P-12537, S94,
P-12540, S95, P-12542, S95, P-12592, S97
Cohen E, FP-115, S48
Hernia (2014) 18 (Suppl 1): S105-S110
Colavita P, FP-12493, S24, FP-12520, S25, P-217, S69,
P-12235, S81, P-12536, S94
Colivita P, IP-140, S9
Conway M, P-192, S63, P-193, S63, P-196, S64,
P-11732, S74, P-12180, S74, P-12221, S78
Conze K, IP-12566, S28
Coombs N, P-181, S60
Copsta T, P-101, S50
Cortés N, V-151, S101
Costa R, P-124, S54, P-125, S54
Costas M, FP-12504, S11, P-12216, S76,
V-12524, S104
Criss C, FP-131, S12, FP-200, S33, FP-130, S47,
FP-132, S49, FP-144, S48, V-210, S101
Criss CR, P-195, S64
Cuenca A, FP-12213, S26
Cunnigaiper N, P-198, S65
Dacey K, P-217, S69, P-12530, S93, P-12536, S94
Daoud I, P-11555, S73
Data J, P-12507, S87
Davenport D, P-205, S67, P-12508, S87
De Deyne P, P-8224, S71
de Freitas L, P-212, S68
de Goede B, P-168, S57
De La Cruz C, P-169, S57
de Lange de Klerk E, FP-11345, S25
De Luca C, V-12567, S104
De Silva G, FP-121, S49
Deeken C, IP-12549, S27, P-12511, S88, P-12525, S92
Deerenberg E, FP-148, S34
DeLozier K, P-12501, S86
Derwin K, P-12501, S86
Devaja A, P-117, S53
Dhanasopon A, P-169, S57
Diaz-Elizondo A, P-129, S54
Diaz-Hernandez J, P-12217, S77
Diez J, P-12577, S96
Dijk SM, P-208, S67
Dijkhuizen F, FP-148, S34
Dillemans B, P-12484, S82
Dissanaike S, P-11228, S73
Doerhoff C, IP-12561, S38, P-12229, S80
Dominguez C, P-185, S61, P-11928, S74
Dominquez M, P-12209, S75
Dumanian G, FP-109, S13, P-176, S59, P-177, S59,
P-12521, S91
Dunkin B, FP-12574, S14
Dunn R, FP-186, S23, P-170, S57
Dwars B, FP-11345, S25
Earle D, IP-12547, S27
Edwards C, P-12592, S97
Ehrenfeld J, FP-10933, S47
Elegbede A, P-219, S69
Elliott H, FP-200, S33
Fajardo M, P-110, S52
Falasco G, P-12208, S75
Farah F, FP-12504, S11, P-12216, S76, V-12524, S104
Hernia (2014) 18 (Suppl 1): S105-S110
Farley D, FP-133, S34, P-12486, S82
Felix E, IP-153, S41
Fernandes V, P-206, S67
Fernández E, P-110, S52
Fernandez-Moure J, FP-12574, S14
Fernando I, P-12211, S75, P-12513, S89
Feryn,T, P-12484, S82
Feyerherd P, P-146, S56
Florez L, P-12577, S96
Floyd D, P-204, S66
Franca F, V-12567, S104
Franklin M, P-12227, S80, P-12510, S88,
V-12485, S103, V-12488, S103
Franz M, IP-12546, S43
Frelich M, FP-116, S12
Frisella M, P-12511, S88
Frisells M, P-12525, S92
Fuentes-Orozco C, P-12509, S87
Furtado M, FP-12504, S11, P-12216, S76,
V-12524, S104
Furukawa T, P-9903, S72, V-143, S100
Ganno H, P-190, S62
Garcia D, P-206, S67
García Pastor P, P-107, S51, P-108, S52, P-112, S52
Garcia R, P-124, S54, P-125, S54
García-Moreno F, P-147, S56
García-Rentería J, P-12509, S87
Gil-Gallardo G, P-129, S54
Gilbert A, FP-113, S35, P-142, S55, P-12234, S81
Gillespie B, P-12226, S80
Gitahy A, P-212, S68
Giunippero A, P-174, S58
Goderich Lalán J, P-110, S52
Goede B, P-208, S67
Goede M, FP-172, S48
Goldblatt M, FP-116, S12, IP-162, S19, FP-182, S24,
IP-163, S39
Gónzalez-Ojeda A, P-12509, S87
Gorganchian F, P-174, S58, P-179, S59
Gould J, FP-116, S12
Greenberg C, FP-115, S48
Greenberg J, IP-160, S15, IP-12580, S38, FP-115, S48,
P-219, S69
Grossi J, P-216, S68, P-224, S70
Gruber-Blum S, P-134, S55
Guajardo-Nieto D, P-129, S54
Gustafson M, P-11555, S73
Haggerty S, P-12497, S85
Haluck R, P-9667, S71
Hammond J, P-12229, S80, P-12495, S84
Hanashiro N, P-145, S55
Hanna M, P-11228, S73
Hansson B, FP-178, S26
Harlaar J, FP-148, S34
Harold K, IP-12550, S19, IP-12594, S37,
P-12224, S79
Hasegawa T, P-191, S63
S107
Hata T, P-191, S63
Heniford B, IP-140, S9, FP-209, S14, FP-12493, S24,
FP-12520, S25, FP-12503, S49, P-195, S64,
P-217, S69, P-12235, S81, P-12522, S91,
P-12523, S91, P-12527, S92, P-12529, S93,
P-12530, S93, P-12536, S94, P-12538, S94
Hernandez M, P-12227, S80, P-12489, S83, P-12510,
S88, V-12485, S103
Herrera G, V-151, S101
Heuvel B, FP-11345, S25
Hicks S, P-12543, S95, P-12544, S96
Hodgman E, P-106, S51
Hofman A, P-168, S57
Holzman M, FP-10933, S47
Hooks W, P-223, S70
Hope W, IP-12545, S16, P-223, S70
Hori T, P-184, S61
Huerta C, P-12209, S75
Hui X, P-169, S57
Ignotz R, FP-186, S23, P-170, S57
Imazu H, P-197, S65
Imazu Y, P-197, S65
Inaba T, P-184, S61
Iqbal A, FP-12213, S26
Iserte Hernandez J, P-107, S51, P-108, S52,
P-112, S52
Ivarsson M, P-187, S61
Jackson T, P-9667, S71
Jacob B, IP-12595, S22, IP-141, S41, P-173, S58,
P-225, S70
Jacobsen G, FP-182, S24, IP-154, S36, IP-155, S45
Jagan B, P-198, S65
Jeekel J, FP-207, S13, IP-12570, S42, P-150, S56,
P-168, S57, P-208, S67
Jenkins M, P-181, S60
Jones P, P-12229, S80, P-12495, S84
Jones R, FP-172, S48
Juza R, P-9667, S71
Kaiser J, FP-10933, S47
Kalish E, P-192, S63, P-193, S63, P-196, S64,
P-11732, S74, P-12180, S74, P-12221, S78
Kanaan E, V-218, S102
Kanth R, P-199, S65
Kao L, P-12543, S95, P-12544, S96
Kasten S, P-12226, S80
Kaufmann R, P-150, S56
Kazemier G, P-168, S57
Keating J, P-12499, S85, P-12507, S87
Kenler A, V-149, S100
Kercher K, IP-12553, S21, P-217, S69
Keus F, FP-126, S11
Kim M, FP-209, S14, FP-12493, S24, FP-12520, S25,
FP-12503, S49, P-195, S64, P-12492, S83,
P-12523, S9, P-12527, S92, P-12530, S93,
P-12538, S94
Kingsnorth A, IP-12599, S30
Kitagawa Y, P-9903, S72, V-143, S100
S108
Kleinrensink G, P-208, S67
Klick J, P-12220, S78
Klobusicky P, P-146, S56
Koch A, P-11073, S73, P-12212, S76, P-12214, S76
Koeslag L, FP-126, S11
Koning G, FP-126, S11
Kulacoglu H, P-188, S62
Kulig J, P-9733, S72, P-12490, S83
Kumar S, P-189, S62
Kuniyoshi F, P-145, S55
Kuwada T, FP-220, S35
Kwon E, P-12219, S77
Ladet S, P-12542, S95
Lalán J, P-10824, S73
Landman B, P-203, S66
Lange J, FP-207, S13, P-150, S56, P-168, S57,
P-208, S67
Larios L, P-10824, S73
LeBlanc K, IP-159, S32
Lecuivre J, P-12542, S95
Lepère M, P-12592, S97
Levy S, P-12508, S87, P-12512, S88
Li L, P-12544, S96
Liang M, P-12543, S95, P-12544, S96
Liao C, P-169, S57
Liese R, P-215, S68
Lincourt A, FP-209, S14, P-217, S69, P-12492, S83,
P-12522, S91, P-12536, S94
Lincourt A
Liu J, P-176, S59
Lo Menzo E, V-213, S102
Lomanto D, P-12542, S95
Lombard J, P-12495, S84
Lomelin D, FP-172, S48
Lont H, FP-148, S34
Lorenz R, P-11073, S73, P-12212, S76, P-12214, S76
Loss A, P-212, S68, V-218, S102
Lovins M, P-169, S57
Maag A, FP-115, S48
Macías-Amezcua M, P-12509, S87
Magalhães S, V-218, S102
Malcher F, FP-12504, S11, P-12216, S76,
V-12524, S104
Manna B, P-216, S68
Marins C, P-212, S68, V-218, S102
Marques T, V-12567, S104
Martin B, FP-10933, S47
Martindale R, IP-12560, S8
Martínez-Sánchez D, P-129, S54
Matthews B, FP-182, S24, IP-12573, S36, P-12511, S88,
P-12525, S92
Matyja A, P-9733, S72, P-12490, S83
Mckinney W, P-195, S64
Megison S, P-106, S51
Meyer A, FP-12504, S11, P-12216, S76, P-12222, S78,
V-12210, S102, V-12524, S104
Miller K, P-194, S64
Hernia (2014) 18 (Suppl 1): S105-S110
Miller M, P-205, S67
Minter R, P-12226, S80
Mirmehdi I, P-12517, S90
Miserez M, IP-12565, S40
Miyahira T, P-145, S55
Mladenovik D, P-117, S53
Molina E, P-10824, S73
Monteiro P, P-224, S70
Montes de Oca J, P-174, S58, P-179, S59
Montes JHM, P-216, S68
Montilla Navarro E, P-107, S51, P-108, S52,
P-112, S52
Mora O, P-10824, S73
Moreno M, V-12488, S103
Morfesis A, P-12223, S79, P-12225, S79
Morrell A, FP-12504, S11, P-12216, S76,
V-12524, S104
Mottin C, P-224, S70
Muñoz A, P-12209, S75
Murphy J, IP-12590, S45
Muschaweck U, IP-12566, S28
Muse T, P-205, S67
Nagahama T, P-190, S62
Nagle A, P-194, S64
Nakata R, P-9207, S71, P-12518, S90
Narayanan M, P-198, S65
Narula V, P-12592, S97
Nealon W, FP-10933, S47
Nery LA, P-216, S68
Nguyen D, P-12543, S95
Nguyen H, P-169, S57
Nguyen M, P-12543, S95, P-12544, S96
Nicolo E, P-12494, S84, P-12496, S84, P-12500, S86,
P-12502, S86
Nikolovski A, P-117, S53
Nishihara M, P-145, S55
Norambuena M, P-12209, S75
Norrby J, P-187, S61
Novacek V, FP-186, S23, P-170, S57
Novitsky Y, FP-131, S12, IP-137, S31, FP-200, S33,
FP-130, S47, FP-121, S49, FP-132, S49, FP-144, S48,
P-215, S68, P-12220, S78, V-111, S99, V-210, S101
Okinaga K, P-184, S61
Okushima N, P-145, S55
Olcucuoglu E, P-188, S62
Oleynikov D, FP-172, S48
Oliveria P, P-212, S68
Olsen R, FP-12574, S14
Oommen B, FP-209, S14, FP-12493, S24,
FP-12520, S25, FP-12503, S49, P-195, S64,
P-12492, S83, P-12523, S91, P-12527, S92,
P-12530, S93, P-12538, S94
Orenstein S, FP-131, S12, FP-200, S33, FP-144, S48,
P-12220, S78
Ortiz-Ortiz C, P-12215, S76, P-12217, S77
Pachero R, P-12577, S96
Padoin A, P-224, S70
Hernia (2014) 18 (Suppl 1): S105-S110
Palacios F, P-11928, S74
Palacios F, P-185, S61
Paley K, P-12486, S82
Palomo R, P-12510, S88
Palomo-Hoil R, P-129, S54
Pareja T, FP-12504, S11
Parikh P, IP-12583, S9
Park E, P-177, S59
Parra-Davila E, P-12217, S77
Pascual G, P-147, S56
Pauli E, P-9667, S71
Peacock J, FP-132, S49
Pellini B, P-11555, S73
Peralta G, P-12510, S88
Peralta-Castillo G, P-129, S54
Pérez-Köhler B, P-147, S56
Pérez-López P, P-147, S56
Peters C, P-12516, S90
Petro C, FP-131, S12, FP-200, S33, FP-214, S33,
FP-130, S47, FP-144, S48, P-12220, S78, V-111, S99,
V-210, S101
Petter-Puchner A, P-134, S55
Phillips M, IP-12562, S15, IP-12563, S31
Phillips S, FP-10933, S47
Pierce R, IP-12600, S46
Piper M, P-12219, S77
Plymale M, P-12508, S87, P-12512, S88
Podolsky E, P-12498, S85
Posielski N, FP-131, S12
Poulose B, IP-12582, S18, IP-12571, S21, FP-182, S24,
IP-152, S44, FP-10933, S47, P-203, S66
Pozo M, V-151, S101
Prebil B, V-114, S99
Premnath R, P-180, S60
Pugh C, FP-115, S48
Quigley L, P-12528, S92, P-12533, S93, P-12537, S94,
P-12540, S95
Rahman S, P-199, S65
Raigani S, FP-131, S12, FP-200, S33, FP-130, S47,
FP-144, S48, FP-121, S49, P-12220, S78
Raj N, P-12487, S82
Ramos R, P-224, S70
Ramshaw B, P-12516, S90, P-12517, S90
Rappoport D, P-11928, S74, P-12209, S75
Rappoport J, P-185, S61, P-11928, S74, P-12209, S75
Rasslan S, P-102, S51, V-103, S98, V-104, S98,
V-105, S99
Raval M, P-194, S64
Ravo B, P-12208, S75
Ray S, P-12525, S92
Real Romo Z, P-129, S54, P-12510, S88,
V-12488, S103
Reddy A, P-198, S65
Redl H, P-134, S55
Reiner M, P-173, S58
Reinpold W, FP-12505, S23, P-10469, S72
Rettenmaier C, FP-116, S12
S109
Reynvoet E, P-12483, S81, P-12484, S82
Ribeiro D, FP-12504, S11
Riberio G, FP-12504, S11
Ripardo J, P-206, S67
Rojas A, P-12217, S77
Roll S, IP-12556, S17, P-216, S68
Romanowski C, P-12229, S80, P-12495, S84
Romo Z, P-12227, S80, V-12485, S103
Rosa R, P-212, S68
Rosales-Velderrain A, V-213, S102
Rose B, P-12223, S79, P-12225, S79
Rosen M, IP-139, S8, FP-131, S12, IP-12582, S18,
FP-182, S24, FP-200, S33, FP-214, S33, FP-130, S47,
FP-144, S48, FP-121, S49, FP-132, S49,
P-12220, S78, V-111, S99
Rosenthal R, V-213, S102
Rosman C, FP-182, S24, FP-178, S26
Ross N, P-183, S60, V-12491, S104
Ross S, FP-209, S14, FP-12493, S24, FP-12520, S25,
FP-220, S35, FP-12503, S49, P-195, S64,
P-12492, S83, P-12523, S91, P-12527, S92,
P-12530, S93, P-12538, S94
Roth J, IP-166, S31, IP-167, S42, IP-12589, S39,
P-205, S67, P-12508, S87, P-12512, S88
Rowbottom J, P-12220, S78
Rowse P, FP-133, S34
Ruiz-Jasbon F, P-187, S61
Ruparel R, FP-133, S34
Russomanno A, P-12226, S80
Sadek R, V-128, S100
Sahoo S, P-12501, S86
Said D, P-125, S54
Salazar V, P-185, S61, P-11928, S74
Salvador P, P-107, S51, P-108, S52
Santa María V, P-174, S58
Santamaría V, P-179, S59
Santo M, P-101, S50
Sawyer M, P-8224, S71
Sbitany H, P-12219, S77
Scheuerlein H, P-12592, S97
Schouten W, FP-148, S34
Schroeder A, P-10469, S72
Schuricht A, IP-135, S38, P-12499, S85,
P-12507, S87
Schwartzman A, P-122, S53
Scott J, P-215, S68
Selzer D, FP-182, S24
Shankar A, P-204, S66
Sharp K, FP-10933, S47
Shenol T, P-117, S53
Silva J, P-185, S61, P-11928, S74
Silveira P, V-218, S102
Simorov A, FP-172, S48
Sing R, FP-12493, S24, P-12492, S83
Skipworth J, P-204, S66
Slater N, P-202, S66, P-222, S69
Smith N, P-12508, S87
S110
Sobacki J, P-12497, S85
Soeken T, P-106, S51
Solecki R, P-9733, S72, P-12490, S83
Soltanian H, FP-214, S33, FP-144, S48, FP-132, S49
Soto-Edwards A, P-12226, S80
Sotomayor S, P-147, S56
Souza J, FP-109, S13, P-177, S59
Soybel D, P-9667, S71
Srinivasa D, V-171, S101
Stockmann H, FP-148, S34
Stoikes N, IP-161, S32
Suchoski J, P-12226, S80
Sugiyama G, P-122, S53
Suzuki H, P-9207, S71, P-12518, S90
Szomstein S, V-213, S102
Szura M, P-9733, S72, P-12490, S83
Tadaki C, FP-172, S48
Tajima K, P-145, S55
Takehara H, P-145, S55
Takushi Y, P-145, S55
Tam S, P-122, S53
Tamayo J, P-10824, S73
Tasciotti E, FP-12574, S14
Tejirian T, P-12218, S77
Tessier D, IP-138, S39
Tevis S, P-219, S69
Thompson D, P-12511, S88
Timmermans L, FP-207, S13, P-150, S56, P-168, S57,
P-208, S67
Torres O, P-10469, S72, P-12209, S75
Troisi R, P-12483, S81
Tsirline V, FP-12493, S24, FP-12520, S25, P-217, S69,
P-12527, S92
Turquier F, FP-186, S23, P-170, S57
Uchida E, P-9207, S71, P-12518, S90
Uehara H, P-145, S55
Uppal L, P-204, S66
Ursu D, P-12226, S80
Ushinohama A, P-206, S67
Utiyama E, P-102, S51, V-103, S98, V-104, S98,
V-105, S99
Van Der Fraenen D, P-12484, S82
Van Doorn H, FP-148, S34
Van Eps J, FP-12574, S14
van Goor H, IP-12551, S28, P-202, S66, P-222, S69
van Jarwaarde J, FP-11345, S25
van Kempen B, P-168, S57
van Laarhoven C, FP-126, S11
Van Overbeke I, P-12483, S81
van Rooji F, P-168, S57
Van Sickle K, V-12231, S103
Hernia (2014) 18 (Suppl 1): S105-S110
Vanlander A, P-12483, S81
Vargas K, P-12515, S89
Vergara Suarez F, P-108, S52
Villegas-Cabelllo O, P-129, S54
Vinhas L, V-218, S102
Voeller G, IP-12558, S20, IP-12559, S21
Vriens P, FP-126, S11
Vyas S, P-204, S66
Wada N, P-9903, S72, V-143, S100
Wallace J, FP-116, S12
Walters A, FP-209, S14, FP-12520, S25, P-217, S69,
P-12235, S81, P-12522, S91, P-12523, S91,
P-12529, S93, P-12530, S93, P-12536, S94,
P-12538, S94
Walters AL, FP-220, S35
Wang J, FP-131, S12
Warren J, P-12515, S89, P-12528, S92, P-12533, S93,
P-12537, S94, P-12540, S95
Wassef A, V-128, S100
Watanabe M, P-9207, S71, P-12518, S90
Weiner B, FP-12574, S14
Weyhe D, P-12542, S95
Whittington H, P-12508, S87
Wichers P, FP-11345, S25
Wiegmann D, FP-115, S48
Wiese M, P-12214, S76
Wijnhoven B, FP-148, S34
Wilke R, P-175, S58
Williams K, FP-209, S14, P-12235, S81, P-12522, S91,
P-12527, S92, P-12529, S93, P-12536, S94,
P-12538, S94
Wilson T, P-12543, S95, V-171, S101
Wittmann J, P-134, S55
Workman C, P-12521, S91
Wormer B, FP-220, S35, P-12235, S81, P-12522, S91,
P-12529, S93, P-12538, S94
Wright R, P-123, S53
Wu A, P-173, S58
Wu Y, FP-132, S49
Xu Z, P-203, S66
Yamaoka K, P-184, S61
Yanaga K, P-191, S63
Yazgan A, P-188, S62
Yoo J, P-12498, S85
Yoshida K, P-191, S63
Young J, FP-113, S35, P-12234, S81
Zabel D, P-192, S63, P-193, S63, P-196, S64,
P-11732, S74, P-12180, S74, P-12221, S78
Zemlyak A, P-217, S69, P-12527, S92
Zihni A, P-12511, S88
Zwischenberger B, P-205, S67
SM
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