Upload
truongkiet
View
213
Download
0
Embed Size (px)
Citation preview
2019 AHS Annual Meeting
March 11–14, 2019, Las Vegas, NV
� Springer-Verlag France SAS, part of Springer Nature 2019
Monday, March 11, 2019
7:00–8:00 Registration & Breakfast
8:00–10:30 Session 1: Opening Session
Moderators: Gina Adrales, MD, MPH &
Benjamin Poulose, MD, MPH
8:00–8:10 Welcome and Opening Remarks
Benjamin Poulose, MD, MPH
USA
8:15–8:30 Introduction of the Americas Hernia Society
World Partners
Gina Adrales, MD, MPH
USA
8:30–8:45 How Social Media Will Change Your Practice
and How to Get Ready
Brian Jacob, MD
USA
8:45–9:00 Robotics in Hernia Surgery: Stalling or Soaring?
Ajita Prabhu, MD
USA
9:00–9:15 Five Key Studies All Hernia Surgeons Should
Know
Sharon Bachman, MD
USA
9:15–9:45 Nyhus-Wantz Lecture
Sergio Roll, MD, PhD
Brazil
9:45–9:52 Safe Hernia Steps Program
Yuri Novitsky, MD
USA
9:52–10:00 Abdominal Core Health: The Time Has Come
Benjamin Poulose, MD, MPH
USA
10:00–10:30 Presidential Address
Gina Adrales, MD, MPH
USA
10:30–11:00 Break, Exhibits & Posters of Distinction
11:00–12:30 Session 2A: The Future Is Here: Robotics inHernia
Moderators: Yuri Novitsky, MD & Dana Telem,
MD
11:00–11:15 Evidence Update for Robotics: Where Do We
Need to Go?
Ajita Prabhu, MD
USA
11:15–11:30 Challenges of Starting a Robotic Program
Jaisa Olasky, MD
USA
11:30–11:45 Rethinking the Laparoscopic IPOM with
Robotics
Allegra Saving, MD
USA
11:45–12:00 From TEP to Robotic Inguinal Hernia Repair:
Why I Changed
David Lourie, MD
USA
12:00–12:15 Hernias, Residents and Robotics: Training the
Next Generation
Michael Meara, MD
USA
12:15–12:30 Robotic Retromuscular Abdominal Wall
Reconstruction
Igor Belyansky, MD
USA
11:00–12:30 Session 2B: Scientific Abstracts—InguinalHernia
Moderators: Diya Alaedeen, MD & Keith Paley,
MD
11:00–11:15 Closure of Direct Inguinal Hernia Defect in
Laparoscopic Hernioplasty to Prevent Seroma
Formation: A Prospective Double-Blind
Randomized Controlled Trial
Yilin Zhu, BS
China
PROGRAM
123
Hernia (2019) 23 (Suppl 1):S1–S7
https://doi.org/10.1007/s10029-019-01889-w
11:15–11:30 Hernia Recurrence Inventory: Inguinal Hernia
Recurrence Can Be Accurately Assessed Using
Patient-Reported Outcomes
Luciano Tastaldi, MD
USA
11:30–11:45 Method of Forming a Three-Layer Back Wall of
the Inguinal Canal and Complete Isolation of the
Spermatic Cord from the Mesh
Tamaz Gvenetadze, MD, PhD
Georgia
11:45–12:00 Preliminary Results at 3-Year Follow Up of
Totally Extraperitoneal Hernia Surgery with
Long-Term Resorbable Mesh
Fernando Ruiz-Jasbon, MD
Sweden
12:00–12:15 Phone Follow-Up After Inguinal Hernia Repair
Jacob Greenberg, MD, EdM
USA
12:30–1:30 Lunch & Learns
1:45–3:00 Session 3A: Avoiding and Managing ChronicGroin Pain After Inguinal Hernia Repair(Panel Session)
Moderators: David Chen, MD & David Krpata,
MD
1:45–2:00 Identifying Patients at Risk for Chronic Groin
Pain Before Operation
Rigoberto Alvarez, MD
Mexico
2:00–2:15 Strategies to Minimize Chronic Groin Pain in
Open and Minimally Invasive Inguinal Hernia
Repair
David Nguyen, MD
USA
2:15–2:30 Diagnosis and Management of Chronic Groin
Pain: An Overview
David Renton, MD
USA
2:30–2:45 Designing a Comprehensive Treatment Center
for Chronic Groin Pain
David Krpata, MD
USA
2:45–3:00 Panel Discussion
1:45–3:00 Session 3B: Scientific Abstracts—Robotics
Moderators: Conrad Ballecer, MD & Talar
Tejirian, MD
1:45–2:00 Automated Surgical Coaching for Technical
Skills Acquisition in Incisional Hernia Repair
Gina Adrales, MD, MPH
USA
2:00–2:15 The Enhanced-View Totally Extraperitoneal
Robotic Rives-Stoppa Abdominal Wall
Reconstruction: A Review of Outcomes
Alex Addo, MD, MPH
USA
2:15–2:30 Robotic-Assisted Ipsilateral Rives Ventral Hernia
Repair vs. Open Rives Ventral Hernia Repair
Joshua Halka, MD
USA
2:30–2:45 Robotic Inguinal Hernia Repair is Being
Adopted by the Majority of Minimally Invasive
Hernia Surgeons
Priscilla Rodrigues Armijo, MD
USA
2:45–3:00 A Cost-Neutral Approach to Surgical Resident
Robotic Inguinal Hernia Training
Sarah Budney, BS
USA
3:00–3:30 Break, Exhibits & Posters of Distinction
3:30–5:30 Session 4A: Should We Be Gambling withOur Hernia Patients? Innovation with RiskSharing Is a Better Bet
AHS Special Session with the Kelley School ofBusinessModerators: Arachana Ramaswamy, MD & Paul
Szotek, MD
3:30–3:35 Introduction
Archana Ramaswamy, MD
USA
3:35–3:50 2018 Barracuda Tank Follow Up: Mesh Suture
(NON-CME)
Greg Dumanian, MD
USA
3:50–4:30 Overview of the US Healthcare System
Nir Menachmi, PhD, MPH
4:30–5:25 How Physicians Can Fix the System
Philip Powell, PhD
5:25–5:30 Closing Remarks
Paul Szotek, MD, MBA
3:35–3:50 2018 Barracuda Tank Follow Up: Mesh Suture
(NON-CME)
Greg Dumanian, MD
USA
3:30–5:30 Session 4B: Scientific Abstracts—VentralHernia
Moderators: Bryan Richmond, MD & Augustin
Alvarez, MD
3:30–3:45 Prehabilitation in Underserved, Minority
Patients With Ventral Hernias: Long-Term
Results of a Randomized Controlled Trial
Karla Bernardi, MD
USA
3:45–4:00 Comparative Efficacy of Transversus Abdominis
Plane Blocks and Epidural Catheters Following
Posterior Component Separation Hernia Repair
David Morrell, MD
USA
4:00–4:15 Repair of Complex Incisional Hernias After
Liver Transplant With TAR: The Experience
from Two Hernia Centers
Luciano Tastaldi, MD
USA
S2 Hernia (2019) 23 (Suppl 1):S1–S7
123
4:15–4:30 Laparoscopic Ventral Hernia Repair: Results and
Challenges of Long-Term Follow-Up
Michael Lew, MD
USA
4:30–4:45 Lateral Abdominal Wall Hernias: A Single
Institution Review of 116 Consecutive Flank
and Lumbar Hernia Repairs
Kathryn Schlosser, MD
USA
4:45–5:00 Polylactide-Caprolactone Composite Mesh Used
for Ventral Hernia Repair: A Prospective,
Randomized, Single-Blind Controlled Trial
Yingmo Shen, MD
China
5:00–5:15 Nanoscience and Hernia Surgery: A Sexy Future
or a Dream That Will Never Come True?
Barbora East, MD, PhD
Czech Republic
5:15–5:30 Early Outcomes Following Use of Autologous
Fenestrated Cutis Grafts in Hernia Repair
Ian Hodgdon, MD
USA
5:30–7:00 Welcome Reception
Tuesday, March 12, 2019
7:00–8:00 Breakfast
8:00–10:30 Session 5: The Great Debate: Mesh,Litigation, Petrochemicals and the Patient(Panel Session)
Moderators: Michael Rosen, MD & Sharon
Bachman, MD
8:00–8:05 Introduction
8:05–8:20 Perceptions of Mesh Use in Hernia Repair
Shirin Towfigh, MD
USA
8:20–8:35 The Problem with Hernia Mesh—Perspective
from the Plaintiff’s Bar
Lisa Lee, JD
USA
8:35–8:50 Medicolegal Defense of Hernia Mesh Related
Lawsuits
Andrew Myers, JD
USA
8:50–9:05 What’s the Rate of Long Term Mesh Related
Complications in Ventral Hernia Repair?
Thue Bisgaard, MD
Denmark
9:05–9:20 Is It Acceptable to Use Petroleum-Derived
Meshes in Hernia Repair?
Mark Benvenuto, PhD
USA
9:20–9:35 Biologics and Bioabsorbable Meshes: Can We
Avoid the Issues with Synthetic Mesh in Ventral
Hernia Repair?
J. Scott Roth, MD
USA
9:35–9:50 #MeshIsBad—How Do We Talk to Patients?
B. Todd Heniford, MD
USA
9:50–10:30 Panel Discussion
10:30–11:00 Break, Exhibits & Posters of Distinction
11:00–12:30 Session 6A: The Changing Face of HerniaSurgery: Defining Who We Are (PanelSession)
Moderators: Vedra Augenstein, MD & Talar
Tejirian, MD
11:00–1105 Introduction
11:05–11:30 The Pathway to Equity: Intentional Steps to
Foster Diversity in Our Profession
Barbara Bass, MD
USA
11:30–11:45 Better Together: Reflections of the First Woman
Americas Hernia Society President
Gina Adrales, MD, MPH
USA
11:45–12:00 Working Toward Gender Equality in Hernia
Surgery: The Role of Men
Jeffrey Janis, MD
USA
12:00–12:15 South American Perspective on Diversity
Among Hernia Surgeons
Evelyn Dorado, MD
Colombia
12:15–12:30 Panel Discussion
11:00–12:30 Session 6B: Scientific Abstracts—AbdominalWall Reconstruction
Moderators: Sean Orenstein, MD & John
Fischer, MD
11:00–11:15 Current Trends and Practices in Complex
Abdominal Wall Reconstruction: Results of a
Physician Survery
Dina Podolsky, MD
USA
11:15–11:30 Appreciation of Post Partum Changes of the
Rectus Muscles in Primary and Re-Do
Abdominoplasty
Lindsay Janes, MD
USA
11:30–11:45 The Incremental Impact of Obesity and Smoking
on Surgical Site Infections After Complex
Abdominal Wall Reconstruction
Andrew Shover, MD
USA
11:45–12:00 The Impact of Inadvertent Enterotomy During
Open Abdominal Wall Reconstruction (AWR)
Angela Kao, MD
USA
12:00–12:15 Does Loss of Domain Impact Outcomes for
Abdominal Wall Reconstruction Procedures?
Miles Landry, MBBS
USA
12:15–12:30 Hybrid vs. Open Abdominal Wall Reconstruction:
Early Outcomes
Alex Addo, MD, MPH USA
12:30–1:30 Lunch & Learns
Hernia (2019) 23 (Suppl 1):S1–S7 S3
123
1:45–3:45 Session 7A: AHS Safe Hernia Steps—Technical Tips for Common Problems inYour Hernia Practice
Moderators: Yuri Novitsky, MD & Lucas Beffa,
MD
1:45–2:00 Open Repair for Smaller Ventral Hernias:
Evidence Based Decisions
Susanne van der Velde, MD, PhD
Netherlands
2:00–2:15 Open Rives-Stoppa Ventral Hernia Repair
Wolfgang Reinpold, MD, PhD
Germany
2:15–2:30 Laparoscopic IPOM
Bernd Stechemesser, MD
Germany
2:30–2:45 Open Inguinal Hernia Repair: Tissue Based
Approach
John Morrison, MD
Canada
2:45–3:00 Open Inguinal Hernia Repair: Mesh Based
Approach
David Chen, MD
USA
3:00–3:15 Laparoscopic Inguinal Hernia Repair: The
Critical View
Edward Felix, MD
USA
3:15–3:30 Strategies for Success in Parastomal Hernia
Repair
Sharon Bachman, MD
USA
3:30–3:45 Incorporating Robotics into Your Hernia
Practice: Starting with the Right Procedures
Conrad Ballecer, MD
USA
1:45–3:45 Session 7B: Video and Special AwardAbstracts
Moderators: Kamal Itani, MD & Flavio Malcher
de Oliveira, MD
1:45–2:00 Females in Hernia Surgery Scholarship: Gender-
Specific Outcomes After Open Hernia Repair
(OVHR)
Kathryn Schlosser, MD
USA
2:00–2:15 Diversity in Healthcare Delivery Grant:
Socioeconomic Disparity Exists Among Those
Undergoing Emergent Hernia Repairs in the
State of New York
Salvatore Docimo, Jr., DO, MS
USA
2:15–2:30 AHSQC Resident Research Grant: Registry-
Based, Randomized Controlled Trial
Comparing Intra-Operative Foley Catheter vs.
No Catheter for Minimally Invasive Inguinal
Hernia Repair
Aldo Fafaj, MD
USA
2:30–2:45 AHSQC Resident Research Grant: Perioperative
Analgesia with Transversus Abdominis Plane
(TAP) Block vs. Epidural Analgesia: Analysis
from the Americas Hernia Society Quality
Collaborative
Ibnalwalid Saad, MD
USA
2:45–3:00 Re-Do TAR
Luciano Tastaldi, MD
USA
3:00–3:15 Panniculectomy, Perioperative Botulinum-Toxin
A and Preperitoneal Ventral Hernia Repair in a
Morbidly Obese Patient with Loss of Domain
Sean Maloney, MD
USA
3:15–3:30 Single Incisional Laparoscopic TEP Hernia
Repair Under Local Anesthesia
Norihito Wada, MD, PhD
Japan
3:45–4:15 Break, Exhibits & Posters of Distinction
4:15–5:30 Session 8A: Hot Topics in ComplexAbdominal Wall Reconstruction
Moderators: Vedra Augenstein, MD & Eric
Pauli, MD, MBA
4:15–4:30 Chemical Component Separation: Practical Use
and Review of the Data
B. Todd Heniford, MD
USA
4:30–4:45 Why Retromuscular? Onlay Can Do the Job
David Webb, MD
USA
4:45–5:00 Performing Posterior Component Separation
(TAR) Correctly
Yuri Novitsky, MD
USA
5:00–5:15 Myofascial Release After Previous Abdominal
Wall Reconstruction
Jeremy Warren, MD
USA
5:15–5:30 Five Plastic Surgery Tips All Hernia Surgeons
Should Know
Jeffrey Janis, MD
USA
4:15–5:30 Session 8B: Scientific Abstracts—VentralHernia IIModerators: Dmitry Oleynikov, MD & Paul
Szotek MD, MBA
4:15–4:30 Prevention of Incisional Hernia with Cutis
Autograft Augmentation
Aran Yoo, MD
USA
4:30–4:45 Computed Tomography Imaging in Ventral
Hernia Repair: Can We Predict the Need for
Myofascial Release?
Wes Love, MD
USA
4:45–5:00 The Impact of Weight Change on Intra-
Abdominal and Hernia Volumes
Kathryn Schlosser, MD
USA
5:00–5:15 Characterization of Information on Surgical
Mesh for Hernia Repair on the Internet
Matthew Miller
USA
S4 Hernia (2019) 23 (Suppl 1):S1–S7
123
Wednesday, March 13, 2019
7:00–8:00 Breakfast
8:00–10:30 Session 9: Special Problems in AbdominalCore Health
Moderators: Richard Pierce, MD, PhD &
Rebecca Petersen, MD
8:00–8:15 The Diastasis Recti Problem: Are There
Solutions That Work?
Salvador Morales-Conde, MD
Spain
8:15–8:30 Femoral Hernia Repair: Practical Tips
Matthew Goldblatt, MD
USA
8:30–8:45 Decision Making in Core Muscle Injury/Sports
Hernia
Giampiero Campanelli, MD
Italy
8:45–9:00 Reimbursement for Hernia Prophylaxis: Myth
and Reality
John Fischer, MD, MPH
USA
9:00–9:15 My Patient Has a Mesh Infection: Now What?
Pilar Hernandez-Granados, MD
Spain
9:15–9:30 Ventral Hernia Management in the Morbidly
Obese Patient
Rana Higgins, MD
USA
9:30–9:45 Fight or Flight? Ventral Hernia in the Emergent
Setting
Salvatore Docimo, Jr., DO, MS
USA
9:45–10:00 Laparoscopic Hiatal Hernia Repair: Keys to
Success
Kyle Perry, MD
USA
10:00–10:15 Complex Hiatal Hernia: When to Involve Your
Thoracic Surgeon Up Front
Aaron Bolduc, MD
USA
10:15–10:30 To Mesh or Not to Mesh: Prosthetic Use in
Hiatal Hernia Repair
Rebecca Petersen, MD
USA
10:30–11:00 Break, Exhibits & Posters of Distinction
11:00–12:30 Session 10A: WWYD (What Would You Do?)from International Hernia Collaboration toAmericas Hernia Society
Moderators: Brian Jacob, MD & Sarah
Bryczkowski, MD
11:00–11:10 Complication After an Open Transversus
Abdominus Release
Andrea Pakula, MD, MPH
USA
11:10–11:20 Incisional Hernia and Diastasis: From the IHC
Archives
David Santos, MD
USA
11:20–11:30 Totally Robotic Parastomal Repair With End
Ileostomy Reversal
Sarah Bryczkowski, MD
USA
11:30–11:45 Robotic Tapp Inguinal Hernia Repair Complicated
By Postoperative Small Bowel Obstruction
Stephen Pereira, MD
USA
11:45–12:00 Chronic Small Bowel Obstruction After IPOM
Lucian Panait, MD
USA
12:00 -12:10 Hernia and Diastasis: How I Do It
Mario Leyba, MD
USA
12:10–12:20 Complication During Open AWR: Divided
Linea Semilunaris
Joseph DeVitis, MD
USA
12:20–12:30 Mystery Finding Prior to Hernia Surgery
Adam Rosenstock, MD
USA
11:00–12:30 Session 10B: Hernia Care in ChallengingScenarios (Panel Session)
Moderators: Jeffrey Blatnik, MD & Shirin
Towfigh, MD
11:00–11:15 Many Hernias, Few Resources…and No Robots!
Charles Filipi, MD
USA
11:15–11:30 How We Approach Hernia Repair in a Tent in
the Amazon
Claudia Lorenzetti, MD
Brazil
11:30–11:45 Managing the Abdominal Wall and Hernias in
the Military
Eric Johnson, MD
USA
11:45–12:00 Training and Capacity Building in Rwanda
Ralph Lorenz, MD
Germany
12:00–12:15 Hernia Decision Making in the Non-Verbal
Patient
Salvatore Docimo, Jr., MD, MS
USA
12:15–12:30 Panel Discussion
12:30–1:30 Lunch & Learns
1:45–3:15 Session 11A: Hernia Prophylaxis—AHS Stopthe Bulge Campaign (Panel Session)
Moderators: Hobart Harris, MD & Dana Telem,
MD
1:45–2:00 Abdominal Wall Closure: European Hernia
Society Guidelines
Filip Muysoms, MD
Belgium
2:00–2:15 What’s the Matter America? Why Not More
Small Bites and Prophylactic Mesh?
Johannes Jeekel, MD
Netherlands
2:15–2:30 Parastomal Hernia Prevention: Do We Have a
Consensus?
Agneta Montgomery, MD
Sweden
2:30–2:45 Why Hernia Prevention Makes Sense
Hobart Harris, MD, MPH
USA
Hernia (2019) 23 (Suppl 1):S1–S7 S5
123
2:45–3:00 Small Bites Versus Prophylactic Mesh: Which to
Use When?
Rene Fortelny, MD
Austria
3:00–3:30 Panel Discussion
1:45–3:15 Session 11B: Scientific Abstracts—Hot Topicsin Hernia
Moderators: Vimal Narula, MD & Claudia
Lorenzetti, MD
1:45–2:00 A New Technique for Peritoneal Flap Closure In
TAPP: A Prospective Randomized Controlled
Trial
Yilin Zhu, BS
China
2:00–2:15 Is the International Hernia Collaboration a Safe
and Effective Resource for Surgeons?
Karla Bernardi, MD
USA
2:15–2:30 Mesh Suture Better Resists Suture Pull-Through
Than Small Bites Surgical Technique
Jason Souza, MD
USA
2:30–2:45 Experience with the Pinq-Phone Telephone
Questionnare for Detection of Recurrences
After Endoscopic Inguinal Hernia Repair
Wouter Bakker, MD
Netherlands
2:45–3:00 A Role for the Integrin Subunit Beta 1 Gene in
Direct Inguinal Hernia with Family History
Lei Zhu, MD
China
3:00–3:15 Management of Abdominal Wall Hernias in
Women of Childbearing Age: A Qualitative
Study Assessing Surgeon Practice
Sara Jafri
USA
3:15–3:30 Prevalence of Posttraumatic Stress Disorder
(PTSD) in Patients with an Incisional Hernia
Hemasat Alkhatib, MD
USA
3:45–4:15 Break, Exhibits & Posters of Distinction
4:15–5:30 Session 12A: AHSQC Panel Session: LongTerm Follow Up and Registry-Based ClinicalTrials
Moderators: Benjamin Poulose, MD, MPH &
Michael Rosen, MD
4:15–4:30 Hybrid Robotic Transversus Abdominus Release
Has Shorter Length of Stay Compared to Open
Transversus Abdominis Release: An AHSQC
Analysis
Alexander DeMare, MD
USA
4:30–4:45 Is Mechanical Fixation Needed in Open
Retromuscular Ventral Hernia Repair?
Richard Pierce, MD
USA
4:45–5:00 Telescopic Dissection vs. Balloon Dissection in
Laparoscopic TEP Repair: A Registry-Based
Randomized Controlled Trial
Luciano Tastaldi, MD
5:00–5:15 Assessing Outcomes of Myofascial Release
Using the AHSQC
Paul Tenzel, MD
USA
5:15–5:30 Integration and Implementation of Patient
Recorded Outcomes (PROs) into Clinical
Practice
Shelby Nathan, MD
USA
4:15–5:30 Session 12B: Scientific Abstracts—ParastomalHernia & Hiatal Hernia
Moderators: Kyle Perry, MD & Kristi Harold,
MD
4:15–4:30 Hiatal Hernia and Gerd: An Indication for
Conversion from Sleeve Gastrectomy to Rous-
En-Y Gastric Bypass
Raelina Howell, MD
USA
4:30–4:45 Prophylactic Mesh Augmentation for Prevention
of Parastomal Hernia
Allison Foster, BS
USA
4:45–5:00 A Retrospective Review with Prospective
Follow-Up of 85 Consecutive Patients Treated
with Miromesh� for Hiatal Hernia Repair
G. Kevin Gillian, MD
USA
5:00–5:15 Large Hiatal Hernia with the Upside-Down
Stomach. What Is the Best Way?
Pavol Klobusicky, MD
Germany
5:15–5:30 Mesh Salvage Following Deep Surgical Site
Infection
Stephen Siegal, MD
USA
Thursday, March 14, 2019
7:00–8:00 Breakfast
8:00–10:00 Session 13: Spectacular Cases (Panel Session)
Moderators: Eric Pauli, MD, Elizabeth Colsen,
MD, Clayton Petro, MD & Paul Colavita, MD
8:00–8:05 Inroduction
Paul Colavita, MD
8:05–8:20 Chronic Groin Pain Leading a 22-Year Old to
Disability. What Now?
Paulo Henrique Fogaca de Barros, MD
Brazil
8:20–8:35 Lateral Abdominal Wall Dehiscence After
Component Separation
Joseph DeVitis, MD
USA
8:35–8:50 Robotic TAPP Inguinal Hernia Repair: A
Palliative Approach in a Patient with Sepsis
and Possible Penumatosis Intestinalis
Osvaldo Zumba, MD
USA
8:50–9:05 Repair of Spontaneous Intercostal Hernia aia
Open Transthoracic Extrapleural Approach
Kathryn Schlosser, MD
USA
S6 Hernia (2019) 23 (Suppl 1):S1–S7
123
9:05–9:20 Abdominal Wall Reconstruciton in a Patient
with an Incomplete Anterior Pelvic Ring
Aldo Fafaj, MD
USA
9:20–9:35 Just Your ‘‘Routine’’ Open Inguinal Hernia
Repair
Sean Maloney, MD
USA
9:35–10:00 Panel Discussion
10:00–10:30 Break
10:30–12:30 Session 14: Special Technique in Ventral andInguinal Hernia
Moderators: Jacob Greenberg, MD, EdM &
Sergio Roll, MD
10:30–10:45 The Laparoscopic Onlay Repair: Why You
Should Consider It
Leandro Totti Cavazzola, MD
Brazil
10:45–11:00 Minimally Open Sublay Technique (MILOS)
Wolfgang Reinpold, MD
Germany
11:00–11:15 A Successful Approach to Managing
Enterocutaneous Fistula
Kristi Harold, MD
USA
11:15–11:30 Extraperitoneal Minimally Invasive Repair
Options
Christiano Claus, MD, PhD
Brazil
11:30–11:45 A New Approach to Laparoscopic Bilateral
Inguinal Hernia Repair: The BTOM
Gustavo Castagneto, MD
Argentina
11:45–12:00 Intraperitoneal Polypropylene in Giant Ventral
Hernia
Claudio Brandi, MD
Closing Remarks
12:00–12:15 Meeting Award Presentations
Benjamin Poulose, MD, MPH
USA
12:15–12:30 Transition of Presidency/Closing Remarks
Gina Adrales, MD, MPH
USA
12:30 Adjourn
Hernia (2019) 23 (Suppl 1):S1–S7 S7
123
Monday, March 11, 2019
Session 1: Opening Session
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1299
How Social Media Will Change Your Practice and How
to Get Ready
Jacob BLaparoscopic Surgical Center of New York
.
IP-1300
Robotics in hernia surgery: stalling or soaring?
Prabhu ACleveland Clinic
.
IP-1301
Five key studies all hernia surgeons should know
Bachman SInova
.
IP-1302
Nyhus-Wantz lecture
Roll SSao Paulo, Brazil
.
IP-1303
Safe hernia steps program
Novitsky YColumbia
.
IP-1304
Abdominal core health: the time has come
Poulose BThe Ohio State University Wexner Medical Center
.
IP-1305
Presidential address
Adrales GJohns Hopkins
.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S8
Monday, March 11, 2019
Session 2A: The Future Is Here: Robotics in Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1306
Evidence update for robotics: where do we need to go?
Prabhu ACleveland Clinic
.
IP-1287
The challenges of starting a robotic program
Olasky JMount Auburn Hospital
Building a robotic surgery practice can be a slow process with many
unique challenges including financial concerns, credentialing issues,
and staffing problems. These obstacles depend in part on the climate
of the institution involved. This talk will cover the most common
barriers to building a robotic hernia program and present strategies for
overcoming them.
IP-1291
Rethinking the laparoscopic IPOM with robotics
Saving ANorton Surgical Specialists/Louisville General Surgery
The laparoscopic IPOM is where minimally invasive ventral hernia
repair got its start in the early 1990s. Compared to open repair, it
allowed for minimal incisions, quicker surgery time and recovery, and
decreased wound morbidity. However, issues including poor or no
defect closure, post-operative pain, and complications from
intraperitoneal mesh placement brought criticism. These critiques
coupled with further advancements in abdominal wall reconstruction
caused it to fall a bit out of favor. With the advent of robotic tech-
nology, some of the technical concerns have now been sorted out.
Robotics has begun restoring the MIS intraperitoneal mesh onlay
technique as a useful approach for hernia repair. In particular, this
procedure arguably may be the most suitable method for certain select
patient groups. Therefore, robotic-assisted laparoscopic IPOM should
be restored as one of the many skills a comprehensive hernia surgeon
should utilize.
IP-1289
From TEP to robotic inguinal hernia repair: why I
changed
Lourie DHuntington Hospital
I could do a 20 min laparoscopic TEP inguinal hernia repair with my
eyes closed (or at least my lens blurred). After thousands of cases,
with great outcomes, why in the world would I ever want to start over
and change? Well, have a seat (at the robotic console) and let me tell
you why now I cannot imagine going back.
IP-1307
Hernias, residents, and robotics: training
the next generation
Meara M.
IP-1308
Robotic retromuscular abdominal wall reconstruction
Belyansky IAnne Arundel Medical Center
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S9
Monday, March 11, 2019
Session 2B: Scientific Abstracts—Inguinal Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1156
Closure of direct inguinal hernia defect in laparoscopic
hernioplasty to prevent seroma formation:
a prospective double-blind randomized controlled trial
Zhu Y, Wang MBeijing Chao-Yang Hospital
Objectives: Seroma is the most frequent postoperative complication
after laparoscopic direct inguinal hernia repair. This randomized
controlled trial evaluated the preventive effect of a simple technique
by closing the direct hernia defect with barbed suture in laparoscopic
direct inguinal hernia.
Methods: 60 patients aged 18 years or older who presented to the
hernia center department in our hospital between October 1, 2017 and
January 1, 2018 with primary direct inguinal hernia were randomized
into the defect-closing group and the control groups. The primary
outcomes were to compare the ultrasonic seroma number and volume
at the inguinal region at 7 days, 1 month and 3 months postopera-
tively. Secondary outcomes included total operative time, acute pain,
chronic pain (pain lasting over 3 months), hospital stay, recurrence
and any other complications.
Results: There were no significant differences in baseline demo-
graphic characteristics between the two groups including age, sex,
hernia type, size of hernia defect, surgical approach and follow-up
time. Compared with control group, there were significantly fewer
patients with seroma formation at 7 days, 1 month and 3 months after
the operations in the defect-closing group (p\ 0.001, p\ 0.001,
p = 0.002, respectively). In addition, ultrasonic seroma volume was
less in the defect-closing group on postoperative day 7 (13.33 ml vs.
30.45 ml, p = 0.02). The acute pain and hospital stay were compa-
rable (p = 0.61, p = 0.85, respectively), and no chronic pain, early
recurrence or other postoperative complications observed in both
groups during the follow-up period.
Conclusions: The simple technique of direct hernia defect closure
with barbed suture in laparoscopic direct inguinal hernia repair is a
secure and effective method, which is easy to perform and could
significantly reduce both incidence and volume of seroma formation
without increasing the risk of recurrence, acute and chronic pain.
FP-1244
Hernia recurrence inventory: inguinal hernia
recurrence can be accurately assessed using patient-
reported outcomes
Tastaldi L, Barros P, Krpata D, Prabhu A, Rosenblatt S,
Altenfelder Silva R, Roll S, Rosen M, Poulose BCleveland Clinic
Background: We aim to determine if inguinal hernia recurrences
could be assessed using the Ventral Hernia Recurrence Inventory
(VHRI), a previously existing patient-reported outcome (PRO) tool
which has already been validated for diagnosing ventral hernia
recurrence.
Methods: Adult patients from two centers (United States and Brazil)
at least 1 year after inguinal hernia repair were asked to prospectively
answer the questions of the VHRI in relation to their prior repair. A
physical exam was then performed by a blinded surgeon, and testing
characteristics were calculated.
Results: 128 patients were enrolled after 175 repairs. All patients
answered the VHRI and were further examined, where a true recur-
rence was present in 32% of the repairs. Self-reported bulge and
patient perception of a recurrence were highly sensitive (83%–93%)
and specific (82%–94%) for the diagnosis of an inguinal hernia
recurrence. Test performance was similar in the American and
Brazilian populations despite several baseline differences in demo-
graphic and clinical characteristics.
Conclusion: The VHRI can be used to assess long-term inguinal
hernia recurrence and should be reestablished as the Hernia Recur-
rence Inventory (HRI). Its implementation in registries, quality
improvement efforts, and research could contribute to improving
long-term follow-up rates in hernia patients.
FP-1118
Method of forming a three-layer back wall
of the inguinal canal and complete isolation
of the spermatic cord from the mesh
Gvenetadze TGudushauri National Medical Center, David Agmashenebeli
University of Georgia
Objectives: The study and comparison of quantitative composition of
spermatozoids prior and after Lichtenstein and Gvenetadze methods.
Materials and methods: For the recent 10 years 1200 patients have
been operated on by the isolation method. 215 patients of the repro-
ductive age (19–40 years.) with the bilateral inguinal hernias became
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S10–S11
the object of study. The patients were allocated into two groups. The
first group contained those 66 patients (30.7%) who underwent
bilateral Lichtenshtein hernia repair. The second group—149 patients
(69.3%) on whom bilateral hernia repairs by Gvenetadze method have
been utilized. Complete spermomorphocitological investigations have
been performed in all groups 2 days prior to surgery, 30 days and
6 months after surgery.
Results: Oligospermia, reduction of the quantitative sperm compo-
sition by 30–35% was revealed only in the first group (p\ 0.01). In
the second group no significant differences was registered. 68 patients
had children after surgery by Gvenetadze method.
Conclusion: Hernioplasty by Gvenetadze prevents male infertility in
all cases especially for bilateral inguinal hernia repair as well as in
reproductive age. The given technique is more solid as the posterior
wall of the inguinal canal presented by the transverse fascia, mesh and
aponeurosis of the external oblique muscle therefore the recurrence
rates of hernia is minimized and practically excluded. Based on the
foregoing results this method is considered as an effective method of
hernioplasty as for young as well for elderly patients.
FP-1093
Preliminary results At 3-year follow up of totally
extraperitoneal hernia surgery with long-term
resorbable mesh
Ruiz-Jasbon F, Ticehurst K, Ahonen J, Norrby J, Ivarsson
MHalland’s Hospital/Kungsbacka
Introduction: Synthetic non-resorbable mesh is almost standard in
hernia surgery nowadays. However several studies have showed
negative effects of permanent implants such as chronic inflammation
and complications involving different organs bordering the mesh.
Moreover promising results regarding pain in patients with lateral
inguinal hernia (LIH) has been published using a slowly resorbable
mesh in Lichtenstein technique. For this reason the aim of the present
study was to find the rate of hernia recurrence and chronic post-
operative pain long-term in patients with LIH repaired with slowly
resorbable implant in TEP procedure.
Methods: Pilot prospective study of TEP repair using TIGR� Matrix
Surgical Mesh in 35 primary LIH. Visual Analogue Scale (VAS) and
Inguinal Pain Questionnaire (IPQ) were employed to assess pain.
Recurrence was determined by ultrasound and clinical examination.
Results: No patients had chronic pain, as defined in the World
Guidelines for Groin Hernia Management, or recurrence at one-year
follow up. 3-year follow up results will be presented at the AHS 2019
Annual Meeting.
FP-1064
Phone follow-up after inguinal hernia repair
Greenberg J, Liu N, Xu Y, Altimari M, Shada A, Funk L,
Lidor AUniversity of Wisconsin
Background: Inguinal hernia repair (IHR) is one of the most com-
monly performed procedures in the United States. With a low rate of
complications and a relatively brief recovery period, many patients
have already returned to work and normal activities by the time of
their postoperative visit. We hypothesized that a phone follow-up
protocol could safely be utilized following IHR.
Methods: Adult patients (age C 18) who underwent elective outpa-
tient IHR at a single institution academic center during 2013–2016
were retrospectively identified from the electronic medical record
(EMR). Phone follow-up patients were contacted by phone 1–2 weeks
following surgery and asked a specific set of questions which were
entered into the EMR. Patients’ baseline characteristics, perioperative
course, and follow-up information were collected from the EMR.
Predictors of surgery outcomes including related 90-day ED visits,
readmissions and reoperations were analyzed using an intention-to-
treat comparing those who received phone follow-up versus in-person
follow-up. Multivariable logistic regression analysis for the outcomes
of interest was performed.
Results: 1039 patients underwent IHR during the study period. 754
were performed via a laparoscopic approach (338 TAPP vs. 416
TEP), while 244 were performed open. 261 patients had bilateral
hernias, while 52 had recurrent hernias. 786 had phone follow-up, and
220 had in-person follow-up only. Baseline demographics and oper-
ative approach were similar between the two groups. The composite
rate of ER visits/readmissions/reoperations within 90 days of surgery
was similar between the phone follow-up and in person groups
(9.80% vs. 7.27%, p = 0.253). Multivariable logistic regression
demonstrated that the odds of having related ER visit/readmission/
reoperation was similar between the two groups.
Conclusion: Patients who underwent phone follow-up had similarly
low rates of adverse outcomes compared to those with in-person
follow-up after inguinal hernia repair. Phone follow-up protocols may
be implemented as a means to decrease healthcare utilization fol-
lowing IHR.
123
S11 Hernia (2019) 23 (Suppl 1):S10–S11
Monday, March 11, 2019
Session 3A: Avoiding and Managing Chronic Groin Pain After Inguinal Hernia Repair(Panel Session)
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1309
Identifying patients at risk for chronic groin pain
before operation
Alvarez RJalisco, Mexico
.
IP-1310
Strategies to minimize chronic groin pain in open
and minimally invasive inguinal hernia repair
Nguyen D.
IP-1312
Diagnosis and management of chronic groin pain:
an overview
Renton DThe Ohio State University Medical Center
.
IP-1313
Designing a comprehensive treatment center
for chronic groin pain
Krpata DCleveland Clinic
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S12
Monday, March 11, 2019
Session 3B: Scientific Abstracts—Robotics
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1315
Automated surgical coaching for technical skills
acquisition in incisional hernia repair
Adrales GJohns Hopkins
.
FP-1226
The enhanced-view totally extraperitoneal robotic
Rives-Stoppa abdominal wall reconstruction: a review
of outcomes
Addo A, Parlacoski S, Broda A, Zahiri R, Lu R, Turcotte J,
Belyansky IAnne Arundel Medical Center
Background: We recently reported 30-day outcomes post enhanced-
view totally extraperitoneal (eTEP) robotic Rives-Stoppa abdominal
wall reconstruction (AWR). This novel minimally invasive approach
allows repair of complex ventral hernias, correction of midline con-
tour abnormalities and restoration of the linea alba. It also allows
wide mesh overlap while avoiding invasive fixation and mesh contact
with intraperitoneal viscera. This study reports our outcomes beyond
the initial 30 days.
Methods: We conducted a retrospective review of all patients who
underwent eTEP robotic Rives-Stoppa AWR between June of 2017
and May of 2018 at Anne Arundel Medical Center. Patient demo-
graphics and perioperative data were evaluated using univariate
analysis.
Results: Ninety-two patients were included for this analysis. Patients
consisted of 52% female and 48% male. Mean age, BMI and median
ASA score were 51 years, 34.15 kg/m2 and 2 respectively. Intraop-
erative data analysis revealed mean operative time of 182.9 min.
Mean area of implanted mesh was 510 cm2. In 22 percent of cases,
drains were placed above the mesh in the retrorectus space and
removed on average 5 days after surgery. The mean length of stay
was 0.4 days as most patients were same day discharge. Average
length of follow-up was 3.6 months. During this time, two patients
developed posterior rectus sheath failure with incarceration of small
bowel requiring emergent exploration, bowel resection and abdominal
wall reconstruction with transversus abdominis release. One patient
had a recurrence within 1 year following surgery.
Conclusion: The eTEP Robotic Rives-Stoppa AWR offers a com-
prehensive approach to the restoration of abdominal wall anatomy in
the least invasive fashion. While outcomes indicate it is both safe and
effective with enhanced recovery for patients, further long-term fol-
low-up is required to better characterize unique complications such as
posterior rectus sheath failure, as well as, long-term recurrence rates.
FP-1171
Robotic-assisted ipsilateral rives ventral hernia repair
versus open rives ventral hernia repair
Halka J, Demare A, Vasyluk A, Iacco A, Janczyk RWilliam Beaumont Hospital
Background: Robotic assisted surgery allows for complex abdominal
wall dissections, such as the Rives retrorectus repair, to be performed
in a minimally invasive manner. Although robotic assistance may
offer distinct advantages, there are potential pitfalls when compared
to the open operation. We describe our initial experience with the
ipsilateral robotic retrorectus repair compared to open for moderate
size ventral hernias.
Methods: Data for all Rives retrorectus hernia repairs performed at
our institution between 2014 and 2017 were gathered from our
institutional database along with the Americas Hernia Society Quality
Collaborative (AHSQC). Patient demographics, operative details, and
short term outcomes data were analyzed.
Results: 121 open patients and 45 robotic assisted hernia repair
patients were analyzed. Patient populations were statistically similar.
Length of stay was significantly shorter in the robotic group (1 day vs.
3 days, p = 0.02). Readmissions, SSO requiring intervention were
statistically similar between groups. While not statistically significant,
readmissions were higher in the robotic group (4% vs. 10% p = 0.23)
and reoperations were higher in the robotic group (3% vs 10%
p = 0.11). The open group had four re-operations, one for posterior
flap disruption and resultant SBO, one for seroma drainage, and two
for hematoma drainage. The robotic group had four re-operations, two
due to SBO from peritoneal flap disruption, one for hematoma
evacuation, and one for abscess drainage. Half of the reoperations in
the robotic group were for SBO secondary to posterior flap disruption.
Seromas were higher in the robotic group (12% vs 6%), but were not
statistically significant.
Conclusion: While robotic-assisted ipsilateral Rives ventral
retrorectus hernia repair may offer advantages compared to the open
procedure, surgeons should be aware of the potential risks involved
with this choice in operation as shown in our initial experience.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S13–S14
FP-1130
Robotic inguinal hernia repair is being adopted
by the majority of minimally invasive hernia surgeons
Rodrigues Armijo P, Oleynikov DUniversity of Nebraska Medical Center
Introduction: Little is known about how robot technology is
employed by minimally invasive general surgeons. Our aim was to
evaluate the needs of established robotic surgeons and of those who
are new to this technology.
Methods: A survey was designed and sent electronically to all
SAGES members. Questions included fellowship training, area of
expertise, robotic simulation and in clinical case use, services offered
in the current hospital, mentorship, likelihood of switching to a dif-
ferent approach, and expectations for the robot. Descriptive analysis
were conducted using STATA/MP 15.1.
Results: Of all survey respondents, 189 self-identified as hernia
surgeons. Among those hernia surgeons, 73.8% had additional fel-
lowship, with majority practicing for 3–6 years (54%). Nearly 40% of
interviewees were MIS surgeons (N = 73), followed by general sur-
gery (34.4%), and bariatrics (13.8%). Surprisingly, 146 respondents
(77.7%) had used the daVinci� in a clinical setting. Among robotic
surgeons, majority is performing less than 10 cases per month using
robotic-assistance. Inguinal hernia repairs are the leading procedures
among those (49%), followed by foregut-related (19.5%), and col-
orectal-related surgeries (17.5%). Nearly 40% of surgeons stated
inguinal hernia repairs to the most often performed procedure using
the robot. Interestingly, 42.5% of hernia surgeons are planning to
switch from open procedures to its robot counterpart, whereas 39.4%
are planning to adopt robotic-assisted procedures rather than laparo-
scopy. Level 1 evidence (47.9%) and cost (24.1%) were the most
pressing needs for robotic research.
Conclusions: Majority of survey respondents have used the daVinci�
in a clinical setting. While robotic cases represent only a portion of
the surgeries performed, inguinal hernia repairs and foregut appear to
be the most common procedures done with robotic-assistance. This
data shows that nearly half of hernia surgeons will be adopting robotic
technology over its open or laparoscopic counterparts.
FP-1191
A cost-neutral approach to surgical resident robotic
inguinal hernia training
Budney S, Richards J, Rubalcava N, Israr S, Weinberg J,
Gagliano R, Gillespie TCreighton University and Medical Center at St. Joseph Hospital
and Medical Center
Introduction: The adoption of robotic surgery has been expensive
and time consuming; however, residency programs are responsible for
training residents in technologies that will be part of their scope of
practice. The lean start-up methodology is a set of operating princi-
ples designed to expedite the research and development phase of
production. Through iterative product releases, producers cycle
through building, measuring, and learning to create a final product. A
well-trained general surgeon applied the lean start-up methodology to
his surgical practice and is now able to perform R-TAPP IHR at an
equivalent or lower cost than L-TEP. Here we examined if applying
lean start-up methodology in training surgical residents has similar
results.
Methods: We completed a retrospective and prospective cost com-
parison analysis of a single surgical educator’s ‘‘last 12 taught’’
L-TEPs (Group A), ‘‘first 12 taught’’ R-TAPPs (Group B), and ‘‘last
12 taught’’ R-TAPPs (Group C). All R-TAPP procedures were per-
formed using lean start-up principles. We performed small batch
analysis of total consumable material cost, including cost of mesh and
‘‘per use’’ cost of robotic instruments. Statistical analysis was per-
formed using one-way ANOVA with post hoc Bonferroni correction.
Statistical significance was defined as p\ 0.05. We determined a line
of best fit for R-TAPP cost versus case number to calculate the case
number when R-TAPP training becomes cost-neutral to L-TEP.
Results: The average cost for Group B was $1867.05 and $207.24
more expensive than Group A. The average cost for Croup C was
$1589.16 saving $70.65 compared to Group A. One-way ANOVA
was significant (p = 0.043). On post hoc analysis, the only statistical
difference was between Group B and Group C (p = 0.008). We cal-
culate that after 15 cases, R-TAPP training becomes cost-neutral.
Conclusion: The lean start-up methodology enables a cost-neutral
approach to robotic surgery training and can contribute to the sus-
tainability of academic robotic training programs.
123
S14 Hernia (2019) 23 (Suppl 1):S13–S14
Monday, March 11, 2019
Session 4A: Should We Be Gambling with Our Hernia Patients? Innovation with RiskSharing Is a Better Bet
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1316
Barracuda tank follow up: mesh suture
Dumanian GChicago, IL
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S15
Monday, March 11, 2019
Session 4B: Scientific Abstracts—Ventral Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1260
Prehabilitation in underserved, minority patients
with ventral hernias: long-term results of a randomized
controlled trial
Bernardi K, Bernardi K, Olavarria O, Holihan J, Cherla D,
Berger D, Ko T, Liang MMcGovern Medical School UTHealth
Background: Previously, we demonstrated that prehabilitation, or
preoperative nutritional counseling and exercise, at a safety net hos-
pital can help patients achieve preoperative weight loss goals and
results in more patients who are hernia-free and complication-free
7-months post-randomization. We hypothesized that prehabilitation in
underserved, obese patients seeking ventral hernia repair (VHR)
results in more hernia- and complication-free patients at 2 years post-
randomization.
Methods: This was a blinded randomized controlled trial at a safety-
net academic institution. Obese patients (BMI 30–40) seeking VHR
were randomized to prehabilitation versus standard counseling.
Elective VHR was performed once preoperative requirements were
met: 7% total body weight loss or 6 months of counseling and no
weight gain. Primary outcome was percentage of hernia-free and
complication-free patients at 2 years post randomization. Complica-
tions included recurrence, re-operation, and mesh complications (i.e.
mesh infection).
Results: A total of 118 patients were randomized, 110 (93.2%)
completed a median (range) follow-up of 26.6 (19.1–35.6) months.
Baseline BMI (mean ± SD) was similar between the groups (preha-
bilitation 36.8 ± 2.6 and standard counseling 37.0 ± 2.6). At late
follow-up, there was no difference in the percentage hernia-free and
complication-free patients (75.0% vs 68.5%, p = 0.527). Almost half
of all patients, 44.2% in prehabilitation and 43.2% in standard
counseling, gained weight over their baseline and 14.5% of patients
(prehabilitation = 5, standard counseling = 10) sought VHR else-
where. Underserved minorities lost less weight on average (8.6 vs
13.8 lbs, p = 0.048) and had a lower percentage of patients were
hernia-free complication-free (65.6% vs 75.0%).
Conclusions: While prehabilitation prior to VHR is feasible and
effective in the short-term at a safety-net hospital, there was no dif-
ference in long-term results. This may be because patients often
regain the weight they lost or seek VHR elsewhere after failing
preoperative requirements. Continuing diet and exercise programs
after VHR, along with national guidelines, and changes in compen-
sation may be important components of tackling VHR in obese
patients.
FP-1189
Comparative efficacy of transversus abdominis plane
blocks and epidural catheters following posterior
component separation hernia repair
Morrell D, Pauli E, Doble J, Hendriksen B, Hollenbeak CPenn State Health Milton S. Hershey Medical Center
Introduction: Recovery protocols have become a point of emphasis
in postoperative care following ventral hernia repair (VHR). How-
ever, little is known about the contribution of a protocol’s individual
components on measurable patient outcomes. This study evaluates the
efficacy of two postoperative analgesia modalities—epidural catheter
or transversus abdominis plane block (TAP-block) following VHR
performed via transversus abdominis release (TAR).
Methods: A retrospective analysis was performed on data prospec-
tively collected between 2012 and 2018. All patients undergoing
VHR via TAR performed by a single surgeon were identified.
Parastomal hernia repairs were excluded. During the study time
frame, the only change made to the recovery protocol was the
modality of post-operative analgesia (epidural or TAP-block). The
dataset was augmented with pain scores, opioid requirements, length
of stay (LOS), and 30-day morbidity collected from the medical
records. Linear regression was used to model LOS.
Results: One hundred fourteen patients met inclusion criteria (61
epidural, 53 TAP-block). All TAP-blocks were performed with 20 mg
of liposomal bupivacaine. The majority (75%) of patients were
modified ventral hernia working group (VHWG) grade 2. There were
no statistically significant differences in postoperative pain scores or
opioid use between the groups. LOS was significantly shorter in the
TAP-block group (4.7 versus 6.1 days, p = 0.012) as was time to
regular diet (3.1 versus 4.9 days, p = 0.0003). Epidural patients
experienced higher rates of urinary tract infection (UTI; 8.2% versus
0%, p = 0.033). After controlling for VHWG grade, surgical site
infection, pneumonia, UTI, and postoperative bleeding, epidural
increased LOS by 1.5 days (p = 0.002).
Conclusions: When compared to TAP-block, epidural use following
VHR via TAR increased LOS, time to regular diet, and UTI rates
without significantly reducing pain scores or opioid requirements.
Future study of the cost-effectiveness of epidural versus TAP-block
locoregional analgesia in VHR via TAR is warranted to refine
existing recovery protocols.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S16–S18
FP-1123
Repair of complex incisional hernias after liver
transplant with TAR: the experience from two hernia
centers
Tastaldi L, Blatnik J, Krpata D, Fafaj A, Alkhatib H, Petro
C, Rosenblatt S, Prabhu A, Rosen MCleveland Clinic
Introduction: The combination of midline and subcostal defects,
proximity to bony prominences and associated lifelong immunosup-
pression are factors that makes the management of incisional hernias
(IH) after orthotopic liver transplant (OLT) challenging. We aim to
report the outcomes of IH repair after OLT using a posterior com-
ponent separation with transversus abdominis release (TAR).
Methods: Post-transplant patients who underwent open, elective IH
repair using TAR and with a minimum of 1-year follow-up were
identified in the Americas Hernia Society Quality Collaborative.
Repairs were performed at two Hernia Centers with permanent syn-
thetic mesh placed in sublay position. Outcomes included 30-day
surgical site infections (SSI) and surgical site occurrences requiring
procedural intervention (SSOPI), unplanned readmissions, reopera-
tions, and hernia recurrence. Recurrence was determined by clinical
examination, imaging studies or using the Ventral Hernia Recurrence
Inventory.
Results: Forty-four patients were identified (mean age 60 ± 8, 75%
males and median BMI 30.7 kg/m2); all were under immunosup-
pression at time of surgery. Median hernia width was 20 cm (IQR
15–27.5) and 98% were clean cases. Fascial closure was achieved in
41 (93%) and there were no intraoperative complications. There were
5 SSIs (4 deep, 1 superficial), 5 SSOPIs (4 wound opening and 1
debridement) and one patient had a mesh infection. Four patients
(9%) were readmitted and 3 patients (6.8%) required reoperation (2
due to 1 bleeding, 1 due to SSI). After a median follow-up of
13 months (IQR 12–17), the recurrence rate was 25%, mostly driven
by central mesh failures. Repair of such recurrences were performed
through onlay or laparoscopic approaches.
Conclusions: In a challenging cohort of patients with large IH, TAR
was shown to have acceptable medium-term results. Further studies
investigating the factors leading to central mesh failures are necessary
to reduce recurrence.
FP-1216
Laparoscopic ventral hernia repair: results
and challenges of long-term follow-up
Lew M, Lewis R, Landry M, Ramshaw B, Forman BUniversity of Tennessee, Knoxville
Background: Laparoscopic ventral hernia repair is a commonly
performed procedure. Although short-term follow-up results have
been frequently published, long-term follow-up remains challenging.
Methods: We implemented a clinical quality improvement (CQI)
program for ventral hernia patients to better measure and improve
outcomes. From 2012 to 2015, 117 consecutive laparoscopic ventral
hernia repair patients from a single hernia program were evaluated.
Long-term follow-up was attempted through a variety of methods
including phone, email and in person clinic visits.
Results: A total of 117 patients had 4 known recurrences, 3 patients
developed chronic pain after hernia repair (two had mesh removal) and
one patient died from aspiration on POD #3. Overall, 54% of patients
were female, mean age was 59, mean BMI was 53.4, and 56% had a
recurrent hernia (1–13 prior repairs). The mean hernia size was 96 cm2,
and mean mesh size was 538 cm2. The attempts to obtain follow-up data
were challenging. Despite multiple attempts and a variety of mecha-
nisms, only 82 patients (70%) have follow-up data for 18 months or
longer (mean 37.2 months, range 18–76 months). Reasons for cessation
of follow-up included deaths unrelated to the hernia repair, but some
patients refused to continue being contacted due to their worry about
unpaid hospital bills and their concern about hernia mesh litigation.
Conclusion: Even with a dedicated hernia program, recurrences and
complications do occur and obtaining long-term follow-up is difficult
after laparoscopic ventral hernia repair. Challenges with obtaining
long-term follow up likely undercount recurrences and complications
and inhibit learning. Innovative methods to increase follow-up can
lead to more accurate outcome measurements and eventually help
lead to improved patient outcomes.
FP-1124
Lateral abdominal wall hernias: a single institution
review of 116 consecutive flank and lumbar hernia
repairs
Schlosser K, Maloney S, Prasad T, Colavita P, Augenstein
V, Heniford BCarolinas Medical Center
Aims: Lateral abdominal wall hernia repair (LAWHR) is a surgical
challenge, as defects often extend to paraspinal muscles and are
bordered by bone on one or multiple sides. This study examines the
outcomes of LAWHR as compared to ventral hernia repair (VHR).
Methods: A prospective, single-center, hernia-specific database was
queried for LAWHR and VHR with preoperative CT scans (2007–2018).
Demographics, operative characteristics, and outcomes were evaluated.
Results: 116 LAWHR and 1022 VHR were identified. Mean age was
58.3 ± 12.4 years, BMI 33.1 ± 7.3, and 58.3% were females. When
compared to VHR, LAWHR had lower BMI (30.4 ± 6.0 vs
33.8 ± 7.5 kg/m2, p = 0.002), smaller defect size (median 68.6, IQR
40.3–135.0 vs. 105.1, IQR 46.6–226.2 cm2), and fewer previous
hernia repairs (median 1, IQR 1–2 vs. 2, IQR 1–3). 63% of LAWR
were incisional, 22% blunt trauma, and 15% primary. More VHR had
concomitant panniculectomy (37.4 vs. 3.5%, p\ 0.0001), Class II-IV
wounds (28.8 vs. 6.0%, p\ 0.001), and component separation (50.4
vs. 20.7%,\ 0.0001), with equivalent rates of primary fascial closure
(89.5 vs. 93.1%, p = 0.2). VHR had higher surgical site occurrence
(SSO 32.5 vs. 16.0%, p\ 0.0001), surgical site infection (SSI 24.1
vs. 12.1%, p = 0.004), and recurrence (12.3 vs. 2.6%, p\ 0.0001).
LAWHR showed a higher incidence of postoperative pain requiring
further intervention, (43.4% vs. 20.0%, p\ 0.0001), such as referral
to pain specialist (34.3% vs. 14.3%) and/or suture site injection (11.2
vs. 6.8%). Median follow up was 18.2 months (IQR 2.1–54.7).
Multivariate analysis controlled for potential confounding factors
(defect size, previous surgeries, contamination, and concomitant
procedures). No significant difference in SSI or SSO was noted
between LAWHR and VHR. LAWHR had lower reoperation (OR 0.3,
CI 0.1–0.8) and recurrence (OR 0.2, CI 0.05–0.9), and higher post-
operative pain requiring intervention (OR 3.8, CI 2.3–6.4).
Conclusion: Differences in etiology and complexity make LAWHR a
significantly different patient population than VHR. The high inci-
dence of patient pain requiring intervention after repair warrants
further investigation.
123
S17 Hernia (2019) 23 (Suppl 1):S16–S18
FP-1163
Polylactide-caprolactone composite mesh used
for ventral hernia repair: a prospective, randomized,
single-blind controlled trial
Shen Y, Chen J, Qin CBeijing Chao-Yang Hospital, Capital Medical University
Objective: Composite surgical mesh is widely used in laparoscopic repair
of ventral hernia but may carry the risk of postoperative adhesion andmore
serious complications. The present study was undertaken to demonstrate
the effectiveness and safety of a new composite polypropylene mesh
coated with poly L-lactide-co-e-caprolactone (EasyProsthesTM) .
Methods: This randomized, controlled trial was designed to compare
EasyProsthes composite mesh (EPM) with ParietexTM Composite
(PCO) in patients undergoing laparoscopic ventral hernia repair (with or
without the hybrid technique). Hernia recurrence, chronic pain, seroma
formation, intestinal fistula and obstruction, wound or abdominal
infection, and ultrasound evidence of viscera adhesion were evaluated.
Results: Forty patients were randomly assigned to each of the EPM
and PCO groups. All patients completed 24 months of follow-up. One
patient in EPM group (2.5%) and two patients in PCO group (5%)
developed mesh-viscera adhesions after surgery (p = 1.000). No
patients developed intestinal fistulas or obstructions. Seventeen
patients in EPM group (42.5%) and 21 in PCO group (52.2%)
developed post-surgical seromas in the operative area (p = 0.370).
One patient from each group developed postoperative wound infec-
tion. There were no cases of abdominal infection and no reports of
chronic pain or hernia recurrence.
Conclusions: The incidence of postoperative complications in EPM
group was similar to that seen with PCO. EPM is safe and effective
when used in ventral hernia repair.
FP-1202
Nanoscience and hernia surgery: a sexy future
or a dream that will never come truth?
East B, de Beaux A, Mickova A, Divin R, Otahal M,
Sovkova V, Vocetkova K, Amler E, Lischke RFN Motol
Introduction: With the growing number of patient complaints related
to various long term side effects of surgical meshes, the search for the
ideal mesh is still on. Reconsidering the mechanical properties of a
standard surgical mesh, and accepting a theory of ‘‘bio’’-scaffolding,
nanofibrous materials that pose the 3D structure of an extracellular
matrix may speed up the initial stages of tissue repair/healing.
Materials and methods: Polycaprolactone (PCL) is a soluble slowly
biodegradable polymer from the polyester family widely used in tissue
engineering. This polymer was tested in forspan or electrospun forms,
by itself, or embedded with growth factors and platelet rich plasma, or in
combination with large pore polypropylene mesh (composite). ‘‘Spray-
on’’ nanofibers were also tested. All spun PCL preparations were
quantified by scanning electron microscopy. Tests were performed
in vitro on 3T3 fibroblasts and in vivo (rabbits, minipigs). Standard large
pore PP mesh and plain suture were used as controls.
Results: Large variability in the diameter of nanofibers produced was
seen depending on the solution ratios, voltage and method of pro-
duction. Dynamic creep properties of healing fascia (both static and
dynamic) were significantly better in the suture compared to PP mesh
group after 6 weeks of implantation. Composite mesh showed better
incorporation than PP mesh. Plain nanofibers had the most favorable
results with the surrounding collagen showing the highest level of
maturity and alignment. However, there was marked variability in
tissue healing response depending on the diameter of the spun PCL.
Conclusion: Spun PCL as a slowly resorbable biological scaffold
‘mesh’ shows significant benefits in both in vitro and in vivo studies
in terms of healing response. The diameter of the spun PCL is one of
many variables to be determined before the era of nanomedicine will
become a clinical reality.
FP-1141
Early outcomes following use of autologous fenestrated
cutis grafts in hernia repair
Hodgdon I, Rajo M, Greiffenstein P, Cook M, Paige J, Yoo
A, Dooley DLSU Health Science Center, New Orleans
Purpose: Hernia repairs are among the most common operations
performed worldwide. Mesh is commonly used, but carries significant
risk, including seroma, infection, fistula, and recurrence. These con-
tribute to increasing healthcare costs. The use of full thickness skin
graft confers many theoretic and economic advantages over the use of
biologic or synthetic mesh. This multi-center retrospective review
examines our results of cutis autograft repair of abdominal wall and
groin hernias.
Method: Following institutional IRB approval, patients who under-
went ventral or groin hernia repair with autologous tissue graft
between March 1 and August 31, 2018 were identified. Demographic
and outcome data was harvested for review. Primary endpoints were
incidence of surgical site infections, seroma, hematoma, and hernia
recurrence. 102 consecutive patients were included. Mean follow up
time was 2.6 months.
Results: Open and laparoscopic techniques were employed (89% vs
11%) to repair 100 hernias (91 ventral, 9 inguinal). Cutis graft was
used for hernia prophylaxis in two patients. Follow up data was
available for 88 patients. We noted 13 surgical site infections, seven
requiring IV antibiotics. There were six patients who presented with
seroma, two requiring evacuation. Three patients had a postoperative
hematoma. There were no hernia recurrences or need for graft exci-
sion. There were two deaths during the study period.
Conclusion: Early outcomes following autologous cutis graft are
similar to those reported in the literature regarding traditional mesh
repair. To the best our knowledge, this is the largest modern retro-
spective review of patients who have undergone hernia repairs with
fenestrated de-epithelized full thickness skin grafts. This is also the
only report of cutis graft being placed either laparoscopically or in the
retrorectus space. Though further studies are needed, our early results
suggest that fenestrated de-epithelialized cutis grafts may be a viable,
cost effective mesh alternative in hernia repair surgery.
123
Hernia (2019) 23 (Suppl 1):S16–S18 S18
Tuesday, March 12, 2019
Session 5: The Great Debate: Mesh, Litigation, Petrochemicals and the Patient(Panel Session)
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1317
Perceptions of mesh use in hernia repair
Towfigh SBeverly Hills Hernia Center
.
IP-1318
The problem with hernia mesh: perspective
from the Plaintiff’s Bar
Lee LSouth Easton, MA
.
IP-1319
Medicolegal defense of hernia mesh related lawsuits
Myers A.
IP-1296
What’s the rate of long-term mesh related
complications in ventral hernia repair?
Bisgaard THvidovre Hospital, University of Copenhagen
Background: To reduce the risk of recurrence mesh reinforcement in
patients undergoing an umbilical- and incisional hernia repair. With-
long term follow up the benefits attributable to a mesh may be offset
in part by mesh-related complications. 1–2.
Methods: Results on long-term complications are based on data from
nationwide cohort studies.
Results: Following umbilical hernia repair the rate of chronic pain is
roughly 5% 3, recurrence 10% 3, mesh-related complications\ 1%,
and claim for financial compensation 0.5%. The hernia recurrence
rate is twice as high in a mesh-free repairs. Following incisional
hernia repair the rate of chronic pain is 15–16% 6, recurrence 15–22%
2, mesh-related complications 4–6% 2, and litigation claim rate 0.9%
4–5. The hernia recurrence rate is 2–3 higher in mesh-free repairs 2.
Conclusion: Mesh should be used as standard in incisional hernia
repair. However, patients should be informed preoperatively that the
beneficial effect of mesh to reduce hernia recurrence may be at risk
for chronic pain and surgical complications. The necessary safety of
the use mesh should be established by routinely use of long-term
marketing surveillance of mesh products.
References1. Poulose D. Ann Surg (2014)
2. Kokotovic et al. JAMA (2016)
3. Christoffersen et al. Am J Surg (2015)
4. Ahonen-Siirtala et al. Scand J Surg 2914
5. Lundsmark et al. Scand J Surg (2018)
6. Christoffersen et al. BJS (2015)
IP-1320
Is it acceptable to use petroleum-derived meshes
in hernia repair?
Benvenuto MDetroit, MI
.
IP-1281
Biologics and bioabsorbable mesh: can we avoid
the issues with synthetic mesh in ventral hernia?
Roth JUniversity of Kentucky
The use of mesh has been widely accepted as the gold-standard for
ventral and incisional hernia repair due to the demonstrated reduction
in hernia recurrence relative to suture based repairs. Synthetic meshes
are the most frequently utilized meshes with proven outcomes and
relatively low cost, thus providing excellent value in hernia care.
However, the use of synthetic mesh is associated with significant
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S19–S20
infrequent complications that include erosion, infection, contracture,
fistula, obstruction, and chronic pain. Additionally, all synthetic
meshes are contraindicated for use in contaminated surgical fields,
although their use in this environment has been reported. The ideal
strategy for managing patients with complex ventral hernias with any
degree of contamination is often debated. Studies have demonstrated
an increased incidence of mesh infection, complications, and recur-
rence when synthetic mesh is implanted in clean-contaminated and
contaminated hernia repairs. Alternatives to synthetic mesh have
evolved due to the clinical need for a durable hernia repair without the
use of a permanent implant. Biologic meshes demonstrated early
promise for complex ventral hernia repair but have fallen out of
mainstream clinical use as a result of variability in clinical outcomes.
Favorable outcomes have been reported with biologic mesh hernia
repairs when utilized as an adjunct to primary fascial closure, most
commonly with the use of component separation techniques but
bridged repairs have universally resulted in failure. Bio-absorbable
meshes have recently emerged as a cost-effective alternative to bio-
logic meshes. Early and mid-term clinical outcomes with bio-
absorbable meshes have demonstrated safety and promising results in
complex hernia patients, although randomized comparative trials have
not been performed. Outcomes with synthetic, biologic and bioab-
sorbable mesh for complex hernia repair will be reviewed and an
algorithmic approach to complex and contaminated hernia repair will
be discussed.
IP-1321
#Meshisbad: how do we talk to patients?
Heniford BCarolinas Medical Center
123
S20 Hernia (2019) 23 (Suppl 1):S19–S20
Tuesday, March 12, 2019
Session 6A: The Changing Face of Hernia Surgery:Defining Who We Are (Panel Session)
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1322
The pathway to equity: intentional steps to foster
diversity in our profession
Bass BHouston Methodist
.
IP-1323
Better together, reflections of the first woman Americas
Hernia Society President
Adrales GJohns Hopkins
.
IP-1324
Working toward gender equality in hernia surgery:
the role of men
Janis JThe Ohio State University Wexner Medical Center
.
IP-1298
South American perspective on diversity among hernia
surgeons
Dorado EFundacion Valle del lili
Introduction: Laparoscopy inguinal hernia surgery is the new diva,
all surgeons are interested in learning the technique but there are
conditions in developing countries such as Central and South America
that make this procedure have some additional challenges.
Main: Evaluate knowledge before and after having inguinal hernia
training programs in Central and South American surgeons.
Methods: According to the needs and wishes of surgeons to learn
laparoscopic techniques in inguinal hernia, a diploma is created that
meets the academic requirements of university endorsement and a
program that covers the basic knowledge to safely perform this
technique. An evaluation was made on the previously about the
knowledge in both open and laparoscopic techniques in inguinal
surgery, and evaluated what facilities they have in their respective
countries and cities to perform laparoscopic hernia surgery and the
availability of meshes, fixers, balloons.
Results: The diploma opens in June 2018, at the end of the year there
were already 3 courses held with surgeons from Colombia, Ecuador,
Costa Rica. A total of 20 people did it. 100% carried out the survey,
of this, 98% had not performed anatomical techniques, and none had
done Shouldice. 20% had attended courses sponsored by laboratories
and 10% had made TAPP. 100% were unaware of the concept of
critical vision in lap inguinal surgery. 100% were unaware of the
approach and management of chronic inguinodynia or how to perform
an adequate radiological evaluation in patients with inguinal
pathology.
Conclusion: The value of graduates with solid academic content
allows the surgeon who does it beyond learning a surgical technique
to approach the patient in an integral way, avoid and know how to
handle complications and perform this type of procedures in a
responsible manner.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S21
Tuesday, March 12, 2019
Session 6B: Scientific Abstracts—Abdominal Wall Reconstruction
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1198
Current trends and practices in complex abdominal
wall reconstruction: results of a physician survey
Podolsky D, Mehta A, Krikhely A, Ghanem O, Malcher F,
Novitsky YNew York Presbyterian, Columbia University Medical Center
Background: Component Separation (CS) procedures have become
an important part of surgeons’ armamentarium. However, the exact
criteria for training, procedure/mesh choice, as well as patient
selection for CS remains undefined. Herein we aimed to identify
trends in CS utilization between various cohorts of practicing
surgeons.
Method: Members of the Americas Hernia Society were queried
using an online survey. Responders were stratified according to their
experience, practice profile ( private vs academic, general vs
hernia surgery ) and volume (low (\ 10/year) vs high) of CS
procedures. We used Chi squared tests to evaluate significant asso-
ciations between surgeon characteristics and outcomes.
Results: 266 responses with overwhelming male preponderance
(88%) were collected. The two most common self-identifiers were
‘‘general’’ (65%) and ‘‘hernia’’ (28%) surgeon. PCS was the most
commonly (68%) used type of CS; endoscopic ACS was least com-
mon (3%). Low-volume surgeons were more likely to utilize the ACS
(p\ 0.05). Only 7% that use PCS learned the technique during their
residency, as compared to 37% that use ACS. 44% felt 5–10 cases
was sufficient to become proficient in their preferred technique.
10 cm-wide defect was the most common indication; 42% had used it
for 5–8 cm defects. Self-identified ‘‘hernia’’ and high-volume sur-
geons were more likely to use synthetic mesh in the setting of
previous wound infections and/or contaminated field (p\ 0.05).
More general/low-volume surgeons use biologic mesh. Contraindi-
cations to elective CS varied widely in the cohort, and 9.5% would
repair poorly optimized patients electively. Severe morbid obesity
was the most feared comorbidity to preclude CS.
Conclusion: The use of CS varies widely between surgeons. In this
cohort, we discovered that PCS was the most commonly used tech-
nique, especially by hernia/high-volume surgeons. There are
differences in mesh utilization between high-volume and low-volume
surgeons, specifically in contaminated fields. Despite its prevalence,
CS training, indications/contraindications, and patient selection must
be.
FP-1061
Appreciation of post partum changes of the rectus
muscles in primary and Re-Do abdominoplasty
Janes L, Fracol M, Dumanian GNorthwestern Memorial Hospital
Background: Abdominoplasty is one of the top five most commonly
performed cosmetic procedures. While widening of the linea alba is a
well-accepted consequence of pregnancy, the changes to the rectus
abdominis muscles are less well known and thus unappreciated and
undertreated.
Methods: After IRB approval, the Northwestern Enterprise Data
Warehouse identified nulliparous and multiparous women, age 18–45,
who underwent abdominal CT between 2000 and present. Measure-
ments included the width and cross sectional area of each rectus
muscle, width of the linea alba, and circumference of the abdominal
cavity at the level of the L3 vertebra. In addition, two case reports
addressing these anatomical changes with muscle modification and
mesh reinforcement are presented.
Results: 60 women were identified that met our inclusion criteria: 15
nulliparous, 15 after 1 pregnancy (para 1), 15 after 2 pregnancies
(para 2), and 15 after 3 or more pregnancies (para C 3). The linea
alba was significantly widened after one pregnancy from 1.14 to
2.29 cm, but did not significantly widen further with each subsequent
pregnancy. The width of each rectus muscle was significantly
widened from 6.00 cm (± 0.60) in nulliparous to 6.61 cm (± 0.58) in
para 1, significantly widened again to 7.03 cm (± 0.46) in para 2, but
not significantly widened after that [6.97 cm (± 1.00) in para 3].
Conclusions: In addition to widening of the linea alba, pregnancy
alters the shape of the rectus abdominis muscle. Correction of muscle
width during abdominoplasty may increase abdominal tone and be a
necessary adjunct in revision procedures.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S22–S24
FP-1265
The incremental impact of obesity and smoking
on surgical site infections after complex abdominal wall
reconstruction
Shover A, Park H, Dubina E, de Virgilio C, Kim D,
Moazzez AHarbor-UCLA Medical Center
Introduction: Surgical site infections (SSIs) after complex abdominal
wall reconstructions (AWR) are potentially preventable and can be
associated with significant consequences. Previous studies have
identified smoking and BMI as risk factors for SSI after complex
AWR, but cutoffs were in large part selected arbitrarily. Our objective
was to analyze and better characterize the association between these
two factors and SSIs.
Method: Patients with a primary diagnosis of a ventral hernia who
underwent an open ventral hernia repair with component separation
were extracted from the ACS-NSQIP 2005–2016 database. Bivariate
and multivariate logistic regression were used to determine the risk
factors associated with SSI. Classification and Regression Tree
(CART) analysis were performed to characterize the relationship
between smoking, BMI and SSIs.
Results: There were 11,978 patients who underwent complex AWR,
with 1369 patients (11.4%) who experienced an SSI following their
AWR. On bivariate analysis, modifiable risk factors including tobacco
use and BMI were associated with a risk of SSI (p\ 0.001). On
multivariate regression analysis, tobacco use (OR 1.5; 95% CI
1.3–1.8), BMI (OR 1.0; 95% CI 1.02–1.04), inpatient status (OR 1.9;
95% CI 1.4–2.7), and White race (OR 1.2; 95% CI 1.1–1.5) were
independently associated with SSIs. CART analysis demonstrated that
the lowest SSI rate occurred in non-smoking patients with a BMI\31 (6.8%), while the highest SSI rate was seen in smokers with a
BMI[ 43 (27.5%). Additionally, BMI had an incremental impact on
the rate of SSIs as BMI increased from 31 to 43, while smoking posed
an additional increased risk in each BMI group.
Conclusion: Among patients undergoing complex AWR, the risk for
SSIs starts at a lower BMI than previously described. Preoperative
optimization of modifiable risk factors including obesity and com-
plete smoking cessation should be attempted before these cases, while
considering the incremental risk associated with BMI during opera-
tive planning.
FP-1075
The impact of inadvertent enterotomy during open
abdominal wall reconstruction (Awr)
Kao A, Huntington C, Maloney S, Prasad T, Colavita P,
Kercher K, Augenstein V, Heniford BCarolinas Medical Center
Introduction: Prior history of abdominal procedures often increases
difficulty of adhesiolysis during AWR and increases the risk of
enterotomy. The impact of enterotomies on outcomes remains poorly
described.
Methods: A prospectively collected database was queried for patients
who underwent open AWR. Patients with and without enterotomies
were compared using standard statistical methods. Contaminated
cases for reasons other than enterotomy were excluded. Quality of life
(QOL) was determined by the Carolinas Comfort Scale.
Results: 2479 patients (47 enterotomies, 2432 without) underwent
AWR. Patients’ age was similar, but enterotomy patients had
increased BMI (34.4 vs. 32.2 kg/m2, p = 0.01) and more previous
abdominal operations (100% vs. 80.2%, p\ 0.0001), including failed
VHR (76.6% vs. 48.3%, p = 0.0001) and colectomy (29.8% vs.
13.9%, p = 0.005). Inadvertent enterotomy rates were higher in
Ventral Hernia Working Group grade 3 (83% vs. 19.4%, p\ 0.0001)
or grade 4 (6.4% vs. 0.9%, p\ 0.0001) hernias and patients with
prior mesh infections (14.9% vs. 4.3%, p = 0.0004), occurring in
8.5% of all patients requiring mesh removal. After 28 months mean
follow-up, enterotomy patients had increased complications: seroma
(25.5% vs. 6.4%, p = 0.004), wound infection (23.4% vs. 6.9%,
p = 0.005), and sepsis (8.5% vs. 0.5%, p = 0.0002). Reoperation
(40.4% vs. 8.4%, p\ 0.0001), readmission (31.9% vs. 11.0%,
p = 0.0002), hernia recurrence (27.7% vs. 4.9%, p\ 0.0001), mesh
infection (10.6% vs. 1.2%, p = 0.0008), and median hospital charges
($63,657 vs. $32,522, p\ 0.0001) were also higher with enterotomy.
Among all patients who underwent VHR with synthetic mesh, inad-
vertent enterotomy increased reoperation (68.8% vs. 10.2%,
p\ 0.0001), wound complications (50.0% vs. 17.9%, p = 0.005), and
mesh infection (25.0% vs. 1.6%, p\ 0.0001). Increased rates of
reoperation (68.7% vs. 31.8%, p\ 0.04) and mesh infection (25.0%
vs. 4.5%, p = 0.03) were seen with synthetic mesh compared to
biologic mesh after enterotomy. Use of biologic mesh after entero-
tomy and synthetic mesh in clean cases resulted in similar QOL.
Conclusions: Enterotomies are a known risk in AWR. They are more
common in patients with previous VHR, increased BMI, and prior
wound complications or mesh infection. Enterotomy leads to higher
rates of complications, including a marked increase in synthetic mesh
infection.
FP-1231
Does loss of domain impact outcomes for abdominal
wall reconstruction procedures?
Landry M, Ramshaw B, Lew M, Lewis R, Forman BUTMCK
Background: High complication and recurrence rates often occur in
patients undergoing abdominal wall reconstruction (AWR). Patients
with a loss of domain (LOD) may have even worse outcomes due to
the added patient complexity. We describe a clinical quality
improvement (CQI) effort to assess the outcomes for patients with
LOD who undergo AW.
Methods: Patient and procedure factors and outcomes were recorded
as part of a CQI program for 133 consecutive patients who underwent
AWR from August 2011– August 2018. During this time, many
improvement initiatives were implemented, including use of long-
term resorbable synthetic mesh, utilizing long-acting local anesthetic
pain blocks as part of a multi-modal pain regimen, and more recently
a prehabilitation program including cognitive behavioral therapy
before surgery. Data was collected to compare outcomes for patients
with and without LOD who underwent AWR.
Results: Of the 133 total patients, 48 (36%) had LOD (determined at
the time of surgery). While patients were similar on some baseline
demographics, those with LOD had higher mean BMI (34.2 vs 31.7)
and higher mean number of prior repairs (3.90 vs 2.65), Patients with
LOD had a similar recurrence rate to patients without LOD (9.1% vs
9.4%) and similar 30-day readmission rates (9.1% vs 9.4%), however,
patients with LOD had a longer mean length of stay (10.0 vs
5.7 days), and a higher 30-day mortality (8.3% vs 0);
Conclusions: Based on these results, attempts at improving outcomes
for patients with LOD who undergo AWR are focusing on improving
length of stay and early mortality rate. This has led to implementing a
mandatory prehabilitation program and increased consideration of
visceral reduction to achieve facial closure and to decrease abdominal
pressure post-operatively.
123
S23 Hernia (2019) 23 (Suppl 1):S22–S24
FP-1222
Hybrid vs open abdominal wall reconstruction: early
outcomes
Addo A, Broda A, Estep A, Lu R, Zahiri R, Turcotte J,
Belyansky IAnne Arundel Medical Center
Background: The hybrid approach to abdominal wall reconstruction
(AWR) for complex hernia defects combines minimally invasive
components separation and retromuscular dissection with open fascial
closure and mesh implantation. This combination may enhance
patient recovery compared to the open approach alone. The purpose
of this study is to evaluate operative outcomes of hybrid vs open
abdominal wall reconstruction.
Methods: A retrospective review was conducted to compare patients
who underwent open versus hybrid AWR between September 2015
and August of 2018 at Anne Arundel Medical Center. Patient
demographics and perioperative data were collected and analyzed
using univariate analysis.
Results: 65 patients were included in the final analysis, 10 in hybrid
and 55 in open groups. Mean age was greater in the hybrid vs. open
group (65.1 vs. 56.2 years, p\ 0.05). The hybrid and open groups
were statistically similar (p[ 0.05) in gender distribution, mean
BMI, and ASA score. Intraoperative comparison found hybrid
patients parallel to open patients (p[ 0.05) in mean operative time
(294.5 vs. 267.5 min), defect size (14.4 vs. 13.6 cm), mesh area and
drain placement. Mean total hospital cost was lower in the hybrid
group compared to the open group ($16,426 vs. $19,054, p = 0.43).
The hybrid group had a shorter length of stay (5.3 vs. 3.6 days,
p = 0.03) after surgery and followed for similar length of time (7.8 vs.
5.3 months, p[ 0.05). The hybrid group showed a lower trend of
seroma, hematoma, wound infection, ileus and readmission rates after
surgery.
Conclusion: A review of patient outcomes after hybrid AWR high-
light a trend towards shorter length of stay, lower hospital cost and
fewer complications without significant addition to operative time.
Long-term studies on a larger number of patients are definitively
needed to characterize the comprehensive benefits of this novel
approach.
123
Hernia (2019) 23 (Suppl 1):S22–S24 S24
Tuesday, March 12, 2019
Session 7A: AHS Safe Hernia Steps—Technical Tips for Common Problems in YourHernia Practice
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1286
Open repair of smaller ventral hernias: evidence based
decisions
van der Velde S, Blonk L, Bonjer JAmsterdam UMC
Repair of a smaller ventral hernia is a procedure often performed in
daily surgical practice, but used methods can vary widely. Ventral
hernias, according to the European Hernia Society (EHS), are broadly
divided into two groups, incisional hernias and primary ventral her-
nias (including umbilical and epigastric hernias). The definition of
small ventral hernias differs between these two groups. Incisional
hernias with a maximum width of 4 cm are defined as small, whereas
primary ventral hernias are defined small with a diameter of less than
2 cm. Although, the definition of small ventral hernias seems some-
what defined, the best surgical technique for repair remains unclear.
In clinical practice open hernia repair is the most frequently used
surgical technique for small ventral hernias. But recent studies sug-
gest that laparoscopic repair, in small ventral hernias, is associated
with less surgical site infections, shorter hospital stay and recurrence,
although a longer operative time was reported. We aim to demon-
strate an algorithm on how to approach a smaller ventral hernia,
taking into account variables like use of prosthetics, closure of the
defect, comorbidity, surgical technique, location of the hernia, width,
size, primary or recurrent hernia, based on available evidence.
IP-1325
Open Rives-Stoppa ventral hernia repair
Reinpold WGermany.
IP-1326
Laparoscopic Ipom
Stechemesser BGermany
.
IP-1327
Open inguinal hernia repair: tissue based approach
Morrison JCanada
.
IP-1328
Open inguinal hernia repair: mesh based approach
Chen DUCLA
.
IP-1329
Laparoscopic inguinal hernia repair: the critical view
Felix E.
IP-1330
Strategies for success in parastomal hernia repair
Bachman SInova.
IP-1331
Incorporating robotics into your hernia practice:
starting with the right procedures
Ballecer CArrowhead Hospital
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S25
Tuesday, March 12, 2019
Session 7B: Video and Special Award Abstracts
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1125
Gender-specific outcomes after open hernia repair
(Ovhr)
Schlosser K, Maloney S, Prasad T, Colavita P, Heniford B,
Augenstein VCarolinas Medical Center
Aims: The impact of gender on surgical outcomes is poorly under-
stood. This study evaluates the impact of gender and abdominal
adiposity on outcomes after OVHR.
Methods: A prospective, single-center, database was queried for
OVHR with preoperative CT scans. Preoperative CTs were studied
using 3-D volumetric software. Demographics, operative character-
istics, and outcomes were evaluated by gender.
Results: 1103 patients (58.1% female) had pre-operative CTs prior to
OVHR. Females had higher BMI (34.6 ± 8.2vs. 31.7 ± 6.1 kg/
m2,p\ 0.0001), more previous surgeries (median 3, IQR 2–4 vs. 2, IQR
2–3, p\ 0.0001), and higher rates of asthma, previous MRSA infection,
and chronic pain (all p B 0.02). Males had higher rates of coronary
artery disease (22.1 vs. 12.3%, p\ 0.0001). Age and number of previous
hernia repairs were not different. Using 3-D volumetric software,
females had slightly smaller defects (135.5 ± 124.5 vs.
163.2 ± 143.7 cm2, p\ 0.0002), more abdominal subcutaneous fat
(7452.0 ± 3626.9 vs. 5788.7 ± 3284.7 cm3, p\ 0.0001), less total
abdominal volume (4423.5 ± 2197.1 vs. 6350.7 ± 3825.5 cm3,
p\ 0.0001), and no difference in hernia volume (952.6 ± 1230.8 vs.
912.7 ± 1361.2 cm3, p = 0.5). The ratio of hernia volume to abdominal
volume was higher in females (0.32 ± 0.51 vs. 0.21 ± 0.35,
p\ 0.0001). Females were more likely to develop wound complications
(39.0 vs. 27.5%, p\ 0.0001), complications of Clavien–Dindo grade
C 3 (CD C 3, 28.9 vs. 30.1%, p = 0.003), and to require readmission
(27.2 vs. 16.0%, p\ 0.0001). Multivariate analysis was performed to
control for potentially confounding factors (age, chronic pain, defect
size, number of previous surgeries, hernia to abdominal volume ratio,
subcutaneous fat volume, component separation, panniculectomy).
Subcutaneous fat volume was associated with readmission (OR 1.006, CI
1.001–1.011) and wound complications (OR 1.01, CI 1.006–1.02).
Hernia to abdominal volume ratio was associated with increased LOS
(2 day, SE 0.7, p = 0.003) and complications (CD C 3 OR 2.14, CI
1.35–3.39). Females had shorter LOS (- 1.1 days, SE 0.6, p = 0.049),
higher readmission rate (OR 1.98, CI 1.29–3.04), but no difference in
surgical site occurrence, infection, procedural intervention, or CD C 3.
Conclusion: Females undergoing OVHR are more comorbid, with
more subcutaneous fat and less total abdominal volume resulting in
higher rates of adverse outcomes and readmissions. The etiology of
these outcomes is not fully explained by identified comorbidities and
warrants further investigation.
FP-1145
Socioeconomic disparity exists among those undergoing
emergent hernia repairs in the state of New York
Docimo S, Yange J, Sun S, Zhu C, Bates A, Talamini M,
Spaniolas K, Pryor AStony Brook Medicine
Introduction: Socioeconomic factors predispose certain populations
to emergent operative procedures. This study evaluates the role of
socioeconomic factors in emergent ventral hernia repairs (EVR),
inguinal repairs (EIR), and umbilical repairs (EUR).
Methods: All patients undergoing ventral, inguinal, and umbilical
hernia repairs from 2008 to September of 2015 in the SPARCS
database were identified. Chi square test with exact P-values from
Monte Carlo simulation determined marginal associations between
repairs (elective vs. emergent) and patient characteristics (gender, age,
race, payment, and region) and co-morbidities. Multivariable logistic
regression models were utilized to examine socioeconomic disparity.
Results: 107,887 ventral, 66,947 inguinal, and 63,515 umbilical
hernias (total 238,349) were noted. Blacks (36.45%) were most likely
to undergo an EVR compared to whites (27.23%; OR 1.55, 95% CI
1.48–1.61), Asians (31.46%; OR 1.31, 95% CI 1.15–1.5), and His-
panics (30.05%; OR 1.3, 95% CI 1.23–1.37). Medicaid patients were
more likely to undergo EVR compared to Medicare (OR 1.44, 95% CI
1.35–1.54) and commercial insurance (OR 1.73, 95% CI 1.64–1.84).
Blacks (34.88%) were most likely to undergo EIR compared to whites
(18.86%; OR 2.2, 95% CI 2.06–2.36), Asians (24.00%; OR 1.74, 95%
CI 1.49–2.02), and Hispanics (27.17%; OR 1.22, 95% CI 1.12–1.34).
Medicaid patients were more likely to undergo EIR compared to
Medicare (OR 2.92, 95% CI 2.65–3.22) and commercial insurance
(OR 4.55, 95% CI 4.19–4.94). Blacks (31.02%) were most likely
undergo EUR compared to whites (24.94%, OR 1.29, 95% CI
1.22–1.36), Asians (26.62%, OR 1.21, 95% CI 1.01–1.46) and His-
panic (28.03%, OR 1.08, 95% CI 1.01–1.16). Medicaid patients were
more likely to undergo EUR compared to Medicare (OR 1.63, 95% CI
1.49–1.78) and commercial insurance (OR 2.31, 95% CI 2.15–2.47).
Conclusion: Race and economic status are contributing factors in
who undergoes an emergent hernia repair in New York State.
IP-1332
Registry-based, randomized controlled trial comparing
intra-operative Foley catheter versus no catheter
for minimally invasive inguinal hernia repair
Fafaj ACleveland Clinic.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S26–S27
IP-1333
Perioperative analgesia with transversus abdominis
plane (Tap) block versus epidural analgesia: analysis
from the americas hernia society quality collaborative
Saad IGreenville Health System
.
V-1186
Re-Do Tar
Tastaldi L, Fafaj A, Alkhatib H, Svestka M, Petro C,
Krpata D, Rosenblatt S, Prabhu A, Rosen MCleveland Clinic
The posterior component separation with transversus abdominis
release (TAR) is an efficient technique in the surgical armamentarium
for the repair of large and complex hernia defects. Driven by the
ability to provide tension-free fascial closure with wide mesh overlap
in sublay position while obviating subcutaneous flaps raising, TAR
gained significant popularity and was adopted by a large number of
general surgeons. Nevertheless, unforeseen complications are inher-
ent to the adoption of an innovative technique or device and the
effects of this widespread adoption remain unknown. One of such
complications has been reported by some surgeons: lateral recur-
rences due to linea semilunaris disruption. In this scenario, a
misunderstanding of the abdominal wall anatomy and surgical planes
can lead to disruption of the linea semilunaris and results in complete
separation of the lateral abdominal wall musculature from their
insertion into the rectus abdominis. In this scenario, a combination of
lateral and midline recurrences along with muscle denervation results
in severely complicated defects. To illustrate such complication, the
case of a 63-year old female w/prior history of transverse colectomy
c/b anastomotic leak and reoperation. The patient developed an
incisional hernia that was repaired at an OSH through an open
approach; per the operative report, TAR was performed and a coated
permanent synthetic mesh was placed. A large recurrence was noted
briefly after the operation, and a CT Scan demonstrated disruption of
linea semilunaris on the right side along with posterior rectus sheath
breakdown.
We aim to present a video and discuss in a thoughtful and detailed
manner, the operative management of such complications by means
of a Re-do TAR. The operative maneuvers are shown step-by-step
and allow the audience to understand why such complications occur
and how they can be repaired in the hands of experienced surgeons.
V-1119
Panniculectomy, preoperative botulinum-toxin
A and preperitoneal ventral hernia repair in a morbidly
obese patient with loss of domain
Maloney S, Gbozah K, Heniford B, Augenstein VCarolinas Medical Center
Introduction: Preperitoneal open ventral hernia repair (PPVHR) is an
effective technique in repairing ventral hernias. By placing a mesh
between the peritoneum and the posterior rectus sheath, the mesh is
isolated from the viscera. Mesh in the preperitoneal plane is less
likely to erode into intestine, cause adhesions and requires less
transfascial sutures which in turn may decrease postoperative pain.
Case report: A 48-year-old woman, BMI 48.0 kg/m2, with a history
of hypertension and sleep apnea, presented to clinic. Her surgical
history includes an abdominal hysterectomy complicated by a post-
operative MRSA infection followed by development of a very large
suprapubic hernia with loss of domain. In preparation for surgery, the
patient lost 32 lb (BMI 42.8 kg/m2) and underwent pre-operative
botulinum-toxin A injections. Using volumetric measurements, the
32-pound weight loss resulted in a 3275 cm3 decrease in adipose
volume.
The procedure begins with a panniculectomy and dissection around
the hernia sac. Meticulous lysis of adhesions and circumferential
preperitoneal dissection were performed next. The peritoneum was
approximated over the viscera. With the defect measuring
27 9 27 cm, fascia could not be brought together. A bilateral external
oblique component separation was subsequently performed. A
30x30 cm biologic mesh was positioned diagonally for 42 9 42 cm
sublay. The mesh was secured with 8 transfascial sutures, and the
fascia was then approximated without tension. Drains were placed in
the subfascial and subcutaneous space. The panniculectomy incision
was closed, and an incisional negative pressure vac dressing was
applied.
Conclusions: PPVHR is an excellent technique for extraperitoneal
mesh placement in ventral hernia repair. Myofascial release may be
combined if needed for fascial reapproximation but PPVHR allows
for extraperitoneal mesh placement even in cases where myofascial
release is not necessary.
V-1132
Single incision laparoscopic TEP hernia repair
under local anesthesia
Wada N, Furukawa T, Kitagawa YKeio University School of Medicine
Introduction: An umbilical port is widely used in many types of
laparoscopic surgeries. For totally extraperitoneal (TEP) hernia repair,
preperitoneal dissection around umbilicus is not always necessary.
We developed a novel minimally invasive technique of single-port in
the lower abdomen laparoscopic TEP inguinal hernioplasty under
local anesthesia which is suitable for overnight hospital admission.
Materials and methods: From January 2012 to December 2015, a
consecutive group of 134 patients with bilateral inguinal hernia was
included. Obese patients, patients with giant hernia or irreducible
hernia were excluded. We used 0.5% lidocaine with epinephrine as
local anesthesia. An incision of 30 mm in the lower abdomen was
made and a wound protector with sealing silicon cap was placed. We
used three 5-mm trocars and a 5-mm flexible laparoscope. A flat self-
fixating mesh with resorbable microgrip was installed and spread over
the myopectineal orifice. No tacking devices were used.
Results: The mean ± SD age was 67 ± 10 and male sex was 84%.
The mean operating time was 176 ± 65 min. Surgical complications
were not observed except for 5 cases of minor seromas (3.7%).
Pneumoperitoneum due to peritoneal injury was occurred in 16 cases
(11.9%) and managed by suturing the defect. During median follow-
up of 32 months, we observed 1 hernia recurrence. Conclusion: The
mid-term outcomes were similar to those of conventional TEP or
open hernia repair. Surgical invasiveness of this technique was min-
imal because the area of dissection in the preperitoneal space is
smaller than that of umbilical TEP. Postoperative recovery was rapid
and patients can walk soon after surgery. This novel procedure may
be feasible in ambulatory setting.
123
S27 Hernia (2019) 23 (Suppl 1):S26–S27
Tuesday, March 12, 2019
Session 8A: Hot Topics in Complex Abdominal Wall Reconstruction
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1334
Chemical component separation: practical use
and review of the data
Heniford BCarolinas Medical Center
.
IP-1335
Why retromuscular? Onlay can do the job
Webb DMemphis, TN
.
IP-1336
Performing posterior component separation (TAR)
correctly
Novitsky YColumbia
.
IP-1337
Myofascial release after previous abdominal wall
reconstruction
Warren JGreenville Health System
.
IP-1338
Five plastic surgery tips all hernia surgeons should
know
Janis JThe Ohio State University Wexner Medical Center
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S28
Tuesday, March 12, 2019
Session 8B: Scientific Abstracts—Ventral Hernia II
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1267
Prevention of incisional hernia with cutis autograft
augmentation
Yoo A, Short C, Hodgdon I, Greiffenstein P, Lau FLSU Plastic Surgery
Background: The U.S. healthcare system repairs 400,000 incisional
hernias (IH) per year. Currently mesh is the mainstay of IH repair,
however, this option is still unsatisfactory due to the inherent risks of
pain, infection and mesh extrusion. Biologic grafts have lower rates of
removal (4.9%), but the cost is significant with a 150 cm2 prosthesis
priced at $2845–$5311. Additionally, in contaminated cases, recur-
rence is 23% when repaired with mesh. Studies suggest the use of
cutis autografts as a cost-effective option that may have less associ-
ated pain, decrease recurrence and graft removal rates. To test the
effectiveness of cutis autografts we performed a double-blinded,
prospective randomized control trial using a validated rat model.
Study design: 400 g, male Sprague–Dawley rats were randomized
into 2 groups: no treatment control group (N = 17) and cutis autograft
experimental group (N = 10). Using a validated rat hernia model,
midline incisions were made and no treatment vs a dermal excision
and cutis autograft underlay intervention was applied. The abdomen
was then closed by a second blinded surgeon.
The primary endpoint was IH formation measured on post-operative
day (POD) 28 by surgeons blinded to group assignment. Secondary
endpoints included: fascia tensile strength, serum inflammatory
markers, tissue inflammatory marker expression and collagen I/III
ratio.
Results: The cutis autograft significantly reduced IH formation (10%
[1/10] vs. 82.4% [14/17] control; p\ 0.00). Secondary endpoints,
including tensile strength showed no difference (1.155 N/mm2 cutis
vs 1.219 N/mm2 control; p = 0.37). Serum CRP & IL-6, as well as
tissue IL-6, MMP11 and 13 showed no difference. Collagen I/III ratio
trended higher in cutis autograft group but again was not significant.
Conclusion: Cutis autograft underlay augmentation of facial closure
reduced IH formation rates in a double-blinded animal RCT. These
results establish the preclinical basis for studies in human subjects.
FP-1224
Computed tomography imaging in ventral hernia
repair: can we predict the need for myofascial release?
Love W, Patel P, Ewing A, Carbonell A, Cobb W, Warren
JGreenville Memorial Hospital
Introduction: The need for additional myofascial release (MR) with
transversus abdominis (TAR) or external oblique release (EOR)
during open retromuscular ventral hernia repair (RMVHR) is often
unpredictable. We developed a novel method of predicting the need
for additional MR based on preoperative computed tomography.
Methods: All patients with midline RMVHR between August 2007
and February 2018 were reviewed. Those with preoperative CT
imaging within 1 year of repair were included. Combined rectus
abdominis width to hernia width (RW:HW) ratio was determined. A
previously described component separation index (CSI), which
measures the deflection angle across the hernia defect was also tested.
Student’s t test determined differences in CSI and RW:HW. Receiver
operator curves were used to determine the highest area under the
curve (AUC) and accuracy of RW:HW or CSI to predict additional
MR.
Results: 342 patients met inclusion criteria. RMVHR alone was
performed in 208 patients, and 134 required additional MR. Mean
RW:HW was 2.4 in patients with RMVHR alone, and 1.2 in those
requiring MR (p\ 0.001). Mean CSI was 0.1 in those with RMVHR
alone and 0.18 in those requiring MR (p\ 0.001). AUC analysis
indicates a RW:HW of\ 1.3 predicted the need for additional MR
with 77.5% accuracy. CSI[ 0.15 predicted the need for additional
MR with 76.3% accuracy. Additionally, RH:HW of\ 0.74 or
CSI[ 0.19 predict the inability to achieve fascial closure even with
MR (n = 14).
Conclusion: Objective measurement of preoperative imaging using
RW:HW or CSI accurately predicts both the need for additional MR
during RMVHR. This tool may prove a useful in preoperative plan-
ning, informed consent, or the need for specialist referral.
FP-1127
The impact of weight change on intra-abdominal
and hernia volumes
Schlosser K, Maloney S, Gbozah K, Prasad T, Colavita P,
Augenstein V, Heniford BCarolinas Medical Center
Background: Weight loss is often encouraged or required before
elective operations, especially in ventral hernia repair (VHR). This
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S29–S30
study evaluates the impact of weight change on intra-abdominal
(IAV) and hernia volume (HV).
Methods: A prospective institutional hernia database was reviewed
for open VHR patients with two preoperative CT scans and recorded
weights. Scans were reviewed using three-dimensional volumetric
software. Demographics, operative characteristics, and outcomes
were evaluated. The impact of weight change on IAV and HV was
assessed using Spearman Correlation Coefficients and linear regres-
sion models.
Results: At the time of hernia surgery, mean BMI of 167 patients was
33.9 ± 7.2 kg/m2, IAV was 3770.9 ± 1875.0 cm3, HV was
1012.5 ± 1309.9 cm3, abdominal subcutaneous fat volume (SQV)
was 6729.6 ± 3701.3 cm3, and total abdominal contents (TAC)
(IAV ? HV = TAC) was 4760.8 ± 2351.5 cm3. Mean time between
scans was 13.5 ± 9.6 months, with weight loss of 1.5 ± 15.2 kg, and
HV increase of 415.0 ± 824.3 cm3. Weight was associated with
change in IAV, SQC, and TAC (Spearman Correlation Coefficient
0.42, 0.42, and 0.48 respectively; (p\ 0.0001 all values), but not with
HV or defect size. A 5 kg weight change (gain or loss) was associated
with change of 100.5 ± 26.3 cm3 in IAV, 100.0 ± 28.9 cm3 TAC,
and 151.5 ± 44.2 cm3 SQV (p\ 0.0008 all values, linear regression
model). When examined by sex, 5 kg weight change was associated
with more change in SQV and IAV in males than females (SQV
201.5 ± 57.4 vs. 103.7 ± 62.9 cm3; IAV 109.7 ± 56.1 vs.
85.1 ± 25.6 cm3). However when stratified by sex, statistical sig-
nificance remained for only IAV in females (p = 0.001), and SQV in
males (p = 0.0008).
Discussion: Weight change is linearly correlated with intra-abdomi-
nal and subcutaneous fat gain or loss, but this correlation varies by
gender. Specifically, males show larger response to weight gain or
loss in the abdomen, while females show smaller and somewhat more
variable changes in visceral and subcutaneous fat.
FP-1168
Characterization of information on surgical mesh
for hernia repair on the internet
Miller M, Blatnik J, Arefanian SWashington University School of Medicine in Saint Louis
Introduction: Hernia repair remains one of the most common sur-
gical procedures performed in the U.S. Surgical mesh used in these
procedures offer many benefits, but there is inherent risk, which has
resulted in lawsuits and increased legal advertisement in the media.
With improving internet access, patients can read potentially biased
and incomplete information concerning mesh, and this can influence a
patient’s healthcare decisions. The goal of this study is to characterize
the presentation and content of information regarding surgical mesh
for hernia repair on websites found through internet search engines
(SE).
Methods: Websites for assessment were found using four keys word
searches targeting surgical mesh on the three most used SEs. The
websites were recorded, and sites on the first two pages of each search
were screened using an internet screening tool (IST). The IST con-
sisted of a battery of dichotomous questions to develop metrics for
website quality, content comprehensiveness, and content depth.
Results: Websites that presented papers scored significantly higher in
all three metrics (i.e. website quality, content, depth). The first four
results of every search were advertisements. Ads account for 36% of
all websites (70% were legal). Legal advertisements that presented
with higher frequency scored the lowest, and significantly lower than
Informational websites. Legal Ads and News sites were the most
skewed when comparing risks and benefits. Furthermore, these sites
referenced data specific to risk only 8% in comparison to 31% from
informational sites. Despite zeroing out search history and cookies,
46% of recommended search terms by the SEs had a negative risk/
legal bias.
Conclusions: These results emphasize the challenges of finding
comprehensive, appropriate information regarding surgical mesh.
Using a SE, the user is likely to be exposed to extraneous information
that is counter to search goals. One recommendation is to use websites
recommended by medical professionals.
FP-1170
Can we see into the future?—development of a risk
calculator app using institutional datasets for predicting
incisional hernia
Kozak G, Basta M, Broach R, Fischer J, Broach R, Fischer
JUniversity of Pennsylvania
Introduction: Incisional hernia (IH) occurs after 10–15% of all
abdominal surgeries and remains among the most challenging,
seemingly unavoidable complications. IH shares features with chronic
diseases including treatment failures, long-term morbidity, and high
healthcare costs. There is a need for a portable, bedside tool to
identify at risk patients. We aim to generate a high fidelity, user
friendly IH prediction App that considers preoperative identifiable
risk.
Method: A retrospective observational cohort study was conducted
from 2005 to 2016 at the University of Pennsylvania. All adult
patients with a clinical condition warranting abdominal surgery were
included. Independent factors associated with IH were identified and
demonstrated the utility of the electronic medical record (EMR) in
creating a preoperative risk stratification model. The model was
translated into unique hernia risk calculator App (iTunes/Android
‘‘Hernia Calculator’’) and website (pennherniariskcalc.com).
Results: Among 29,739 patients included, the incidence of operative
IH was 3.9% (N = 1127) at an average of 57.9 months follow up.
Fifteen risk factors were determined significant in univariate analysis.
Multivariate logistical regression analysis identified 5 risk factors
including emergent surgery (OR = 4.1, p\ 0.001), history of prior
abdominal surgery (OR = 2.6, p\ 0.001), smoking (OR = 1.7,
p\ 0.001), open surgery (OR = 1.6, p\ 0.001), and obesity (OR =
1.5, p\ 0.001). Variables were weighted according to ß-coefficients
generating 8 unique models determined by the index abdominal
operation. These models demonstrated excellent risk discrimination
(C-statistic = 0.76–0.89).
Conclusions: This work highlights a fully designed and integrated
risk calculator App generated from a multi-year, longitudinal multi-
hospital dataset. Surgeons may utilize it to communicate with patients
at the bedside, offer risk reductive strategies, and design stratified
cohorts for clinical trials. The App provides real-time risk estimation,
the ability print and embed risk scores in EHR, and to demonstrate the
effects of risk reductions.
123
S30 Hernia (2019) 23 (Suppl 1):S29–S30
Wednesday, March 13, 2019
Session 9: Special Problems in Abdominal Core Health
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1280
The diastasis recti problem: are there solutions
that work?
Morales-Conde SUniversity Hospital Virgen del Rocio
Rectus problems is an entity not well defined that normally surgeons
face. Most patients visit surgeons because they do not know exactly
what they have, because they are referred by their general practi-
tioners who think patients have a hernia or for cosmetic reasons, but
patient are not aware that there are some health problems that could
be associated to the diastasis, such as pelvic organ prolapse or back
pain.
Patients affected by this entity could be grouped in two: obese
patients, with or without a hernia associated, and young female post-
partum. Both groups of patients should be explored properly in order
to identify the presence of a concomitant hernia and vice versa, those
with a primary hernia of the linea alba should be investigated since a
high rate of recurrence are related to previous presence of a rectus
diastasis.
An obese patient with rectus diastasis with no hernia associated
should not undergo a surgical repair. On the other hand, those pre-
senting a hernia together with the diastasis of the middle line should
be operated of both entities at the same time, considering the mini-
mally invasive approach a good alternative. The surgical technique
should not be just focus on closing the defect of the hernia, being
necessary to reconstruct the linea alba, that could be done using
different accesses: transabdominally, placing a mesh intraabdomi-
nally or dissecting the retromuscular space and placing a mesh in this
position, or totally extraperitoneal.
Young females post-partum could be grouped in two, those with
an excessive of skin and those who do not have this problem. If the
first scenario is faced and open dermolipectomy together with a
reconstruction of the linea alba should be performed, being preferred
by our group to place a retromuscular mesh better than performing a
plication. In case there is no excessive of skin different.
IP-1339
Femoral hernia repair: practical tips
Goldblatt MMedical College of Wisconsin
.
IP-1278
Decision making in core muscle injury/sports hernia
Campanelli G, Bruni P, Morlacchi A, Lombardo F, Cavalli
MIstituto Clinico Sant’Ambrogio, Milano Hernia Center, University
of Insubria
The pubic inguinal pain syndrome (PIPS) is a clinical condition where
there is often no real hernia and it frequently occurs in professional
athletes.
The pain experienced is recognized at the common point of origin
of the rectus abdominis muscle and the adductor longus tendon on the
pubic bone and the insertion of the inguinal ligament on the pubic
bone.
Our etiopathogenetic theory is based on three factors:
– the compression of the three nerves of the inguinal region,
– the imbalance in strength of adductor and abdominal wall muscles
caused by the hypertrophy and stiffness of the insertion of rectus
muscle and adductor longus muscle,
– the partial weakness of the posterior wall.
At the beginning, our surgical procedure, after a reasonable time
of FKT, included the release of all three nerves of the region, the
correction of the imbalance in strength with the partial calibrated
tenotomy of the rectus and adductor longus muscles and the repair of
the partial weakness of the posterior wall with a lightweight or bio-
logical mesh.
In the last years, acquiring confidence in the tenotomy of the
rectus muscle and doing it always deeper, we discovered a new
anatomic finding: posteriorly to the abdominal rectus muscle, cra-
nially to its insertion in the pubic bone, where the preperitoneal fat is
usually present in normal patient with real inguinal hernia, a thick-
ened ‘‘pseudo aponeurosis’’ is found.
Its incision induces a clear release and excellent results with
complete relief of symptoms after resume of physical activity.
This new etiopathogenetic hypothesis is object of study by radi-
ologist and anatomopathologist.
Once again to note the importance to distinguish patients complain
PIPS from patients with a real inguinal hernia. Patients underwent to
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S31–S32
unproper surgical treatment of inguinal hernia could lead to very
difficult case of chronic post-operative pain.
IP-1340
Reimbursement for hernia prophylaxis: myth
and reality
Fischer JUniversity of Pennsylvania
.
IP-1285
My patient has a mesh infection. Now what?
Hernandez-Granados PFundacion Alcorcon University Hospital
Mesh infection is one of the worst nightmares that a surgeon and a
patient can suffer. It can appear even years after the surgery. The
incidence is around 6–10%. Staphylococcus aureus is isolated in
culture sin 70% of cases. There are many risk factors for developing
mesh infection; related to the patient (tobacco, obesity) and to the
surgery (open surgery, emergent surgery, gastrointestinal surgery,
microporous meshes). Some years ago, treatment of mesh infection
leaded to mesh explantation in all cases. It can be a difficult surgery
with high risk of visceral injury, leaving abdominal wall defects
greater than the previous one and without possibility to close. Actu-
ally, conservative treatment is the preferred approach. The
conservative management starts with debridement, cleansing, sys-
temic antibiotics and negative pressure therapy. With this approach,
about 80% of macroporous meshes could be salvaged. Some authors
proposed use negative pressure therapy with instillation of saline and
they report better results with less days of treatment and high rate of
success. Laminar or composite meshes do not have this rate of salvage
and some authors have tried to perform percutaneous drainage fol-
lowed by antibiotic irrigation in selected cases. Other approach can be
partial removal of mesh when there are chronic sinuses, removing
only the piece of infected mesh identified after methylene blue
injection.
If mesh infection cannot be controlled with conservative man-
agement, explanation is recommended. Controversy exists about
single or two-staged surgery. Biologic meshes became the mesh of
choice in one-staged approach, but later on, high rate of mesh
infection, and recurrences has been reported. Now, synthetic macro-
porous meshes are recommended in contaminated cases with good
results. Biosynthetic meshes (absorbable in the long-term) would be
used in some cases but there aren�t enough information yet.
IP-1341
Ventral hernia management in the morbidly obese
patient
Higgins RMedical College of Wisconsin
.
IP-1342
Fight or flight? Ventral hernia in the emergent setting
Docimo SStony Brook, NY
.
IP-1343
Laparoscopic hiatal hernia repair: keys to success
Perry KThe Ohio State University Wexner Medical Center
.
IP-1344
Complex hiatal hernia: when to involve your thoracic
surgeon up front
Bolduc AAgusta, GA
.
IP-1345
Complex hiatal hernia: when to involve your thoracic
surgeon up front
Petersen RUniversity of Washington Medical Center
123
S32 Hernia (2019) 23 (Suppl 1):S31–S32
Wednesday, March 13, 2019
Session 10A: WWYD (What Would You Do?) from International Hernia Collaborationto Americas Hernia Society
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1279
Complication after an open transversus abdominus
release
Pakula AMarian Regional Medical Center
Introduction: Gastrointestinal leak or fistula after Transversus
Abdominus Release (TAR) is exceedingly rare and therefore no
standardized management currently exists. Given the complexity of
the problem, decisions with how to proceed can be decided through a
collaborative approach.
Methods/Results: We report a 38 year-old male with history of
necrotizing pancreatitis which required multiple operations resulting
in an open abdomen and large abdominal wall hernia. A TAR was
performed 2 years after his last operation. A medium weight
macroporous polypropolene mesh was placed in the retromuscular
space for the repair, and a closed gastric tube site was stapled off
during the repair. He recovered well during the early post-operative
period until a change in the drain output was noted, and cat scan
imaging documented that the gastric staple line was leaking into the
retromuscular space. The management of this complication involved
nasogastric tube decompression of the stomach, with the initiation of
antibiotics. The drain output decreased significantly and the staple
line dehiscence was definitively closed via an endoscopic suture
closure. Local irrigation was performed through a small opening of
the midline wound. Upper gastrointestinal contrast study was per-
formed which confirmed closure of the gastric leak. The patient’s diet
was advanced and he recovered well. 8 months follow up demon-
strates no evidence of hernia recurrence or wound issues.
Discussion/Conclusion: Gastric leak with mesh contamination fol-
lowing complex hernia repair with TAR is a rare complication. This
case demonstrates the successful management with endoscopic
methods while salvaging the hernia repair and avoiding mesh
explantation. Collaboration through the IHC helped to facilitate this.
IP-1284
Unexpected challenges in minimally invasive
management of a large ventral incisional hernia
Santos D, Limmer A, Ledet C, Gibson H, Ballecer CUniversity of Texas MD Anderson Cancer Center
Background: Minimally invasive management of large ventral inci-
sional hernias can be challenging due to the need for component
separations and patient disease. Many patients have previous surgical
interventions that increase the technical difficulty of operation. The
introduction of new technology, such as robotic surgery, can also
introduce complexity in management. We present a case of robotic
transversus abdominus release (rTAR) in a patient with Lynch syn-
drome, a Boari flap for a history of ureteral cancer, and an occult
femoral hernia.
Materials and methods: Preoperative optimization resulted in 40 lb
weight loss. A mentorship with an International Hernia Collaboration
Mentor was created. The mentee completed two tissue labs, 6 months
additional skill building with other robotic surgeries after initial
instruction in rTAR, and multiple didactic sessions in preparation for
the case. Mentee arranged collaborative practice runs with anesthesia,
nursing, and surgical technologists prior to introduction to the insti-
tution. rTAR was performed via the technique described by AM
Carbonell et al. Practice based efficiencies were evaluated.
Results: rTAR provided successful closure of the ventral incisional
hernia. Intraoperative challenges included scarring from previous
Boari flap and occult femoral hernia. Despite intraoperative practice
runs, inefficiencies persist. Patient had uneventful discharge, required
no narcotics, and had high patient satisfaction. No recurrent ventral
incisional hernia at 1 year on computed tomography, but developed
new contralateral ureteral cancer.
Discussion and conclusion: Early experience with rTAR is promis-
ing from a patient perspective. rTAR requires extensive preparation
from a mentor–mentee relationship, continuing technical improve-
ment, and practice based changes that require constant revision.
Patient disease can challenge performance of rTAR despite adequate
preparation. Feasibility and generalizability of rTAR is undergoing
evaluation.
ABSTRACTS
Hernia (2019) 23 (Suppl 1):S33–S35
123
IP-1293
Totally robotic parastomal repair with end ileostomy
reversal
Bryczkowski S, Pereira S, Rosenstock A, Zumba O,
Mazpule GHackensack Meridian Health JFK Medical Center/Surgical Practices
Associates, PA
Introduction: Creation of an ileostomy is a relatively common
operation in emergency general surgery and colorectal surgery. One
of the common complications of an ileostomy is a parastomal hernia.
This case report highlights the management of parastomal hernia
repair at the time of ileostomy reversal.
Methods: A retrospective review of the clinical records of the first
reported totally robotic parastomal hernia repair with ileostomy
reversal with video documentation. An extensive literature search was
done. The daVinci Xi� robot was used. Apple iMovie for MacOS was
used for video editing.
Results: Patient was a 72-year-old female with end ileostomy and
parastomal hernia. She initially presented with superior mesenteric
artery thrombosis secondary to large abdominal aortic aneurysm
resulting in dead bowel. After undergoing damage control laparotomy
and ileocecectomy, the patient underwent an abdominal closure and
end ileostomy. She presented for follow-up 12 months later for
reversal of the ileostomy and was found to have a large parastomal
hernia. She underwent an elective robotic end ileostomy reversal and
parastomal hernia repair without complication. The daVinci Xi robot
was used. Three 8 mm ports were placed. She underwent robotic
enterolysis, stapled division of the end ileostomy, mobilization of the
colon, and intracorporeal anastomosis using the robotic stapler. The
parastomal hernia sac was separated from the fascia. The fascia was
closed with running barbed suture. The robot was undocked and the
small portion of terminal ileum was excised. The anterior fascia was
closed in an open fashion. The skin was closed over a �’’ penrose.
She remains recurrence free at 6 month follow-up.
Conclusion: Ileostomy creation and reversal is a common operation
associated with a high incidence of complications. This case report is
the first of its kind to.
IP-1295
Robotic TAPP inguinal hernia repair complicated
by postoperative small bowel obstruction
Pereira S, Rosenstock A, Mazpule G, Zumba O,
Bryczkowski SHackensack University Medical Center
Introduction: Robot assisted laparoscopy is an increasingly common
method of inguinal herniorrhaphy. Early postoperative small bowel
obstruction (SBO) is a known potential complication of traditional
laparoscopic TAPP inguinal herniorrhaphy. Here we report a case of
early postoperative SBO following robotic TAPP inguinal hernior-
rhaphy and discussion of its management.
Methods: A retrospective review of the clinical records of a case of
early postoperative SBO following robotic TAPP inguinal
herniorrhaphy.
Results: A 58 year-old male underwent an uncomplicated robotic
bilateral inguinal hernia repair and was discharged home the same
day. He presented to the emergency department with nausea, vomit-
ing, and obstipation after previous return of bowel function on
postoperative day #2. CT imaging revealed a small bowel obstruction
with a transition point in the right lower quadrant, suspected to be at
the site of peritoneal flap closure. He was taken to the operating room
for diagnostic laparoscopy and was found to have a defect it the
peritoneal flap through which a loop of small bowel had herniated,
causing the bowel obstruction. The herniated bowel was reduced
laparoscopically, and the peritoneal defect was repaired with an
omental flap. He ultimately recovered and was discharged home in
good condition. The patient followed up and remained free of
recurrence at 12-months.
Conclusion: Early postoperative SBO following minimally invasive
inguinal herniorrhaphies are usually a result of technical failure and
caused by herniation of small bowel through a peritoneal flap defect.
It has been speculated that peritoneal flap closure during a robotic
TAPP repair may reduce the incidence of postoperative SBO. This
case highlights the potential for peritoneal flap defects to cause
postoperative SBO following robotic TAPP repairs despite meticu-
lous closure of the peritoneal flap. A high index of suspicion and early
intervention are critical for treatment.
IP-1288
Chronic small bowel obstruction after IPOM
Panait LAtlantiCare Physician Group
Introduction: Small bowel obstruction following incisional hernia
repair is not an uncommon entity. In the absence of hernia recurrence,
other potential repair-related causes should be sought.
Methods: A 45 year-old male with history of laparoscopic umbilical
hernia repair (IPOM) 6 years ago had multiple subsequent hospital
admissions for recurrent episodes of small bowel obstruction.
Extensive imaging testing was performed, but the exact cause of
obstruction was not diagnosed. His episodes resolved with conser-
vative management. Later review of the imaging studies revealed a
decompressed loop of small bowel consistently in the same position,
supraumbilically and to the right of the midline. The patient agreed to
undergo diagnostic laparoscopy in hopes of definitive diagnosis and
treatment.
Results: The diagnostic laparoscopy revealed multiple small bowel
adhesions to the mesh, with a loop being intimately adhered in
between the mesh and the abdominal wall. Robotic lysis of adhesions
was undertaken with partial removal of the mesh in order to free the
affected intestinal loop.
Conclusions: Mesh-related complications following incisional hernia
repair may present insidiously and be missed by clinical or radio-
logical examinations. Surgical intervention is sometimes necessary
for accurate diagnosis and definitive treatment.
P-1346
Hernia and diastasis: how I do it?
Leyba M.
IP-1347
Complication during open AWR: divided linea
semilunaris
DeVitis JSpectrum Health
.
123
S34 Hernia (2019) 23 (Suppl 1):S33–S35
IP-1294
Mystery finding prior to hernia surgery: a bezoar
Rosenstock A, Bryczkowski S, Mazpule G, Zumba O,
Abdelfatah E, Pereira SHackensack University Medical Center
Introduction: An incisional ventral hernia is one of the most com-
mon complications following an emergent laparotomy. Diagnostic
imaging is a routine part preoperative planning prior to ventral hernia
repair. Here we report an interesting case of a bezoar with associated
small bowel obstruction (SBO) in a 55 year-old male who presented
for elective repair of an incisional ventral hernia following emergent
sigmoidectomy and discuss the management.
Methods: A retrospective review of the clinical records of the first
reported bezoar and SBO with associated incisional ventral hernia. An
extensive literature search was done.
Results: A 55 year-old male presented with anorexia and weight loss
associated with an incisional ventral hernia 8-months following
emergent open sigmoidectomy for perforated diverticulitis done at an
outside hospital. CT imaging revealed a bezoar with an associated
SBO and ventral hernia. He was taken to the operating room and
found to have a retained operating room blue towel that eroded into
the small bowel causing a partial SBO. The towel and small bowel
were resected en-bloc with a primary small bowel anastomosis. The
ventral hernia was repaired primarily. He ultimately recovered
without hernia recurrence at so far a year and a half after surgery.
Conclusion: This case highlights a commonly talked about, but rarely
reported surgical complication of a retained foreign body. There are
even rare case reports of lap pads that have eroded into bowel. Most
importantly, though this case should be a warning to every surgeon
never to use non-radiopaque or non-countable towels in the abdom-
inal cavity. During an open transversus abdominus release hernia
repair, it taught to use a countable towel prior to starting the release to
protect the bowel. Most hospitals do not routinely stock this item, and
this case should demonstrate the potential complications of using
‘‘regular’’ blue towels.
123
Hernia (2019) 23 (Suppl 1):S33–S35 S35
Wednesday, March 13, 2019
Session 10B: Hernia Care in Challenging Scenarios (Panel Session)
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1348
Many Hernias, few resources…and no robots!
Filipi COmaha, NE
.
IP-1297
How we approach hernia repair in a tent in the Amazon
Lorenzetti C, Brandalise ACenter Medical of Campinas Foundation
Health Expeditions is a Brazilian non-profit organization founded in
2003 by a group of volunteer doctors with the goal of bringing spe-
cialized medical attention, principally surgical treatment, to the
indigenous populations who live in the isolated region of the Brazilian
Amazon. It is a complement to existing health programs, with the
intention of preventing unnecessary traveling, not always feasible, of
the patient and his family to the town centers.
Registered as OSCIP, Health Expeditions established in 2004 the
Program ‘‘Operating in the Amazon’’ in the region of the Upper Rio
Negro in association with the institutions representing the local
indigenous population and works in coordination of the basic health
care in the region. In order to attend to people who live far from
surgical centers, BHE developed Mobile Surgical Center, adapting to
the special needs, transported and assembled specially for this pur-
pose. It is innovative in Brazil being the first time used by a civilian
organization.
Up to and including September of 2018, BHE completed 41
expeditions with a total of 8003 surgeries and 56,604 consultations.
The larger number of operations are ophthalmology and general
surgery. Other surgeries include pediatric, orthopedic, gynecological
and odontological operations. Also in 2011, BHE completed 7
Expeditions/SOS Haiti to attend the victims of the earthquake which
occurred in January in Haiti, with 359 surgeries and 1407 consulta-
tions from January to October where 78 volunteer professionals
worked in Les Cayes.
In addition to the volunteer doctors, Brazilian Health Expeditions
has the support of other professionals and institutions who help make
this program viable, such as the Ministry of Defense, the Military
Command of the Amazon and the Brazilian Air Force besides
donations of socially responsible companies.
IP-1282
Managing the abdominal wall and hernias
in the military setting
Johnson ECleveland Clinic
Care of injured patients in the modern battlefield setting can be dif-
ficult, and must be achieved often with limited resources. Abdominal
wall defects in the setting of abdominal trauma can be particularly
challenging and require a thoughtful approach. In this presentation,
we will discuss some of the challenges posed to the general surgeon in
the setting of traumatic abdominal injuries sustained in combat. We
will discuss an individualized approach to these patients.
IP-1290
Training and capacity building in Rwanda
Lorenz R, Oppong C, Lechner M, Frunder A, Sedgwick D,
Wiessner R3 ? Surgeons Hernia Center
Introduction: Hernia operations are one of the most common pro-
cedures in General and Visceral Surgery also in Africa. There are a
many possibilities to treat Hernias today. In rural Africa the Bassini
repair seems to be the gold standard until now. Endoscopic equipment
and commercial meshes are frequently not available. The success in
Hernia Surgery is mainly dependent on the skills and experience of
the surgeons. There exist not any evidence on the Surgical Education
in Africa until now.
Methods: Since 2015 the Authors developed in a German-British
collaboration of two humanitarian organizations ‘‘Surgeons for
Africa’’ and ‘‘OperationHernia’’ a first standardized training course
for younger surgeons in Africa. This education program starts with a
2 day theoretical course including anatomical training, lectures and
video demonstrations. The second part includes practical training in
small groups in the OR for 3–5 days. The hands on training includes
inguinal hernia repair with two standardized open operation tech-
niques (SHOULDICE and LICHTENSTEIN Repair) and the use of
local anesthesia. All parts of the training course are continuously
evaluated.
Results: The first two courses of this Basic Hernia Training with 29
participants took place in Rwanda in 2016 and 2017. Formal pre-
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S36–S37
course evaluation was conducted to assess the personal surgical
experience of the trainees. We will present the arguments for this
training and all results of the continuous evaluation. At the end of the
training course the majority of the trainees were assessed as able to
perform mesh and pure tissue repair of simple inguinal hernias to an
acceptable standard.
Summary: Because of differences in number of hospitals and sur-
geons, the surgical capacities and patients specifics hernia education
in Africa should be managed and organized completely different. We
have developed a standardized specific hernia basic training course
for Rwanda in Eastern Africa.
IP-1349
Hernia decision making in the non-verbal patientSalvatore Docimo, Jr., MD, MS
123
S37 Hernia (2019) 23 (Suppl 1):S36–S37
Wednesday, March 13, 2019
Session 11A: Hernia Prophylaxis—AHS Stop the Bulge Campaign
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1350
Abdominal wall closure: European hernia society
guidelines
Muysoms FBelgium
.
IP-1351
What’s the matter America? Why not more small bites
and prophylactic mesh?
Jeekel JRotterdam, The Netherlands
.
IP-1352
Parastomal hernia prevention: do we have a consensus?
Montgomery ASweden
.
IP-1353
Why hernia prevention makes sense
Harris HSan Francisco, CA
.
IP-1354
Small bites versus prophylactic mesh: which to use
when?
Fortelny RAustria
.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S38
Wednesday, March 13, 2019
Session 11B: Scientific Abstracts—Hot Topics in Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1158
A new technique for peritoneal flap closure in TAPP:
a prospective randomized controlled trial
Zhu Y, Wang MBeijing Chao-Yang Hospital
Background and purpose: Transabdominal preperitoneal (TAPP)
approach has been widely used for inguinal hernia repair. One critical
and difficult step for the beginners of TAPP is peritoneal flap closure
with laparoscopic suture. To facilitate the suture step, we describe a
new suture method for laparoscopic closure of the peritoneal flap in
TAPP. A prospective Randomized Controlled Trial was carried out to
evaluate the efficacy of the new suture method compared with the
conventional method.
Methods: Eighty patients who presented to our hospital between
September 2017 and February 2017 with primary unilateral inguinal
hernia were randomized into the conventional suture method group
and the new suture group for TAPP repairs. The primary outcome was
the suture time to complete the peritoneal flap closure. Secondary
outcomes included the cases numbers of peritoneum tearing, need of
additional suture and suture line breaking.
Results: The suture time in the new suture method group was sig-
nificantly shorter than that of the conventional group
(715.3 ± 132.4 s vs 840.71 ± 137.9 s, P\ 0.001), furthermore,
there were significant less number of cases of peritoneal tearing in the
new suture method group than in the conventional suture method
group (4 vs 11, P\ 0.01) .
Conclusion: The new suture method is relative easy to learn for the
beginners who performing TAPP procedures as compared with the
conventional method, and less peritoneal tearing is encountered when
using this method for peritoneal flap closure.
FP-1261
Is the International Hernia Collaboration a safe
and effective resource for surgeons?
Bernardi K, Bernardi K, Hope W, Scott J, Shah S, Milton
A, Ko T, Hughes T, Liang MMcGovern Medical School at UTHealth
Introduction: Social media is a growing medium for disseminating
ideas among surgeons. The International Hernia Collaboration (IHC)
is a widely utilized social media platform to share ideas and advice on
managing hernia-related diseases. Our objective was to assess the
safety and effectiveness of advice provided.
Methods: Overall, 60 consecutive, deidentified clinical threads were
extracted from the IHC in reverse chronological order. Three hernia
specialists evaluated all threads for unsafe posts, unhelpful comments,
and mention of established evidence-based management strategies.
Positive and negative controls for safe and unsafe answers were
included in seven threads, and reviewers were blinded to their pres-
ence. Reviewers were free to access all online and professional
resources (except the IHC).
Results: There were 598 unique responses (median 10, 1–26
responses per thread) to the 60 clinical threads/scenarios. The review
team correctly identified all positive and negative controls. Most
responses were safe (96.6%) but many were unhelpful (28.4%). For
16 threads, the reviewers believed there was an established evidence-
based answer, however, only 6 were provided. In addition, 14
responses were considered unsafe, but only 4 were corrected.
Conclusions: The vast majority of responses were considered helpful
(71.4%), however, evidence-based management is typically not pro-
vided, and unsafe recommendations often go uncontested. While the
IHC allows wide dissemination of hernia-related advice/discussions,
surgeons should be cautious when using social media for clinical
advice. Mechanisms to provide evidence-based management strate-
gies and to identify unsafe advice are needed to improve quality
within online forums and to prevent patient harm.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S39–S41
FP-1246
Mesh suture better resists suture pull-through
than small bites surgical technique
Souza J, Scheiber C, Dearth C, Pisano A, Liacouras PWalter Reed National Military Medical Center
Introduction: At its core, incisional hernia is the result of suture pull-
through, which results in early fascial dehiscence and failed healing
of the abdominal wall tissues. The small bites surgical technique
supported by the STITCH trial aims to better distribute forces at the
suture-tissue interface, as demonstrated in a previously reported
porcine tensile force model. Despite this change in technique, the
incidence of incisional hernia remains high. By incorporating mid-
weight polypropylene mesh material into a hollow-bore surgical
suture, mesh suture aims to improve force distribution at the suture-
tissue interface by altering suture design, rather than surgical tech-
nique. Using the porcine model previously described, the efficacy of
mesh suture to resist suture pull-through was compared to the stan-
dard and small bites surgical technique.
Methods: A midline laparotomy was made in 28 porcine abdominal
wall specimens. Samples were randomized into four groups and a
7 cm long segment was repaired using four different combinations of
closure technique and suture material—1 polydioxanone double loop
at 1 cm bites/travel, 1 polydioxanone double loop with 0.5 cm
bites/travel, 2-0 polydioxanone with 0.5 cm bites/travel, and 3.4 mm
mesh suture with 1 cm bites/travel. Using a MTS Bionix Load Frame,
linear force was applied until suture pull-through occurred.
Results: The mean force required for suture pull-through was sig-
nificantly higher for mesh suture (473.3 N), than for the other three
groups (1 polydioxanone 1 cm bites: 324.3 N, 2-0 polydioxanone
0.5 cm bites = 355.4 N, 1 polydioxanone 0.5 cm bites = 386.6 N). A
one-way ANOVA was performed showing a significant difference
between groups (p = 0.009). Post-hoc analysis confirmed the signif-
icance (all p-values\ 0.05).
Discussion/Conclusion: This study validates the role of suture size
and spacing on force distribution at the suture tissue interface, but
suggests that altering suture design may be a more effective strategy
to prevent suture pull-through than altering surgical technique.
FP-1089
Experience with the PINQ-PHONE Telephone
Questionnaire for detection of recurrences
after endoscopic inguinal hernia repair
Bakker W, Roos M, Kerkman T, Burgmans IDiakonessenhuis Utrecht
Background: The PINQ-PHONE is a 4-question telephone ques-
tionnaire designed and validated as a method of follow-up for the
detection of recurrences after laparoscopic inguinal hernia repair. The
aim of this study was to evaluate the PINQ-PHONE by describing our
experience with the questionnaire in a high-volume randomized
controlled trial.
Methods: 5 year follow-up of a randomized controlled trial by means
of the PINQ-PHONE was carried out among 769 patients that
underwent endoscopic totally extraperitoneal (TEP) inguinal hernia
repair. PINQ-PHONE questionnaire outcomes were compared with
the clinical assessment for a recurrence. An experience with the
PINQ-PHONE survey was conducted among the executing
researchers. Furthermore, positive predictive values (PPV) for each
question of the PINQ-PHONE separately and the overall question-
naire were determined.
Results: 52 patients (6.8%) had a positive PINQ-PHONE response
and were invited to visit the outpatient clinic, thus preventing follow-
up visits in 93.2% of included patients. In 2 patients a recurrence was
detected (0.3%). The PPV of question 1 (0.040) and 2 (0.100) was
much lower than that of question 3 (0.222) and 4 (0.286). The overall
PINQ-PHONE’s PPV was 0.057. The PPV of only questions 3 and 4
combined was 3 times higher with 0.183, and no recurrence would
have been missed. The survey among five researchers produced that
the PINQ-PHONE was a user-friendly questionnaire. All researchers,
on average, executed the questionnaire in\ 5 min and considered
questions 3 and 4 as adequate questions for the detection of inguinal
hernia recurrences. Three and 4 out of 5 researchers did not think of
questions 1 and 2, respectively, as adequate questions.
Conclusions: From our experience we recommend to renew the
PINQ-PHONE using only questions 3 and 4. Due to a much higher
PPV more patients can refrain from visiting the outpatient clinic and
still all recurrences are safely detected.
FP-1057
A role for the integrin subunit beta 1 gene in direct
inguinal hernia with family history
Zhu L, Cai M, Li S, Tang JHuadong Hospital Affiliated to Fudan University
Background: Inguinal hernia is one of the most common disorders in
surgery around the world. People with family history of inguinal
hernias have higher risk of developing inguinal hernias. However,
etiology of inguinal hernia heredity still remains unknown. This study
aims to illustrate the characteristics of genetic expression and possible
molecular mechanisms within patients with direct inguinal hernia
(DIH) and positive family history of DIH.
Methods: We performed mRNA sequencing on three cases of DIH
with family history comparing to 3 without family history in blood
and transversalis fascia (TF) respectively after qualified quality check.
The differentially expressed genes (DEGs) between the two groups
were statistical identified. An in-depth analysis using bioinformatics
tools based on the DEGs was performed through using Gene Ontol-
ogy (GO) enrichment, Kyoto Encyclopedia of Genes and Genomes
(KEGG) pathway enrichment, and protein–protein interaction net-
work analysis.
Results: We get 1747 up-expressed and 2694 down-expressed DEGs
using P value\ 0.05 as the cut-off criteria between DIH with family
history or not in blood samples and 1882 up-expressed and 561 down-
expressed DEGs in tissue samples. The phagosome pathway is the
only significant pathway which is down-regulated consistently both in
blood and TF samples. We found 7 hub genes (FCGR3A, TUBA1B,
NCF4, CTSS, HLA-DQA1, ITGB1 and CD14) on phagosome path-
ways. We used reverse transcription-quantitative polymerase chain
reaction (RT-qPCR) to verify the Integrin Subunit Beta 1 (ITGB1)
mRNA expression level. Low expression level of ITGB1 may influ-
ence dysfunction of basement membrane (BM), collagen IV and
leading to the interruption of mechanotransduction.
Conclusions: Our study is the first one to investigate the micro level
of familial direct inguinal hernia. ITGB1 may play a key role in
pathogenesis of direct inguinal hernia with family history. It is pos-
sible to identify high risk inguinal hernia population after genomic
testing for early treatment in the future.
123
S40 Hernia (2019) 23 (Suppl 1):S39–S41
FP-1276
Management of abdominal wall hernias in women
of childbearing age: a qualitative study assessing
surgeon practice
Jafri S, Vitous C, Seven C, Novitsky M, Dimick J, Telem DMichigan Medicine
Introduction: A lack of evidence-based consensus on optimal man-
agement of abdominal wall hernias in women of childbearing age
exists. In this context, we sought to explore surgeon practice and
understand the factors impacting surgeon decision-making in this
patient population.
Methods: We conducted 21 semi-structured, qualitative interviews
with practicing surgeons in a large statewide quality collaborative.
Surgeons were diverse with respect to demographics, training, and
institutional settings. A clinical vignette was designed to capture
surgical approaches and factors motivating decision-making for
repairing abdominal wall hernias in women of childbearing age.
Through thematic analysis, we located, analyzed, and reported pat-
terns within the data.
Results: Thematic analysis demonstrated a wide variety of patterns
concerning operative approaches to women of childbearing age.
Regarding family planning, 57% (n = 12) of surgeons indicated
desired future pregnancy would impact operative timing and
approach, while 43% (n = 9) stated it would not. Three major themes
that emerged during analysis of scenarios where surgeons altered their
approach in women of childbearing age included: (1) the majority of
surgeons demonstrated a preference to defer an operation until the
completion of childbearing, even for patients desiring repair. (2)
Surgeons described the necessity of a thorough discussion of options
with the patient and would recommend deferring the operation,
though would ultimately concede to patient preference. (3) Surgeons
described variability in mesh utilization. Gender, generational, and
practice location differences did not motivate decisions.
Conclusion: Marked polarization in the approach to women of
childbearing age with abdominal wall hernias exists. Nearly half of
surgeons do not account for future childbearing when managing
abdominal wall hernia. Conversely, the remainder exhibit bias
towards deferring an operation despite patient preferences. These
findings highlight the need for patient-shared decision-making aids to
stimulate unbiased discussion and ensure patients are provided uni-
form information when deciding on management options.
FP-1122
Prevalence of posttraumatic stress disorder (PTSD)
in patients with an incisional hernia
Alkhatib H, Tastaldi L, Fafaj A, Krpata D, Petro C,
Rosenblatt S, Rosen M, Prabhu ACleveland Clinic Foundation
Introduction: Despite good technical outcomes of surgery, some
hernia repair patients report constant concern about having a hernia
recurrence requiring additional repair. These feelings of chronic
anxiety and hyper-vigilance are similar to those experienced by
individuals who have Posttraumatic Stress Disorder (PTSD). We
aimed to investigate the prevalence of PTSD in patients with an
incisional hernias presenting for evaluation at our institution.
Methods: All patients scheduled for clinic visit due to an incisional
hernia at our institution were eligible for participation. PTSD was
screened using the PCL-5 checklist for DSM-5. Patient-reported
quality of life and pain scores were also assessed using validated tools
(HerQLes and PROMIS Pain Intensity 3a survey, respectively). Other
potential risk factors were collected and analyzed.
Results: A total of 131 patients were enrolled (mean age 57.5 ± 11.4,
53% females, and with a median of 3 prior abdominal operations and
one prior hernia repair). 8% had been in the military and 2% reported
deployments. PTSD prevalence was 32% [95% CI 24%–40%]. Out of
the 42 patients screening positive (PTSD ?), 72% related their
symptoms to their previous operations and the resulting complications
while 12% related it to the hernia itself. PTSD ? patients had lower
quality of life scores (39.4 ± 7.4 vs. 55 ± 15.2, P\ 0.001), and
higher pain scores (54.2 ± 9.1 vs. 44.2 ± 10, p\ 0.001). The
number of prior abdominal surgeries and hernia repairs was also
significantly higher in the PTSD ? subgroup, as well as a history of
open abdomen.
Conclusion: Almost one-third of patients undergoing hernia repair
report symptoms of PTSD that are often associated with a worse
perception of the disease and history of multiple prior abdominal
surgeries and hernia repairs. The influence of these findings on
patient’s recovery is unknown. Hernia repair may require a multi-
disciplinary team addressing these significant issues to ensure optimal
care for such patients.
123
Hernia (2019) 23 (Suppl 1):S39–S41 S41
Wednesday, March 13, 2019
Session 12A: AHSQC Panel Session: Long Term Follow Up and Registry-Based ClinicalTrials
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1230
Hybrid robotic transversus abdominus release
has shorter length of stay compared to open transversus
abdominus release: an AHSQC analysis
DeMare A, Halka J, Vasyluk A, Iacco A, Janczyk RBeaumont Health
Background: Open Transversus Abdominus Release (oTAR), tradi-
tionally necessary for the repair of large ventral hernias, is associated
with a substantial hospital length of stay (LOS). Robotic Transversus
Abdominus Release (rTAR) offers the benefits of minimally invasive
surgery (MIS) with decrease LOS vs. oTAR, but this technique may
be inadequate for large, complex hernias. In Hybrid Robotic
Transversus Abdominis Release (hrTAR), limitations of MIS are
overcome by first performing a robotic flap dissection and subse-
quently opening the hernia sac. This modification allows for large
mesh placement, linea alba medialization, secure closure of wide,
complex fascial defects, and resection of the hernia sac and skin. Our
aim was to compare short-term outcomes between hrTAR and oTAR
patient cohorts.
Methods: Multi-institutional data of patients who underwent hrTAR
or oTAR were collected by utilizing the Americas Hernia Society
Quality Collaborative (AHSQC) between 2016 and 2018. Propensity
score matching was used to compare hrTAR to oTAR cohorts,
specifically focusing on median LOS.
Results: In total, 95 hrTAR and 285 oTAR patients met our inclusion
criteria. Patient and hernia characteristics were similar between
groups with a median hernia width of 12 cm. Median LOS [in-
terquartile range (IQR)] was significantly decreased for the hrTAR
cohort [3 days (IQR 3)] vs the oTAR cohort [5 days (IQR 3),
P\ 0.001]. Surgical site occurrence (SSO) occurred less frequently
in the hrTAR group [5% vs 15%, P = 0.015], but there was no sig-
nificant difference in SSI or SSO requiring procedure interventional
between groups. There were also no differences between groups in
30-day rates of readmission, reoperation, or major complications.
Conclusion: hrTAR has significantly lower LOS and incidence of
surgical site occurrences compared to oTAR.
IP-1355
Is mechanical fixation needed in open retromuscular
ventral hernia repair?
Pierce RVanderbilt University Medical Center
.
IP-1356
Telescopic dissection versus balloon dissection
in laparoscopic TEP repair: a registry-based
randomized controlled trial
Tastaldi LCleveland Clinic
.
FP-1235
Assessing outcomes of myofascial release using
the AHSQC
Tenzel P, Bilezikian J, Israel I, Appleby P, Hope WNew Hanover Regional Medical Center
Myofascial release techniques at the time of complex hernia repair
allow for tension free closure of the midline fascia. Two of the main
techniques used include the external oblique release (EOR), which
can be performed open or endoscopically, and the transverus
abdominus release (TAR). Each technique has their reported advan-
tages and disadvantages but there have been few comparative studies.
The purpose of this project was to compare outcomes of these
myofascial release techniques.
Data from the Americas Hernia Society Quality Collaborative was
queried on 5/12/2018. All patients undergoing open incision hernia
repair with an open or endoscopic external oblique release or a
transversus abdominus release were evaluated and compared with
outcomes including hernia recurrence, quality of life, and 30 day
wound complications.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S42–S43
There were 3109 patients that met inclusion criteria of undergoing
open repair of incisional hernia with an EOR or TAR and 501 patients
that met inclusion criteria of undergoing open or laparoscopic
external oblique release. There were no differences in outcomes
comparing EOR and TAR for hernia recurrence, QOL, or 30 days
surgical site infection (SSI) rate. The EOR had a significantly higher
rate of surgical site occurrences (SSO’s) compared to TAR (p\ 0.05)
however this did not result in an increase in procedure intervention for
the SSO. There were no differences in outcomes comparing open and
laparoscopic EOR for hernia recurrence, quality of life, or 30 days
surgical site infection (SSI) rate. The laparoscopic EOR had a sig-
nificantly higher rate of surgical site occurrences (SSO’s) compared to
the open EOR (p\ 0.05) however this did not result in a significant
increase in procedural intervention for the SSO.
Equivalent outcomes were achieved using the open and endo-
scopic EOR or TAR techniques in open repair of incisional hernia. All
techniques offer good outcomes and are important adjuncts in the
repair of complex incisional hernias.
FP-1173
Integration and implementation of patient recorded
outcomes (PROS) into clinical practice
Kozak G, Nathan S, Messa C, Thrippleton S, Broach R,
Fischer JHospital of the University of Pennsylvania
Introduction: Patient reported outcomes (PROs) quantify self-re-
ported perceptions of health and quality of life and aid in capturing
the full effect of disease burden and interventions. Implementation of
PROs can be a challenge with respect to work flow and patient survey
burden. We report the strategy and process associated with successful
implementation of a disease specific questionnaire over a 30-month
period.
Method: A retrospective chart review from September 2016 to
August 2018 was conducted. All ventral hernia (VH) encounters
(n = 714) for a single surgeon were assessed and analyzed at 6-month
intervals. Encounters were excluded if VH was not the primary
diagnosis or if the visit fell within 2 weeks of another survey visit. We
monitored the implementation process by educating office members,
identifying appropriate patients, and eventually integrating the survey
into the EMR.
Results: During a 30-month implementation process, 35/64 (55%),
42/48 (88%), 54/61 (89%), 51/56 (91%), and 63/71 (89%)
(p\ 0.0001) pre-surgery surveys were completed for five consecutive
6-month intervals. The post-surgery questionnaire completion rate
showed similar trends; 11/51 (22%), 43/68 (63%), 48/53 (91%), 58/70
(83%) to 55/70 (79%) (p\ 0.0001) for the same five consecutive
6-month windows. During this time point, 461 of 612 (75%) surveys
were completed and the total questionnaire administration rate
increased 210% (from 40% to 84%, p\ 0.0001). A 210% increase in
successful survey administration was released through the process.
Conclusions: The administration of PROs began by reading survey
questions directly to patients and has evolved to an integrated,
automatic, real-time scoring questionnaires embedded in the EMR.
The successful implementation of PROs was four-fold: office and
staff engagement/education, optimization of work flow, identification
of proper patients, and electronic integration of the survey. PROs can
be administered consistently and effectively in clinical practice
through a process-driven strategy that focuses on healthcare stake-
holder engagement and education.
123
S43 Hernia (2019) 23 (Suppl 1):S42–S43
Wednesday, March 13, 2019
Session 12B: Scientific Abstracts—Parastomal Hernia & Hiatal Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1233
Hiatal hernia and gerd: an indication for conversion
from sleeve gastrectomy to Roux-En-Y gastric bypass
Allen D, Howell R, Cherasard P, Hall K, Barkan A,
Brathwaite CNYU Winthrop Hospital
Introduction: For patients with hiatal hernia (HH) or gastroe-
sophageal reflux disease (GERD), sleeve gastrectomy (SG) has been
shown to exacerbate GERD, prompting some patients to be converted
to Roux-en-Y gastric bypass (RNY). This study presents the incidence
and short-term outcomes of SG to RNY conversion in patients with
HH and GERD.
Methods: Our prospectively-maintained database was retrospectively
reviewed for patients with HH and GERD who underwent SG to RNY
conversion from January 2007 to December 2017 at a Metabolic and
Bariatric Surgery Accreditation and Quality Improvement Program
Center of Excellence.
Results: 32 patients underwent SG to RNY conversion, and 18 were
eligible for inclusion. Sixteen patients were female (89%). Mean age
was 46 years (range 27–63), body mass index 42.8 (range 29–64), and
weight 267 lb (range 180–476). Co-morbidities included: hyperten-
sion (n = 9; 50%), obstructive sleep apnea (n = 8; 44%),
osteoarthritis (n = 8; 44%), and diabetes (n = 2; 11%). 44% of
patients had GERD prior to SG and the remaining 56% were noted to
develop de novo GERD prior to RNY conversion; p = 0.0003, Chi
square). Mean time between initial SG and conversion to RNY was
35 months (range 1–87). All conversions were performed minimally-
invasively (56% laparoscopic, 44% robotic). HH was concomitantly
repaired in 6 patients (33%; 1 synthetic mesh, 5 suture cruroplasty).
Mean length of stay was 3.2 days (range 2–9). 30-day events inclu-
ded: 1 reoperation (5.6%), 2 readmissions (11%), 4 complications
(22%), and no mortalities. Complications were classified using the
Clavien-Dindo grading system: 1 grade II, 2 grade IIIa, and 1 grade
IV.
Conclusion: Prior to bariatric surgery, there should be continued
vigilance to identify HH and patient counseling regarding the risk of
worsening or de novo GERD following SG. RNY may be the primary
procedure of choice in the setting of HH and GERD to decrease the
likelihood of requiring revisional surgery.
FP-1247
Prophylactic mesh augmentation for prevention
of parastomal hernia
Foster A, Fox S, Love W, Warren J, Carbonell A, Cobb W,
Pearson D, Allen J, Dean KGreenville Health System
Parastomal Hernia (PSH) occurs in 50–80% of stoma patients and
causes significant morbidity. There is no optimal PSH repair tech-
nique, and recurrence rates remain high. Prophylactic mesh
augmentation (PMA) decreases PSH incidence without increasing
complications.
A retrospective review was performed of patients undergoing
PMA during end stoma creation between Jan 2015 and Jul 2018. 24
patients were treated with stapled transabdominal ostomy reinforce-
ment with retromuscular mesh (STORRM), and the remainder with
standard retromuscular keyhole mesh. All but two patients received
large-pore polypropylene mesh reinforcement. Primary outcome was
development of PSH. Secondary outcomes are surgical site infection
or occurrence (SSI or SSO).
55 patients were included: 32 end colostomy, 9 end ileostomy, 1
loop colostomy, 12 ileal conduit and 1 colonic diversion/urostomy.
Mean age was 60 years. One-third had significant comorbidities:
diabetes (21.8%), COPD (9%), smokers (30%), and obesity
(BMI[ 30; 30.9%). Fifteen patients had a concurrent ventral hernia
repair. Stoma site-specific SSI occurred in 4 (7.3%) patients, and SSO
in 13 (23.6%). Eight patients required procedural intervention, and
one required mesh explantation. At mean follow up of 24 months,
12.7% had a clinical or radiologic PSH. 23 patients (41.8%) were able
to be contacted for phone survey, and 7 additional patients (12.7%)
reported symptoms of PSH (pain, bulge, pouching difficulty, pro-
lapse). Recurrence rate was lower with STORRM, with only 1
documented recurrence (4.2% vs 19.4%; p = 0.94), though not sta-
tistically significant.
Retromuscular prosthetic mesh augmentation at the time of per-
manent stoma creation significantly reduces the risk of developing a
parastomal hernia.
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S44–S45
FP-1053
A retrospective review with prospective follow-up of 85
consecutive patients treated with Miromesh� for hiatal
hernia repair
Gillian G, Bansal DVirginia Heartburn and Hernia Institute
Introduction: The failure rate for laparoscopic repair of large hiatal
and paraesophageal hernias is commonly reported to exceed 10%.
These failures are often a result of a breakdown of the integrity of the
primary tissue closure of the hiatus. Efforts to reinforce these closures
with permanent and biologic/absorbable meshes have shown promise
in some series. Unfortunately, the techniques and materials utilized
are far from standardized and the complications can be severe. A
simplified and effective biologic mesh cruroplasty is demonstrated.
Methods: 85 consecutive patients undergoing laparoscopic Nissen
fundoplication for hiatal (62) or paraesophageal (24) repairs had their
cruroplasty reinforced with a novel biologic prosthetic derived from
perfusion decellularization of porcine liver (MiroMesh�). After pri-
mary hiatal closure the mesh was secured as an onlay patch with
permanent suture.
Results: The mesh caused no postoperative complications or delays in
diet advancement. 73 (85.9%) of the subject were available for an
IRB approved structured interview 1.3 years (range 0.5–1.8) months
from the time of surgery. Preoperative DeMeester score was 18.9 (SD
14.9) and the GERD-HRQL was 27.7. This cohort reported a drop in
GERD-HQRL scores to 7.1, a satisfaction rate of 95% and no
endoscopic/surgical reinterventions. Only 9% of these patients had
utilized a PPI at any time in the preceding 3 months.
Conclusion: MiroMesh� placement to reinforce the hiatal repair
during laparoscopic Nissen fundoplication was easily accomplished
and has not resulted in any complications to date. Excellent GERD-
HRQL scores 1.3 years after surgery suggest that a durable repair has
been achieved to this point. This information should encourage sur-
geons seeking to reduce recurrent hiatal hernias in their own
practices. It is hoped that this technique will show a reduction in
recurrent hiatal hernias over an extended follow up and benefit a
larger group of.
FP-1153
Large hiatal hernia with the upside-down stomach.
What is the best way?
Klobusicky P, Feyerherd P, Hilfinger U, Hoskovec DHelios St. Elisabeth Hospital
Introduction: The upside-down stomach (UDS) is an extreme form
of a hiatal hernia (HH) and of gastric organoaxial volvulus in a
supradiaphragmatic hernia sac. The aim of this observational study
was to analyze the results of patients with large hiatal hernia and UDS
after surgical closure on the laparoscopic way with or without fun-
doplication. The laparoscopic repair of such hernias is a therapeutic
option, performed mostly in centers by experienced surgeons.
Methods: From 2011 to 2018, 21 patients, with giant HH and UDS,
divided in two groups (10 and 11 Pts), were primarily treated by
laparoscopic surgery at the surgical Department of Helios St. Elisa-
beth Hospital in Bad Kissingen. First group was treated by
laparoscopic suture-based hiatoplasty, with the second group it was
accompanied by dorsal hemifundoplication. Demographic data,
operations data morbidity and mortality were recorded prospectively.
Follow-up was conducted by means of a questionnaire via phone
interview.
Results: In the period of 2011–2018, 21 patients (19$2#) were
diagnosed with a symptomatic giant HH and UDS at our clinic. There
were no intraoperative complications and no conversions. Postoper-
ative complications occurred in one patient (4.7%). Median
postoperative stay was 5 days (2–17). The median follow-up was
29 months by means of a questionnaire via a phone interview. No
significant difference between the two groups, based on the postop-
erative complications and recurrence, was recorded. There were two
subclinical axial recurrences recorded, one per group and no
reoperations.
Summary: Laparoscopic suture-based hiatoplasty of large HH and
UDS is a relatively safe method with significant long-term efficacy in
terms of symptoms control and quality of life. Additional use of
dorsal hemifundoplication does not seem to be necessary.
FP-1166
Mesh salvage following deep surgical site infection
Siegal S, Morrell D, Orenstein S, Pauli EOregon Health and Science University
Introduction: Following herniorrhaphy, deep surgical site infections
with mesh involvement (dSSI-MI) traditionally necessitate mesh
removal, putting patients at risk for hernia recurrence. There is no
consensus about managing dSSI-MI with salvage strategies. We
describe our outcomes following dSSI-MI at two high-volume hernia
centers.
Methods: A retrospective review of hernia repairs complicated by
dSSI-MI with subsequent salvage attempt was undertaken. Outcome
measures included duration of antibiotic use, recurrent dSSI-MI, need
for mesh excision, postoperative complications, and hernia
recurrence.
Results: 13 patients underwent attempted mesh salvage (female = 8,
mean age = 61, mean BMI = 31.4). 46% had prior mesh repairs and
23% had prior SSI. Twelve underwent open ventral or parastomal
repair (10 sublay and 1 onlay macroporous polypropylene, 1 sublay
biosynthetic poly-4-hydroxybuterate). Six cases required concomitant
bowel surgery. Five infections resulted from GI tract leak (3 ostomy
complications, 1 colonic anastomotic leak, and 1 gastric perforation).
92% required reoperation for wound debridement. Seven received
negative-pressure wound therapy (NPWT, average 29 days). Mesh
was left intact in 83%, while 17% required less than 0.01% of mesh
area excision during salvage therapy. All patients received antibiotics
(average 21.4 days). There was one pulmonary embolism, one epi-
sode of septic shock, two prolonged mechanical ventilations, three
blood transfusions and one mortality as the result of a stroke. With a
median follow up of 16 months, there were two recurrent SSIs and
one new parastomal site hernia managed non-operatively.
Conclusion: Mesh salvage without complete explantation is feasible
following dSSI-MI, with a low rate of recurrent hernia formation or
long-term infections. Salvage attempts were undertaken primarily in
patients with retromuscular macroporous polypropylene, suggesting
that repair type and mesh choice influence the decision-making and
ability for salvage. This cohort did require significant postoperative
care (re-operations, prolonged antibiotics, NPWT) and had a high rate
of additional morbidities.
123
S45 Hernia (2019) 23 (Suppl 1):S44–S45
Thursday, March 14, 2019
Session 13: Spectacular Cases (Panel Session)
� Springer-Verlag France SAS, part of Springer Nature 2019
FP-1137
Chronic groin pain leading a 22-year old to disability.
What now?
Fogaca de Barros P, Tastaldi L, Favacho B, Freitas
do Amaral P, Hernani B, Altenfelder Silva R, Chen D, Roll
SSanta Casa de Sao Paulo School of Medical Sciences
A 22 y/o male who presented to Hernia Clinic due to bilateral chronic
postoperative inguinal pain (CPIP). Past surgical history is positive
for an elective, open, bilateral inguinal hernia repair with mesh due to
a small symptomatic left inguinal hernia and an asymptomatic right
inguinal hernia. Surgery was complicated by severe neuropathic pain
resulting in impairment in quality of life and leading the patient to be
on worker’s compensation for the past 2 years. CPIP was initially
managed by pain specialists, and nerve blocks provided only minimal
and transient relief. Sequentially, patient has undergone an open mesh
removal in the right side with attempted neurectomy that, unfortu-
nately, was unsuccessful as the operative report describe that the
nerves could not be located due to exuberant scar tissue. Bilateral
CPIP persisted (VAS 10 R and VAS 6 L) associated with difficulty for
ambulation (walking on crutches) and major depressive disorder.
Dermatomal mapping was consistent with bilateral involvement of
the IIN, IHN and GFN nerves and patient was offered a bilateral triple
neurectomy with removal of remaining mesh.
In August 2018, a bilateral laparoscopic neurectomy of the GFN
and bilateral open neurectomy of IIN and IHN, mesh removal on the
left side and repair of resultant recurrence through a Shouldice
approach was performed. Intraoperatively, it was noted that technical
failure contributed to the CPIP, particularly with several permanent
sutures fixating mesh in the medial aspect and entrapping the IHN.
Recovery was uneventful, and patient was discharged on POD2. At
30-day follow-up, patient reports that is pain- free and the der-
matomal mapping is consistent with bilateral triple neurectomy.
We believe this case provides the opportunity to discuss quality
improvement in indications for hernia repair and hernia repair tech-
nique. Also, it is an excellent opportunity to comprehensively address
prevention, diagnosis and management of CPIP.
FP-1044
Lateral abdominal wall dehiscence after component
separation
DeVitis J, Banks-Venegoni A, Conway R, Wright GSpectrum Health
Background: Lateral abdominal wall hernias are an uncommon yet
devastating complication of the component separation technique for
repair of ventral hernias. There is a paucity of literature describing
repair techniques and outcomes for such complications. In this case,
we present a potential algorithm for operative strategy to deal with
such complications.
Case: 70-year-old male with a past medical history of diabetes mel-
litus, former tobacco abuse, and surgical history of multiple ventral
hernia repairs and chronic mesh/wound infections presented to the
Advanced Hernia Clinic for a recurrent infection of his mesh. He was
taken to the operating room for open ventral hernia repair with
explantation of prior mesh, external oblique release on the left,
implantation of biologic mesh, and placement of a negative wound
pressure system. On post-operative day 4, the patient was noted to
have a fascial dehiscence with evisceration of intra-abdominal con-
tents. He was subsequently taken back to the operating room for
exploration and found to have a 13 cm defect at the point of the
external oblique release. Botulinum toxin injections were applied to
the oblique muscles to facilitate delayed closure. A Whitman patch
was eventually placed for segmental closure of the dehiscence. The
repair was completed on post-operative day 22 using a combined
technique of underlay Phasix mesh, followed by prolene mesh sutures
for primary closure of the defect. The repair was effective and has
thus far shown no signs of recurrence despite his many co-morbidities
and infections.
Conclusion: Lateral abdominal wall defects present a unique chal-
lenge for reconstructive surgeons. In this case, we present a
management strategy of acute fascial dehiscence after component
separation by use of botulinum toxin injection, the Whitman patch,
and the mesh suture technique.
FP-1237
Robotic TAPP inguinal hernia repair: a palliative
approach in a patient with sepsis and possible
pneumatosis intestinalis
Zumba O, Scholer A, Mazpule G, Pereira S, Rosenstock AHackensack University Medical Center
The use of robotics to perform minimally invasive surgery has
emerged as a viable option for most general surgery procedures. The
robotic platform offers robust repair with minimal complications,
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S46–S48
most notably for inguinal hernias. The utilization of the robot for
Transabdominal Preperitoneal (TAPP) inguinal hernia repair allows
for correction of large defects by resection of the hernia sac and mesh
placement. However, this repair method is usually confined to the
elective setting due to the requirements of robotic surgery, including:
the use of CO2 for insufflation, general anesthesia, and possible
increased OR time. Here, we present the surgical video of a 77-year-
old-male with a chronically incarcerated large inguinal hernia that
resulted in a small bowel obstruction and sepsis, thought to be sec-
ondary to findings of pneumatosis intestinalis on imaging. This video
shows a robotic TAPP inguinal hernia repair as a palliative procedure
in a critically ill patient. Specifically, the demonstration of incomplete
resection of this patient’s large hernia sac with anticipation of a large
postoperative seroma, is a unique approach in this emergent situation.
As a result of this procedure, this patient with multiple comorbidities
and high surgical risk for morbidity and mortality, had both resolution
of his small bowel obstruction and therapeutic repair of his chronic
inguinal hernia.
FP-1037
Repair of spontaneous intercostal hernia via open
transthoracic extrapleural approach
Schlosser K, Maloney S, Augenstein VCarolinas Medical Center
Introduction: Spontaneous intercostal hernias have been described in
the literature, but mesh fixation and rib re-approximation is chal-
lenging, with paucity of mesh fixation sites. Here we discuss the
repair of a spontaneous intercostal hernia via transthoracic
extrapleural approach.
Case report: A 66-year-old male presented with left flank bulge and
discomfort. Patient had a history of hypertension, anxiety, chronic
cough, obesity (BMI 31.4 kg/m2), open inguinal hernia repair and
laparoscopic cholecystectomy, and no history of chest wall trauma.
He described a coughing fit with sudden sharp flank pain, ecchymosis
and bulge. A soft bulge at the anterior axillary line between ribs nine
and ten was easily reducible. CT scan revealed disruption of internal
intercostal muscle and separation of ribs (7.9 cm on left vs. 2.9 cm on
right). Due to persistent discomfort, he was taken for open repair of
left intercostal hernia with preperitoneal mesh, open reduction and
internal fixation of adjacent ribs. Intraoperative findings included an 8
by 15 cm hernia. A preperitoneal plane was developed for placement
of a 33x25 cm synthetic mesh secured with transabdominal and
transthoracic sutures. Titanium plates were placed on ribs nine and
ten and secured with screws. Six #5 steel wires were driven through
the ribs and plate holes, and the intercostal gap was reapproximated
by twisting the wires. A Jackson-Pratt drain was placed, tissues were
closed by layers, a liposomal bupivacaine intercostal block was per-
formed, and an incisional VAC was placed. The patient did well
postoperatively and was discharged on postoperative day 4.
Discussion: The repair of intercostal flank hernias is poorly described
in the literature. Approach requires integration of complex hernia
repair as well as familiarity with rib fixation techniques. Here we
describe repair of intercostal flank hernia with preperitoneal mesh
placement and open reduction and internal fixation of ribs.
FP-1176
Abdominal wall reconstruction in a patient
with an incomplete anterior pelvic ring
Fafaj A, Svestka M, Wood H, Mesko N, Billow D, Petro C,
Krpata D, Rosen M, Prabhu ACleveland Clinic
Purpose: Suprapubic incisional hernias can be challenging to repair
given the need for reliable fixation which usually involves the pubis.
Bony defects in the pelvis make it difficult to achieve appropriate
mesh overlap and fixation, posing a major challenge for the recon-
structive surgeon. Our multidisciplinary approach to repair a large
suprapubic hernia in the setting of an incomplete anterior pelvic ring
is presented step-by-step in this video.
Materials and method: A 64-year-old male with a prior history of
osteomyelitis requiring resection of the pubic symphysis and rami
presented to hernia clinic with a large suprapubic incisional hernia.
Past surgical history included prostatectomy, right inguinal hernia
repair and cystectomy with urinary diversion by means of an Indiana
Pouch, which required revision due to incontinence. Operative strat-
egy was planned with the collaboration of Orthopedic and Urology
specialists; elective hernia repair with combined reconstruction of the
anterior pelvic ring and revision of the Indiana pouch was offered.
Results: An open, bilateral posterior myofascial release was per-
formed followed by revision of the urinary diversion channel. The
anterior pelvic ring was reconstructed with a four-hole dynamic
compression plate which was anchored in place by two 6.5 mm
cannulated screws with the aid of guide pins and fluoroscopy. A large
piece of synthetic mesh was placed as a sublay and fixated with bone
anchors and into the metal plate. Patient recovery was uneventful and
he was discharged on postoperative day 8.
Conclusion: A suprapubic hernia associated with a bony defect in the
pelvis is a challenging clinical scenario. Reconstruction was achieved
with good short-term results by a multidisciplinary team.
FP-1097
Just your ‘‘Routine’’ open inguinal hernia repair
Maloney S, Schlosser K, Heniford B, Augenstein VCarolinas Medical Center
Introduction: Inguinal hernia repairs are one of the most common
general surgery procedures, with an incidence of 28 per 100,000 in
the United States. Incarcerated or strangulated hernias are usually
repaired open. Paratesticular liposarcoma is a very rare disease (161
cases reported in the literature) which has the potential to present like
an inguinal hernia. Based on the rarity of the disease, the role of
treatment outside of radical excision (radiotherapy or chemotherapy)
is not well established.
Case report: A 68-year-old gentleman presented to clinic with a
4-month history of an increasing right inguinal hernia. According to
the patient, he had minimal discomfort, and the hernia had progressed
from reducible to incarcerated. He had no previous intraabdominal
surgery. After appropriate clearance and discussion of risks and
benefits, the patient was taken to the operating room. The scrotal
contents would not reduce under anesthesia therefore open approach
was implemented. After dissection it was noted that scrotum con-
tained a 14x9 cm mass starting at the inguinal canal. The mass was
sent to pathology and found to be a low grade liposarcoma of the cord
(Grade 1/3; Stage pT2b pNX). Urology was unavailable to perform an
oncologic resection. The inguinal floor was reinforced with mesh.
Postoperative MRI revealed another mass extending from the inguinal
canal down into the scrotum. The patient underwent a radical
123
S47 Hernia (2019) 23 (Suppl 1):S46–S48
orchiectomy and compartment resection 3 weeks later. Despite neg-
ative margins, the patient had one recurrence requiring another
excision 11 months after initial surgery. He was recently seen with
imaging and does not have cancer or hernia recurrence.
Conclusion: We present a gentleman with an apparent incarcerated
inguinal hernia which at the time of surgery was identified to be a
liposarcoma requiring subsequent oncological resection. Although
rare, surgeons should keep paratesticluar liposarcoma in the differ-
ential with incarcerated inguinal hernias.
123
Hernia (2019) 23 (Suppl 1):S46–S48 S48
Thursday, March 14, 2019
Session 14: Special Technique in Ventral and Inguinal Hernia
� Springer-Verlag France SAS, part of Springer Nature 2019
IP-1357
The laparoscopic onlay repair: why you should consider
it
Totti Cavazzola LBrazil
.
IP-1358
Minimally open sublay technique (Milos)
Reinpold WGermany
.
IP-1359
A successful approach to managing enterocutaneous
fistula
Harold KMayo Clinic
.
IP-1360
Extraperitioneal minimally invasive repair options
Claus CJacques Perissat Institute/Positivo University
.
IP-1292
A new approach to laparoscopic bilateral hernia repair:
the BTOM
Castagneto G, Raimondi SSanatorio Guemes
Since the early description of the TAPP technique for the repair of
inguinal hernias, few modifications have been proposed. The recur-
rence rate of TAPP hernioplasty has been reported between 1 and 5%.
Studies on the causes of recurrence have shown that its etiology is
multifactorial, however they agree that most recurrences of TAPP
technique are direct hernias. Another situation that has attracted
attention is postoperative pain and its relationship with the type of
fixation. We will present our BTOM technique as a safe and feasible
alternative to reduce the number of recurrences and chronic postop-
erative pain in TAPP bilateral hernioplasties.
IP-1283
Intraperitoneal polypropylene in giant ventral hernia
Brandi CHospital Italiano de Buenos Aires, Argentina
Purpose: Show our experience and technique of repairing giant
ventral hernias by placing intraperitoneal polypropylene mesh.
Methods: retrospective descriptive study of a prospective cohort of
patients undergoing elective IH repair using intraperitoneal uncoated
PPE mesh at the Department of General Surgery of a high complexity
University Hospital.
Results: Between January 1992 and December 2013, 695 IH repairs
were performed using intraperitoneal uncoated PPE mesh. The
omentum was placed between the mesh and bowel in 507 patients
(73%). In 188 patients (27%) it was not possible to place the omentum
between the mesh and bowel; therefore, in 69 patients (9.92%) the
PPE mesh was placed over the bowel, whereas in 119 patients
(17.12%) a Vicryl_ mesh was placed between the bowel and PPE
mesh. Six hundred and seventy-eight (97.5%) IH repairs were open
whereas 17 (2.5%) were laparoscopic. Postoperative complications
consisted of seroma (5.9%), hematoma (4.3%), wound infection
(4.8%), and mesh infection (4.0%). Recurrence of IH occurred in 52
patients (7.4%) after a mean follow-up of 59 months. Four (0.5%)
patients required additional surgery due to intestinal occlusion. Nei-
ther acute nor chronic ECFs were encountered during follow-up in
695 patients.
Conclusion: Based on these results, the placement of intraperitoneal
uncoated PPE mesh for elective IH repair might be a safe procedure.
Posters
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S49
Posters
� Springer-Verlag France SAS, part of Springer Nature 2019
P-1004
Postoperative-treatment following open incisional
hernia repair: a survey and a review of literature
Paasch C, Strik M, Anders SHELIOS Klinikum Berlin-Buch
Introduction: Incisional hernias of the abdominal wall are frequent
complication after laparotomy (9–20%). Open incisional hernia repair
with sublay mesh placement (SMP) on the posterior rectus sheath is
described as being a sufficient method for repairing incisional hernia.
In order to ensure wound healing and to therefore prevent recurrence,
carrying an abdominal binder (AB) or a pressure dressing (PD) and
physical rest for a certain time is the common postoperative recom-
mendation, though the evidence for post-operative treatment is low.
Hence, we conducted a survey to reveal the different recommenda-
tions given by surgical departments (SD).
Methods: We conducted a survey among 65 German SDs of the XXX
Hospital Group. The SDs were interviewed about the number of open
incisional hernia repair with SMP in the time frame of 2013–2014, the
known recurrence rate (RR), their recommended prescription of the
AB/PD and the time of physical rest.
Results: The head physicians of 48 surgical departments answered the
questionnaire. The survey revealed 42 different recommendations of
postoperative-treatment. The majority of the SDs advices 4 weeks
(20.5%) of physical rest and no prescription of the AB (29.5%). No
correlation between the known RR and the duration of physical rest
was detected. No head physician’s prescribes a PD.
Conclusions: Due to our findings we assume that a short period of
physical rest is a considerable postoperative treatment following an
open incisional hernia repair with SMP. By reducing the individual
incapacity for work and immobility this would have a social-eco-
nomic impact. The use of a PD may prevent seroma formation.
Further investigations with randomized clinical trials are mandatory
to support our hypothesis.
https://doi.org/10.1016/j.ijsu.2018.04.014
P-1005
Comparison of polypropylene mesh and poly-L-lactic
acid polypropylene mesh for laparoscopic total
extraperitoneal (TEP) inguinal hernia repair
Agca B, Iscan AUniversity of Health Sciences, Fatih Sultan Mehmet Training
and Research Hospital, General Surgery Department
Introduction: When the results of the laparoscopic groin repair are
examined, it is suggested that the cause of chronic agrin and foreign
tissue sensation is polypropylene patches and patch-fixing products.
In this study, polypropylene patch (Prolene� Ethicon) and poly-L-
Iactik-acid polypropylene patch (4DMesh�-CousinBiotech) were
compared in laparoscopic total extraperitoneal hernia repair.
Materials and methods: Between January 2014 and December 2017,
a total of 357 patients between 20 and 80 years of age were enrolled
in the Istanbul Fatih Sultan Mehmet Training and Research Hospital.
The data of the patients were retrospectively analyzed and the results
were compared between group 1 (polypropylene patch) and group 2
(poly-L-Iactik -acid-polyproplene patch). Surgeons, complications,
patch stabilizers, postoperative pain and long-term outcomes were
examined retrospectively.
Results: Group 1 and 2 were 192 (66.4%) and 97 (33.6%), respec-
tively. Operative periods were 48.3 min in group 1 and 38.4 min in
group 2 and less statistically significant in group 2 (p\ 0.05). There
was no difference in complications (Group 1/2: 32/20 p: 0.1). Patch
fixation was observed to be less in group 2 (Group 1: 4.1 vs 2.3 p:
0.001). There was no difference in pain after surgery (Group 1: VAS:
3.4 vs. 3.2, p: 0.4). The mean follow-up was 24 months and recur-
rence was observed in 4 patients and all patients were in group 1.
Conclusion: Poly-L-lactic-acid-polypropylene patch significantly
decreased the number of mesh fixation times and did not cause hernia
recurrence during follow-up.
P-1006
Prevention procedure for the development ofinguinal
hernia after prostatic surgery
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Minguez
Ruiz G, Serra Lorenzo R, Gutierrez Corral N, Delgado
Sevillano R, Serrano Gonzalez S, Campos Alvarez CUniversity Hospital San Agustin
Background: It is well known that inguinal hernia after retro-pubic
prostatectomy is common adverse event. We have evaluated our
series of inguinal hernia after prostatectomy and assessed the effect of
simultaneous prevention procedure carried out at prostatectomy.
Object and method: From 2003 to 2016, 97 patients who were
carried out retro-pubic prostatectomy at single cancer center and
diagnosed as postoperative inguinal hernia were referred to our
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S50–S100
institution. At this cancer center dissection of peritoneum from vas
deference and transection of processus vaginalis was carried out as
prevention procedure for inguinal hernia from 2009. Incidence of
inguinal hernia and association of prevention procedure were com-
pared and the effect was evaluated.
Results: Break down of the treated hernia was lateral hernia: 97.
Medial hernia: 3. Patients were classified into two groups by the
prevention procedure (Group-pre without prevention and Group-post
with prevention). Incidence of inguinal hernia in the Group-pre was
(5.9% 64/781) and in the Group-post was 4.1% (53/737). By cumu-
lative observation onset of inguinal hernia among Group-pre was
6.1%: 1 year, 6.2%: 2 year, 3.5%: 3 year, 6.6%: 5 year, 6.3%:
6 year). Those among Group-post were (1.9%: 1 year, 2.3%: 2 year,
2.9%: 3 year, 3.4%: 4 year, 2.8%: 5 year) respectively. Incidence of
inguinal hernia in the Group-pre was statistically higher than that in
the Group-past. 3 year: p\ 0.01, 2 year, 4 year, 6 year: p\ 0.05,
4 year: p == 0.09 by Chi square) Mean interval of prostatectomy and
onset of hernia was 8 months in the Group-pre and 9 months in the
Group-post. The difference was not statistically different. (p = 0.75
Mann–Whitney test).
Discussion: Our result remonstrated that simple prevention procedure
could satisfactory reduce the incidence of inguinal hernia by 60%.
These results suggested possible role of processus vaginalis in
development of inguinal hernia.
P-1007
Incarcerated abdominal wall hernia: experience on 200
cases
Jorge Barreiro J, Garcia Bear I, Minguez Ruiz G, Pire
Abaitua G, Campos Alvarez C, Delgado Sevillano R,
Serrano Gonzalez S, Gutierrez Corral N, Serra Lorenzo RUniversity Hospital San Agustin
Objectives: Incarcerated and strangulated abdominal wall hernias are
life-threatening conditions requiring prompt surgical intervention,
irrespective of location. In addition, emergency hernia repair carries a
substantial morbidity and mortality risk. The aim of this study was to
share the experiences and outcomes of treatment of incarcerated
abdominal wall hernia in a large teaching hospital.
Methods: This is a retrospective analysis of electronic patient charts.
All patients who underwent surgery for incarcerated abdominal wall
hernias from January 2007. Until December 2015 were analyzed. Pre-
, peri- and postoperative parameters were analyzed. The validated
Clavien-Dindo classification (CDC) was used for post-operative
morbidity and mortality analyzed.
Results: A total of 200 patients were included for analysis. Male to
female ratio was 102.75. Median age was 63 years (range 21–90).
Mean BMI was 29.7 kg/m2. 51 patients were ASA-score 1; 72
patients ASA 2; 55 patients ASA 3 and two patients were ASA 4. The
majority of patients presented with an incarcerated umbilical hernia
(n = 72, 37.8%), followed by 45 patients with an inguinal hernia
(23.2%) and 39 patients with an incisional hernia (20.0%). In 92 cases
(51.1%), hernia contents were strangulated, and bowel resection was
performed in 29 patients (14%). Overall post-operative morbidity rate
was 45.2% (n = 71). 30% were CDCl–2 (n = 55), 11.6% CDC3–4.
30-day mortality in our series was 5.0% (9/180). ASA 3–4, age[ 90
and bowel resection were associated with significantly higher post-
operative complications (p\ 0.05). Mesh repair in incarcerated her-
nias was not associated with higher post-operative morbidity
compared to primary repair (p = 0.3).
Conclusion: Surgeons must be aware of the increased post-operative
risks in older patients, patients with significant comorbidities and after
hernia repair with bowel resection.
P-1008
Hernia repair in cirrhotic patients
Jorge Barreiro J, Garcia Bear I, Delgado Sevillano R,
Serrano Gonzalez S, Campos Alvarez C, Pire Abaitua G,
Sanchez Turrion V, Arias Pacheco R, Ramos Perez VUniversity Hospital San Agustin
Introduction: Cirrhosis is the end stage of severe liver damage
caused by hepatitis virus, alcohol and autoimmune hepatitis etc. We
sometimes encounter groin hernias and umbilical hernias in those
patients. I make a presentation about the general aspects of hernia
surgery to cirrhotic patients and our experiences.
Preoperative examinations: Cirrhotic patients often have some
typical symptoms which influence surgical procedures, such as
ascites, engorgement of the abdominal wall subcutaneous veins and
hypocoagulability. To identify ascites and subcutaneous varicose, CT
scan should be performed. Preoperative blood examinations for
hypocoagulability, such as platelet count, APTT, PT and HPT are also
necessary.
Anesthesia: Usually cirrhotic patients have hypocoagulability caused
by the decreased platelets and lowering of coagulation factors. Gen-
eral anesthesia is often preferred for hernia surgery to cirrhotic
patients. Epidural anesthesia or spinal anesthesia is not indicated.
Operative technique: Minimally invasive technique should be per-
formed to cirrhotic patients because of those symptoms caused by the
lowering of liver function. We mostly performed plug and patch
technique to minimize the area for dissection. Preperitoneal wide
dissection by TAPP, TEP and TIPP is not indicated, because it has a
high risk of retroperitoneal bleeding. Particularly, when retroperi-
toneal bleeding occurs following TAPP and TEP, it is difficult to
diagnose the amount of bleeding without CT scan. In all cases,
complete peritoneal closure is unavoidable.
Results: Between 2008 and 2017, we experienced 36 inguinal her-
nias, 5 umbilical hernias. Emergency operation was performed in 5
cases of inguinal hernias and 1 case of umbilical hernia due to
incarceration. Plug and patch was performed to elective inguinal and
umbilical cases. IP tract repair was performed to one emergency
inguinal case and simple closure to one umbilical emergency case
with intestinal resection. All cases recovered and discharged with
small complications after surgery.
Conclusions: Hernia surgery to cirrhotic patients has more risks than
usual. Considering all risk.
P-1009
Mesh suture for contaminated incisional hernia repair
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Delgado
Sevillano R, Campos Alvarez C, Serrano Gonzalez S,
Minguez Ruiz G, Arias Pacheco R, Sanchez Turrion VUniversity Hospital San Agustin
Background: Suture closures of incisional hernias are recognized as
having high recurrence rates, while prosthetic planar meshes and
bioprosthetic meshes have their own drawbacks to use, especially in
non-sterile fields. In this study, we sought to evaluate the results of a
new technique that uses strips of mesh as sutures for closure of
contaminated incisional hernias.
Methods: 70 patients with contaminated hernias 5 cm wide or greater
by preoperative CT scan were closed with mesh sutures. Surgical site
occurrence, infections, and hernia recurrence were compared to
similar patient series reported in the literature.
123
S51 Hernia (2019) 23 (Suppl 1):S50–S100
Results: Of 58 patients, 22 had clean-contaminated wounds, 20 had
contaminated wounds, and 16 were infected. 70% of the patients
underwent an anterior perforator sparing components release for
hernias that averaged 10.5 cm transversely (range 5–28 cm). SSO
occurred in 27% of patients while SSI was 19%. There were no
fistulas or delayed suture sinuses. With a mean follow-up of almost
12 months, 5 midline hernias recurred (6%). In these same patients,
three parastomal hernias repaired with mesh sutures failed out of 6,
attempted for a total failure rate of 15%.
Conclusion: Mesh sutured closure represents a simplified and effec-
tive surgical strategy for contaminated midline incisional hernia
repair.
P-1010
Early repair of ventral incisional hernia improves
quality of life after surgery for abdominal malignancy:
a prospective, case-controlled study
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Aguado
Suarez N, Gutierrez Corral N, Ramos Perez V, Serra
Lorenzo R, Minguez Ruiz G, Arias Pacheco RUniversity Hospital San Agustin
Background: Recent work has shown that over 40% of patients
undergoing surgery for abdominal malignancy develop ventral inci-
sional hernias (VIH) after 2 years. We hypothesized that early repair
of a VIH for cancer survivors would improve long-term quality of life
(QOL).
Methods: All patients presented to our clinic with a history of surgery
for abdominal malignancy and a complaint of VII-I were prospec-
tively invited to enroll. QOL was assessed at baseline and 3, 6, 12, 18,
and 24-month follow-up using abdominal wall-specific (HerQLes)
and cancer-specific (FACT-G) instruments. At the study’s conclusion,
patients were divided into 2 groups—those that underwent VIH repair
during the study’s course (Repair Group) and those that did not
(Control Group). Categorical variables were analyzed using Pearson’s
Chi Square and continuous variables with Wilcoxon rank sum test.
Results: 100 patients were enrolled. Overall, 66 patients (55%)
underwent VIH repair, with 39 repairs (78%) occurring within
3 months of initial evaluation. 76 (79%) had complete 1-year follow-
up data, and 24 (36%) had 2-year data, with a mean follow-up
duration of 15.6 months. At baseline, both groups were similar with
respect to demographics, cancer stage, and HerQLes/FACT-G scores.
The Repair Group showed improvements over baseline HerQLes
scores at 3, 6, l2, and 18-month timepoints (median increasing
47–59), while the Control Group showed no improvement (median
increasing 49–54), p = 0.037. FACT-G scores in the Repair Group
similarly showed QOL improvement over baseline at the 3, 6, and l2-
month timepoints (median increasing 84–90), whereas the Control
Group did not (median increasing 82–86), p = 0.046.
Conclusions: Repair of VIH after surgery for abdominal malignancy
can improve abdominal wall-specific and cancer-specific QOL,
making post-resection abdominal wall reconstruction an important
aspect of cancer survivorship and suggesting a role for hernia pro-
phylaxis at the initial operation.
P-1011
Visceral obesity as a predictor of hernia recurrence
after abdominal wall reconstruction
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Aguado
Suarez N, Gutierrez Corral N, Ramos Perez V, Arias
Pacheco R, Minguez Ruiz G, Serra Lorenzo RUniversity Hospital San Agustin
Introduction: High body mass index (BMI) increases the risk of
postoperative complications and recurrence after abdominal wall
reconstruction (AWR). However, BMI is an anthropometric measure
that does not provide specific information on mass and placement of
different tissues. We hypothesized that visceral fat volume (VFV),
measured on computed tomography (CT) scans, was a better predictor
than BMI for recurrence after AWR.
Method: Consecutive patients undergoing AWR at our institution
from 07/10/2010 to 05/12/2016 were included in this study. Data was
collected from a prospective database and all patients were sum-
moned for clinical follow-up. VFV was calculated from preoperative
CT scans using an automatic segmentation tool. The primary and
secondary outcomes were hernia recurrence and 30-day postoperative
surgical site occurrences (SSO), respectively.
Results: We included 200 patients undergoing AWR for a mean
hernia defect of 10.4 cm 9 16.5 cm (transverse x longitudinal). 60
patients (28%) developed recurrence during follow-up. VFV was
significantly associated with hernia recurrence (5.6 vs. 4.3 L,
P = 0.011, univariable analysis). After multivariable Cox-regression,
VFV remained significantly associated with hernia recurrence (HR
1.12 per 0.5 L increase of VFV, 95% CI 1.04–1.19, P = 0.018). In
contrast, BMI was not associate with hernia recurrence in the uni- or
multivariable analyses. (29%) developed a SSO. VFV was signifi-
cantly higher in the group of patients who developed SSO compared
to those who did not (mean 5.1 vs. 4.6 L, P = 0.011). A multivariable
logistic regression model showed that VFV was significantly associ-
ated with the development of SSO (OR 1.19 per 0.5 L increase of
VFV, 97% CI 1.14–1.27 P = 0.008).
Conclusion: VFV was significantly predictive of both hernia recur-
rence and SSOs after AWR. This study suggests VFV as a promising
risk assessment tool for patients undergoing AWR.
P-1012
Comparative analysis between laparoscopic vs open
inguinal hernia in a university hospital: Results
at 15 years
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Minguez
Ruiz G, Serra Lorenzo R, Gutierrez Corral N, Arias
Pacheco R, Aguado Suarez N, Delgado Sevillano RUniversity Hospital San Agustin
Introduction: Inguinal hernias are the most frequent, occupying
between 50 and 60% of all hernias in the abdominal wall. The
laparoscopic approach to inguinal hernia repair has been shown to be
beneficial in reducing postoperative pain and facilitating an earlier
return to normal activity.
Aims: To compare and analyze the results at 15 years of laparoscopic
vs open inguinal hernia repair. To classify the patients studied
according to the different variables: age, sex, type of surgery per-
formed. Compare recovery time to perform daily activities and return
to work activity.
Materials and methods: Retrospective, descriptive and observational
study. We included all patients (300 operated on inguinal hernioplasty
123
Hernia (2019) 23 (Suppl 1):S50–S100 S52
between January 1, 2001 and December 31, 2016 Data were collected
by telephone survey, effective in 178 patients (60.3%) and Clinical
History analysis.
Conclusion: In our Hospital, both types of surgeries are indicated for
the repair of herniated defects of the groin. We did not find significant
differences in the recurrences and other complications, although in the
postoperative satisfaction of the patients, the shortening of time to
resume daily and work activity.
P-1013
Early experience with incisional fascial reinforcement
to prevent hernias: patient selection, techniques
and outcomes
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Minguez
Ruiz G, Serra Lorenzo R, Serrano Gonzalez S, Arias
Pacheco R, Campos Alvarez C, Sanchez Turrion VUniversity Hospital San Agustin
Introduction: Incisional hernias (IH) continue to increase morbidity,
cost and disability for patients. There may be an opportunity to
decrease rates of ll-I with incisional fascial reinforcement (IFR) at the
time of laparotomy. There have not been many studies detailing how
IFR fits into the hernia ecosystem-specifically, deciding what patients
may benefit from IFR and what techniques should be considered.
Herein, we will provide a dual-institution review of patient selection,
description of technique, and early outcomes after IFR.
Methods: A dual-institution retrospective chart review was per-
formed of prospectively collected data. Patient characteristics and
identifiable hernia risk factors were determined. Additionally, oper-
ative technique and early post-operative outcomes were observed.
Standard statistical tests were applied.
Results: 69 cases of IFR were analyzed, 39 of which were males. The
average age and BMI of patients was 58 and 29.5 respectively. The
most common procedures during IFR were colorectal 27, abdominal
aortic aneurysm (AAA) repair (18 and gynecologic 15). All patients
were counseled on mesh characteristics, surgical complications and
hernia morbidity. All cases used a biosynthetic mesh, with 22 placed
as an onlay. Average time for mesh insert, 29 min, was recorded for
14 patients. 6 of the cases had mesh fixed with fibrin glue. One patient
had a dehiscence, two had seromas, zero had SSI, and zero had lH
with 6-month average follow-up.
Discussion: Appropriate patient selection and risk counseling are
essential in ensuring that IFR is successful. The most feasible and
efficient techniques need to be implemented in order to decrease the
burden of IH. Early results using onlay placement of a biosynthetic
mesh in high-risk patients undergoing colorectal, AAA, and gyne-
cologic procedures seem promising. Further studies need to be
conducted in order to assess long-term efficacy in each of these
populations with this technique and type of mesh.
P-1014
Abdominal wall reconstruction: effect of BMI
on surgical outcomes
Jorge Barreiro J, Garcia Bear I, Pire Abaitua G, Arias
Pacheco R, Minguez Ruiz G, Aguado Suarez N, Ramos
Perez V, Serra Lorenzo R, de Paz Moran MUniversity Hospital San Agustin
Background: Incisional Hernias are the most common long term
complication following a laparotomy. There is a high recurrence rate
after primary herniorraphy without mesh, therefore mesh repair of any
hernia defect[ 2 cm is the standard of care due to a lower rate of
recurrence. Obesity is a risk factor in the development of incisional
hernia and a major risk factor for hernia complication. The aim of the
study was to evaluate the effect of obesity on surgical outcomes after
abdominal wall reconstruction.
Method: This was a single institution, retrospective study that
examined data between 2001 and 2016 of all patients that had
abdominal wall reconstruction (rectrorectus repair and component
separation repair). Patients were stratified into BMI[ 40 and
BMI\ 40. Records with missing relevant data and patients under-
going panniculectomy during the same inpatient stay were excluded.
Univariate analysis and multivariate logistic regression were used to
compare outcomes between the two groups.
Results: A total of 502 patients were identified after inclusion and
exclusion criteria were met. The BMI\ 40 group had 353 patients,
with a mean BMI of 31.6, and the BMI[ 40 group had 149 patients,
with a mean BMI of 45.8. Median length of follow-up was similar
between the two groups, 4.6 months for BMI\ 40 vs 4.2 months for
BMI[ 40. The BMI\ 40 group had a relatively higher rate of
recurrence at 5 vs 1% for the BMI[ 40 group (p = l). A multivari-
able analysis demonstrated BMI wasn’t a predictor of hernia
recurrence rate after surgical repair.
Conclusion: Results of the study show obesity did not significantly
contribute to recurrence of incisional hernia and post-operative
complications in patient who had undergone abdominal wall recon-
struction repair.
P-1016
Internal hernia through a congenital broad ligament
defect
Ierardi K, Beffa LKent Hospital
Introduction: Internal hernias are considered complicated hernias
and cause between 0.6 and 6% of all small bowel obstructions.
Rarely, internal hernias occur secondary to congenital mesenteric
defects. Our patient presented with an exceedingly uncommon cause
of internal hernia through a congenital defect in the broad ligament.
Case: A 62-year-old female presented with a 6-month history of
intermittent abdominal pain which acutely worsened on the day of
presentation. She described progressively smaller caliber stools over
the previous 3 months with minimal passage of flatus in the last day.
Her pain was rated at an 8/10 with some association with movement.
She had no previous medical or surgical history and was not taking
any medications. Vital signs showed she was afebrile with a blood
pressure of 180/80, heart rate of 103 bpm, and a respiratory rate of 20
breaths per minute. Clinical examination revealed a mildly tender, but
soft abdomen with high-pitched tinkling bowel sounds. Computed
tomography scan revealed a small bowel obstruction with a transition
point in the right adnexal region. She was admitted and failed to
123
S53 Hernia (2019) 23 (Suppl 1):S50–S100
improve with conservative measures. Diagnostic laparoscopy
demonstrated herniation of small bowel through a defect in the broad
ligament medial to the right ovary. The bowel was reduced after
enlarging the internal hernia defect in the broad ligament. Due to
concern for future herniation the fallopian tube, ovary, and suspensory
ligament were removed, thus opening the entire right pelvic space.
Discussion: A defect in the broad ligament represents approximately
4–7% of all internal hernias. Surgical management is mandatory and
options include suture repair of the defect or salpingo-oophorectomy.
Salpingo-oophorectomy permanently eliminates the risk of recurrence
but should be reserved for post-menopausal patients. Surgeons may
also consider intraoperative prophylactic repair of broad ligament
defects when noticed incidentally to reduce future hernia risk.
P-1017
Reducing the incidence of postoperative urinary
retention in totally extraperitoneal laparoscopic
inguinal hernia repair: a prospective, randomized,
double-blind, placebo controlled trial
Shikhman A, Caparelli M, Allamaneni S, Hobler SJewish Hospital
Introduction: Post-operative urinary retention (PUR) occurs at a
higher frequency in laparoscopic vs open inguinal hernia repair
(1–22% vs 0.4–3%). Preoperative tamsulosin has been demonstrated
to decrease PUR, however, it has not been studied in laparoscopic
inguinal hernia repair (LIHR). In a previous retrospective review, we
have identified our PUR rate at 18.8% for LIHR. Our goal is to
determine the efficacy of preoperative tamsulosin on the incidence of
PUR.
Methods: A prospective, randomized, double-blind, placebo-con-
trolled trial was designed. All elective LIHR patients are randomized
to receive 0.4 mg dose of tamsulosin or placebo within 2 h preop-
eratively. Randomization and blinding is performed by the pharmacy.
Catheterization criteria include the inability to urinate within 6 h post-
operatively with confirmation by bladder ultrasound. To reach sta-
tistical significance approximately 350 patients will need to be
enrolled.
Results: Currently, we have enrolled 35 patients in the study. Urinary
retention has not yet been observed. We anticipate completion of data
collection by mid 2019.
Conclusions: Although our institutional rate of PUR is consistent
with current literature it remains a significant and frequent compli-
cation that demands improvement. We aim to study the efficacy of
preoperative tamsulosin in reducing the incidence of PUR. If suc-
cessful, this would be a strong contribution to our patients and the
surgical community by decreasing catheterization rates and unplan-
ned admissions as well as increasing patient satisfaction.
P-1018
Incidence of postoperative urinary retention in totally
extraperitoneal laparoscopic inguinal hernia repair:
single surgeon experience
Shikhman A, Caparelli M, Allamaneni S, Hobler SJewish Hospital
Introduction: Post-operative urinary retention (PUR) occurs at a
higher frequency in laparoscopic compared to open inguinal hernia
repair (1–22% vs 0.4–3%). Some previously described risk factors
include older age, history of BPH and general anesthesia. The aim of
this review is to identify our PUR rate for LIHR and determine the
associated risk factors.
Methods: Retrospective review of LIHR (170 patients Jan 2015–Jan
2017) by a single surgeon was performed and the rate of PUR was
defined by need for catheterization. Catheterization criteria included
inability to urinate within 6 h post-operatively with symptoms of
urinary retention and confirmation via bladder ultrasound.
Results: Postoperative urinary retention was observed in 18.8% (32/
170) of elective LIHR. PUR occurred in all males (92%) while
operation duration did not differ between groups (60 vs 69 min,
P = 0.08). All patients received general anesthesia. Bilateral repairs
were performed in 28% (OR 1.20, P = 0.68) of patients experiencing
retention. There was no difference in PUR between left and right
repairs (P = 0.28). Older age was a significant risk factor for PUR
(59.6 vs 66 years, P\ 0.05).
Conclusions: Our review indicates a PUR rate of 18.8% in LIHR.
Older age ([ 60 years) was the only significant risk factor con-
tributing to PUR. Although, our rate is in line with current literature
this remains a significantly common complication which deserves
attention in future studies.
P-1019
The grip concept: from bench to bedside in ventral
hernia repair
Kallinowski F, Gutjahr D, Harder F, Nessel RUniversity Hospital Heidelberg
Ventral hernia repair is burdened with high recurrence rates. A new
methodology resembling coughing actions was developed as a bench
test. It permits the assessment of the grip of a reconstruction. The
ability of ventral hernia repair to withstand dynamic impact strain
(DIS) is directly related to the grip of the reconstruction.
DIS impacts were delivered with a computer-controlled,
hydraulically driven tissue model (Kallinowski et al. Hernia
21:455–467, 2017 https://doi.org/10.1007/s10029-017-1583-1, 2017).
The GRIP concept was previously published (Kallinowski et al. Front.
Surg. 4:78. https://doi.org/10.3389/fsurg.2017.00078, 2018). A total
of 30 patients with incisional hernia were treated so far according to
the grip concept. Data were entered into the HERNIAMED registry
opening a new chapter called STRONGHOLD.
Within the first 3 months from September to December 2017, 15
patients (10 female, 5 male) were registered. Age ranged from 34 to
92 years (64.4 ? 12.2 years). Most patients were obese and had
known risk factors for the development of incisional hernia (10/15).
Patients were generally fit (93% ASA II and III). Elective repair was
performed in 14 cases. In one case, a bowel laceration was oversewn
intraoperatively without sequelae. Mesh size was on the average
10fold the defect size. In principle, the mesh was sutured in place (14/
15). The grip value was found to vary between 14 and 646
(mean ? SD: 105 ? 152) and tended to drop as hernia size increased.
Hospital stay was 6 days on the average (range 2–10 days). So far, no
recurrence occurred.
The grip calculation is a novel way to assess biomechanical sta-
bility in ventral hernia repair. In clinical practice, the grip tends to
drop as hernia sizes increase. Care should be taken to reach adequate
grip values even at larger hernia sizes.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S54
P-1020
Tissue elasticity markedly influences the grip of ventral
hernia repair
Nessel R, Gutjahr D, Harder F, Kallinowski FKlinikum am Gesundbrunnen SLK Kliniken Heilbronn GmbH
High recurrence rates are observed after ventral hernia repair. A
bench test to assess mechanical stability prior to surgery is highly
sought after. Dynamic intermittent strain (DIS) resembling coughing
actions permits the assessment of the stiction of a reconstruction. The
resulting measure is called grip. The ability of ventral hernia repair to
withstand DIS impacts is investigated to assess the influence of the
tissue elasticity on the grip values.
DIS impacts were delivered hydraulically with an aluminum
cylinder containing a plastic bag the flow of water being driven by
computer-controlled valves (Kallinowski et al. Hernia 21:455–467,
2017 https://doi.org/10.1007/s10029-017-1583-1, 2017). The GRIP
concept was previously used to develop safe fixation techniques
(Kallinowski et al. Front. Surg. 4:78.
https://doi.org/10.3389/fsurg.2017.00078, 2018). Since different tis-
sues exhibits various viscoelastic properties porcine bellies and beef
flank were compared using DIS impacts.
The viscoelastic properties of the tissues were assessed using
TissueAnalyzerTM. Beef flanks were found to have twice the elasticity
of porcine belly preparations taking double the stress as well. As a
results a prefabricated hernia defect of five diameters markedly
increased its size upon DIS straining in beef flanks up to 7.5 cm on
the average whereas porcine belly preparations varied ? 20% staying
almost constant on the average. Recalculation of grip values taking
the hernia size at the 10th DIS impact into account gave the same
result related to hernia size regardless of the tissue laxity.
The grip calculation is a novel way to assess biomechanical sta-
bility in ventral hernia repair. Higher grip values are necessary as
hernia sizes increase. This is more pronounced with increased tissue
laxity. Care should be taken to reach adequate grip values in lax
tissues.
P-1021
Outcomes of transversus abdominis release in emergent
incisional hernia repair
Alkhatib H, Tastaldi L, Krpata D, Petro C, Rosenblatt S,
Rosen M, Prabhu AThe Cleveland Clinic Foundation
Purpose: Elective repair of large incisional hernias using posterior
component separation with transversus abdominis release (TAR) has
acceptable wound morbidity and long-term recurrence rates. The
outcomes of using this reconstructive technique in an emergent set-
ting remains unknown. We aim to report 30-day outcomes of TAR in
non-elective settings.
Methods: All patients undergoing open TAR in non-elective settings
were identified within the Americas Hernia Society Quality Collab-
orative (AHSQC). Outcomes of interest were 30-day Surgical Site
Infections (SSIs), Surgical Site Occurrences (SSOs), SSOs requiring
procedural intervention (SSOPIs), medical complications, and
unplanned readmissions and reoperations.
Results: 61 patients met inclusion criteria. Mean BMI was
36.6 ± 8.8 kg/m2 and mean hernia width was 14.4 ± 7.1 cm. 42
(68.9%) were recurrent hernias and bowel obstruction was the most
frequent cause for emergent surgery (80.3%). Surgical field was
classified as clean in 68.9% of cases, with an 88.3% use of permanent
synthetic mesh and fascial closure achieved in 93.4%. There were 16
(26.2%) total wound events, 9 (14.8%) were SSIs. There were 9
(14.8%) SSOPIs, 7 of which were wound opening, 1 wound
debridement, and 1 percutaneous drainage. At least one wound or
medical complication was reported for 38% of the patients. There
were no mortalities.
Conclusion: Not surprisingly, TAR in an emergent setting is asso-
ciated with increased wound morbidity requiring procedural
interventions and reoperations compared to what has previously been
reported for elective cases. The long-term consequences of this
wound morbidity with regard to hernia recurrence are as of yet
unknown.
P-1022
Comparative study of desarada: tissue based technique
versus lichtenstein technique for primary inguinal
hernia repair
Jain MAIIMS, New Delhi
The presentation is a comparative and prospective study between
Desarda and tissue based technique versus Lichtenstein technique for
primary inguinal hernia repair. The study done was designed to
establish the clinical outcomes of hernia repair using the physiolog-
ically dynamic tension free inguinal herniorrhaphy using external
oblique aponeurosis, a non mesh tissue only repair, which is
acclaimed to be able to restore the normal physiology of the inguinal
canal as compared to the mesh based repairs. In this study there was
statistically significant difference between the physiologically
dynamic tension free inguinal herniorrhaphy using external oblique
aponeurosis and Lichtenstein method in regard to post operative pain
scores, mean hospital stay and return to daily activities. As far as peri
operative complications are concerned there was statistically signifi-
cant difference in frequency of seroma formation only.
The most evident indications for the use of the physiologically
dynamic tension free inguinal herniorrhaphy using external oblique
aponeurosis technique include:
1. Use in young patients.
2. In contaminated surgical fields.
3. In the presence of financial constraints or.
4. If a patient disagrees with the use of mesh.
The tissue only repair was shown to take a significantly shorter
operative time.
To conclude the tissue based herniorrhaphy showed better out-
comes in terms of,
1. VAS (pain).
2. ADLs.
3. Shorter operative time.
4. Reduced post operative complications of seroma formation.
Though the recurrence rate of physiologically dynamic tension
free inguinal herniorrhaphy using external oblique aponeurosis tech-
nique for hernia repair after a follow-up of 1.5 years is comparable to
that of Lichtenstein method which is considered a standard procedure
of management of inguinal hernia.
123
S55 Hernia (2019) 23 (Suppl 1):S50–S100
P-1023
Spontaneous lateral abdominal wall hernia containing
an incarcerated appendix
Caparelli M, Runyan B, Hobler SThe Jewish Hospital
Introduction: Lateral abdominal wall defects are a rare entity that
presents a unique challenge to surgeons. The lateral abdominal wall is
defined by the linea semilunaris medially, posterior paraspinal mus-
cles laterally, costal margin superiorly and iliac crest inferiorly. We
report a previously undescribed spontaneous lateral abdominal wall
hernia containing an incarcerated appendix that was repaired by an
open underlay technique.
Case: The patient is an 81-year-old female with a remote history of
hysterectomy that presented with a small, painful right lower quadrant
abdominal mass. She did not have a history of trauma, intra-ab-
dominal infection, incisional defects, smoking or obesity. CT scan
showed a 2 cm hernia defect in the right lower quadrant. The hernia
was 3 cm medial to the anterior superior iliac spine, lateral to the
rectus and superior to the inguinal ligament. The hernia protruded
through the transverse abdominis and internal oblique muscles and
contained a normal appendix. The patient underwent open surgical
repair with composite mesh placed in an underlay fashion.
Discussion: In this report we describe a new location for a lateral
abdominal wall hernia. Whereas Spigelian hernias protrude through
an area of weakness just lateral to the rectus sheath; the hernia that we
describe was located lateral to the semilunar line penetrating the
internal oblique and transversus abdominis muscles and contained a
hernia sac. The size and location of the defect was favorable for an
open approach, which we showed to be safe and effective.
P-1026
Comparison of intraperitoneal ventralex St Patch Vs
Onlay Mesh Repair in Small and Medium Primer
Umbilical Hernia
Agca B, Iscan YFatih Sultan Mehmet Training and Research Hospital
Aim: The high recurrence rates seen in non-mesh suture repairs
increase the demand for mesh suture repairs. Although the size of the
hernia plays an active role in the use of the mesh, the counter-view is
that the use of the mesh should be preferred regardless of the size of
the hernia. In our study, the clinical results of two different mesh
types applied under elective conditions to small-and medium-sized
umbilical hernia cases were examined.
Materials and methods: Between January 2015 and May 2018,
intraperitoneal Ventralex ST repair and onlayprolene mesh repair
were performed in 88 primary umbilical hernia cases. All patients
were over 18 years of age and had symptomatic and primary
umbilical hernia, the diameter of which was less than 4 cm. The
scoring of recurrence rates, short and long-term postoperative com-
plications and pain were calculated.
Results: The mean follow-up period was 23 months (with range
7–46 months) and no recurrence was observed in both groups. There
was no statistically significant difference between gender character-
istics, ASA scores, hernia defect diameters, hospital stay period and
return to work time. The duration of the surgery in Ventralex ST
group was 35.9 ± 4.1 min. (P\ 0.05). The BMI in Ventralex ST
group was 30.5 ± 3.5 kg/m2 (P\ 0.05).Analgesic intake in onlay
mesh group was 8.2 ± 1.9 (P\ 0.05). The VAS values of the 1st and
7th day of the onlay mesh repair group were statistically significantly
higher than the values of the Ventralex group. (P\ 0.05). The rates of
early and late postoperative complications such as seroma, hematoma,
wound infection, and recurrence were similar between the procedures.
Discussion: We think that the Ventralex ST mesh performed with
open surgical technique under elective conditions for primitive
umbilical hernias can be safely used because of its quick applicability
and low rates of complication and recurrence.
P-1029
A hierarchical postgraduate year competency based
model for robotic surgery education
Lewis J, Cervone A, Brandt JNorthwell, Peconic Bay Medical Center
Surgical resident education is an evolving paradigm encompassing
open operative technique and rapidly expanding minimally invasive
operations with the incorporation of robotic technology. Our goal is to
demonstrate a hierarchical education model that provides a step-wise,
competency-based learning process ultimately resulting in creden-
tialing in robotic surgery using the Da Vinci Surgical System during
the course of surgical residency. The competency-based model would
parallel The General Surgery Milestone Project� set forth by the
Accreditation Council for Graduate Medical Education.
The model’s benchmarks encompass the following categories:
Port Placement, Patient Cart Setup, Docking and Undocking, Instru-
ment Insertion and Exchange, Surgeon Console Settings, Camera
Control, Clutching, EndoWrist� Instrument Manipulation, 3rd Arm
Control, Range of Motion, Retraction, Dissection, Suturing, Applying
Energy, Troubleshooting and Communication. The resident would
also review recorded operations performed by a senior robotic sur-
geon. Additionally, the resident’s operative video will provide
constructive critiques for operative technique, ergonomics, and safety
metrics.
The DaVinci Residency and Fellow Training Program would be
the foundation for a curriculum based on a post-graduate year that
would be easily adoptable by training programs with extemporaneous
efforts. The model provides a structured solution for robotic education
while providing critical constructive feedback through senior resi-
dents and attending surgeons. Competent senior residents would
provide a social structure to mandate surgical competency of junior
residents in robotic surgery. As surgical resident education progresses
into data and performance-driven metrics so should a structured
credentialing process.
P-1030
Laparoscopic extraperitoneal endocopic staple based
sublay operation (LEESS) with mesh: interims analysis
of an initial patient cohort
Hashim D, Meyer F, Albayrak NSt. Anna Hospital Herne
Background: Patients with symptomatic midline abdominal hernia
(umbilical, infraumblical, port-a-cath, &/or epigastric hernias) and
concomitant rectus abdominis diastasis represent a growing clinical
problem. The optimal management of this complex hernia situation is
the subject of debate in the literature. This paper reports on the early
results of an innovative surgical technique aimed at managing this
hernia situation.AIM: To analyze early postop. outcome characterized
by morbidity (in particular, by intraop., specific and general com-
plication rate) and mortality based on a unicenter observational study
123
Hernia (2019) 23 (Suppl 1):S50–S100 S56
to reflect daily surgical practice in hernia surgery using a novel sur-
gical approach such as LEESS.
Methods: LEESS with mesh a is a surgical technique recently known
in the literature for its good outcome for midline hernia repair via
transperitoneal route (Brazilian Technique) & Endoscopic Compo-
nent Separation Techniques. The early postop. outcome results for the
first 50 patients are presented here in this systematic clinical unicenter
observational study on quality assurance.
Results: Two patients (4%) developed postoperative complications
requiring redo surgery. These were two cases of internal herniation
through a defect in the posterior rectus sheath, the herniated intestine
was reduced and the defect was sutured laparoscopically. All other
complications were successively managed with conservative treat-
ment. After 11 months, 4 out of 50 (8%) patients reported occasional
pain, including pain at rest in one patient. 5 out of 50 (10%) devel-
oped a symptomatic subfascial seroma.
Conclusion: The LEESS technique with mesh augmentation is an
innovative, minimally invasive surgical procedure for treatment of
patients with a complex abdominal wall hernia comprising symp-
tomatic umbilical, port-a-cath, and/or epigastric hernias with
concomitant rectus abdominis diastasis.
P-1031
Simultaneous umbilical hernia repair is a necessary
part of strategic planning for laparoscopic
cholecystectomy
Morfesis FOwen Drive Surgical Clinic
Umbilical defects (primary, post-partum and incisional) can cause
technical problems in laparoscopic cholecystectomy (LC) operations
(1). They interfere with trocar placement and can contribute to inci-
sional hernia postop. Additional contributing factors include prior
incisions (C-sections, where prior umbilical defect may not have been
effectively closed and tubals), prior abdominoplasty which can affect
blood supply and healing of trocar sites and need for mini-lap to
remove enlarged gall bladders. A cohort of 100 LC over a 5 year
period was retrospectively reviewed: 100 cases with a minimum of 6
month followup:27 men and 73 women, average age approximately
50 years. Risk factors for a variety of hernia defects (above) were
reviewed and total patients at risk from factors estimated at about
60% of female patients (prior C-section, tubals, minilap, abdomino-
plasty, primary hernias and prior surgery in abdomen)and 10% of
male patients (related to 5% estimate of underlying hernias and 5%
incidence of minilap. extraction of gall bladder): 27 of these 100
patients had concomitant defects repaired; the defect was used as a
primary trocar site whenever possible and then repaired with
absorbable suture if incidental, permanent suture if larger and biologic
re-inforced if defect greater than 2.5 cm in diameter. Detection, use
and repair of these defects was part of strategic planning of surgery;
the risk otherwise could contribute to incisional hernia risk postop.
There were no infections (other than expected SSI rate treated only
with antibiotics orally), complications or recurrences. (1) LC
accompanied by umbilical hernia repair; E. Kamer et al.; JPGM 2007,
vol 53, p 176–180.
P-1032
Inguinal hernia repair with a new fixation free 3d
multilamellar preperitoneal implant
Malik D, Dhakad DEternal Hospital
Objective: Prosthetic reinforcement is the gold standard in inguinal
hernia repair. Almost 20–30% patients complain of postoperative pain
due to irritation and inflammation caused by the mesh and methods of
fixation and about 4–10% of these, feel severe chronic postoperative
pain. So a single arm study was conducted for the assessment of
postoperative pain after inguinal hernia repair with a new 3D, mul-
tilamellar self-fixating Proflor mesh.
Methods: From Oct 2012 to July 2018, 265 patients of Inguinal
hernia were repaired with Proflor mesh (a new frixation free 3D
multilamellar preperitoneal implant- Insightra) where no suture fixa-
tion was done. All patients were assessed on visual analog scale
(VAS) at 7 days, 3 months, 6 months and 1 year and examined for
perioperative/postoperative complications.
Results: According to VAS, pain was reported in a range from 1 to 3
during the first week. No perioperative complications occurred. 22
postoperative complications were reported. 10 seromas,2 ecchymosis,
9 hypoaesthesia, 1 postoperative pain from 7th postoperative day
onwards which was initially intolerable but reduced in intensity after
2 months and was minimal at the end of 6 months. No recurrence was
found.
Conclusions: Postoperative complication rates were comparable to
the world literature. The use of this new mesh could be an alternative
method to reduce chronic postoperative pain after inguinal hernia
repair. Although further studies with long term results are still needed
to establish it as a gold standard.
P-1034
Learning curve for unilateral endoscopic totally
extraperitoneal (TEP) inguinal hernioplasty
in a teaching hospital our country
Agca B, Iscan Y, Memisoglu KUniversity of Health Sciences, Fatih Sultan Mehmet Training
and Research Hospital, General Surgery Department
Purpose: More than a hundred different techniques for repair of
inguinal hernia and femoral hernia has been described. In the guide
published in 2018, only open mesh technique and laparo-endoscopic
mesh techniques are generally approved. We sought to estimate the
learning curve for laparoscopic TEP repair in a teaching hospital our
country.
Methods: Patients with a primary unilateral inguinal hernia who
underwent laparoscopic TEP repair between the dates of May 2013
and May 2018 were included in the study. The patients were divided
into seven groups. The first four groups consisted of 20 patients and
the other three groups consisted of 100 patients per group.
Results: 349 of the 380 patients were male and 31 were female and
the mean age was 52 ± 14.2 (SD) years. The mean duration of
operation was 46 ± 25.9 (SD) minutes. There was a statistically
significant difference between the groups in terms of the duration of
the operation (p\ 0.05). The duration of the operation plateaued
as\ 1 h after 60 surgeries. A total of 7 patients were converted to
open surgery. Seroma and hematoma in 3 patients and hernia recur-
rence in 4 patients were detected.
Conclusions: It has been concluded that a surgeon performing a
certain number of inguinal hernia operation in her/his surgical career
can complete the learning curve for TEP repair after 60 operations
123
S57 Hernia (2019) 23 (Suppl 1):S50–S100
when appropriate technical conditions are provided, and that subse-
quent surgery can be performed in an optimal time with low
complication and recurrence rates.
Keywords: Laparoendoscopic repair, TEP, learning curve, duration
of surgery.
P-1035
Finding the optimal mesh for hernia patients- is
comprehensive mesh labelling adequate?
Karatassas A, Hensman C, Pantinniot P, Reid J, Leopardi
L, Nabeel I, Maddern G, Hewett P, Anthony AUniversity of Adelaide, Discipline of Surgery, The Queen Elizabeth
Hospital
Blatnik and others advocate comprehensive mesh labelling (size,
composition, pore size, weight, barrier protection and biomechanical
properties) providing a quick overview of key properties, optimising
mesh selection. This approach, supported by the AHS, presumes that
comprehensive labelling will allow surgeons to extrapolate regarding
the tissue response to the mesh and hence eventual patient outcome.
Although helpful, this is a crude method for determining patient’s
tissue response to mesh. A better, more scientific approach involves
developing a mesh tissue integration (MTI) index based on an animal
model. Currently, there is no universal model that is used to compare
meshes. We require one model, with standardized methods of inter-
pretation to allow comparison of meshes. We propose a porcine
model, placing mesh in subrectus and intraperitoneal positions (with
barrier protection). Analysis will be performed using specific
macroscopic and microscopic parameters based on International
Standards (ISO 10993-6) to obtain a grade from 0 to 5 on the fol-
lowing components;
• MTI Index (rate of tissue integration over 3 months).
• Fibrotic sub-index (degree of fibrosis).
• Adhesion sub-index (degree of adhesions for an intraperitoneally
placed mesh).
• Mesh degradation sub-index (to measure rate of degradation or
resorption of the mesh in vivo after 2 years).
An optimal mesh with ratings of five in each category will have
rapid MTI, minimal fibrosis or adhesions and no resorption. Based on
these four components surgeons may select mesh which is appropriate
for their patient.
It is simplistic to believe that indices based on animal studies
translate into predictable patient outcomes considering the diversity
and complexity of patients (as multiple medical comorbidities influ-
ence the tissue response to the mesh). To appreciate the significance
of the MTI index, a longitudinal database that records mesh indices
and patient characteristics against outcomes is pivotal in progressing
hernia management towards a truly holistic and tailored approach.
P-1036
Complex diaphragmatic and ventral hernia repair
after damage control thoracoabdominal surgery
Siegal S, Orenstein SOregon Health and Science University
We present a challenging diaphragm and ventral abdominal closure
after damage control thoracoabdominal surgery. A 40-year-old female
with T3N2 esophageal adenocarcinoma underwent laparoscopic
esophagectomy complicated by aortic laceration and massive blood
loss requiring open conversion with thoracoabdominal incision for
hemorrhage control. Damage control necessitated temporary closure
with negative pressure therapy. Subsequent esophagectomy was
completed with temporary chest and abdominal closure. During
intraoperative examination on postoperative day 8, the diaphragmatic
defect was noted to be under significant tension. A bridged repair was
performed, suturing to the edges of the left hemidiaphragm and
central tendon of the diaphragm. Biologic mesh was utilized due to
concern for infection from prolonged open abdomen. On postopera-
tive day 10, she underwent complex abdominal closure of a 17x30 cm
defect with bridged vicryl mesh. This was covered with bilateral
lipocutaneous advancement flaps over a 20x25 cm area. Undue ten-
sion was noted in the subxiphoid location, thus a negative pressure
wound dressing was applied to this area. After a prolonged intensive
care unit course, the patient was transferred to the ward on postop-
erative day 31, receiving enteral nutrition through her jejunostomy
tube. She was safely discharged home on postoperative day 39.
2 weeks later she was seen for follow up. Her wound was mostly a
bed of healthy granulation tissue, though there was some superficial
tissue necrosis at the inferior margin requiring bedside debridement
and punctate areas of exposed mesh along the thoracotomy aspect of
the incision. She was otherwise tolerating her feeds, taking recre-
ational oral intake, and having improved energy and ambulation.
Ongoing wound care efforts continue at this time, and the patient will
be evaluated for a future abdominal wall reconstruction following
completion of chemotherapy and preoperative optimization. This case
highlights unique surgical technique and decision making in a com-
plex hernia closure after damage control thoracoabdominal incision.
P-1039
Assessing risk in patients with liver failure: do risk
calculators over estimate a patient’s risk of mortality
following hernia repair?
Jackson J, Helm M, Turner B, Goldblatt MMedical College of Wisconsin
Background: Abdominal hernia repairs are common procedures;
however, patients with cirrhosis are known to be at considerable risk
for hernia repair. Several morbidity and mortality risk assessment
calculators for patients with liver disease have been developed to
attempt to add objectivity to the decision of whether these surgeries
should be performed. We sought out to determine if these risk cal-
culators accurately determined the mortality rate for hernia repairs.
Methods: The American College of Surgeons National Surgery
Quality Improvement Program datasets from 2013–2016 were queried
for patients who underwent an abdominal hernia repair. Patients were
included if they had pre-operative ascites and an American Society of
Anesthesiologists classification of III/IV. Mayo Clinic’s ‘‘Post-
Operative Mortality Risk in Patients with Cirrhosis’’ risk calculator,
Model for End-Stage Liver Disease (MELD) calculator, and a sur-
gical 5-item modified frailty index were assessed to determine
whether they accurately predict morbidity and mortality following
abdominal hernia repair. All predicted mortalities were compared to
the actual incidence of mortality. A high c-statistic indicates excellent
predictive performance of a risk calculator.
Results: In total, 560 patients met inclusion criteria. All risk calcu-
lators overestimated the risk of mortality. ‘‘Post-Operative Mortality
Risk in Patients with Cirrhosis’’ yielded an AUC = 0.76 and
p-value\ 0.0001. MELD score predicted mortality yielded an
AUC = 0.73 and p-value\ 0.0001. The modified 5-item frailty index
yielded an AUC = 0.54 and p-value of 0.46.
Conclusions: None of the three risk assessment calculators that were
examined are good mortality predictors following hernia repair in
123
Hernia (2019) 23 (Suppl 1):S50–S100 S58
patients with cirrhosis and ascites. All of the mortality predictors
over-estimate the true 30-day operative mortality. The ‘‘Post-opera-
tive Mortality Risk in Patients with Cirrhosis’’ was the best predictor
of mortality.
P-1040
Repair of umbilical hernia resolves concomitant ascites;
umbilical hernia acting as a ‘‘Pump’’ for ascites
Morfesis FF Morfesis
48 year old cirrhotic patient (alcoholism) had clinical evidence of
transudative ascites (symptomatic) with rapid expansion of umbilical
hernia containing fluid. The hernia was successfully repaired with
resection of large portion incarcerated round ligament using suture
(hernia diameter about 2.5 cm.). 1 year follow up confirms resolution
of clinical evidence of ascites with resection of round ligament
incarceration and hernia repair, in absence of other clinical maneu-
vers. Pathology of round ligament otherwise unremarkable without
gross evidence of large veins. Clinical result could be consistent with
round ligament acting as a ‘‘pump’’ shifting transudate into lower
pressure umbilical hernia area outside of abdomen causing accumu-
lation of fluid and rapid expansion. The pressure differential between
intra-abdominal venous pressure of, for example, 18 mm Hg and
outside pressure (theoretically only pressure of skin) of hernia could
explain this observation. Additional data and observation and anec-
dotal findings could be useful to interpret and confirm validity of this
observation. Normal transudative ascites is thought to only accumu-
late above intra-abdominal venous pressure of 20 mm. HG but a
marginally lower pressure could account for accumulation in presence
of incarcerated ‘‘sump’’ for fluid and resolution when ‘‘sump’’ is
resolved. As long as pressure of resistance to stretching of skin was
less than this venous pressure, this would lead to accumulation of
fluid and resultant expansion of hernia and observation noted.
P-1046
False positive imaging results diagnosing occult
recurrent inguinal hernias
Ongos K, Albin M, Albin DHernia Center of Southern California, Inc
Inguinal hernia repairs are one of the most commonly performed
procedures in general surgery. Every year it has been estimated that
about 20 million inguinal hernia repairs are performed around the
world. After hernia surgery, it is common for hernia specialists to see
patients that experience discomfort or pain. Chronic inguinal pain has
been experienced by 18% of patients after undergoing open inguinal
hernia repair, while 6% of patients experienced chronic pain after
laparoscopic groin hernia repair. The patients with persistent pain fall
into two categories: recurrent hernia or inguinodynia, resulting from a
neuropathy of some type. In the absence of hernia reoccurrence on
physical examination, these patients will usually get either a diag-
nostic CT scan, an ultrasound, or an MRI. In this study, we focused on
the operative findings of patients who have had prior hernia surgery
with an imaging study that was positive for an occult recurrent
inguinal hernia. An occult hernia was defined as an imaging detected
recurrence that was not present on examination. Patients experiencing
chronic pain in the absence of a occult recurrent hernia were excluded
from the study. Preliminary findings showed a false positive rate of
50%. In these cases, the most common operative findings were a cord
lipoma or scar tissue. Often these patients complain of pain out of
proportion to what was seen operatively and would be expected.
Clinical judgment is imperative in determining the need for surgery in
these patients. Our objective is to treat the patient and not the radi-
ological findings.
P-1047
Improved anchoring mechanism for hernia repair mesh
Levinson H, Ibrahim M, Everitt J, Green J, Ruppert DDuke University Medical Center
Ventral hernia recurrence is the leading complication (* 30%
10-year recurrence rate) following hernia repair and it is caused by
anchor point failure at the mesh, suture, tissue interface. To overcome
this problem, we developed a hernia mesh (T-line mesh) with inte-
grated anchoring mesh extensions, akin to roots of a tree, that are 15
times the width of #0 suture and replaces the need for suture fixation.
Mesh extensions enhance high-tensile load distribution; significantly
reducing tissue stress and anchor point failure. Pre-clinical proof of
concept data is presented herein. The T-line mesh was knitted from
polypropylene (a heavy-weight, macroporous, mesh construction)
with equivalent physical characteristics (e.g. thickness, pore area, and
areal density) to a predicate mesh. The T-line mesh outperformed the
predicate mesh in all benchtop mechanical tests (i.e. suture retention
strength, ball burst, tongue tear resistance, and tensile strength and
strain). The T-line mesh and predicate mesh were implanted in a
swine ventral hernia model (n = 4/group) for 1, 30 and 90 days. Upon
analysis, there were no abnormal gross findings from either mesh.
Inflammation, bio-incorporation and fibrosis were statistically similar
between the T-line mesh and predicate mesh. The predicate mesh was
noted to contract more than the T-line mesh. The T-line mesh
anchoring strength (134.5 ± 54.5 N) was * 275% greater than the
predicate mesh anchoring strength (49.0 ± 13.4 N); exceeding
physiologic thresholds. The T-line mesh has supra-physiologic
anchoring strength, overcomes the most common mechanical failure
modes of currently used commercial meshes, and meets early safety
standards for implantation in humans. The data presented in this
abstract are the basis for ongoing commercial development of a novel
T-line mesh for durable hernia repair and hernia prevention.
P-1048
Laparoscopic hiatal hernia repair in association
with Nissen–Rossetti fundoplication: outcomes
and experience
Santivanez Palomino J, Nassar R, Ricaurte A, Hernandez J,
Escobar R, Giron FHospital Universitario Santa Fe de Bogota
Introduction: Hiatal hernias are common disorders characterized by
the protrusion of any abdominal structure other than the esophagus
into the thoracic cavity through a widening of the diaphragmatic
hiatus. In patients with confirmed gastro esophageal reflux, antireflux
surgery is an option for the management of their condition. Some-
times the hernia is not the indication for the procedure but when
repaired, according to the type of hernia, a fundoplication to address
reflux disease may be mandatory. We present our experience with
laparoscopic hiatal hernia repair in association with an anti-reflux
technique.
Methods: Retrospective case series. All fundoplication laparoscopic
cases performed by one surgeon where recorded between 2013 and
123
S59 Hernia (2019) 23 (Suppl 1):S50–S100
2017. Data recorded included demographic data, hernia defect size,
mesh time, and complications, and two- year follow up. A descriptive
analysis of the available demographic variables and risk factors was
carried out, as well as postoperative outcomes and follow-up. The
data are presented according to the nature of the variables.
Results: 44 patients were included. Body mass index was 28.5 kg/m2
(range 19–45 kg/m2), among which 11 patients were obese. From the
44 patients, 40 (90.9%) underwent primary sutured crural repair and 5
(11.4%) had mesh reinforcement. Laparoscopic Nissen-Rossetti fun-
doplication was performed in 34 patients (77.2%), and modified Hill
in 6 patients (13.6%). According to the hiatal hernia classification: 21
patients (47.7%) had type 1, 7 patients (15.9%) type 2 hernia, 13
patients (29.5%) type 3 and 3 patients (6.8%) had type 4. The com-
plication rate was less than 1% and there was no conversion to open
surgery. In the two-year follow up 4 patients (9%) had reflux, and 2
(2.5%) reported hernia reproduction.
Conclusions: General primary crural repair in association with
modified posterior gastropexy (Nissen-Rossetti fundoplication) pro-
vides favorable protection from gastroesophageal and pharyngeal
reflux and can be properly used in the treatment of GERD.
P-1049
Laparoscopy is the gold standard in the treatment
of inguinal hernias in young workers, comparative
study about 800 cases
Zatir S, Medjamea A, Haridi A, Mejahdi S, Nassim O,
Arbouz M, Meliani B, Selmani ZMilitary Hospital University of Oran
We adopted the treatment of inguinal hernias by laparoscopy see the
postoperative benefits of this surgical approach. We operated 400
patients for inguinal hernias of age a period of 04 years, the age of our
patients varies between 20 and 45 years, all our patients are profes-
sional soldiers, 48% right hernia, inguinal hernia 35% left, 13%
inguinal bilateral hernias, 4% recurrent hernias.so we compared our
results with 400 patients operated for inguinal hernia by lichtestein
procedures.
P-1051
Improved hernia measurement: initial outcomes
of a novel retractable laparoscopic measuring device
Soriano I, Wernsing DPennsylvania Hospital
Aims: To demonstrate the benefits of using a novel retractable la-
paroscopic measurement device (RLMD) to determine the size of a
hernia compared to other current measurement methods.
Backgorund: Current methods of hernia measurement are either
inaccurate, cumbersome, or both. A novel RLMD allows the surgeon
to quickly and accurately measure the internal aspects of the hernia
for proper mesh sizing.
Methods: Eight surgeons from multiple institutions were asked to
measure 3 defects on each of two laparoscopic hernia repair simu-
lators using different methods of measurement. They were first asked
to estimate the defect size by eye, then by using the grasper, and then
by using the RLMD. After measuring the 3 defects on the first sim-
ulator, they were then asked to move on to the second simulator to
measure replicated defects that were identical to the first simulator.
Results: On hernias[ 7.5 cm, the average absolute error for each
method was 3.8 cm (r = 2.6 cm) when estimating by eye, 1.7 cm
(r = 2.3) when using graspers, and 0.6 cm (r = 0.5 cm) when using
the RLMD. The difference in measurement when measuring the same
sized defects in each simulator also varied with each method. When
estimating by eye the difference was 2.6 cm (r = 2.5), the grasper
method was 1.5 cm (r = 2.4), and RLMD was 0.7 cm (r = 0.6 cm).
Conclusion: The RLMD was more accurate and consistent than the
other two laparoscopic measurement methods.
P-1054
Robotic transversus abdominis release: one year
outcomes in a community setting
Manieri C, Rhemtulla I, Santoro PChristiana Care Health System
Background: The morbidity of complex ventral hernia repair using
open component separation techniques has been well described. Our
aim is to investigate and discuss short term outcomes after complex
abdominal wall reconstruction utilizing a robotic transversus abdo-
minis release (TAR) in a community setting.
Methods: A retrospective review of a prospectively maintained
database of abdominal wall reconstruction cases performed by a
single surgeon was conducted at an independent academic community
hospital system from May 2017 to June 2018. Inclusion criteria
included a TAR and robotic approach. Patients underwent a stan-
dardized technique of abdominal wall reconstruction using robotic
assistance, with no open conversions. Our primary outcome for this
review was hospital length of stay. Secondary analysis included
surgical site infections, complications, readmissions, and operative
time.
Results: 16 patients were identified within the study period. The
average patient age was 54 (36–74) and BMI was 34 (26–49). The
average length of stay was 2.1 hospital days (1.1–3.4). There was 1
surgical site event consistent with a non-infected seroma. There was 1
readmission for pneumonia and pericarditis over a 30 day period.
There was no hernia recurrence within the study period and no patient
was lost to follow-up. The average time on the robotic console was
228 min (170–319) and the average defect measured 96 cm2
(25–217).
Conclusion: Robotic-assisted abdominal wall reconstruction is a
viable option in the repair of complex ventral hernias. It appears to
have low morbidity, short length of stay, and can be safely imple-
mented in a community hospital setting. These results add to the very
limited data available regarding robotic abdominal wall reconstruc-
tion. More investigation is needed to validate these findings as well as
to determine long term hernia recurrence rates.
P-1055
A single centre study of the frequency of complications
post open primary ventral hernia mesh repair: on lay
versus in lay techniques
Dhadlie S, Vujcich E, Ratnayake SCaboolture Hospital
Introduction: Open mesh ventral hernia repair is a common proce-
dure performed by general surgeons. Recent meta-analysis comparing
in lay to on lay mesh repairs demonstrated a lower frequency of
surgical site infection with in lay repairs. There was no difference in
the rate of recurrence or seroma formation.1 Ventral hernias and the
complications from repair can significantly affect an individual’s
123
Hernia (2019) 23 (Suppl 1):S50–S100 S60
quality of life and have health care implications in relation to pro-
longed admissions and readmissions. 2, 3.
Design: Retrospective study of patients who had a primary ventral
hernia mesh repairs that were readmitted within 30 days of the pro-
cedure between 1st May 2015 to and inclusive of 31st May 2018.
Patients: 312 patients had primary ventral hernia repairs (including
umbilical hernia mesh repairs). 71 were readmitted within 30 days of
their procedure, 29 of which had complications related to the pro-
cedure. 41% patients were male.
Results: 80% of readmission had an on lay repair. The mean length of
readmission was 2 days. The mean time to readmission was 16 days
(range 1–30 days).
The mean age of patients was 51 (range 31–84 years). 30% of patients
had type 2 diabetes, vascular disease or obesity. Complications were
attributed to haematomas (17%), infected seromas (73%) and wound
infection (10%). There was a return to theatre in 34% cases.
Polypropylene (prolene) mesh was used in 60% of cases.
Conclusion: Infected seromas as complication of on lay mesh repair
was the most frequent readmission. There are several factors that are
known to affect the risk of developing incisional hernia and contribute
to poor outcomes post hernia repair such as age, obesity, infection,
diabetes and smoking.3 Only one-third of patients had these comor-
bidities which suggest that the technique of repair.
P-1056
Long-term results of laparoscopic totally extra-
peritoneal groin hernia repair with self-gripping
polyester mesh
Stavert B, Chan D, Ozmen J, Loi KSt George Public Hospital, Sydney, Australia
Background: Laparoscopic groin hernia repair is an increasingly
common procedure, with benefits of reduced post-operative pain and
infection. Postoperative chronic pain remains an ongoing concern in
about 10% of patients. Parietex ProGrip (Covidien, Dublin, Ireland), a
polyester self-gripping mesh, has a theoretical benefit of avoiding
tacks for mesh-fixation. This case series reflects our long-term
experience of this technique. Methods: We conducted a retrospective
case series with two surgeons from November 2011 to December
2017. Patients were identified through operative Medicare Benefits
Schedule item number search (laparoscopic groin hernia repair,
30,609). Clinical documentation was reviewed, with length of stay,
mesh infection, chronic pain, recurrence and reoperation as primary
data points. Results: A total of 514 patients underwent 780 laparo-
scopic inguinal hernia repairs with self-gripping polyester mesh
during this period. There were 53 female (10.3%) and 461 male
patients (89.7%). Unilateral hernia repair was performed in 248
patients (48.2%).
P-1058
Postoperative abdominal wall bulging of laparoscopic
ventral hernia repairs
Tang J, Zhu L, Li SHuadong Hospital Affiliated to Fudan University
Background: Laparoscopic ventral hernia repairs (LVHR) is one of
most popular operations in general surgery. Postoperative abdominal
wall bulging which was rarely mentioned in the past decades is one of
the common postoperative complications of LVHR. This study aims
at systematic reviewing abdominal wall bulging following LVHR.
Methods: A computer-aided search of the PubMed and Embase
databases was conducted to find relevant English-language publica-
tions on the postoperative abdominal wall bulging of laparoscopic
ventral hernia repairs. The following search terms were used: [la-
paroscopic surgery AND (ventral hernia OR incisional hernia) AND
postoperative complication AND (bulging OR protrusion OR even-
tration OR pseudoreccurence)]. No beginning date limit was used.
The search was updated until 31 July 2018. Review articles, meta-
analyses, abstracts, editorials or letters, case reports, tutorials and
guidelines for management articles were excluded. Full-text articles
were then reviewed to definitively determine if the study was eligible
for inclusion.
Results: A total of 11 studies were included for evaluation. The
incidence of LVHR postoperative abdominal wall bulging was
1.3–21.5%. Postoperative abdominal wall bulging may be related to
the area of abdominal wall defect, defect closure in operation, and the
type of implant patch. A patient could be diagnosed as post-LVHR
abdominal wall bulging if he/she meets the criteria in medical history,
clinical features and imaging examination. As preventions, surgeons
should pay attention to recognition and full exposure of fascia defect
edge, returning hernia content, fascia defect closure and patch overlap
and fixation in primary LVHR. When a re-operation is employed,
surgeon could fix a larger mesh tightly over the previous mesh.
Conclusions: Abdominal wall bulging after laparoscopic ventral
hernia repair is not a rare complication and should be diagnosed
carefully. A second surgery is needed when patients dissatisfied with
abdominal wall appearance or dysfunction. Prevention is always
better than treatment.
P-1059
Association of Wilms Tumor 1 gene polymorphism
with inguinal hernia in Chinese Han population
Zhu L, Li S, Tang J, Wang NHuadong Hospital Affiliated to Fudan University
Purpose: Inguinal hernia repair is one of the most commonly per-
formed operations in the world, yet little is known about the genetic
mechanisms that predispose individuals to develop inguinal hernias.
A genome-wide association study identified Wilms Tumor 1 gene
(WT1) as one of novel susceptibility loci underlying inguinal hernia
and 8 single-nucleotide polymorphisms (SNPs) of WT1 were reported
significant in western world. However, this result had not been veri-
fied in Chinese population. Our study aims at confirming the
association of WT1 polymorphism with inguinal hernia in Chinese
Han population.
Methods: 91 participants with surgically diagnosed inguinal hernias,
and 70 physically active controls without any history of connective
tissue disease and hernia were recruited for this case–control genetic
association study. This study employed multiplex Polymerase chain
reaction (PCR) method in combination with the next generation
sequencing for WT1 SNP genotyping (rs10835894, rs11031762,
rs11031779, rs1799925, rs2301251, rs3809060, rs5030178 and
rs7925851).
Results: There are no statistically significant differences of sex,
hernia type, malignancy history between cases group and controls
group. Significantly, more patients gave a positive family history for
an inguinal hernia compared to healthy controls (OR 3.635, 95% CI
1.364–9.660, P = 0.007). All the SNPs in two groups conformity with
Hardy–Weinberg equilibrium. WT1 SNP (rs7925851) was identified.
Our results revealed an increased frequency of WT1 rs7925851 AA
genotype in inguinal hernia patients (OR 1.704, 95% CI 1.114–2.605,
P = 0.049). Moreover, Allele G of rs3809060 could be a risk allele for
inguinal hernias (OR 2.084, 95% CI 1.236–3.516, P = 0.006).
123
S61 Hernia (2019) 23 (Suppl 1):S50–S100
Conclusions: This study confirmed that polymorphism of the WT1 is
associated with an increased risk for developing inguinal hernias in
Chinese Han population. Therefore, rs3809060 and rs7925851 locus
may play key roles in molecular mechanism of inguinal hernia
pathophysiology.
P-1062
Endometriosis and hernia: a ‘‘Hidden’’ source of pelvic
pain and the multi-disciplinary role of pelvic physical
therapy
Sarrel SSallie Sarrel PT ATC DPT
Endometriosis is a condition in which tissue similar to but not the
same as the lining of the uterus is found throughout the pelvic cavity.
176 Million women worldwide experience symptoms which may
include heavy bleeding, excessive menstrual cramps, abdominal,
back, and leg pain, urinary issues and painful sex. Pelvic Physical
Therapy is a sub specialty of physical therapy focused on the hip,
lower abdomen, and pelvis from the bones, to the muscles, including
the pelvic floor, to the nerves and fascia. Ongoing pelvic pain post
excision of endometriosis by a gynecology specialist may be treated
by a pelvic physical therapist. In 1 year, in a private, single practi-
tioner, pelvic physical therapy practice specializing in post excision
of endometriosis issues, 14 occult, or no bulge, hernias were identified
as ongoing sources of pelvic pain. The pelvic physical therapist was
trained in multiple techniques to identify and treat ilioinguinal,
femoral and genitofemoral nerve symptoms. All 14 patients did not
have hernia seen in the retroperitoneal space during excision but
arrived to physical therapy with symptoms consistent with hernia. On
examination by an occult hernia general surgery specialist, all 14
were positive for no bulge hernias. Occult hernia may contribute to
pain during sex, genital pain, groin pain, pelvic floor pain, increased
lower abdominal pain during menstruation, perceived urinary pres-
sure and leg pain. Too often women have an ovary removed to treat
pain generated from these hernias. In the endometriosis patient hernia
may be missed during follow-up visits and surgery with the gyne-
cologist. As a driver in pelvic pain, occult hernia should become more
widely recognized as a source of pelvic pain in the general surgery
community. The Pelvic Physical Therapist and the General Surgeon
play a role in progressing the ongoing endometriosis pain patient as
part of a multi-disciplinary team.
P-1063
Surgical management during non-elective admission
for incisional hernia decreases readmission rate
in the national readmission database
Rives G, Beck W, Taylor J, Davis B, Bhavaraju A, Karim
S, Reif R, Sexton KUniversity of Arkansas for Medical Sciences
Management of non-elective admissions for incisional hernia is
variable. Patients are managed medically or surgically, a decision
where morbidity and symptomatology often guide treatment. While
surgery is the more definitive treatment, there is no widely accepted
guideline in treating incisional hernias. Although readmission data is
lacking, it was our goal using the data available to evaluate the rate of
readmission when comparing the two modalities. We hypothesized
that while increasing cost, surgical management would decrease
readmissions. Using the National Readmission Database, a
retrospective analysis was performed using univariate and bivariate
statistics comparing the management of non-elective admissions for
incisional hernia. There were 208,239 patients with non-elective
admissions. In comparison, 162,473 patients were managed medically
whereas 45,766 underwent surgical treatment. The average length of
stay was 6.1 days and 8.5 days for medical and surgical therapy,
respectively. The readmission rate was 19.3% for medical manage-
ment compared to 6.6% for those managed surgically. The Elixhauser
Readmission and Mortality Scores were 19.4/6.35 for medical therapy
and 12.2/3.8 for surgical therapy. In regard to costs, the total costs all
admissions were $68,175 for patients managed medically and $98,464
for those managed surgically. Of patients with initial medical therapy
that were readmitted (31,355), 1018 (3.25%) underwent operative
therapy on first readmission. An additional 4690 eventually under-
went an operation for 18.2% of the total readmitted population. Of
patients with initial surgical therapy that were readmitted (n = 3028),
52% (n = 1567) underwent an operation on their first readmission. In
conclusion, operative management of patients admitted non-electively
with incisional hernia decreases readmission rate and increases cost.
Furthermore, up to 18% of patients in the medical therapy group
eventually underwent operative therapy.
P-1065
Resilience and healing of a novel reinforced bioscaffold
(RBS) matrix in the setting of high-risk incisional
hernia repair after enterocutaneous fistula (ECF)
takedown
Awad S, Tran-Chao H, Lee D, Makris K, Chiu L, Becker
N, Gillory L, Chai CBaylor College of Medicine, MED VAMC
Purpose: Concurrent repairs of incisional hernias with mesh after
ECF takedown exhibit high surgical site infection rates (SSI). Syn-
thetic mesh is not routinely used. Reinforced BioScaffolds (OviTex
P 1S, 6 layers of sheep extracellular matrix interwoven monofilament
polypropylene) offer an alternative. We report the clinical course of a
patient who developed a SSI after ECF takedown with hernia repair
with OviTex RBS, and demonstrate the rapid incorporation of the
matrix with resultant skin grafting and complete healing.
Methods: A 66 year old male with O2 dependent COPD and severe
malnutrition underwent multiple laparotomies for duodenal perfora-
tion, small bowel resections and takebacks elsewhere with resultant
EC fistulas. He presented for ECF takedown and incisional hernia
repair. ECF takedown and retrorectus hernia repair with 20x20 cm
OviTex P 1S RBS was performed. 1 week postop, a deep SSI with
dehiscence of skin and anterior rectus sheath closures developed,
exposing the RBS. The RBS was left in place and wound care was
initiated with wet to dry followed by wound VAC placement.
Results: Contrary to other biologic and synthetic meshes in this
setting, RBS seamlessly and effectively incorporated within the
wound with rapid granulation. By 8 weeks, an excellent bed of tissue
that allowed for STSG had formed. The patient is 12 months postop
with a completely healed incision and no recurrence.
Conclusion: This is the first report describing RBS in AWR in a high
risk contaminated case. RBS was resilient to infection and allowed
robust wound healing and STSG more rapidly than other synthetic or
biologic scaffolds, without recurrence of the hernia. These results
may be due to the unique known effects of this ECM on wound
healing 1. Further study is warranted.
1. Ovine-Based Collagen Matrix Dressing: Next-Generation Collagen
Dressing for Wound Care, Advances in Wound Care, 2016, Vol. 5, #
1, pp 1–9
123
Hernia (2019) 23 (Suppl 1):S50–S100 S62
P-1067
Does polypropylene mesh increases apoptosis in duct
deferens and testis? Experimental assay in rats
Damous S, Damous L, Miranda J, Birolini C, Montero E,
Utiyama EHospital das Clınicas da Faculdade de Medicina da Universidade de
Sao Paulo
Background: The impact of hernia repair in testicular function and
fertility remain uncertain. This study evaluated the duct deferens and
testicles of rats submitted to bilateral inguinotomy with mesh placing.
Methods: 60 male Wistar rats were distributed in three groups, in
according to the treatment: (1) control (C): only inguinotomy; (2)
MDD: mesh placed on duct deferens; and, (3) MSF: mesh placed on
spermatic funiculus. After 30 and 90 postoperative days the duct
deferens was collected in the site of mesh implantation. Two assays
for apoptosis evaluation were performed by immunohistochemistry—
cleaved casapase-3 and TUNEL. Results are expressed as percentage
of positively area.
Results: The apopstosis were similar on duct deferens in both assays
on 30 and 90 postoperative days (p[ 0.05). In the testis, there was no
difference for cleaved casapase-3 (p[ 0.05) however in the TUNEL
assay there was an increase in apoptosis after 90 days of surgery in
the both mesh groups (p\ 0.05 C vs. MDD and MSF).
Conclusion: Inguinotomy with mesh placing does not promote
apoptosis in the deferent duct of rats in the short and long term but in
the testicles increased apoptosis in the long term evaluation. Further
investigations are necessary to assess long-term testicular function
and the real impact on male fertility.
P-1069
Minimally invasive ventral hernia repair using
the ‘Venetian Blinds’ technique
Chan D, Ravindran P, Fan H, Talbot MSt George Hospital
Purpose: Ventral hernia repair utilising a ‘Venetian blinds’ technique
of plication in combination with mesh reinforcement, closes the
hernia defect and reduces risk of seroma formation. This totally intra-
corporeal technique avoids anterior abdominal wall incisions. Pre-
operative Botulinum toxin A (BTA) injections facilitates laparoscopic
suturing of the midline abdominal wall defect. In non-midline hernias,
defect closure can negate restricted lateral spaces which crowd mesh
fixation. This series demonstrates an early experience of using min-
imally-invasive ‘Venetian blinds’ technique in ventral abdominal
hernia repair.
Methodology: A single centre prospective case series was conducted
between April 2016 and December 2017 using the ‘Venetian blinds’
technique for repair of complex ventral abdominal hernias. Twelve
patients (7 midline, 5 non-midline) were involved in the study during
this time period. Midline ventral hernia patients received a dose of
BTA 4–6 weeks prior to surgery. Hernias were repaired with mini-
mally invasive ‘Venetian blinds’ technique, with synthetic mesh-
reinforcement (11 laparoscopic, 1 robotic).
Results: 12 patient (2 male, 10 females) with a mean age of 66.6 and
body mass index of 31.8 were included. Mean operation time 135 min
and length of stay of 4.75 days. Mean follow-up of 17.5 months
(range 4.6–28.6). No recurrence of hernia to date. Two patients
converted to a laparoscopic-open hybrid approach. One patient had an
infected seroma treated with antibiotics only. Another developed
pneumonia.
Conclusion: Minimally-invasive ‘Venetian blinds’ technique with
BTA is a novel and feasible technique for repair of complex ventral
hernias that reduces the potential for seromas and wound infections
overlying mesh placement.
P-1071
The impact of intraoperative Foley catheters
on postoperative urinary retention after inguinal hernia
surgery
Crain N, Tejirian TKaiser Permanente Southern California Medical Group
Indwelling urinary catheters, commonly known as Foley catheters
(FC), are often used during inguinal hernia operations; however, the
impact of intraoperative Foley catheter use on postoperative urinary
retention (POUR) is not well understood. We conducted a retro-
spective study on 27,012 inguinal hernia operations across 15
Southern California Kaiser Permanente medical centers over
6.5 years. We focused on unplanned returns for POUR to the urgent
care (UC) or emergency department (ED) within the first postopera-
tive week. In total, 239 (0.85%) patients returned to UC/ED with the
primary diagnosis of POUR, majority being male [235 (98%) men vs.
4 (2%) women]. Overall, there was a higher rate of UC/ED returns for
POUR for older patients, as observed between the age groups\ 50,
50–65, and[ 65 years old [0.27, 0.68, and 1.65%, (p\ 0.00001)].
There was a higher incidence of POUR in open repairs utilizing
general anesthesia vs. local with monitored anesthesia care [0.7% vs.
0.3%, (p\ 0.0001)]. Laparoscopic inguinal operations comprised
5017 of the total operations, 28% of which had intraoperative FC use.
While the incidence of POUR was greater in laparoscopic vs. open
inguinal hernia repair [2.21 vs. 0.58%, (p\ 0.00001)], there was no
difference in POUR returns when comparing intraoperative FC vs. no
FC use in the laparoscopic approach [2.36% vs. 2.15%, (p = 0.33)].
For all laparoscopic operations, there was no difference when com-
paring intraoperative FC vs. no FC use in urinary tract infection
within 7 days [0.8 vs. 0.6%, (p = 0.28)] and 30 days [1.7 vs. 1.5%,
(p = 0.28)]. Only one patient returned with a bladder injury following
a bilateral laparoscopic hernia repair with no FC use. POUR can be
minimized by avoiding general anesthesia for open inguinal hernia
repairs, however intraoperative Foley catheter use does not affect
POUR or UTI rates for laparoscopic repair.
P-1072
An analysis of early postoperative returns after inguinal
hernia surgery
Crain N, Tejirian TSouthern California Kaiser Permanente Medical Group
Although inguinal herniorrhaphy is low risk, patients still return to the
urgent care or ED. We performed a retrospective study on 19,296
inguinal hernia operations across 14 Southern California Kaiser
Permanente medical centers over 5 years. Unplanned returns within
the first postoperative week were evaluated focusing on four poten-
tially avoidable diagnoses (AD): pain, constipation, urinary retention,
and nausea/vomiting. Overall, 1370 (7%) patients returned to the
urgent care/ED, of which 537 (39%) had an AD. There was no dif-
ference in total returns [7.1 vs. 7.4%, (P = 0.33)] or AD returns [2.8
vs. 2.6%, (P = 0.44)] for males vs. females. Of the 537 total AD
returns, there were 205 (38%) patients with pain, 191 (36%) with
urinary retention, 112 (21%) with constipation, and 29 (5%) with
123
S63 Hernia (2019) 23 (Suppl 1):S50–S100
nausea/vomiting. Most AD returns (78%) occurred within the first
three postoperative days. Pain was greater in open operations [44 vs.
26%, (P\ 0.05)], and urinary retention was greater in the laparo-
scopic group [27 vs. 55%, (P\ 0.05)]. The overall rate of return was
higher for laparoscopic compared with open unilateral operations [8
vs. 6% (P\ 0.05)], but similar between approaches for bilateral
operations [11 vs. 10%, (P = 0.32)].
P-1073
The establishment, development and preliminary data
analysis of chinese hernia registry
Qin C, Shen Y, Chen JBeijing Chao-Yang Hospital, Capital Medical University
The introduction of the tension-free hernia repair concept open a new
chapter for Chinese hernia surgery. Since 1997, we experienced
20 years of dramatic development with fruitful achievement,
including implementation of new surgical techniques and medical
devices, experiences accumulation and establishment of treatment
guidelines. Now, more than 1.5 million inguinal hernia procedures
and around 150,000 abdominal wall hernia operations are carried out
each year. However, China is such a vast country with imbalanced
development. The quality of medical care in hernia surgery is not
uniform due to various kinds of irregular operations. How to change
this situation? Hernia registry is an application-oriented outcome
research tool which could monitor and evaluate our daily clinical
practice, ultimately, investigate its effectiveness (outcome research).
Many hernia societies in European and American nations have built
up their own hernia database. Great quality improvement has been
achieved. The successful experience of Germany hernia database—
Herniamed, is worth learning and introducing. Follow the example of
Herniamed, we designed a new Internet-based Chinese and English
bilingual registry system. Via the Internet, all relevant patient data
(comorbidities, previous operations, staging, specific surgical tech-
nique, medical devices used, perioperative complications and follow-
up data) can be entered into this registry database, meanwhile some
special issues are added according to Chinese national conditions,
especially the issues have not been clarified or still remain contro-
versial in the latest guidelines. Up to now, more than 180 hernia
centers nationwide were volunteer to join the Hernia Registry in
China in the past 6 months, and more than 28,000 pieces of hernia
diseases data have been collected and recorded in Chinese Hernia
Registry. The prototype of the Internet based Chinese hernia database
has been established, with this framework was built and participants
were enrolled, we believe this system will provide continuous
improvement for Chinese hernia surgery.
P-1074
Mini- or less open sublay (MILOS) repair for incisional
hernias: the Creighton experience
Schroeder A, Tubre D, Reinpold W, Fitzgibbons RCreighton University Medical Center
Introduction: Retrorectus mesh placement is widely accepted as the
gold standard for the repair of incisional hernias. The open procedure
requires an extensive abdominal wall dissection but has the advantage
of extraperitoneal mesh placement. Laparoscopic intraperitoneal
onlay mesh (IPOM) repair avoids the extensive dissection and is
associated with less surgical site infections, however the intraperi-
toneal mesh placement can result in a variety of adverse outcomes.
Recently a hybrid operation, termed the MILOS (mini/less open
sublay) technique has been described by Dr. W. Reinpold (Hamburg,
Germany). We present preliminary data from an ongoing study at
Creighton University Medical Center (CUMC) comparing MILOS
repair to laparoscopic IPOM repair.
Methods: Dr. Reinpold personally demonstrated the first two MILOS
procedures at our institution. Subsequent procedures were performed
independently. Patient data and outcomes from MILOS repairs and
laparoscopic IPOM repairs are collected prospectively. An enhanced
recovery after surgery (ERAS) protocol is utilized to reduce opioid
use. Follow up is carried out at 2 weeks, 6 months, and 12 months.
Results: Seven MILOS repairs and 9 laparoscopic IPOM repairs have
been performed since January 2018. The two groups were comparable
in terms of patient characteristics and included mostly midline inci-
sional hernias. Hernia size (mean 48.6 cm2 vs. 18.2 cm2, p = 0.04)
and mesh size (mean 410.4 cm2 vs. 175.4 cm2, p = 0.0002) were
larger in the MILOS group. Hospital stay was slightly shorter in the
laparoscopic IPOM group (mean 2.3 days vs 1.0 days, p = 0.06).
There was no difference in the morphine equivalent dose (MED) in
the two groups (mean 3.4 mg vs. 6.2 mg, p = 0.46). There were no
immediate complications or recurrences.
Conclusion: Our initial experience with the new MILOS technique
indicates its reproducibility and safety in large incisional hernias. This
is an ongoing study and results will be updated as the sample size
increases.
P-1076
Racial disparities are prevalent in laparoscopic
utilization for inguinal hernia repair
Mitchell A, Harner A, Drevets P, Allen G, Zakaud Dakaud
A, Hilton L, Holsten SAugusta University
Introduction: Laparoscopic inguinal hernia repair has gained wide-
spread adoption throughout the United States. The known benefits of
the procedure include lower community costs, lower postoperative
pain, quicker recovery, and reduction in chronic pain. Recent inter-
national society guidelines suggest that a majority of patients are
candidates for laparoscopic repair, and increased utilization has been
seen over the past few years. We aimed to determine if patient race
had any impact on receiving a laparoscopic repair.
Methods: The 2011–2015 NSQIP databases were individually quer-
ied for the CPT codes 49505, 49507, 49520, 49521, 49651, and
49652. Univariate and multivariate analyses were conducted with
‘‘Laparoscopic Surgery’’ as the primary endpoint. Race, age, gender,
and comorbidities were analyzed to determine if there were any
significant disparities between different populations. Subgroup anal-
yses were conducted in the 2015 cohort.
Results: On initial review, African American patients were more
likely to receive a laparoscopic repair when compared to Whites (OR
1.14, 1.04–1.25, p = 0.0048). Multivariate analysis showed an
opposite relationship (OR 0.80, 0.71–0.90, p = 0.0001). Subgroup
analyses showed that African American men (OR 0.71, 0.62–0.81,
p\ 0.0001) and White women (OR 0.48, 0.40–0.58, p\ 0.0001)
were significantly less likely to undergo laparoscopic repair when
compared to White men and African American women, explaining
the univariate and multivariate findings. Other factors with a signifi-
cant impact on laparoscopic utilization included ASA class, bleeding
disorders, age, weight, gender, diabetes, and Asian race (OR 0.43,
0.31–0.58, p\ 0.0001). The disparities were present throughout all
cohorts.
Conclusion: Racial disparities are extremely prevalent in utilization
of laparoscopic inguinal hernia repair. Surgeon judgment alone in
123
Hernia (2019) 23 (Suppl 1):S50–S100 S64
determining if laparoscopic repair should be offered may be flawed,
and we suggest instituting protocols to eliminate racial disparities in
laparoscopic utilization.
P-1077
Incisional hernia repair with self-expanding
polypropylene mesh
Martins de Oliveira Neto R, Roberto Puglia C, Roberto
Corsi P, Soares Gallo A, Fernando Rodrigues Alves de
Moura LHospital Samaritano de Sao Paulo, Americas Servicos Medicos
Incisional hernias still represent a challenge to the surgeons, espe-
cially the large—complexes ones. Several methods are been proposed
and used, with very different results achieved. In the field of the open
approach the most common complications are the occurrence of
‘‘seromas’’ due to the subcutaneous dissection, infections, pain and
recurrence. The author presents the initial experience with the Self-
expanding polypropylene mesh. The unique design and technique of
this mesh, offer patients the benefits of an intraabdominal repair,
while offering surgeons the ease of an open anterior approach, with
the added ability to use mechanical fixation. The parietal side is
constructed of two layers of monofilament polypropylene mesh,
providing rapid tissue ingrowth and strong incorporation into the
abdominal wall. The visceral side is made of submicronic ePTFE,
which provides a permanent barrier minimizing tissue attachment. In
our first series of 10 patients with complexes hernia, the results were
very promising and encouraging. We notice no complications such as
‘‘seromas’’ or recurrence, and less pain referred by the patients.
P-1078
Robotic inguinal herniorrhaphy: initial experience
Martins de Oliveira Neto R, Roberto Puglia C, Roberto
Corsi P, Soares Gallo A, Fernando Rodrigues Alves de
Moura LHospital Samaritano de Sao Paulo, Americas Servicos Medicos
The robotic surgery provided the surgeon with refinement of move-
ments, delicacy in maneuvers and procedures, visualization with
better definition in three dimensions and ergonomics for the surgeon.
The authors present their initial experience in the treatment of ingu-
inal hernia with robotic surgery. In this initial experiment, 15
procedures were performed. All procedures were performed by the
same technique as performed by the laparoscopic route, except for the
fixation of the mesh, which was performed with suture. There were no
intercurrences. Surgical time was higher in the first procedures, but
presented a substantial decrease over the others. All patients were
discharged the day after the procedure. There was a marked reduction
of the postoperative pain in patients submitted to robotic inguinal
herniorrhaphy. The authors conclude from this initial experience that
robotic inguinal herniorrhaphy is feasible, safe and it is a quick
learning method for the surgical team.
P-1079
Cosmetic umbilical/ventral hernia repair
Meknat A, Rimpel B, Greenberg YBrookdale University Hospital and Medical Center
There are a variety of approaches when it comes to umbilical hernia
(UH) repair. Cosmetic results take a backseat with conventional open
UH repairs often leaving an undesirable scar. With smaller and less
central incisions, laparoscopic UH repair is a preferred modality for
cosmetic results given similar efficacy with respect to recurrence
rates. But even the laparoscopic repair has its cons: multiple incisions
beyond the umbilicus. We describe our technique of open UH repair
utilizing a single trans-umbilical incision. Special emphasis is placed
on creating flaps and dissecting the subcutaneous tissue free from the
umbilical stalk. This meticulous dissection allows for a more cos-
metically pleasing closure, leading to greater patient satisfaction.
A vertical trans-umbilical incision is made using a #15 blade.
Continuing with the same blade, skin flaps are raised, carefully sep-
arating the umbilical skin from the underlying hernia sac. The sac is
carefully dissected free from surrounding subcutaneous tissue. Next,
the sac is opened and the content reduced into the peritoneal cavity.
The hernia sac is then excised. Standard of care is applied when it
comes to determining the type of fascial closure. A mesh is used if the
defect is greater than 3 cm, given the patient does not have ascites, in
an inlay fashion. Otherwise, the defect is closed with #0 Vicryl suture
in a figure of eight fashion. The superior cosmetic results come from
placing three sub-dermal stitches through one flap end, anchoring
them to the underlying fascia, and coming back out through the other
flap’s sub-dermal layer in an interrupted fashion. This ultimately
recreates the umbilicus in a cosmetically pleasing way. 4-0 Biosyn is
then used to re-approximate the remaining skin. Xeroform and a
compression dressing are placed into the re-created umbilicus.
This technique is easy to perform, has similar efficacy to any other
technique,
P-1080
Current practice patterns for primary umbilical hernia
repair in the United States
Koebe S, Greenberg J, Huang L, Phillips S, Lidor A, Funk
L, Shada AUniversity of Wisconsin School of Medicine and Public Health
Introduction: The approach to primary umbilical hernia (PUH) repair
varies depending on hernia size, patient age, sex, BMI, comorbidities,
and surgeon technique. Of these, only hernia size has been widely
studied. This study evaluates umbilical hernia repair technique with
respect to several patient characteristics. We hypothesize that the
approach to repairing umbilical hernias will vary with BMI, age, and
sex.
Methods: A retrospective study was performed using data from the
prospectively maintained Americans Hernia Society Quality Collab-
orative. All patients undergoing elective, clean PUH from 2013 to
2018 were identified. Patient characteristics were compared using
Pearson’s test or Wilcoxon rank sum test. Multivariate logistic
regression was performed to assess the independent effect of BMI,
age and sex on mesh use.
Results: 3475 patients were included. Seventy-four percent of
patients were male. Men undergoing PUH were older (54.1 vs.
45.8 years, p\ 0.001), with a higher BMI (31.6 vs 30.2, p\ 0.001).
Hernia defect size was similar. Mesh was used more commonly in
men (67% vs 60%, p\ 0.001). An open approach was more common
than laparoscopic/robotic (75% vs. 25%, respectively). Use of
123
S65 Hernia (2019) 23 (Suppl 1):S50–S100
laparoscopic/robotic approach increased with BMI and hernia size but
was not associated with age or sex. Mesh was used in 33% of
repairs B 1 cm, and 82% of repairs[ 1 cm in size (p\ 0.001). On
multivariate analysis, mesh use was associated with increasing hernia
width (OR 5.5, CI 4.7–6.3) and BMI (OR 1.8, CI 1.5–2.1) but not age
or sex.
Conclusion: The majority of PUH are performed open. Despite
umbilical hernias being more common in women, the majority of
those undergoing repair in our dataset are male. BMI and hernia size
influence operative technique including mesh use for PUH, but age
and sex do not. Most over 1 cm in diameter are repaired with mesh.
This suggests an opportunity for development of better guidelines to
standardize mesh use for PUH.
P-1081
Robotic abdominal wall hernias treatment: initial
experience
Martins de Oliveira Neto R, Roberto Puglia C, Roberto
Corsi P, Soares Gallo A, Fernando Rodrigues Alves de
Moura LHospital Samaritano de Sao Paulo, Americas Servicos Medicos
Abdominal wall hernias represent a common condition in surgical
practice. They may present as simple or sometimes extremely com-
plex cases the laparoscopic surgical treatment is consecrated and
widely used today with excellent results. The advent of robotic sur-
gery, or assisted by the robot, allowed the surgeon to use a more
meticulous and ergonomic platform, which can bring advantages in
the treatment of complex cases. The authors present their initial
experience with abdominal wall hernias treated with the robotic
platform. Nineteen procedures were performed. They consisted in 15
inguinal hernias and 4 ventral hernias (incisional ones). We used our
routine surgical technique in all cases. All the procedures were per-
formed without any intraoperative intercurrences. All patients were
discharged the day after the procedure was done. The most important
characteristic observed was the significant decrease in postoperative
pain. We conclude that this is a promising and safe method for the
treatment of abdominal wall hernia cases.
P-1082
Ventral hernia: surgical treatment with robotic
platform, initial experience
Martins de Oliveira Neto R, Roberto Puglia C, Roberto
Corsi P, Soares Gallo A, Fernando Rodrigues Alves de
Moura LHospital Samaritano de Sao Paulo, Americas Servicos Medicos
Among the abdominal wall hernias, ventral hernias represent an
important and common part of daily surgical practice. It can range
from small umbilical hernia to large and complex incisional hernias,
which can cause severe physical disabilities to patients and even
potentially life-threatening complications. Among the techniques
used, surgeons have a range of open or laparoscopic procedures, with
or without the use of prostheses, with the most different results. The
robotic platform provided the surgeon with a meticulous and detailed
technique through fine movements and three-dimensional vision of
high definition, besides a very favorable ergonomics. Within the
authors’ initial experience with the robotic platform, we performed
some cases of ventral hernias. Our initial experience consisted of 4
cases of patients with ventral hernia. Of these, three patients had
complex incisional hernias and one patient had an important
endometriotic lesion of the anterior musculature, associated with
hernia in a previous C-section scar. All patients underwent robotic
surgical treatment without complications. We Used suture to perform
the fixation of the mesh in all cases. All patients were discharged the
day after the procedure. The patients evolved without complications
and with a marked decrease in postoperative pain. We observed that
the superiority of the robotic platform for performing the surgical
procedure was striking. We conclude that, although still in initial
experience, the robotic platform is extremely promising for the
treatment of complex ventral hernias.
P-1084
The Ramirez ‘‘Component Separations’’ method
for closure of large abdominal defects modified by mesh
augmentation: early postoperative outcome of 84
patients in our hospital
Ceno M, Paul D, Kottmann T, Berger DKlinikum Mittelbaden Baden–Baden
Introduction: This study presents an overview about the early post-
operative outcome of 84 patients who underwent a big incisional
hernia operation repair using the component separations technique of
Ramirez with additional mesh augmentation.
Materials and methods: In the period from 2003 to 2014, 84 patients
with complicated incisional hernia and recurrent hernia of the
abdominal wall, were surgically treated in our department using
Ramirez-modified component separation by additional augmentation
of the abdominal wall with non-resorbable mesh. In our prospective
study, all 84 patients underwent a postoperative examination and the
risk factors for the wound healing disorder were identified and have
been statistically analyzed.
Results: The median age of the patients was 64 years. At the time of
surgery 89% of the patients were over 49 years old. In between
n = 84 patients who underwent surgery where 40% female (n = 33)
and 60% male (n = 51) patients. The median BMI of our patients was
31. The majority of patients was assigned to ASA class 2. The rate of
the primary ventral hernia was 58.3% (n = 49). The mean hernia size
was 13.6 cm. The operations were all performed by a single surgeon.
The results of the follow-up during 120 days after operation and the
statistical analysis for the evaluation of possible risk factors for
wound healing disorder are presented. Wound healing is evaluated
according to Hernia Ventral Group 2004 and the postoperative
complications according to the Clavien-Dindo classification.
Conclusion: The posterior component separation with additional
mesh implantation is a feasible option for repairing giant primary and
recurrence hernia of the abdominal wall.
P-1085
Ovine polymer-reinforced bioscaffold in abdominal
wall reconstruction
Sawyer MComanche County Memorial Hospital
Introduction: Abdominal wall reconstruction (AWR) techniques are
increasingly used for incisional herniorrhaphy. This series describes
the use of ovine polymer-reinforced bioscaffolds (OPRBS) for repair
augmentation in AWR.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S66
Methods: Retrospective review was conducted of a consecutive series
of 23 patients in whom OPRBS was utilized to augment AWR with
myofascial advancement flaps. Demographic, perioperative, and fol-
low-up data were analyzed.
Results: There were 13 female and 10 male patients. Fifteen had
recurrent hernias (65.2%). Mean age was 60.8. Mean BMI was 33.3.
Comorbidities included obesity (60.1%), hypertension (56.5%), pre-
vious wound infection (39.1%), diabetes mellitus (34.8%) and recent
smoking history (26.1%). Mean Ventral Hernia Working Group grade
was 2.8 ± 0.8. There were eight Grade 3 and five Grade 4 patients.
Enterocutaneous fistulae were present in all Grade 4 patients, two of
which were through synthetic mesh. Concomitant procedures were
performed in 11 patients (47.8%). These included small bowel
resection in three, enterocutaneous fistula resection with associated
small bowel in three, colon resection in one, gastric bypass reversal in
one, and panniculectomy in three. Synthetic mesh was removed in 11
patients (47.8%), and biologic matrix in two. Transversus abdominis
release was performed in 78.3% and anterior release in 21.7%.
OPRBS was placed in the retrorectus space (82.6%), as IPOM
(13.0%) or as onlay (4.4%). Mean follow-up was 13.2 ± 8.0 months
(range 4–27). There were two hernia recurrences (8.9%). Wound-
related complications occurred in 7 patients (30.4%), including four
superficial infections, two seromas, and one superficial wound
necrosis. These were all effectively treated without the need for
removal of OPBRS.
Discussion: Early experience with OPRBS in AWR is encouraging in
this challenging patient population. OPRBS possesses salutary prop-
erties of both biologic, and synthetic materials. Long-term follow-up
and larger study populations are needed to confirm these findings.
P-1086
The results of using extended totally extraperitoneal
repair (eTEP) for ventral hernias: our experience
Akhmetov A, Kashchenko V, Lodygin A, Mitsinskaya A,
Mitsinskii MThe L.G. Sokolov Memorial Hospital 122
Introduction: There was the first reference about eTEP Sublay for
ventral hernias in 2017. 75 patients were followed by during 1 year in
5 centers.
Materials and methods: Our study includes 11 patients (the mean
age 55.3, BMI 34.6, ACA 2): 4—with large umbilical or epigastrium
hernia, 4—with umbilical hernia and diastasis recti abdominis and
3—with recurrent ventral hernia. All patients had preoperative com-
puter tomography. Two methods were used: ‘‘upper’’ technique—6
and ‘‘lower’’ technique—5 patients. After entering to the retromus-
cular mesh placement (position of ports was chosen according to the
technique), the dissection was performed with the help of the balloon,
then additional ports were set. Then we made total tissue dissection
(Rives Stoppa) from ensiform process to the pubis, with the excision
of the hernial sac. We stitched up the white line of the abdominal
cavity layer by layer. The defects of the lower part of anterior
abdominal wall were also tightly stitched up. Polypropylene mesh
‘‘medium hardness’’ was fixed in 9 and ‘‘easy’’—in 2 cases. It was
fixed two seams in one case, there were no fixation in other cases. We
drained the retromuscular mesh placement for 1 day.
Results: 2 patients had seroma (type 1), there were no repeated sur-
gery and common complications. We used EuraHS QoL scale for
assessment quality of life: the chronic pain—1, there is no movement
limitation.
Conclusion: Using the ‘‘new’’ technique eTEP for ventral hernias is
possible in conditions of herniological centre equipped with
endovideosurgical instruments. Early and relatively long-term results
show the high efficiency and good cosmetic result.
P-1087
What are the indications of the posterior separation
component hernia repair for ventral hernias?
Akhmetov A, Kashchenko V, Lodygin A, Mitsinskaya A,
Mitsinskii MThe L.G. Sokolov Memorial Hospital §122
Relevance: Posterior separation component hernia repair are used
only in some clinics in Russian Federation. We mean TAR (by
Novitsky) as well as PSCT (by Carbonell). The indications of these
types of surgery are discussed.
Materials and methods: There were 385 patients with epigastric and
large umbilical hernias: 29% of patients with W2-7.5% needed pos-
terior separation component hernia repair. 112 patients had
preoperative computer tomography, respiratory function, banding in
order to minimize the SAG. Four patients had the lateral localization
of hernias. We made the standardized PSCT. We did not drain the
retromuscular mesh placement, only the hernia sac subcutaneously for
1 day. When it was the lateral position of hernia, we extracted the
defect after TAR, sewed from the two sides, it was necessary to set
polypropylene mesh type Progreep (self-locking) in one case.
Results: Postoperative course was the same as after ‘‘sublay’’ tech-
nique: the same number of bed-days and frequency of the
complications. We had 1 seroma type 1 requiring no surgical cor-
rection—we prefer the puncture and controlling ultrasonography in
dynamics—fifth day after surgery. There were no early relapses.
Patients were followed during 1 year and recorded in the hernological
registry ‘‘Hernia-lab’’. There were no infectious complications and no
late relapses.
Conclusion: Using preoperative SCT helps us to choose the optimal
variant of the surgery. When W2 is 8 cm and W2 is less than 6–8 cm,
in the conditions of intraoperative evaluation, and if the abdominal
pressure is reduced to a significant tension of the tissues, it is nec-
essary to use PSCT. Lateral or parastomal hernias are also the
important conditions of this type of surgery.
P-1088
Is young age a risk factor for chronic postoperative
inguinal pain (CPIP) after endoscopic totally
extraperitoneal (TEP) repair?
Bakker W, van Hessen C, Verleisdonk E, Clevers G,
Davids P, Schouten N, Burgmans IDiakonessenhuis Utrecht
Purpose: A generally known risk factor for developing chronic
postoperative inguinal pain (CPIP) after inguinal hernia repair is
young age. However, studies discussing young age as a CPIP risk
factor are mainly based on open repairs. The aim of this study is to
determine if young adults (age 18–30) are also more prone to expe-
rience CPIP after totally extraperitoneal (TEP) inguinal hernia repair,
compared to older adults (age C 31).
Methods: A prospective study was conducted in a high-volume TEP
hernia clinic in 919 patients. Patients were assessed preoperatively, at
3 months, 1 year and 2 years after TEP mesh repair. The primary
outcome was clinically relevant pain (NRS 3–10) in young adults
compared to older adults at 3 months follow-up. Secondary outcomes
were pain 1 and 2 years postoperatively, the impact of pain on daily
123
S67 Hernia (2019) 23 (Suppl 1):S50–S100
living, foreign body feeling and testicular pain. Furthermore, age-
categories were analyzed to determine potential age dependent CPIP
risk factors.
Results: Follow-up was completed in 867 patients. No significant
difference was found between young adults and older adults for
clinically relevant pain at 3 months follow-up (p = 0.723). At all
follow-up time points no significant differences were found for
clinically relevant pain, any pain (NRS 1–10), mean pain scores, the
Inguinal Pain Questionnaire (IPQ) and the Carolina Comfort Scale
(CCS). The subgroup analyses showed no age dependent risk factor
for CPIP development.
Conclusion: Young age is not associated with a higher risk of CPIP
after endoscopic TEP hernia mesh repair, which justifies this tech-
nique in patients 18–30 years of age.
P-1090
Comparison of laparoscopic totally extraperitoneal
inguinal hernia repair (TEP) and lichtenstein repair
in terms of sexual, sensory, quality of life and urinary
functions
Iscan Y, Sahan C, Agca B, Karip B, Memisoglu KFatih Sultan Training and Research Hospital
Introduction: Many studies have shown that laparoscopic inguinal
hernia surgery is more advantageous than open surgery. The purpose
of this study is to reveal the differences between the two different
methods in terms of sexual, sensory, quality of life and urinal results.
Materials and methods: Between July 2017 and January 2018,
sexually active 42 male patients were randomized by laparoscopic
total preperitoneal method (TEP) and Lichtenstein method (LCH)to
perform inguinal hernia repair. Patients were evaluated preopera-
tively, at 1st and 6th months postoperatively by the International
Sexual Function Index (ICIEF),International Prostatic Symptom
Score, AS, BECK Depression Scale, Inguinal Region Discrimination
Test (DT),DN4 Neuropathic Pain Questionnaire, FSH, LH and Total
Testosterone levels and SF-36 were assessed.
Results: Patients with a mean age of 49.86 ± 11and a BMI of
25.51 ± 2.84 were randomized into two groups as LCH (20) and TEP
(22).There was no significant statistically difference between the two
groups in terms of FEVA, IPSS and VAS. There was no significant
difference between the two groups in preoperative and postoperative
1st month in BECK depression scale. But in 6th month in LCH group,
BECK levels were statistically significantly higher when compared
with TEP group. At the 1st and 6th month DT, the measurements in
the LCH group were found to be statistically higher than the TEP
group. At the 1st and 6th months after the operation, DN4 values were
found to be significantly higher in the LCH group compared to the
TEP group. In uroflowmeter analyzes There was no difference
between the groups. However, reductions in urine volume in the TEP
group were statistically significant. In the SF36 analysis, the LCH
group showed statistically significant lower physical activity potential
and energy-vitality-vitality values at postoperative 6th month.
Conclusion: In terms of sexual function, urodynamics and pain, TEP
did not show any advantage for LCH. The LCH method was disad-
vantageous in neuropathic pain and discriminant analysis. In terms of
quality of life, the results of the TEP method are more pleasant.
P-1091
Incidence of asymptomatic inguinal hernias
as an incidental finding
van Hessen C, van Hessen C, Bakker W, Verleisdonk E,
Sanders F, Burgmans JDiakonessenhuis Utrecht
Introduction: An inguinal hernia is a clinical diagnosis. Only in case
of clinical doubt, ultrasound may be required. However, in day-to-day
practice this modality is often requested for men with groin com-
plaints. In some cases an incidental inguinal hernia is found with an
alternative cause for groin complaints. Studies on the prevalence of
asymptomatic inguinal hernias as an incidental finding among healthy
men have never been published.
Methods: This observational study consisted of a cross-sectional
analysis of groin ultrasound. The target population for this analysis
involved healthy men (ASA I or II) between 40 and 65 years old, with
a Body Mass Index\ 40 and without groin complaints or a medical
history of inguinal hernia. After signing the informed consent, a groin
ultrasound was made of both groins under Valsalva maneuver and
scored positive or negative by a specialized ultrasound technician, in
consultation with the radiologist.
Results: A total of 100 patients underwent groin ultrasound. In 10
patients (10%) an unilateral inguinal hernia was found. There were no
other findings in this study population.
Conclusion: In 10% of healthy men without groin complaints,
ultrasound shows an inguinal hernia. Hence, the chance that groin
complaints are wrongly attributed to an incidental inguinal hernia
found on ultrasound, appears to be considerable.
P-1092
One-stop routing for surgical interventions; a cost-
analysis of endoscopic groin repair
van Hessen C, van Hessen C, Roos M, Frederix G,
Verleisdonk E, Clevers G, Davids P, Burgmans JDiakonessenhuis Utrecht
Purpose: Single visit totally extraperitoneal (TEP) inguinal hernia
repair is an efficient service without impairment of safety or com-
plication rate. Data on the economic impact of this approach are rare.
The aim of this study was to compare the costs between the single
visit (SV) TEP and the regular TEP in an employed healthy popu-
lation from a hospital and societal point of view.
Methods: Retrospectively collected hospital costs and prospectively
collected societal costs were obtained from patients treated between
July 2016 and January 2018. Outcome measures consisted of all
documented institutional care, productivity loss and medical
consumption.
Results: For analysing the hospital costs a total of 116 SV patients
were matched to 116 regular patients. The hospital costs of a mean
SV patient were €1148.78 compared to €1242.84 for a regular patient,
with a mean difference of €94.06. Prospective analyses of 50 SV
patients and 50 regular patients demonstrated higher societal costs for
a mean regular patient (€2188.33) compared to a mean single visit
patient (€1621.44). The mean total cost difference between a SV TEP
repair and a regular TEP repair equaled €660.95 corresponding to a
19.3% decrease in costs.
Conclusions: This comprehensive cost-analysis showed that in an
employed, healthy population, the single visit TEP repair outprices
the regular TEP repair, with savings of €660.95 per patient, reflecting
a 19.3% decrease in costs. This routing is mainly interesting from a
123
Hernia (2019) 23 (Suppl 1):S50–S100 S68
societal point of view as the difference is mainly impacted by a
decrease in societal costs.
P-1094
Accelerated neutral atom beam (ANAB) treatment
of polypropylene mesh increases tissue integration
and reduces bacterial attachment
Khoury J, Kirkpatrick S, Phok B, Shashkov DExogenesis Corp
Prosthetic meshes are commonly used in the repair of abdominal wall
hernias. Meshes firmly reinforce the weakened area and provide
tension-free repair that facilitates the integration of surrounding tis-
sues. However, complications with the mesh relating to infection,
fibrosis, adhesions, mesh rejection, and hernia recurrence remain
high. An ideal mesh would be inert, resistant to infection, able to
maintain long-term tensile strength, rapidly integrate into the host
tissue, and remain flexible. Modifications of polymer weight and
mesh pore size have shown minor improvement in reduction of
infection and increased tissue integration; however, major improve-
ments are still required. In this study, we tested NanoAccelTM argon
(Ar) based ANAB treatment to modify the surface of polypropylene
(PP). ANAB utilizes accelerated clusters of Ar ions which are then
dissociated, and clusters electromagnetically removed. The resulting
neutral Ar atoms collide with a surface and cause mechanical and
physical changes without chemical modifications. Using PP coupons
and surgical mesh (Chirag Meditech), we treated the surface and
measured ability of normal human fibroblasts to attach and proliferate
(MTS assay); ability of P. aeruginosa bacteria to attach and begin
colonization (cell count); and mechanical strength of the mesh (In-
stron). Results show that absorbance of MTS increases from
0.135 ± 0.020 for control to 0.211 ± 0.018 for ANAB treated PP
(p\ 0.0027), indicating a significantly increased cell attachment and
proliferation. Bacterial attachment at 3 h decreased from
1267.4 ± 683.0 bacteria on control to 117.2 ± 25.1 on ANAB-trea-
ted PP, at least a tenfold reduction (p\ 0.0056). Tensile strength,
however was not affected (p = 0.247), maintaining strength and
flexibility. Taken together, this indicates that ANAB-treatment of
polypropylene mesh may result in significantly improved integration
with reduced risk of bacterial attachment.
P-1100
Intermittent small bowel volvulus following robotic
transabdominal preperitoneal hernia repair: a rare
complication caused by the barbed suture
Gupta A, Arguello-Angarita M, Glanville J, Mazpule G,
Pereira S, Rosenstock AHackensack University Medical Center
Case presentation: A 68-year-old male patient presented with
1 week of intermittent right lower quadrant abdominal pain, 1 month
after robot-assisted laparoscopic transabdominal preperitoneal
(TAPP) repair of right inguinal and umbilical hernias. A computer
tomography (CT) scan of the abdomen showed swirling of small
bowel mesentery—a finding concerning for an internal hernia. A
diagnostic laparoscopy was performed to further evaluate the etiology
of his abdominal pain. Intra-operatively, terminal ileum was found to
be adherent to the tail of a barbed absorbable suture that was used to
close the peritoneum following the patient’s hernia repair. A short tail
of the suture had been left and had become adherent to the bowel,
causing the bowel to rotate around this point. The distal portion of the
suture was cut flush to the bowel, and the proximal portion of the
suture was cut flush to the peritoneal flap. The bowel was untwisted
and returned to its normal position. The patient’s postoperative course
was uneventful, and he was discharged the following day.
Discussion: In recent years, surgeons have been using knotless, bar-
bed suture more often, especially in laparoscopic and robotic inguinal
and ventral hernia repairs. Although rare, similar complications (e.g.
small bowel obstruction, volvulus) caused by the barbed suture have
been reported since its adaptation, especially in the context of
inframesocolic surgeries. The complication described above could
have been prevented by ensuring the tail of the suture was not
exposed. The case presented suggests that there can be unforeseen
complications with barbed suture and that direct exposure of the
bowel to this suture may result in future complications. These com-
plications are unpredictable and can arise even after the appropriate
use of barbed suture.
Conclusion: Proper handling of barbed suture should be further
evaluated in order to avoid the aforementioned complications.
P-1101
Ventral hernia repair outcomes predicted by a 5-item
modified frailty index using NSQIP variables
Balla F, Yheulon C, Stetler J, Patel A, Lin E, Davis SEmory University Hospital
Introduction: Frailty is defined as a decrease in physiologic reserve
giving rise to vulnerability that is separate from the normal aging
process. Previous studies have validated an 11-item modified frailty
index (mFI) using NSQIP variables to predict outcomes for surgical
patients. Newer studies have condensed this to a 5-item mFI; how-
ever, this has not been validated for use to predict outcomes in ventral
hernia surgery. The aim of this study is to validate the 5-item mFI in
ventral hernia patients as well as determine outcomes and the relative
impact of each frailty variable.
Methods: The NSQIP database was queried from 2011 to 2016 for
patients undergoing ventral hernia repair. Spearman’s rho correlation
was used to determine the degree of correlation between 11-item and
5-item mFI raw frailty scores. Chi squared testing was used to
determine odds ratios (95% CI) for accumulating frailty variables in
both indices with regard to complications vs a baseline of zero
variables present on the 11-item scale. Complications were defined by
the Clavien-Dindo (CD) classification. Univariate and multivariate
analyses were performed on each frailty variable to determine their
relative weighted impacts on outcomes.
Results: 97,905 patients (99.45%) had complete data using the 5-item
mFI. Only 11,549 patients (11.73%) had complete data using the
11-item mFI. There was no difference between groups with regard to
the 5 mutually shared frailty variables, BMI, emergent vs non-
emergent procedures, operative time, or laparoscopic approach. For
each accumulating variable in both indices, the 5-item mFI predicts
incidence of any complications, major complications, and discharge
not to home similarly to the 11-item mFI. The most significantly
weighted variable for complications and discharge not to home is
functional status.
Conclusion: A 5-item mFI accurately predicts outcomes similar to
the validated 11-item mFI and captures more patients for analysis.
123
S69 Hernia (2019) 23 (Suppl 1):S50–S100
P-1102
Outcomes of ventral hernia repair in the obese
and morbidly obese: a single institution NSQIP review
Gleason F, Feng K, Baker S, Washburn P, Perkins C,
Richman J, Morris M, Parmar AUniversity of Alabama at Birmingham
Introduction: Post-operative outcomes of ventral hernia repairs
(VHR) in obese and morbidly obese patients are poorly defined. To
identify the association between obesity and postoperative outcomes,
we reviewed our experience in this patient population. We hypothe-
sized that postoperative morbidity and readmission would increase
with increasing body mass index (BMI).
Methods: We identified all patients undergoing elective VHR at our
institution from 2012 to 2017 who were included in the ACS NSQIP.
Hernia specific characteristics were abstracted through chart review.
Hernia width was classified using European Hernia Society width
classification. Surgical site occurrence (SSO) was defined as any
surgical site infection or wound disruption. Descriptive statistics were
calculated, and factors associated with SSO and readmissions in a
bivariate analysis were included in a logistic regression model.
Results: A total of 334 patients underwent elective VHR and had
complete data on hernia characteristics. The mean age was 58.1, 57%
were female, 80.2% were ASA class III, and 14.7% were active
smokers. Average BMI was 31.4. Average hernia length was 8.6 cm
and hernia widths were W1 (34.4%), W2 (44.3%), and W3 (21.3%),
and were similarly distributed across BMI categories. Operative
approach included open (70.0%), laparoscopic (24.6%) and robotic
(5.4%). Mesh was used in 62% of cases. Postoperative SSO occurred
in 5.7% of the cases, and the 30-day readmission rate was 7.2%. In a
logistic regression model adjusting for hernia width, duration of
operation, and patient smoking history, increasing BMI was only
weakly associated with increased SSO (OR 1.081, CI 1.02–1.15) and
unplanned readmission (OR 1.06, CI 1.01–1.12).
Conclusion: We demonstrated that acceptable immediate post-sur-
gical outcomes for elective ventral hernia repair are possible in a
select population of older, obese patients with large hernia defects.
While increasing BMI was associated with increased SSO and read-
missions, these effects were relatively small.
P-1103
Systematic review of robotic-assisted
versus laparoscopic ventral hernia repair
Sarkar A, Mo S, Chan D, Ravindran P, Talbot M, Fisher OSt George Hospital
Background: Ventral hernia repair is among the most commonly
performed general surgical operation. Minimally invasive surgery
through laparoscopic repair has become popular over the last decade.
Robotic-assisted repair is gaining traction with articulated move-
ments, making intra-corporeal defect closure easier. This systematic
review evaluates the current evidence of robotic-assisted ventral
hernia repair (RVHR) versus laparoscopic technique of ventral hernia
repair (LVHR).
Methods: A literature search was conducted using PubMed, Medline,
EMBASE and Cochrane Library databases. Comparative studies
adopting robotic-assisted versus laparoscopic technique for ventral
hernia repair; with C 3 patients; in English language were included.
A predetermined set of data comprising demographic, operative
details, morbidity and mortality outcomes were collected. The review
was conducted in accordance with the PRISMA Statement.
Results: Nine eligible studies, comprising of 1523 patients (889
LVHR; 634 RVHR) were included. Weighted mean age was
53.6 years (LVHR) vs 55.5 years (RVHR) and 55.9% (LVHR) vs
57.8% (RVHR) were female patients. Weight mean BMI (32.8 vs
32.3) and ASA (2.3 vs 2.4) were also similar between LVHR and
RVHR. Weighted mean operation time was shorter in the LVHR
(92.4 min, range 65–121 min) compared to the RVHR group
(134.7 min, range 107–245 min). The conversion to open surgery was
2.7% (LVHR) vs 0.95% (RVHR). Hernia recurrence rates were 4.7%
(LVHR) vs 5.3% (RVHR). Two deaths were reported in the LVHR
patients.
Conclusion: Both robotic-assisted and laparoscopic techniques result
in similar hernia recurrence rates, with longer operation times but
lower conversions to open surgery in the RVHR group. Randomized
controlled trials are required to further assess this area.
P-1106
Fatty inguinal hernia (sacless inguinal hernia)
Aldohayan AKing Saud University Hospital
Background: Fatty Inguinal Hernia [FIH] is inguinal defect filled
with extraperitoneal fat and no sac. Laparoscopic repair of inguinal
hernia requires the presence of a SAC, either direct or indirect
inguinal hernia. Many surgeons aborted the laparoscopic surgery in
absence of the sac. Preoperative examination is important to diagnose
the FIH.
Aim: In presence of suspicion of FIH, laparoscopic examination of
deep inguinal & Hesselbach’s triangle is necessary to diagnose and
manage.
Materials and methods of FIH: The study started from January 2017
till June 2018. All the patients were either examined clinically or by
ultrasound of the groan.
Results: There were 50 patients who were diagnosed inguinal hernia,
8 fatty indirect inguinal hernias and 3 fatty direct inguinal hernias are
encountered.
Conclusion: For a long time, patients who had FIH were managed
improperly, here by we illuminate the case of FIH which surgeon can
miss if were not aware of FIH.
P-1107
Abdominoperineal resection: does closure technique
matter?
Patel P, Ly J, Mak J, Foster LWaikato Hospital
Perineal hernia following abdominoperineal resection.
Aims: To identify the local perineal hernia rate following
abdominoperineal resection (APR) and make comparisons of these
rates between different wound closure techniques.
Methods: Retrospective analysis was carried out on all patients who
underwent an APR (based on ICD-10 coding) at Waikato Hospital
between January 2005 and March 2016. Baseline characteristics were
collected. Patients were grouped based on technique of perineal
wound closure—Simple Suture alone (SSC), Simple Suture with
Vacuum Assistance (SSC ? VAC), Mesh Assisted (MAC) and Ver-
tical Rectus Abdominus Muscle flap (VRAM). Perineal hernia events
documented for each group.
Results: 97 patients were identified and 80 were included in the study
(17 exclusions) This included: SSC 50 (62%), 13 SSC ? VAC (16%),
11 MAC (14%) and 6 VRAM (8%). Perineal hernia rate was 13% (10/
123
Hernia (2019) 23 (Suppl 1):S50–S100 S70
80). This includes 10% (5/50) for SSC, 23% (3/13) for SSC ? VAC,
33% (2/6) for VRAM and none for MAC.
Conclusion: Perineal hernia rates were lowest for MAC compared to
any other group. We believe this is related to a relatively smaller
pelvic floor defect and a tension free closure with the use of mesh.
This may similarly be the case when the perineal defect is closed with
SCC, as occurs in selected cases. The rates were highest with VRAM
closure.
P-1108
Minimum incisional hernioplasty assisted
with laparoscope for ambulatory inguinal hernia
surgery
Imazu H, Imazu YImazu Surgical Clinic
Introduction: I perform a Minimum incisional hernioplasty (MIH)
operation to use a laparoscope with local or epidural anesthesia for an
ambulatory groin hernia operation from 2012. This method is
transinguinal preperitoneal hernioplasty using conventional mesh
repair and laparoscope, it has the following some 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 diagnosed type of the hernia by ultrasonography before an
operation and decided an operation method. I perform the transin-
guinal preperitoneal hernioplasty from 1.5 to 2 cm length wound.
Until the handling of hernia sac, I used a magnifying glass (4.5 times
expansion). After this processing, I detached as much as possible
between peritoneum and preperitoneal fat tissue layer from an inci-
sional route using 3 mm diameter laparoscope. After detachment, I
measure a detachment range and insert mesh of size as big as pos-
sible. After that, I insert it in prepetitoneal fat tissue layer, and
unfolded the mesh enough under using laparoscope.
Result: I was operated on to 2255 patients 2338 lesions). Their sex
ratio were 9:1 (males: females), with mean age of 57.2 years (range
18–91). The type of hernia was indirect hernia 1741 lesions, direct
hernia 546 lesions and femoral hernia 16 lesions and combine 35
lesions. All cases average operation time were 57 min (with in
bilateral) and mean wound length was 1.66 cm. All cases came home
on same day (mean postoperative time was 37 min) and no severe
complications.
Conclusions: There was not the case that a day surgery was not
possible. The severe complications are not seen after operation, and
the inguinal hernia day surgery is basically possible in all cases by
MIH.
P-1109
Laparoscopic and percutaneous short stitch technique
repair for ventral hernia (a novel technique)
Aldohayan A, AlBalawi M, Bassas R, Alaqel MKing Saud University Hospital
Background: Ventral hernia repair (VHR) is a common procedure.
Despite the frequency of VHR, the optimum repair method has not
been established yet. The aim of this study is to analyze outcomes of
VHR using a combined open (small bite short stitch technique
(SBSST)) and laparoscopic technique.
Method: A retrospective review was conducted for 46 patients who
received a combined laparoscopic and open ventral hernia repair at
the medical city of King Saud university in Riyadh, Saudi Arabia.
Main outcome measures included postoperative complications and
recurrence.
Surgical technique: Mesh size is determined by adding 5 cm longer
than hernia defect size. The mesh is mounted with five sutures to the
edges and center of the mesh number as per the principles set by the
author of patent number US92049SSB.After ports are established and
reduction of hernia sac and content is carried out, small incision is
made over the neck of sac where the sac is incised with sac excision,
the mesh is introduced through the defect of the wound in aseptic
technique which then followed by primary repaired using (SBSST).
The sutures are retrieved through the abdominal wall and mesh is
tacked to the abdominal wall using capture. Transfacial suture
through abdominal wall keeps the mesh in place.
Results: The study started from May 2016 to May 2018, there are 46
patients who underwent ventral hernia repair using this technique
were included. Majority of patients were female (N = 28). The mean
age and body mass index (BMI) were 52.2 years and 32.36 (kg/m2)
respectively. The mean defect size was 33.9 cm2. Postoperative
complications included 2 seroma (4.3%) occurrences, 1 hematoma
(2.1%) and 1 superficial infection (2.1%). At a mean follow up of
17.1 months (range 6–28), there was no evidence of hernia recurrence
or chronic pain.
Conclusion: We demonstrate.
P-1110
Laparoscopic inguinal hernia repair using poly-4-
hyroxybutyrate (P4HB) mesh
Aldohayan A, Albalawi M, AlAqel M, Bassas RKing Saud University Hospital
Background: Inguinal hernia repair is one of the most common
surgical procedures performed by a general surgeon. The use of a
prosthetic implant is usually necessary for successful repair. How-
ever, widely used non-absorbable synthetic meshes have been
associated with recurrence and complications related to significant
shrinkage and foreign body implantation. The non-absorbable prolene
mesh is standard mesh used in laparoscopic repair of inguinal hernia.
The prolene mesh shrunken in the first few months, it may reach to
30% of its original size. Most of the recurrences of laparoscopic repair
of inguinal hernia occurred in the first post-operative year. On the
other hand, phasix mesh (P4HB) start to be absorbed after 1 year. In
the presence of that information we advocate the usage of phasix
mesh (P4HB) in laparoscopic repair of inguinal hernia.
Method: A retrospective review of patients undergoing laparoscopic
inguinal hernia repair with P4HB by one surgeon as day case surgery
were performed. The procedure carried out using 3 ports size 5 mm.
P4HB (PhasixTM) Mesh (15 9 15) has being introduced and spread
over to cover inguinal and femoral area. The mesh is fixed to pubic
bone and anterior abdominal wall by capture trackers. The incised
peritoneum is tacked to the other edge of the peritoneum. The main
outcome measures were hernia recurrence and post-operative com-
plications. Recurrence rates were determined either by physical
examination or via phone follow-up.
Result: The study started from 16 November 2010 to August 2018,
there are 15 patients who underwent LIHR with P4HB were included.
The median patient age was 53.2 years and the median body index
(BMI) was 26.6 kg/m2. There were no mortality, hernia recurrence,
seroma or surgical site infections reported. The median follow-up
period was 13.3 months.
Conclusion: LIHR with P4HB have yielded promising results in term
of patient outcomes, notably the absence of hernia recurrence.
123
S71 Hernia (2019) 23 (Suppl 1):S50–S100
P-1111
The use of poly-4-hydroxybutyric acid (P4HB) mesh
in laparoscopic ventral hernia repair (LVHR)
Aldohayan A, Albalawi M, Bassas R, Alaqel MKing Saud University Hospital
Background: Ventral hernia repairs (VHR) are considered to be some
of the most commonly practiced surgical procedures worldwide.
Traditionally, non-absorbable synthetic meshes were used in VHR,
which have been tied to a variety of adverse outcomes such as
recurrence, chronic pain and complications resulting from foreign
body implantation and associated shrinkage. Subsequent advances in
medical devices saw the development of absorbable poly-4-hyroxy-
butyrate (P4HB) meshes such as the Phasix ST Mesh. However,
studies on the viability and potential of this new type of mesh have
been scant. In this study, we report our initial evaluation of the use of
P4HB Phasix ST Mesh in patients undergoing LVHR.
Method: We conducted a retrospective review of all patients under-
went LVHR by one surgeon at Medical city of King Saud University
in Riyadh, Saudi Arabia. Main out comes measures included hernia
recurrence and post-operative complications.
Results: The study is done in Medical City of King Saud University
from November 2016 TO June 2018, there are 17 who underwent
LVHR with P4HB (Phasix ST) were included. The median patient age
was 60.7 years. The median body index (BMI) was 33.3 kg/m2. Post-
operative complications included 1 seroma, 1 early discomfort, 1
chronic pain ([ 3 months) and 1 conversion to open repair due to
huge loss of abdominal domain. There were no mortality, hernia
recurrence, and surgical site infection. The median duration of follow
up was 8 months.
Conclusion: This paper is demonstrating that LVHR with P4HB
(Phasix ST) Mesh had promising early outcomes. However, larger
cohorts of patients as well as longer follow-up durations are required
to corroborate our findings and allow further, more robust analyses.
P-1113
Short-term outcomes for Onlay and Sublay mesh
placement in the management of primary umbilical
hernias: preliminary report of a prospective
randomized trial
Kumaira Fonseca M, Tarso L, Gus J, Pedroso J, Oliveira H,
Cunha C, Cavazzola LHospital Materno-Infantil Presidente Vargas
Introduction: Current evidence supports prosthetic mesh reinforce-
ment to improve long-term results in the surgical management of
primary umbilical hernias. The anatomic position of mesh placement
has several implications on the technical complexity of tissue dis-
section, operative time, incidence of local wound complications,
postoperative pain and recurrence; however, its ideal location is not
yet established. This interim report compares early outcomes fol-
lowing onlay versus sublay mesh placement in elective primary open
umbilical hernia repairs.
Methods: Prospective randomized double-blind study conducted on
female patients diagnosed with primary umbilical hernias (defect size
range 0.5–6.5 cm) and admitted to a secondary hospital in a residency
training program setting. Between October 2017 and August 2018, 25
subjects representing 30% of the estimated targeted sample size were
randomly assigned to either onlay or sublay mesh repair group. The
operative time, early surgical site complications, postoperative pain
and short-term recurrence were reported.
Results: No statistically significant differences were observed
between groups regarding patients’ demographics, comorbidities or
defect size. The median operative time was significantly shorter in the
sublay group (42 vs 65 min, p\ 0001). Surgical site occurrences and
pain severity index on the 30th postoperative day were greater in the
onlay group with no statistical significance (33 vs 20%, p = 0.65; 2.38
vs 1.67, p = 0.4), none requiring surgical reintervention. No recur-
rences were reported after a median follow-up of 7.6 months
(IQR = 1.3–11).
Conclusions: The preliminary data presented herein suggests both
techniques are safe, efficient and associated with low complication
rates. Though considered technically more challenging, sublay repair
group was related to shorter operative times, which suggests the
feasibility of this procedure in a surgical residency program. Further
cases from this ongoing study and completion of long term follow-up
is expected to assess the effect of different mesh fixation techniques in
a larger sample size.
P-1114
The use of narrow mesh for the repair of inguinal
hernia
Nicolo E, Tuveri MJefferson Regional Medical Center
The use of Narrow Mesh for the repair of inguinal hernia.
We retrospectively analysed 185 consecutive patients with pri-
mary and recurrent inguinal hernia treated with the Narrow Mesh
(NM), a new shaped alloplastic mesh. Parameters such as hernia type,
operation time, type of anaesthesia, complications, hospital stay and
recurrence were evaluated. Two hundred three procedures were per-
formed on 185 adult male patients. Inguinal hernias were unilateral in
167 patients, bilateral in 18 patients. Median age was 47 (range
18–77). According to Nyhus classification, there were 35 (17%)
Nyhus type I hernias, 44 (22%) Nyhus type II hernias, 54 (27%) with
Nyhus type IIIa hernias, 39 (19%) with Nyhus type IIIb hernias, and
31 (15%) with Nyhus type IV hernias. Epidural anaesthesia was used
in 61 (30%) procedures, while local anaesthesia was used in 142
(70%). Ileo-inguinal nerve excision occurred in 37 (18%) patients. No
intra-operative complications were registered. Median operation time
was 38 (range 21–86) min. Median hospital stay was 13 (range 6–36)
h. After a median follow-up of 61 months (range 48–77), there were
not recurrences. Chronic inguinal pain at 1 year occurred in 1 patient
(0.5%).
We conclude that the NM repair is a safe and effective repair with
a low rate of postoperative complications, low recurrence rate and a
very low incidence of chronic inguinal pain.
P-1115
Optimizing nomenclature in endoscopic hernia repair:
how to achieve ‘‘Critical View’’ in TAPP and TEP
Claus C, Furtado M, Malcher F, Cavazzola LJacques Perissat Institute/Positivo University
Introduction: Interest in endoscopic repair of inguinal hernia has
recently increased among surgeons. However, posterior inguinal
anatomy is not usual for general surgeons and there’s a lack of
standardization and reproducibility of surgical repairs. These are
factors that preclude dissemination of endoscopic approach. Recently
Feliz and Daez described 10 fundamental steps to the success of
laparoscopic repair.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S72
Objectives: facilitate understanding of surgical steps and create a
form of universal communication between surgeons.
Methods/Results: Standard dissection and anatomical recognition of
posterior inguinal anatomy in 3 zones of dissection and 5 triangles, as
follows. Zone 1: lateral area. Main anatomical references: anterior
superior iliac spine, iliopsoas muscle, iliopubic tract. Aim of dissec-
tion: reach the ilio-psoas muscle; keep fat tissue in contact with the
pelvic wall; avoid manipulation of nerves; avoid traumatic fixation of
mesh. Zone 2: medial area. Main anatomical references: rectus
abdominis, bladder and pubic bone. Aim of dissection: visualize
entire pubic bone til the symphysis; reduce preperitoneal fat of
transversalis fascia (direct hernia); dissect the bladder at least 2 cm
below the pubic bone. Zone 3: central area. Main anatomical refer-
ences: spermatic vessels and vas deferens (in woman—round
ligament); external iliac vessels; inferior epigastric vessels; deep
inguinal ring. Aim of dissection: reduce the peritoneal sac of the deep
inguinal ring (indirect hernia) to at least the level of vas deferents
crossing external iliac vein; reduce tissue anteriorly to iliac vein and
visualize it (femoral hernia); explore the deep ring and reduce lipoma
if present. At the end of dissection, the surgeon must recognize the
figure of an inverted Y (corresponding to the inferior epigastric
vessels, spermatic vessels and vas deferens) and 5 triangles (disaster,
pain, indirect, direct, femoral).
Conclusion: This is a very simple way to leave standardize and easily
disseminate posterior inguinal anatomy and endoscopic hernia
surgery.
P-1117
Endoscopic totally extraperitoneal approach (TEA)
for primary ventral hernia repair
Li B, Qin C, Miao J, Li Y, Gong DAffiliated Hexian Memorial Hospital of Southern Medical University
Background: Numerous surgical alternatives have emerged for the
treatment of ventral hernia. Following the same principle of TEP
technique for inguinal hernia. We developed a novel approach to treat
primary midline ventral hernia——endoscopic totally extraperitoneal
approach (TEA).
Methods: During September 2017 and June 2018, fourteen consec-
utive cases of primary midline ventral hernias were repaired using the
TEA procedure. During the procedure, we built up pneumoperi-
toneum in the Retzius space directly through a 12 mm Trocar which
was located on the suprapubic region. After 2 working ports were
placed, we dissected this extraperitoneal space cranially, hernia sacs
will be reduced or transected during the dissection. After an ample
extraperitoneal space was built cephalad, a large mesh could be
placed in the epigastric preperitoneal position to repair the defect.
Results: All operations were successful without open conversion. The
mean operation time was 100 min (75–135 min). Postoperative pain
was mild and the mean VAS was 2.0 on first postoperative day. The
average postoperative stay in hospital was 2.1 days (1–3 days). One
case experienced postoperative seroma but without adverse effect on
the final outcome and no recurrences during the follow-up period of
3–11 months.
Conclusions: TEA procedure is safe, feasible and minimally invasive
requiring no specific device. It is in compliance with the anatomical
and physiological natures of the abdominal wall, which could reduce
trauma and postoperative complications dramatically. Besides there is
no need for expensive anti-adhesion mesh and fixation tacker, which
make it more cost effective. TEA is a good technique for the surgical
treatment of primary ventral hernia.
P-1128
Massive abdominal hernia after sternal infection
Schlosser K, Maloney S, Augenstein V, Heniford BCarolinas Medical Center
Introduction: The development of subxiphoid hernias is a known
complication after cardiac surgery. Here we discuss the repair of a
massive abdominal and chest wall hernia after sternal infection with
debridement.
Case report: A 74-year-old male physician with history of hyper-
tension, coronary artery disease, and remote inguinal hernia repair
presented for hernia repair. The patient had a history of Adult Onset
Still’s Disease with associated myocarditis requiring emergent coro-
nary artery bypass with aortic and mitral valve replacement.
Postoperative sternal infection and dehiscence secondary to Candida
required multiple sternal debridements with subsequent herniation of
abdominal contents into the chest and extending subcutaneously to
the sternal notch. He had a previously failed hernia repair and a
cholecystotomy tube due to prior cholecystitis. On exam, he had a flat
abdomen with a healed midline scar and obvious subcutaneous
intestine extending well up his chest wall. CT demonstrated an
abdominal and chest wall hernia with viscera extending from
umbilicus to clavicles. Surgical repair was performed with Plastic
Surgery. Following a laparotomy, lysis of adhesions, excision of prior
synthetic mesh, and cholecystectomy, a preperitoneal plane was
developed. The peritoneum was closed over the viscera, and a 30 by
35 cm synthetic mesh was placed in the preperitoneal space. The
mesh was fixated to the inferior costal margin with care to protect the
pericardium and secured with transfascial sutures in the lateral and
inferior abdomen. Bilateral subcutaneous advancement flaps and
posterior rectus release enabled primary closure of abdominal fascia
over the mesh. A layered subcutaneous and cutaneous closure was
performed. Postoperative course was notable only for a medically
managed episode of atrial fibrillation and a small seroma which
resolved spontaneously.
Discussion: Cardiothoracic intervention can lead to challenging
subxiphoid hernias. Here we describe successful repair of a massive
abdominal and chest wall hernia after partial sternotomy.
P-1129
The impact of gender on ventral hernia repair (VHR)
outcomes
Schlosser K, Maloney S, Prasad T, Colavita P, Augenstein
V, Heniford BCarolinas Medical Center
Aims: The relationship of patient gender to surgical outcomes has
been rarely studied, poorly understood and often not considered. This
study evaluates the impact of gender on outcomes after VHR.
Methods: Demographics and outcomes were examined for all Inter-
national Hernia Mesh Registry VHRs (2007–2017), including
laparoscopic (LVHR) and open VHR (OVHR). Ideal quality of life
(QOL) was defined as no pain, movement limitation, or mesh
sensation.
Results: 1850 patients underwent VHR in the study period (41.2%
LVHR, 58.8% OVHR). 44.1% of VHR patients were female. LVHR
was performed in 48.8% of females and 35.2% of males (p\ 0.0001).
Females patients had higher BMI (32.0 ± 8.0 vs. 30.7 ± 5.7 kg/m2,
p\ 0.009), larger hernias (51.6 ± 76.4 vs. 38.9 ± 96.6 cm2), and
longer hospital stay (3.2 ± 4.3 vs. 2.1 ± 2.9 days). Females were
more likely to have a recurrent hernia (20.7 vs. 13.8%, p\ 0.0001),
be on immunosuppression (3.9 vs. 1.1%, p = 0.006), and have
123
S73 Hernia (2019) 23 (Suppl 1):S50–S100
preoperative symptoms (74.5 vs. 52.5%, p\ 0.0001). Preoperative
non-ideal QOL was consistently associated with non-ideal QOL at 1,
6, 12, and 24 months postoperatively (OR 2.5, CI 1.54–4.07; OR
1.91, CI 1.40–2.62; OR 4.03, CI 2.66–3.11; OR 3.14, CI 2.13–4.62;
OR 4.72, CI 3.05–7.29, respectively). LVHR was associated with
non-ideal QOL at 1, 6, and 12 months (OR 1.81, CI 1.33–2.46; OR
1.51 CI 1.05–2.17; OR 1.56, CI 1.12–2.2, respectively). Following
surgery, females had no difference in surgeon-confirmed recurrence
or complications (infection, seroma, reoperation). More females had
non-ideal QOL at 1, 6, 12, and 24 months after surgery (53.8 vs.
41.0%, 37.2 vs. 28.0%, 35.6 vs. 22.4%, 37.6 vs. 22.7%, p\ 0.0002
all values). Multivariate analysis controlled for potential confounding
factors (gender, operative approach, BMI, defect area, number of
previous recurrent hernias, presence of multiple defects, and pre-op
non-ideal QOL). Females had non-ideal QOL at 1 month and
12 months (OR 1.76, CI 1.29–2.42; OR 1.46, CI 1.04–2.06,
respectively).
Conclusion: Females undergoing VHR experience more non-ideal
postoperative QOL. The etiology of these differences is poorly
understood and warrants further investigation.
P-1131
Characteristics of the clinical trials conducted
in the field of abdominal herniology
Ahmed F, Shahzad N, Krpata DDow Medical College
Background: Clinical trials are often heterogeneous in their
methodology, which can compromise the interpretability and com-
parability of their results. The methodological quality of trials in
abdominal herniology has not been assessed previously.
Objective: The aim of the study was to identify the strengths and
weaknesses of the methodology used in abdominal hernia clinical
trials.
Methods: Clinicatrials.gov was searched using the term ‘hernia’, and
the results were screened to include trials studying abdominal (ventral
or inguinal) hernias from October 2007 to October 2016. The
Aggregate Analysis of ClincalTrials.gov (AACT) dataset was loaded
onto a relational database management system (Post-
greSQL) to extract the data of the screened trials. SPSS v.23 was
used for all descriptive analysis.
Results: Out of the 985 interventional trials yielded by our search
strategy, 315 met the inclusion criteria. Inguinal hernias were more
frequently studied than ventral hernias (53.7% and 44.4% respec-
tively). About half (45%) of the trials were completed, but only 17.6%
of the completed studies had reported their results on clinicaltrials.-
gov. Although randomization was common (87.3%), less than half
(45%) of the trials were double-blinded. ‘Procedure’ was the preva-
lent intervention (45%), and pain was the most common primary
outcome measure (42%). Around 72% of the trials specified their
primary purpose as ‘treatment’. A large majority (80%) had a parallel
group design. Majority (62.9%) of the studies were single center
studies. Around 59% of the studies had an enrollment size between 1
and 100. Of the 239 trials that listed primary investigators, 87.4%
were led by males.
Conclusion: Our study identifies lack of double-blinding, and lack of
multicenter studies as the primary shortcomings in abdominal
herniology clinical trials. Pain, a subjective measure, is often used as
the primary outcome. The staggering gender disparity amongst pri-
mary investigators is concerning and should be inquired further.
P-1133
Epigastric hernia has been forgotten?
Sanchez-Montes IGeneral Hospital Tlahuac
Introduction: The epigastric hernia coined by Leveille in 1812.
These include hernias through the upper part of the linea Alba, but
exclude umbilical hernia. The etiology of the epigastric hernia (EH) is
approximately 10 paired neurovascular bundles perforate this fascia
anteroposteriorly, creating small orifices through which preperitoneal
fat can insinuate itself, starting incipient hernias that grow with age
and increased weight. These anatomical characteristics explain the
main reason why these hernias are multiple in 20% of patients. EH is
found in 5–10% of autopsies, and from other sources of reports,
according to surgically treatment hernias are present among 0.5–5%.
Purpose: The aim this presentation is to remember that the EH exists,
and can be repaired with a tension free repair technique.
Materials and methods: From January 2000 until August 2018, my
professional experience I performed 48 operations in the same
number of patients with EH, out of them 45 patients with primary
hernias, 3 with a first recurrence. Mean age was 52 years (23 to 81).
There were 22 males, and women 26. The mean of body mass index
(BMI) was 32.19 kg/m2. Associated with umbilical hernia in 44%
operated at the same time. The size of the defect varied from 1 cm to
5 cm intraoperatively.
The Surgical technique was mesh small plug when the size
defect\ 2.5 cm and preperitoneal mesh repair when the defect
was[ 2.6 cm. All our patients we follow up 1, 3, 6 months and every
year.
Result: There were minor complications, three patients developed
seroma, none of them presented infection and recurrent hernia.
Conclusion: Those techniques simplify the repair and the advantage
of producing minimal postoperative pain, there was not a recurrence.
P-1134
Comparison of various inguinal hernia repairs
in the community setting
McCoy K, Madris B, Symons WStamford Hospital
Surgery continues to adapt and evolve with the primary goal of
improving outcomes through use of increasingly less invasive pro-
cedures. The superiority of laparoscopic compared to open surgery for
outpatient procedures, such as the inguinal hernia repair, has been
well documented over the past several years. Laparoscopy has a
prolonged learning curve however robotic surgery may expedite this
learning curves with its 3D visualization and articulating instrumen-
tation. Our study looks to prove that there is a potential future role for
robotic surgery in the outpatient setting.
In this study, we performed a retrospective analysis of 90 patients
who underwent either a laparoscopic or robotic-assisted laparoscopic
or open inguinal hernia repair at Stamford Hospital, from July 2017 to
August 2018 with same day discharge. The following characteristics
were analyzed for both subsets of patients: gender, BMI, type of
repair, operative time, recovery room time, immediate post-operative
pain, and post-operative pain 3 h after surgery.
Our study demonstrated longer average operative time for patients
undergoing robotic hernia repair (79.125 min) compared to laparo-
scopic repair (50.5 min) and to open repair (64 min), which was
statistically significant (p value =\ 0.05). Patients who underwent
robotic inguinal hernia repair had a lower average numerical pain
score in the post-operative period and received less post-operative
123
Hernia (2019) 23 (Suppl 1):S50–S100 S74
narcotics compared to the laparoscopic and the open cases. There was
a statistically significant difference in post-operative narcotic usage
between the open and robotic groups.
This study highlights several possible advantages of robotic
inguinal hernia repair, including lower post-operative pain scores and
less narcotic usage required in the post-operative period. These trends
needs to be further studied to determine their overall significance in
the field of hernia surgery.
P-1135
A study of mesh compliance: implications for proper
splinting for fascial repair in abdominal wall
reconstruction
Langstein H, Ferzoco S, Pacella S, Greenhalgh E, Farrell BUniversity of Rochester School of Medicine and Dentistry
Introduction: Mesh reinforcement of ventral hernias has been shown
to reduce recurrence rates. The precise mechanism whereby synthetic
or biologic meshes reduce recurrence is not fully known. It appears
that mesh placement may offload or splint the primary fascial repair
until it becomes sufficiently strong enough to support the normal
pressures of the abdominal wall. Once this strength is achieved, the
ideal mesh provides ongoing support without altering the native
compliance of the abdominal wall. Therefore, the mesh needs to have
low compliance initially and should then become somewhat more
pliable and compliant long term. Native compliance of the human
abdominal wall ranges between 11 and 32%. This study was per-
formed to test the initial compliance of two mesh systems—
reinforced biologic mesh (OviTex, TelaBio) and resorbable
monofilament mesh (Phasix, Bard) in order to measure their suit-
ability to offload fascial repairs.
Materials and methods: OviTex Core (4 layers), OviTex 1S (6
layers), OviTex 2S (8 layers) and Phasix were tested for uniaxial
tensile strength per ASTM D638 using the Type IV test configuration.
Uniaxial compliance was determined as a post-test calculation.
Results: The results of the testing and post-test mean compliance
calculations are presented in below:
Compliance STD Sample Size
OviTex 14.2% 4.56% 36
OviTex 1S 11.9% 3.60% 36
OviTex 2S 10.9% 2.82% 36
Phasix 52.5% 7.63% 5
The measured difference in compliance is well illustrated using
video.
Conclusions: This study evaluated the compliance or ‘‘elasticity’’ of
two types of meshes used in abdominal wall repair and found OviTex
meshes to be significantly less compliant than Phasix. OviTex meshes
do not stretch to the degree that Phasix does, and appear to be better
suited to offload or splint a primary fascial repair,
P-1136
Repair of giant inguinal hernia
Kircher C, Abidi H, Shebrain SBronson Methodist Hospital
A 76-year old gentleman presented with a giant right inguinal hernia.
Over last 20-years, the hernia has progressively increased in size and
adversely affecting his quality of life (QL) leading to; loss of the
normal micturition mechanism requiring self-catheterization, back
pain and postural change and perturbation to his stance with shifting
the center of body mass due to progressively increasing weight of the
scrotum, and mechanically-limited ambulation. On examination
(Figure 1a), he has scaphoid abdomen (most bowel has migrated to
scrotum) with a giant, non-reducible right inguinoscrotal hernia,
extending down to the level of his knees. He was hesitant to undergo
surgery. However, he was hospitalized for a small bowel obstruction
within his hernia as seen in a CT scan (Figure 1b) and was managed
non-operatively. After a pre-operative medical optimization, an
elective open repair was performed. An inguinal incision was utilized.
Hernia sac and spermatic cord structures were identified. Cord
structures were protected. While in Trendelenburg position, the hernia
sac contents (the majority of the small bowel, appendix, cecum,
ascending and transverse colon (Figure 2a–d) were sequentially
reduced to the abdomen. A partial omentectomy was performed.
During the repair, the peak airway pressure was monitored. The
stump of the sac was closed using non-absorbable suture (NAS). A
tension-free prolene mesh repair was performed. The mesh was
sutured to the inguinal ligament, the conjoint tendon using interrupted
0 NAS. A new internal ring was recreated. Layers closure [(the
external oblique aponeurosis (2-0 Vicryl), Scarpa’s fascia (3-0 Vicryl)
and the skin (stapler)] was performed. A suction drain was placed
within the right scrotum. The patient was extubated. He was dis-
charged home on POD#3. He developed early satiety that improved
over 2 weeks. At 5-months follow-up, the patient is doing well, with
pain resolved, tolerating general diet and better QL (Figure-3A.
P-1138
Results of robotic ventral hernia repair with phasix
bioabsorbable mesh: a fellowship council accredited
training fellowship’s experience Stefanie Haynes Do,
Frederick Sabido Md, Facs, Richmond University
Medical Center, Staten Island, New York
Haynes S, Sabido FRichmond University Medical Center
Introduction: The use of the robotic platform for ventral hernia
repair has been proven to result in less surgical site infections and
surgical site occurrences in multiple studies. We report our experience
which further promotes the impact that robotics has had on reducing
recurrence rates and post-operative complications specifically when
fully resorbable mesh is utilized.
Methods: The American Hernia Society Quality Collaborative data-
base was used to identify patients undergoing robotic ventral hernia
repair from March 2017–August 2018 by a program director and
fellow. The primary outcome measured was recurrence at 4 weeks,
20 weeks and 17 months. Secondary outcomes included SSIs, SSOs,
readmission and chronic pain. Patient demographics and intraopera-
tive data were collected. All repairs utilized the Intuitive daVinci Si
robotic platform. Primary closure of the hernia defect was completed
with absorbable unidirectional barbed suture and uniquely a fully
123
S75 Hernia (2019) 23 (Suppl 1):S50–S100
resorbable Phasix monofilament mesh was positioned as an
intraperitoneal onlay (IPOM).
Results: A total of 48 patients undergoing ventral hernia repair were
examined- 22 female and 26 male. The mean age was 54 and BMI
33.8. The types of ventral hernias repaired were umbilical (40%),
incisional (33%), epigastric (21%), and Spigelian (0.06%). The mean
ASA was 1.9 and operative time was 0–59 min. All patients were
discharged on the same day post operatively. Recurrence at 4 weeks
was 0%, 20 weeks 0% and 17 months 4% (2/48). There were no SSIs,
SSOs, readmissions or mesh infections reported. The average pain
post operatively was moderate and current pain was 0/10 on the pain
scale.
Conclusions: This preliminary data demonstrates that fully resorbable
mesh combined with the benefits of robotic technique for ventral
hernia repair can reduce or eliminate the incidence of recurrence and
post-operative complications which has not been shown to date.
P-1139
Management of incarcerated spighelian hernias
in a tertiary academic center in Brazil
Pivetta L, Barros P, Tastaldi L, Barros R, Fantauzzi M,
Hernani B, Assef J, Altenfelder Silva R, Roll SSanta Casa de Sao Paulo School of Medical Sciences
Introduction: A Spigelian hernia (SH) presenting acutely with pain,
incarceration or strangulation is a rare and challenging clinical sce-
nario. We aim to describe different operative approaches for the
management of SH illustrated by three cases that were managed at the
emergency service (ER) of a tertiary academic center in Sao Paulo,
Brazil.
Methods: (1) 32-year-old male, IVDA and unfortunately in a
homeless situation, presented to the ER with a 2-day history of
abdominal pain and small bowel obstruction. A painful mass could be
palpated at left lower quadrant consistent with an incarcerated SH.
Repair was performed through an open approach with hernia reduc-
tion, defect closure and placement of a medium-weight polypropylene
mesh (MWPP) in preperitoneal position. (2) 64-year old female,
presented to ER with recurrent episodes of right lower quadrant pain.
CT-Scan demonstrated a reducible right SH. Repair was performed
through a laparoscopic transabdominal preperitoneal (TAPP)
approach, with defect closure and placement of MWPP as a sublay.
(3) 72-year old female presented to ER with a 1-day history of left
lower quadrant pain without any palpable mass. A CT Scan demon-
strated a bilateral SH with small bowel incarceration on the left side.
Repair of bilateral SH’s was performed through a laparoscopic
approach with intraperitoneal onlay mesh (IPOM).
Results: There were no intraoperative complications; neither required
bowel resection and recovery of patients was uneventful. Patients
were discharged on postoperative days 2, 1 and 1 respectively. Patient
1 was lost to follow-up. Patients 2 and 3 had no wound or medical
complications and are recurrence-free at the last follow-up available
(3 months and 4-years respectively).
Conclusion: SH can be managed in an acute setting through different
approaches. Surgeons should be aware of the possibility of incar-
cerated SH in patients presenting to ER with abdominal pain and
palpable masses in the.
P-1140
Intra-abdominal malignancy of unknown origin
presenting as a strangulated umbilical hernia: a case
report
Kumaira Fonseca M, Bastos R, Oliveira H, Cunha C,
Rehbein P, Varella M, Crespo AHospital de Pronto Socorro de Porto Alegre
Introduction: Intra-abdominal primary tumours and metastasis have
been reported as rare contents of umbilical hernia sacs. These
malignancies can be misdiagnosed as an incarcerated or strangulated
hernia. The current report describes an intrahernial neoplasm with no
primary sites found presenting as a strangulated umbilical hernia.
Case report: A 65-year old female patient with a history of a pre-
viously reducible umbilical hernia presented to the Emergency
Department (ED) complaining of a painful ulcerative lesion with
purulent discharge and overlying skin necrosis in the periomphalic
region. Abdominal computed tomography revealed a large expansive
mass arising from the mesenteric fat, surrounded by a segment of
ileus and protruding through the umbilicus. No symptomatic or
radiological evidence of bowel ischemia, obstruction or peritonitis
was observed. Surgical exploration of the hernia sac and excision of
the tumorous mass was performed by a midline laparotomy. Exten-
sive histological examination and further immunohistochemical
staining of the specimen revealed epithelioid and fusocellular
malignant cells with abundant atypical mitotic figures, yet failed to
identify the specific primary source of the tumour. The patient was
discharged after an uneventful recovery and declined to proceed
further investigation or treatment. After 4 months, she was readmitted
to the ED with acute bowel ischemia due to tumour progression and
multi-focal dissemination of the disease found intraoperatively,
expiring within 12 h after presentation.
Discussion: Although intrahernial tumours are rarely seen in clinical
practice, an umbilical mass may present as the first manifestation of
undiagnosed malignancy. Longstanding umbilical hernia that sud-
denly become incarcerated or strangulated warrants clinical suspicion
and additional diagnostic evaluation for neoplastic disease.
P-1142
Hernia repair for the underserved: fostering surgical
education and assisting underserved populations
in Brazil
Kawamoto Fujikawa V, Lima Konichi R, Copin Tenorio R,
Sembarski Oliveira E, Fogaca de Barros P, Altenfelder
Silva R, Chen D, Filipi C, Roll SSanta Casa de Sao Paulo School of Medical Sciences
Background: Hernia Help—Hernia Repair for the Underserved
(HRFU) is a non-governmental organization (NGO) that has the
objectives of (1) provide free hernia surgery to underserved popula-
tions, (2) train local surgeons in a competency-based training program
and (3) assist local authorities in creating self-sustaining hernia repair
teams that can provide further care in the community. We aim to
report the outcomes of 3 missions of HRFU in Brazil.
Patients and methods: From September 2014 through August 2018,
four missions took place in the state of Sao Paulo, involving under-
served communities who rely on the medical care provided by the
Brazilian public health system. Local surgeons were invited to par-
ticipate in a series of 3–5 inguinal hernia repairs, directly mentored by
one of the expert HRFU-affiliated volunteer trainers.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S76
Results: Four missions were performed in 7 different cities; 236
inguinal hernias were repaired and 52 local surgeons were trained.
Five percent of patients were female. All patients had inguinal hernias
that were more frequently unilateral (94%); 57% were on the right
side. All procedures were performed using the Lichtenstein technique,
with permanent synthetic mesh, 95% (224) were performed under
local anesthesia and there were no intraoperative complications.
There were 14 complications (5.9%): 11 were hematomas, 2 were
surgical site infections and one patient developed chronic groin pain.
No recurrences were detected to the date this abstract was produced.
Eleven surgeons were selected by the organization to serve as trainers
in subsequent missions.
Conclusion: Humanitarian endeavors like HRFU can not only pro-
vide free, high-quality surgical care to underserved populations but
more importantly, are a valuable initiative to educate surgeons in
developing countries to build a sustainable hernia program in their
communities.
Renata Yumi Lima konichi.
P-1143
Bioprosthetic versus synthetic mesh: analysis
of integration in an experimental animal model
Adelman D, Cornwell KMD Anderson Cancer Center
Introduction: Synthetic and bioprosthetic meshes play important
roles in ventral hernia repair. Although sometimes used inter-
changeably, these devices have inherently different properties. We
therefore sought to better understand how these materials interact
with the host environment to optimize surgical techniques and
improve outcomes.
Methods and materials: Synthetic mesh (polypropylene) or bio-
prosthetic mesh (acellular fetal/neonatal bovine dermis, SurgiMend)
was implanted in a novel rat intra-abdominal implant model. Three
variables were modified with each material: (1) tight or loose tissue
apposition, altered by modifying suture placement; (2) abdominal
wall injury, altered by selective abrasion of the peritoneal lining; and
(3) suture material. After 5 weeks, the meshes and abdominal wall
were evaluated grossly and histologically. Analyses focused on the
degree of inflammatory response, neovascularization, and mesh
adherence to surrounding tissues.
Results: Synthetic mesh adhered to the abdominal wall and visceral
organs, regardless of variable, due to a foreign body-mediated
inflammatory reaction. SurgiMend was adherent to the abdominal
wall only in areas of suture placement, which also served as points of
neovascularization. Denuding the peritoneal lining increased Surgi-
Mend to tissue adherence in those areas. Degradable sutures yielded
greater inflammation, increasing the magnitude and distribution of
cells repopulating the matrix, but ultimately did not affect the strength
of the tissue attachment to the abdominal wall.
Conclusions: The inflammatory and wound healing responses with
bioprosthetic mesh seem fundamentally different from synthetic
mesh. Further understanding of these differences may lead to
improved outcomes in adherence and vascularization of the materials,
and ultimately improved efficacy of hernia repair.
P-1144
Effect of suture type on the attachment strength
and assimilation of extracellular matrix biomaterials
in hernia repair
Adelman D, Cornwell KMD Anderson Cancer Center
Introduction: Acellular dermal matrices (ADMs), like synthetic
meshes, are used in ventral hernia repair. We previously demonstrated
that SurgiMend, derived from fetal/neonatal bovine dermis, integrates
through suture approximation and localized tissue injury, acting as
points of adherence and neovascularization. We wondered if altering
the suture material would affect the integration process, hypothesizing
that more rapidly degradable sutures might increase local inflamma-
tion yielding greater neovascularization of the mesh, but at the
expense of lessened tissue adherence.
Materials and methods: SurgiMend was placed intra-peritoneally,
altering suture type (Prolene, PDS, Maxon, Vicryl, Vicryl Rapide),
selective abrasion of the peritoneum (none vs some), and length of
experiment (4 vs 12 weeks). Implants were grossly visualized; half
subjected to mechanical strength/mobility testing against the
abdominal wall, half analyzed histologically.
Results: Attachment strength range was 3 N–15 N for all conditions,
3 N–6 N once the suture degraded (or permanent suture transected).
All were statistically significantly lower than the attachment strength
with tissue abrasion (12.88 N ± 5.93). Inflammation was centered
about the suture material, with inflammatory response highest with
Vicryl and Vicryl Rapide, lowest with Prolene. With increased
inflammation, more cells were counted at the 4 week time point, on
the anterior surface of the implant closest to the abdominal muscle.
This effect diminished, leaving fewer and more evenly distributed
cells with time and once the suture had degraded. With prolene,
regions of the implant were virtually cell free at 4 weeks and
remained low at 12 weeks. In the abrasion condition (pro-
lene ? abraded peritoneum), an even distribution of cells was found
throughout the implant at both time points, in quantities significantly
higher than prolene alone.
Conclusion: Cell repopulation and attachment strength of SurgiMend
are dominated by environmental factors of the surgical procedure.
Suture type and peritoneal abrasion may play important roles in post-
implantation mesh physiology and efficacy of hernia repair.
P-1146
3d T-shaped mesh for linea alba reinforcement: results
in an animal model
Hernani B, Barros P, Tastaldi L, Neto I, Amaral P, Ferreira
F, Silva R, Garcia D, Roll SSanta Casa de Sao Paulo School of Medical Sciences
Introduction: The use of prophylactic mesh as a way to reduce
incisional hernia formation in high-risk populations is gaining
increasing attention. We have hypothesized that in an animal model,
the reinforcement of linea alba with an innovative polypropylene ‘‘3D
T-shaped’’ mesh during laparotomy closure could result in increased
resistance in tensiometric measures.
Methods: A model with New Zealand rabbits was used, and 27 animals
were operated. Following a midline incision, animals were divided into
three groups according to method laparotomy closure: (1) 10 9 3 cm
3D T-shaped medium-weight polypropylene coated mesh; (2) 10 9
3 cm 3D T-shaped medium-weight polypropylene uncoated mesh and
(3) control-closure without mesh reinforcement. In groups 1 and 2,
123
S77 Hernia (2019) 23 (Suppl 1):S50–S100
mesh was sutured along the fascial edges. After 4 months, animals were
euthanized, the abdominal wall was resected and exposed to ten-
siometer testings. Additional outcomes included incisional herniation,
visceral adhesions to the mesh and wound complications.
Results: 26 animals survived the experiment and were euthanized.
There was no significant difference between the groups in maximum
tensile strength (p = 0.250) or stretching of the abdominal wall under
maximal tension (p = 0.839). Also, no significant difference in inci-
sional hernia rates between groups was seen (p = 1.0), with a single
incisional hernia seen in the control group and none in the experi-
mental groups. Visceral adhesions to the abdominal wall and mesh
were noted in all cases with mesh reinforcement but in only 55% of
the control group (p = 0.02). The degree of visceral adhesions was
higher in the group with uncoated mesh when compared to the
uncoated mesh (p\ 0.05) and control groups (p\ 0.05). No animals
had wound complications.
Conclusion: In rabbits, the addition of a ‘‘3D-shaped’’ mesh in the
current format as a method to reinforce laparotomy closure has not
resulted in significant differences in tensiometer measures when
compared to simple closure of the abdominal wall.
P-1147
Laparoscopic hiatal hernia repair in 51 patients:
outcome and experience
Yang HBeijing Chaoyang hospital
Background and objectives: Hiatal hernia is a common condition
and quite often associated with symptomatic gastro-esophageal reflux
disease (GERD). The aims of this study were to examine the safety
and efficiency of the laparoscopic hiatal hernia repair (LHHR) with
mesh to reduce the GERD symptomes and hiatal hernia recurrence.
Methods: We retrospectively reviewed LHHR from July 2012 to July
2017. The primary outcome was the efficiency of this procedure, and
this was evaluated by the control of the GERD and hiatal hernia
related symptomes and the recurrence rate of hiatal hernia. The sec-
ondary outcome was the safety of the procedure, and this was
evaluated by the incidence of complications.
Results: A total of 51 patients who underwent LHHR during this
period. The Dor fundoplication was performed at the same time if no
contraindication. The average operation time was 100 ± 19.6 min,
the average blood loss was 28 ± 15.4 ml, and average hospital stay
was 2ds.The GERD related symptoms and hiatal hernia related
symptoms were significantly improved. The patients return to normal
diet within 4 weeks after operation. The follow up was on average
32 months, and no recurrence or mesh related complications
identified.
Conclusions: LHHR with mesh is a safe and efficient procedure, and
is able to reduce the recurrence compare to the suture repair.
P-1148
Patients with systemic reaction to their mesh: real
people with real problems
Towfigh S, Fadaee N, Sharma R, Mazer LBeverly Hills Hernia Center
Purpose: We have noticed an increasing number of patients pre-
senting with systemic reaction to their hernia mesh. We present our
experience in diagnosing and treating this interesting subpopulation
of patients who require mesh removal due to a bonafide reaction to the
mesh product itself.
Methods: All patients who underwent mesh removal for mesh reac-
tion from Aug 2013-Aug 2018, were compared to those with no mesh
reaction, e.g., meshoma, hernia recurrence, infection, etc.
Results: Over 5 years, 112 required mesh removal. Of these, 18
(16%) were for systemic reaction to the mesh product itself. Their
incidence increased annually, from 9% in 2013, to 33% in 2017.
Those with mesh reaction were significantly younger (40 vs 56 years.,
P\ 0.001) and significantly more likely to be female (72% vs 36%,
P = 0.004) than those with no mesh reaction. Common complaints
included rash, swelling, fatigue, joint pain, headache, and exacerba-
tion of underlying chronic illness. Some already had allergies to
multiple pathogens. In some, we performed skin allergy testing for
Type IV hypersensitivity to the mesh.
All patients underwent complete mesh removal. Their pain improved
2 weeks postoperatively (6/10 down to 3/10), similar to those with no
mesh reaction (5/10 down to 3/10, P = NS). Long-term follow-up at
1 year showed resolution of symptoms in 78%.
Conclusions: We present insight into diagnosis and treatment of a
unique but rising population of patients who suffer from a true mesh
reaction. They tend to be younger and female. They present with
symptoms not typically seen post-herniorrhaphy, such as new rash,
swelling, fatigue, joint pain, headache, and exacerbation of their
underlying chronic illness. Allergy testing is in its early stages, but
seems promising. Pain improvement is expected after mesh removal.
Complete mesh removal resolved symptoms in 78% of patients.
P-1149
Treatment of the post-partum abdominal wall
dysfunction
East B, Vitujova M, Radvansky J, Lischke RFN Motol
Background: Post-partum floppy belly is a common issue bothering
many new mothers. With the number of pregnancies, the problem
worsens and combined with rectus diastasis leads to a surgical
reconstruction with a use of a large mesh with a potential loss of
abdominal wall compliance. Medical physiotherapy is able to help
these patients lose weight and strengthen their abdominal wall
including the diastasis with no need of a subsequent surgery.
Methods: From 1.1.2015 to 14.9.2018 62 patients with post-partum
umbilical hernia and rectus diastases were assigned into the Motion
therapy programme we have established at our institution in coop-
eration with the Sportsmed and Rehabilitation dpt. Since the cost
effectiveness analysis has proven its benefits, national health insur-
ance authorities have decided to fully cover it. It consists of aerobic
exercise, nutritional advice and intensive rehabilitation utilizing
Vojtas method, DNS and neuromuscular activation.
Results: All 62 patients have completed the course. Unlike in the
other patients’ groups, in this cohort we have observed 100% com-
pliance with the programme. None of our patients had to have a rectus
diastasis repair and although not all were completely reduced, with
improving trends we felt it was not necessary to operate. Only 9
patients had umbilical hernia repair so far. The smaller hernias
became asymptomatic and could be left unrepaired. With a follow-up
of 3–34 months we have not had any recurrence yet.
Conclusion(s): Female abdominal wall when stretched during preg-
nancy can result in a severe medical and psychological issue.
Abdominoplasty is not covered by the general health insurance and
for many it is not an affordable option. However, pregnancy is a
physiological process and we believe the consequences don’t always
have to lead to a surgery. The MTP has proven to be effective both in
physical and mental aspect of this complex issue.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S78
P-1150
The management of mesh infection after laparoscopic
inguinal hernia repair
Yang HBeijing Chaoyang hospital
Aim: With the increasing number of laparoscopic inguinal hernia
repair, the mesh infection after laparoscopic surgery is not rare
especially in large volume centers. To present our experience of
managing mesh infection after laparoscopic inguinal hernia repair in
19 patients.
Methods: Nineteen extensive mesh infection cases (2012–2017) were
included in our study, and all were managed by laparoscopic mesh
excision after preoperative workup. After mesh removal and a drai-
nage was inserted in preperitoneal space, the peritoneal flap was
closed with 3/0 absorbable consecutive suture.
Results: All the patients underwent the operation uneventfully. One
case had sigmoidectomy for fistula, and two cases need second
laparoscopic surgery for the infection on the contralateral side and for
the residual mesh around pubic bone separately. In total, three
recurrence was identified during follow up.
Conclusion: Laparoscopic mesh excision is an effective and mini-
mally invasive method to cure infection, and to avoid unnecessary
interruption of healthy layers of abdominal wall at the same time.
P-1151
Bilateral incarcerated inguinal hernia with unilateral
sigmoid adenocarcinoma containing hernia sac
successfully repaired using a robotic transabdominal
preperitoneal approach: a case report
Musonza T, Haubert L, Loor MBaylor College of Medicine
Introduction: We report a successful robotic transabdominal
preperitoneal repair of giant bilateral inguinal hernias for a patient
with an incarcerated sigmoid cancer within his left inguinal hernia.
Case report: A 52-year-old male with end stage renal disease,
hypertension, recent 5-vessel CABG, obstructive sleep apnea, distant
open appendectomy and no prior groin surgery presented with
symptomatic incarcerated bilateral inguinal hernias. These hernias
had been present for many years. However, he recently underwent
colonoscopy and biopsy of a 1.0 cm sigmoid polyp which revealed
moderately differentiated adenocarcinoma with invasion into the
submucosa. Interestingly, this lesion, which was tattooed and clipped
endoscopically, was in a portion of the sigmoid colon which resided
within his left inguinal hernia. A robotic approach to hernia repair and
sigmoidectomy was chosen to minimize morbidity associated with
large incisions. Examination of the pelvis revealed very large inguinal
defects bilaterally. Reduction of the left sided pantaloon hernia was
undertaken, in conjunction with a robotic sigmoid mobilization by the
colorectal surgeon. Sigmoidectomy and anastomosis were completed,
and the specimen extracted via a 7 cm lower midline incision. The
bilateral hernias were repaired in a transabdominal pre-peritoneal
fashion using biosynthetic mesh. The large hernia sacs were imbri-
cated at the time of peritoneal flap closure. The patient did well
following surgery. He required a brief stay in the intensive care unit
for hypovolemia. He was discharged from the hospital on post op day
8. Final pathology was negative for malignancy. Patient returned to
work 4 weeks following surgery.
Conclusion: A robotic transabdominal preperitoneal approach to
large incarcerated bilateral inguinal hernias is feasible in the re-
operative abdomen and for the multi-morbid patient. Through the
carefully coordinated efforts between surgery teams, procedures such
as these that combine hernia repair with an oncologic resection, can
be safely executed in a minimally invasive fashion.
P-1152
Analysis of sublay herniorrhaphy for elderly primary
lumbar hernia: a clinical study of 21 patients
Huadong D, Ying-mo SDepartment of Hernia and Abdominal Wall Surgery, Beijing Chao-
Yang Hosipital, Captial Medical University
Objective: To explore the safety and effectiveness of Sublay
Herniorrhaphy for Elderly Primary Lumbar Hernia.
Methods: The clinical data of 21 patients with elderly primary lumbar
hernia underwent Sublay Herniorrhaphy between January 2015 and
March 2018 in Beijing Chao-Yang Hospital of Capital Medical
University were analyzed retrospectively.
Results: Operations were completed successfully in all 21 cases. The
mean lumbar defect was (2.4 ± 0.4) cm (range 1.5–3.0 cm).The
mean operation time was (43.4 ± 13.2) min (range 25–75 min) and
the mean hospital stay was (3.0 ± 1.0) days (range 1–5 days).The
postoperative VAS pain score was (2.6 ± 0.9) scores (range2–6
scores).There were no complications such as wound infection. All
cases were followed up for 2–37 months (18.6 ± 11.3) without
obvious chronic pain, foreign body sensation and recurrence.
Conclusion: The Sublay herniorrhaphy in Elderly primary lumbar
hernia by using the preperitoneal patch is safe and feasible. Its effi-
cacy in short-term is certain.
Keywords: Lumbar hernia elderly; Preperitoneal space; patch
P-1159
Nbca chemical medical glue for mesh fixation
in inguinal hernia repair (Lichtenstein, TAPP Or TEP)
Shen Y, Qin C, Chen JBeijing Chao-Yang Hospital, Capital Medical University
Objective: Although the approach of fixing the mesh with non-ab-
sorbable synthetic suture has been adopted, it is disadvantaged by the
large number of stitches and an increased incidence of complications
such as postoperative pain, chronic pain, and hematoma or hydrops
formation. With the aim of reducing these complications, some
researchers have adapted medical adhesives in tension-free hernior-
rhaphy and have achieved satisfactory results. We conducted this
study using a novel lightweight polypropylene mesh that has been
proven to be associated with fewer complications for inguinal
herniorrhaphy to imply the effectiveness of n-butyl-2-cyanoacrylate
(NBCA) glue for mesh fixation in Lichtenstein tension-free hernior-
rhaphy and laparoscopic herniorrhaphy for inguinal hernias.
Methods: A total of 2136 patients with primary unilateral inguinal
hernia were included. In 893 cases, NBCA adhesive (Compont
Medical Adhesive, 1.5 ml/tube; Beijing Compont Medical Devices
Co., Ltd., Beijing, China) was used during Lichtenstein herniorrhaphy
while the left 1243 cases was used in the fixation of the mesh during
the laparoscopic herniorrhaphy (TAPP or TEP). Operation time,
postoperative length of stay, visual analogue scale (VAS) score,
incidence of chronic pain and hematoma formation, and hernia
recurrence were evaluated.
Results: The operative time was 36.2 ? 10.3 min and the postoper-
ative length of stay was 1.2 ? 0.6 days. The minimum follow-up was
123
S79 Hernia (2019) 23 (Suppl 1):S50–S100
24 months, there were no hernia recurrence or wound infection in
either group. The postoperative VAS score was 1.6 ? 0.7, there was
no postoperative pain occurred (visual analogue score[ 4, lasted
3 months). 13 (1.5%) hematomas occurred in the open cases and 17
(1.4%) cases occurred in the laparoscopic group.
Conclusions: Application of chemical medical adhesive in tension-
free herniorrhaphy for inguinal hernia appears to be a safe and
effective approach.
P-1161
Lichtenstein repair of indirect inguinal hernias
with biological (acellular tissue matrix) grafts
in adolescents and young adult patients (13–45 years
old)
Shen Y, Chen JBeijing Chao-Yang Hospital, Capital Medical University
Objective: To evaluate the outcomes of Lichtenstein hernioplasty
using acellular tissue matrix (ACTM) grafts in adolescents and young
adult patients (13–45 years old).
Methods: In this study, 317 patients, 13–45 years old, with primary
unilateral indirect inguinal hernias, received Lichtenstein hernioplasty
using ACTM mesh. The outcome measures were the length of the
operation, postoperative visual analogue scale (VAS) pain score,
length of hospitalization, postoperative complications and recurrence
rate.
Results: The operative time was (31.2 ? 5.8) min and the length of
hospitalization (1.4 ? 0.7) days. The minimum follow-up was
24 months, there were two postoperative wound infections (0.6%)
and fully recovered by change of dressing for 1 month; there were no
chronic postoperative pain (visual analogue score[ 4, lasted
3 months) or local foreign body sensation occurred; 13 patients
(4.1%) developed scrotal hydroceles and recovered by the scrotal
puncturation. There were no recurrences and other complications.
Conclusions: Lichtenstein hernioplasty using ACTM grafts is a safe
and available treatment in adolescents and young adult patients
(13–45 years old).
P-1162
Necrotazing fasciitis after incisional hernia repair
Rappoport J, Carrasco J, Dominguez C, Sanguineti A,
Sepulveda P, Sandoval G, Castillo C, Silva J, Jauregui CClinic Hospital, University of Chile
Introduction: Necrotizing fasciitis (NF), is a severe clinical condi-
tion with high risk of mortality. Estimated incidence is about 0.4–1
per 100.000 habitants. The mortality risk may reach about 70–80% in
cases of Toxic Shock.
Aim: The aim of the present study it’s to present a clinical case and
literature review.
Clinical case: Female, 70 years old, diabetes mellitus (DM), arterial
hypertension, recurrence urinary tract infections, with chronic
antibiotic (AB) use. Retroperitoneal tumor resected 5 years previ-
ously, tumor, colon, partial urinary and bladder resection was
performed, followed by ostomies and iliostomies. Ostomie closure
was attempted in several occasion, but failed and the patient remains
with colostomy (COL) at left flank. Developed hugh Incisional Her-
nia, 30 cm Hernia Sac, 20 cm Hernia Ring. Submitted to protocol of
Bolutin Toxin (BT) and Preoperative Pneumoperitoneum (PP), that
was interrupted because the patient developed Intestinal Obstruction.
Was submitted to surgery performing Enterolysis and Primary Hernia
Repair, closure hernia defect with flaps of the hernia sac and Onlay
Heavy Weight Polypropylene mesh. After 48 h developed FN and
Septic Shock. Emergency exploration was performed with abdominal
cavity review, that did not show septic problems. Extensive skin and
subcutaneous tissue resection was performed. Occlusion of the
abdominal defect with Vicryl mesh, 15 per 30 cm, and VAC 30 per
40 cm initially. Requiered ICU, vasoactive drugs, mechanical venti-
lation, traqueostomy, endovenous antibiotics and nutritional support
for 1 month, submitted to seven surgical explorations and finally
cutaneous flap covering the defect. Survived and egress in good
general conditions.
Comments: Patients with risk factor as DM, AB use, COL usuary,
old age, represent a high risk of developed FN and strict post oper-
atory care for early diagnosis and treatment must be enforced.
P-1164
Safety of the bupivacaine HCL collagen-matrix implant
(Inl-001) after soft-tissue surgery
Leiman D, Niebler G, Minkowitz HUniversity of Texas Health Science Center, HD Research Corp
Surgical site infiltration with bupivacaine, a common component of
multimodal postoperative pain management, results in short-lived
postsurgical analgesia. INL-001, a biocompatible and bioresorbable
bovine collagen-matrix designed for extended local delivery of
bupivacaine, is being developed for relief of postsurgical pain when
implanted in the surgical site during soft-tissue surgeries. The clinical
development program consisted of 11 clinical studies with 100 mg to
300 mg of INL-001: 7 Phase 1/2 studies; 2 pharmacokinetic (PK)-
specific studies; and 2 randomized, double-blind Phase 3 studies.
Patients in the PK and Phase 3 studies received 3 INL-001 collagen-
matrix implants, each containing 100 mg bupivacaine, or placebo
collagen-matrix implants (in Phase 3 studies only) following open
inguinal hernia repair. Overall, 892 subjects received a collagen-
matrix implant, with 66.2% of subjects receiving any dose of INL-001
(n = 612) experiencing C 1 treatment-emergent adverse event
(TEAE), and 68.2% of subjects receiving placebo collagen-matrix
implant (n = 280) experiencing C 1 TEAE. In the 2 pivotal Phase 3
studies, both of which met their primary efficacy endpoint of summed
pain intensity over 24 h, 62.3% of INL-001-treated subjects (n = 411)
and 68.8% of placebo collagen-matrix implant-treated subjects
(n = 208) experienced C 1 TEAE. In both groups, about 3% of
TEAEs were deemed to be treatment-related. Across the dataset there
was no evidence of bupivacaine toxicity or any adverse effect on
wound healing with INL-001. The results of these studies support that
INL-001 is well-tolerated and may provide an alternative method for
extended relief of postsurgical pain after soft-tissue surgeries.
P-1165
Abdominal wall reconstruction in immunosuppressed
patients: series of cases in Latin America
Cabrera P, Ramirez N, Perez C, Gonzalez A, Kadamani A,
Casas F, Roman C, Mosquera MFundacion Cardioinfantil-IC
Introduction: Abdominal wall reconstruction is considered a surgical
challenge in immunosuppressed patients due to their varying out-
comes. The purpose of these cases is to describe the surgical
treatment and the short and long-term outcomes of an abdominal wall
123
Hernia (2019) 23 (Suppl 1):S50–S100 S80
reconstruction using an anterior component separation in immuno-
suppressed patients at Fundacion Cardioinfantil, Instituto de
Cardiologıa in Bogota, Colombia.
Methods: All immunosuppressed patients who underwent abdominal
wall reconstruction using an anterior component separation surgical
technique between February and May of 2017.
Results: Patient 1: previous history of renal transplant with
immunosuppressant treatment and a recurrent incisional hernia of
13 9 10 cm, with posterior seroma that resolved. Patient 2: previous
history of lung transplant and necrotizing acute pancreatitis that
required surgical treatment with marsupialization of the pancreatic
cells and therapeutic peritoneal lavage, without any complications,
hernia of 26 9 12 cm. Patient 3: previous history of systemic lupus
erythematosus (SLE) presenting a retroperitoneal hematoma with
posterior evisceration, hernia of 26x16 cm, with posterior surgical site
infection treated with lavage, VAC therapy, and skin graft.
These three patients underwent an abdominal wall reconstruction
using an anterior component separation and placement of a high
density polypropylene mesh (30x30 cm). All patients were receiving
prednisolone and (n = 2) tacrolimus as their immunomodulatory
therapy. There was no mortality reported at 30 days and the follow-
ups at 3–6–10 months did not present hernia recurrence.
Conclusions: Abdominal wall reconstruction anterior component
separation and polypropylene mesh reinforcement is a safe approach
in immunosuppressed patients. The multidisciplinary approach, the
ideal moment for surgery, and the surgical technique chosen for each
patient constitutes the principal factors in determining a favorable
result.
P-1167
Abdominal wall reconstruction for liver transplant
patients
de la Torre J, Kurapati S, Denney BUAB
Introduction: Component separation has been established as an
effective technique for complex abdominal wall reconstruction. Pre-
vious study of component separation with acellular dermis onlay
multipoint fixation has been demonstrated to be effective. Incisional
hernias following orthotopic liver transplantation (OLT) presents a
particular challenge since immunosuppression and pre-existing inci-
sions present additional challenges for the reconstruction.
Methods: The records of 183 patients who underwent complex
abdominal wall reconstruction from 2010 were reviewed. Patients
were identified by CPT codes for component separation and a history
of liver transplantation. Information regarding the OLT was available
in all eight of the patients who underwent transplantation. Data
included date of OLT, the location of the incision placement for OLT,
diagnosis for transplantation and postoperative immunotherapy
(Table 1). Seven of the patients had a standard Chevron incision. Data
reviewed included patient demographics and comorbidities, con-
comitant procedures, and characteristics of the reconstruction such as
surgical incision. Primary data endpoints were complications fol-
lowing surgery, including recurrence.
Results: The study group consisted of 9 patients, 8 who were OLT
recipients and a single patient who was a partial liver donor. In the
study group, there were no recurrences and primary approximation of
the fascial defect was achieved in 100% of the patients. A chevron
incision was used in 66% of cases and biologic material was used in
78%. Overall morbidity was 11%, with one patient identified with
deep venous thrombosis. There were no significant wound healing
problems. In the overall group, the recurrence rate was 7% and
primary approximation of the fascial defect was achieved in 92% of
the patients. Significant complications occurred in 17%.
Conclusions: Modified abdominal wall reconstruction with compo-
nent separation and onlay biologic mesh is a reliable approach to
address hernia defects in patients who have had liver transplants.
P-1169
Left diaphragmatic hernia following thoracoabdominal
aortic repair: an unusual case
Mosquera M, Tellez L, Perez C, Castillo A, Gonzalez A,
Cabrera P, Kadamani A, Ramirez N, Roman CFundacion Cardioinfantil-IC
Diaphragmatic herniation is a rare complication, with an unknown
incidence, following any thoracoabdominal procedure. However, it
has a high risk of mortality once emergency surgery has been per-
formed due to visceral strangulation. We present the case of a
67-year-old male, with previous history of diaphragmatic rupture in
2000, who later required thoracoabdominal aortic aneurysm repair in
November 2017. 6 months later, patient presents multiple episodes of
coffee ground emesis, wherein a left diaphragmatic herniation was
documented with migration of the stomach, omentum and spleen.
Through a laparoscopic approach, the herniated contents were
reduced and a pulmonary decortication was required. Primary closure
was achieved by thoracoscopy due to pleural and pulmonary adhe-
sions as well as spleen interposition. We emphasize the importance of
clinical suspicion once the surgical precedent has been identified.
P-1172
Chronic post-operative pain strongly correlates
with patch fixation method used in tension-free inguinal
hernias repair under local anesthesia
Qin C, Shen Y, Chen JBeijing Chao-Yang hospital, Capital Medical University
Objective: To identify factors associated with post-operative chronic
pain in tension-free inguinal hernia repair under local anesthesia.
Methods: The data of 2875 cases of tension-free inguinal hernia
repair under local anesthesia, performed from January 2013 to May
2015, were retrospectively analyzed.
Results: A month later, among the 2875 cases, a total of 83 (2.89%)
patients reported post-operative pain; 3 months later, only two cases
sill have pains, and the occurrence rate is 0.69%. All the patients with
pains have not last over 6 months. Age, gender, type of hernia,
occurrence of complications and pre-existing underlying diseases
showed no correlation with chronic post-operative pain, while the
patch suture fixation method showed significant correlation
(P\ 0.001). Four fixation methods were used: 7-stitch, 5-stitch,
3-stitch and 0-stitch patch fixation. Significant differences in post-
operative pain incidence were found among the groups. The stitch-
free method did not increase postoperative complications.
Conclusion: Multiple factorial analyses demonstrated that patch fix-
ation method is an independent risk factor for chronic pains after
tension-free inguinal hernia repair under local anesthesia.
123
S81 Hernia (2019) 23 (Suppl 1):S50–S100
P-1174
Effect of bupivacaine HCL collagen-matrix implants
(Inl-001) on pain and opioid use in subgroups
after inguinal hernia repair
Leiman D, Niebler G, Minkowitz HUniversity of Texas Health Science Center, HD Research Corp
INL-001 (bupivacaine HCl collagen-matrix implant) delivers bupi-
vacaine over time into the surgical wound. In 2 Phase 3, randomized,
double-blind studies (MATRIX-1, MATRIX-2), subjects undergoing
elective, open, tension-free mesh inguinal hernia repair under general
anesthesia were randomized to receive 3 INL-001 100-mg bupiva-
caine HCl matrices or 3 placebo matrices. Parenteral morphine was
available for breakthrough pain. When able, subjects began oral
acetaminophen (650 mg tid) and immediate-release morphine PRN.
Subjects assessed pain intensity (PI) using an 11-point numerical
rating scale. Sum of PI (SPI) and total use of opioid analgesia (TOpA)
in milligram IV morphine equivalents were calculated from matrix
implantation (Time 0). The primary endpoint for both studies was SPI
0–24 h (SPI24) for patients receiving INL-001 compared with pla-
cebo. Analysis of SPI24 and TOpA 0–24 h (TOpA24) was performed
for the following subgroups: sex, history of previous ipsilateral hernia
repair, age, race, body mass index (BMI), and multiple hernia history.
Data from MATRIX-1 and MATRIX-2 were also pooled. The pri-
mary endpoint was met in both studies and the pooled population
(P = 0.0004, P = 0.0001, and P = 0.0001, respectively). For all sub-
groups, SPI24 and TOpA24 were lower in the INL-001 vs placebo
arms. Decreases in SPI24 were significant for most subgroups
(P\ 0.02 each), but not in women and subjects with history of
multiple hernias. TOpA24 was significantly reduced in most sub-
groups (P\ 0.03 each), except for individuals aged C 75 years and
subjects with a history of multiple hernias. Adverse events were
reported in 62.3% of subjects treated with INL-001 and 68.8% treated
with placebo; most were mild/moderate in severity and unrelated to
study treatment. Results from 2 Phase 3 studies of subjects under-
going hernioplasty demonstrate that INL-001 is a novel bupivacaine
delivery technology that produces extended, opioid-reducing post-
surgical analgesia regardless of age, race, sex, BMI, or history of
hernia or ipsilateral hernia repair.
P-1178
Initial experience in posterior component separation
with transverse abdominis (TAR) muscle release
in a University Hospital in Chile
Quezada N, Achurra P, Jacubovsky I, Munoz R, Crovari F,
Jarufe N, Morelli C, Pimentel FPontificia Universidad Catolica de Chile
Background: Posterior component separation with TAR during
abdominal wall reconstruction for ventral hernias has become an
appealing option for the management of complex ventral hernias. We
report our initial experience with TAR in the first 30 consecutive
patients in a University Hospital in Chile.
Objective: To report our initial experience and short term outcomes
with TAR for the treatment of complex ventral hernias.
Methods: Retrospective case series of the first 30 patients with
complex ventral hernias who underwent an abdominal wall recon-
struction with posterior component separation and TAR between
December 2016 and September 2018. Demographic, perioperative
data and early outcomes were included for analysis.
Results: During the study period, 30 patients underwent an abdominal
wall reconstruction using posterior component separation and TAR.
Average age was 61 years old (range 29–83), 55% were women and
average BMI was 32. The average width of the hernia defect was
12 cm (range 3–17 cm), two patients had multiple defects and three
had parastomal hernias.
All patients underwent a complete preoperative evaluation and were
asked to lose weight before surgery and all patients achieved midline
closure. One-side TAR was performed in four patients, six patients
underwent a combined procedure (80% cholecystectomy) and 10
patients were operated by a laparoscopic eTEP approach. Average
operative time was 2.5 h.
Overall morbidity was 13%, 2 patients had an infection (one had
the mesh removed), 1 patient had a wound seroma and 1 patient had a
medical decompensation (Chronic kidney disease). Overall mortality
was 0% and 1 patient had a reoperation (for mesh removal and wound
lavage). No recurrences have been identified so far in early follow-up.
Conclusion: Posterior component separation with TAR has a safe
learning curve with promising results similar to those reported in the
literature.
P-1180
Thirty day outcomes after umbilical hernia repair:
comparison of a high volume center versus AHSQC
database
Lo Menzo E, Aleman R, Frieder J, Fonseca C, Milla C,
Ortiz Gomez C, Szomstein S, Rosenthal RCleveland Clinic Florida
Introduction: There is no consensus on the best method for umbilical
hernia repair. The aim of this study was to evaluate the 30 day out-
comes of patients undergoing primary umbilical hernia repair (UHR)
at our institution versus the American Hernia Society Quality Control
(AHSQC) database.
Methods: We retrospectively reviewed all patients who underwent
ventral hernia repair at our institution from 2012 to 2017. Common
demographics (table 1 and 2) and outcomes were collected, and 30
postoperative days outcomes were compared to the AHSQC database
(Table 3).
Results: Of the 261 ventral hernia repairs performed, 47.5%
(N = 124) were UHR. Males and Caucasians composed 64.5%
(N = 80) and 60.5% (N = 75) of our population, respectively. Dia-
betes was present in 11.3% (N = 14) and hypertension in 30.7%
(N = 38) of our patients. The mean age was 54.91 ± 15.02 with a
prevalent open repair of 73.4% (N = 91) and no use of mesh in 83.9%
(N = 104). A direct relationship was observed between operative time
less than 2 h and length of stay greater than 24 h. Our surgical site
Table 3 – 30 day postoperative complicationsSSI N (%) p=0.7290Cleveland Clinic Florida 1/261 (0.38)AHSQC (All) 51/5630 (0.91)SSO p=0.0019Cleveland Clinic Florida 4/261 (1.53)AHSQC (All) 319/5630 (5.67)SSO requiring procedural intervention p=0.1877Cleveland Clinic Florida 1/261 (0.38)AHSQC (All) 88/5630 (1.56)Re-admission p=0.0760Cleveland Clinic Florida 0/261 (0)AHSQC (All) 71/5630 (1.26)SSI: surgical site infection; SSO: surgical site occurrence
123
Hernia (2019) 23 (Suppl 1):S50–S100 S82
occurrences (SSO) was 1.5% compared to the AHSQC 5.6%
(p = 0.0019). Surgical site infection (SSI), SSO requiring interven-
tion, and readmission showed a comparable incidence to the AHSQC
database.
Conclusion: Our study shows that the majority of the umbilical
hernias are done open with no mesh, with very low complications.
Our SSO rate is lower compared to AHQC, however all the other
outcome measures are comparable.
P-1181
Long-term follow-up of a randomized controlled trial
of Lichtenstein repair versus the Valenti technique
for inguinal hernia
Mitura KSiedlce Hospital, Department of General Surgery
Purpose: The aim of the study is to offer a prospective comparative
assessment of long-term outcomes for inguinal hernia repair using
Valenti and Lichtenstein techniques.
Materials and methods: 568 surgical procedures for unilateral
inguinal hernia repair using the Valenti (group V) or the Lichtenstein
technique (group L) were performed. After the mean follow-up time
of 9 years (8–12), 185 patients (70.1%) treated using Valenti method
and 186 patients (71.3%) treated using Lichtenstein method were
clinically assessed. All clinical data were registered in National
Hernia Registry. The rate of recurrence was assessed as primary
outcome. The secondary outcome involved chronic pain (VAS).
Results: 9-year recurrence rate was 2.2% in both groups. No signif-
icant difference in recurrence rate was demonstrated in analysis
adjusted for surgeon’s education, type of hernia, hernia size, hernia
duration, or BMI between two groups [OR 1.0; 95% CI 0.69–1.67;
p = 1.0]. In follow-up the majority of patients reported no pain
(71.9% in V; 73.7% in L). A constant pain was reported by 4 patients
in each group. Severe pain was reported by 1.6% in V and 2.1% in L.
Conclusions: Inguinal hernia repairs using Valenti and Lichtenstein
methods show high long-term effectiveness and do not significantly
differ in the recurrence rate. Both methods ensure a low rate of
chronic pain. The use of a single mesh size with a precisely defined
shape and of a uniform mesh fixation method ensures the standard-
ization of surgical technique. The Valenti method is an
uncomplicated, technically reproducible procedure with a low learn-
ing curve.
P-1182
The influence of different sterilization types
on mosquito net mesh characteristics in groin hernia
repair
Mitura K, Kozieł SSiedlce Hospital, Department of General Surgery
Background: In low-resource countries, a suture repair is still in
common use due to the limited access to commercial mesh implants.
The search for less expensive alternatives to the synthetic meshes has
led to using mosquito nets. Sterilized mosquito net appears to be a
low-cost and commonly available product that closely resembles
commercially available meshes. However, the extent to which ster-
ilization alters the structure of mosquito nets is still unknown. The
aim of this research was to assess the effects of different sterilization
types on physico-mechanical properties of mosquito nets.
Materials and methods: Nine different polymers were analyzed (six
mosquito nets from low-resource countries, one European net and two
commercial meshes). The analyzed parameters included: polymer
type, net surface area, fiber diameter, net thickness, mesh weight, pore
size, tensile strength and tear force. The measurements were taken
before sterilization, after sterilization at 121 �C and at 134 �C.
Results: Sterilization altered net surface and pore size, but did not
significantly alter the single fiber diameter, weave of filaments or net
thickness. Steam sterilization did not affect the tensile strength or tear
force.
Conclusions: Sterilization at 121 �C reduces the mosquito net surface
area[ 40%, resulting in a loss of macroporous structure and turning
the mesh into hard, shrunken, non-pliable masses. Sterilization at
134 �C causes some mosquito nets to melt and completely destroys
their porous structure. Maximum pressure in the abdominal cavity is
higher than the tensile strength and tear force of some locally avail-
able mosquito nets; therefore, these nets should not be used.
P-1183
Influence of ethnicity-related differences in inguinal
canal dimensions on the mesh size for open
and laparoscopic groin hernia repair in low-resource
countries in Africa
Mitura K, Kozieł SSiedlce Hospital, Department of General Surgery
Introduction: The access to surgery in Africa is significantly limited.
Treatment outcomes in Africa differ significantly compared to those
achieved in Europe or the US. Therefore, to popularise tension-free
repair, it is essential to determine the economically justified mesh size
for the African population. The aim of this study was to conduct
anthropometric evaluation of inguinal canal in African and European
patients to determine their effects on the mesh size.
Methods: The measurements were made in 44 adult males in Africa
(Group I) and were compared to measurements in 45 consecutive
Caucasian males (Group II). The mean age of patients was respec-
tively 48.3 and 51.2 years.
Results: There were no statistically significant differences in the
internal ring diameter between both (2.2 vs 2.1 cm; p = 0.58). The
distance between the pubic tubercle and the inferomedial border of
the internal inguinal ring was significantly shorter in group I (3.8 vs
5.1 cm; p\ 0.001). Similar differences were demonstrated in the
length of transverse arch aponeurosis (2.9 vs 4.0 cm; p\ 0.001). The
distance between the pubic tubercle and anterior superior iliac spine
in group I was approximately 2 cm shorter on each side (10.0 vs
11.8 cm; p\ 0.001).
Conclusions: Anatomical differences in inguinal dimensions between
Central African and European populations support the need to adjust
the standard size of synthetic mesh used for hernia repair to the needs
of local populations. The significantly smaller dimensions of the
inguinal canal in African males allow the use of smaller meshes.
P-1184
Postoperative acute pancreatitis following difficult
robotic repair of bilateral inguinal hernias
Doerhoff CCapitol Region Medical Center
Background: Post operative pancreatitis first reported by Schneider
and Sebening in 1928. For years, postoperative pancreatitis (POP)
123
S83 Hernia (2019) 23 (Suppl 1):S50–S100
was described following biliary and pancreatic surgery. Later, POP
was associated with GI tract and open heart surgery. Today, POP
maybe associated with any procedure requiring anesthesia.
Discussion: Acute pancreatitis is divided between mild and severe
pancreatitis (SAP). Mild pancreatitis is treated with IV hydration,
NPO and nutrition. 20% of patients with pancreatitis are complicated.
SAP has a mortality of 15–30%. And 30% of patients with necrotizing
pancreatitis develop a secondary infection and if left untreated, have a
mortality of 100%.
Methods: 72 year old, white male with bilateral inguinal hernias.
PMHx: robotic radical prostatectomy 2 years prior and plug patch
repair of right inguinal hernia. The patient underwent robotic expla-
nation of mesh plug with repair of recurrent right inguinal hernia and
nonrecurrent left inguinal hernia using 12 cm x 15 cm preperitoneal
mesh. Fibrin was used to glue mesh to soft tissue and permanent tacks
were used to secure mesh to coopers ligament and mesh to mesh.
Peritoneum was closed with an absorbable suture. Anesthesia time
was 4 h and 45 min, operative time was 4 h and console time was 3 h
30 min. EBL 50 cc. Patient was discharged same day post opera-
tively. Patient presented to ER first post operative day complaining of
abdominal pain. Amylase was 1812U/l and Ct scan demonstrated
acute pancreatitis.
Conclusion: Etiology of POP is unclear. Morbidity and mortality of
POP is the same as any patient developing pancreatitis. POP can
occur following any procedure requiring anesthesia. POP should be
considered for a patient who complains of severe abdominal.
P-1187
Is gender really a handicap?
East BFN Motol
Introduction: In the Czech Republic (CR), political correctness and
gender equality has not reached the levels of some western countries.
Some areas of medicine remain ‘boys clubs’ with high rates of
bossing, mobbing and other forms of bullying towards woman. The
aim of this study was to look for evidence that such activity is also
prevalent in Czech surgical specialties.
Materials and methods: All available sources (National registry of
medical statistics, Ministry of education, National sociological office,
and Czech surgical society list of members) were searched for the
numbers of female surgeons and their work positions within the team
hierarchy. Social media platforms were also searched for possible
explanations for gender disparity.
Results: 1507 surgeons are registered in the Czech surgical society.
Out of the 52 honorary members, 14 board members and 132 foreign
honorary members, there are no woman. Currently, 54% of doctors
are woman but only 20% in general and 10% in orthopedic surgery.
Out of all professors only 15% are woman although more than 60% of
university assistants are female. In surgery, less than 1% of the pro-
fessors are female and none are involved in the leadership of
university facilities. Social media provided a broad spectrum of
possible explanations—woman are perceived to be less reliable, have
poorer decision making skills, lack intelligence and manual skills.
Their lower resistance to stress is also mentioned. However,
according to a recent questionnaire among health professionals,
female staff are exposed to more stress and verbal abuse, but they take
less sick days than their male counterparts.
Conclusion: Female inferiority is a myth no longer acceptable. There
is a serious lack of female role models in surgery in the CR. It is
hoped that with international initiatives and collaborations, that this
gender imbalance will be corrected.
P-1188
High mobility group box-1: potentially a key mediator
in the development of incisional hernias
Larsen N, Reilly M, Thankam D, Fitzgibbons D, Agrawal
DCreighton University School of Medicine
Patients undergoing a laparotomy have approximately a 10–20%
chance of developing an incisional hernia (IH), although these num-
bers vary widely in the literature primarily dependent on the patient
population being studied. Regardless the morbidity, mortality, and
socioeconomic impact for treating these hernias are immense.
Although many clinical factors such as smoking, infection etc. have
been correlated with the development of an IH, few studies have
evaluated the underlying molecular mechanisms. The majority of the
reports that have been published deal with the disorganization of the
extracellular matrix (ECM), alterations in type I and type III collagen,
matrix metalloproteinases (MMPs), and tissue inhibitors of metallo-
proteases (TIMPs). However, the underlying molecular mechanism
that leads to ECM disorganization is largely unknown. We hypothesis
that sterile inflammation mediated by one of the damage-associated
molecular pattern (DAMP) molecules, high mobility group box 1
(HMGB-1), is associated with the development of IH. We tested our
hypothesis in the surgically discarded IH tissue collected from the
patients who underwent IH repair surgery using immunohistological
techniques. The H&E staining revealed ECM disorganization and
inflammation in the island of tissue harvested during the concurrent
panniculectomy and hernial sac harvested from the IH patients. The
protein expression of HMGB1 and its receptors such as TLR2, TLR4,
and RAGE, and the mediators of NLRP3 inflammasome pathway,
particularly Caspase-1, NLRP3, and ASC protein, were found to be
upregulated in these tissue specimens in comparison with the normal
control tissue. Similarly, an increase was observed in mRNA tran-
scripts as determined by qRT-PCR analysis. These findings suggest an
association of HMGB1-mediated sterile inflammation in the IH tis-
sues, however, further research is warranted to investigate the role of
HMGB-1 in the molecular pathogenesis of IH. Such findings could be
critical in identifying novel therapeutic targets in the management of
IH formation.
P-1190
74 year old with loss of domain and a massive squamous
cell carcinoma of the abdominal wall
Alkhatib H, Tastaldi L, Fafaj A, Svestka M, Petro C,
Krpata D, Prabhu A, Rosen MCleveland Clinic Foundation
74 year old male with complex past surgical history presented with
complete loss of domain, a massive wound that developed squamous
cell carcinoma, foul smelling discharge, and bloody output from his
abdominal wound. His past surgical history include perforated
diverticular disease requiring hartmann’s procedure. From there, he
developed necrotizing fasciitis in the abdominal wall requiring
extensive debridement and closure via synthetic mesh and multiple
split-thickness skin grafts. Hartmann’s was later reversed and dense
abdominal adhesions were found eroding into the small bowel with
multiple small bowel abscesses. Mesh was removed and the resulting
defect was repaired using absorbable mesh. Patient went on to
develop mesh infection and chronic infected abdominal wall, which
was biopsied and showed invasive, well differentiated, squamous cell
carcinoma.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S84
Due to multiple issues presenting at once, a comprehensible
approach was planned and a permanent repair of the defect was
deferred. Once inside the abdomen, multiple pieces of infected mesh
were exposed and removed, and enterocutaneous fistulas were taken
down. It then became apparent that what was thought to be an
infected mesh fistula was actually the tumor eroding into the right
lower quadrant and retroperitoneum. The mass was then circumfer-
entially dissected for grossly negative margins. The bowel was also
adhered to the mass and needed to be resected. Total colectomy was
performed with end ileostomy in the lateral abdominal wall. The size
of the resected mass was 30 9 30 cm, which left a massive defect in
its place. Abdominal wall was reconstructed using split thickness skin
grafting from left thigh (450 cm sq) with implantation of a 30 9
30 cm absorbable mesh. Patient recovery was complicated by high
output stoma requiring TPN, and was discharged on POD 16.
P-1192
Outcomes following robotic ventral hernia repair
Sharbaugh M, Patel P, Zaman J, Feustel P, Singh TAlbany Medical Center
Short-term success following robotic-assisted ventral hernia repair
(RVHR) is well established, however, long-term outcomes are
unknown. In this study, we followed a cohort of patients 2 years after
RVHR to demonstrate durability and examine risk factors for
recurrence.
A retrospective analysis of RVHR performed by a single surgeon
from 2012 to 2016. The technical approach for hernia repair consisted
of primary fascial closure and a pre-peritoneal mesh when possible.
The primary end-point of recurrence was determined based on
physical exam or imaging documented in the medical record.
108 RVHRs were performed over 4 years. Mean age was
52.72 ± 13.61 years, BMI was 33.07 ± 7.82 kg/m2, and hernia
defect size was 70.1 ± 86.3 cm2. 17.6% of patients were diabetic,
13.9% were smokers pre-operatively, 72.2% were ASA class 3 or
higher, and 29.6% had prior VHR. Primary fascial closure was
achieved in all RVHRs, with 23.1% requiring component separation.
Mesh was used in 97.2% of patients; 79.5% had pre-peritoneal mesh
and 17.6 had intra-peritoneal onlay mesh. 98% of patients had long-
term follow-up at a mean of 625.6 days. Recurrence rate was 12%,
with one recurrence attributed to an inguinal hernia fixed concurrently
with a midline defect. Recurrent hernia patients were more likely to
be female (p = 0.029). Otherwise, there were no statistically signifi-
cant differences in age, BMI, ASA class, incidence of diabetes,
smoking status or number of previous hernia repairs Hernia defect
size and peri-operative complications including SSO, ileus, obstruc-
tion, or any other medical complication were not predictive of
recurrence. Technical approach did not affect outcomes.
RVHR is safe and durable with a low recurrence rate at a mean of
22 months post-operatively. Female gender is a risk factor for
recurrence.
P-1193
Exhortation to lose weight prior to complex ventral
hernia repair: nudge or noodge?
DeLong C, Ssentongo P, Ssentongo A, Pauli E, Soybel DPenn State Hershey Medical Center
Background: Weight loss is advocated for obese patients contem-
plating open complex ventral hernia repair (cVHR). In this study, we
tested the hypothesis that the prospect of a major operation such as
cVHR does not alone motivate patients to sustainable weight loss.
Methods: Data on 230 patients (BMI range 30–63 kg/m2) undergoing
cVHR from January 1, 2012, to July 30, 2017, were collected retro-
spectively and analyzed. Reviewed in each record was the interval of
1 year prior to the surgeon’s initial evaluation to 1 year after
operation.
Results: For all patients, diet and weight loss were recommended
prior to operation. At the initial office visit, 121 had been losing
weight (Group A, downward trajectory) and 109 were gaining weight
(Group B, upward trajectory). By the time of operation, 56 (46%) of
patients in Group A had continued to lose weight, whereas 69 (63%)
in Group B had been motivated to lose weight (2 (1,
N = 230) = 107.9, p\ 0.0001). Of 125 patients (Groups A & B) who
had lost weight between the first encounter with their surgeon and the
time of operation, 65 (52%) regained some/all of the weight lost
before operation; of the 105 patients (Groups A&B) who had not lost
weight prior to operation, 68 (65%) had gained more weight at 1 year
follow-up. Above 40 kg/m2, pre-operative BMI was positively and
significantly correlated with post-operative hyperglycemia (OR 2.4,
95% CI 1.27, 4.76, p = 0.008) and wound occurrence (OR 2.02, 95%
CI 1.01, 3.97, p = 0.04).
Conclusions: With conventional exhortation, pre-operative weight
loss occurred only in about half of our patients, and was often
unsustainable after operation. Exhortation to lose weight before and
after surgery is likely to be perceived more as noodge than nudge,
suggesting that individualized strategies are needed to promote long-
term healthy behaviors and outcomes in obese patients undergoing
cVHR.
P-1195
Potential predictors for hernia follow-up
after emergency department discharge
Hodgdon I, Adams E, Leonardi C, Dooley D, Nguyen QLSU HSC Department of Surgery
Background: Follow-up after Emergency Department (ED) diagnosis
of symptomatic hernias are documented as low as 23%. This is
concerning since up to 3% of unrepaired hernias will eventually
incarcerate or strangulate. We studied rates of symptomatic hernias at
our institution and investigated if demographics could predict patient
follow-up.
Methods: We looked at 1 year of ED discharges (n = 375) with
ventral or inguinal hernias. Patient sex, race, ethnicity, language,
insurance type, age, body mass index (BMI), Area of Deprivation
Index (ADI), and Charlson Comorbidity Index (CCI) was collected.
Patients received emergency surgery (EMS, n = 36) or clinic
appointment (n = 339). Follow up rate and 95% CI was calculated
excluding EMS patients using the frequency procedure of SAS.
Univariate and multivariate odds to follow-up and EMS were mod-
elled using logistics regression (proc glimmix) in SAS.
Results: Follow-up rate was 52.2% [95% CI (46.9, 57.5)]. No sig-
nificant univariate association was observed between follow-up and
sex, race, ethnicity, language, insurance type, age, BMI, ADI and
CCI. However, in a multivariate analysis, the OR to follow-up
decreased by 12% [OR 0.88, 95% CI (0.80, 0.97)] for each unit
increase in CCI. There is a univariate association between EMS and
CCI. The odds of having EMS are increased by 13% [OR 1.13, 95%
CI (1.01, 1.25)] for each unit increase in CCI, although this becomes
insignificant when gender is included in the model due to females
having higher CCI.
Conclusions: Our finding of lower follow-up rates and higher EMS
rates in older patients with more comorbidities is troubling given the
123
S85 Hernia (2019) 23 (Suppl 1):S50–S100
risks posed to these vulnerable patients. We propose that institutions
modify the way they are managing older, sicker patients with
symptomatic hernias by implementing a faster ED to surgery route to
prevent follow-up loss in this population.
P-1197
Abdominal wall reconstruction with polipropilene
double mesh repair after traumatic lumbar hernia
Santos de Miranda J, Damous S, Murakami A, Yoo J,
Zuardi A, Faro Junior M, Tanaka E, Birolini C, Utiyama EClinics Hospital from University of Sao Paulo, School of Medicine
Traumatic Lumbar Hernia (HLT) presents a technical challenge due
to its anatomical region, close to bone prominence, and lesions
associated with abdominal trauma. Its surgical treatment is chal-
lenging, and there is no consensus in the literature due to the rarity of
these cases, concerning the repair technique, as well as the ideal
moment for the surgical treatment and diagnostic method to be used.
The primary objective was to verify the effectiveness of the surgical
approach with technical standardization of double mesh repair in
patients with a traumatic lumbar hernia. A prospective 30 cases series
study from 2006 to 2017, was conducted with a delayed standardized
double polypropylene repair with preperitoneal and Onlay mesh
placement, plus flank muscles reconstruction reimplanted at iliac
crest. The surgical data analysis include the relapse rate, surgical
complications, operation time, demographic characteristics of the
patients, trauma mechanisms, timing and methods used for diagnosis,
type of lesion, locations, and size of lesions. The main results found in
this study demonstrated no relapsed with one reoperation due to
chronic mesh infection. The abdominal computed tomography was
the method of choice for abdominal wall evaluation and the diagnosis,
especially at the acute phase. The delayed standardized approach was
safe and effective for the correction of traumatic rupture of the
abdominal wall. There is no physical limitation of the patients and if
the quality of life increases significantly after reconstruction of the
abdominal wall.
P-1199
Biosynthetic Scaffold mesh lowers recurrent hernia rate
in high-risk ventral hernia repair with surgical site
occurrences
Ceppa E, Parker M, Barrio M, House M, Socas J, Reed R,
Nakeeb AIndiana University Health University Hospital
Considerations for mesh use in ventral hernia repair (VHR) include
patient comorbidities and potential infection risk. Patients who are
anticipated higher risk with respect to the Ventral Hernia Working
Grade (VHWG) and CDC wound classifications tend to avoid syn-
thetic mesh in order to decrease postoperative surgical site
occurrences (SSO). A novel alternative for increased strength with
lower infection risk includes biosynthetic hybrid meshes. The goal of
this project was to assess the SSO in high risk patients who underwent
VHR with either synthetic or biosynthetic mesh over a 6-month
postoperative period. Retrospective review with data collection using
CPT4 procedural codes for ventral hernia repair in 2017 from a single
center. Associations and statistical analyses were used to compare
surgical site occurrences (SSO) in high-risk patients using either
OviTex biosynthetic or synthetic mesh. Two cohorts of 50 consecu-
tive patients who underwent VHR with OviTex biosynthetic or
synthetic mesh were compared. SSO was found in 36% of the OviTex
cohort; the majority were VHWG class 3 (61%), CDC wound
class[ II (61%), had concomitant procedures (67%), and a length of
stay (LOS) of 11 days. SSO was found in 22% of the synthetic cohort,
which included VHWG class 2 (91%), CDC wound class I (91%),
only 9% underwent concomitant procedures, and a LOS of 3 days.
Patients who underwent VHR with OviTex mesh had an increased
number of SSO, yet had higher VHWG and CDC wound classifica-
tions compared to patients receiving synthetic mesh. The OviTex
group had a higher overall number of patients with SSO but had a
significantly lower rate of hernia recurrence. Postoperative SSO
increased hernia recurrence, but less common in the OviTex group.
Overall, the data suggests that biosynthetic mesh is a more desirable
option in hernia repair in high risk patients.
P-1200
The uncommon presentation of a newborn female
with a right inguinal hernia containing testicular tissue:
a case report
McCoy K, Eveland A, Norden SStamford Hospital
An inguinal hernia is a common finding in newborn babies, occurring
more frequently in males and premature infants. This report docu-
ments the unusual finding of testicular tissue with seminiferous
tubules contained in the hernia sac of a newborn female following
open right inguinal hernia repair.
We report the case of a healthy newborn female born at 39 weeks
and 6 days by vaginal delivery with a small right-sided easily redu-
cible inguinal hernia. Her bowel sounds were active and normal
female genitalia was present. She was discharged home with outpa-
tient follow up and underwent an open right inguinal hernia repair. A
mass was noted inside the hernia sac which appeared to be gonadal
tissue adherent to the posterior wall of the sac. We took a small wedge
biopsy and then performed a high ligation of the hernia sac, which
was removed and sent for pathology. The pathology results of the
biopsy tissue showed testicular with seminiferous tubules. Inguinal
hernias in female infants are normally caused by a patent processus
vaginalis that does not obliterate during gestation. While such hernias
typically contain ovarian tissue, in this case we present the unusual
case of an inguinal hernia in a healthy female infant that contained
testicular tissue and seminiferous tubules.
P-1204
Pilot study: utilization of quantitative measures
to predict opioid usages in patient undergoing hernia
repair
Prasath V, Chen Y, Harmon J, Duncan M, Bicket M,
Adrales G, Nguyen HJohns Hopkins- Bayview Medical Center
Evidence shows patients with diagnoses of depression and anxiety
have an increased risk of substance abuse. We sought to determine
whether opioid usage after elective surgery is associated with pre-
operative depression and anxiety.
A pilot study using validated questionnaires to measure depression
and anxiety were administered pre-operatively to patients undergoing
elective inguinal herniorrhaphy, followed by standardized post-oper-
ative interviews measuring opioids and pain outcomes. We assessed
for depression severity (Patient Health Questionnaire-9, PHQ-9), risk
123
Hernia (2019) 23 (Suppl 1):S50–S100 S86
of opioid misuse (Screener and Opioid Assessment for Patients with
Pain-Revised, SOAPP-R), anxiety (Anxiety Sensitivity Index, ASI)
and catastrophizing (Pain Catastrophizing Scale, PCS) pre-opera-
tively. We compared patients with high use of opioids after surgery
([ 5 pills) to those with low/no opioid use.
Of 12 patients recruited, most were male (83%) and white (75%),
with median age 59 (IQR 57–64). A majority of repairs were per-
formed laparoscopically (67%), while four (33%) underwent open
repairs. Three (25%) patients were taking pain prescriptions pre-op-
eratively and two (17%) of the three were taking oxycodone. All
patients were prescribed Oxycodone (5 mg tabs) after surgery, with 8
high users and 4 low/no opioid users. Compared to low/no users,
regular opioid users had a higher baseline catastrophizing, with sig-
nificantly higher scores in the area of Rumination (p = 0.029) and
Magnification (p = 0.028) but not Helplessness (p = 0.093). High
opioid users’ median PCS score was 15 points higher, their median
ASI score was 5 points higher, their median PHQ-9 score was 2 points
higher, and their median SOAPP-R score was 4 points higher than
low users. This places them at a greater risk for misusing opioids
taken in the long-term.
There may be a correlation between a patient’s post-operative
opioid usage and their depression severity, anxiety sensitivity, or pain
catastrophizing measured with PHQ-9, ASI, and PCS, respectively.
P-1205
Incisional hernia repair after orthotopic liver
transplant: a match control study
Lo Menzo E, Ortiz Gomez C, Romero Funes D, Frieder J,
Fonseca Mora M, Milla Matute C, Szomstein S, Rosenthal
RCleveland Clinic Florida
Background: The Incidence of ventral incisional hernia (VIH) after
orthotopic liver transplant (OLT) has been reported up to 30%.
Transplant patients have an increased risk of complications and a
higher rate of recurrence after VIH repair. The aim of this study is to
determine the outcomes of VIH after OLT.
Methods: All the patients who underwent VIH at our institution and
recorded the American Hernia Society Quality Collaborative
(AHSQC) were reviewed from November 2012 to August 2018.
Patients who had previous OLT were identified and matched in a 1:1
to a control population by age, gender, BMI and comorbidities.
Postsurgical outcomes were compared.
Results: A total of 677 patients were reviewed, of which 49% (315)
underwent VIH and 51% (362) primary ventral hernia repair. From
the VIH repair group, 2.85% (9) had history of previous OLT. We
observed a homogeneous population regarding gender and predomi-
nant white ethnicity in both groups. Transplant patients were noted to
have a higher preoperative ASA score compared to control (77.78%
vs 44.44%, p = 0.1469). The most common type of repair was
laparoscopic for OLT and control groups (55.56% and 77.78%,
respectively). Patients in the control group were found to have a
shorter Length of Hospital Stay (LOS) and a predominant operative
time less than an hour (0.25 ± 0.71 vs 3.43 ± 1.72, p = 0.0003 and
11.11% vs 55.56%, p = 0.0455; respectively). Patients in the trans-
plant group had significantly larger defects (13.11 ± 8.88 vs
5.44 ± 2.30, p = 0.0233 for length and 12.67 ± 9.760 vs
5.00 ± 2.00, p = 0.0346 for width). No readmissions, reoperations or
complications were reported in any of the groups.
Conclusions: VIH repair seems to be safe in patients with history of
OLT. VIH defects in this population tend to be larger compared to
other causes of VIH. Consequently, longer LOS and Operative times
were observed for this population.
P-1206
Open ventral hernia repair (VHR)
with panniculectomy, panniculectomy denied
by insurance and without panniculectomy
Arnold M, Otero J, Huntington C, Prasad T, Colavita P,
Augenstein V, Heniford BCarolinas Medical Center
Aims: Open VHR with concomitant panniculectomy (CPVHR)
allows for excellent operative exposure and excision of poor quality
tissue. However, insurance denial often limits concomitant pan-
niculectomy (DPVHR). This study compares outcomes of patients
undergoing CPVHR, DPVHR, and those not offered panniculectomy
(NOVHR).
Methods: A prospectively collected database was queried
(1999–2017). QOL was assessed with the Carolinas Comfort Scale
(CCS). Pairwise and multivariate analysis (MVR) compared NOVHR,
CPVHR, and VHRDP.
Results: 2158 patients underwent 1529 NOVHR, 587 CPVHR, and
55 DPVHR. DPVHR were younger compared to NOVHR and
CPVHR (53.4 vs. 56.7 vs. 57.3; p = 0.03), had larger defects
(304.4 cm2 vs. 285.1 cm2 vs. 146.5 cm2), more frequent preperitoneal
mesh placement (94.1% vs. 83.2% vs. 93.0%), and components
separation (64.8% vs. 35.0% vs. 53.7%); (all p\ 0.0001). CPVHR
had more diabetics than NOVHR or DPVHR (34.7% vs. 20.8% vs.
31.4%), higher BMI (36.7 vs. 32.2 vs. 35.3), and more previously
failed hernias (75.8% vs. 54.2% vs. 74.6%); (all p\ 0.001). On
pairwise analysis there was no significant difference between
NOVHR, CPVHR, and DPVHR in outcomes including length of stay
in days (6.8 vs. 8.2 vs. 6.5), readmission (7.1% vs. 14.0% vs. 9.3%),
hernia recurrence (10.6% vs. 7.4% vs. 1.9%), seroma (17.7% vs.
23.6% vs. 22.6%), or cellulitis (8.5% vs. 17.4% vs. 7.6%). On MVR,
CPVHR had increased odds of wound complications (OR 1.5, CI
1.01–2.4), but no difference in hernia recurrence (OR 1.3, CI 0.6–2.6),
pneumonia, respiratory failure, or readmission. QOL at 1, 6, 12, and
24 months was equivalent between groups in all CCS domains.
Conclusion: Panniculectomy during VHR is associated with
increased complications, but has equivalent quality of life. CPVHR
was not associated with hernia recurrence on MVR. This may be due
to increased use of CPVHR in contaminated surgical fields. This data
suggests that concomitant panniculectomy can safely be offered to
select patients, but is not a routine component of ventral hernia repair.
P-1207
Endoscopic-assited linea-alba reconstruction plus mesh
fixation for treatment of umbilicus hernia, epigastric
hernia and rectus abdominis diastasis: preliminary
results of a single center
Youssef M, Brasil H, Amaral P, Barros P, Altenfelder Silva
R, Barchi L, Pivetta L, Roll S, Zilberstein BSanta Casa de Sao Paulo School of Medical Sciences
Aim: The management of primary ventral hernias with contiguous
rectus diastasis remains debatable. We aim to report our initial
institutional outcomes with a laparoscopic-assisted plication of rectus
diastasis (RD) with concomitant ventral hernia repair.
123
S87 Hernia (2019) 23 (Suppl 1):S50–S100
Methods: Consecutive patients who have undergone the repair of
umbilical or epigastric hernias associated with contiguous RD were
identified in a prospectively maintained database. Surgeries involved
a laparoscopically-assisted dissection of the subcutaneous space along
with closure of the hernia defect and plication of RD with barbed
sutures in a running fashion. A permanent synthetic mesh in onlay
position was placed and fixated with adhesives. Outcomes included
wound complications, unplanned reoperations, length of hospital stay
and hernia recurrence. Recurrence was determined either by clinical
examination, imaging studies or using the Ventral Hernia Recurrence
Inventory.
Results: Fifteen patients were identified (mean age 47 ± 10, BMI
26 kg/m2 and 80% males). Mean hernia width was 3 cm (± 1) and
60% patients had concurrent umbilical and epigastric hernias in
addition to the RD. Mean operative time was 110 min (± 16), there
were no intraoperative complications or conversions. All patients
remained with closed suction drains in place for an average of
15 days. There were three surgical site infections (2 superficial, one
deep), and one patient demanded mesh removal due to mesh infec-
tion. After a median 18 months (IQR 17–22) follow-up, recurrence
rate was 13.3%.
Conclusion: Preliminary results of this technique when performed at
our institution appear favorable. Further studies with multi-institu-
tional experiences and larger number of patients are necessary to
determine the role of this surgical technique in the armamentarium of
the hernia surgeon.
P-1208
Outcomes of incisional hernia repair in obese patients
from the AHSQC database: a single institution
experience
Lo Menzo E, Ortiz Gomez C, Frieder J, Fonseca Mora M,
Milla Matute C, Bellini A, Szomstein S, Rosenthal RCleveland Clinic Florida
Background: Obesity has been associated with an increased rate of
complications and a higher rate of recurrence after incisional hernia
repair. We aim to determine the effect of BMI in the laparoscopic and
open approach for incisional hernia repair.
Methods: We reviewed our prospectively recorded data in the
American Hernia Society Quality Collaborative (AHSQC) from
November 2012 to August 2018. Patients who underwent incisional
hernia repair at our institution were included. The population was
divided into two groups, BMI C 30 and BMI\ 30 and an indepen-
dent analysis was done for laparoscopic and open approaches in both
groups. Description of basic demographics and comorbidities was
performed. ASA scores, number of prior recurrences and outcomes
were compared.
Results: A total of 643 patients were reviewed from which 49% (315)
underwent incisional hernia and 51% (328) ventral hernia repair.
From the incisional hernia group, 56.19% (177) had a BMI C 30 and
41.90% (132) a BMI\ 30. We observed a predominant male and
white population and a similar mean age in both groups
(60.09 ± 0.78 vs 60.78 ± 0.97; p = 0.5766). Obese patients were
noted to have a higher preoperative ASA compared to non-obese
(ASA3 47.48% vs 24.17%, p = 0.0004 and 52.63% vs 24.39%,
p = 0.0098; laparoscopic and open approach respectively). Although
not statistically significant, there was a trend for obese patients to
have the procedure done open (67.57 vs 38.13, p = 0.0950, and 32.43
vs 42.10, p = 0.2333; respectively). There was no statistical differ-
ence between obese and non-obese regarding operative time,
readmission or reoperation rate for either laparoscopic or open
approach. However, a higher laparoscopic-to-open conversion rate
was observed in the obese population (4.52 vs 1.52, p = 0.1958).
There was no statistically significant difference in defect-size for
either group. Length of stay (LOS) was significantly lower in the non-
obese population who underwent laparoscopic repair.
Conclusions: Obese patients have a higher laparoscopic-to-open
conversion rate. Although complication rates in obese and non-obese
patients did not differ in either approach, obese patients who under-
went laparoscopic repair seem to have a longer LOS.
P-1209
A case of a spermatic cord sarcoma following
a laparoscopic bilateral inguinal hernia repair
Eid M, White BDartmouth Hitchcock Medical Center
Soft tissue sarcomas of the genitourinary tract are exceedingly rare
malignancies with spermatic cord sarcomas accounting for less than
2% of all urologic tumors. While these typically present as painless
slow growing testicular masses, we describe a case of a spermatic
cord myxofibrosarcoma presenting as a recurrent inguinal mass a
month after a bilateral laparoscopic inguinal hernia repair.
A 57 year-old gentleman presented to his general surgeon with a
recurrent right groin mass 1 month after a laparoscopic bilateral
inguinal hernia repair. The post-operative course was uncomplicated,
and the mass was asymptomatic.
On exam, he had a non-reducible, firm painless right groin mass in
the location of his previous hernia. Physical exam confirmed
intrascrotal location of bilateral testis and ultrasound of the right
inguinal canal revealed a solid 4x3 cm lesion with vascularity. The
patient was offered core needle biopsy to help establish tissue diag-
nosis, but he desired direct surgical intervention.
At the time of open right inguinal exploration, a solid mass was
found along the spermatic cord, initially thought to be possible
ischemic lipoma after laparoscopic repair. Frozen section pathology
demonstrated an 8.5 cm invasive malignancy. Intraoperative urologic
consultation was obtained, and a sarcoma was considered the likely
diagnosis. The patient underwent an oncologic resection of the mass
with a right radical orchiectomy and high ligation of the spermatic
cord. Final pathology was consistent with high grade myxofibrosar-
coma and he underwent post-operative XRT to the right groin.
This case illustrates the small but real potential of failing to
diagnose inguinal canal neoplasm at time of laparoscopic inguinal
surgery. Malignancy and the need for potential orchiectomy should
strongly be considered in any vascularized, solid masses of the
inguinal canal arising even after seemingly uncomplicated laparo-
scopic inguinal hernia surgery.
P-1210
Morbidity and readmissions after laparoscopic
recurrent inguinal hernia repairs: comparison
to NSQIP database
Lo Menzo E, Frieder J, Sarmiento-Cobos M, Milla Matute
C, Ganga R, Rammohan R, Szomstein S, Rosenthal RCleveland Clinic Florida
Background: The outcomes of laparoscopic repair of recurrent
inguinal hernia after previous open repair are not frequently reported.
We report short term outcomes over the last 5 years and compared
123
Hernia (2019) 23 (Suppl 1):S50–S100 S88
them to the National Surgical Quality Improvement program (NSQIP)
database.
Methods: We retrospectively reviewed our laparoscopic recurrent
inguinal hernia repairs performed between 2010 and 2016. The
30 day readmissions, reoperations and post-operative complications
were compared to same outcomes from NSQIP. To reduce the effect
of confounding factors we used propensity case match. All tests were
two-tailed and performed at a significance level of 0.05.
Results: A total of 176 cases from our institution were compared to
3431 of the NISQIP database. Base line characteristics and co mor-
bidities were significantly different between the groups prior to the
match. Our cohort had older patients (64.8 ± 13.8 vs 61.83 ± 15.38
p\ 0.001) with higher incidence of renal Failure (18.75 Vs 0.15,
p\ 0.001) and CVA (7.95 vs 0.06,\ 0.001). Following the
Propensity case match, the reoperation rates, post op wound infection,
post op PE, post op renal failure and post op bleeding rates were
similar. However, 30 day readmission (14.77 vs 3.64, p\ 0.001),
pneumonia (1.7 vs 0.11, p = 0.01), urinary retention (5.11 vs 0,
p\ 0.001) were higher in our cohort. The operation time was higher
in our population (98.3 ± 39.89 vs 73.06 ± 44.76 p\ 0.001).
Conclusion: We conclude that the higher 30 day readmission,
pneumonia and urinary retention are attributed to the increased age
and comorbidities in our cohort.
P-1211
Intercostal incisional flank hernia after open
nephrectomy: a case report
Santos de Miranda J, Batistela F, Damous S, Faro Junior
M, Zuardi A, Yoo J, Tanaka E, Birolini C, Utiyama EClinics Hospital, Sao Paulo School of Medicine
Intercostal hernias are rare protrusions from abdominal contents due
to the previous incision at the lateral abdominal wall. They are seen
most commonly at the lower part at the lateral abdominal wall nearby
weak portions like the inferior lumbar triangle. Even when the ribs
protect the lateral intercostal area if a herniation is present, the patient
has a high risk of incarceration and strangulation. Retroperitoneal fat,
the liver, small and large bowel, even the stomach and the spleen can
be present as a hernia contend. We present a successful case of a
single mesh polypropylene preperitoneal repair. An 83-year-old
female patient was treated at Abdominal Wall Surgery Group from
the III Clinical Division at Clinics Hospital, Sao Paulo School of
Medicine. She had a past medical history of hypertension and right
open nephrectomy with 20 cm incision at the age of 69, due to renal
cell carcinoma. There isn’t any complication after this procedure.
After 6 months appeared a progressive bulging at the primary incision
portion, just between the 10th and 11th intercostal space. The patient
does not look for medical treatment because of the few symptoms.
The bulged increase and the patient complained of high degree pain
during Valsalva. The computer abdominal tomography confirms the
diagnostic and reveals the right hepatic lobe into the hernia sac. An
open surgical procedure was done with an incision at the site of the
previous one, following extensive preperitoneal dissection with full
reduction of the abdominal content. The hernia sac was resected and
closed by continuous absorbable sutures. A synthetic, monofilament,
nonabsorbable high large pore polypropylene mesh reinforced the
weakness incisional area and was fixed by six rapid absorbable stit-
ches at the preperitoneal space previous dissected. After 1 year
follow-up, the is no recurrence and all symptoms resolved.
P-1213
Epidemiological profile of patients diagnosed
with abdominal wall hernias in a public hospital
in Salvador
Pedreira Junior N, Bastos C, Santos F, Santana Neto O,
Cunha V, Guimaraes V, Rivison M, Cunha LHospital Geral Ernesto Simoes Filho
Introduction: Complex hernias have an increased difficulty and a
high time consumption for the surgical treatment. According to the
guidelines of the European Society of Hernias, we can define it as
complex by analyzing various criteria, such as its size, location, tissue
condition, patient history and previous abdominal surgeries. Other
important criteria are related to the presence of obesity, malnutrition
or diabetes. The correct surgical indication aims to circumvent the
difficulties of the treatment and restore the functionality of the
abdominal wall of these patients, exposing it to the lowest possible
risk.
Metodology: This is a descriptive, prospective, case-series study of
patients diagnosed with a complex hernia, using retrospective infor-
mation obtained from the surgical protocols and patient’s charts at the
Ernesto Simoes Filho General Hospital (Salvador, Bahia, Brazil), as
well as the literature reviews.
Results: During the study, 61 patients were admitted at the abdominal
wall ambulatory. 43 were woman, representing 70.4%. The mean age
was 54.6 years, varying from 31 to 80. Obesity was present in 56.3%
of the patients and overweight in 25.5%. 50% of the patients had
systemic arterial hypertension. The classification was mainly inci-
sional (93.4%) and 39.7% had a history of recurrence. 4 patients
relapsed more than 4 times. Regarding the location of the hernias,
81% of the patients presented midline hernias; 5.1% iliac fossa; 5.1%
inguinal; 3.6% inguinoscrotal; 3.6% subcostal; 1.8% lumbar. There
was a loss of domain in 67% of the cases.
Conclusion: The high prevalence of the epidemiological character-
istics demonstrated (age, gender, obesity, associated comorbidities,
presence of incisional hernia, mainly in the midline, and loss of
domain) emphasizes the importance of knowing the clinical profile of
hernia patients to the definition of its diagnosis, complexity and future
surgical therapy.
P-1214
Concomitant panniculectomy with complex ventral
hernia repair: increased surgical site occurrences does
not alter recurrence rates
Alimi Y, Devulapali C, Caso R, Jackson B, Falola R, Sosin
M, Evans K, Nahabedian M, Bhanot PMedstar Georgetown University Hospital
Background: Ventral Hernia Repairs (VHR) in obese patients can
have high complication and recurrence rates, partially contributed
from excess anterior abdominal skin and subcutaneous tissue
inhibiting exposure and adding tension to the repair. Studies exam-
ining the safety of a combined procedure have yielded conflicting
results. We appraised our outcomes with combined VHR/pan-
niculectomy in comparison to a matched cohort of patients receiving
VHR alone.
Methods: A retrospective review was conducted on all patients
undergoing VHR ± panniculectomy from 2007 to 2017. The
VHR/panniculectomy group was matched 1:1 by age and BMI to
VHR alone. All panniculectomies were performed by a plastic sur-
geon. Patient demographics, comorbidities, operative variables, and
123
S89 Hernia (2019) 23 (Suppl 1):S50–S100
outcomes were collected. Descriptive statistics and Chi squared test
were used to compare the two groups.
Results: A total of 43 patients underwent VHR/panniculectomy and
were matched by age and BMI to 41 patients undergoing VHR alone
(n = 84). Two patients from the VHR/panniculectomy were unable to
be matched because lack of a patient with comparable BMI in the
VHR group. There was no significant difference between the two
groups in regard to patient demographics, comorbidities, and opera-
tive variables. There was no significant difference in the overall
complication rates between VHR/panniculectomy and VHR alone
groups (33 v. 20%, p = 0.17). Surgical site occurrences were signif-
icantly higher in the VHR/panniculectomy group (30 v. 10%,
p = 0.02). However, the hernia recurrence rate was identical at 7%.
Conclusion: Complex ventral hernia repair with concomitant pan-
niculectomy in obese patients is associated with increased risk for
surgical site occurrences. However, the long-term recurrence rate is
not affected. Additionally, the improvement in patient satisfaction and
quality of life with panniculectomy should be considered.
P-1215
Opioid prescribing trends in the acute surgical setting
Hlavacek C, Frey A, Wood BBrookwood Baptist Health, General Surgery Residency
Background: Opioid overdose is the leading cause of injury-related
death in the United States. Majority of current narcotic research
studies chronic pain and does not address the acute surgical setting.
Alabama is consistently one of the highest opioid prescribing states in
the country. Our project sought to evaluate our program’s prescribing
trends compared to other non-affiliated surgeons and to actual patient
need.
Methods: A survey was distributed to all Brookwood Baptist (BB)
surgeons and residents, as well as to non-affiliated surgeons in an
online forum, the National Robotic Surgery Collaboration (non-BB).
The various narcotics prescribed were compared using Morphine
Milligram Equivalent (MME) conversion. Prospective data was col-
lected for 50 robotic inguinal hernia repairs performed by the same
surgeon. All patients were discharged the same day and given 30
Norco/Percocet 7.5 mg. On the first postop visit, patients reported
how many pills they had required. Student t-tests were used to
compare prescriber habits.
Results: There were 80 survey respondents, 32 BB and 48 non-BB.
BB-affiliated surgeons prescribed significantly higher MME than non-
BB surgeons; on average 55% more (158.1 vs. 102.2, p\ 0.001). BB
residents and faculty did not exhibit differences in prescribing trends
(p = 0.62). The quantity of narcotics consumed at the first postop visit
in the prospective study averaged ten 7.5 mg Norco/Percocet or 76.1
MME.
Conclusion: Compared to current literature recommendations (75
MME), majority of surgeons, BB and non-BB, are prescribing too
many narcotics after inguinal hernia repair. Our study shows that
patient need is representative of this ideal 75 MME recommendation.
With this information, surgeons have a unique opportunity to modify
their prescribing trends and potentially help tackle the opioid epi-
demic by decreasing the possibility for postop opioid dependence and
eliminating excess narcotics that may be distributed to unintended
persons.
P-1217
Correlation of mesh size and ileus with laparoscopic
ventral hernia repair
Albertson S, Figueroa C, Smith M, Barrios CUniversity of California, Irvine
Laparoscopic repair has become a widely popular technique for
ventral hernias. One significant complication is post op ileus. This can
lead to discomfort and prolonged hospital stay for the patient. We
hypothesized that mesh size/surface area would correlate with the
development of ileus. Methods: We analyzed the data of 75 patients
that underwent laparoscopic ventral hernia repair with mesh. Logistic
regression was used to relate mesh size to the development of ileus.
Student’s t test was used to compare hospital length of stay in patients
with and without ileus.
Results: Ileus developed in 7 patients. Patient with ileus had a larger
mesh size but this did not achieve statistical significance (309 v 261,
p = 0.41). There was an increased odd ratio of 1.02 per 10 cm
squared. In other words, each 10 cm squared increase in size
increased the risk of ileus by 2% but again this did not reach statistical
significance. There was a significant difference in hospital length of
stay in patients with ileus v no ileus (7.7 v 2.5 days).
Discussion: Our data indicates that patients with ileus after laparo-
scopic ventral hernia repair experience significantly longer hospital
stays. However, increasing mesh size only weakly correlates with
increase in risk for ileus and is not predictive of which patients may
develop an ileus. Therefore, consideration of mesh size will not assist
in assessing which patient s may benefit from longer post op obser-
vation. Further studies to assist in the determination of patients at risk
for ileus after ventral hernia repair are warranted.
P-1218
Does preoperatve American Society of Anesthesiologists
(ASA) classification predict the risk of recurrence
after incisional hernia repair?
Lo Menzo E, Maria F, Cristian M, Joel F, Camila O,
Samuel S, Raul RCleveland Clinic Florida
Introduction: The ASA classification system is performed preoper-
atively to assess the risk of complications during surgery, however no
evaluation among each category has been conducted to its possible
association with hernia recurrence. The purpose of the study is to
determine the correlation between ASA classification and likelihood
of incisional hernia recurrence.
Methods: After IRB approval, we reviewed all patients entered in the
AHSQC database from July of 2012 to September of 2018. Patients
with recurrent incisional hernia repair were compared to patient who
had incisional hernia repair for the first time. The population was
matched for age and gender in a ratio 1:2. Assessment for physical
functional status prior to surgery was performed.
Results: Of 337 patients with incisional hernia, 116 patients had
recurrence. After matching populations; the overall mean age was
59.3 ± 12.3 years, leaded by male in 53% (n = 180). Predominance
of ASA class among recurrent and not-recurrent incisional hernia
patients was as follows; ASA Class 3 in 51% (n = 53) and 35%
(n = 79) respectively, followed by ASA Class 2 in 49% (N = 57) and
58.3% (n = 129) respectively. Additionally, ASA Class 1 and 4 were
predominant in the recurrent hernia group. When analyzed the
recurrent group alone; no statistical significance was found for
reoperation (p = 0.9) or operative approach used (p = 0.42). Wider
123
Hernia (2019) 23 (Suppl 1):S50–S100 S90
defect size and wider mesh was not correlated to ASA class 3
(p = 0.000 and p = 0.001 respectively). Hernia and mesh width for
ASA class 3 of 8.1 cm (range 1.5–22 cm) and 16.5 cm (range
7–33 cm) respectively followed by ASA class 2 on Average 7.3 cm
(range 2–22.5 cm) and 15.8 cm (range 4–30 cm) on average respec-
tively. The likelihood of having a larger or wider hernia was not
statistically significant for any of the cases (p = 0.22 and p = 0.48
respectively).
Conclusion: The individual ASA score does not predict the risk of
recurrence, nevertheless patients with wider defects and recurrent
incisional hernias are often categorized among ASA classs 2 or 3.
P-1219
Use of progressive pneumoperitoneum in the repair
of giant inguinal hernia
Sanchez-Montes IGeneral Hospital Tlahuac
Introduction: Giant inguinal hernia are usually found in developing
countries due to delay in seeking medical attention. The operative
treatment of giant inguinal is a challenge for surgeon. Often obesity,
renal and cardiopulmonary diseases are predisposing factors for the
development of those hernias. Goni Moreno (1947) was the first the
use of progressive pneumoperitoneum with successful. The aim of
this technique is insufflation of air into the abdominal cavity in order
to make room to accommodate herniated viscera, through of catheter
in abdominal wall and to avoid in postoperative abdominal com-
partment syndrome.
Purpose: The purpose of this paper has presented the results using a
progressive pneumoperitoneum repair technique apply in giant
inguinal hernia.
Materials and methods: From 2001 until 2018 progressive pneu-
moperitoneum (PP) has been performed 6 patients with giant inguinal
hernia. Five of them had primary hernia and one had a recurrence.
The mean age of the patients was 65.5 (65–91) years. The BMI was a
mean 32.36. All of them had concomitant diseases such as hyper-
tension, chronic obstructive lung disease or diabetes. The PP
technique involves insufflating natural ambient air into abdominal
cavity by Tenckhoff catheter dialy from 400 to 1000 cc per day over
7–14 days. Every day measures urinary volume, abdominal circum-
ference, and every 2 days creatinine and urea were determined. It had
used low dose heparin prophylaxis during all procedure. It perfor-
mance inguinal repair by general anesthesia, in five patients used
Lichtentein technique and one was Rives with polipropilene mesh.
Results: All patients complained nausea, and loss weight because
they did not have appetite by abdominal distention. Only one patient
in postoperative had big hematoma, required orquidectomy.
Conclusion: The use of PP in the repair of giant inguinal hernia
avoids complication like abdominal compartment.
P-1220
Surgical site occurrence following abdominal wall
reconstruction within the 30-day postoperative period:
an AHSQC analysis
Lo Menzo E, Maria F, Cristian M, Carlos R, Camila O,
Rene A, Samuel S, Raul RCleveland Clinic Florida
Introduction: The component separation technique has been widely
used for large incisional hernia repair. The aim of this study is to
report the incidence of surgical site occurrence requiring procedural
intervention (SSOPI) after open ventral hernia repair with abdominal
wall reconstruction (AWR).
Methods: After IRB approval, we reviewed all the patients entered in
the AHSQC database from July of 2012 to September of 2018.
Patients who had AWR were then selected for the study. Stratification
depending on the size of the defect and SSOPI was performed. SSOPI
was defined as need for the following types of re-intervention: wound
reopening, debridement suture excision, percutaneous drainage, or
mesh removal during the 30-day postoperative period. The hernia size
was measured by preoperative CT-scan.
Results: From a total of 643 patients, AWR was performed in 2.48%
(n = 16) patients. SSOPI was found in 25% (n = 4) patients presented
regardless of the hernia width (HW). The average age of the study
group was 59.13 years. When the patients were stratified by hernia
size, 25% (4 out of 16) developed SSOPI. Of which all had hernia
defect size average of 17.9 cm (SD 15; range 10–25 cm) of Length
and 15 cm (SD 4.8 cm; range 13–22.3 cm) of width. Among the
patients who did not developed SSOPI; 75% (n = 12), the defect size
was 13.3 cm (SD 5.2; range 5–17.2 cm) and 12.1 cm (SD 3.8; range
6.2–13.5 cm) for length and width respectively. No statistical sig-
nificance was found between the groups for length (p = 0.13) or width
(p = 0.22). After multivariate analysis the type of mesh was statisti-
cally significant (P = 0.41), and permanent synthetic vs biological
mesh were statistically significant (p = 0.05). Non-healing wound had
higher Hernia length (25 cm) and HW (22.3 cm) when compared to
deep surgical site infections and seroma. Appropriate treatment was
given without complications.
Conclusion: The initial hernia size and the location of the mesh did
not seem to be a predictor of developing surgical site occurrence
requiring procedural intervention after open ventral hernia repair with
abdominal wall reconstruction, however the type of mesh must be
considered when intervened.
P-1223
Indications and results of the use of progressive
preoperative pneumoperitoneum (Ppp) in patients
with complex hernias with loss of domain
Pedreira Junior N, Mendes R, Dutra V, Santos F,
Guimaraes V, Cerqueira C, Cunha L, Cancado AHospital Geral Ernesto Simoes Filho
Introduction: PPP is used in correction of complex hernias with loss
of domain (LD). It promotes an increase of abdominal cavity volume
(ACV), reestablishes the intra-abdominal pressure (IAP) and
diaphragmatic function. Literature indicate it when relation between
hernia sac volume (HSV) and ACV (LD) is greater than 20–25% or in
large defects.
Methods: Prospective study on the effects and results of the use of
PPP in cases of complex hernias with LD, attended to by the
abdominal wall group of Ernesto Simoes General Hospital, in Sal-
vador, Bahia, Brazil. The analyzed variables were: gender, age, BMI,
indications, time, total gas volume and complications of PPP and
increase of ACV.
Results: From August 2017 to July 2018, PPP was used in 9 cases.
Mean age was 56 years (38–79), female (60%), mean BMI at
admission 30.4 (19.1–46.5), mean volume ratio 43% (8%–114%),
mean total gas volume was 15.2 L (7.5 L–28 L) and mean ACV
increase was 58% (13–106). About 5 patients had dyspnea, 1
abdominal pain, 1 nausea and vomiting, 1 shoulder pain, 3 had no
symptoms associated with PPP.
123
S91 Hernia (2019) 23 (Suppl 1):S50–S100
Discussion: Tanaka, et al., systematized the volume calculation by
CT and performed PPP when LD[ 25%. Sabbagh, et al. used PPP
when LD[ 20%, because there may be already a risk of an increase
in IAP and need for viscerorreduction. Torregrossa-galud, et al. used a
mean total ambient air volume of 8.6 L (4.5–13.3 L), with daily
insufflation of 500–1400 ml for 13–16 days. Renard et al., used
2000 ml/day for 14 days. During the study, the daily and total mean
of infusions performed was similar to the literature.
Conclusion: This study presents results in accordance with the lit-
erature. However, there is no consensus on standardization on the best
technique, indication and time used in literature.
P-1225
Results of component separation technique
in a Brazilian Public Hospital: series of cases
Pedreira Junior N, Dourado M, Santana Neto O, Mendes R,
Guimaraes V, Cancado A, Cunha LHospital Geral Ernesto Simoes FIlho
Introduction: The component separation technique (CST) is one of
the multiples options for repair of large abdominal wall defects,
correction of hernias related to multiple approaches, necrosis or
infection of abdominal wall. The technique is based on an advance-
ment flap of the rectus abdominis muscle, which allows
reconstruction of the abdominal wall, maintaining adequate tension
and preserved physiological function. When correctly indicated, it
presents low complication rates, and the previous CST presents a rate
of 10% of relapses, compared to 30% of recurrences, when a large
ventral hernia surgery is used.
Methodology: This is a descriptive, prospective, case-series study of
patients diagnosed with a complex hernia, using retrospective infor-
mation obtained from the surgical protocols and patient’s charts at the
Ernesto Simoes Filho General Hospital (Salvador, Bahia, Brazil), as
well as the literature reviews.
Results: For this study, the component separation technique was
applied in patients with hernial ring diameter greater than 10 cm, in
elective surgeries in patients followed by the complex hernia outpa-
tient clinic HGESF. Data from 12 patients (n = 12) were analyzed,
being 6 men and 6 women, with a mean BMI of 30.6, who had
incisional hernias. Only 3 had a history of recurrence, with an average
of 2 relapses per patient. 8 presented giant defects ([ 15 cm), and 4
had a large defect (10–15 cm), with an average defect of 16 cm. The
screen was placed as onlay in all patients, underwent general anes-
thesia, with an average surgical time of 4 h (± 2.15). They have been
followed up on an outpatient basis for 6 months on average, with
some patients with up to 12 months of follow-up and 0 recurrences to
date.
Conclusion: This work presents the efficacy of the anterior compo-
nent separation technique in the treatment of large complex hernias.
P-1227
Improving post-operative outcomes for abdominal wall
reconstruction through an enhanced recovery protocol
Voigt C, Whitenack N, Vonk J, Collister P, Brown S,
Maloley-Lewis B, Mukkai Krishnamurty D, Fitzgibbons RCreighton University
Introduction: Enhanced recovery after surgery (ERAS) protocols
have shown efficacy in decreasing re-admissions, length of stay
(LOS), and post-operative complications. The effect of ERAS
protocols in improving post-operative outcomes in patients under-
going abdominal wall reconstruction (AWR) has not been studied. In
this study, we evaluated post-operative outcomes following imple-
mentation of a resident driven implementation of ERAS protocol in
patients undergoing AWR in a single institution.
Methods: A single surgeon (RJF) began implementation of the ERAS
protocol in 10/2017 in all patients undergoing AWR (N = 14) with
multimodal pain management (intra-thecal morphine, IV ketamine
and lidocaine, magnesium, ketorolac, IV and oral acetaminophen,
gabapentin and rescue oral narcotics), early ambulation, immuno-
nutrition, early post-operative diet, and removal of foley catheter on
POD 1. These patients were compared to a historical cohort of 23
patients from 4/2015 to 9/2017 who received a combination of
epidural and IV narcotics for pain management, and foley catheter in
place till epidural was discontinued. Charts were reviewed for
demographic information and outcomes including LOS, readmission,
and urinary retention. Data were analyzed with Student’s t-test and
Fisher’s exact test as appropriate. A linear regression model was used
to assess LOS, adjusting for age and sex. P value\ 0.05% was
considered significant.
Results: There was a significant difference in age (pre-ERAS
60 ± 14 years, post-ERAS 48 ± 16 years, p\ 0.01). There were no
significant difference in sex. There was a significant improvement in
LOS (pre-ERAS 5.7 ± 2.2 days, post-ERAS 4 ± 1 days, p\ 0.01).
There was no significant difference in readmission despite the earlier
discharge in the ERAS group. Post-operative urinary retention rates
were similar in both groups.
Conclusion: ERAS protocol after AWR resulted in a significant
decrease in LOS. This study, while limited by sample size, provides
evidence for the effectiveness of ERAS protocols in major AWR
surgery.
P-1228
Modified retromuscular Sugarbaker with transversus
abdominis release via enhanced-view totally
extraperitoneal (Etep) access: single-center experience
Addo A, Broda A, Estep A, Lu R, Zahiri R, Turcotte J,
Belyansky IAnne Arundel Medical Center
Background: A variety of operative approaches have been described
to address parastomal hernias, a common complication of long-term
stomas. Accordingly, outcomes have varied due to this lack of stan-
dardized care. The current study sought to evaluate our outcomes post
enhanced-view totally extraperitoneal (eTEP) Sugarbaker technique
utilizing transversus abdominis release (TAR).
Method: A retrospective review of all patients who underwent eTEP
Sugarbaker parastomal hernia repair with TAR at Anne Arundel
Medical Center between December of 2015 and June of 2018 was
conducted. Demographic, intraoperative and postoperative outcomes
data were analyzed using univariate analysis.
Results: Ten patients were included in the final analysis. Laparo-
scopic (n = 1) and robotic (n = 9) were used for patients. 50% of
patients were male, mean BMI was 28.5 kg/m2 and median ASA class
was 3. Mean operative time was 264.1 min and mean total hospital
cost was 17,386 US dollars. The mean length of stay was 3.9 days
(range 1–10 days) and patients were followed after surgery for an
average of 11 months. There was no 30-day readmissions or reop-
erations. Four patients suffered from ileus, seroma or prolonged
urinary retention after surgery, all managed nonoperatively. There
was no incidence of recurrence, mesh infection or mesh erosion into
the bowel conduit during follow-up.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S92
Conclusion: The eTEP access Sugarbaker repair with TAR modifi-
cation, enables extraperitoneal dissection of wide restromuscular
space for mesh placement thus limiting implant exposure to intra-
abdominal viscera. This novel technique needs further long-term
follow-up but early results are promising.
P-1229
Use of complex abdominal reconstruction techniques
(CART) after exploratory laparotomy and open
abdomen (OA)
Kao A, Maloney S, Otero J, Prasad T, Lincourt A, Kasten
K, Colavita P, Heniford B, Augenstein VCarolinas Medical Center
Introduction: Open abdomen (OA), or temporary abdominal closure
with planned relaparotomy, can be a life-saving damage control
strategy for both trauma and non-trauma patients. Prolonged OA
therapy often leads to challenges with abdominal closure, however
long-term data on the prevention of incisional hernias in OA patients
is poorly understood. This study evaluates utility of CART for OA
patients.
Methods: An institutional (Premier) database was queried for non-
trauma patients requiring emergent laparotomy and OA at a tertiary
referral center (2012–2016). Use of CART included component
separation and prophylactic mesh placement.
Results: 203 patients (mean 62.4 ± 13.5 years) underwent laparo-
tomy with OA (average number of reoperations 1.6 ± 1.5; hours left
open 53.4 ± 83.0). 23 (11.3%) patients had CART, including 6
(3.0%) with component separation and 19 (9.4%) with mesh repairs.
Compared to patients without CART, those requiring component
separation/mesh had more operations after index laparotomy
(2.8 ± 2.1vs. 1.4 ± 1.4, p\ 0.0001) and prolonged OA time
(121.5 ± 103.9vs. 44.1 ± 75.5 h, p\ 0.0001). Types of component
separation included posterior approach (n = 4) and external oblique
release (n = 2). Among mesh repairs, biologic mesh was used in 12
(63.2%) patients and synthetic mesh in 7 (36.8%). Mesh was placed
retrorectus in 11 (57.9%), as an onlay in 4 (21.1%), and 4 (21.1%) as a
bridge. Of OA patients surviving to closure, 29.3% developed an
incisional hernia, 3.9% had fascial dehiscence, and 2.0% had ente-
rocutaneous fistula after a mean follow-up of 13.0 ± 16.0 months.
After excluding bridged repairs, rates of hernia (36.8% vs. 26.8%) and
fascial dehiscence (8.7% vs. 4.7%) were similar between CART and
no CART (p[ 0.05).
Conclusions: Primary fascial closure after OA management can be
technically challenging, particularly in patients with multiple reop-
erations and prolonged time before attempted closure. Use of CART,
such as component separation and prophylactic mesh, may lower rates
of wound dehiscence and subsequent hernias. Additional large studies
are needed to further evaluate the impact of CART, however in this
patient population with excess tension on OA closure, consideration
may be given to preoperative tension-reducing strategies such as
rapid-acting neurotoxin.
P-1234
Feasibility of robotic-assisted retromuscular ventral
hernia repair as an outpatient procedure
Lundberg J, Lee B, Peterson E, Gagliano R, Weinberg J,
Gillespie TSt Joseph’s Hospital and Medical Center
Open posterior component separation of the rectus muscle with
placement of inlay mesh is the standard by which all midline
abdominal wall hernia repairs should be measured. Robotic tech-
niques for this procedure have reduced patients’ length of stay (LOS).
A relatively novel application of this technique is the unidock robotic
retromuscular ventral hernia repair (ur-RVHR), which only uses three
ports and putatively reduces postoperative pain. Enhanced recovery
pathways after surgery (ERAS) have also helped decrease LOS.
Transverse abdominis plane (TAP) blocks improve pain control over
standard regimens. Innovative techniques of mesh fixation avoid
trans-abdominal fixation sutures and consequent morbidity. In
aggregate, these advancements have developed with a view toward
decrease healthcare costs and optimizing patient outcomes. We pre-
sent a clinical pathway for repair of midline abdominal wall hernias
that used an ERAS protocol, TAP block, and ur-RVHR technique
with placement of self-adherent mesh. We hypothesized our clinical
pathway would decrease LOS compared to published norms.
A single surgeon’s series of 11 patients undergoing elective three
port ur-RVHR were analyzed. All patients followed the ERAS pro-
tocol and underwent a preoperative TAP block. Self-adherent
polyester mesh was used without supplemental fixation strategies.
Length of stay was measured.
Median LOS for was 22 h and 57 min. 8 of 11 patients were
discharged within 24 h and qualified for outpatient status. All other
patients were discharged in less than 2 days. The greatest LOS was
37 h and 52 min. Average operating time was 240 min. There were
no 30 day readmissions or surgical site infections.
The median LOS using our pathway was less than 23 h and
compares favorably to the previously reported LOS r-RHVR of
2 days by the American Hernia Society Quality Collaborative. The
long-term effect of our pathway requires further study.
P-1238
Abdominal wall reconstruction with large
polypropylene mesh: is bigger better?
Hughes T, Buckley T, Plymale M, Davenport D, Roth JUniversity of Kentucky
Background: Abdominal wall reconstruction (AWR) techniques
continue to evolve in an effort to improve outcomes. Previously, large
meshes were created in the operating room by suturing multiple
meshes (MM). With the availability of large polypropylene mesh up
to 50 9 50 cm (LM), AWR may be accomplished with a single mesh.
This study evaluates clinical and economic outcomes following AWR
with component separation utilizing MM and LM.
Methods: A retrospective study of patients undergoing AWR
between was performed with review of health records and cost
accounting data. Patients that underwent AWR with LM were iden-
tified and case matched 1:1 with patients undergoing MM repair
based upon comorbidities, defect size and wound class. Clinical and
economic data were evaluated.
Results: 24 patients underwent AWR with LM. 20 patients (10F,
10 M) who underwent AWR with LM were matched with 20 MM
AWR (11F, 9 M). Age, BMI, ASA 3 ?, never smoker, diabetes, and
COPD were similar. Hernia characteristics including incidence of
123
S93 Hernia (2019) 23 (Suppl 1):S50–S100
recurrent repair, incidence of prior mesh infection, CDC wound class,
defect size, mesh size were similar between LM and MM.
Operative cost ($4295 vs. $3669, p = 0.127), operative time (259 min
vs 243 min, p = 0.817), blood loss (230 ml vs 230 ml, p = 0.995),
length of stay (5.5 vs 6.2, p = 0.484), wound complication (30% vs
20%, p = 0.716), infected seroma (5% vs 5%, p = 1.000), non-wound
complication (15% vs 30%, p = 0.451) and readmission (5% vs 15%,
p = 0.605) were similar between LM and MM respectively.
Conclusions/Recommendations: This is the first report of patients
undergoing AWR with a large 50 9 50 cm polypropylene mesh. In
this small cohort, clinical outcomes were similar between those
undergoing repair with multiple sutured mesh sheets and a single
large mesh. Further prospective studies with long-term follow up are
required to appreciate the clinical and economic impacts of AWR
with large mesh.
P-1239
(Ballon) Comparison between balloon and telescopic
dissection in fully extraperitoneal laparoscopic inguinal
repair (PET): partial results from a randomized
controlled prospective study
Zanirati T, Cavazzola L, Araujo T, Wolkweiss BHospital de Clınicas de Porto Alegre
Laparoscopic repair is technically challenging. Comparing TEP and
TAPP, we identified relative advantages of TEP as no peritoneal
violation, less risk of hernia in the portal or opening of the parietal
peritoneum, lower risk of intraperitoneal visceral lesions. We devel-
oped this project to investigate if the use of a balloon trocar device
would reduce the surgical time for the preperitoneal space dissection
in TEP in relation to the dissection performed only with the use of
laparoscopic optics. Randomized, controlled clinical trial with a
sample of 26 patients, 13 in each group.
Results: 5 EHS I and 9 EHS II were found in the telescopic group 4
EHS I, 4 EHS II and 2 EHS III. In three cases there were problems
with the trocar or with the balloon, occurring leakage in two and
rupture of the balloon in another. Three patients presented seroma,
with improvement after drainage, two of the balloon group and one of
the telescopic group. Dissection time was 75.4 min (telescopical) vs
54 (balloon) P = 0.124, total surgical time 89.6 vs 85.2 P = 0.759.
Conclusion: The balloon trocater dissection method is safe and has
the same rate of recurrence in the literature and with a tendency to
reduce surgical time.
P-1240
Multiple, recurrent, infectious hernia repair
in the complicated obese patient
Richards J, Gillespie T, Huang DCreighton University and Medical Center at St. Joseph Hospital
and Medical Center
A 43-year-old female with BMI of 32 and a past surgical history of
sleeve gastrectomy, wound infection, multiple ventral hernia repairs
and previous mesh explantation presented with two symptomatic
recurrent abdominal wall hernias. The patient’s most recent recur-
rence was repaired with onlay absorbable mesh. Another piece of
previously implanted synthetic mesh remained in her upper abdomen
with a superior hernia as well as a second hernia lateral to the midline.
The lateral hernia defect was 10.2 cm. Her rectus muscles were
attenuated and narrow. She had a large diastasis of the midline. She
had a history of chronic panniculitis and was evaluated by plastic
surgery.
During surgery all previous mesh was explanted. She underwent a
bilateral posterior component separation with posterior transversals
release. A 40 9 25 cm piece of perforated biological mesh was fix-
ated in in the retromuscular space. Fascial closure was tension free.
Plastic surgery performed a lateral abdominoplasty. Multiple drains
were placed. There were no immediate complications.
22 days later she presented with abdominal pain, erythema, and
edema of the incision. CT scan showed a subcutaneous collection.
She also had intra abdominal fluid collections above and below the
mesh. She underwent operative incision and drainage of the superfi-
cial fluid collection. A wound vacuum assist device ultimately was
applied. Interventional radiology placed intra abdominal drains.
Cultures grew Cutibacterium. She was placed on antibiotics. She
improved and was discharged with two intra abdominal drains. Fol-
low up CT 2 weeks later showed recurrent fluid collection away from
the two other previous drain sites. A third drain was placed by
interventional radiology.
Currently there is no recurrence of the hernia. It is unclear if this
mesh infection can be treated with drains and antibiotics. She is being
considered for mesh explantation.
P-1243
Initial experience in Etep Rives-Stoppa in a University
Hospital in Chile
Quezada N, Achurra P, Jacubovsky I, Munoz R, Crovari F,
Jarufe N, Pimentel FPontificia Universidad Catolica de Chile
Background: Minimally invasive hernia repair provides faster
recovery and less infections. The eTEP Rives-Stoppa (eTEP RS) is an
excellent minimally invasive technique for ventral hernia repair with
a sublay mesh position but it has been associated with a long learning
curve.
Objective: To report our initial experience and short term outcomes
with eTEP RS for the minimally invasive management of ventral
hernias in a University hospital in Chile.
Methods: Retrospective case series of the first 26 patients with
ventral hernias who underwent a minimally invasive abdominal wall
reconstruction with an eTEP RS approach between December 2016
and September 2018. Demographic, perioperative data and early
outcomes were included for analysis.
Results: During the study period 26 patients underwent a eTEP RS
abdominal wall reconstruction. Average age was 55 years old (range
38–77), 65% were man, 20 patients were ASA II and the rest were
ASA I. All patients had a midline defect with a maximum defect
width of 8 cm (range 1–8), 14 patients had multiple midline defects.
All patients underwent a complete preoperative evaluation and were
asked to lose weight before surgery and all patients achieved midline
closure. Average operative time was 120 min (range 60–200) and was
lower throughout the learning curve. Patients with inguinal hernias
and diastasis recti were also managed in the same laparoscopic pro-
cedure. Two patients underwent a Hybrid approach for the
management of large hernia sacs. The average mesh size used was
500 cm2 (range 100–720).
One patient had a reoperation for the drainage of a hematoma,
explored with a laparoscopic approach. There was no mortality in this
initial series. No surgical sites infection were identified in this initial
case series.
Conclusion: eTEP RS is a complex procedure but it has a safe
learning curve with promising results similar to those reported in the
literature.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S94
P-1245
Mesh removal and tailored neurectomy for treatment
of chronic postoperative inguinal pain: a single center
experience
Tastaldi L, Krpata D, Prabhu A, Fafaj A, Alkhatib H,
Svestka M, Rosenblatt S, Rosen MCleveland Clinic
Background: Chronic postoperative groin pain (CPIP) is a chal-
lenging long-term complication after inguinal hernia repair. We aim
to evaluate our institutional experience with the surgical treatment of
CPIP.
Methods: All patients who underwent surgical treatment of CPIP at
our institution from August 2014 through February 2017 were iden-
tified. A retrospective review of electronic medical records and
telephone interviews were performed to complement database infor-
mation. Measured outcomes included reduction in pain scores and
patient satisfaction at final follow-up.
Results: 15 consecutive patients operated at our institution responded
to a telephone interview. Mean age was 44 years, and 67% were male.
Prior meshes were removed along with mesh fixation in all cases. Ten
patients (67%) had a neurectomy performed, being 6 selective and 4
triple neurectomies. Mean baseline pain score was 7.66 (SD2, range
4–10). At a mean follow-up of 14 months, a significant reduction in
pain scores was seen (mean 3.26, SD 3.44, p\ 0.002, 95% CI
2.52–6.27). Ten patients (67%) had improvement in their symptoms
and would recommend surgical management for a friend with CPIP,
and 8 (53%) patients reported being ‘‘pain-free’’ or ‘‘almost pain-
free.’’ Seven patients (47%) are still affected by pain and with QoL
impairment despite some degree of pain reduction.
Conclusions: CPIP is a complex problem with multiple factors that
influence operative management. Our approach of mesh removal with
tailored neurectomy conferred CPIP resolution in over half of the
patients in this cohort. Careful patient selection and pre-operative
counseling to define expectations should be performed surgical
treatment for CPIP.
P-1248
An evaluation of fascial closure techniques in open
ventral hernia repair: practice patterns and short-term
outcomes
Tenzel P, Bilezikian J, Israel I, Appleby P, Hope WNew Hanover Regional Medical Center
The best method for fascial closure during hernia repair remains
unknown. This study evaluates the impact of fascial closure tech-
niques on short-term outcomes.
All patients undergoing open ventral hernia repair were queried
using the Americas Hernia Society Quality Collaborative (AHSQC)
database. Analysis was stratified by suture type (absorbable, perma-
nent) and technique (figure-of-eight, running, interrupted). Outcome
measures included Surgical Site Infection (SSI), Surgical Site
Occurrence (SSO), SSO requiring intervention (SSOPI), recurrence
rate, and quality of life. Descriptive statistics and logistic regression
were performed.
6544 patients were included. Two-thirds of surgeons closed fascia
during ventral hernia repair with absorbable suture, and 1/3 with
permanent suture. In the absorbable group, 17% used figure-of-eight,
46% running, and 4% interrupted suture. In the permanent group,
13% used figure-of-eight, 8% running, and 11% interrupted suture.
There was no significant association between SSO and closure
technique (p = 0.2). However, SSO and suture type was significant
(p\ 0.001) with the odds of SSO for closure with absorbable suture
being 61.7% higher than the odds of permanent. Fascial closure
technique and suture type had no significant association (p[ 0.5)
with SSI, SSOPI, hernia recurrence rate, or HerQLes or NIH promis
3a scores at 30 days or 6 months.
Fascial closure technique and suture material do not have a major
impact on outcomes in ventral hernia repair. Despite a significantly
higher rate of SSO for absorbable sutures compared to permanent, this
did not increase the rate of interventions.
P-1251
How does contamination impact outcomes in abdominal
wall reconstruction?
Lewis R, Ramshaw B, Forman BUniversity of Tennessee Medical Center-Knoxville
Introduction: The use of hernia mesh is a common practice in
abdominal wall reconstruction (AWR) operations. Many AWR
operations are performed in the setting of chronically and/or acutely
infected and contaminated surgical fields.
Methods: A single hernia program implemented the principles of
clinical quality improvement (CQI) in an attempt to improve out-
comes for hernia patients. A resorbable synthetic hernia mesh was
used in place of a variety of biologic meshes for patients undergoing
AWR in either contaminated or non-contaminated surgical fields as
an attempt to improve the care process.
Results: Ninety-two patients who underwent AWR were included
over an 48-month time interval (08/2011 to 08/2015), of which 62 did
not have pre-operative or intra-operative sings of active infec-
tion/contamination (non-contaminated) and 30 did have clinical signs
of active infection (contaminated). In the non-contaminated group,
there were four surgical site occurrence (SSO) (6%) and five surgical
site infections (SSI) (8%), for a total wound complication rate of 14%.
In the contaminated group, there were 10 SSOs (33%) and seven SSIs
(23%), for a total wound complication rate of 57%. Despite the rate of
wound complications, most were minor, required little or no treatment
and were resolved within 2 months. In both contaminated and non-
contaminated groups, there were no mesh related complications and
no mesh removal (partial or total) was required.
Conclusion: In this group of AWR patients, the use of resorbable
synthetic mesh in place of a variety of biologic meshes was imple-
mented in a process for quality improvement. Value improvement for
patients was demonstrated by the lack of mesh-related complications,
including removals, and decrease in mesh costs compared with bio-
logic options.
P-1253
Laparoscopic treatment of incarcerated
and strangulated groin hernias: a preliminary
experience
Bilezikian J, Appleby P, Israel I, Tenzel P, Eckhauser F,
Hope WNew Hanover Regional Medical Center
Groin hernia repair is one of the most commonly performed surgical
procedures in the United States, with a reported strangulation risk
of\ 1% per year. Risk factors for strangulation include older age, co-
morbidities including ASA stage, and late presentation/hospitaliza-
tion. Traditional surgical management has employed an open
123
S95 Hernia (2019) 23 (Suppl 1):S50–S100
approach through single or multiple incisions. The advent of laparo-
scopic surgery offers a minimally invasive alternative, but experience
to date has been limited.
We report our preliminary experience with eight patients who
underwent laparoscopic repair of incarcerated or strangulated groin
hernias at a single institution between 2013 and 2018. Demographics,
perioperative and short-term outcomes were reviewed, and descrip-
tive analysis was performed.
Our series consisted of seven women and one man with an average
age of 80.4 years (range 62–92 years). There were six femoral hernias
and two inguinal hernias. Two patients underwent manual hernia
reduction in the ED and urgent repair within 24 h; the remaining six
patients (75%) underwent emergent surgical intervention. All patients
underwent small bowel resection through a small para-umbilical
incision and TAPP repair using Bard 3DMax light mesh. Four
patients developed complications (50%), including ileus in three
patients, one of whom developed a pelvic abscess that did not require
operative intervention, and C. difficile colitis in one patient. Average
length of stay (ALOS) for the entire group was 7 days but increased
nearly three-fold in patients with complications (10.1 days versus
3.7 days, respectively). Five patients (62.5%) were available for
30-day follow-up with no hospital readmissions, mesh-related com-
plications or evidence of recurrence.
The results of this study suggest that laparoscopic repair of
incarcerated or strangulated groin hernias may be a feasible alterna-
tive to the more conventional open approach. Additional randomized
controlled studies are needed to confirm efficacy and safety and
identify patients who would benefit most from this approach.
P-1254
The intersection of gender, ventral hernia repair,
and abdominal wall quality of life
Bernardi K, Bernardi K, Olavarria O, Lyons N, Milton A,
Holihan J, Kao L, Ko T, Liang MUniversity of Texas He
Introduction: Ventral hernias drastically affect a patient’s abdominal
wall quality of life (AW-QOL). Previous studies showed that women
without ventral hernias have a lower mean baseline AW-QOL by 7%
compared to men. Also, other studies suggested that women may have
worse outcomes after surgery. The aim of this study was to determine
the effects of gender in AW-QOL after ventral hernia repair (VHR).
Methods: Patients from a specialty hernia clinic at a single safety-net
academic institution eligible for VHR were enrolled. All patients
completed a validated, hernia-specific, modified activity assessment
scale (mAAS) survey before surgery and 2 years after VHR. On this
scale, 1 is poor QoL, 80 is normal, and 100 is perfect; a change of 7 is
the minimum clinically important difference. Primary outcome was
the patient factors independently correlated with AWL-QOL; these
were identified using multivariable analysis. Secondary outcomes
included the difference in baseline, post-operative, and the change in
QOL scores were compared by gender using t-test.
Results: A total of 276 patients scheduled for a ventral hernia repair
were enrolled, 67% were females. The average baseline AW-QOL
score was lower in women when compared to men (32.5 ± 3.2 versus
40.1 ± 2.1, p = 0.041). At 2 year follow up, the scores were equiv-
alent for both gender groups (66.6 ± 2.3 versus 66.7 ± 3.1,
p = 1.00); however, improvement in AW-QOL score was higher in
females compared to males (34.1 ± 2.6 versus 26.6 ± 3.0,
p = 0.051). On multivariable analysis multiple factors were identified
as influencing change in AW-QOL, including, age (0.23), body mass
index (BMI) (- 3.12), gender (15.14), hernia type (incisional 11.16),
and hernia area on CT-scan (0.39).
Conclusion: Although women with a ventral hernia have lower AW-
QOL score at baseline, they experience a greater improvement in their
AW-QOL after VHR. Despite former studies showing that women
may experience worse outcomes after VHR differences in baseline
AW-QOL may not have been accounted for.
P-1255
Prevalence of hernias among patients undergoing
computed tomography and their impact on quality
of life
Olavarria O, Bernardi K, Milton A, Lyons N, Shah P, Ko T,
Kao L, Liang MMcGovern Medical School at UTHealth
Introduction: With the growing obesity epidemic and widespread use
of advanced imaging there is a need to quantify the prevalence and
impact of hernias. Our aim was to determine the prevalence of
abdominal wall hernias among patients undergoing CT scans and
their impact on abdominal wall quality of life (AW-QOL).
Methods: Consecutive patients undergoing elective CT abdomen/
pelvis scans were enrolled. History and standardized physical exam-
ination were performed. AW-QOL was measured through the
modified Activities Assessment Scale, a validated, hernia-specific
survey. On this scale, 1 is poor AW-QOL, 100 is perfect and a change
of 7 is the minimum clinically important difference. CT scans were
reviewed for the presence of ventral or groin hernias. The number of
patients and their AW-QOL scores were determined for four groups:
no hernia, clinical or radiographic hernias, clinically apparent hernias,
and hernias only seen on radiographic imaging (occult hernias).
Results: A total of 246 patients were enrolled of whom 76 (30.8%)
were overweight and 105 (42.6%) were obese. Physical examination
detected a ventral hernia in 50 (20.3%) patients and a groin hernia in
17 (6.9%) patients while CT scan revealed 128 (52.0%) and 64
(26.0%) respectively. Of patients with a hernia on CT scan, 85
(34.5%) had an occult ventral hernia and 40 (16.2%) had an occult
groin hernia. The AW-QOL, median (IQR), of patients with no hernia
was 84 (46), while the AW-QOL of those with a clinical hernia was
62 (55) and 77 (57) among those with an occult hernia.
Discussion: One-fourth of individuals undergoing CT abdomen/pelvis
scans have a clinical hernia while over 40% have an occult hernia.
Compared to individuals with no hernias, patients with clinically
apparent or occult hernias have a significantly lower median AW-
QOL (by 22 and 7 points respectively). Randomized trials are needed
to determine if operative repair improves AW-QOL.
P-1256
The role of biosynthetic mesh in abdominal wall hernia
repair in the setting of obesity, recurrence and high risk
patients
Lighter M, Roberts JSt. Mary Mercy Livonia
Background: The repair of abdominal wall hernias pose a difficult
problem for surgeons in the presence of obesity, recurrent hernias and
high risk patient characteristics.
Methods: A retrospective review of 22 patients who underwent
abdominal wall hernia repair with a biosynthetic GORE SYNECOR
Biomaterial hybrid mesh by a single surgeon at a single institution,
between 2016 and 2018. Indications for use included the following
pre-operative patient characteristics, which posed risks for potential
123
Hernia (2019) 23 (Suppl 1):S50–S100 S96
complications: a BMI[ 40; chronic recurrent hernia and hernia
repair requiring panniculectomy. Types of procedures performed
include laparoscopic, robotic and open repairs with underlay, onlay or
retromuscular mesh placement with or without myofascial release,
with or without panniculectomy. Patients were followed up post-op-
eratively at 2 weeks and at 30 days.
Results: Of the 11 patients who had primary hernia repairs, three
underwent a laparoscopic procedure with underlay mesh placement.
Seven patients had an open procedure, six with retromuscular mesh
placement with myofascial release, and one with an onlay mesh, four
panniculectomies. One patient underwent a robotic repair with
underlay mesh with a recurrent hernia reported at 30 day follow-up.
Of the 11 patients who underwent repair for a recurrent hernia, two
had a laparoscopic procedures with underlay mesh. Nine had an open
procedure, two with onlay mesh, one of which developed a post-
operative seroma, one with underlay mesh placement, six with
retromuscular mesh placement who underwent a myofascial release,
four with panniculectomy.
Conclusion: Biosynthetic hybrid mesh (GORE SYNECOR Bioma-
terial) is an alternative in complex cases where pure biologic mesh
has been traditionally utilized, such as in the presence of obesity,
multiple co-morbidities, recurrent hernias and high risk patients. Our
early data demonstrates acceptable outcomes in complex cases
specific to recurrence rates and postoperative morbidity and mortality.
Keywords: Abdominal wall hernia, Biosynthetic Hybrid mesh.
P-1257
Patient related factors that affect abdominal wall
quality of life
Olavarria O, Bernardi K, Milton A, Lyons N, Shah P, Ko T,
Kao L, Liang MMcGovern Medical School at UTHealth
Introduction: It has been shown that ventral and groin hernias affect
patient abdominal wall quality of life (AW-QOL). However, it is
unknown what other factors can alter patient AW-QOL. We sought to
identify factors independently associated with AW-QOL among
patients undergoing computed tomography (CT) scans of abdomen/
pelvis.
Methods: Patients undergoing elective CT scans of abdomen/pelvis
were enrolled. In general, CT scans were performed with oral and
intravenous contrast with 5 mm cuts. History and standardized
physical examination were performed by a surgeon blinded to the CT
scan results. CT scans were reviewed for the presence of ventral and
groin hernias by three surgeons blinded to the results of the physical
examination. AW-QOL was measured through the modified Activities
Assessment Scale, a validated, hernia-specific survey. On this scale, 1
is poor QoL, 80 is normal, and 100 is perfect; a change of 7 is the
minimum clinically important difference. Primary outcome was
patient related factors associated with poor AW-QoL. Multivariable
linear regression was performed to identify these variables.
Results: A total of 489 patients were enrolled, of which 290 (59.3%)
had a ventral hernia, 126 (25.8%) had an inguinal hernia, and 144
(29.4%) had no hernia. On univariate analysis, differences in QOL
were affected by the following: obesity (BMI[ 30 kg/m2), current
smoker status, presence of an ostomy, previous abdominal surgery,
previous ventral hernia repair, ventral hernia on exam, and hernia
size. On multivariable analysis, female sex (- 6.2), obesity (- 7.3),
presence of an ostomy (-11.9), previous VHR (-15.6), and hernia on
CT (- 6.7) were independently associated with poor AW-QOL.
Discussion: Multiple factors affect patients AW-QOL, not just her-
nias. The factors with the largest negative impact on AW-QOL are
iatrogenic: prior ventral hernia repair or creation of an ostomy. With
increasing focus on patient QOL, more research is needed to under-
stand AW-QOL among patients with and without hernias.
P-1258
Primary thoracoabdominal hernia repair: a challenging
trifecta of abdominal wall, chest wall and diaphragm
herniation
Alayon-Rosario M, Griscom T, Warren J, Carbonell A,
Cobb WGreenville Health System
Primary thoracoabdominal hernias are a rare event involving the tri-
fecta of abdominal wall hernia, chest wall defect, and diaphragm
hernia. We report our experience with repair of this rare entity. A
retrospective analysis of thoracoabdominal hernia repairs between
July 2010 through July 2017 was performed. Data included demo-
graphics, inciting events, operative findings and repair technique, and
outcomes. Recurrence, surgical site occurrences and medical com-
plications were recorded. Six patients were identified with
thoracoabdominal hernias. All were male, five were current or former
smokers, and four with diagnosis of chronic obstructive pulmonary
disease. All hernias resulted from an episode of violent coughing.
Repair was performed in open fashion in five patients, and robotically
in one. Mesh reinforcement for ventral hernia was used in four
patients, and rib plating with wire fixation of involved ribs was used
in three. No intraoperative complications occurred. There were two
chest wall recurrences (33%) and two ventral hernia wall recurrences
(33%) that both were re-repaired with suture and lap mesh, respec-
tively. The two chest wall recurrences were originally repaired by
suture reapproximation of the ribs alone. No chest wall recurrences
developed in patients closed with plating and wire fixation. No
recurrent diaphragm defects reported. Surgical site infection occurred
in one patient (16%). Primary thoracoabdominal hernias pose a real
challenge to the hernia surgeon. An open approach with step-wise
reconstruction provides a durable result. We recommend rib plating
and wire closure, as well as mesh reinforcement of abdominal wall.
P-1259
An evaluation of ventral hernia repair with a new
prosthetic mesh
Bilezikian J, Israel I, Appleby P, Tenzel P, Hope WNew Hanover Regional Medical Center
Mesh is generally recommended for repair of ventral and incisional
hernias. There are many types of mesh that can be used for hernia
repair including permanent synthetic meshes, absorbable synthetic
meshes, and biologic meshes. Synecor is a new permanent synthetic
mesh made of a combination of absorbable synthetic component and a
permanent synthetic component that can be used intraperitoneally or
within the layers of the abdominal wall. There is little data concerning
outcomes related to this new mesh product. The purpose of this
project is to review our outcomes using Synecor mesh in ventral
hernia repair.
A retrospective review of all patients undergoing ventral hernia
repair using Synecor mesh was performed using the Americas Hernia
Society Quality Collaborative (AHSQC) database from 4/2016 to
9/2018. Demographic, perioperative, and short-term outcomes (SSI,
SSO, SSOPI) were reviewed and descriptive statistics were
performed.
123
S97 Hernia (2019) 23 (Suppl 1):S50–S100
There were 31 patients who underwent ventral hernia repairs using
Synecor mesh. Average age was 58 (range 29–78) with 45% male and
87% Caucasian. 94% of cases were clean cases. Comorbidities were
found in 68% of patients. Open repairs were performed in 39% of
cases and included a retrorectus repair in 67% and TAR in 75% of
open cases. Laparoscopic repairs were performed in 42% of cases and
robotic in 19% with 78% having closure of defect during repair. At
30 day follow up, the rate of SSI was 3%, SSO was 6% and SSOPI
was 3%. There were 16% complications and recurrence rate was 6%
at an average follow up of 115 days (range 30 days–1 year).
Synecor mesh represents a new synthetic mesh that may be used
for ventral hernia repair in either an open, laparoscopic, or robotic
fashion. Short-term, preliminary results appear favorable but more
study is needed to be able to fully evaluate this new mesh prosthetic.
P-1262
Pancreatic adenocarcinoma with pancreatic pseudocyst
within diaphragmatic hernia
Israel I, Tenzel P, Bilezikian J, Hope W, Fillion MNew Hanover Regional Medical Center
A 64-year-old Caucasian male presented to the ED with abdominal
pain for 4 days. He denied nausea, vomiting, diarrhea, fevers or chills.
He had no significant past medical history and his only surgery was a
tonsillectomy. Work up in the emergency department revealed pan-
creatitis likely secondary to gallstones. He was discharged and
underwent an elective and uneventful laparoscopic cholecystectomy
with negative intraoperative cholangiogram 8 weeks later.
10 weeks postoperatively, he presented to his primary care
physician for reflux type symptoms, abdominal fullness, and nausea.
An abdominal ultrasound was ordered concerning for a
15 9 15 9 10 cm loculated pancreatic pseudocyst, therefore he was
referred to gastroenterology for an EUS. EUS revealed 13 mm
hypoechoic mass within the midbody of the pancreas. The pseudocyst
was thought to be a sequalea of gallstone pancreatitis but after EUS
confirming mid body mass with distal pancreatic duct dilation, it was
likely this was actually due to the pancreatic adenocarcinoma. 3 days
after his clinic visit, he presented to the ED for increasing nausea and
inability to tolerate any oral intake. CT scan revealed 10x8 cm pan-
creatic pseudocyst extending into the esophageal hiatus.
He was taken to the operating room for resection of pancreatic
adenocarcinoma and pseudocyst. The crura were identified and the
pseudocyst wall was noted to be densely adherent to the aorta. The
risk of detrimental injury to the aorta was thought to outweigh the
benefit of repairing the defect. We decided to resect what pseduocyst
we could and drain this area. A 10 Fr Jackson-Pratt drain was placed
in the thorax between the crura to drain the residual pseudocyst and
another 10 Fr Jackson-Pratt drain was placed overlying the pancreatic
neck.
Post operatively he had a fascial abscess requiring drainage but
otherwise did well. He started gaining weight and had no additional
diaphragmatic hernia symptoms.
P-1263
Validating the ventral hernia recurrence inventory
(VHRI) In hernia widths ‡ 10 cm
Alkhatib H, Luciano T, Fafaj A, Svestka M, Petro C,
Krpata D, Prabhu A, Poulose B, Rosen MCleveland Clinic Foundation
Introduction: The Ventral Hernia Recurrence Inventory (VHRI) has
been validated before in a cohort of patients with a mean hernia width
of 6 ± 4.5 cm. Hernia defects C 10 cm have different anatomic
diruptions, with different contour outcomes after surgery, which may
affect the validity of the VHRI.
Methods: The Americas Hernia Society Quality Collaborative
(AHSQC) registry was quired for all patients with hernia widths
C 10 cm who underwent open ventral hernia repair with at least
1 year response to the VHRI, and a CT scan or ultrasound recorded in
the same period. Sensitivity, specificity, negative predictive value,
and positive predictive value were calculated for each question in the
VHRI.
Results: The sensitivity and specificity for ‘‘Do you feel or see a
bulge?’’ was found to be 70% [95% CI 51%–88%) and 81% [77%–
87%], respectively. The negative predictive value was found to be
94% [CI 91%–100%]. The same question combined with ‘‘Do you
feel your hernia has come back?’’ did not result in improved sensi-
tivity or specificity.
Conclusion: As hernia width increases, the validity of the VHRI
decreases. However, answering ‘‘No’’ to ‘‘Do you feel or see a
bulge?’’ continues to be a good marker for absence of a hernia
recurrence.
P-1264
Hernia occurrence after prophylactic mesh placement:
a single institution retrospective review
Israel I, Tenzel P, Bilezikian J, Appleby P, Hope WNew Hanover Regional Medical Center
Prophylactic mesh use has decreased rate of incisional hernias
specifically in stoma creations and open aortic surgery. The purpose
of this study was to evaluate complications and hernia occurrence
rates in patients who underwent prophylactic mesh augmentation
between 2016 and 2018 in single institution.
A retrospective review was performed of 30 patients who under-
went prophylactic mesh augmentation for ostomy creation or aortic
surgery between June 2016 and August 2018. All patients had pro-
phylactic mesh augmentation in either the retrorectus or preperitoneal
space. Six of the patients underwent prophylactic mesh augmentation
for prevention of incisional hernia. The other 24 patients underwent
prophylactic mesh placement for prevention of parastomal hernia
occurrence. Three patients were lost to follow up and two have future
follow up appointments scheduled. The rest of the 25 patients were
followed for hernia occurrence and other complications. Follow up
was defined as either imaging or physical exam after discharge from
original post operative hospital stay.
2 of the 30 patients (7%) suffered complications from the mesh
placement. One patient (3.5%) suffered a significant abdominal
wound infection requiring partial explant of mesh. One patient (3.5%)
had a large seroma collection. Of the 25 patients (83%) with follow
up, there have been no recurrences noted at an average follow up of
147.2 days (range 18–730).
Prophylactic mesh augmentation has demonstrated some promis-
ing results in decreasing hernia occurrences in the group of studied
123
Hernia (2019) 23 (Suppl 1):S50–S100 S98
patients. Further study is needed to evaluate long term efficacy and
safety of this use of mesh.
P-1266
Reeves–Stoppa repair in the setting of chylous ascites
Christensen A, Bock S, Miller HUniversity of New Mexico
Background: Chylous ascites (CA) is a rare form of ascites based on
distinct fluid characteristics including a milky appearance and a
triglyceride level of[ 200 mg/dL. Malignancy and cirrhosis account
for approximately two-thirds of all CA cases in western countries.
Other etiologies include traumatic, congenital, infectious, neoplastic,
postoperative, cirrhotic, and cardiogenic. The management of CA
consists of identifying and treating the underlying disease process,
dietary modification, and diuretics. If medical management fails,
surgical exploration and ligation of the lymphatic duct may be
necessary.
Case presentation: We present a 53-year-old female with a history of
a right peri-nephric lymphangioma resection complicated by lym-
phatic leak, followed 12 years later by a total abdominal hysterectomy
complicated by fascial dehiscence. This then resulted in a moderate
sized ventral hernia. Standard medical management failed to control
her lymphatic leak. Over the next 3 years, she required several trips to
the emergency department for incarceration of her incisional hernia as
well as one hospitalization for gallstone pancreatitis. To correct her
incisional hernia, an elective Reeves-Stoppa repair was specifically
chosen in the setting of her CA to be completed concurrently with
cholecystectomy and repair of the lymphatic leak. Due to dense
adhesions, we were unable to isolate the lymphatic duct, therefore a
large volume of Fibrillar and Tisseel was applied over the area of the
leak. After a difficult dissection, a retro-rectus, preperitoneal mesh
repair was completed without complication. 1 year later the patient
has no evidence of hernia recurrence or ascites on follow up CT
imaging.
Conclusions: We present a 53 y/o female with a history of gallstone
pancreatitis, chylous ascites, and a symptomatic ventral incisional
hernia for which a single stage open cholecystectomy, the use of
hemostatic agents for her chyle leak, and a Reeves-Stoppa repair were
successful.
P-1268
Incisional hernia. Experience at a university center
Rappoport J, Martinez G, Dominguez C, Silva J, Carrasco
J, Jauregui C, Sanguineti A, Castillo CClinic Hospital, University of Chile
Aim: The AIM of the present study is to report the experience in the
treatment of incisional Hernia (IH), at our universitary center.
Methods: 672 patients, with IH, were attended at the Clinic Hospital,
University of Chile, between 2012 and 2016. Prospectively records of
demography, comorbidities, elective or emergency surgery, primary
surgery, type of herniorraphy performed and mesh employed, and
post operatory (30 days), morbimortality were analyzed. Stadistic
analysis: Chi square.
Results: Demography: 72% female and 28% male. 57% below
65 years. BMI mean 27 kg/m2. Comorbidities: Hypertension 43%,
Diabetes 15%, Hypothyroidism 6%, CPO 2.3%. Primary surgery:
biliary 24%, gynecologic 15%, coloproctological 12%, gastric 11%,
exploratory laparotomy 5%. Emergency surgery 5%, elective 92%
repair: without mesh 3%, with mesh: 86% Onlay, 7% Sublay, 2%
Inlay and 2% Intraperitoneal. Polypropylene mesh in 85%. Postop-
erative morbidities: wall hematoma 1%, enterotomy 2%, (recognized
and repaired at the same surgery), and enterocutaneous fistulae 0.1%.
97% of the patients did not present any morbidity; the present series
did NOT presented mortality. Routine use of subcutaneous drain and
abdominal elastic belt. Mean hospital stay: 3 days.
Discussion: Elective surgery, limited to BMI below 32, drastically
reduced post operatory morbidity. Onlay technic, showed excellent
results.
P-1270
Offering minimally invasive surgery in low resources
scenarios: early experience in brazil eTEP access
Grossi J, Grossi J, Santos, Azevedo, Paim D, Claus C,
CavazzolaSao lucas Hospital
Background: The advances in hernia surgery shows the most sur-
geons adopted the laparoscopic approach for treatment of ventral
hernia, because they have a less of hospital stay, surgical site infection
and faster recovery. One way to repair laparoscopic is enhanced-view
totally extraperitoneal (eTEP) with association the better repair insert
the retromuscular mesh and include closer the defect. We show our
multicenter early experience in low resources hospitals in Brazil.
Methods: A review of multicenter a prospectively maintained data-
base of ventral hernia defects evaluation of 39 patients who
underwent laparoscopic e-TEP for ventral, lombar, umbilical and
incisional hernia repair between January 2017 and July 2018. All
patients underwent include in analysis. 60 days post operative out-
comes was evaluation.
Results: All patients underwent include. Almost the same proportion
with 22 male and 17 female. The mean age was 50.7, the body mass
index was 29, the mean operation room time of 147 min. Localization
of defect was preference in medial line with 80% and 20% out.Mean
of size of defect was 5 cm and only 12.8% have more than one defect,
associated diastases 1.9 cm. There is no significant statistic difference
between male and female diastase sizes with p = 0.38. There were no
intraoperative complications. Hematomas was the most complication
with 4 patients, the second was seroma and 1 case of posterior
recurrence. All the complications was treatment with drainage and
good results on minimum follow up 60 days. There is no significant
difference between centers when compare operation room time and
complications.
Conclusion: The early experience in low resources hospitals in Brazil
shows the patients no different outcomes in different centers and
outcomes using e-TEP approach. This technique is reproducible and
can be offer in low resources centers but need surgeon training and
experience to do safely for treatment of ventral and incisional hernias.
P-1271
Robotic surgery experience for the general surgery
resident
Bollenbach S, Ballecer C, Thomas E, Prebil BMaricopa Integrated Health System
Background: Open surgery has been the mainstay for hernia repairs,
however technological advances have led to an ever increasing
number of robotic-assisted surgeries. Thus, the importance of robotic
training for the General Surgery resident cannot be overemphasized.
It is imperative that residents receive training that exposes them to
123
S99 Hernia (2019) 23 (Suppl 1):S50–S100
robotic surgery, provides console time, a formal curriculum, and
overcomes other common limitations to training.
Discussion: Despite incorporation of robotic surgery into the general
surgeon’s armamentarium, successful implementation of robotics into
surgery residency curricula has lagged behind. Current literature
highlights resident experience assisting with docking and trocar
placement rather than time on the console. It also suggests that robotic
training interferes with education as a result of limiting exposure to
other laparoscopic or open cases. The University of Alabama estab-
lished a formal curriculum, from which our program adapted their
own resident education protocol. Prior to console time, residents must
complete online robotic training and attend a workshop where they
are introduced to the robot, docking, instrument exchange, simulator
and console training. Residents must complete 6 designated simulator
modules and score 90% or greater, 5 cases as bedside assistant and 5
cases as console surgeon. Our residents accumulate roughly 140
robotic cases during the rotation, 50–75 of which are hernia repairs.
Summary: Based on current literature, there appears to be minimal
console time and limited access to the simulator, hindering training.
Our facility’s experience demonstrates it is possible for residents to
have significant hands-on experience and education, resulting in
proficiency with robotic hernia repairs. Further refinement and
increased implementation of robotic surgery protocols will optimize
robotic training. A major key to success is involvement of attendings
who have demonstrated proficiency and are past their respective
learning curves. A rare scenario in many academic programs.
P-1272
Out come of lichtenstein hernioplasty in rural India
Gandhi CBharati Medical College and Hospital, Sangli, Maharashtra
Inguinal hernia is the commonest surgical disease. Altered ratio of
collagen 1&3 causes weakness of fascia transversalis. Which is the
cause of inguinal hernia. This is a retrospective observational study of
150 inguinal hernioplasty at our institute from 2012 to 2014.
Surgeries were done by faculties and residents. Patients were
followed for 2 years for recurrence and chronic groin pain. We had
0.66% recurrence and 2% mild chronic groin pain at 2 years follow-
up. Not a single case of neurogenic severe or moderate groin pain.
Lichtenstein hernioplasty gives satisfactory long term result for
rural Indian population.
P-1273
Abdominal wall bulging following laparoscopic ventral
hernia repairs
Tang J, Zhu L, Li SHuadong Hospital Affiliated to Fudan University
Background: Laparoscopic ventral hernia repairs (LVHR) is one of
most popular operations in general surgery. Postoperative abdominal
wall bulging which was rarely mentioned in the past decades is one of
the common postoperative complications of LVHR. This study aims
at systematic reviewing abdominal wall bulging following LVHR.
Methods: A computer-aided search of the PubMed and Embase
databases was conducted to find relevant English-language publica-
tions on the postoperative abdominal wall bulging of laparoscopic
ventral hernia repairs. The following search terms were used: (la-
paroscopic surgery AND (ventral hernia OR incisional hernia) AND
postoperative complication AND (bulging OR protrusion OR even-
tration OR pseudoreccurence)). No beginning date limit was used.
The search was updated until 31 July 2018. Review articles, meta-
analyses, abstracts, editorials or letters, case reports, tutorials and
guidelines for management articles were excluded. Full-text articles
were then reviewed to definitively determine if the study was eligible
for inclusion.
Results: A total of 11 studies were included for evaluation. The
incidence of LVHR postoperative abdominal wall bulging was
1.3–21.5%. Postoperative abdominal wall bulging may be related to
the area of abdominal wall defect, defect closure in operation, and the
type of implant patch. A patient could be diagnosed as post-LVHR
abdominal wall bulging if he/she meets the criteria in medical history,
clinical features and imaging examination. As preventions, surgeons
should pay attention to recognition and full exposure of fascia defect
edge, returning hernia content, fascia defect closure and patch overlap
and fixation in primary LVHR. When a re-operation is employed,
surgeon could fix a larger mesh tightly over the previous mesh.
Conclusions: Abdominal wall bulging after laparoscopic ventral
hernia repair is not a rare complication and should be diagnosed
carefully. A second surgery is needed when patients dissatisfied with
abdominal wall appearance or dysfunction. Prevention is always
better than treatment.
P-1274
Prospects of hernia and abdominal wall surgery
in China
Tang J, Zhu L, Li SHuadong Hospital Affiliated to Fudan University
Nowadays, hernia and abdominal wall surgery is developing rapidly
in China. Not only inguinal hernia, incisional hernia and other
abdominal hernias in open prosthetic repairs are popular in China, but
also laparoscopic and robotic hernia repairs have been carried out
throughout the country. Due to the unbalanced development in dif-
ferent areas of our country, there is still existence of irregular
diagnosis and treatment in hernia. Therefore, Chinese Hernia Society
had published guidelines on diagnosis and treatment of inguinal
hernia in adults (2018 version) and guidelines on diagnosis and
treatment of incisional hernia (2018 version). In addition to this,
Chinese registry of hernia and abdominal wall surgery and quality
control standards are on the threshold of development, although there
is still a long way to go. A few etiology, genetics and molecular
epidemiology studies have been reported, although basic research of
hernia is weak in the whole world. The exact pathogenesis and
inheritance pattern are worth us to further study. The progress of
hernia and abdominal surgery is inseparable from the development of
repair materials. At present, the repair materials are mainly composed
of synthetic materials and biomaterials. The prosthetics related
adverse events in the long term should not be ignored, although
prosthetic repairs can reduce postoperative hernia recurrence rate.
Mesh shrinkage, erosion, adhesion and infection are all common
complications, as the spread of standard treatment, these postopera-
tive complications may phase down. Researchers had made some
innovations on materials science, textile science and even bioengi-
neering, although there is no ideal repair material yet, the future of
materials is worthy of the expectation of hernia and abdominal wall
surgeons.
123
Hernia (2019) 23 (Suppl 1):S50–S100 S100
Videos
� Springer-Verlag France SAS, part of Springer Nature 2019
V-1041
Mesh non-fixation in laparoscopic transabdominal
preperitoneal (TAPP) inguinal hernia repair: technique
padronization
Neves V, Madureira F, Iglesias A, Rodrigues HHospital Universitario Gaffree e Guinle
Introduction: The laparoscopic repair of inguinal hernia by the TAPP
technique requires a stapler to fix the mesh, making the method
expensive. This article proposes the use of a modified technique for
the repair of inguinal hernia, trying to offer a cheaper method and
with less chronic pain.
Methods: 19 patients were operated at the Hospital Universitario
Gaffree e Guinle. All submitted to videolaparoscopic TAPP inguinal
hernioplasty with polypropylene mesh and non-fixation.
Discussion: There was no recurrence in the operated hernias, which
suggests a safe procedure. There was also no incidence of pain after
the 30th PO. The incidence of surgical site infection was 5.3%, which
was within the expected range.
Conclusion: The chosen technique seems safe as well as lower cost
than the traditional one.
V-1083
A case of bilateral spigelian hernia repair
Fazendin J, Fazendin A, Fazendin E, Onopchencko AHahnemann University Hospital
Spigelian hernias comprise a small minority (1–2%) of all abdominal
wall defects. Even more rare is the incidence of bilateral Spigelian
hernias in the adult population. Laparoscopic repair of abdominal wall
hernias has been proven safe and effective. However, due to the rarity
of these hernias, there are no large case series to provide a consensus
for best approach. Trans-abdominal, totally extra-peritoneal and trans-
abdominal pre-peritoneal approaches have all been proven to be
effective. In this video we present an interesting case of bilateral
Spigelian hernias treated by laparoscopic trans-abdominal pre-peri-
toneal repair. We make special emphasis on the importance of trocar
placement for optimal management of this rare condition.
V-1126
Reverse-Tar: maximizing mesh overlap on open flank
hernia repair
Tastaldi L, Alkhatib H, Fafaj A, Petro C, Svestka M,
Rosenblatt S, Krpata D, Rosen M, Prabhu ACleveland Clinic
We aim to present an educational video demonstrating a novel
approach to allow for the extension of mesh overlap into the midline
during open flank hernia repair. For such, we selected the case of a
50-year old female who presented to the Hernia Clinic with a large
traumatic flank hernia resultant of an MVA. The patient had no prior
abdominal operations, had a BMI of 31 and was a lifetime non-
smoker. Preoperative CT-SCAN demonstrated an 11 cm flank hernia
with herniation of colon and small bowel, resultant from evident
avulsion of the musculature of the lateral abdominal wall.
In such an approach, the patient is positioned in lateral decubitus,
and a traditional open flank incision is performed. Upon dividing the
muscles of the lateral abdominal wall, the preperitoneal space is
developed in all directions; the border of the psoas muscle is identi-
fied medially. The innovation of this technique consists in incising the
peritoneum invested in the posterior rectus sheath, dividing the
transversus abdominis fibers and finally incising the posterior lamella
of the internal oblique, gaining access to the retromuscular space. As
such, the retromuscular space is dissected in the direction of linea
alba, and a wide pocket for extending mesh overlap into the midline is
created. This surgical maneuver is particularly helpful to ensure
adequate mesh overage in all directions when repairing large flank
hernias. Note that in this approach, we perform the same dissection of
a TAR, but in a reverse manner: from preperitoneal to retromuscular
space. The repair was completed with two large pieces of permanent
synthetic mesh that were sewed together, placed as a sublay and
fixated with transfascial sutures. The video we intend to present
demonstrates the technique step-by-step, and we argue that has a
strong educational purpose for the audience.
V-1155
Laparoscopic approach for patients with refractory
postoperative chronic pain
Narita M, Hata H, Matsusue R, Yamaguchi T, Otani T, Ikai
IKyoto Medical Center
Background and aim: Postoperative chronic pain (POCP) is com-
plex disease and there is no standard of care for refractory cases. We
have operated POCP patients who were refractory for conservative
therapy. The aim of this study was to present our laparoscopic sur-
gical technique for patients with refractory postoperative chronic
pain.
VIDEO ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S101–S103
Patients and methods: We evaluated 5 patients who underwent
surgical intervention via laparoscopic approach between 2013 and
2018 in the treatment of POCP, which was refractory for conservative
therapy.
Results: Four patients were male and the median age was 61 years
(ranging from 50 to 69). Median duration between primary surgery
and surgical intervention in the treatment of POCP was 23.4 months
(ranging from 12.9 to 43.0 months). Case 1 who had neuralgia of
iliohypogastric nerve underwent laparoscopic tripleneurectomy via
retroperitoneal approach. Case 2 who had nociceptive pain and dys-
uria following inguinal hernia repair using transinguinal preperitoneal
approach underwent mesh removal via laparoscopy. Three patients
(case 3–5) who had meralgia paresthetica underwent partial mesh
removal using laparoscopic approach. In case 2, surgical intervention
resulted in cure of dysuria but mild pain remained. Pain completely
disappeared immediately after surgery in the remaining 4 patients.
Conclusions: Laparoscopic approach is effective treatment option for
selected patients with refractory POCP.
V-1177
Robotic repair of an iatrogenic diaphragmatic hernia
Petro C, Petro C, Alkhatib H, Fafaj A, Tastaldi L, Prabhu ACleveland Clinic
Introduction: A 55-year-old man presented with a painful left
diaphragmatic hernia 8 years after a liver transplant, likely due to a
retraction injury.
Methods: The patient was placed in the supine position and after
laparoscopic access, adhesiolysis and port placement, the robotic
platform was used to dissect and reduce the incarcerated hernia
contents. The defect was closed with interrupted figure-of-eights
using braided 0 nylon suture. Mesh reinforcement was not utilized.
Results: The patient was discharged on postoperative day 2 after
resolution of transient nausea. He followed-up at 1 month with res-
olution of his preoperative pain and he was otherwise well.
Conclusion: The robotic approach can facilitate the repair of
diaphragmatic hernias high in the chest that may otherwise be chal-
lenging to access by open or traditional laparoscopic platforms.
V-1179
The challenging inguinal hernioplasty
Doerhoff CCapitol Region Medical Center
Background: 1 in 7 males will require inguinal hernia repair. Robotic
radical prostatectomy’s (RRP) are performed on 95% of patients who
meet criteria for removal of prostate cancer. The challenging inguinal
hernioplasty is a patient with both RRP and preperitoneal mesh.
Discussion: In the author’s opinion Find fat and begin lateral to
medial dissection. Midline dissection to pubic symphysis. Find
coopers ligaments. Locate any cord structure. Extended retroperi-
toneal dissection. 15 cm x 20 cm mesh. Use TSM mesh if insufficient
peritoneum to cover mesh. Reduce IAP to 8 mmHg. Utilize reliable
fixation (e.g. tacks to Coopers, fibrin glue to soft tissue, and double
crown non-absorbable suture to cephalad portion of mesh.)
Methods: Patient 1: Status post RRP with plug repair has recurrent
LIH and nonrecurrent RIH. Patient 2: Failed LIH TAPP and failed
open plug patch repair of recurrence. Patient 3: Failed TAPP for large
right scrotal hernia.
Conclusion: The robot has facilitated inguinal hernioplasty. How-
ever, there remain challenging repairs for patients who have RRP and/
or previous hernia repair with preperitoneal mesh. Methodical dis-
section and patience is necessary for safe hernioplasty of challenging
defects.
V-1194
Robotic repair of spigelian hernia
Arefanian S, Frisella M, Miller M, Blatnik JWashington University in Saint Louis
Background: Spigelian hernia is a rare type of hernia that occurs in
the lateral border of rectus abdominis muscle. Different methods have
been used for surgical repair of this abdominal wall defect, including
open and laparoscopic techniques. Here we present the robotic-as-
sisted repair of a left side Spigelian hernia.
Description: A 56-year-old male presented with the left flank bulge
that was increasing in size as well as constipation and discomfort. He
had a large left Spigelian hernia with an approximate size of
5 9 5 cm. He underwent a robotic-assisted hernia repair with syn-
thetic mesh. The patient tolerated the surgery and postoperative
course well.
Conclusion: Robotic-assisted Spigelia hernia repair is a new tech-
nique for repair of this uncommon hernia with acceptable and
satisfying results.
V-1196
Robotic explantation after robotic transabdominal
preperitoneal inguinal hernia repair for chronic pain
Tchokouani L, Jacob BThe Mount Sinai Medical Center
This is a 49-year-old man experiencing a pulling and nocioceptive
chronic pain since undergoing a robotic bilateral inguinal hernia
repair 1 year prior to evaluation. After undergoing all the proper
workup including, but was not limited to, imaging, injections and
physical therapy, he decided to pursue surgical mesh excision. First, a
diagnostic laparoscopy was performed with subsequent standard port
placement for a Robotic Transabdominal Preperitoneal hernia repair.
The mesh was identified and meticulously dissected away from the
major inguinal structures. We were able to identify and preserve most
of the genitofemoral nerves, the gonadal vessels, the vas deferens, the
inferior epigastric vessels, the iliac arteries and veins bilaterally. A
small piece of mesh was left along the posterior surface of the right
inferior epigastric vessels where it met the iliac vessels. The left side
was dissected in similar fashion. There was no more mesh connecting
the right and left groins as identified during the preoperative evalu-
ation. All the other mesh was explanted completely in combined total
of 5 large pieces. We were able to preserve a preperitoneal flap in the
central portion of the explantation zone, but we had to sacrifice
peritoneum at the lateral edges of the dissection where it was thin.
Once the explant was complete we proceeded to close the peritoneum.
The patient reported improved symptoms after mesh removal at the
follow up appointments and is much happier. In conclusion, patients
who present with chronic pain after inguinal hernia repair should be
carefully assessed and worked up to treat the true etiology of their
symptoms. The dogma of acceptable chronic pain after inguinal
hernia repair should be challenged and every patient given individ-
ualized treatment.
123
S102 Hernia (2019) 23 (Suppl 1):S101–S103
V-1242
Robotic approach for recurrent inguinal hernias
after repairs with previous preperitoneal mesh
Amaral P, Pivetta L, Barros P, Hernani B, Neto I, Franciss
M, Tastaldi L, Altenfelder Silva R, Roll SHospital Alemao Oswaldo Cruz
Supporters of the robotic platform argue that enhanced visualization,
improved surgeon ergonomics and refined precision of movements
are all factors that make such robotic-assisted laparoscopy superior to
the standard laparoscopic approach. Reoperative fields with previous
preperitoneal mesh such as those in recurrent inguinal hernias after
prior laparoscopic repairs are challenging clinical scenarios in which
these potential benefits of the robotic platform are desirable. Histor-
ically, our group treated recurrent inguinal hernias after laparoscopic
repairs using open approaches. With the availability of the robotic
platform at our institution and after gradually overcoming the learning
curve, we have transitioned to treat such recurrences through a robotic
transabdominal preperitoneal approach (r-TAPP). In this video, we
present the case of a 72-year male with a multiply recurrent bilateral
inguinal hernias after two failed laparoscopic approaches (TEP and
TAPP). PSH includes a remote history of a laparoscopic gastric
bypass, placement of a penile prosthesis and CABG. A CT scan
demonstrated bilateral recurrent inguinal hernias with the penile
prosthesis device being in the middle of the operative field.
In this video, we present step-by-step, an r-TAPP approach to deal
with these challenging cases. In summary, a large peritoneal flap was
created, and bilateral direct recurrences were noted (M3). The penile
prosthesis was dissected out of the operative field, and the hernia sacs
were reduced of the direct defects were reduced. In this case, the prior
meshes were partially removed, and new permanent synthetic meshes
were placed and fixated. Patient recovery was uneventful and is now
6 months after the operation without a hernia recurrence.
V-1249
Laparoscopic approach for Etep transversus abdominis
release (TAR)
Quezada N, Achurra P, Jacubovsky I, Munoz R, Crovari F,
Jarufe N, Pimentel FPontificia Universidad Catolica de Chile
Posterior component separation with TAR during abdominal wall
reconstruction for ventral hernias has become popular in many hos-
pitals around the world. Minimally invasive approach can help to
reduce wound complications but its associated to a long learning
curve,
As a developing country we do not have a robot available so we
began our experience in laparoscopic TAR 1 year ago and we have
performed over 10 procedures now with very good perioperative
results.
We present a fulHD video (1080p) of the main steps of a lap TAR
with an eTEP approach and the key tips and tricks to achieve the
procedure at the beginning of the learning curve.
V-1269
No hernia too far: a robotic approach to a flank hernia
Weimer S, Ballecer CMaricopa Medical Center, Center for Minimally Invasive Robotic
Surgery
A 53 year old male is referred for a large left flank hernia that
developed after a thoracoabdominal incision for exposure during an
L4 laminectomy. He has had persistent discomfort with activity and a
large, unsightly bulge on his left flank at the site of the incision. A CT
scan confirmed a left flank hernia 10 cm 9 15 cm containing colon
and small bowel. We performed an rTAPP left flank incisional hernia
repair with mesh with the patient in a right lateral decubitus position.
The patient did well and was discharged post-operative day 1.
V-1275
Laparoscopic approach to recurrent hernia
after cystectomy and laparoscopic paraileal conduit
hernia repair
Lo Menzo E, Fonseca Mora M, Milla Matute C, Rivera C,
Ortiz Gomez C, Shah R, Szomstein S, Rosenthal RCleveland Clinic Florida
Introduction: Patients with Urothelial Cancer who undergo
Laparoscopic Cystectomy may develop Incisional hernia or paras-
tomal hernia in approximately 22.8% and 18% of the cases
respectively. The aim of this video is to illustrate the management of a
patient who developed recurrent suprapubic hernia after laparoscopic
paraileostomy hernia repair.
Method: A 76 year-old male, with a 1-year history of para-ileal
conduit hernia, is seen in clinic for recurrent suprapubic hernia after a
previous laparoscopic para ileal conduit hernia. The CT-shows small
defect in the inguinal space and weakness of the rectus muscle above
the symphysis. Following insertion of trocars, dissection of the
omentum was performed. Previous mesh was in adequate position
with no recurrence. No para-ileoal recurrence was observed, however
a left direct suprapubic hernia with significant laxity of the left lower
quadrant were evident. Following identification of Cooper�s ligament,
a 25 9 20 cm Ventralight mesh was placed using 1# PDS sutures.
Through stab wound incision the sutures were pulled out through the
abdominal wall, the mesh is fixed and taut adequately. Using per-
manent tacks, the mesh was secured circumferentially. The patient
tolerated well the procedure and was discharged on the same day.
Conclusion: Redo laparoscopic hernia after previous laparoscopic
para ileal conduit hernia is feasible and safe.
123
Hernia (2019) 23 (Suppl 1):S101–S103 S103
Author Index
� Springer-Verlag France SAS, part of Springer Nature 2019
Author IndexAbdelfatah E, IP-1294, S35
Abidi H, P-1136, S75
Achurra P, P-1178, S82, P-1243, S94, V-1249, S103
Adams E, P-1195, S85
Addo A, FP-1222, S24, FP-1226, S13, P-1228, S92
Adelman D, P-1143, S77, P-1144, S77
Adrales G, IP-1305, S8, IP-1315, S13, IP-1323, S21, P-1204, S86
Agca B, P-1005, S50, P-1026, S56, P-1034, S57, P-1090, S68
Agrawal D, P-1188, S84
Aguado Suarez N, P-1010, S52, P-1011, S52, P-1012, S52,
P-1014, S53
Ahmed F, P-1131, S74
Ahonen J, FP-1093, S11
Akhmetov A, P-1086, S67, P-1087, S67
Alaqel M, P-1109, S71, P-1110, S71, P-1111, S72
Alayon-Rosario M, P-1258, S97
AlBalawi M, P-1109, S71, P-1110, S71, P-1111, S72
Albayrak N, P-1030, S56
Albertson S, P-1217, S90
Albin D, P-1046, S59
Albin M, P-1046, S59
Aldohayan A, P-1106, S70, P-1109, S71, P-1110, S71, P-1111, S72
Aleman R, P-1180, S82
Alimi Y, P-1214, S89
Alkhatib H, FP-1122, S41, FP-1123, S17, P-1021, S55, P-1190, S84,
P-1245, S95, P-1263, S98, V-1126, S101, V-1177, S102,
V-1186, S27
Allamaneni S, P-1017, S54, P-1018, S54
Allen D, FP-1233, S44
Allen G, P-1076, S64
Allen J, FP-1247, S44
Altenfelder Silva R, FP-1137, S46, FP-1244, S10, P-1139, S76,
P-1142, S76, P-1207, S87, V-1242, S103
Altimari M, FP-1064, S109
Alvarez R, IP-1309, S12
Amaral P, P-1146, S77, P-1207, S87, V-1242, S103
Amler E, FP-1202, S18
Anders S, P-1004, S50
Anthony A, P-1035, S58
Appleby P, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,
P-1264, S98
Araujo T, P-1239, S94
Arbouz M, P-1049, S60
Arefanian S, FP-1168, S30, V-1194, S102
Arguello-Angarita M, P-1100, S69
Arias Pacheco R, P-1008, S51, P-1009, S51, P-1010, S52,
P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53
Arnold M, P-1206, S87
Assef J, P-1139, S76
Augenstein V, FP-1037, S47, FP-1075, S23, FP-1097, S47,
FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,
P-1129, S73, P-1206, S87, P-1229, S93, V-1119, S27
Awad S, P-1065, S62
Azevedo M, P-1270, S99
Bachman S, IP-1301, S8, IP-1330, S25
Baker S, P-1102, S70
Bakker W, FP-1089, S40, P-1088, S67, P-1091, S68
Balla F, P-1101, S69
Ballecer C, IP-1284, S33, IP-1331, S25, P-1271, S99, V-1269, S103
Banks-Venegoni A, FP-1044, S46
Bansal D, FP-1053, S45
Barchi L, P-1207, S87
Barkan A, FP-1233, S44
Barrio M, P-1199, S86
Barrios C, P-1217, S90
Barros P, FP-1244, S10, P-1139, S76, P-1146, S77, P-1207, S87,
V-1242, S103
Barros R, P-1139, S76
Bass B, IP-1322, S21
Bassas R, P-1109, S71, P-1110, S71, P-1111, S72
Bastos C, P-1213, S89
Bastos R, P-1140, S76
Bates A, FP-1145, S26
Batistela F, P-1211, S89
Beck W, P-1063, S62
Becker N, P-1065, S62
Beffa L, P-1016, S53
Bellini A, P-1208, S88
Belyansky I, IP-1308, S9, FP-1222, S24, FP-1226, S13, P-1228, S92
Benvenuto M, IP-1320, S19
Berger D, FP-1260, S16, P-1084, S66
Bernardi K, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,
P-1257, S97
Bhanot P, P-1214, S89
Bhavaraju A, P-1063, S62
Bicket M, P-1204, S86
Bilezikian J, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,
P-1262, S98, P-1264, S98
Billow D, FP-1176, S47
Birolini C, P-1067, S63, P-1197, S86, P-1211, S89
Bisgaard T, IP-1296, S19
Blatnik J, FP-1123, S17, FP-1168, S30, V-1194, S102
Blonk L, IP-1286, S25
Bock S, P-1266, S99
Bolduc A, IP-1344, S32
Bollenbach S, P-1271, S99
Bonjer J, IP-1286, S25
Brandalise A, IP-1297, S36
Brandi C, IP-1283, S49
Brandt J, P-1029, S56
Brasil H, P-1207, S87
Brathwaite C, FP-1233, S44
Broach R, FP-1173, S43
Broda A, FP-1222, S24, FP-1226, S13, P-1228, S92
Brown S, P-1227, S92
Bruni P, IP-1278, S31
ABSTRACTS
123
Hernia (2019) 23 (Suppl 1):S104–S109
Bryczkowski S, IP-1293, S34, IP-1294, S35,
IP-1295, S34
Buckley T, P-1238, S93
Budney S, FP-1191, S14
Burgmans I, FP-1089, S40, P-1088, S67
Burgmans J, P-1091, S68, P-1092, S68
Cabrera P, P-1165, S80, P-1169, S81
Cai M, FP-1057, S40
Camila O, P-1218, S90, P-1220, S91
Campanelli G, IP-1278, S31
Campos Alvarez C, P-1006, S50, P-1007, S51, P-1008, S51,
P-1009, S51, P-1013, S53
Canccado A, P-1223, S91, P-1225, S92
Caparelli M, P-1017, S54, P-1018, S54, P-1023, S56
Carbonell A, FP-1224, S29, FP-1247, S44, P-1258, S97
Carlos R, P-1220, S91
Carrasco J, P-1162, S80, P-1268, S99
Casas F, P-1165, S80
Caso R, P-1214, S89
Castagneto G, IP-1292, S49
Castillo A, P-1169, S81
Castillo C, P-1162, S80, P-1268, S99
Cavalli M, IP-1278, S31
Cavazzola L, P-1113, S72, P-1115, S72, P-1239, S94, P-1270, S99
Ceno M, P-1084, S66
Ceppa E, P-1199, S86
Cerqueira C, P-1223, S91
Cervone A, P-1029, S56
Chai C, P-1065, S62
Chan D, P-1056, S61, P-1069, S63, P-1103, S70
Chen D, IP-1328, S25, FP-1137, S46, P-1142, S76
Chen J, FP-1163, S18, P-1073, S64, P-1159, S79, P-1161, S80,
P-1172, S81
Chen Y, P-1204, S86
Cherasard P, FP-1233, S44
Cherla D, FP-1260, S16
Chiu L, P-1065, S62
Christensen A, P-1266, S99
Claus C, IP-1360, S49, P-1115, S72, P-1270, S99
Clevers G, P-1088, S67, P-1092, S68
Cobb W, FP-1224, S29, FP-1247, S44, P-1258, S97
Colavita P, FP-1075, S23, FP-1124, S17, FP-1125, S26,
FP-1127, S29, P-1129, S73, P-1206, S87, P-1229, S93
Collister P, P-1227, S92
Conway R, FP-1044, S46
Cook M, FP-1141, S18
Copin Tenorio R, P-1142, S76
Cornwell K, P-1143, S77, P-1144, S77
Crain N, P-1071, S63, P-1072, S63
Crespo A, P-1140, S76
Cristian M, P-1218, S90, P-1220, S91
Crovari F, P-1178, S82, P-1243, S94, V-1249, S103
Cunha C, P-1113, S72, P-1140, S76
Cunha L, P-1213, S89, P-1223, S91, P-1225, S92
Cunha V, P-1213, S89
Damous L, P-1067, S63
Damous S, P-1067, S63, P-1197, S86, P-1211, S89
Davenport D, P-1238, S93
Davids P, P-1088, S67, P-1092, S68
Davis B, P-1063, S62
Davis S, P-1101, S69
de Beaux A, FP-1202, S18
de la Torre J, P-1167, S81
de Paz Mora�n M, P-1014, S53
de Virgilio C, FP-1265, S23
Dean K, FP-1247, S44
Dearth C, FP-1246, S40
Delgado Sevillano R, P-1006, S50, P-1007, S51, P-1008, S51,
P-1009, S51, P-1012, S52
DeLong C, P-1193, S85
Demare A, FP-1171, S13, FP-1230, S42
Denney B, P-1167, S81
DeVitis J, IP-1347, S34, FP-1044, S46
Devulapali C, P-1214, S89
Dhadlie S, P-1055, S60
Dhakad D, P-1032, S57
Dimick J, FP-1276, S41
Divin R, FP-1202, S18
Doble J, FP-1189, S16
Docimo S, IP-1342, S32, FP-1145, S26, IP-1349, S37
Doerhoff C, P-1184, S83, V-1179, S102
Dominguez C, P-1162, S80, P-1268, S99
Dooley D, FP-1141, S18, P-1195, S85
Dorado E, IP-1298, S21
Dourado M, P-1225, S92
Drevets P, P-1076, S64
Dubina E, FP-1265, S23
Dumanian G, IP-1316, S15, FP-1061, S22
Duncan M, P-1204, S86
Dutra V, P-1223, S91
East B, FP-1202, S18, P-1149, S78, P-1187, S84
Eckhauser F, P-1253, S95
Eid M, P-1209, S88
Escobar R, P-1048, S59
Estep A, FP-1222, S24, P-1228, S92
Evans K, P-1214, S89
Eveland A, P-1200, S86
Everitt J, P-1047, S59
Ewing A, FP-1224, S29
Fadaee N, P-1148, S78
Fafaj A, IP-1332, S26, FP-1122, S41, FP-1123, S17,
FP-1176, S47, P-1190, S84, P-1245, S95, P-1263, S98,
V-1126, S101, V-1177, S102, V-1186, S27
Falola R, P-1214, S89
Fan H, P-1069, S63
Fantauzzi M, P-1139, S76
Faro Junior M, P-1197, S86, P-1211, S89
Farrell B, P-1135, S75
Favacho B, FP-1137, S46
Fazendin A, V-1083, S101
Fazendin E, V-1083, S101
Fazendin J, V-1083, S101
Felix E, IP-1329, S25
Feng K, P-1102, S70
Fernando Rodrigues Alves de Moura L, P-1077, S65, P-1078, S65,
P-1081, S66, P-1082, S66
Ferreira F, P-1146, S77
Ferzoco S, P-1135, S75
Feustel P, P-1192, S85
Feyerherd P, FP-1153, S45
Figueroa C, P-1217, S90
Filipi C, IP-1348, S36, P-1142, S76
Fillion M, P-1262, S68
Fischer J, IP-1340, S32, FP-1173, S43
Fisher O, P-1103, S70
Fitzgibbons D, P-1188, S84
Fitzgibbons R, P-1074, S64, P-1227, S92
Fogacca de Barros P, FP-1137, S46, P-1142, S76
Fonseca C, P-1180, S82
Fonseca Mora M, P-1205, S87, P-1208, S88, V-1275, S103
Forman B, FP-1216, S17, FP-1231, S23, P-1251, S95
Fortelny R, IP-1354, S38
Foster A, FP-1247, S44
Foster L, P-1107, S70
Fox S, FP-1247, S44
Fracol M, FP-1061, S22
Franciss M, V-1242, S103
Frederix G, P-1092, S68
123
S105 Hernia (2019) 23 (Suppl 1):S104–S109
Freitas do Amaral P, FP-1137, S46
Frey A, P-1215, S90
Frieder J, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88
Frisella M, V-1194, S102
Frunder A, IP-1290, S36
Funk L, FP-1064, S109, P-1080, S65
Furtado M, P-1115, S72
Furukawa T, V-1132, S27
Gagliano R, FP-1191, S14, P-1234, S93
Gandhi C, P-1272, S100
Ganga R, P-1210, S88
Garcia Bear I, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,
P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53
Garcia D, P-1146, S77
Gbozah K, FP-1127, S29, V-1119, S27
Ghanem O, FP-1198, S22
Gibson H, IP-1284, S33
Gillespie T, FP-1191, S14, P-1234, S93, P-1240, S94
Gillian G, FP-1053, S45
Gillory L, P-1065, S62
Giron F, P-1048, S59
Glanville J, P-1100, S69
Gleason F, P-1102, S70
Goldblatt M, IP-1339, S31, P-1039, S58
Gong D, P-1117, S73
Gonzalez A, P-1165, S80, P-1169, S81
Green J, P-1047, S59
Greenberg J, FP-1064, S109, P-1080, S65
Greenberg Y, P-1079, S65
Greenhalgh E, P-1135, S75
Greiffenstein P, FP-1141, S18, FP-1267, S29
Griscom T, P-1258, S97
Grossi J, P-1270, S99
Guimaraes V, P-1213, S89, P-1223, S91, P-1225, S92
Gupta A, P-1100, S69
Gus J, P-1113, S72
Gutierrez Corral N, P-1006, S50, P-1007, S51, P-1010, S52,
P-1011, S52, P-1012, S52
Gutjahr D, P-1019, S54, P-1020, S55
Gvenetadze T, FP-1118, S10
Halka J, FP-1171, S13, FP-1230, S42
Hall K, FP-1233, S44
Harder F, P-1019, S54, P-1020, S55
Haridi A, P-1049, S60
Harmon J, P-1204, S86
Harner A, P-1076, S64
Harold K, IP-1359, S49
Harris H, IP-1353, S38
Hashim D, P-1030, S56
Hata H, V-1155, S101
Haubert L, P-1151, S79
Haynes S, P-1138, S75
Helm M, P-1039, S58
Hendriksen B, FP-1189, S16
Heniford B, IP-1321, S20, IP-1334, S28, FP-1075, S23,
FP-1097, S47, FP-1124, S17, FP-1125, S26, FP-1127, S29,
P-1128, S73, P-1129, S73, P-1206, S87, P-1229, S93, V-1119, S27
Hensman C, P-1035, S58
Hernandez J, P-1048, S59
Hernandez-Granados P, IP-1285, S32
Hernani B, FP-1137, S46, P-1139, S76, P-1146, S77, V-1242, S103
Hewett P, P-1035, S58
Higgins R, IP-1341, S32
Hilfinger U, FP-1153, S45
Hilton L, P-1076, S64
Hlavacek C, P-1215, S90
Hobler S, P-1017, S54, P-1018, S54, P-1023, S56
Hodgdon I, FP-1141, S18, FP-1267, S29, P-1195, S85
Holihan J, FP-1260, S16, P-1254, S96
Hollenbeak C, FP-1189, S16
Holsten S, P-1076, S64
Hope W, FP-1235, S42, FP-1261, S39, P-1248, S95, P-1253, S95, P-1259,
S97, P-1262, S98, P-1264, S98
Hoskovec D, FP-1153, S45
House M, P-1199, S86
Howell R, FP-1233, S44
Huadong D, P-1152, S79
Huang D, P-1240, S94
Huang L, P-1080, S65
Hughes T, FP-1261, S39, P-1238, S93
Huntington C, FP-1075, S23, P-1206, S87
Iacco A, FP-1171, S13, FP-1230, S42
Ibrahim M, P-1047, S59
Ierardi K, P-1016, S53
Iglesias A, V-1041, S101
Ikai I, V-1155, S101
Imazu H, P-1108, S71
Imazu Y, P-1108, S71
Iscan A, P-1005, S50
Iscan Y, P-1026, S56, P-1034, S57, P-1090, S68
Israel I, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97,
P-1262, S92, P-1264, S98
Israr S, FP-1191, S14
Ivarsson M, FP-1093, S11
Jackson B, P-1214, S89
Jackson J, P-1039, S58
Jacob B, IP-1299, S8, V-1196, S102
Jacubovsky I, P-1178, S82, P-1243, S94, V-1249, S103
Jafri S, FP-1276, S41
Jain M, P-1022, S55
Janczyk R, FP-1171, S13, FP-1230, S42
Janes L, FP-1061, S22
Janis J, IP-1324, S21, IP-1338, S28
Jarufe N, P-1178, S82, P-1243, S94, V-1249, S103
Jauregui C, P-1162, S80, P-1268, S99
Jeekel J, IP-1351, S38
Joel F, P-1218, S90
Johnson E, IP-1282, S36
Jorge Barreiro J, P-1006, S50, P-1007, S51, P-1008, S51,
P-1009, S51, P-1010, S52, P-1011, S52, P-1012, S52,
P-1013, S53, P-1014, S53
Kadamani A, P-1165, S80, P-1169, S81
Kallinowski F, P-1019, S54, P-1020, S55
Kao A, FP-1075, S23, P-1229, S93
Kao L, P-1254, S96, P-1255, S96, P-1257, S97
Karatassas A, P-1035, S58
Karim S, P-1063, S62
Karip B, P-1090, S68
Kashchenko V, P-1086, S67, P-1087, S67
Kasten K, P-1229, S93
Kawamoto Fujikawa V, P-1142, S76
Kercher K, FP-1075, S23
Kerkman T, FP-1089, S40
Khoury J, P-1094, S69
Kim D, FP-1265, S23
Kircher C, P-1136, S75
Kirkpatrick S, P-1094, S69
Kitagawa Y, V-1132, S27
Klobusicky P, FP-1153, S45
Ko T, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,
P-1257, S97
Koebe S, P-1080, S65
Kottmann T, P-1084, S66
Kozak G, FP-1173, S43
Kozieł S, P-1182, S83, P-1183, S83
Krikhely A, FP-1198, S22
123
Hernia (2019) 23 (Suppl 1):S104–S109 S106
Krpata D, IP-1313, S12, FP-1122, S41, FP-1123, S17,
FP-1176, S47, FP-1244, S10, P-1021, S55, P-1131, S74,
P-1190, S84, P-1245, S95, P-1263, S98, V-1126, S101, V-1186, S27
Kumaira Fonseca M, P-1113, S72, P-1140, S76
Kurapati S, P-1167, S81
Landry M, FP-1216, S17, FP-1231, S23
Langstein H, P-1135, S75
Larsen N, P-1188, S84
Lau F, FP-1267, S29
Lechner M, IP-1290, S36
Ledet C, IP-1284, S33
Lee B, P-1234, S93
Lee D, P-1065, S62
Lee L, IP-1318, S19
Leiman D, P-1164, S80, P-1174, S82
Leonardi C, P-1195, S85
Leopardi L, P-1035, S58
Levinson H, P-1047, S59
Lew M, FP-1216, S17, FP-1231, S23
Lewis J, P-1029, S56
Lewis R, FP-1216, S17, FP-1231, S23, P-1251, S95
Leyba M, IP-1346, S34
Li B, P-1117, S73
Li S, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100,
P-1274, S100
Li Y, P-1117, S73
Liacouras P, FP-1246
Liang M, FP-1260, S16, FP-1261, S39, P-1254, S96, P-1255, S96,
P-1257, S97
Lidor A, FP-1064, S109, P-1080, S65
Lighter M, P-1256, S96
Lima Konichi R, P-1142, S76
Limmer A, IP-1284, S33
Lin E, P-1101, S69
Lincourt A, P-1229, S93
Lischke R, FP-1202, S18, P-1149, S78
Liu N, FP-1064, S109
Lo Menzo E, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,
P-1218, S90, P-1220, S91, V-1275, S103
Lodygin A, P-1086, S67, P-1087, S67
Loi K, P-1056, S61
Lombardo F, IP-1278, S31
Loor M, P-1151, S79
Lorenz R, IP-1290, S36
Lorenzetti C, IP-1297, S36
Lourie D, IP-1289, S9
Love W, FP-1224, S29, FP-1247, S44
Lu R, FP-1222, S24, FP-1226, S13, P-1228, S92
Luciano T, P-1263, S98
Lundberg J, P-1234, S93
Ly J, P-1107
Lyons N, P-1254, S96, P-1255, S96, P-1257, S97
Maddern G, P-1035, S58
Madris B, P-1134, S74
Madureira F, V-1041, S101
Mak J, P-1107, S70
Makris K, P-1065, S62
Malcher F, FP-1198, S22, P-1115, S72
Malik D, P-1032, S57
Maloley-Lewis B, P-1227, S92
Maloney S, FP-1037, S47, FP-1075, S23, FP-1097, S47,
FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,
P-1129, S73, P-1229, S93, V-1119, S27
Manieri C, P-1054, S60
Maria F, P-1218, S90, P-1220, S91
Martinez G, P-1268, S99
Martins de Oliveira Neto R, P-1077, S65, P-1078, S65, P-1081, S66,
P-1082, S66
Matsusue R, V-1155, S101
Mazer L, P-1148, S78
Mazpule G, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46,
P-1100, S69
McCoy K, P-1134, S74, P-1200, S86
Meara M, IP-1307, S9
Medjamea A, P-1049, S60
Mehta A, FP-1198, S22
Mejahdi S, P-1049, S60
Meknat A, P-1079, S65
Meliani B, P-1049, S60
Memisoglu K, P-1034, S57, P-1090, S68
Mendes R, P-1223, S91, P-1225, S92
Mesko N, FP-1176, S47
Messa C, FP-1173, S43
Meyer F, P-1030, S56
Miao J, P-1117, S73
Mickova A, FP-1202, S18
Milla C, P-1180, S82
Milla Matute C, P-1205, S87, P-1208, S88, P-1210, S88,
V-1275, S103
Miller H, P-1266, S99
Miller M, FP-1168, S30, V-1194, S102
Milton A, FP-1261, S39, P-1254, S96, P-1255, S96, P-1257, S97
Minguez Ruiz G, P-1006, S50, P-1007, S51, P-1009, S51,
P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53
Minkowitz H, P-1164, S80, P-1174, S82
Miranda J, P-1067, S63
Mitchell A, P-1076, S64
Mitsinskaya A, P-1086, S67, P-1087, S67
Mitsinskii M, P-1086, S67, P-1087, S67
Mitura K, P-1181, S83, P-1182, S83, P-1183, S83
Mo S, P-1103, S70
Moazzez A, FP-1265, S23
Montero E, P-1067, S63
Montgomery A, IP-1352, S38
Morales-Conde S, IP-1280, S31
Morelli C, P-1178, S82
Morfesis F, P-1031, S57, P-1040, S59
Morlacchi A, IP-1278, S31
Morrell D, FP-1166, S45, FP-1189, S16
Morris M, P-1102, S70
Morrison J, IP-1327, S25
Mosquera M, P-1165, S80, P-1169, S81
Mukkai Krishnamurty D, P-1227, S92
Munoz R, P-1178, S82, P-1243, S94, V-1249, S103
Murakami A, P-1197, S86
Musonza T, P-1151, S79
Muysoms F, IP-1350, S38
Myers A, IP-1319, S19
Nabeel I, P-1035, S58
Nahabedian M, P-1214, S89
Nakeeb A, P-1199, S86
Narita M, V-1155, S101
Nassar R, P-1048, S59
Nassim O, P-1049, S60
Nathan S, FP-1173, S43
Nessel R, P-1019, S54, P-1020, S55
Neto I, P-1146, S77, V-1242, S103
Neves V, V-1041, S101
Nguyen D, IP-1310, S12
Nguyen H, P-1204, S86
Nguyen Q, P-1195, S85
Nicolo E, P-1114, S72
Niebler G, P-1164, S80, P-1174, S82
Norden S, P-1200, S86
Norrby J, FP-1093, S11
Novitisky Y, IP-1303, S8
Novitsky M, FP-1276, S41
Novitsky Y, IP-1336, S8, FP-1198, S22
123
S107 Hernia (2019) 23 (Suppl 1):S104–S109
Olasky J, IP-1287, S9
Olavarria O, FP-1260, S16, P-1254, S96, P-1255, S96, P-1257, S97
Oleynikov D, FP-1130, S14
Oliveira H, P-1113, S72, P-1140, S76
Ongos K, P-1046, S59
Onopchencko A, V-1083, S101
Oppong C, IP-1290, S36
Orenstein S, FP-1166, S45, P-1036, S58
Ortiz Gomez C, P-1180, S82, P-1205, S87, P-1208, S88,
V-1275, S103
Otahal M, FP-1202, S18
Otani T, V-1155, S101
Otero J, P-1206, S87, P-1229, S93
Ozmen J, P-1056, S61
Paasch C, P-1004, S50
Pacella S, P-1135, S75
Paige J, FP-1141, S18
Paim D, P-1270, S99
Pakula A, IP-1279, S33
Panait L, IP-1288, S34
Pantinniot P, P-1035, S58
Park H, FP-1265, S23
Parker M, P-1199, S86
Parlacoski S, FP-1226, S13
Parmar A, P-1102, S70
Patel A, P-1101, S69
Patel P, FP-1224, S29, P-1107, S70, P-1192, S85
Paul D, P-1084, S66
Pauli E, FP-1166, S45, FP-1189, S16, P-1193, S85
Pearson D, FP-1247, S44
Pedreira Junior N, P-1213, S89, P-1223, S91, P-1225, S92
Pedroso J, P-1113, S72
Pereira S, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46,
P-1100, S69
Perez C, P-1165, S80, P-1169, S81
Perkins C, P-1102, S70
Perry K, IP-1343, S32
Petersen R, IP-1345, S32
Peterson E, P-1234, S93
Petro C, FP-1122, S41, FP-1123, S17, FP-1176, S47,
P-1021, S55, P-1190, S84, P-1263, S98, V-1126, S101,
V-1177, S102, V-1186, S27
Phillips S, P-1080, S65
Phok B, P-1094, S69
Pierce R, IP-1355, S42
Pimentel F, P-1178, S82, P-1243, S94, V-1249, S103
Pire Abaitua G, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,
P-1010, S52, P-1011, S52, P-1012, S52, P-1013, S53, P-1014, S53
Pisano A, FP-1246, S40
Pivetta L, P-1139, S76, P-1207, S87, V-1242, S103
Plymale M, P-1238, S93
Podolsky D, FP-1198, S22
Poulose B, IP-1304, S8, FP-1244, S10, P-1263, S98
Prabhu A, IP-1300, S8, IP-1306, S9, FP-1122, S41, FP-1123, S17,
FP-1176, S47, FP-1244, S10, P-1021, S55, P-1190, S84, P-1245, S95,
P-1263, S98, V-1126, S101, V-1177, S102, V-1186, S27
Prasad T, FP-1075, S23, FP-1124, S17, FP-1125, S26, FP-1127, S29,
P-1129, S73, P-1206, S87, P-1229, S93
Prasath V, P-1204, S86
Prebil B, P-1271, S99
Pryor A, FP-1145, S26
Qin C, FP-1163, S18, P-1073, S64, P-1117, S73, P-1159, S79,
P-1172, S81
Quezada N, P-1178, S82, P-1243, S94, V-1249, S103
Radvansky J, P-1149, S78
Raimondi S, IP-1292, S49
Rajo M, FP-1141, S18
Ramirez N, P-1165, S80, P-1169, S81
Rammohan R, P-1210, S88
Ramos Perez V, P-1008, S51, P-1010, S52, P-1011, S52, P-1014, S53
Ramshaw B, FP-1216, S17, FP-1231, S23, P-1251, S95
Rappoport J, P-1162, S80, P-1268, S99
Ratnayake S, P-1055, S60
Raul R, P-1218, S90, P-1220, S91
Ravindran P, P-1069, S63, P-1103, S70
Reed R, P-1199, S86
Rehbein P, P-1140, S76
Reid J, P-1035, S58
Reif R, P-1063, S62
Reilly M, P-1188, S84
Reinpold W, IP-1325, S25, IP-1358, S49, P-1074, S64
Rene A, P-1220, S91
Renton D, IP-1312, S12
Rhemtulla I, P-1054, S60
Ricaurte A, P-1048, S59
Richards J, FP-1191, S14, P-1240, S94
Richman J, P-1102, S70
Rimpel B, P-1079, S65
Rivera C, V-1275, S103
Rives G, P-1063, S62
Rivison M, P-1213, S89
Roberto Corsi P, P-1077, S65, P-1078, S65, P-1081, S66, P-1082, S66
Roberto Puglia C, P-1077, S65, P-1078, S65, P-1081, S66,
P-1082, S66
Roberts J, P-1256, S96
Rodrigues Armijo P, FP-1130, S14
Rodrigues H, V-1041, S101
Roll S, IP-1302, S8, FP-1137, S46, FP-1244, S10, P-1139, S76,
P-1142, S76, P-1146, S77, P-1207, S87,V-1242, S103
Roman C, P-1165, S80, P-1169, S81
Romero Funes D, P-1205, S87
Roos M, FP-1089, S40, P-1092, S68
Rosen M, FP-1122, S41, FP-1123, S17, FP-1176, S47,
FP-1244, S10, P-1021, S55, P-1190, S84, P-1245, S95,
P-1263, S98, V-1126, S101, V-1186, S27
Rosenblatt S, FP-1122, S41, FP-1123, S17, FP-1244, S10, P-1021, S55,
P-1245, S95, V-1126, S101, V-1186, S27
Rosenstock A, IP-1293, S34, IP-1294, S35, IP-1295, S34,
FP-1237, S46, P-1100, S69
Rosenthal R, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,
V-1275, S103
Roth J, IP-1281, S19, P-1238, S93
Rubalcava N, FP-1191, S14
Ruiz-Jasbon F, FP-1093, S11
Runyan B, P-1023, S56
Ruppert D, P-1047, S59
Saad I, IP-1333, S27
Sabido F, P-1138, S75
Sahan C, P-1090, S68
Samuel S, P-1218, S90, P-1220, S91
Sanchez Turrion V, P-1008, S51, P-1009, S51,
P-1013, S53
Sanchez-Montes I, P-1133, S71, P-1219, S91
Sanders F, P-1091, S68
Sandoval G, P-1162, S80
Sanguineti A, P-1162, S80, P-1268, S99
Santana Neto O, P-1213, S89, P-1225, S92
Santivanez Palomino J, P-1048, S59
Santoro P, P-1054, S60
Santos D, IP-1284, S33
Santos de Miranda J, P-1197, S86, P-1211, S89
Santos F, P-1213, S89, P-1223, S91
Santos H, P-1270, S99
Sarkar A, P-1103, S70
Sarmiento-Cobos M, P-1210, S88
Sarrel S, P-1062, S62
Saving A, IP-1291, S9
Sawyer M, P-1085, S66
123
Hernia (2019) 23 (Suppl 1):S104–S109 S108
Scheiber C, FP-1246, S40
Schlosser K, FP-1037, S47, FP-1097, S47,
FP-1124, S17, FP-1125, S26, FP-1127, S29, P-1128, S73,
P-1129, S73
Scholer A, FP-1237, S46
Schouten N, P-1088, S67
Schroeder A, P-1074, S64
Scott J, FP-1261, S39
Sedgwick D, IP-1290, S36
Selmani Z, P-1049, S60
Sembarski Oliveira E, P-1142, S76
Sepulveda P, P-1162, S80
Serra Lorenzo R, P-1006, S50, P-1007, S51, P-1010, S52, P-1011, S52,
P-1012, S52, P-1013, S53, P-1014, S53
Serrano Gonzalez S, P-1006, S50, P-1007, S51, P-1008, S51, P-1009, S51,
P-1013, S53
Seven C, FP-1276, S41
Sexton K, P-1063, S62
Shada A, FP-1064, S109, P-1080, S65
Shah P, P-1255, S96, P-1257, S97
Shah R, V-1275, S103
Shah S, FP-1261, S39
Shahzad N, P-1131, S74
Sharbaugh M, P-1192, S85
Sharma R, P-1148, S78
Shashkov D, P-1094, S69
Shebrain S, P-1136, S75
Shen Y, FP-1163, S18, P-1073, S64, P-1159, S79, P-1161, S80,
P-1172, S81
Shikhman A, P-1017, S54, P-1018, S54
Short C, FP-1267, S29
Shover A, FP-1265, S23
Siegal S, FP-1166, S45, P-1036, S58
Silva J, P-1162, S80, P-1268, S99
Silva R, P-1146, S77
Singh T, P-1192, S85
Smith M, P-1217, S90
Soares Gallo A, P-1077, S65, P-1078, S65, P-1081, S66, P-1082, S66
Socas J, P-1199, S86
Soriano I, P-1051, S60
Sosin M, P-1214, S89
Souza J, FP-1246, S40
Sovkova V, FP-1202, S18
Soybel D, P-1193, S85
Spaniolas K, FP-1145, S26
Ssentongo A, P-1193, S85
Ssentongo P, P-1193, S85
Stavert B, P-1056, S61
Stechemesser B, IP-1326, S25
Stetler J, P-1101, S69
Strik M, P-1004, S50
Sun S, FP-1145, S26
Svestka M, FP-1176, S47, P-1190, S84, P-1245, S95, P-1263, S98,
V-1126, S101, V-1186, S27
Symons W, P-1134, S74
Szomstein S, P-1180, S82, P-1205, S87, P-1208, S88, P-1210, S88,
V-1275, S103
Talamini M, FP-1145, S26
Talbot M, P-1069, S63, P-1103, S70
Tanaka E, P-1197, S86, P-1211, S89
Tang J, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100, P-1274,
S100
Tarso L, P-1113, S72
Tastaldi L, IP-1356, S42, FP-1122, S41, FP-1123, S17,
FP-1137, S46, FP-1244, S10, P-1021, S55, P-1139, S76,
P-1146, S77, P-1190, S84, P-1245, S95, V-1126, S101,
V-1177, S102, V-1242, S103, V-1186, S27
Taylor J, P-1063, S62
Tchokouani L, V-1196, S102
Tejirian T, P-1071, S63, P-1072, S63
Telem D, FP-1276, S41
Tellez L, P-1169, S81
Tenzel P, FP-1235, S42, P-1248, S95, P-1253, S95, P-1259, S97, P-1262,
S92, P-1264, S98
Thankam D, P-1188, S84
Thomas E, P-1271, S99
Thrippleton S, FP-1173, S43
Ticehurst K, FP-1093, S11
Totti Cavazzola L, IP-1357, S49
Towfigh S, IP-1317, S19, P-1148, S78
Tran-Chao H, P-1065, S62
Tubre D, P-1074, S64
Turcotte J, FP-1222, S24, FP-1226, S13, P-1228, S92
Turner B, P-1039, S58
Tuveri M, P-1114, S72
Utiyama E, P-1067, S63, P-1197, S86, P-1211, S89
van der Velde S, IP-1286, S25
van Hessen C, P-1088, S67, P-1091, S68, P-1092, S68
Varella M, P-1140, S76
Vasyluk A, FP-1171, S13, FP-1230, S42
Verleisdonk E, P-1088, S67, P-1091, S68, P-1092, S68
Vitous C, FP-1276, S41
Vitujova M, P-1149, S78
Vocetkova K, FP-1202, S18
Voigt C, P-1227, S92
Vonk J, P-1227, S92
Vujcich E, P-1055, S60
Wada N, V-1132, S27
Wang M, FP-1156, S10, FP-1158, S39
Wang N, P-1059, S61
Warren J, IP-1337, S28, FP-1224, S29, FP-1247, S44, P-1258, S97
Washburn P, P-1102, S70
Webb D, IP-1335, S28
Weimer S, V-1269, S103
Weinberg J, FP-1191, S14, P-1234, S93
Wernsing D, P-1051, S60
White B, P-1209, S88
Whitenack N, P-1227, S92
Wiessner R, IP-1290, S36
Wolkweiss B, P-1239, S94
Wood B, P-1215, S90
Wood H, FP-1176, S47
Wright G, FP-1044, S46
Xu Y, FP-1064, S109
Yamaguchi T, V-1155, S101
Yang H, P-1147, S78, P-1150, S79
Yange J, FP-1145, S26
Yheulon C, P-1101, S69
Ying-mo S, P-1152, S79
Yoo A, FP-1141, S18, FP-1267, S29
Yoo J, P-1197, S86, P-1211, S89
Youssef M, P-1207, S87
Zahiri R, FP-1222, S24, FP-1226, S13, P-1228, S92
Zakaud Dakaud A, P-1076, S64
Zaman J, P-1192, S85
Zanirati T, P-1239, S94
Zatir S, P-1049, S60
Zhu C, FP-1145, S26
Zhu L, FP-1057, S40, P-1058, S61, P-1059, S61, P-1273, S100,
P-1274, S100
Zhu Y, FP-1156, S10, FP-1158, S39
Zilberstein B, P-1207, S87
Zuardi A, P-1197, S86, P-1211, S89
Zumba O, IP-1293, S34, IP-1294, S35, IP-1295, S34, FP-1237, S46
123
S109 Hernia (2019) 23 (Suppl 1):S104–S109