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Topic: INCISIONAL HERNIA - "Difficult case" as specialistic case: real loss of substance, multi recurrences, infections, fistulas, lombocel, burst abdomen, reconstruction of the entire wall © Springer-Verlag 2014

PO:54 REPAIR OF LARGE ABDOMINAL INCISIONAL HERNIA BY RECONSTRUCTING THE MIDLINE AND USE OF AN ONLAY OF BIOLOGICAL MATERIAL M. Tuveri', A. Tuveri2, E. Nicol03

lOspedale N.S. di Bonaria - u.o. Chirurgia Generale, San Gavino Monreale, ITALY 2CDC Sant'Elena - Dipartimento di Chirurgia Generale, Quartu Sant'Elena, ITALY 3Jefferson Hospital - Department of Surgery, Pittsburgh, USA

Background: The main principle of abdominal incisional hernia repair is to restore the anatomical and physiological integrity of the abdominal wall by reconstructing the midline. Ideally, midline structural support is restored by midline approximation of local musculo-aponeurotic tissues. Approximation of these tissues without tension on the suture line will restore the elasticity and flexibility of the abdominal wall. However, 30% to 50% of defects larger than 6 cm recur after primary closure, because of the tension on the suture line. Insertion of an allo­plastic material to decrease or eliminate tension on the suture line can reduce the incidence of recurrence to 10% or less. But inorganic pros­thetic materials have been associated with a high risk of complications such as protrusion, extrusion, infection, and intestinal fistulization. With the availability of biological materials, surgeons are increasingly using these materials for effective surgical management of abdominal incisional hernia The aim of this study was to determine the feasibility and efficacy of repairing large abdominal incisional hernias by recon­structing the midline using bilateral abdominis rectus muscle sheath (ARS) relaxing incisions and a biological material onlay.

Methods: Between January 2002 and December 2009, 104 patients underwent repair oflarge incisional hernias at 2 community hospitals. After replacement of hernia sac contents into the peritoneal cavity, a relaxing incision was made in the ARS bilaterally. Then the midline was closed primarily. The biological material was onlaid and sutured to the lateral edges of the relaxed ARS. Main outcome measures were postoperative complications and hernia recurrence.

Results: Median age 61 years (range, 39-86) years. Body mass index was 34 (range, 23-44). Of the 104 patients, 37 had undergone I or more previous repairs. In 19 patients (18%), mesh had been used. In 14 patients the mesh had been placed as a sub lay, and in 5 patients the mesh had been placed laparoscopically. We removed the mesh in all 19 cases. Size of the defect was 195 (range, 150-420) cm2

• Median operation time was 125 (range, 75-255) minutes. Four patients (3.8%) had a large wound hematoma that required operative drainage. Four (3.8%) patients developed skin necrosis at the edge of the wound, exposing the biological material; they were treated conservatively with dressings and oral antibiotics and discharged 9 days after surgery. Three (2.8%) developed urinary tract infection, which was treated successfully with appropriate oral antibiotics. One (0.9%) developed

pneumonia postoperatively; this was successfully treated with appro­priate antibiotics and the patient was discharged 10 days after surgery. Wound seroma occurred in 57 (55%) patients. In all cases, the ser­oma was suspected by physical examination and both confirmed and managed by fine needle aspiration, with or without sonography. The median time between surgery and diagnosis of seroma was 19 days (range, 12-42). The mean time to complete resolution was 52 days (range, 28-130). Mortality was nil. The mean follow-up period was 78 months (range, 23-121). Six (5.7%) of the 71 patients had recur­rence of abdominal incisional hernia. The recurrence was diagnosed by physical examination and confirmed by a CT scan of the abdomen. No chronic abdominal pain occurred.

Conclusions: The procedure adheres to principles of surgery, not only restoring the anatomy and integrity of the abdominal wall but also its function (flexibility and elasticity, allowing active contraction and passive relaxation). Furthermore, the onlay of biological material promotes complete and definitive healing of the sutured midline, with­out the high risks of infection and other complications of inorganic materials. Further studies are required to confirm the advantages of our technique for reconstructing the midline with use of a biological material onlay.

PO:55 THE USEFUL TECHNIQUE IN A LAPAROSCOPIC INCISIONAL HERNIA REPAIR SURGERY WITH A LARGE SIZE MESH T. Tsuruma', M Nagayama', S Nakano' 1 Department of Surgery, JR Sapporo Hospital, Sapporo, JAPAN

Purpose: Laparoscopic surgery in incisional hernia is a very useful surgical method because of minor abdominal destruction, visualization of hernia resion, etc. In difficult case, such as a hernia with large size or closer to the bladder, some techniques are required to prevent recur­rences. So, we demonste a case report of a patient who have two her­nias closer to the bladder undergoing laparoscopic sugery, and advance some useful techniques.

Methods: A 62-year-old female patient (standing tall at 147cm, weight 46kg, and B.M.1. 21.3) who have two incisional hernias closer to the bladder after gynecological operation was underwent a laparoscopic incisional hernia repair surgery. The diameter of two hernias were 8 cm x 5cm and 5 cm x 3 cm. The safety margin of mesh was 5cm. So, we selected Ventralight ST mesh whose size was 25.4 cm x 20.3 cm, which was a medium-weight monofilament polypropylene mesh covered with a hydrogel barrier on the visceral side. And then, the mesh was cut into 25 x 16 cm before the insertion into abdominal cavity. First, 5mm optical access trocar was inserted in hypochondriac region with little adhesion. Then, other trocars were inserted at each side of abdomen wall in order for tight mesh fixation. In case using large mesh, trocars are required for

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both sides, because mesh fixation device cannot fix ipsilateral marge of mesh. After the insertion of mesh into abdominal cavity, the mesh was hung by three points on a long axis in the appropriate position. With that, the space could be secured under the mesh. So, the mesh was absolutely fixed by fixation device using the double-crown technique. Further­more, ligation fixation was also carried out in all the layers. And lower side of the mesh was inserted into prevesical space.

Results: 19 patients with incisional hernia have underwent lapa­roscopic surgery since July, 2010. There is no recurrence until now. 4 patients had complications that were subcutaneous hemorrhage, mesh bulging, intestinal paralysis, and seroma. The complications except for mesh bulging were improved by conservative management.

Conclusion: Laparoscopic incisional hernia repair surgery is a very minimally invasive surgery. So, it might be an ideal surgical treatment method. However, in the case with large size hernia, the management of large mesh in abdominal cavity might be very difficult. Like the above, the mesh hanging technique by three points on a long axis in the appropriate position might be very useful. In addition, trocars are required for both sides. These techniques might be beneficial in laparo­scopic incisional hernia repair surgery using large size mesh.

PO:56 SPONTANEOUS GASTRIC PERFORATION IN INCISIONAL HERNIA: A RARE CAUSE OF A LIFE-THREATENING COMPLICATION F. Trombetta l

, R. Moscato l, F. Ghiglione l

, T. Ciamporcero l,

E. Galasso l, M. Morino l

I] SCDU General Surgery University of Turin. (Dir. Prof M. Morino) Company City hospital and health Science, Turin, ITALY

Introduction: Spontaneous gastric perforation in incisional hernia is a rare and potentially life-threatening complication of abdominal-wall inci­sional hernia. We present a case of a spontaneous gastric perforation in a 69-year-old female patient with BMI of 41, who came to our attention for a median sub-umbilical permagna hernia. It is the outcome of an emer­gency laparotomy for post-partum hemorrhage performed 30 years ago.

Description: The clinical presentation included a wide hernial defect. The sac containing part of the transverse colon, loops of small intes­tine, omentum, initial skin suffering, abdominal muscle laterally dis­placed in the sub-umbilical area and cutaneous-adipose laxity of the lower abdomen.

She performed a bariatric surgical evaluation. The surgeon did not give absolute surgery's contraindications, but showed to the patient the high risk of postoperative complications. Once the patient has been informed of the risks, she decided to consult her G.P. and only then to communicate her decision.

A morning she arrived to the emergency room for asthenia, hyper­thermia and abdominal pain. The surgical evaluation showed that she was suffering; she had vital signs compromised with an increase of inflammatory markers like in a septic shock in acute abdomen.

The clinical situation was severe so she was referred to the emer­gency surgery for explorative laparotomy with evidence of intraopera­tive gastric perforation and associated peritonitis.

We treated the gastric perforation with breach's resection and suture in two layers, we reduced into the abdomen the intestinal loops and we performed separation of the components sec. Ramirez to expand the abdominal cavity. Finally, we placed an intraperitoneal biological mesh, fixed to the fascia with non-absorbable braided points.

Results: The post-operative course was complicated by dehiscence and infection of the surgical wound. After revision of the surgical

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wound and multiple medications, it was decided to place the VAC device to obtain wound's healing. After one year, the patient is in good conditions, she increases by an additional 10 kg of weigh. Actually she has a little recurrence of 3 cm without current indications for surgery.

Discussion: Incisional abdominal wall hernias are still a challenging problem for the surgeon. Bowel perforation in patients with hernias occurs either from trauma to abdomen or from trauma directly to her­nia. Most hernias are repaired in an elective way in order to prevent complications. Although complications are rare, they might be severe if not promptly addressed. The complications of abdominal wall her­nias are incarceration, strangulation and bowel perforation. This report describes an unusual complication of abdominal hernia. We don't know what caused the weakening of stomach's wall resulting in a per­foration but we can assume a stretching ischemia of the bowel caused by the significant size of the hernia. Histological examination showed necrotic and suppurative inflammation of the subserosal and inflam­matory peritoneal effusion with signs of fungal infection. This surgery is considered contaminated, so it was impossible an anatomical repair or the use of a synthetic mesh for the high rate of complications. In the absence of a deferred closing system like ABThera©, the wound's repair was performed with a biological mesh. VAC therapy was use­ful in the management of post-operative complications of the surgical wound obtaining a good healing by secondary intention.

PO:57 EVALUATION OF RETROMUSCULAR MESH REPAIR TECHNIQUE FOR GIANT VENTRAL INCISIONAL HERNIAS M. Tharao l

, B NDUNGU2, H SAIDF, PMWIGEJ, J GICHERE3 1ST Mary's Hospital, Nairobi, KENYA 2The University of Nairobi, Nairobi, KENYA 3Kenyatta National Hospital, Nairobi, KENYA,

Introduction: Incisional hernia is a common surgical condition with a reported incidence of 2-11 % following all laparotomies. Results of tissue repair have been disappointing. The use of prosthetic materials in incisional hernia repairs has diminished reherniation rates markedly. The optimal approach for giant abdominal incisional hernias is still under discussion.

Objectives: The aim of the study was to evaluate the use of the Rives-Stoppa retromuscular mesh repair technique for the treatment of large and complex incisional hernias.

Materials and methods: Over a 5-year period, (2010-2014) 15 open repairs were performed using the Rives-Stoppa technique for large, com­plex and unusual site abdominal wall incisional hernias. Three (20%) had previously undergone incisional hernia repair. All patients were evaluated with respect to operative time and postoperative complications. The pros­thesis used was pure polypropylene; the size ranged from 15x 20cm to 20x 25 cm (mean area 325 sq.cm.). Results were documented and statisti­cally analyzed. Follow-up consisted of clinic visit up to 12 months post­operatively and at least one subsequent clinic visit or telephone interview; mean follow-up time was 30 months (range 10- 45 months).

Results: In this study on 15 patients, there were 12 female (75%) and 3 (25%) male patients whose age ranged between 25 and 68 years with mean of 48.4 years. The mean operative time was 90 ± 18.04 mins. The

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mean period of drainage was 3.0 ± 2 days. Seroma was encountered 1 patient and no patient had surgical site infection warranting prosthesis removal. No recurrence has been reported during the follow-up period (10- 45 months).

Conclusion: On the basis ofthis study, the Rives-Stoppa technique has shown excellent long-term results, with minimal morbidity, in patients with large and complex incisional hernias. We therefore suggest that the Rives-Stoppa procedure is the repair of choice in such patients.

PO:58 IMPROVED OUTCOMES IN THE MANAGEMENT OF HIGH-RISK INCISIONAL HERNIAS: A SINGLE CENTRE EXPERIENCE 1. Skipworth!, 1. Younis!, D. Floyd!, A. Shankar! lRoyal Free and University College London Hospital Complex Hernia Unit, London, UNITED KINGDOM

Introduction: Abdominal wall reconstruction (AWR) is complex in the setting of multiple co-morbidities, previous or recurrent infection, loss of domain and bowel involvement; often on the background of co-mor­bidities such as obesity, diabetes and malignancy. Traditional repair methodologies previously described are associated with significant mor­bidity, leading our unit to develop a novel technique for complex A WRs.

Methods: A retrospective review of A WRs performed as a combined, single-stage procedure, by a general and plastic surgeon, was undertaken (Feb 2009-0ct 2014). Standardised repair involved radical resection of attenuated, poorly-vascularised soft-tissuelhernia sac, component sepa­ration (where necessary), intra-peritoneal mesh insertion (VentrioTM & VentralexTM (Bard) composite mesh for ventral hernia working group (VHWG) grades 1 and 2; Strattice™ (LifeCell) biological mesh for grades 3 and 4, and high-risk grade 2), midline fascial closure, and abdominal wall reconstruction (with soft-tissue flaps where necessary).

Results: 114 (77 biologica1l37 composite) patients underwent AWR (78F / 36 M; mean age 56 years, mean BM! 33.3 kglm2, median length of stay 8 nights, median follow-up 35 months). 12(10.5%) patients were VHWG grade 4,53(46.5%) grade 3, 40(35.1%) grade 2 and 9(7.9%) grade 1. 38(33.3%) were recurrent hernias, 21(18.4%) had diabetes, 35(30.7%) had a current diagnosis of malignancy, 18(15.8%) were smokers, 6(5.3%) had stomas, 8(7.0%) had COPD and 14(12.3%) had ischaemic heart disease.

32(28.1 %) patients developed complications including seven (6.1 %) readmissions; 18(15.8%) surgical-site occurrences (14 wound infections (one treated by ultrasound-guided drainage, three treated with vacuum dressing therapy, one treated via haematoma evacuation in theatre and one treated via debridement of wound with subsequent resuturing), 15 seromas (two aspirated and the rest treated conservati­vely), 2 haematomas (both treated conservatively»; 1(0.9%) return to theatre; 8(7.0%) respiratory and 3(2.63%) cardiac complications. Cli­nical follow-up revealed 4(3.5%) hernia recurrences: 1 has undergone further repair and 3 are asymptomatic and under active follow-up. No patients have required mesh removal.

Conclusions: Despite the high-risk nature of the cohort, this opera­tive technique is associated with a low incidence of recurrence and a low risk of surgical-site occurrences (including 0% mesh explanta­tion), a finding that may be dependent upon comprehensive resection of poorly-vascularised soft-tissue (bioburden reduction) and subse­quent abdominal wall reconstruction utilising healthy tissue. Further­more, the low incidence of surgical-site occurrences in grade 2 patients repaired with synthetic mesh has led to a change in our unit's practice, with biological mesh now exclusively reserved for grade 3 or 4 AWRs.

PO:59 LAPAROSCOPIC REPAIR OF RECURRENT INCISIONAL HERNIA R. SarangP lSir Ganga Ram Hospital, New Delhi, INDIA

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Author: Dr. Rathindra Sarangi, Sf. Consultant Surgeon. Department of General and Laparoscopic Surgery, Sir Ganga Ram Hospital, New Delhi. 110060, India

Relapses following conventional repair procedure is higher in recurrent than in primary incisional hernia.

The incidence ranges from 30 to 50% in recurrent hernia where as it is 11 to 20% following primary repair.

Recurrence commonly occurs within first three years following the surgery, that too within first six months.

Operations for recurrent incisional hernia are associated with high morbidity. The aim of this study was to evaluate the efficacy of lapa­roscopic surgery in these group of patients.

This study was done by a single surgeon. Out of 440 incisional hernia surgery done during the period 2004 to 2013 79 patient had recurrent incisional hernia. Forty patients had anatomical repair, onlay mesh repair had been done in twenty five patients and fourteen patients had undergone I P 0 M repair earlier. Forty two out of the seventy nine patients could be successfully operated laparoscopically. Fourteen patients who had undergone previous laparoscopic repair six could be operated laparoscopically and the rest had onlay mesh repair.

The average operation time was 70 minutes, and the average post operative stay was 2 days. A large mesh was used in 12 patients and the rest had medium size mesh.

The patients attended the follow up clinic 2,6, 12 months following the surgery. There were complications like seroma in 6 patients, bowel injury in four which could be repaired laparoscopically. The proce­dure was converted to open because of dense bowel adhesions. Four patients had recurrence and one patient died twenty five days fol­lowing the surgery due to sepsis following large bowel injury.

Laparoscopic repair of recurrent incisional is difficult but feasible. Careful handling of bowel and omentum is very important in preven­ting morbidity and mortality. Defects measuring more than 10cm. in diameter should ideally be avoided for reapair laparoscopically. Proper placement of appropriate size of prosthetic material should be done to achieve minimal re-recurrence.

Dr. Rathindra Sarangi, MS, Senior Consultant Surgeon Sir Ganga Ram Hospital New Delhi - 110060 Mobile No. 9810022579

PO:60 SYNTHETIC BIO-ABSORBABLE TISSUE SCAFFOLD IN ABDOMINAL WALL RECONSTRUCTION: A SINGLE SURGEON EXPERIENCE P Morehead!, J Williams I.2

lMedical Center Navicent Health - Department o/Surgery, Macon, USA 2Coliseum Hospital- Department o/Surgery, Macon, USA

Introduction: Ventral and incisional hernias pose a difficult problem for surgeons today. Incisional hernia complicates some 2-20% of lapa­rotomies. This problem has been met with many proposed solutions over the course of surgical history including the use of many different types of mesh and tissue repairs. The purpose of our study was to review and

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evaluate the effectiveness of abdominal wall reconstruction using syn­thetic bio-absorbable tissue scaffold in the repair of ventral hernias.

Methods: This study reviews a cohort of patients who underwent abdominal wall reconstruction utilizing synthetic bio-absorbale tissue scaffold and repair of ventral hernia by a single surgeon in a tertiary referral center. Surgical techniques included intraperitoneal, retrorectus, and onlay placement of synthetic bio-absorbable tissue scaffold com­bined with unilateral or bilateral myofascial advancement including transversus abdominus release, posterior component separation, and anterior component separation methods. The surgical technique evolved during the data collection process based on surgical outcomes. The cur­rent preferred method includes posterior component separation with retrorectus placement of the mesh material. Patients were seen in fol­low up at 2 weeks, 6 weeks, 6 months, 1 year, 2 years, and as needed post-operatively. The primary outcome was recurrence, and the second­ary outcome was wound complication requiring intervention (infection, dehiscence, seroma, hematoma, etc.).

Results: A total of 49 consecutive patients were reviewed from 2010 to 2014. All patients underwent hernia repair with synthetic bio-absorba­ble tissue scaffold (85.7% retrorectus, 8.1% intraperitoneal, and 6.1% onlay placement). 34 patients (69.4%) had bilateral posterior com­ponent release; 9 patients (18.4%) had bilateral anterior component release; 3 patients (6.1 %) had unilateral posterior component release; 2 patients (4%) had transversus abdominus release; and 1 patient (2%) did not require component release. 55% of patients were obese (BMI> 30).16.3% of patients were on steroids at the time of repair. Mean follow up was 25 months (5.5 - 46.4 months). Recurrence was diagnosed in 4 patients (8.1 %). Wound complications requiring inter­vention occurred in 3 patients (6.1 %).

Conclusion: The use of synthetic bio-absorbable tissue scaffold as mesh in combination with other hernia repair techniques offers an effective and durable repair across a broad range of clinical scenarios, including repairs in the face of enterotomy, fistula, bowel resection, stoma rever­sal, and chronic wounds. Additionally, this choice of mesh offers a finan­cial benefit over commercially available biologic mesh products while offering low recurrence and wound complication rates, and should be considered for abdominal wall reconstruction procedures.

PO:61 RETRO RECTUS APPROACH TO VENTRAL AND INGUINAL HERNIA REPAIR K. Minamimura!, K Mafune!, S Irie!, T Kobayashi!, T Hirata! 1Mitsui Memorial Hospital, Tokyo, JAPAN

Introduction: Despite recent improvement in the repair for ventral hernia using composix mesh, the incisional hernia of suprapubic region is difficult to fix this mesh. We adopt the retro rectus approach of Stoppa procedure to suprapubic incisional hernia and bilateral inguinal hernia.

Aims: The aim is to identifY the early and late complications associ­ated with this procedure.

Patients and methods: A total of 34 consecutive patients (mean age, 66.1) underwent a Stoppa repair, 31 in bilateral inguinal hernia, 3 in suprapubic incisional hernia, 1 in partial resection of rectus muscle of metastatic colon cancer. For all patients except those who lack of peritoneum use the polypropylene mesh. The recurrent inguinal hernia was 5 cases (16%) in bilateral inguinal hernia.

Results: One of the patients had composix mesh and other had polypro­pylene mesh. Median operating time and blood loss were 120 min and

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80 ml. 13 cases of patient had no drainage catheter and median length of draining was 3.3 days. Median postoperative stay and follow up was 9.2 days and 23.6 months. Total recurrent rate was 3%. Infection requiring removal or partial resection of the prosthesis occurred in 2 patients (5.9%). Continuous discharge after removal of catheter was seen in those patient.

Conclusion: Stoppa repair is reasonable technique for complex incisional hernias with comparatively lower recurrence rates. The long continuous discharge after removal draining raise the possibility of infection of mesh.

PO:62 NEO-REGENERATION OF ABDOMINAL WALL APONEUROSIS USING AUTOLOGUS ADULT TISSUE STEM CELLS INVIVO BY DESIRED METAPLASIA IN THE REPAIR OF LARGE INCISIONAL HERNIAS B. Matapurkar!, A Bhargave! 1M A Medical College & associated Hospitals LNJp, GBP Hospitals, New Delhi, INDIA

Repair of Large and Recurrent Abdominal Incisional Hernias is a dif­ficult surgical problem. Last quarter of 20th century has witnessed pioneering research on Stem Cell use in medical management. The pioneering scientific research on use of Adult Stem cells in Regene­rative surgery based on Matapurkar's Hypothesis on Embryological principles has established new physiological phenomina of desired metaplasia. The same has been published in many peer reviewed scientific journals. A new technique for incisional hernia repair in WJS in 1991 which was published in R Maingot's Text book of Abdomi­nal Operations in 1997. Regeneration of abdominal wall aponeurosis published in W J S in 1999. The incisional hernia repair in 60 patients with15 years follow up with neo-regeneration of abdominal wall apo­neurosis using stem cells of autologus peritoneum, will be presented. The Marlex Mesh is used in the Peritoneal Sandwich gives strength and permits regeneration of wall aponeurosis in the repair of hernia (see image). This repair minimizes complications and provides lasting repair with drastic cosmatic improvement.

Hypothesis, Desired Metaplasia, repair technique, along with neo-organo-histogenesis will be explained & presented in details.

PO:63 COMPONENTS SEPARATION TECHNIQUE FOR THE TREATMENT OF COMPLEX INCISIONAL HERNIAS: OUR FOUR-YEARS EXPERIENCE J. Lopez-Monc1usr, MA. Garcia-Urena!, LA. Blazquez-Hernandor, DA. Melero-MontesI, A. Robin!, C. Jimenez-Ceinos1, R. Becerra-Ortiz!, A. Aguilera!, A. Moreno!, E. Gonzalez! 1General Surgery Department, Henares Hospital, Coslada, SPAIN

Introduction: Our purpose is to show our results with the different component separation techniques for the treatment of complex inci­sional hernias.

Methods: Retrospective review the results of the components sepa­ration techniques performed in our institution since the introduction of these techniques. Demographic data, typo of surgical field, type of incisional hernia, surgical technique, surgical time, type of mesh, post­operative local and systemic complications, mortality, admission time, follow up and recurrence of incisional hernia were recorded.

Results: Fifty-six components separations were performed in our insti­tution from April 2010 to September 2014 for the treatment of complex

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incisional hernias. Mean age was 62 years (range 20-85 years). Respect the type of incisional hernias, 18 cases were midline hernias (32%), 15 cases midline and lateral hernia (27%), 20 lateral hernias (36%) and 3 parastomal hernias without midline hernia (5%). Surgical fields were clean in 41 cases (73%), clean-contaminated in 6 (11 %), contaminated in 7 (12.5%) and dirty in 2 cases (3,5%). Mean surgical time was 210 min­utes (SD 83). The technique of component separation performed was anterior component separation in 9 cases (16%), Carbone\l's posterior component separation in 14 cases (25%) and Rosen-Nowitzky poste­rior component separation in 33 cases (59%). In 42 cases we employed a polypropylene mesh (75%) and in 14 cases both polypropylene and long term bioabsorbable meshes (25%). Forty-two patients (75%) didn't developed any local complications respect 14 (25%) patients with local complications. Posoperative mortality was O. Mean admis­sion time was 8 days (SD 8,4), and mean follow up was 16,2 months (SD 12). Recurrence was 7 of the 56 cases (12,5%).

Conclusions: Components separation technique (including anterior and posterior techniques) is a good option for the repair of highly com­plex abdominal incisional hernias, with an acceptable recurrence rate and a low rate of surgical complications.

PO:64 OUTCOMES AND MANAGEMENT OF RECURRENT INCISIONAL HERNIAS D. Lightl, L Horgan lNorthumbria NHS Trust, Newcastle upon Tyne, UNITED KINGDOM

Purpose: Recurrent incisional hernias are a technical challenge in her­nia surgery. There is variable consensus on the management and surgi­cal options for such conditions. We investigated our experience with complex incisional hernias for management and outcomes.

Methods: Cases of recurrent incisional hernia were identified from a comprehensive hospital database and reviewed retrospectively over the last 10 years. There were no exclusions. There were a number of surgeons involved with an interest in complex hernia surgery.

Results: 54 patients were included. The mean age was 57 years. 27 were male. The mean ASA grade was 2. 28 patients had a previous laparo­scopic incisional hernia repair (all with composite mesh). 26 patients had previous open incisional hernia repair (6 sutured, 14 proline mesh, 6 permacol). 2 patients had a complex fistula from previous open repairs.

The mean defect size for laparoscopic surgery was 8cm. The mean defect size for open surgery was 12cm.

27 patients had a laparoscopic redo incisional hernia repair. All had intra-peritoneal placement. 3 patients had midline closure with proline sutures. All had composite mesh. 27 patients had open redo incisional hernia repairs. 3 patients had suture repair, 6 had an onlay repair with proline mesh, 4 had a bridging repair with biological mesh, 14 had a retro-rectus repair (5 biological mesh, 6 proline, 3 composite mesh). 9 patients also had a component separation. No patients had a drain in the laparoscopic group. 19 patients had a drain in the open surgery group.

Mean post op stay was 2 days for a laparoscopic repair and 5 days for open repair. In the laparoscopic group, 1 patient developed early small bowel obstruction and returned to theatre, 1 patient had a cel­lulitis and 3 had a symptomatic seroma. All were discharged between 6 to 24 weeks follow up with no recurrences. In the open group, 4 had a symptomatic seroma, 3 developed skin necrosis managed with VAC dressing. There was 1 recurrence (managed conservatively). All were discharged at 6 to 24 weeks.

Conclusions: Laparoscopic surgery for recurrent incisional hernias is tech­nically feasible with significant reduction in post operative stay and reduced complications. Open surgery may be necessary for larger hernias. There is

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a higher risk of complications in this group. Sublay or retrorectus mesh placement have less risk of complications. Strattice mesh has a reduced incidence of seroma and skin complications compared to permacol.

PO:65 LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA IN SOLID ORGAN-TRANSPLANTED PATIENTS: THE METHOD OF CHOICE? J Lambrecht!, M Skauby2, E Trondsen2, A Vaktskjold!·3, 00yen2 lSykehuset Innlandet Health Trust, Gj/!Jvik, NORWAY 20sl0 University Hospital, Oslo. NORWAY 3Hedmark University College, Elverum, NORWAY

Background: Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ-transplanted (Tx) population with larger defects, a high rate of recurrence and a tendency towards more seromas and infectious problems.

Methods: 31 Tx/lS patients with a control group of70 non-IS patients with incisional hernia (6/7 recurrences) were included in a prospec­tive interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR).

Results: Follow-up time & rate was 37 months & 95%. 100 LVHR's were completed as there was one conversion in the TxllS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (p = 0.37) and the overall complication rates were 19% vs. 27% (p = 0.80). The TxllS group had a higher mesh-protrusion rate (29% vs. 13%, p = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% ofkidney-Tx).

Conclusion: Incisional hernias in TxlIS patients may be treated by LVHR with the same low complication rate and recurrence rate as non-IS patients. By LVHR the highly problematic seroma/infection problems encountered in TxlIS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the TxlIs population, and should be the method of choice.

Original article published in Transplant International, Volume 27, Issue 7, pages 712-720, July 2014. Article first published online: 9 MAY 2014. DOl: 10.11111tri.12327. (ClinicaITrials.gov number: NCT00455299, date: 5 May 2006).

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PO:66 RECURRING INCISIONAL HERNIA REPAIR AFTER APPENDECTOMY v. Kulic', M. Matkovic IGeneral Hospital Krusevac, Department of Surgery, Krusevac, SERBIA

Purpose: Incisional hernia following appendectomy is a rare compli­cation occuring in less than 0,12% of patients. Recurrance after inci­sional hernia repair is extremly rare.

Methods: We present a 60-year old male with recurring incisional her­nia after open appendectomy. Twentyeight years ago he was operated on because of perforated appendix with wound healing complications. After two years a classic incisional hernia repair was performed in another medical institution. Three years latter he has got a recurrence of hernia.

Results: This year in April, we performed a recurring incisional hernia repair. The hernial sac was dissected and we reduced the omentum within. A piece od Herniamesh 8x15cm was placed on retromuscu­lar space. The oblique muscles were drawn together with stitches and external obilique aponeurosis was sutured continously. Now he is recovered without recurrence of hernia.

Conclusions: Mc Burney incisional hernia is the result of wound infection associated with purulent peritonitis. Too tightly tightened sutures of the muscles and a drain placed through the incision are the common causes. Placed polypropylen mesh in preperitoneal space is a better choice of incisional hernia repair than classic tenssion technic.

PO:67 DEVELOPMENT OF INFECTIOUS ABDOMINAL WALL HERNIA IN RATS L. Knaapen', R Lomme', H Goor van' 1 Radboudumc, Nijmegen, NETHERLANDS

Introduction: Use of (synthetic) mesh in contaminated or infected her­nia repair is under debate due to risk of mesh infection and removal, and questionable durability of the repair. Clinical studies from both biological and synthetic mesh use in these complicated circumstances give equivo­cal results and no mesh appears superior in terms of infection resistance. Surprisingly, hardly any mesh has been properly tested under experimen­tal infectious conditions with real clinical relevance. Major experimental flaws are the use of a bacterial inoculation and abdominal wall excision model instead of a true infectious hernia model, and uncontrolled 'pollu­tion' with other micro-organisms than in the inoculums.

In the search ofthe ideal mesh that withstands infection and conta­mination and performs similar as compared to non-infectious circums­tances, we developed a rat infectious hernia model mimicking hernia repair under circumstances of contamination or infection originating from the GI tract (e.g. perforated diverticulitis, colonic surgery with spill, enterocutaneous fistula). The intial phase of the model develop­ment is reported here.

Method: Fifty male wi star rats were randomized by computer gen­eration in four groups; Control (no infection; n = 5), Low dosage of bacteria (lOE2 bacteria; n = 15), moderate dosage of bacteria (10E4 bacteria; n = 15) and high dosage of bacteria (lOE6; n = 15).

A 3 cm midline incision and a Ix2 cm full-thickness abdominal wall defect (including peritoneum) was created using a Ix2 cm tem­plate under complete sterile condition. The defect was bridged with a plastic sheet to create a fascial dehiscence. To create an infectious environment, a known concentration of E. coli and B. fragilis mixed with a standardized amount of fecal matter was placed on the plastic

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sheet in the subcutaneous space. Controls received no bacteria and fecal matter on the sheet. Skin was closed over the sheet with staples.

Rats were sacrificed day 7 after operation, the skin was opened and the area of the sheet was inspected for abnormalities. Swabs were taken from the plastic sheet and the surrounding tissue for culture of E. coli, B. fragilis and S Aureus (,pollution').

Primary efficacy endpoint was bacterial count of the plastic sheet and the subcutaneous tissue. Secondary efficacy endpoints were mor­tality, signs and symptoms of infection, and variation in other micro organisms cultured. Rats were prematurely sacrificed when humane endpoints were reached.

Results: Forty of the fifty rats (weight 269 to 325 g (mean 298; SO 14)) died or were prematurely taken out the experiment for reach­ing humane endpoints due to severe peritonitis. After making 4 model adjustments (0.5 10E2 bacteria, thickening the fecal suspension into a pasty suspension, centering the paste on the sheet, and removal of vis­ible liquid slurry) the following 10 rats (5 experimental and 5 controls) survived the 7 day period and were sacrificed.

Bacterial cultures of the sheet and subcutaneous tissue showed a bacterial count of lOE6 E coli in all 5 experimental rats. Bacteria were absent in control rats. All 5 experimental rats developed a huge abscess in the abdominal wall where the defect was created, complicating sur­gical excision of the sheet.

Conclusion: With small amounts of bacteria combined with a fecal vehiculum a rat model of macroscopic and 'microscopic' infectious abdominal hernia of or tract origin can be created without 'pollu­tion' with S Aureus. In a second experiment this model will be used to evaluate infection sustainability of different meshes implanted after removal of the plastic sheet.

PO:68 COMPLEX VENTRAL HERNIAS F Iudica', P Cingolani' 1 Hospital Universitario Austral, Pilar, ARGENTINA

Introduction: Complex ventral hernias repair is a real challenge for a general surgeon.

A complete knowledge of the anatomy and physiology of the abdo­minal wall are mandatory to achieve better outcomes in the resolution of that complex cases.

Methods: Ajudicious election of patients and a adequate preoperative preparation (weight loss, diabetes correction and use of preoperative pneumoperitoneum) are factors that should be take in consideration in the preoperative period.

The use of release incisions (Albanese"s releases) and a mesh rein­forcement in retrorectal space was the thecnique preferred.

In a few cases the mesh should be left in the intraperitoneal space.

Results: We show our serie of 25 complex cases (loss of domain) with this approach, our complication rate, recurrences rate lower to 3%, and outcomes.

The most frequent complications was seromas and haematomas. we experience show a low rate of mesh infections and an excellent recovery of abdominal wall functionality.

Conclusion: The use of retrorectal space with mesh reinforcement and release incisions in the abdominal wall is the technique that we prefer for the resolution of this complex cases.

Although we use a taylor surgery for the treatment of the abdominal wall defects, our "plan A " aforementioned is the use of a mesh in the retrorectal space, release incisions and a complete physiologic restitu­tion of abdominal wall.

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PO:69 IS THERE AN INDICATION FOR A BIOLOGIC MESH IN GIANT INCISIONAL HERNIAS F. IsemerI, D Sohlbach 1St. Josejs-Hospital, Wiesbaden, GERMANY

Introduction: The surgical therapy of the giant and!or contaminated! infected hemias with or without loss of domain is controversy. It is the question if the implantation of a classic mesh is adequate or if it is neces­sary to use a biologic mesh. Are there contraindications for a synthetic mesh and what could be relevant indications for a biologic mesh.

Methods: In 2011-2014 we saw 6 patients with giant hernias with contamination or infection of the abdominal wall. 4 of them had a BMI > 45kg/m2. One patient had a small bowel fistula after repeated surgery, two an anus praeter. 2 patients have been treated as emer­gency cases.

The CT scan in all patients revealed an atrophy of the rectus muscle structure with its lateralisation in all cases and a loss of domain in 4 patients. All patients got a surgical procedure including a component separation of the abdominal wall, implantaion of a biologic mesh (Strattice, LifeCell, USA) and reconstruction of the abdominal wall with resection of the panniculus. The data were been collected prospectively.

Results: In all cases the reconstruction of the abdominal wall was succesfully done with alignment of the subcutaneous tissue. The one small bowel fistula was succesfully closed by resection, one anus praeter was led through the mesh and abdominal wall, the other patient with an anus praeter got a continuity-resection. 2 patients required an ICU-therapy for 2 and 6 days. 2 superficial infections of the subcutane­ous space have been treated by VAC-Therapy.

Conclusion: There are some special situations in incisional hernias where the classic way of hernia surgery with component separation and stabilisation with a synthetic mesh is not adequate and sufficient.

We see an indication for implantation of a biologic mesh if we find a combination of the following conditions: contamination/infection of the abdominal wall, bowel fistula, lateralisation with atrophy of the rectus muscle, high BMI > 40kg/m2, loss of domain. In all cases plas­tic surgery of the abdominal surface was necessary. To avoid wound infection the preservation of the perforans vessels is important.

In all patients the stability of the abdominal wall is sufficient up to now without any hernia recurrency.

In all cases we saw no chance to perform any sufficient recons­truction of the abdominal wall with a classic synthetic mesh. Patients who got previous repeated surgery with complications belonging to a synthetic and its removal do not allow to get another synthetic mesh in the next operation.

Our Incisional Hernia Score could be helpfull to reveal the neces­sity for implanting a biologic mesh.

PO:70 ABDOMINAL WALL RECONSTRUCTION FOLLOWING GIANT WOUND METASTASIS RESECTION AFTER COLON CANCER SURGERY- A CASE REPORT M. Gregorczyk1

, K. Barski1

IProfessor Orlowski Public Hospital, Clinical Ward of General Surgery, Warsaw, POLAND

Introduction: Thanks to laparoscopic surgery, treatment of colorec­tal cancer has reached better short-time outcomes comparing to open

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surgery. However long-term outcomes, including wound recurrence remain comparable. About 1 % of patients are diagnosed with wound or port-site metastasis which is relatively low when compared to other complications. Wound metastasis after colorectal cancer sur­gery requires complex reconstructive approach. Low number of cases in literature explains lack of clear recommendations for treatment of incisional site metastases. We hereby present a case of 75-year-old female patient that was diagnosed with recurrent tumor in postopera­tive wound after open right hemicolectomy for adenocarcinoma and underwent an abdominal wall reconstruction.

Methods: Patient data was gathered from the medical records and operating room records. Procedure and postoperative effect was docu­mented photographically. Patient's follow-up was obtained from out­patient surgical clinic records.

This 75-year-old female was admitted electively for symptomatic tumor located in her suprapubic region of abdomen. She had open right hemicolectomy with drainage 5 months ago because of the cecum tumor infiltrating transverse colon. Pathology report revealed poorly differentiated adenocarcinoma described as T4a, NIB, Mx in TNM classification. The patient undertook complete adjuvant che­motherapy treatment.

She complained of hard ulcerative mass in suprapubic region. Physical examination on admission revealed palpable, hard, immo­

bile ulcerated tumor with a diameter of about 8x8 centimeters located on the border of: umbilical and suprapubic regions of abdomen.

The patient was operated on and laparotomy was performed. It revealed the tumor measuring IOx8x8 centimeters without metastases to the parietal peritoneum and internal abdominal organs. However the mass was infiltrating medial edges of both rectus abdominis. Adhesions between intestinal loops and anterior abdominal wall were released. The anterior abdominal wall was reconstructed using compo­nent separation and sublay technique with Vypro mesh (PVMLl) with dimensions of 28xl8 centimeters. Vacuum drainage of both rectus sheaths and subcutaneous tissue were performed The skin was closed with skin stapler.

Results: The patient did not present any complications during postop­erative period.

Conclusion: Adequate follow-up of patient after advanced colorectal cancer resection is crucial for early diagnosis of wound recurrence and decreases required range of abdominal wall reconstruction. Resection of the metastasis and subsequent reconstruction surgery should be decided individually. Clear guidelines for surgical approach should be elaborated in future studies.

PO:71 SURGICAL TREATMENT OF INCISIONAL HERNIAS WITH MESHES AT THE RISK OF SURGICAL WOUND INFECTION B. Gogia1, R. Alyautdinov2

I A. V. Vishnevsky Institute of Surgery, Moscow, RUSSIA

Background: Now at risk of purulent complications the tactics of abstinence from the use of non-absorbable implants is recognized. In such cases, traditionally two-stage treatment is carried out: I-st stage­elimination of purulent process,

2-nd stage - hernia repair.

Purpose: To develop the tactics of surgical treatment of incisional her­nias complicated by chronic purulent process as a result of prostheses application.

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Methods: From 1993 to the present time we have carried out 61 opera­tions of the patients who along with incisional hernias had chronic suppurative processes affecting the front abdominal wall.

Age of the patients ranged from 32 to 75 years. 36 patients had purulent fistulas over hernia protrusion, 20 - trophic ulcers, 4 patients - ligature fistulas in combination with trophic ulcers and one patient -enteric fistula. The majority of patients in this category had hernias of large and giant sizes. In 26 (42.6%) cases postoperative hernias were recurrent and multiple-recurrent.

In 32 patients meshes were placed in Onlay position and in 29 patients - in Sublay position. In 40 cases polypropylene meshes were used, in 21 cases - Dacron ones.

Results: Microbiological investigation of biopsies of surgical wounds: gram-positive micro flora dominated over gram-negative microflora. Microorganisms were inoculated as monocultures in 77,0% of cases, microbial associations were revealed in 10,0% of cases, in 13,1% of patients bacterial growth was not observed. The most commonly S. aureus and S.epidermidis were inoculated.

In the early postoperative period acute purulent inflammation was observed in 5 (8,2%) patients. In the long-term period recurrence of herniation appeared in I (\.6%) cases and in 2 (3.2%) cases formed ligature fistula after using Dacron mesh. After using polypropylene mesh no case of hernia recurrence was observed.

Conclusions: In chronic purulent process in incisional hernia repair can be performed with the use of polypropylene mesh, with simul­taneous elimination of the source of infection and strict measures of antimicrobial prophylaxis.

PO:72 GIANT RECURRENT HERNIA, LAPAROSCOPIC APPROACH AND COMBINED TREATMENT U. Forgione! lCEHBA, Buenos Aires, ARGENTINA

Introduction: Hernias are pathologies with stereotyped signosintoma­tologia and diverse forms of presentation, given its multifactorial com­ponent and the possibility of multiple recurrences.

Objective: to show a case of paramedian hernia and hernia repaired wound postcholecystectomy anatomically shaped and relapsed again.

Material and method: A pte is presented. 73 years who presented episodes of abdominal pain without leukocytosis, middle bulge in region ecograia wound and showing continuity solution in 13 cm suture line aponeurotica visceral content, so that VEDA and VCC is performed without finding pathology and TAC showing eventrogeno ring and images compatible with hollow viscera contrast in even­trogeno sack. Therefore you perform laparoscopic combined explo­facion to reduce the content and evaluating cavity, both content and continent and its features, perform resection in abdominal wound fibrotic and painful face the edges together to open the continuum and then laparoscopic placement separator woven polypropylene mesh protected dried cellulose (Phisiomesh J & J) of 30 50 cm over­lap covering the defect and fixed with trans facial and Tackers points. The pte evolved satisfactorily, is discharged to the 4th day of po stop and to date is whether recurrence.

Conclusion: The combination oflaparoscopic and conventional meth­ods is not a new action but we want to demonstrate once again its possibilities, its indications and results, which to date are highly satis­factory and prevent comorbidities, but may increase the risks of sum of procedures, if they are performed quickly and know the result is good.

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PO:73 LAPAROSCOPIC LOWER LATERAL INCISIONAL HERNIA REPAIR AFTER KIDNEY TRANSPLANT G. Damiano!, V D Palumbo, G Spinelli, S Ficarella, S Buscemi, E Sinagra, A Marrazzo, A I Lo Monte 1 University of Palermo- Dept. Surgical, Oncological, & Stoma tho logical Disciplines, Palermo, ITALY

Introduction: Post-incisional hernia in renal transplant patients is a complication that affects negatively the global outcome of transplant and the quality of life. The repair of this condition is classically per­formed by open repair with mesh. Evidences now suggest that lapa­roscopic repair could be the technique of choice for this category of patients can be performed in these patients with optimal results. The anchorage of mesh close to the graft should be performed by combina­tion of fibrin sealant and tacks.

Methods: a case of post incisional hernia in a kidney transplant recipi­ent was repaired by laparoscopic onlay mesh technique. The dual coated Suprarnesh® mesh was anchored with absorbable tacks and fibrin sealant on the side in contact with graft surface.

Results: Patients was discharged after 4 days. The 3 months follow-up did not show mesh displacement or recurrence

Conclusions: Laparoscopic onlay mesh repair may become the gold standard for kidney transplanted patients affected by post incisional hernia. The difficulties of anchorage of the mesh close to the graft can be overcome by combination with fibrin sealant glue. This technique seems to offer advantages for this population of patients.

PO:74 CLOSURE OF COMPLEX EVISCERATION AND PREVENTION OF ABDOMINAL WALL HERNIA WITH DOUBLE MESH USING THE "SANDWICH" TECHNIQUE AND COMMON TRANSFACIAL SUTURES TO BOTH MESHES JR Naranjo-Fernandez!, A Cuado Soriano, E Martin Orta, Z Valera-Sanchez, M Intantes-Ormad, J Pifian-Diez, A Dominguez-Amodeo, A Ruiz-Zafra, E Navarrete-Carcer, F Olivia-Mompean, J Padillo-Ruiz lHospita/ Universitario Virgen Macarena, Sevilla, SPAIN

Introduction: Treatment for abdominal wall closure in complex evis­ceration is sometimes a challenge for the surgeon.

In patients with complete evisceration after abdominal surgery with exteriorization of bowel loops and a thin abdominal muscle, we pro­pose the closure using two meses. One of them is placed intraperitoneal onlay, low density composite with visceral surface of collagen. The second mesh is polypropylene of high density and it is located onlay.

Methods: We present the technique in five patients with com­plete evisceration. Three women after bowel resection for intesti­nal obstruction. Two men after urologic surgery, one of them with intestinal obstruction due to incarceration of small bowel loop in the drain hole.

Patients with weak abdominal wall and no po sible primary closure by the large gap. We place intraperitoneal onlay composite mesh with parietal face of polyester and visceral face of collagen. We use transfa­cial sutures to fix both mesh.

We close the peritoneum over the first mesh which cover all viscera that can be in contact with them by the collagen face. Then we place

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the second mesh onlay using transfascial sutures of the first mesh. It is the same fixation that support both meshes.

Results: We have good clinical outcomes without increased intra abdominal pressure neither skin necrosis. We reported wound infec­tion in three patients in which it was not necessary to remove the mesh. At follow-up none of them has presented an incisional hernia.

Conclusion: The used two mesh fixed with the same suture, allows distributing the intraabdominal pressure.

We perform this technique in patients with complete evisceration, large fascial separation and abdominale weak muscles. The closure with double mesh does not increase in intra-abdominal pressure.

PO:75 RIVES-STOPPA TECHNIQUE FOR LARGE MIDLINE INCISIONAL HERNIA: 10 YEARS OF EXPERIENCE IN A DISTRICT TEACHING HOSPITAL V. Cijanl, M. Scepanovic2

, P. Bojovic3

IClinical Hospital Center Zvezdara - Surgery department, Belgrade, SERBIA

Introduction: Incisional hernia is a frequently complication of abdominal surgery and an important source of morbidity with occur­rence rate ranging from 2-20% for patients undergoing midline laparotomy. Incisional hernia repair with primary closure techniques were associated with recurrence rates as high as 30-60%. The use of prosthetic materials has diminished reherniation rates markedly to approximately 6-10%. Rives-Stoppa procedure, in which the pros­thesis is placed between the rectus abdominis muscle and the poste­rior sheath, offers excellent results and is the method of choice for the repair of large midline incisional hernias. The aim of this study was to evaluate the outcomes of the Rives-Stoppa hernioplasty per­formed in a district general hospital for a lO-year period.

Methods: A retrospective-prospective database of 154 patients who underwent repair of large midline incisional hernia (greater than io cm in diameter) with the Rives-Stoppa technique using 30 x 30 cm polypropylene macroporus flat mesh - Herrnesh 3 (Herniamesh® S.r.l. Italy), between 2004.-2014. year was maintained. Data regard­ing demographics, co-morbidity, complications and hospitalisation were recorded. Patient satisfaction following the operation was also assessed.

Results: During the study period, 60 males and 94 females of mean age 59,5 were evaluated; with 74 % of concominant diseases and median hospitalisation of 9 days. There were 3,25% perioperative complications, 9 patients developed postoperative haematoma, 13% had wound seroma and 3,9% wound infections without mesh removal. Also observed were 2 deep vein thrombosis, 4 partial skin necrosis and 5 patients with chronic pain and abdominal discom­fort. The overall postoperative mortality rate was 2,6%. Recurrent hernias had appeared in 8,4% at follow-up. The quality oflife after surgery was good for 85% patients, and they were satisfied with the operation.

Conclusion: In summary, results of this study demonstrates that the Rives-Stoppa procedure is a safe, effective method with an accept­ably low rate of postoperative complications and remarkably lower recurrence than conventional procedures and therefore is our preferred method for hernia repair in patients with large midline incisional her­nias. Surgeon experience and a team approach are important factors in obtaining good results.

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PO:76 SANDWICH TECHNIQUE IN THE TREATMENT OF LARGE AND COMPLEX INCISIONAL HERNIAS AND ABDOMINAL WALL DEFECTS. OUR 53-CASE SERIES M. Bustos-Jimenezl, MJ. Tamayo-Lopez2

, JA. Martin-Cartes3

IN. U. Virgen del ROclO, Sevilla, SPAIN 2H. U. Virgen del ROclO, Sevilla, SPAIN 3H. U. Virgen del ROclO, Sevilla, SPAIN

Introduction: Surgical treatment of large, complex abdominal wall hernias or defects is an interesting challenge. Primary closure of those hernias is often not possible. There is little agreement about the most appropriate technique or prosthetic to repair these defects, in spite the fact of the prevalence of ventral hernias.

Sometimes despite being contaminated surgical fields, we are often faced to reinforce with bio-prosthetic meshes.

Despite being the components separation technique (CST) is a prac­tical option recurrence rates remain unacceptably high. In an attempt to reduce recurrences, we frequently add an absorbable underlay mesh and a lightweight polypropylene on-lay mesh to the traditional compo­nents separation technique.

Our objective was to determine mesh practice patterns of recons­tructive surgeons with regard to indications, most appropriate tech­nique, and experience with complications in order to work those large and complex hernias out.

Methods: 53 consecutive patients who underwent abdominal wall reconstruction by means of a synthetic tissue scaffolds (STS) reinforce­ment between October 2009 and December 2013 were retrospectively reviewed. Analysis of demographics, indications for STS placement, surgical technique, complications, and follow-up data was performed.

They underwent a "sandwich" procedure with an absorbable under­lay mesh (STS) added to a lightweight polypropylene on-lay one.

Results: A "sandwich" procedure was used for abdominal wall repair in 53 patients. In all of them, STC was positioned using an intraperito­neal technique associated to a lightweight polypropylene on-lay mesh and the components separation technique. At a mean follow-up time of 30.1 months, most patients had successful outcomes.

Complications included seroma, recurrence, and infection. One of our patients died from multi-organ failure unrelated to hernia repair.

Conclusions: This study shows that complex abdominal wall defects can be successfully reconstructed using a "sandwich" procedure with a low rate of recurrence and complications. Moreover, repair oflarge, complex abdominal wall hernias by an underlay CST and a lightweight polypropylene on-lay mesh results in lower recurrence rates compared to historical reports of CST alone.

PO:77 A RATIONALE FOR THE REPAIR OF MASSIVE INCISIONAL HERNIA IN A PATIENT WITH MORBID OBESITY AND SMALL BOWEL OBSTRUCTION A Rapoportl, I Waksman2

, 0 Efremov\ A Bukinl, S Biswasl

IZiv Medical Center, Safed, ISRAEL 2Western Galilee Hospital, Naharia, ISRAEL

Introduction: It is accepted that in clinical practice repair may be deferred where the hernia is reducible, causes few symptoms and the patient is unfit for surgery. The rationale for bariatric surgery preceding massive inci­sional hernia repair is well known, but how to manage these patients who complicate with episodes of small bowel obstruction is less clear. Their care may depend on how well they are able to access urgent specialist care.

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The case of a 65 year old woman with a massive incisional her­nia and BMI of 56 is presented. Surgery was deferred until operative conditions were optimised significantly and small bowel obstruction precipitated urgent repair.

Methods: A 65 year old woman was assessed in the outpatient clinic having previously had multiple abdominal surgical procedures, includ­ing appendicectomy, Caesarian section, hysterectomy, laparotomy for small bowel obstruction and, lastly, incisional hernia repair with mesh with an incision that extended up to the epigastrium (8 years previously).

She presented with a massive incisional hernia with an abdominal 'apron' reaching almost to the floor and some superficial ulceration of the skin overlying the hernia. She was housebound as a result of morbid obesity and the massive hernia.

After initial assessment, she was advised to undergo bariatric surgery. Laparoscopic sleeve-gastrectomy procedure was performed (with considerable modifications to port insertion in order to maintain a position well above the origin of the hernia). After uncomplicated recovery, the patient lost 28kg over a period of 3 months.

The decision was taken to defer incisional hernia repair for as long as possible in order to maximise weight loss. In the interval, howe­ver, the patient was admitted as an emergency to the hospital with acute small bowel obstruction on three occasions - the first 2 episodes resolved with conservative management but during the last episode laparotomy for small bowel obstruction became necessary.

Results: The patient was prepared for urgent laparotomy and the spe­cialist surgeon in charge of her care (and heading our hernia repair unit) was informed. He came in from home and attended surgery with the on-call team.

At laparotomy, small bowel obstruction secondary to adhesions was found. The hernia was obstructed and chronically incarcerated as a result of adhesions to the sac. Careful adhesiolysis was performed and the hernia was reduced into the peritoneal cavity. The hernia specialist performed abdomi­nal wall repair via the Rives-Stoppa technique using ULTRAPRO flat mesh.

The patient made an uneventful recovery and remains free of recur­rence after 3 months.

Conclusion: The decision to defer surgery in order to optimise the patient in terms of physiological fitness and to improve the physical characteristics of the attenuated abdominal wall (that result in difficult repair and unacceptably high rates of recurrence), proved crucial to the success of this patient's incisional hernia repair.

Complicated, massive incisional hernias may be managed conser­vatively while the conditions for their repair are optimised. Emergent complications may supervene but are better managed after the patient has been optimised.

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PO:78 THE OUTCOMES OF SYNTHETIC MESH REPLACEMENT IN PATIENTS PRESENTING WITH CHRONIC MESH INFECTION CAUSED BY STAPHYLOCOCCUS AUREUS C. BirolinP, I.S. Miranda1, E.M. Utiyama1

, S. Rasslan1, D. BirolinP 'Abdominal Wall and Hernia Surgery, University of Sao Paulo School of Medicine., Sao Paulo, BRAZIL

Objective: To evaluate the short and long-term outcomes in patients presenting with active chronic mesh infection caused by Staphylo­coccus aureus, who underwent removal of the infected mesh with simultaneous reconstruction of the abdominal wall with polypropyl­ene mesh replacement.

Introduction: Chronic mesh infection (CMI) is a challenging surgical condition, and Staphylococcus aureus (SA) is the main bacterial agent found in cultures taken from the infected mesh. There is an agreement that infected mesh must be removed and that a simultaneous repair with synthetic mesh is contraindicated. But the repair ofthese complex defects using component separation techniques or biological meshes presents high rates of wound infection and hernia recurrence. The role of synthetic meshes is being reevaluated in contaminated surgi­cal fields, and there is experimental data showing that monofilament polypropylene mesh can be cleared of SA contaminants.

Methods: A prospective series of 22 patients operated between 2006 and 2014 was included in this study. All patients presented with chronic mesh infection caused by SA. The treatment protocol included the complete removal of the infected mesh followed by the anatomical reconstruction of the abdominal wall and reinforcement of the repair, using a new onlay heavyweight polypropylene mesh. The outcomes included early and late wound complications, medical complications and hernia recurrence.

Results: From 2006 until 2014, 22 patients (9M, 13F), with a mean age of 57,2 years and mean BMI of 29,3 kglm2, were treated for CMI, caused by SA. Suppurative sinuses were present in 21 patients, and I had an infected seroma. An associated recurrent incisional hernia was observed in 14 patients, and two patients required a complex abdomi­nal wall reconstruction due to enteric fistulas; bowel resections or other potentially contaminated procedures were associated in 10 patients. The short-term results showed an uneventful postoperative course in 14 (63,6%) patients; I (4,5%) patient developed a minor wound infec­tion and was treated with dressings and antibiotics; 5 (22,7%) patients had wound infections requiring debridement and three of them required partial (2) or total (I) mesh removal. Two patients died due to medical complications during the early post-operative period. On the long-term follow-up, there was one hernia recurrence after total mesh removal and one persistent sinus after a partial mesh removal; 95% of the patients were considered free of infection after a mean follow-up of 30 months.

Conclusion: Synthetic mesh replacement in patients suffering from CMl caused by SA has an acceptable incidence of postoperative wound infec­tion and prevents hemia recurrence. Large-pore polypropylene mesh is a suitable material to be used in the infected surgical field as an onlay graft.

PO:79 LAPAROSCOPIC REPAIR FOR RECURRENT INCISIONAL HERNIAS: A SINGLE INSTITUTE EXPERIENCE C. Bertoglio', C Magistro, P De Martini, D Lo Conte, S Di Lernia, G Ferrari, R Pugliese 'Azienda Ospedaliera Ospeda/e Niguarda Cd Granda, Milan, ITALY

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Introduction: Treatment of recurrent incisional hernias (RIH) has been frequently associated to unsatisfactory post-operative (PO) mor­bidity and high failure rates. We propose an update of the last 3 years of a study conducted retrospectively to investigate our experience in laparoscopic repair (LR) for RIH along a period often years

Methods: The case records of 69 patients with RIH who underwent LR in our institution between January 2002 and November 2011 were reviewed and previously published. Operative technique with onlay placement of ePTFE meshes fixed with titanium tacks has been already described and well standardized. We provide an update of patients' demographic data and comorbidities, intraoperative course, PO complications and recurrences at follow up that were system­atically collected and analyzed from December 2011 and December 2013.30 more patients with RIH located both in the midline (26 cases) and laterally (4 cases) were reviewed and the results compared with those derived from the past decade's experience.

Results: Mean operative time was 129 ± 71minutes. Mean hospital stay was 3.9 ± 2.3 days. No conversion or intraoperative complications were recorded. PO mortality was 3% following intestinal infarction in 1 patient while overall morbidity was 13,3% (4 patients) with a preva­lence ofseroma lasting over eight weeks in 5 patients (16,6%). Along a mean follow up of 14 months (range 9-20) recurrence rate was null while incidence of chronic pain was 16.6%

Conclusions: Surgical treatment for RIH remains controversial according to the lack of studies in literature on this specific topic. Our recent results after 10 years experience of LR confirmed the previous satisfactory results in terms of PO morbidity and recurrence rate. Lap­aroscopic approach to these challenging hernias seems to be affected by a slight higher incidence of seroma and chronic pain

PO:80 USE OF PROGRESSIVE PNEUMOPERITONEUM FOR THE TREATMENT OF MASSIVE ABDOMINAL HERNIAS-RETROSPECTIVE REVIEW Y. Bendavid l , A. Depeaultl i Universite de Montreal, Montreal, CANADA

One of the greatest challenges of herniology is the treatment of giant hernias, characterized by a hernia sac volume greater the 25% of the volume of the true abdominal cavity. These hernias cause an impor­tant impairment in quality of life, and pose a risk of catastrophic obstruction of strangulation within the hernia sac or at the hernia neck. Emergency operation on these patients is perilous at best. Elec­tive repair of these hernias has been rendered possible by various adjuncts, one of which is the use of progressive pneumoperitoneum (PP) to recreate the abdominal domain before reintegrating the vis­cera. Goni Moreno described this innovative technique in the 1940s (Goni-Moreno 1947). PP allows for augmentation of the volume of the proper abdominal cavity by re-establishing proper position and function of the diaphragms. Stretching of the different muscular and fascial components of the abdominal wall is also accomplished through the use of PP. Finally PP facilitates viscerolysis through an elongation and sometimes lysis of the visceral adhesions to the abdo­minal wall, or grafted skin. We wished to bring forward again this old and often forgotten technique, and to show that with this approach, it becomes feasible to effectively treat massive ventral and ingui­nal hernias, without requiring the use of more drastic measures, like omental or even visceral (small bowel, colon, uterus, etc ... ) resec­tions. We also wish to present our results, to document our technique and to prove that the repair of these giant hernias is feasible with low morbidity and very low mortality.

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A retrospective study was done and all patients reqUlnng PP between 2010 and 2014 at Maisonneuve-Rosemont Hospital were included. Nine patients with massive hernias received PP during the study period. All patients had either an incisional or an inguinal hernia. A peritoneal dialysis catheter was inserted in the abdomen for PP. After

2 to 4 weeks of intermittent insuffiations, hernia repair was per­formed. All repairs were performed by a single surgeon (YB) and a retromuscular repair with polypropylene mesh was used for all but one patient. Demographic data, hernia characteristics, intraoperative details and perioperative morbidity and mortality were obtained. Fol­low up visit data was collected, and Carolinas Comfort Scale (CCS) hernia related quality of life questionnaire was administered by phone.

All patients were males between the ages of 48 and 70 years old. Three had inguinal hernias and six had incisional hernias. Insuffiations were performed regularly and the length of time before hernia repair varied from a few days to about two months. The insuffiations were carried out on an ambulatory basis in one patient, and other patients were admitted because of mobility challenge or because they were referred from other cities. Side effects of the PP were early abdomi­nal discomfort, shoulder pain, loss of appetite, dyspnea. One patient had an asymptomatic pneumopericardium. Repairs were performed without any abdominal organ resection, except one short small bowel resection (severe adhesions to previous mesh). All repairs were per­formed using mesh except for one patient in whom the deficit was so large (50 cm) that no mesh was available to fill the defect. Post operative complications varied from ileus and wound infection to ICU admission for toxic megacolon. There was one recurrent inguinal her­nia 1 year after surgery.

We believe that PP is safe and effective. Furthermore, visceral resections for volume reduction are not necessary with this technique. Few complications were encountered and PP can be done as an outpa­tient. Finally, the CCS results showed overall patient satisfaction and good hernia repair-related quality oflife.

PO:81 SUCESSFULL LAPAROSCOPIC REPAIR OF INCISIONAL HERNIA WHO ALREADY UNDERWENT OPEN HERNIORRAPHY Y. Baikl, Mingu OH, Youngjin Park, Wonyoung Choi, Inwoong Han, Changhyung Lee iDongguk University, I/san, SOUTH KOREA

Introduction:We experience sucessfull laparoscopic repair of inci­sional hernia who already underwent open herniorraphy but recurred case. so we hypothesis that laparoscopic approach is another treatment mordality after open herniorraphy

Result: 49 years old women is health, she have a rhematoid arthritis and take a pill. Viw of the operation history, she underwent right hemi­colectomy due to abdominal wall invasion actinomycosis, 7 years ago.

At that time abdominal wall defect develop, operator use mesh repair but few months later infection and incisional hernia develop, but tolerable. there was no need re-operation and supportive treatment is optimal.

lyear ago huge para-rectus muscle incisional hernia develop, daily working is impossible.

We choose laparoscopic approach, Intra operatively finding was omentum and bowel adhesion to hernia site. we do adhesionolysis and New large mesh apply to the incisional hernia site.

After second operation, no specific event pahhen, after operation 3weeks later patient discharges from hospital. now we check 2nd time 6months interval. she recover fully and happily doing daily working.

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Conclusion: Laparoscopic repair, especially recurred case after open herniorraphy. is good treatment plan for incisional hernia

PO:82 INITIATIVE VOLUME REDUCTION SURGERY, COMPONENT SEPARATION TECHNIQUE AND BIOLOGICAL MESH REPAIR IN GIANT VENTRAL HERNIA: A CASE REPORT F.Q. Chen, Y.M. Shen,1. Chen' 1 Department of Hernia and Abdominal Wall Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, CHINA

Introduction: The surgical treatment of giant ventral hernias with loss of abdominal domain remains a surgical challenge due to large defect, enormous hernia contents, and limited abdominal cavity. Increased intra-abdominal pressure may lead to abdominal compartment syn­drome (ACS) resulting in fatal organ dysfunction. Replacement of bowels into the abdominal cavity can also cause intestinal obstruction and high-tension wound dehiscence postoperatively.

Presentation of Case: We report the case of a 67-years-old female developed a rare and giant incisional hernia with the history of choledocholithotomy about 16 years ago. The mass was measured about 60 cm x 40 cm, the hernia defect size was 27 cm, and the body mass index of 31.8 kg/m2, the ratio of hernia sac volume to intra-abdominal volume more than 30%. The patient was found with compromised respiratory function and venous return resulting from loss of abdominal domain. Ascites were observed in both original and secondary abdominal cavity. Initial management involved a multidisciplinary evaluation, improving abdominal wall compli­ance and optimizing general condition. A combination of several surgical techniques were performed to this case, including Initiative Volume Reduction Surgery (IVRS) by debulking of hernia contents (omentectomy, right hemicolectomy and a small bowel resection), component separation technique (CST), and onlay ACTM biological patches (ThormaIGEN® thoracic surgical graft produced by Grand­hope Biotech Co., Ltd., bovine pericardium tissue graft, Guangzhou, China). The wound healed by one-stage, and no evidence of hernia recurrence was observed at 1 year follow-up.

Discussion: Early surgical intervention is still recommended to giant incisional hernia to avoid the severe complications. There are

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many problems associated with the management of giant hernia, such as serious intra-abdominal hypertension (e.g. ACS), wound complications and recurrence. Several surgical techniques are proposed to repair these complicated hernias in literature, such as progressive pneumoperitoneum, CST, autologous myofascial flaps and surgical debulking of hernia contents. None of single technique could successfully deal with all of the giant hernias, particularly with significant loss of domain. Therefore, we performed a combi­nation of strategies in this case. In the support of present evidence, biological mesh is the wisest choice for surgeon to decease the incidence of potential infection under the situation of contaminated bowel resection.

Conclusion: Despite the high risk of infection, debulking of hernia contents should not be completely discarded. However, a planning IVRS with sufficient preparation and evaluation, in combination with CST or biological mesh, may be feasible in the selected patients with giant hernia. Giant hernia repair is still a challenging surgical proce­dure and lack evidence-based method from carefully designed rand­omized clinical trials.