O29 IDENTIFYING PREDICTORS OF VENTRAL HERNIA RECURRENCE: SYSTEMATIC REVIEW AND META-ANALYSIS

Aim Ventral hernias are increasing in prevalence and many recur despite attempted repair. To date, much of the literature is underpowered and divergent. As a result there is limited high quality evidence to inform surgeons succinctly which perioperative variables influence postoperative recurrence. This systematic review aimed to identify predictors of ventral hernia recurrence. Material and Methods PubMed was searched for studies reporting prognostic data of ventral hernia recurrence between 1 January 1995 and 1 January 2018. Extracted data described hernia type (primary/incisional), definitions of recurrence, methods used to detect recurrence, duration of follow-up, and co-morbidity. Data were extracted for all potential predictors, estimates and thresholds described. Random-effects meta-analysis was used. Bias was assessed with a modified PROBAST (Prediction model Risk Of Bias ASsessment Tool). Results Screening of 18 214 abstracts yielded 274 individual studies for inclusion. Hernia recurrence was defined in 66 studies (24.1 per cent), using 41 different unstandardized definitions. Three patient variables (female sex, age 65 years or less, and BMI greater than 25, 30, 35 or 40 kg/m2), five patient co-morbidities (smoking, diabetes, chronic obstructive pulmonary disease, ASA grade III–IV, steroid use), two hernia-related variables (incisional/primary, recurrent/primary), six intraoperative variables (biological mesh, bridged repair, open versus laparoscopic surgery, suture versus mesh repair, onlay/retrorectus, intraperitoneal/retrorectus), and six postoperative variables (any complication, surgical-site occurrence, wound infection, seroma, haematoma, wound dehiscence) were identified as significant prognostic factors for hernia recurrence. Conclusions This study summarized the current evidence base for predicting ventral hernia recurrence. Results should inform best practice and future research.

P026 PREOPERATIVE ABDOMINAL WALL RELAXATION WITH BOLULINUM TOXIN A INJECTION CAN FACILITATE SURGICAL REPAIR OF INCISIONAL HERNIAS: LONG-TERM SINGLE CENTER FOLLOW-UP OF 12 PATIENTS

Aim It was investigated how preoperative botox injection in the abdominal musculature both facilitates the surgical repair of incisional hernias and reduce the rate of hernia recurrence. Material and Methods Botulinum toxin A injections was given to 12 patients (7 female and 5 male) suffering from complex incisional wall hernia, 4 to 6 weeks preoperatively. Mean age was 54 years. 9 patients were treated by anterior and/or posterior component separation repair and 3 by Rives-Stoppa repair. By all patients the mesh could be placed in the retromuscular position. No bridging was necessary. Results After a follow-up of 3 to 4 years we examined the patients clinically and by sonography. The rate of incisional hernia recurrence was low as well as the rate of side effects like chronic pain, persisting paresthesia and mobility disorders of the abdomen. Conclusions Preoperative injection of botulinum toxin A can help to reduce the risk of further hernia recurrence after surgical repair of complex incisional hernias of the abdominal wall.

P133 ROBOTIC ASSISTED REINFORCED BIOLOGIC AUGMENTED REPAIR (REBAR) IN INGUINAL HERNIA: TWO-YEAR OUTCOMES

Aim The objective of this study is to identify two-year recurrence and complication rates using robotic assisted reinforced biologic augmented repair (ReBAR) in inguinal hernia repair. Material and Methods A retrospective review identified all robotic inguinal hernia repairs utilizing a reinforced biologic mesh performed by a single surgeon from May 2018 through May 2019. All repairs employed the robotic transabdominal preperitoneal (rTAPP) approach combined with the ReBAR technique. Patients with prior repairs and bilateral hernias were included. All patients were followed post-operatively using secure messaging to assess outcomes, including hernia recurrence and other complications. Results A total of 57 patients undergoing the rTAPP ReBAR were identified. Of these patients, there were 18 bilateral hernias repaired for a total of 75 inguinal hernia repairs. In addition, 5 of the hernias had previously been repaired. Two-year outcomes identified 1 recurrence (1.3%) at 345 days post-operatively and one complication of small bowel obstruction requiring takeback unrelated to the ReBAR. There were no complications of chronic groin pain or seromas in this cohort. Conclusions In conclusion, the two-year recurrence rate in this population of 75 inguinal hernias repaired using the robotic assisted ReBAR was 1.3%. With low recurrence and complication rates, the robotic assisted ReBAR technique appears to be a safe and durable option for inguinal hernia repairs.

P160 ENDOSCOPIC ANTERIOR COMPONENT SEPARATION OR OPEN TRANSVERSUS ABDOMINUS RELEASE ARE NOT ASSOCIATED WITH INCREASED WOUND MORBIDITY FOLLOWING INCISIONAL HERNIA REPAIR

Aim Traditional anterior component separation during incisional hernia repair is associated with a high rate of postoperative wound morbidity. Because extensive subcutaneous dissection is avoided by endoscopic anterior component separation (eACS) or open transversus abdominis release (TAR), we hypothesized that these techniques did not increase the incidence of surgical site occurrence compared to incisional hernia repair without component separation. Material and Methods This was a retrospective cohort study of patients undergoing open, retro-rectus incisional hernia repair. Component separation during retro-rectus repair was performed using eACS or TAR. The primary outcome was 30-day incidence of postoperative surgical site occurrence. Secondary outcomes included length of stay, 30-day readmission, 30-day reoperation rate and 3-year recurrence rate. Results A total of 322 patients underwent retro-rectus repair, 168 (52%) of whom received either eACS or TAR. Addition of eACS or TAR was neither associated with surgical site occurrence, (odds ratio: 0.82, confidence interval: 0.40-1.68, P = 0.596) nor with hernia recurrence (hazard ratio 0.80, CI 0.27-2.40, P = 0.693). There was no significant difference between the groups regarding the frequencies of 30 day-readmission or 30-day reoperation. Conclusions The addition of eACS or TAR to a retro-rectus incisional hernia repair was not associated with increased wound morbidity or hernia recurrence.

P073 SYNCHRONOUS VERSUS DELAYED SURGICAL TREATMENT OF MORBID OBESITY AND VENTRAL HERNIA. PRELIMINARY RESULTS OF A RETROSPECTIVE SINGLE CENTER STUDY

Aim The worldwide increase in morbid obese patients raises controverises regarding the best timing of treatment for concomitant ventral hernias (VH). We present the preliminary experience at a referral center for bariatric surgery (BS): synchronous versus delayed ventral hernia repair (S-VHR, D-VHR) have been compared. Material and Methods From 2009, 40 consecutive morbid obese patients eligible for BS presented with concomitant VH. Symptoms and characteristics of the VH were evaluated to choose between S-VHR (28 patients), primary (n = 12) or mesh augmented (n = 16), and D-VHR (12 patients). 90-day postoperative complications and hernia recurrence were evaluated. Results 3 patients out of 16 in the mesh group experienced superficial surgical site infections. 4 patients in the D-VHR had a bowel incarceration within 20 days after BS and required emergency surgery with mesh implantation. No complications occurred in the primary repair group. The recurrence rate was around 19% in both groups of the S-VHR. Nonetheless the group that received mesh repair had a significant higher mean value of the defect. In the D-VHR cohort 1 patient was lost at follow up while 3 patients were not operated on due to inadequate weight loss. No recurrences occurred in the 4 patients requiring emergency surgery. Conclusions: D-VHR is associated with worse early postoperative outcomes; primary suture repair should be considered in preventing bowel incarceration but synchronous mesh repair is preferred in large symptomatic hernias for its acceptable postoperative morbidity and hernia recurrence at 1 year.

O51 BIOSYNTHETIC MESH VERSUS NON-ABSORBABLE SYNTHETIC MESH IN COMPLEX ABDOMINAL WALL REPAIR (CAWR): A UK NHS COST-CONSEQUENCE ANALYSIS OF MANAGEMENT STRATEGIES

Aim CAWR is marked by high complication and hernia recurrence rates. Different management strategies of CAWR may result in a significant reduction in quality of life and increased financial burden. The use of certain non-absorbable synthetic meshes in CAWR may be associated with an increased risk of adverse events for certain patients. Recent evidence suggests that biosynthetic meshes may contribute to lower complications and may be more cost-effective. Material and Methods To compare the cost between a synthetic mesh, and a bio-synthetic mesh in the management of patients undergoing CAWR. A cost-consequence model was developed to simulate clinical pathways for patients undergoing CAWR with different management strategies. Clinical parameters were informed by literature review and expert opinion. Adverse events associated with the use of a mesh, resource utilisation and re-admissions were compared between patient management strategies over a period of two years. Costing information were gathered from national tariffs using NICE methodology. Results Use of a biosynthetic mesh was associated with a significant reduction in total costs (£15,489 / €17,953) compared to a synthetic mesh at two years. Cost-savings were driven by a lower rate adverse events (hernia recurrence [2% vs.8%] and sepsis [5% vs. 12%] respectively), and resource utilisation after the initial procedure in the management of complications. There was no difference in the intra-procedural time and complications. Conclusions The use of a certain biosynthetic mesh is likely to be highly cost saving compared to a certain synthetic mesh in high-risk patients undergoing CAWR. Well conducted comparative clinical studies are needed to inform robust economic modelling.

P131 A NEW THREE-STEP HYBRID APPROACH IS A SAFE PROCEDURE FOR INCISIONAL HERNIA: EARLY EXPERIENCES WITH A SINGLE CENTRE RETROSPECTIVE COHORT

Aim In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh. Material and Methods From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤10 cm underwent an elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed. Results Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks. Conclusions A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.