Hernia (2016) 20 (Suppl 2):S139–S174 DOI 10.1007/s10029-016-1482-x

ABSTRACTS

Oral Communications

 Springer-Verlag France 2016

O000-Video Large incisional hernia: rives retromuscular repair with prosthesis, technique and results C. Rizzetto1, D. Da Ros1, L. Fei2, M. Schiano di Visconte1, G. Munegato1, R. Del Giudice1, T. Cipolat Mis1 1 S. Maria dei Battuti ULSS7, General Surgery, Conegliano, Italy, 2 Second University of Naples, Gastrointestinal Surgery, Naples, Italy Background: The surgical management of large incisional hernia (LIH) remain a therapeutic challenge due to the difficulty of closing the abdominal wall without increasing the intra-peritoneal pressure. The aim of this report is to present the long term results of twoinstitutional study on a new surgical approach with a free lateral double layer prosthesis totally in polypropylene, in order to avoid dangerous increase in the abdominal pressure. Methods: It is made up by two overlapping prostheses: the upper one is a polypropylene mesh (PM), the lower one is an polypropylene smooth film (PSF) and the two layers are joined together only in the middle with an inner row of stitches. The first part of the operation is performed according to Rives retromuscular repair. The PM, shaped according to the size of the peritoneal defect, is fixed to the peritoneum through short interrupted sutures. The PSF must be shaped according to the dissection plane between the rectus muscle and it posterior fascia, largely exceeding the margins of the defect. Results: the study is a prospective cohort study comprising 29 patients treated from April 2010 to December 2015 in two different hospitals for LIH using the new prosthesis. We recorded no postoperative mortality. After placement of the prosthesis one patient (3.4 %) presented wound infection, two (6.9 %) experienced a postoperative seroma and one patient had an haematoma (3.4 %). At a median follow-up of 28.5 months (IQR 22–36) no hernia relapse occurred. Conclusions: A tension-free abdominal wall reconstruction can be easily achieved by the application of free lateral double layer prosthesis totally in polypropylene. It is a safe and feasible option that can be employed to manage Rives repair in cases of LIH defects with difficult closure of posterior peritoneal-aponeurotic plane where conventional prosthetic meshes could be unsuitable and without occurring to components separation.

O001 The history of teaching surgery T.H.J. ten Cate UMC Utrecht, Utrecht, Netherlands Given the breadth of the topic of this invited key-note address a focused view will be presented using selected topics. Current educational concepts, relevant for surgical training, such as competencybased training, entrustable professional activities, deliberate practice, mastery learning, simulation, resident working hours restriction, cognitive load and the navigating the working memory, will be put in a historical perspective of surgical training.

O003 How to teach (a surgical resident) the TEP? J.P.J. Burgmans Diakonessenhuis, Utrecht, Netherlands At present, many surgeons consider TEP repair as the preferable technique for inguinal hernia repair. It is associated with a reduction of CPIP, has better outcomes regarding time to return to work and gives an unprecedented overview of the entire groin area. The most important drawback of the TEP technique is its long learning curve due to the limited working space and different appreciation of the anatomical landmarks. The EHS guidelines suggest to perform the first 30–50 TEP procedures under supervision of an experienced TEP surgeon, preferably in a high volume center. Our hernia center is part of a teaching hospital for surgical residents. Based on our experience and research, we developed an educational program to teach the TEP. All young residents start with a 1-day training course of the groin consisting theoretical information, lectures of anatomy and cadaver studies. During the first 1–3 years, residents gain experience in laparoscopic surgery. After this period, motivated residents have the possibility to be trained by an experienced surgeon. The first step is to repeat the anatomy and to study the theoretical background and possible pitfalls by an e-learning module. After completing this module, the training starts. The first 10–12 procedures

123

S140 are performed by the experienced surgeon, all steps are explained and possible pitfalls are mentioned. After this introduction the resident starts to perform the operation step-wise. After 30–50 procedures, residents perform the TEP on their own. We advise to select relative young and slender male patients with a unilateral (non-scrotal) reducible hernia and no previous abdominal surgery to avoid frustration and overcome the on-going learning curve in a safe and feasible way. After 100 repairs more complex hernia cases can be performed.

O005 Endoscopic neurectomy: how I learned it and what you need to learn it D.C. Chen Lichtenstein Amid Hernia Clinic at University of California Los Angeles, California, USA As advances in hernia repair have reduced the rates of hernia recurrence, chronic pain has become a primary concern and important outcome. Significant neuropathic pain arising after herniorrhaphy and persisting for greater than 6 months that is refractory to conservative and interventional measures may be addressed surgically. Multiple surgical options for chronic pain exist. Efficacy of these techniques varies and a tailored approach based upon symptomatology, neuroanatomy, and technique of the original repair is necessary to optimally address this problem. Selective or triple neurectomy of the ilioinguinal, iliohypogastric, and inguinal portion of the genital branch of the genitofemoral nerve performed through open or endoscopic methods may remediate neuropathic inguinodynia. Endoscopic retroperitoneal neurectomy is an excellent approach for remediation after both anterior and preperitoneal repairs if mesh removal is not indicated and proximal access to the nerves is needed. This approach avoids the scarred reoperative plane and allows for reliable identification of the inguinal nerves. A thorough understanding of the neuroanatomy of the retroperitoneal lumbar plexus and its inherent variability is essential to facilitate safe access and successful outcomes. Careful and judicious patient selection is essential to maximize benefit and minimize the inherent morbidity of proximal neurectomy.

O007 How to retain skills: gaming and/or warming up in surgical training? H.O. ten Cate Hoedemaker UMCG, Groningen, Netherlands The value of gaming in training basic laparoscopic surgical skills is acknowledged nowadays. The early protagonist of the use of games in laparoscopic training is James B. Rosser. He pointed out that playing games on commercially available game consoles was effective in developing laparoscopic skills. Apart from his work the use of gamification in simulation was restricted to simple modules in laparoscopic simulators. These simulators quite often aim at teaching technical skills, rules and knowledge. We started a project to develop a game called ‘‘Underground’’, for a commercially available game console. It is specifically designed and restricted to train basic technical laparoscopic skills such as working from a 2D screen, inverse movement of instruments, fulcrum effect, lack of tactile feedback, situational awareness, working bimanually and avoiding collateral damage. If you make the comparison to learning how to ride a bicycle during rush hour in the center of Rotterdam it all starts with the first lessons in the safe backyard of the house learning to keep the balance

123

Hernia (2016) 20 (Suppl 2):S139–S174 and using the brakes. That is the purpose of this specific game, acquiring the very basic skills. For this purpose a game was developed without any resemblance to human anatomy. That sounds weird but is in a sense not stranger than the FLS peg transfer. Staying away from the human anatomy gave us an enormous design freedom to make an immersive challenging game where building tasks, controlled demolition, finding solutions and fighting enemies have found a place. We see training with this game as a first step towards laparoscopic proficiency. It will not replace box trainers, simulators and certainly not training in the OR. As soon as a resident is confident with the basic mechanics he or she will have the opportunity to take care of more complex tasks such as paying attention to anatomy. There are many other tools to train the same basic tasks. Box trainers and simulators are widely available nowadays. These tools are effective if they are being used. It is however a widely experienced fact in skills centers all over the world that residents do not very much like these tools. The tasks to be fulfilled are of a repetitive nature, not challenging the users brain. The way to make residents using simulators is by making them obligatory. This is of course a legitimate way but the drawback is that residents will stop using the simulators as soon as they reached the desired level. And this is a pity because every sportsman appreciates the value of repetitive training basic skills. That applies to surgeons as well. The more you practice the better you will become. The available time in the OR is however limited. An effective tool outside the OR that is enjoyable to use can fill the gap. For that reason gamification could work in simulators to make them more pleasurable even after reaching an obligatory certificate. A successful game is being played without external motivation or obligation. Does this all makes sense? Yes it does. Rosser and we could prove that playing a computer game before doing the first laparoscopy of the day works as a warming up device even in very experienced surgeons. The actual challenge does not lie in finding more prove for the effectiveness but lies in the further development of the game to make it really an addictive experience. We see this project as a lean start-up and we are learning from experiences from the 1.0 version. The holy grail is to make a seriously entertaining game that is effective, affordable and above all fun to play.

O008 The value of online (video) learning for surgical training E.J.P. Vlieger INCISION Group, Amsterdam, Netherlands There are huge differences in the quality of surgical education, surgical training is slow and there is a huge lack of surgeons in the world. A global standard of surgical procedures described step-by-step which can be accessed anytime and anyplace, which would remedy the above mentioned problems. Description: INCISION has developed a step-by-step approach that dissects any surgical procedure into clear surgical steps. We use these steps in our educational films of procedures to create practical guide. These online guides help residents and surgeons prepare efficiently for practical work in OR, bring structure and speed into surgical training and are offered as time and place independent Continuing medical education (CME). The step-by-step approach creates a uniform surgical language for increased knowledge transfer. Research: A pilot was conducted to investigate the effect of INCISION e-learning as a learning guide. Methods: The pilot was conducted in Indonesia at three universities. The intervention group (N = 7) used an open abdominal hysterectomy INCISION e-learning module, the control group (N = 7) used conventional teaching approaches. The outcomes were measured with

Hernia (2016) 20 (Suppl 2):S139–S174 knowledge tests before and after the intervention, a modified Ritzman questionnaire and a direct observation of procedural skills (DOPS). Data were analyzed descriptively, and followed by analysis using Mann–Whitney U and Wilcoxon signed-rank test. Results: This pilot study shows that the INCISION e-learning is useful (86 %), comprehensible (82 %) in use and that the online content was helpful for their understanding (88 %). The residents also feel more confident in their surgical knowledge (82 %) and used their OR time more efficient (81 %) after following the INCISION approach. Discussion: This pilot study showed an increase in knowledge using the INCISION e-learning module, and increases the likelihood of success in future studies. The lack of internet access in more remote area is an important factor to keep in mind.

O010 German hernia education program R. Lorenz1, B. Stechemesser2, W. Reinpold3, F. Ko¨ckerling4 1 3+CHIRURGEN Herniacenter, Herniacenter, Berlin, Germany, 2 Hernia Center Cologne, Hernia Center Cologne, Cologne, Germany, 3 Krankenhaus Grob-Sand, Herniacenter, Hamburg, Germany, 4 Vivantes Klinikum Spandau, Klinik fu¨r Allgemein-/Viszeralchirurgie, Berlin, Germany There are many possibilities to treat Hernias today. But the Success in Hernia Surgery is mainly dependent on the skills and experience of the surgeons. Summed up there is a big challenge to train residents and registrars in these widespread possibilities of Hernia surgery today. We analyzed the literature and our Herniamed Database to get an insight about the influence of surgeons into quality of hernia operations. Furthermore we made in October 2014 together with the Surgical Society of Germany an anonymous survey along all German Surgeons for the future demands in hernia-related education. Since 2011 the Authors developed in collaboration with the German Hernia Society the first standardized training course for younger surgeons. This 3-day Training course Hernie Kompakt marks a first step of an education program of the German Hernia School. Hernie Kompakt contains 1 day in the anatomy with cadaver operations. A second day is hands on training and a third day are state of the art lectures. The second step of the German Hernia School-Hernie konkret will train the surgeons in specific Operation techniques in selected competence hospitals and hernia centers hands on. The third step of the Hernia School Hernie komplex will train advanced surgeons in the field of complex hernia cases. We will present the results of the literature and the survey. Our Heniamed data analysis shows especially for the endoscopic procedures that high volume centers have less complications than low volume centers. The first 8 courses of Hernie kompakt with 50 participants were held in Berlin, Hamburg, Cologne and Munich and firstly in September 2014 in Salzburg/Austria. All courses got an excellent feedback. The first Hernie konkret and Hernie komplex courses are planned for 2016.

O012 PRIMA trial: primary mesh closure of abdominal midline wounds A.P. Jairam Erasmus University Medical Center Rotterdam, Rotterdam, Netherlands Introduction: Incisional hernia (IH) is one of the most frequent postoperative complications after abdominal surgery. Patients with an

S141 abdominal aortic aneurysm (AAA), or patients with a BMI C 27 have a risk of developing an IH of more than 30 %. The PRIMA trial was initiated to evaluate the effectiveness of primary mesh augmentation in these high-risk patients. Methods: The PRIMA trial is double blind randomized controlled multicenter trial. Patients undergoing elective midline laparotomy due to the presence of an AAA and/or a BMI C 27 were included. Patients were randomized into 3 groups: abdominal closure with primary sutures (PS), onlay mesh augmentation (OMA), or sublay mesh augmentation (SMA). Primary endpoint of the study was the presence of IH during 2 years of follow up. Secondary endpoint was the presence of postoperative complications. Results: 480 patients were included and randomly assigned into one of three groups: 107 in the PS group, 188 in the OMA group and 185 in the SMA group. In total, 91 patients with an IH were detected. Statistically significant more patients with an IH were detected after PS compared to OMA (p = 0.001) and after PS compared to SMA (p = 0.027). No differences in IH incidence were found between OMA and SMA (p = 0.107). 37 % of patients developed a postoperative complication. Statistically significant (p = 0.002) more seromas were detected after OMA (18.1 %) compared to PS (4.7 %) and SMA (7 %). No differences between the groups were found in surgical site infections (SSI). Conclusion: The results are highly statistically significant and show that prevention is possible with both OMA and SMA. Seromas are significantly more seen in OMA compared to PS and SMA, without an increased risk of SSI. Mesh augmentation is indicated for prevention of IH in high-risk patients.

O014 The MATCH review; meta-analysis on materials and techniques for laparotomy closure E.B. Deerenberg1, N.A. Henriksen2, L. Venclauskas3, R.H. Fortelny4, M. Miserez5, F.E. Muysoms6 1 Erasmus Medical Center, Surgery, Rotterdam, Netherlands, 2Kroege Hospital, Surgery, Copenhagen, Denmark, 3Lithuanian University of Health Sciences, Surgery, Kaunas, Lithuania, 4Hernia Center Wilhelminenspital, Surgery, Vienna, Austria, 5University Hospitals KU Leuven, Surgery, Leuven, Belgium, 6AZ Maria Middelares, Surgery, Ghent, Belgium Background: The aim of this review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing closure materials and techniques for emergency and elective laparotomies. The primary endpoint was incisional hernia and the secondary endpoints were burst abdomen and surgical site incision (SSI). Methods: A systematic computerized literature search was conducted using Medline, EMBASE and the Cochrane library including publications until October 2015. The quality of the RCTs was evaluated by at least 3 assessors using critical appraisal checklists from SIGN. Meta-analyses were performed with Review Manager v5.3. Results: A total of 25 RCTs were included for incisional hernia and 34 RCTs for burst abdomen/SSI as endpoints. There was no evidence from RCTs using the same suturing technique in both study arms, that any suture material (fast absorbable/slowly absorbable/non-absorbable) is superior in reducing incisional hernias. There is a trend that using rapid absorbable sutures in an interrupted technique results in more incisional hernias than a continuous suturing technique with slowly or non-absorbable sutures (odds ratio (OR) = 0.79; 95 % CI: 0.60, 1.05). There is no evidence that continuous suturing is superior in reducing incisional hernias compared to interrupted suturing (OR = 1.20; 95 % CI: 0.84, 1.71). For continuous suturing the small

123

S142 bites technique results in significantly less incisional hernias than a large bites technique (OR = 0.41; 95 % CI: 0.19, 0.86). Conclusion: The best-evidenced technique for closure of a laparotomy incision is a small bites continuous suturing technique with slowly-absorbable sutures.

O015 The teachers perspective in laparotomy-closure A.C. de Beaux Royal Infirmary of Edinburgh, Edinburgh, UK So often—closing time is coffee time!! If we are to reduce the huge burden of incisional hernia to our patients and health care systems, this generation and those to come must focus on this important part of abdominal surgery. And more research is required to find the optimum technique of abdominal wall closure, that is reliable, reproducible and easy to perform for each patient. For most elective midline abdominal wall closure, the evidence is pointing to the method of small bite, small stitch closure. Paramedian and perhaps transverse incisions have an inherently lower incisional hernia rate so planning incision location is also important. In high risks groups of scar failure, consideration of closure re-enforcement with mesh may be a useful adjunct. The dilemmas come in emergency surgery. There is very little evidence but…? Is speed of closure important in the unstable patient—rarely! Is there a need for re-look laparotomy?—for example after damage limitation surgery and bowel anastomosis to be performed in several days time—so a temporary closure before more definitive closure. Is the abdomen better left open in severe cases of sepsis or penetrating trauma?—so looking at healing by secondary intention, or late closure of the laparostomy. Laparotomy closure is NOT something to delegate to the lowest member of the surgical staff. But it is a useful training event for even the most junior surgeon in knot tying, needle and suture manipulation, and the handling of tissues. Closing time is NOT coffee time!

O016 Prevention of incisional hernias from laparotomies or after stoma reversal with biological mesh: a systematic review of the literature F.E. Muysoms1, A. Jairam2, M. Lopez-Cano3, M. Smietanski4, G. Woeste5, I. Kyle-Leinhase1, F. Koeckerling6 1 Maria Middelares Ghent, Surgery, Gent, Belgium, 2Erasmus Medical Center, Surgery, Rotterdam, Netherlands, 3Vall d’Hebron University, Surgery, Barcelona, Spain, 4District Hospital Puck, Medical University, Surgery, Gdansk, Poland, 5Universitatskliniklum, Surgery, Frankfurt An Main, Germany, 6Vivantes Hospital, Surgery, Berlin, Germany Background: Prophylactic mesh augmented reinforcement (MAR) during closure of abdominal wall incisions has been proposed in patients with increased risk for development of incisional hernias (IH). As part of the BioMesh consensus project a systematic literature review has been performed to detect those studies where MAR was performed with a biological or biosynthetic mesh. Methods: A computerized search was performed within 12 databases (Embase, Medline, Web-of-Science, Scopus, Cochrane, Cinahl, Pubmed publisher, Lilacs, Scielo, ScienceDirect, ProQuest, Google scholar) with appropriate search terms. Qualitative evaluation was

123

Hernia (2016) 20 (Suppl 2):S139–S174 performed using the MINORS score for cohort studies and the JADAD score for RCTs. Results: For midline laparotomy incisions and stoma reversal wounds, 2 RCTs, 2 case control studies and 2 case series were identified. The studies were very heterogeneous in type of mesh (cross linked versus non cross linked), mesh position (intraperitoneal versus retromuscular versus onlay), surgical indication (gastric bypass versus aortic aneurysm), outcome results (effective versus non effective). After qualitative assessment we have to conclude that the evidence on the efficacy and safety of biological meshes for prevention of incisional hernias is very low (GRADE). No comparative studies were found comparing biological mesh with synthetic non-absorbable meshes for the prevention of incisional hernias. Conclusion: There is no evidence that for closure of laparotomies in patients at high risk for incisional hernias or after stoma reversal a prophylactic biological mesh is effective. There is no evidence that in this setting a biological mesh should be preferred to synthetic nonabsorbable mesh, both in clean or clean-contaminated surgery.

O017 Short stitch trial 6:1 (Monomax): a prospective trial on elective and emergency closures of abdominal wounds M. Golling, S. Felbinger Das DIAK, General and Visceral Surgery, Schwa¨Bisch Hall, Germany Background: One randomized trial (STITCH) has given 1b evidence in support of performing short stitches ([4:1) for midline laparotomies. Aim of our prospective, non-randomized, monocentric study is a comparative analysis of the perioperative complication (SSI and wound dehiscence) and IH-incidence following elective and emergency laparotomies in midline and transverse incisions. Methods: The trial started 1/2013 with 226 patients so far included in a database CRF. The surgeons aimed at performing a 6:1 suture/wound length ratio (SL/WL) in all laparotomies (midline, transverse and L-shaped incisions). Elective and emergency laparotomies were included and patient specific data (risk factors, intra- and postop parameters, like surgical site infection/occurrence (SSI/SSO) and length of stay (LOS) were entered into the registry database (supplied by BBraun). The postop follow up is presently only based on the perioperative data (complications/reoperation). Results: Overall 86 % (194/226) were operated electively, while 14 % (32/226) had an emergency laparotomy, 68 % (n = 153) had a midline, 16 % (n = 36) a transverse and 16 % (n = 37) a combined, inverted L-shaped laparotomy (liver and complex bile duct operations). There was a definite learning curve with respect to the bite width (lat.margin). SL/WL ratio in midline (6.2 ± 1.8) and transverse (6.4 ± 2.8) laparotomy was similar, but were significantly different in the bite width (median: 0.48 ± 0.17 vs transverse 0.38 ± 0.14, p \ 0.05).Comparing the trial results to our historic control group until 2013, the rate of burst abdomen/2 wound dehiscence decreased from 3.2 to 1.5 %. No increased rate of SSI and wound dehiscence was shown following emergency laparotomies. Conclusion: To sufficiently perform a short stitch 6:1 suture, a learning curve is required (bite width !). Median and transverse (2 layered) laparotomies can be closed safely by a 6:1 SL/WL ratio. Wound infection and dehiscence was halved compared to our historic patient cohort. Emergency laparotomies can also be safely performed with the Short Stitch technique.

Hernia (2016) 20 (Suppl 2):S139–S174

O018 Prevention of incisional hernia using a prophylactic mesh after colorectal surgery. Results of a risk factor based algorithm N. Argudo Aguirre1, J.A. Pereira Rodriguez1, J.J. Sancho Insenser1, M.P. Iskra Marco1, M. Pera1, M. Lopez-Cano2, L. Grande1 1 Hospital del Mar, General and Digestive Surgery, Barcelona, Spain, 2 Hospital Vall d’Hebron, General and Digestive Surgery, Barcelona, Spain Background: The incidence of Incisional Hernia (IH) after colorectal surgery is reported to be as high as 40 %. IH affects the patient’s quality of life and its repair increases healthcare costs. There are no specific measures to prevent this problem. The objective of the study is to validate and analyze the utility of an algorithm for the placement of a prophylactic mesh following a midline laparotomy for colorectal resection to prevent IH in high-risk patients. Methods: A prospective study was conducted including all patients undergoing a midline laparotomy for colorectal resection in the period between January 2011 and June 2013, after the implementation of an algorithm for the placement of a prophylactic low weight large pore propylene mesh in high- risk patients. The results were compared to those obtained in a retrospective series at the same institution (between 2006–2008) in which no prophylactic meshes were applied. Results: From the 232 patients eligible for the study, 159 were included in the final analysis. The algorithm was correctly followed in 58.5 % of cases (N = 93; 54 mesh and 39 suture). The intention to treat analysis demonstrated a lower global incidence of IH when compared to the previous series (11.9 vs. 41.0 %; P = 0.0001). The subgroup analysis confirmed a significant decrease of IH in patients with BMI [ 29 (19.6 vs. 54.8; P = 0.0003), those who presented with two or more risk factors for IH (10.5 vs. 38.5 %; P = 0.0001), and patients with no risk factors (7.1 vs. 29.8 %; P = 0.0036). Conclusions: The implementation of an algorithm for the application of prophylactic measures, such as mesh placement, reduces the incidence of IH. The use of a prophylactic mesh reduces the incidence of IH especially in the presence of obesity and other risk factors, but it was also proven beneficial in patients with no specific risk factors for IH.

O021 No evidence for the use of postoperative abdominal binders T. Bisgaard Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark Methods: A systematic literature search was conducted (2010–2015). All types of postoperative GI surgical studies were included. Postoperative outcome measures were pain, discomfort, seroma formation, physical function, ambulation, and pulmonary function, and compliance. Results: Use of abdominal binders were common with a high compliance ([90 %) although most patients reported inconvenience using the abdominal binder. Overall, studiers were highly heterogeneous and mostly of poor quality. Three randomized trials (n = 123; 48–70), 1 retrospective study (n = 89), and 2 reviews (1 systematic review) including mainly studies before 2010 (a total of 12 studies, n = 730; 12–202) were identified. The reviews included a mixture of gastrointestinal surgical procedure. The use of postoperative ventral hernia repair was studied in one randomized controlled trial (laparoscopic umbilical repair). Abdominal binders were used 1 day up to 1–2 weeks after surgery.

S143 Available evidence suggested that physical function in terms of walking distance may by be improved by using abdominal binders. Other outcome measures were not improved using abdominal binders. There were no clinical effects using abdominal binders during the first 7 days after laparoscopic umbilical hernia repair compared with no binders (randomized trial). However, the vast majority of patients randomized to a postoperative abdominal binder were satisfied using the binder after umbilical hernia repair. Conclusion: Routine use of postoperative abdominal after laparotomy and laparoscopic umbilical repair do not comprise any important effects on clinical outcomes. Procedure-specific high quality randomized clinical trials may provide evidence for routine use for abdominal binders before and after ventral hernia surgery laparotomy.

O022 Do patients need perioperative physiotherapy in abdominal wall hernia surgery J.P. van Wingerden Spine and Joint Centre, Rotterdam, Netherlands Objective: Abdominal wall hernias are common. A regular procedure is to surgically embed a ‘mesh’ to cover the herniation. The results of this intervention are at least ambiguous. In a Dutch rehabilitation centre patients with chronic back pain received training of the abdominal wall as part of regular proceedings. Some of these patients had an abdominal hernia. Surprisingly the training procedure positively influenced the abdominal hernia also. Anatomical analysis revealed that the transverse abdominal muscle plays an important role in control of the abdominal wall and thus the abdominal hernia. In addition this muscle may play an important role in functional recovery of patients after abdominal wall surgery. To explore the beneficial contribution of preoperative physical training in patients with abdominal wall herniations a specific study setup was constructed. Design: Prospective cohort study on 50 preoperative patients with abdominal hernia (epigastric and para-umbilical). Setting: Patients diagnosed with an abdominal hernia will receive abdominal wall training for 8 weeks (once a week). For this purpose cooperation is seeked with surgical departments of hospitals in the region. Main outcome measures: Functional control of abdominal wall using ultrasound, determination of daily life quality using Quebec Backpain Disability Score (QBDS) and SF36, Pain score, and finally clinical observation of level of control of the abdominal hernia. Results: The present result is that we have at our disposal a promising training method for patients with abdominal hernia which may support, or even be a substitute for abdominal wall hernia surgery. The true surplus value of this training method must be determined. Conclusion: This study setup allows to determine the beneficial contribution of abdominal training in preoperative patients with abdominal hernia. This study must be considered a pilot study. Secondary, the surplus value of this training method in postoperative abdominal patients needs to be investigated.

O023 Does abdominal wall function recover after incisional hernia repair? H. Piza-Katzer Privat Office, Austria The abdominal wall is a complex system of fibers and has its function in stabilisation of the lower back and pressure build-up for coughing

123

S144 and evacuation of the bowels. In case of incisional hernias after median laparotomy, which occur in 10–20 %, reconstruction is a great challenge for the surgeon. As methods of repair doubling of fascias, implantation of mesh grafts and muscle transfers have been described. In the following lecture we discuss anatomical characteristics of the linea alba as well as the pathomechanism and changes of abdominal muscle in cases of medial incisional hernias. We then present a concept of anatomical and functional restoration of the abdominal wall in a selected patient population. Besides an exact surgical technique patient’s compliance for weight reduction, special workout and wearing a bodice pre- and postoperative is inevitable for a good result. Functional and radiological late results are demonstrated in 3 cases.

O024 Prophylactic incisional negative pressure wound therapy in patients undergoing complex abdominal wall repair F.E.E. de Vries, J.J. Atema, O. Lapid, M.C. Obdeijn, M.A. Boermeester Academic Medical Center, Surgery, Amsterdam, Netherlands Background: Patients undergoing complex abdominal wall surgery are at high risk to develop wound complications. First introduced in orthopaedic surgery in 2006, prophylactic negative pressure wound therapy (NPWT) has been suggested as a new method to prevent wound complications by its application on a closed incisional wound. Our aim was to evaluate if prophylactic NPWT reduces wound infections and other wound complications in patients undergoing complex ventral abdominal wall repair. Methods: Retrospective before-after comparison nested in a consecutive series of patients undergoing elective complex ventral abdominal wall repair between September 2012 and April 2015. Starting January 2014, prophylactic NPWT was applied on the closed incisional wound for a minimum of 5 days. Wound infections according to the Surgical Site Infection classification, as well as other wound complications were recorded. Results: During the study period 66 patients were operated who fulfilled the inclusion criteria. Thirty-two patients were included in the prophylactic NPWT group and 34 in the control group. Groups were comparable regarding baseline characteristics. The majority involved (clean) contaminated operations due to enterocutaneous fistula, enterostomies or infected mesh. Median duration of prophylactic NPWT was 5 days (IQR 5–7). Overall wound infection rate was 33 %. Prophylactic NPWT was associated with a significant decrease in postoperative incisional wound infection rate (47 versus 19 %; p = 0.013, OR 0.25 (95 % CI 0.08–0.77)). Prophylactic NPWT failed to reduce other wound complications, nor did it decrease the number of interventions, emergency department visits and re-admissions. Conclusion: Prophylactic NPWT seems a promising solution to prevent wound infections in complex abdominal wall surgery. Randomized controlled trials are needed to investigate the real value of prophylactic NPWT and to investigate if prophylactic NPWT is cost-effective.

O025 A complex approach to ventral hernia patient’s: let’s make them breathe first B. East, M. Joachimova, T. Krejci, J. Hoch Faculty Hospital Motol, 1st Surgery Department, Prague, Czech Republic Background: Ventral-hernia surgery is no longer a matter of just closing the abdomen creating a dysfunctional, rigid scar. A lot of

123

Hernia (2016) 20 (Suppl 2):S139–S174 focus is dedicated to a true physiological repair. Patient are often borderline in BMI, age, overall and especially cardiac fitness. They have dysfunctional abdominal wall making it impossible to use it in an essential need of all humans-breathing. Their posture is wrong, pelvic floor loose, contractions of the diaphragm disorganized. Methods: In 2015 all patients with large abdominal wall defects and BMI over 30 or considered high-risk according to the ASA scale were advised to join a special programme designed in cooperation with the Department of sports medicine. Patient were meant to loose body fat, improve overall fitness and mainly to learn, how to use pelvic floor and coordinate its movements with diaphragm in a breathing cycle. This programme took 3-months to complete and included an ergometer stress test, nutritional guidance and 3 sessions a week, each with 30 min of aerobic exercising and 30 min of rehabilitation. Results: Out of the 75 patients only 20 decided to join he programme. All 20 patients enjoyed it and continue to visit some form of group fitness class since. All have lost weight, although the mean weight loss was only 2 kg, their muscle vs. fat body mass ratio has changed significantly. All were found to have a severe posture and breathing dysfunctions. In 4 patients there were unrecognized heart conditions. There was significantly less complications in this cohort. No pulmonary complications were observed and the hospital stay was on average 4 days shorter, all were mobilized first post-operative day and shown a better compliance and faster recovery. Conclusion(s): We believe that a thorough pre-operation preparation and patient education is essential in ventral-hernia surgery. Unfortunately the compliance to such programme is low.

O026 Chronic postoperative inguinal pain (CPIP): definition and work up E.K. Aasvang Rigshospitalet, Copenhagen University, Copenhagen, Denmark The international definition of persistent postoperative pain in general has been suggested to include pain lasting more than 2–3 months, but CPIP should perhaps first be considered if pain outlasts 6 months to exclude the often self-limiting mesh-related inflammatory response. In contrast to earlier definitions, pre-existing preoperative pain is a wellknown risk for persistent pain, and should not be reason for exclusion. Thus, the pain should either develop after the procedure or be different in terms of intensity, quality or location from the pre-operative pain. In this context, other reasons for pain should be excluded e.g. infection or recurrence of hernia. Importantly, an assessment of the impact of pain on the patient’s quality of life, i.e. pain related activity impairment is also crucial to identify relevant patients. The basis for assessment of CPIP includes a structured and detailed history of surgical findings and procedures (mesh placement, fixation, nerve handling etc.), details of pain and related impairment of activities including sexual function and dysejaculation. Other reasons for pain needs to be excluded, and imaging techniques may aid in this context, but the value of identifying specific reasons for CPIP is limited, as inflammation and irregular meshes are seen in both pain- and pain-free patients. Routine use of diagnostic blocks to identify nerves for transection or decompression is also currently not supported by evidence. Evaluation of the sensory function by questionnaires or quantitative sensory testing is recommended to further our understanding of the underlying pathogenic mechanisms for CIP, but cannot be yet be used as tool for selection of patients for specific treatments. In conclusion, diagnostic protocols for selection of patients for specific treatments for CPIP do not exist, but a multifactorial evaluation and standardized collection of data from patients are essential to advance the treatment possibilities and success.

Hernia (2016) 20 (Suppl 2):S139–S174

O029 Mesh removal to release chronic pain D.C. Chen Lichtenstein Amid Hernia Clinic at University of California Los Angeles, California, USA Due to the success of mesh and tension free techniques, chronic pain has surpassed recurrence as the more relevant quality indicator of successful inguinal hernia repair. The adoption of mesh based repairs, however, has not increased the incidence of chronic pain as all methods of inguinal hernia repair create risk and post-inguinal herniorrhaphy pain preceded the era of mesh. Inguinodynia refractory to conservative measures may require operative remediation for specific rectifiable problems such as entrapment neuropathy, foreign body, meshoma, recurrence, and orchialgia. At times, mesh complications occur and mesh removal may improve pain. Mesh folding, contraction, wrinkling, migration, erosion, and infection may all lead to mesh inguinodynia. Three dimensional mesh products or folding of a flat mesh may create a meshoma. Typical mesh-related pain is nociceptive in character and leads to pressure, constant symptoms, and foreign body sensation. This may be accompanied by neuropathy depending on involvement of the inguinal nerves. Open, laparoscopic, robotic, and hybrid techniques are utilized and tailoring depending on location, symptoms, original operative repair, type of mesh as well as the need for neurectomy help to guide a safe and optimal operative approach.

O030 Identification of the inguinal nerves: is it necessary and feasible? G. Campanelli University of Insubria, Istituto Clinico Sant’Ambrogio, Sant’ambrogio, Italy Studies reporting the results of the role of the identification of all three inguinal nerves concluded that identification and preservation of all the three nerves during open inguinal hernia repairs reduces chronic incapacitating groin pain to less than 1 % and the risk of developing inguinal chronic pain increased with the number of nerves concomitantly undetected. For all these reasons, the identification and protection of all three inguinal nerves is strongly recommended. Necessary for identification and preservation of all three nerves is the knowledge in detail of the neuroanatomy of the region. Iliohypogastric nerve arises from L1, among psoas muscle fibers. It course laterally on the anterior face of the quadrates lumborum muscle and pierces the transversus muscle. The abdominal branch runs between transversus muscle and internal oblique muscle and pierces the internal oblique muscle cranially to the internal ring. Subsequently, the iliohypogastric nerve courses approximately horizontally and ventrally to the internal oblique muscle perforating the external oblique aponeurosis at a mean of 3.8 cm cranially from the external ring. Ilioinguinal nerve runs parallel with iliohypogastric nerve, caudally to it. The ilioinguinal nerve pierces the internal oblique muscle laterally closed to iliac spine or just laterally from the internal ring. The ilioinguinal nerve runs ventrally and parallel to the spermatic cord and it leaves the inguinal canal by passing through the external ring. Genitofemoral nerve arise from L2, among psoas muscle fibers, course caudally in oblique way, it runs along external iliac artery and it splits in two branch. The vast majority of genital branches enterer the inguinal canal laterocaudally through the internal ring and then joins the cremasteric artery and vein. After running through the inguinal canal at the dorsocaudal side of the spermatic cord, it pass through the external ring.

S145

O031 Anterior neurectomy in a pediatric population with abdominal wall neuralgia: an observational study M. Siawash, R.M. Roumen, M.R. Scheltinga Ma´xima Medical Center, Surgery, Veldhoven, Netherlands Background: Anterior cutaneous nerve entrapment syndrome (ACNES) is a condition of neuropathic pain that originates from the abdominal wall. Next to systemic analgesics, treatment of this neuralgia includes local nerve blocks and neurectomy. Unfortunately, outcome of these interventions are largely unknown for pediatric patients. Main objective of this study was to investigate the safety and success rate of anterior neurectomy in children with abdominal wall neuralgia. Methods: Prospective observational study in patients younger than 18 with failed non-surgical treatment who underwent anterior neurectomy. Patients were excluded in case of previous surgery for ACNES. Success was defined as absence of pain at the follow up. Relapse was defined as pain recurrence at the original area. Results: From the total population of 66 adolescents, 60 met the study criteria. 80 % was female and mean age was 15 years (±2 SD). 10 % had multiple pain spots and the right lower abdomen was affected in majority (75 %). Median surgery time was 25 min (range 10–62). At 1 month post-surgery evaluation (n = 56, 93 %) 52 children were satisfied with the outcome (87 %). On the contrary, 8 children reported no effect. Complications other than a local hematoma, were not reported. The outcome was irrespective of demographics, pain intensity, -duration and localisation. Conclusion: Surgery is well tolerated and has a viable short term success in children with failed conservative treatment for abdominal wall neuralgia.

O032 New pathological findings in the mechanisms of chronic post-herniorrhaphy pain syndromes with the use of mesh R. Bendavid1, V. Iakovlev2 1 Shouldice Hospital and St Michael Hospital, Surgery, Toronto, Canada, 2St Michael Hospital, Pathology, Toronto, Canada The issue of chronic post-herniorrhaphy pain has become the overriding complication at a time when polypropylene meshes have become ubiquitous in hernia repair. No convincing evidence favours either nerve resection or nerve preservation in the prevention of postoperative chronic inguinodynia. A study of 33 mesh explants were divided into: (a) Those removed due to severe pain (17); (b) Those removed due to recurrence but no pain (14); (c) Those removed because of pain and recurrence (2). We have demonstrated a significant neo-innervation within mesh pores (which we estimated to range between 4000–20,000 depending on the type of mesh). Each mesh pore can, over time, following shrinkage, distortion, folding, act as a constricting mechanism creating mini-compartment and entrapment syndromes! A significant statistical correlation was observed: the higher the number of ingrown nerves within the mesh, the more severe the pain clinically. Lighter meshes, depending on the knit pattern, present more pores per square centimeter than heavier meshes and would appear to offer the same complications. The acknowledged incidence in the literature of this chronic pain has been quite well substantiated by the Swedish and Danish hernia registries and is estimated to be about 10 %. In these patients the

123

S146 severity of the pain amounts to a significant objectionable change in the quality of life of the patient. Vladimir Iakovlev, Pathologist. Robert Bendavid, Surgeon.

O033 Chronic pain and method of surgery in groin hernia repair K.J. Lundstrom1, P. Nordin1, H. Holmberg2 1 Ostersunds Hospital, Department of Surgery, Ostersund, Sweden, 2 Umea˚ University, Registry Center North, Umea˚, Sweden Background: Chronic pain after groin hernia repair is common and one of the main problems in herniorrhaphy. Laparoscopic repairs has been considered as possibly associated with less chronic pain in randomized trials, but remains controversial. Aim: To analyse the frequency of chronic pain from a non selected whole population (Sweden) in respect of method of repair. Method: From the virtually complete Swedish Hernia Register, 25,000 patients have answered a validated questionnaire (Inguinal Pain Questionnaire) sent 1 year after groin hernia surgeries done in Sweden between 2013 and 2015. Pain was dichotomized and was defined as pain not able to ignore and affecting daily activities. Data on several variables including age, gender, BMI, surgeon experience and occurrence of postoperative complications or not were collected and adjusted for in multivariable analysis. Limits of the study was the lack of information of preoperative pain and the answer frequency of 74 %. Results: Data has been collected, however not yet completely analysed. Preliminary findings on 9988 patients, since the last 15,000 analysis is currently performed and will be completed within this month, are presented below. Chronic pain was not statistically significantly different between the methods of surgery, whereas a trend towards less pain in Laparoscopic Total Extra Peritoneal repair (n = 855) vs. Lichtenstein (n = 8431) was seen (RR 0.81 CI 0.62–1.06) Laparoscopic Trans Abdominal Pre peritoneal repair (n = 123) had a trend with increasing pain compared with Lichtenstein (RR 1.16 CI 0.67–2.00). Conclusions: Present results, however preliminary, suggest no statistical difference in chronic pain between the methods of repair a large study of chronic pain after herniorrhaphy.

O034 The role of surgical expertise with regard to chronic postoperative inguinal pain (CPIP) after Lichtenstein correction of inguinal hernia: a systematic review J.F.M. Lange, V.M. Meyer, D.A. Voropai, E. Keus, A.R. Wijsmuller, J.R. Ploeg, J.R.E.N. Pierie Universal Medical Centre Groningen, Groningen, Surgery, Groningen, Netherlands Objective: The aim of this study was to evaluate whether a relation exists between surgical expertise and incidence of chronic postoperative inguinal pain (CPIP) after inguinal hernia repair using the Lichtenstein procedure. Background: CPIP after inguinal hernia repair remains a major clinical problem, despite many efforts to address this problem. Recently case volume and specialization have been found correlated to significant improvement of outcomes in other fields of surgery; to date these important factors have not been reviewed extensively enough in the context of inguinal hernia surgery. Methods: A systematic literature review was performed to identify randomized controlled trials reporting on the incidence of CPIP after

123

Hernia (2016) 20 (Suppl 2):S139–S174 the Lichtenstein procedure and including the expertise of the surgeon. Surgical expertise was subdivided in expert and non-expert. Results: In a total of 16 studies 3086 Lichtenstein procedures were included. In the expert group the incidence of CPIP varied between 6.9 and 11.7 % versus an incidence of 18.1 to 39.4 % in the nonexpert group. Due to the heterogeneity between groups no statistical significance could be demonstrated. Conclusion: The results of this evaluation suggest that an association between surgical expertise and CPIP is highly likely warranting further analysis in a prospectively designed study.

O035 The best mesh to use in incisional hernia repair: the scientists view U. Klinge University Hospital of the RWTH Aachen, Aachen, Germany Assuming that scientists are looking for scientific solutions of clinical problems with mesh procedures any idea of a ‘‘best mesh’’ should reduce the risk for e.g. mesh infections, mesh related adhesions or pain, mesh shrinkage and migration, or even recurrences. Features found to be relevant in preclinical trials as well as in clinical studies of explanted mesh failures include the kind of polymer, the type of fibre, the pore geometry, or the biomechanical properties in relation to those of the recipient tissues. Parameters, which are able to reflect the outcome, are e.g. the rate of mesh explantation because of infection, pain, erosion, fistula formation or recurrence, the intensity of inflammation and scarring at the interface, the contraction or folding of the device after tissue integration. But even the best mesh construction in a tension free condition may result in inadequate risks when put under tension, or an excellent design for an retromuscular application may result in catastrophes when place within the abdominal cavity. Correspondingly, the risk benefit ration has to be defined separately for every mesh used with a specific procedure. Furthermore, as the risks of a permanent implant often manifest with a delay of even years the cumulative risks increases with the life time of the patient. Consecutively all mesh related risks have to be considered as being much higher for young patients with an expected survival time of several decades compared to aged patients with a limited survival time. Correspondingly the age of the patient is of major relevance when making up the risk benefit ratio for a patient even with ‘‘best meshes’’.

O037 The HIPPO randomized double blind trial comparing self-gripping Parietex Progrip Mesh and sutured Parietex Mesh in Lichtenstein hernioplasty; a long term follow-up study M.J. Molegraaf, B. Torensma, B. Grotenhuis, V. de Ridder, J.F. Lange, D.J. Swank Erasmus MC, Rotterdam, the Netherlands Introduction: Chronic post-operative inguinal pain (CPIP) has become the most common complication of inguinal hernioplasty. Important etiologic factors are mesh characteristics and fixation. This study compares two types of fixation for the same mesh. It was hypothesized that a self gripping non-sutured mesh (Parietex Progrip) will cause less chronic pain compared to a sutured mesh after Lichtenstein inguinal hernia repair without enhancing the recurrence rate. Methods: The HIPPO trial is a two center double blind randomized clinical trial. Three hundred fifty patients were randomized; 153 were

Hernia (2016) 20 (Suppl 2):S139–S174 allocated to the sutured Parietex mesh (L group) and 149 to the selfgripping Parietex Progrip mesh (P group). Hernia repair was done according to Lichtenstein as described by Amid et all. Included were unilateral primary inguinal hernia in man patients aged 18 years and older. Follow-up took place after 2 weeks, 3, 12 and 24 months. The main endpoint was the amount of CPIP defined as any VAS [ 0 and the effect on the quality of life measured by VAS, SF36, verbal rating scale and the McGill pain questionnaire. Secondary endpoints were duration of surgery, post-operative complications, recurrence rate, costs, return to work and daily activities, genital and sexual problems. Results: No statistical differences were observed between the two study groups with respect to demographic data. The mean duration of surgery was significant shorter in the Progrip group (44.4 vs 53.4) and was reduced with 17 % (p = 0.001). Post-operative complications were evenly distributed between the groups. Concerning CPIP and the distribution of pain severity scores, no statistically significant difference was observed between the two groups at 3-month, 1- and 2-year follow-up period. The overall incidence of CPIP was 15 % at 3 months declining to 7 % at 24 months. The number of patients reporting to have inguinal pain prior and 2 years post operatively was significantly declined (p = 0.000). Compared to baseline, VAS scores and QOL pain scores were significantly improved at 2 years. The rate of hernia recurrence after 24 months was 2.4 in the Progrip group and 1.2 %, in the Liechtenstein group (p = 0.213). Conclusions: The self-fixating Parietex Progirp mesh can be safely used in inguinal hernia repair without enhancing recurrence rates and with the additional advantage of reducing the operative time compared to the classic Lichtenstein technique. Its use is not accompanied by reduced rates in CPIP.

O040 Will tissue-engineering help us in incisional hernia repair? A. Petter-Puchner Ludwig Boltzmann Institute for Clinical and Experimental Surgery, Wien, Austria Introduction: Tissue engineering (TE) has probably replaced ‘stem cells’ as omnipotent Wunderformel in surgical sciences. However, there optimism is justified when we regard the field of hernia research as translational playground of applied TE. Methods: In the presentation, successful and less successful examples of TE in hernia repair will be given. Biologic fixation, biologic meshes, 3D synthetic matrices are already part of the clinical routine. New compound and sandwich techniques, including cell seeded therapies together with individually tailored and plotted matrices will play a role in soft tissue repair and reconstruction and form the door openers to ‘real’ functionality. Results: TE has arrived in hernia repair and in many cases to the eminent benefit of our patients. The focus must be on meaningful innovation and the recognition of limits and risks.

O042 A prospective nationwide study on long-term meshrelated complications after incisional hernia repair D. Kokotovic Køge University Hospital, Department of Surgery, Køge, Denmark Background: Foreign body implantation by a synthetic mesh is the gold standard in incisional hernia repair, but the risks of long-term

S147 mesh-related complications has not been documented. The objective of the study was to investigate the risks of long-term mesh-related complications after elective incisional hernia repair. Methods: Prospective nationwide cohort study including all patients undergoing elective open and laparoscopic incisional hernia repair registered in the Danish Hernia Database from January 2007 to December 2010. A 100 % follow-up was obtained by merging data with prospective registrations from the Danish National Patient Registry supplemented with a manual review of patient records. Risk factors were evaluated by multivariate analysis. Results: In total, 2875 patients were included in the analysis (1118 patients with open repairs and 1757 patients with laparoscopic repairs). Median follow-up after open and laparoscopic repair were 61 months (range 47–81) and 64 months (range 49–79), respectively. Throughout the study period, mesh-related complications increased continuously in a linear manner up to a level of 5 % after 5 years (open 6.0 %, laparoscopic 4.1 %). Life-threatening complications occurred in 1.4 % (95 % CI 1.0–1.8) of the patients. In total, 3 (0.1 %; 95 % CI 0.0–0.2) patients died in relation to a mesh complication after laparoscopic repair. Increasing mesh size was an independent risk factor for mesh-related complications. Conclusions: The long-term risk of mesh-related surgical complications after incisional hernia repair increased continuously to a level of 5 % after 5 years indicating that the risk of complications is likely to extend beyond the first 5 postoperative years. Nationwide clinical databases are important in monitoring the long-term safety of prosthetic foreign body materials.

O043-Video Down to up tar: starting transversus abdominis release from linea arcuata provides an easier way to perform posterior components separation M. Garcia-Uren˜a1, L.A. Blazquez1, J. Lopez-Monclus2, A. Robin1, D. Melero1, A. Aguilera1, P. Lo´pez1, A. Cruz1, R. Becerra1, E. Gonza´lez1, C. Jime´nez1, N. Palencia1, A. Galvan1, A. Moreno1 1 Henares University Hospital, Surgery, Madrid, Spain, 2Puerta de Hierro University Hospital, Surgery, Madrid, Spain Background: Posterior components separation technique with transversus abdominis release (TAR) is becoming the best option for the management of complex incisional hernias. The big advantage of this technique compared with the anterior component separation technique is the avoidance of the morbidity related with de wide dissection of the subcutaneous tissue: mainly seromas, cutaneous necrosis and mesh exposure. We present a modification of TAR technique that makes it easier to perform. Materials and Methods: In this video, a surgical dissection of a frozen cadaver is shown, insisting on the most important technical aspects: complete retromuscular dissection, dissection of Bogros and Retzius spaces, preservation of the lateral neurovascular bundles, lateral incision of the rectus sheath medial to these bundles, wide retromuscular extension to reach psoas, myopectineal orifice, quadratus lumborum and fascia diaphragmatica. Results: Our modification consists of performing this section starting from linea arcuata, once the space of Bogros has been dissected, instead of beginning with the section of the transversus abdominis muscle fibers. A finger placed between the peritoneum and the posterior rectus sheath can help us to avoid opening the peritoneum. At this level, the dissection can be carried out in two planes depending on the quality of the peritoneum: between the transversus abdominis and the fascia transversalis or between the fascia transversalis and the peritoneum. When reaching the supraumbilical area a section of the transversus abdominis fibers is finally needed.

123

S148 Conclusions: The frozen cadaver dissection shown as an educative video is an excellent tool for teaching TAR technique. Starting the TAR dissection from linea arcuata (DOWN TO UP TAR) is an excellent modification that may help to correctly perform this technique.

O046 What’s the truth about biologics? A. Montgomery Ska˚ne University Hospital, Malmo¨, Sweden, Malmo¨, Sweden The introduction of the synthetic meshes in the late 1950th was a major breakthrough for augmentation of the abdominal wall when the ‘‘biological’’ tissue failed. Techniques to handle infectious complications were lacking and mesh explantation was the most common solution. Biological meshes/matrix of different acellular extracts were introduced in the late 1990s for abdominal wall reconstruction with the aim to reduce the risk of infection and rejection in contaminated fields. There is a remaining uncertainty, after 15 years on the market, on indications for its use in abdominal wall conditions. The costs of the biological meshes are extremely high and it is important to clarify when and if these products are to be recommended. A nice update on clinical evidence for the use of biological products in different situations, including the abdominal wall, was lounged in August 2015 by the Canadian Agency for Drug and Technologies in Health in a ‘‘Rapid response report’’. They lounged four question to be answered: 1. What is the clinical effectiveness of biological mesh products? 2. What is the cost-effectiveness? 3. What are the evidence-based guidelines regarding appropriate clinical indications? 4. What are the evidence-based guidelines regarding it’s the use? Abdominal wall hernias were included in this analyses and diaphragmatic and perineal hernias as well as rectopexias were excluded from this analysis. A total five systematic reviews and one guideline was included. No randomised control trial comparing biologic to synthetic mesh was reported on. The systematic review by Darehzereshki et al. is the only study that compared outcome for both biologic and synthetic mesh studies. A total of eight studies including 328 with biologic and 561 with nonbiologic mesh were analysed. A large heterogeneity was seen between groups. The recurrence rate was 17 % with no difference between groups. Infectious wound complications were 11 % for biologics and 36 % for nonbiologic meshes with a difference between groups (p \ 0.001). There was no difference in the overall complication rates between groups. The Canadian Agency for Drug and Technologies in Health concluded that evidence for clinical effectiveness and safety of biological mesh was positive or neutral. The questions raised could not be thoroughly answered. Majority of publications concluded that there is insufficient high quality evidence to support the use of biological mesh products. Overall, there is insufficient evidence to suggest the optimal place in therapy for biological mesh products.

O048-Video Fully resorbable mesh: a safe option for ventral hernioplasty after mesh rejection A. Babo, C. Antunes, M. Delgado, S. Ribas Braga Hospital, General Surgery, Braga, Portugal Background: Conventional meshes for hernia repair and abdominal wall reinforcement are usually made from polypropylene, polyester or

123

Hernia (2016) 20 (Suppl 2):S139–S174 other synthetic plastic materials known to promote foreign body reactions and a state of chronic inflammation that may lead to longterm complications. Preclinical studies have shown that biocompatible resorbable mesh maintains mechanical integrity beyond the point where newly formed tissue is capable of carrying the abdominal loads. Methods: We present a case of a 78 years-old female, BMI 28.2, with a VHW Grade III EHS M3W3 incisional hernia after a umbilical herniorraphy procedure. The patient was submitted to a first attempt of closure using an onlay mesh but developed a serious infection complicated with a prosthetic rejection. After the debridation of the infected tissue she underwent repair with restoration of the midline using open posterior component separation (Rives-Stoppa technique) and sublay mesh. After an episode of previous mesh rejection, we used of a fully biocompatible resorbable mesh. Results: The surgery was perform in 2h 36 m, without any intercurrence. The patient was discharge at D3 of post-op, after removal of the sublay drains, and scheduled for weekly appointment for surveillance and operative wound care. Until this time, no recurrence was detected. Conclusion: The use of this mesh offered the benefit of a fully resorbable material with a predictable strength profile that supports wound healing throughout the postoperative period, although there is lack of a strong evidenced that confirm this indication. This surgery represented an improvement in quality-of-life for this patient.

O049 Single-stage complex incisional hernia repair using biologic mesh M. Tabbara, S. Carandina, M. Bossi, C. Polliand, C. Barrat Avicenne Hospital, Department of Digestive and Metabolic Surgery, Bobigny, France Introduction: Treatment modalities for complex incisional hernia (CIH) in the presence of contaminated or infected field are not yet universally established. The arrival of biological mesh (BM) offered surgeons the option to manage these difficult clinical cases in a singlestage strategy. The purpose of this study is to establish the effectiveness, strength and benefits of the single-stage repair of CIH using BMs. Methods: This is a 6-year (2009–2015) retrospective study of 41 patients who underwent single-stage CIH repair using BM in a context of contaminated or infected fields. The safety of the procedure was assessed by complications occurring in the immediate postoperative period. The strength of the hernia repair was evaluated according to the recurrence of the hernia on follow-up. Results: Forty-one patients were identified (71 % F, 29 % M). The average age was 60 years (28-90), the average ASA score was 2.3 and the mean BMI was 34.5 kg/m2 with a rate of obesity reaching 39 %. Indications for BM use were: the presence of a stoma or parastomal hernia (14 pts., 34 %), the presence of infected prosthesis (9 pts., 22 %), the presence of enterocutaneous fistula (5 pts., 12 %) and concomitant gastrointestinal surgery (13 pts., 32 %). The rate of postoperative complications was 66 % (27 pts.). These included: abscess (n = 12), recurrent or persistent parietal seroma (n = 15), enterocutaneous fistula (n = 1) and hematoma (n = 3). The average follow-up time was 16 months (1–41). The hernia recurrence rate was 29 % (12/41). Three patients (9 %) died during the follow-up period of a cause unrelated to the CIH repair. Conclusions: BMs used in single-stage repair of CIH in the presence of contaminated or infected field are associated with high rates of complications and recurrence rates. Nevertheless, in these complex cases where the closure of the abdominal defect and the covering of

Hernia (2016) 20 (Suppl 2):S139–S174 the bowels are life-saving steps; the use of BMs remain the best option.

O050 Mesh infections: lessons learned from 200 cases for eventual excision or success of salvage V.A. Augenstein, T. Cox, C. Hlavacek, T. Bradley, P. Colavita, L.J. Blair, C.R. Huntington, T. Prasad, A.E. Lincourt, B.T. Heniford Carolinas Medical Center, GI Minimally Invasive Surgery, Charlotte, USA Background: While mesh implantation significantly reduces hernia recurrence, mesh infection (MI) can lead to complex postoperative problems and may still result in mesh explantation (ME). This series evaluated 200 mesh infections identifying factors that predicted need for excision or ability to salvage mesh. Methods: A prospective study of consecutive MI patients was performed from 2004–2016 at a tertiary referral center. Non-explantation therapy (NET) including antibiotics and procedural therapy, was attempted in all patients. Statistics included Chi square, Fisher’s, and Wilcoxon–Mann–Whitney tests. Results: 200 consecutive hernia repair MI were treated in 195 patients, 74 % were referrals. Patients characteristics included: mean age 56.6 ± 12.5 years, body mass index(BMI) 35.9 ± 8.2 kg/m2, 56.5 % female, 39.5 % diabetic, 29.5 % smokers, 95.7 % recurrent, prior number of hernia repairs averaging 1.8 ± 1.4 repairs (84.1 % performed open). Follow-up was 33.9 ± 27.5 months (median 27 months) from the time initial mesh infection through treatment completion. Meshes types included heavy-weight mesh polytetrafluoroethylene (PTFE, 45.4 %) or polypropylene (PPE, 46.0 %). Median time-to-infection was 138 days; average time-to-infection was 30.9 months (range: 6–9343 days). Intestinal-mesh fistulas were found in 33 cases (16.5 %). The most common bacteria was Staphylococcus aureus (MRSA, 49.4 %). All had attempted NET, and none presented with sepsis during treatment. During long-term follow-up, NET failed in 72 (86 %) due to recurrent infections. All current smokers failed. Salvage rates of polypropylene (PPL) was higher (29 %) than PTFE (7.8 %), and only one case involving multifilament polyester; p = 0.01. Lightweight PPL was more frequently salvaged than heavyweight (39.5 % vs. 2.0 %, p \ 0.001). Of the 26 NET, 23 % remain on antibiotic suppression therapy. Conclusion: In world’s largest study on mesh infections to date, attempted NET was found to be safe but most MIs require excision. Essentially all PTFE/PPL, multifilament polyester, and heavyweight PPL meshes require explantation. Lightweight PPL mesh in nonsmokers with non-MRSA infections has the best success in ability to salvage the mesh.

O051-Video Robot-assisted laparoscopic repair of bilateral spigelian hernias L.F. Gonzalez-Ciccarelli, F.M. Bianco, D. Daskalaki, R. GonzalezHeredia, S. Durgam, P.C. Giulianotti University of Illinois at Chicago, Minimally Invasive and Robotic Surgery, Chicago, USA Introduction: Spigelian hernias are rare ventral hernias deriving from an anterior wall defect. They are limited medially by the lateral edge of the rectus abdominis muscles and medially by the semilunar

S149 (Spigel) line. Bilateral spigelian hernias incidence is even more rare with only a handful of cases described in the literature. The aim of this study is to report a case of a bilateral spigelian hernia treated with the robotic platform. Methods: A 53-year-old female diagnosed with bilateral Spigelian hernias, presented with a 3-month history of recurrent abdominal pain associated with intermittent bilateral palpable masses on the paraumbilical region. The patient underwent a robotic-assisted hernia repair. Procedure started by placing of three robotic trocars along a concave line surrounding the hernias. The robotic cart was docked between l patients’ legs. Bilateral abdominal wall defects were identified, measuring 4 cm on the left and 3 cm on the right, containing omentum. Complete detachment of the omentum and hernia sac was performed using a combination of monopolar hook and bipolar focerps. The two defects were primarily closed in a running fashion and covered with mesh that were fixed with circumferential running sutures. Results: The operation was completed in 167 min. Estimated blood loss of 5 ml. No intraoperative or post-operative complications. Patient was discharged at the same day. At 3-month follow up there were no complications or evidence of recurrence. Conclusion: Robotic bilateral spigelian hernia repair is a feasible, safe and effective technique. The robotic platform facilitate intracoporeal suturing, allowing primary closure of the facial defects and mesh fixation with circumferential running sutures.

O052 Ambulatory Goni Moreno: a simple and safe procedure M. Antor, S. Hamel, L. Schwarz, V. Bridoux, J.J. Tuech, H. Khalil Rouen University Hospital, Digestive Surgery, Rouen, France Background: Surgical treatment of large incisional hernia with loss of domain present post operative risk as respiratory complications, abdominal compartment syndrome. Progressive preoperative pneumoperitoneum (PPP, also know as the Goni Moreno Protocol) was used to prevent complications. The aim of this prospective study was to analysed our ambulatory protocol. Methods: From February 2014 to November 2015, 8 patients underwent surgery for incisional hernia with loss of domain using progressive pre operative pneumoperitoneum. All patients had ambulatory procedure for the creation of the pneumoperitoneum. Results: The median age of patients was 65 years (range 57–79) with a median BMI of 31 (range 27–44). The median parietal defect was 19 cm in diameter (range 6–28). Each patient followed a respiratory rehabilitation, preventif anticoagulant therapy and carries an abdominal restraining belt. An Intra abdominal port-a-cath was inserted under local anesthesia in ambulatory. Air is injected into the abdominal cavity twice a week for 3 weeks. Each insufflation (1.5–2 L) was performed in our ambulatory unit with medical supervision (dyspnea, pain, subcutaneous emphysema, electrocardiogram). Each patient had a follow-up sheet to complete at home (dyspnea, pain, others symptoms). CT scan was performed at the beginning and at the end of the protocol to evaluate the impact of the PPP on volumetric study of the patient. No complications were observed during protocol. Conclusion: Progressive Preoperative Pneumoperitoneum realised in ambulatory is safely provided, it is well supported by measures to prevent any potential complications.

123

S150

Hernia (2016) 20 (Suppl 2):S139–S174

O053 Postponed enterocutaneous fistula takedown: a systematic review and meta-analysis on outcomes and timing

O055 Individual approach for patients with ventral eventration: various components separation technique with mesh augmentation

F.E.E. de Vries, J.J. Atema, O. van Ruler, M.J.M. Serlie, M.A. Boermeester Academic Medical Center, Surgery, Amsterdam, Netherlands

M. Zuvela, D. Galun, I. Palibrk, J. Velickovic, N. Bidzic, A. Bogdanovic University Clinic for Digestive Surgery, HPB unit, Belgrade, Serbia

Background: Timing of enterocutaneous fistula (ECF) surgery has changed. Nowadays, most specialized centers recommend postponing surgery by several months and emphasize that abdominal sepsis has to be resolved and patient’s and intra-abdominal condition improved before definitive surgery. Our aim was to study the outcome of patients undergoing postponed ECF takedown surgery. Methods: PUBMED, EMBASE, and the Cochrane Library were systematically reviewed on the outcomes of elective ECF takedown surgery (ECF recurrence, mortality, morbidity, hernia recurrence, total closure and enteral autonomy). If appropriate, meta-analysis was performed. Results: Twelve studies comprising 1225 patients who underwent elective surgery for ECF were included in present review. Fistula recurrence rates ranged from 5 to 33 %. Five studies in which all patients had a minimal waiting period of 3 months showed a weighted pooled recurrence rate of 9 % (95 % CI 5–14) compared to 21 % (95 % CI 15–26) in the other seven studies that included patients with a waiting periods of less than 3 months. Weighted pooled mortality rate was 3 % (95 % CI 2–5). Total fistula closure rates were reported in eight studies and ranged from 82 to 97 %. Hernia recurrence was reported in 3 studies, weighted pooled hernia recurrence was 31 % (95 % CI 0.24–0.39). Morbidity data could not be quantified due to the use of different definitions. Enteral autonomy in patients depending on total parenteral nutrition (TPN) before reconstructive surgery was only mentioned in two studies and was 79 and 86 % after reconstructive surgery. Conclusion: Postponed ECF takedown after at least 3 months is associated with lower recurrence and acceptable mortality rates compared with takedown without this time limit restriction. Prospective studies and standardized data registration across intestinal failure centers is needed.

Background: To present treatment strategies for abdominal wall eventration based on individual approach for each case and associated surgical risks. Methods: Individual operative strategy for the management of patients with abdominal wall eventration (hernia defect larger than 10 cm consisting of large part of abdominal viscera) depends on hernia size and location; quality of the surrounding tissue; presence of infection and volume of exteriorized viscera in hernia sac. Surgical treatment consists of: (a) enlargement of the abdominal cavity using various components separation techniques (Maas modification CST, Ennis modification CST, Lindsey modification CST, Levine-Karp ‘‘method of wide myofascial release’’or combination of these techniques); (b) abdominal wall hernioplasty (sublay or onlay technique); (c) prolonged muscle relaxation and mechanical respiratory support in intensive care unit. Between January 2005–January 2016 101 patient with abdominal wall eventration was electively operated. Results: Mean operative time was 190 (110–360) min. Mean hospital stay was 13 (5–87) days. During the mean follow-up of 29 (1–124) months 57 (56.4 %) patients had complications: 9 (8.9 %) seroma, 2 (2 %) hematoma, 9 (8.9 %) wound/mesh infections, 31 (30.7 %) skin necrosis, 4 (4 %) pain, and 7 (6.9 %) recurrence. There were 7 (6.9 %) postoperative deaths: 5 (4.9 %) due to significant comorbidities and 2 (2 %) due to postoperative compartment syndrome. Conclusion: Eventration disease is a complex surgical problem and its treatment is associated with different complications. Individual strategy for each patient based on multidisciplinary approach using different components separation techniques with mesh augmentation can prove postoperative results.

O054-Video Incisional hernia M3W3 repair using posterior component separation, T.A.R. and sublay mesh V.G. Radu, M. Lica, A. Radu Life Memorial Hospital, Department of surgery, Bucharest, Romania One of the biggest challenges in the abdominal wall surgery is the large incisional hernia (W3, width [ 10 cm). Covering a large gap with a plastic prosthesis without suturing the abdominal wall defect does not restore the abdominal wall physiology. The solution is to abandon bridging and restore the linea alba. How? In this case the key is component separation. This video presents the posterior component separation with TAR (transversus abdominis release) and sublay mesh. These procedure allows the approximation of the defect edges (L17 cm W12.4 cm) under physiological tension. Procedure last for 4.5 h without incidents. Patient was discharge safely 5 days later.

123

O056 The impact of groin surgery during childhood on the incidence of inguinal hernia repair and postoperative complications in adults A. Sokratous Mora Hospital, Surgical Department, Mora, Sweden Background: Pediatric inguinal hernia, hydrocele and cryptorchidism are common congenital anomalies affecting children, in some cases requiring surgical intervention. The correlation between the surgical treatment of these conditions and inguinal hernia acquired later in life is poorly studied. The aim of this study was to examine the effect of groin surgery during childhood on the incidence and surgical outcome of inguinal hernia repair in adults. Methods: Data from the Swedish Inpatient Register and the Swedish Hernia Register were cross-linked, by the use of Personal Identity Number. The incidence of inguinal hernia repair at the age of 15 or older and its postoperative complications in the cohort were compared to the expected incidence determined from the Swedish population in 2014 stratifying for age and sex.

Hernia (2016) 20 (Suppl 2):S139–S174 Results: There were 68 238 children aged 0–14 years found to undergo groin surgery between 1964 and 1998. The median follow-up time after an operation in the groin was 30.8 years (21.0–50.0). Of those, 1118 were found to have undergone inguinal hernia repair as adults between 1992 and 2013. The observed to expected incidence ratio of inguinal hernia repair in the cohort was significantly elevated [1.43 (1.33–1.53)], for men [1.32 (1.25–1.41)] as well as for women [4.30 (3.28–5.55)]. The increase was also seen in the subgroup of children operated bilaterally. No significant impact on postoperative complications, reoperations or operative time was seen. Conclusions: Those who undergo surgery in the groin during childhood are at higher risk of operation for acquired inguinal hernia later in life. Surgery during childhood did not affect the outcome after hernia repair in adult age.

O057 A clinical study on mesh shrinkage and dislocation in incisional hernia mesh repair comparing intraperitoneal to retromuscular position: a cohort of the PROLOVE RCT A. Montgomery, P. Rogmark, O. Ekberg Ska˚ne University Hospital, Department of Surgery, Malmo¨, Sweden Background: The fibroblast ingrowth of the mesh may cause mesh contraction, especially when using small pore meshes. Mesh shrinkage or dislocation may cause a later recurrence. Does mesh behavior differ between intraabdominal and retromuscular placement? Methods: The cohort of patients operated in one center of a multicenter RCT on laparoscopic (LHR) vs open hernia repair (OHR) was included. A large pore polypropylene mesh (Proceed) fixated with tackers as a double Crown was used in LHR and a retromuscular small pore heavy weight mesh only sutured to the midline in OHR. The borders of the mesh in the OHR were intra-operatively marked with metal clips. X-ray was performed postoperative day 1 and after 1 year. Total length and width were measured between the same clip/Tackers and a dislocation was reported. All measurements were made independently by an experienced radiologist and two surgeons and compared for consensus. Results: In total 37/47 patients remained for analysis; 20 LHR and 17 OHR. Sex, age and BMI did not differ between groups. Hernia defect (oval) area was median 32 cm2 in LHR, and 20 cm2 in OHR (p \ 0.140). Implanted mesh size was 300 cm2 for LHR and 240 cm2 for OHR (p \ 0.341). Measurements between observers were identical in 58 % of patients and consensus made in the rest. At 1 year longitudinal distance was median 96 % in LHR and 99 % in OHR (p \ 0.287) groups and transverse distance was 97 % in LHR and 106 % in OHR (p \ 0.002). Dislocation was seen in 4 LHR and 1 OHR with 3 recurrences, all in the LHR group. Conclusion: Mesh shrinkage after 1 year is not a clinical issue for an intraperitoneal large pore mesh or a retromuscular small pore mesh. Dislocation due to disruption of fixation may be an issue in LHR with the risk of a recurrence.

O058 Giant icisional hernia repair optimizes truncal function and quality of life K.K. Jensen, K. Munim, M. Kjaer, L.N. Jorgensen Bispebjerg University Hospital, Digestive Disease Center, Copenhagen, Denmark Background: It has been suggested that reconstruction of the abdominal wall in patients with incisional hernia leads to

S151 improvement in function, but it is unknown whether this relates specifically to the abdominal wall or is due to improvement in wholebody fitness. Methods: We performed a prospective case–control study of consecutive patients with giant incisional hernia who underwent abdominal wall reconstruction (AWR) with restoration of linea alba. Truncal muscle flexion and extension strength, hand grip strength, leg power, and quality of life (SF-36 and Carolinas Comfort Scale) were examined pre- and 1 year post-operatively. Patients were compared with a control group of patients (C) with an anatomically intact abdominal wall. Results: A total of 18 patients undergoing AWR were compared with 18 patients in the C-group. At 1-year follow-up, patients who underwent AWR showed an improvement in truncal flexion (postop 539 (range 371–1093) vs. preop 487 (342–960) Newton [N], P \ 0.001) and truncal extension strength (622 (352–903) vs. 581 (190–796) N, P = 0.005). There was no significant change in hand grip strength or leg extension power. Hernia-specific quality of life was improved at follow-up (postop 3.0 (0.0–55.0) vs. preop 22.0 (0.0–55.0), P = 0.033). Preoperatively, patients with giant incisional hernia had a decreased truncal flexion strength/leg power ratio compared with individuals with an intact abdominal wall (2.27 (1.65–4.00) (AWR) vs. 2.61 (2.21–4.26) N/W (C), P = 0.049). This ratio increased significantly (23.8 %, P \ 0.001) after AWR and was no longer statistically different from patients with an intact abdominal wall (P = 0.443). Conclusions: Patients with giant incisional hernia demonstrated specific impairment of abdominal wall muscular function compared with patients with an intact abdominal wall. This deficit was offset 1 year after AWR, whereas upper- and lower extremity strength remained unchanged.

O059-Video Fixation of a polypropylene mesh with anti-adhesive barrier using a positioning system in combination with cyanoacrylate glue in laparoscopic ventral hernia repair K. Van Langenhove, S. Van Cauwenberge, E. Reynvoet, B. Dillemans AZ Sint-Jan, General Surgery, Bruges, Belgium Background, aims and design: A 48-year old female patient was seen in our outpatient clinic. She is known with Crohn’s disease. In the past she underwent multiple abdominal procedures because of abdominal abcedations and fistulas. She presented with pain in the upper epigastric region. Physical examination showed a supra-umbilical bulging that was partial reducible but reoccurred during Valsalva. A supra-umbilical hernia was diagnosed and the decision was made for a laparoscopic hernia repair. The patient is considered a high risk patient since her obesity and smoking habits. Results: A laparoscopic repair of a supra-umbilical hernia was performed. After defect closure a Ventralight Echo PS 11.4 cm mesh (Bard-Davol) was introduced intra-abdominally and correctly positioned. To fixate the mesh a cyanoacrylate glue (Liquiband) was applied on the anterior mesh surface. After removing the balloon the mesh was firmly fixated to the abdominal wall. There were no postoperative complications and only minor postoperative pain, with a Visual Analogue Scale for Pain (VAS)-score of 3/10. Patient was discharged on postoperative day 1. A follow-up visit after two weeks showed a good wound healing, a VAS-score of 1/10 and no hernia recurrence. Conclusion: As shown in this video cyanoacrylate glue can easily be applied on an intraperitoneal mesh with an anti-adhesive barrier. Glue

123

S152 fixation is a possible alternative to overcome the immediate postoperative pain caused by mesh fixation with tackers. A larger group of patients and longer follow-up are necessary to determine if mesh fixation with only glue or tackers in combination with glue is a valid method to reduce postoperative pain and recurrence in laparoscopic ventral hernia repair.

O060 How to build up specialized hernia centers and is benefits for the patients, surgeons and health care F. Ko¨ckerling Vivantes Hospital Berlin, Berlin, Germany Hernia surgery has become increasingly more complex over the past 25 years because of the introduction of novel endoscopic, but also conventional techniques. Therefore, there is a need for hernia centers in which hernia surgery is practiced by specially accredited hernia surgeons who as far as possible master all hernia surgical techniques and play an active role in training and continuing education as well as in the field of science. At present, there are two processes for certification of hernia centers by hernia societies or non-profit-organizations: 1. Certified Center of Excellence in Hernia Surgery (COEHS) by the non-profit organization Surgical Review Corporation (SRC). 2. Certified Hernia Center of the German Hernia Society (DHG) and the German Society of General Society of General and Visceral Surgery (DGAV). The certification process in Germany is broken down into three stages: DHG (German Hernia Society)—seal of quality assurance in hernia surgery, Center of Competence and Center of Reference for Hernia Surgery. For all stages participation in a hernia registry is obligatory. The following outcome quality is required: Total complication rate for inguinal hernia surgery \5 %. Reoperation rate for inguinal hernia surgery \2 %. Reoperation rate for incisional hernia surgery \10 %. Infection/revision rate after open incisional hernia surgery \10 %. Infection/revision rate after laparoscopic incisional hernia surgery\3 %. Further requirements for a Center of Competence is a case load of 200 hernias and for a Center of Reference 250 hernias per year. Special consultation for hernia patients must be offered, a special postoperative pain management for hernia operations must be available, a morbidity conference must be held at least once monthly and postoperative pain intensity must be recorded.

O062 Do we need to teach hernia surgeries in less privileged countries?

Hernia (2016) 20 (Suppl 2):S139–S174 Method of repair: Current method of repair in Ghana is by a high tension technique (Bassini; Nylon-Darn, modified Bassini) with very high rate of recurrence of up to 25 %. Conclusion: Evidence supports the need to teach hernia surgery in Ghana. Introduction of mesh repair in Ghana by Operation Hernia, UK charity, and their pioneering work in training should be commended. Training in the local setting reduces cost and retains skills. Availability of low-cost mesh introduced in Ghana by Operation Hernia will make the process sustainable. References: 1. Beard JH, Oresanya LB, Ohene-Yeboah M, Dicker RA, Harris HW (2013) Characterizing the global burden of surgical disease: a method to estimate inguinal hernia epidemiology in Ghana. World J Surg 37(3):498–503 2. Ohene-Yeboah M, Beard JH et al (2015) Prevalence of inguinal hernia in adult men in the Ashanti Region of Ghana. World J Surg. [Epub ahead of print] 3. Ohene-Yeboah M (2003) Strangulated external hernias in Kumasi. West Afr J Med 22(4):310–313

O063 How to teach hernia surgery in less privileged countries F.C. Oppong Nuffield Health, UK Background: The surgical disease burden on less privileged countries, caused by hernias, is well documented. In Ghana, a West Africa country, it is estimated that in 10 years there will be a back log of a million people with hernias requiring surgery. Hernia Surgery has been identified as one of the 15 surgical conditions for which provision of access to basic surgery can provide 80 % of the basic surgical needs of low income countries. One of the most important limiting factors, however, is the lack of adequate numbers of appropriately trained health personnel. Method and results: This paper discusses two issues: the acute human resource crisis that is hampering delivery of safe and sustainable hernia surgery in these environments and the various approaches to capacity building by employing both traditional and novel methods in teaching hernia surgery.

O064 How to improve quality in complex hernia surgery

B. Boateng-Duah GPHA Hospital, Takoradi, Ghana

J.A. Wegdam1, E.M.M. Mommers1, E.H.M. Berkvens1, T.S. Vries Reilingh1, S.W. Nienhuijs2 1 Elkerliek Hospital, Surgery, Helmond, Netherlands, 2Catharina Hospital, Surgery, Eindhoven, Netherlands

Background: The evidence for the need to teach hernia surgery in less privileged countries is overwhelming. This paper will be based mainly on experience in Ghana. Prevalence in the population is estimated at 3.15–13 %. Symptomatic hernias is estimated at 200 per 100,000 population1,2. Method and results: Review of relevant literature suggests that at the current rate of repair of about 30 per 100,000 there will be a backlog of 1 million hernias in need of repair over 10 years1. The population affected are active and of working age—farmers, farm hands, and fishermen. This has predictable implications on quality of life and productivity. Mortality from complications is high 12 %3. Inadequate medical manpower: The very poor doctor/population ratio in less privileged countries is well documented.

Background: Centralization leads to quality improvement in complex hernia surgery. A vast number of complex hernia patients, managed by a multidisciplinary team, enhances outcome by better decision making, tailored surgery, experienced surgeons and improved complication management. However, to increase the volume of patients, process redesign is a prerequisite. This narrative study reviews the effect of process redesign of hernia care on the volume of complex hernia patients in a single institution. Methods: Since 2012 ten steps in process redesign of complex hernia care were implemented: (1) regional referral agreements of complex hernia cases; (2) consensus on the definitions of complex hernia’s and complex hernia patients; (3) two-surgeons-per-operation policy; (4)

123

Hernia (2016) 20 (Suppl 2):S139–S174 business case development; (5) advertisement and PR; (6) local education of nursing staff; (7) introducing specific complex-herniarepair-slots at the OR; (8) implementing monthly multidisciplinary meetings with pulmonologist, ICU-staff, anesthesiologist and physical therapist; (9) case-management and (10) detailed pre-, per- and postoperative registration of patient characteristics, complications and recurrences. Results: During a 5-year period (2011–2015) a 48 % increase of new ventral hernia patients was observed (n = 109 in 2011 to n = 161 in 2015). More than 40 % of these new patients were referred from outside the area of adherence. A tendency was seen for more unfavorable hernia parameters (larger defects with multiple recurrences) and patients characteristics (comorbidities). Both the complexity of the hernias operated increased and the non-approval for an operation following a multidisciplinary meeting. An operation is refused, or delayed until a preconditioning program has been finished, in one of every three new patients. The annual number of open complex hernia repairs doubled (n = 50) year, likewise the number of laparoscopic repairs (n = 60 annually). A subsequent increase in other hernias was seen as well. Conclusion: Process redesign of complex hernia care increased the volume of hernia patients, the first step in improving quality.

O065 HerniaSurge guidelines: specialised hernia centers G.H. van Ramshorst1, H.J. Bonjer1, D. Cuccurullo2, R. Bittner3, H. Tran4 1 VU Medical Center, Surgery, Amsterdam, Netherlands, 2Ospedali dei Colli, Surgery, Naples, Italy, 3Hernia Center, Euromedclinic, General, Visceral and Vascular Surgery, Fu¨rth, Germany, 4Sydney Medical School at Westmead Hospital, Surgery, Sydney, Australia Background: The term ‘‘hernia center’’ is frequently used as a marketing tool. Our goal was to define ‘hernia center’, ‘hernia specialist’ and to find relating evidence on these subjects. Methods: A systematic review was performed to investigate the relation between outcomes in inguinal hernia surgery and center volume, surgeon volume, surgeon specialisation, and center specialisation. Results: For inguinal hernia repair, what constitutes high- and lowvolume centers was unclear, making outcome comparisons difficult. Due to paucity of data, most studies were unable to establish a clear relationship between ‘high-volume’ hernia centers and improved outcomes. However, a surgeon’s caseload appeared to more important for inguinal hernia surgery outcome than a center’s caseload. A surgeon’s case volume was inversely related to that surgeon’s (operation for) recurrence rate. The ability to discern a true hernia center of excellence from one with average experience and outcomes may lie in certification of hernia surgery centers. In Germany, two certification processes exist for hernia centers. Three certification levels exist: level 1, with the Germany Hernia Society seal of quality assurance in hernia surgery; level 2, competence center for hernia surgery and level 3, reference center for hernia surgery. For each level, hernia centers need to meet several requirements on, for example, registration and follow-up of patients, minimum operation numbers and involvement of science and training. Conclusion(s): Hernia specialists are surgeons with mastery/expert level hernia surgery skills who actively train, educate and research in their field. In order for centers and surgeons to be certified as a hernia center or a hernia specialist, minimum requirements on numbers of operations, follow-up and quality control should be met.

S153

O066 Do we need a specialized hernia center? And if so what is it? O. Buyne Radboudumc, Department of General Surgery, Nijmegen, Netherlands Modern view on surgery focuses on super specialisation and gaining specific expertise in order to achieve better results. Combining of and exchanging skills and knowledge between different centers participating in a hospital network will improve outcome. Complex abdominal wall surgery or hernia surgery should be treated to these modern standards. Therefore five enthusiastic and experienced hernia surgeons from five hospitals (both Academic and non-Academic) in the eastern part of the Netherlands joined forces with the intention to optimize their quality of care for patients with complex abdominal wall hernias. Each hospital has certain expertise in different techniques of hernia repair. In addition, individual surgeons are seasoned in both surgical practice as well as scientific research considering hernia surgery. Collective data registration, perioperative protocols, research and innovation as well as sharing knowledge and skills are keypoints of this collaboration. The first step made was launching an expert panel called DutchHCLOSE using a web-based application for presentation of all patient data necessary for adequate consultation. Up to now 15 complex cases were enrolled and helpful advices were given to the case presenters. During this year fine tuning of the data registration system and innovation of perioperative care (of which pre-operative optimalisation is a key issue) are the main goals to achieve. Furthermore, in the near future, access to the panel will become available for every surgeon who wishes to consult an expert on hernia surgery. In this way, we expect to offer distinctive, sustainable and sound care to the complex hernia patient, without the need of face-to-face consultation of the patient in another hospital. We will present some examples of patient reviews and highlight in more detail the advantages of this panel.

O068 Intraperitoneal mesh: yes or no? M. Schreinemacher AMC, Amsterdam, Netherlands The use of mesh is regarded the standard of surgical care in abdominal wall hernia repair because of reduced recurrence rates. One of the aspects to be considered in such repairs is the position of the mesh relative to the peritoneum, i.e. the extraperitoneal or intraperitoneal position. The former is most commonly achieved by an open approach, the latter by a laparoscopic approach. Compared with the extraperitoneal position, the intraperitoneal position entails a direct contact between the mesh and the viscera, but also the possibility of laparoscopic repair. These features may hold both benefits and drawbacks. For instance, the direct contact between mesh and viscera may induce adhesions, adhesion related complications or even fistula. On the other hand, a laparoscopic approach may offer a shorter hospital stay, a lower risk of wound infections and better recognition of multiple hernias. In order to improve outcomes after intraperitoneal mesh placement, mesh materials and fixation devices are the major variables that can be influenced. As such, sheet-like barriers shielding the mesh

123

S154 structure from the viscera and more chemically inert materials, collagen based meshes and new polymers have been designed. Today, only a handful of clinical studies on this subject are available, compared with a vast majority of experimental research. All in all, only limited clinical evidence is available for the net result of intraperitoneal versus extraperitoneal mesh implantation. Available clinical studies are mostly observational and have important limitations, necessitating a solid integration of best available clinical and experimental research. Definite evidence for or against the use of intraperitoneal meshes will be unlikely to emerge since it is only one out of multiple factors to be considered in a patient tailored approach of abdominal wall hernia repair.

O069 Extraperitoneal meshes: any danger about it G. Pascual Universidad de Alcala, Madrid, Spain One of the most widely used biomaterials to repair abdominal wall defects is polypropylene, in a mesh format. Its use has been generalized over time, and now it is considered as one of the best biomaterials to treat tissue defects extraperitoneally, even when they are infected. Not lacking drawbacks, polypropylene shows poor performance in the peritoneal interface. Complications have been reported such as intestinal fistula and migration to hollow organs, therefore, its use in said interface should be avoided. This biomaterial, which holds optimal biocompatibility, has been the object of constant modification aimed at better adapting it to the functional needs of the host tissue. Hence, the classic prostheses, nowadays known as heavyweights, are being gradually replaced by lighter materials with a simple spatial configuration and, more importantly, with a larger pore size (lightweight prostheses). In general a mesh with large pores made of monofilaments provides a reduced surface area and causes less scarring and inflammation than those with small pores and thereby reduces the rate of scar contraction. The use of light weight meshes are able to reduce the quantity of foreign material that is left implanted in the host and to generate the minimum amount of fibrosis possible in receiving tissues, without producing rigidity and deterioration of the mechanical resistance. Although there are individual variations concerning the repair process after the implantation of these types of materials, there is no doubt that the fibrosis generated by the conventional heavyweight prostheses would be decreased with the use of lightweight prostheses. The abdominal wall acts as a dynamic system that undergoes acute and constant pressure changes and the ultimate goal in the repair process is to maintain its function in the most physiological way possible with the consequent adaptation of the prosthesis to the host tissue.

O071 Quality of life and hernia development 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction U. Petersson1, T. Bjarnason2, M. Bjo¨rck3, A. Montgomery1, P. Rogmark1, M. Svensson4, K. So¨relius3, S. Acosta1 1 Skane University Hospital, Department of Surgery, Malmo¨, Sweden, 2 Kristianstad Hospital, Department of Surgery, Kristianstad, Sweden, 3 University Hospital, Section of Vascular Surgery, Uppsala, Sweden, 4 Falu Hospital, Department of Surgery, Falun, Sweden Background: Long-term results after open abdomen treatment are scarcely reported. This study reports on incisional hernia (IH)

123

Hernia (2016) 20 (Suppl 2):S139–S174 incidence, abdominal wall (AW) discomfort and quality of life (QoL) 5 years after open abdomen treatment with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM). Methods: This is a 5-year follow-up study of patients included in a prospective multicentre study 2006–2009. Physical examination, patient interview, chart review, questionnaires on abdominal wall and stoma complaints and the SF-36 questionnaire were included in the protocol. Results: Of 111 included patients, 55 (12 women, 43 men; median age 70 years) were alive and eligible for follow-up. Follow-up rate was 91 %. Cumulative IH incidence during the whole study was 62 % and one-third of the IHs had been repaired. At the 5-year follow-up 59 % of IHs were clinically detectable. AW-symptoms were equally reported by patients with (15/23) and without (11/21) IH (p = 0.541). The study group as a whole reported lower SF-36 scores than the population mean for component scores and all subscales except Bodily Pain. Patients with major co-morbidity had lower Physical Component Score (31.6 [95 %, CI 25.6–37.4]) compared to those without (48.9 [95 %, CI 46.2–51.4]). Major co-morbidity was not associated with IH (p = 0.56), AW-symptoms (p = 0.54) or stoma (p = 0.10). Patients with IH or other AW-symptoms had similar SF36 results compared to those without, whereas patients with a stoma had [5 point lower mean scores for General Health, Social Function and Physical Component Score compared to those without. Conclusions: Open abdomen treatment with VAWCM results in high incidence of IH and lower QoL at 5 years. However, there was no detectable difference in abdominal wall complaints or QoL in patients with an IH compared to those without. The lower QoL seems mainly to be associated with the presence of major co-morbidity.

O072 Obesity affects the behaviour of macrophages on biomaterials in vitro as predicted with monocyte subsets in the blood G.S.A. Boersema1, L. Utomo1, Y. Bayon2, N. Kops1, E. van der Harst3, J.F. Lange1, Y.M. Bastiaansen-Jenniskens1 1 Erasmus Medical Center, Surgery, Rotterdam, Netherlands, 2 Medtronic-Sofradim Production, R&D, Tre´voux, France, 3Maasstad Hospital, Surgery, Rotterdam, Netherlands Background: Macrophages play a key role in the foreign body response to implanted biomaterials used for hernia repair. They obtain a pro-inflammatory phenotype in response to the low-grade inflammation in obesity. The aims of this study were to investigate to what extend obesity affects the acute response of macrophages to biomaterials in vitro and whether this can be predicted with parameters measured in blood. Methods: Obese (n = 20, BMI 43.8 ± 6.5) and age and gender matched lean persons (n = 20, BMI 22.9 ± 2.6) were included. Peripheral blood was collected to isolate CD14 + monocytes and to analyses the monocyte subsets based on presence of CD14/CD16 surface markers. Monocytes were seeded on polypropylene (PP), polylactic acid (PLA), polyethylene terephthalate (PET) monofilament, and PET multifilament (mPET) and cultured for 3 days. IL-6, TNF-a, CCL18, and IL-1ra were measured in the culture medium. C-reactive protein (CRP) was measured in serum. Results: Macrophages from obese patients produced more IL-6 (on PET, p = 0.022) and less CCL18 (for all materials) and IL-1ra (on PLA, p = 0.026) than macrophages from lean subjects. TNF-a was unchanged. Percentages of classical monocytes (CD14++/CD16-) in blood negatively correlated with IL-6 production by macrophages cultured on biomaterials. Percentages of intermediate monocytes (CD14++/CD16+) positively correlated with IL-6 production of

Hernia (2016) 20 (Suppl 2):S139–S174 macrophages cultured on PLA and negatively with CCL18 production on PET and mPET and IL-1ra production on PET. A positive correlation was also seen between CRP and IL-6 on PET and mPET. Conclusion: Monocyte-derived macrophages of obese patients respond predominantly pro-inflammatory to biomaterials than macrophages from lean subjects. Interestingly, variations were seen among the behavior of macrophages from obese patients, which could be partially predicted by monocyte subsets in peripheral blood or CRP levels of the patient. This knowledge and culture model can contribute to personalized hernia treatment.

O073 Desarda versus Lichtenstein technique for primary inguinal hernia: a randomized multi-center controlled trial W.B. Ahmed1, A.A. Redwan2 1 Sohag University, General Surgery, Sohag, Egypt, 2Assiut University, General Surgery, Assiut, Egypt Background: The techniques for treatment of inguinal hernia range from the tissue-repairs to the tension-free hernioplasty. The use of a mesh for repair not free of complications and had high costs. The Desarda technique for inguinal hernia repair is a new tissue-based method application of the external oblique muscle aponeurosis in the form of an undetached strip has been established as a new concept in tissue based hernia repair. Aim: To compare the standard mesh-based Lichtenstein technique with the tissue-based Desarda technique. Methods: In this prospective study, patients with Inguinal hernia That were referred and enrolled in the study for elective Desserda or Lichtenstein repair between May 2012 and May 2015 at Sohag and Assiut university hospitals, Egypt; Operation, anaesthesia, rescue analgesia and postoperative care were standardized. Patients were assessed for operation time, postoperative pain, hospital stay, foreign body sensation, complications and recurrence rate in the postoperative period on day 1, 1 week, 1, 12 and 24 months, postoperatively. Results: Of 130 patients, 65 underwent Desserda (D) and 65 underwent Lichtenstein repair (L) between May 2012 and May 2015 at Sohag and Assiut University Hospital in Egypt. In Desserda group (D) 64OF 65 patients were male and in Lichtenstein repair group (L) 65 of 65 were male. The patient’s age for (L) Group was 37.34 ± 10.88 and for (D) group was 32.60 ± 10.55. As regard operative time the mean operative time for D group was significantly lower than (L). No statically detected significant different in both group as regard hospital stay, intraoperative, postoperative complication, mortality rate, recurrence rate, or post-operative pain. Conclusion: Desserda repair was comparable to Lichtenstein repair but we recommend using Desserda repair in our hospitals as the method of choice for most of the patients due to low cost and recurrence rate, simple repair as well as our limited resources.

O074-Video Robotic assisted ePTFE incisional hernia repair in liver transplant patient R.D. Berta, D. Tassinari, R. Bellini, R. Mancini, C. Moretto, A. Sawilah, M. Anselmino Pisa University Hospital-Bariatric Surgery Unit, General Surgery, Pisa, Italy Introduction: Several reports demonstrate that incisional hernia is a common complication after Liver Transplant (LT). The management

S155 of subxiphoid and subcostal incisional hernias, especially in patients on chronic immunosuppressive therapy, is challenging. The risk of mesh infection and the overlap mesh fixation to the diaphragm with tacks are the main concerns. Authors describe ePTFE mesh (GORE) laparoscopic repair of a large Mercedes incisional hernia, in a liver transplanted patient, fixed to the diaphragm using Da Vinci Surgical System. Methods: A 38 year old man underwent to liver transplant due to chronic delta hepatit in 2013. He was referred to our Unit for a large Swiss cheese subxiphoid and subcostal bilateral incisional hernia (mean area 87, 51 cm2). In supine position, pneumoperitoneum was created in the left flank with an open approach. 2 9 12 mm and 5 mm trocars were inserted into the left side of the abdomen and adhesiolysis was performed. 2 additional trocars were inserted: 12 mm under the umbilicus and a robotic one on the right flank. 3 Dual Mesh (GORE) pre-shaped meshes (24 9 18 + 15 9 10 + 15 9 15) were inserted into the peritoneum through a 12 mm port, and suspended to the abdominal wall with titanium tacks. The Da Vinci Surgical System was docked from the patient’s head. The meshes were sutured with 2/0 prolene single stitches to the emidiaphragms with needle driver and Cadiere forceps. The robot was removed and meshes were fixed to the abdominal wall using Protacks. Results: Overall time of the procedure was 300 min: laparoscopic adhesiolysis took about 120 min, docking and undocking about 15 min. The patient had uncomplicated postoperative course and was discharged on 5th postoperative day. Conclusion: Robotic assisted ventral hernia repair seems to be helpful reducing the risks of anatomical injuries and mesh infection.

O075 A prospective, multicenter, observational study on quality of life after laparoscopic inguinal hernia repair with ProGripTM laparoscopic self-fixating mesh according to the EuraHS-QoL instrument F.E. Muysoms1, A. Vanlander2, R. Ceulemans3, I. Kyle-Leinhase1, M. Michiels3, I. Jacobs3, P. Pletinckx1, F. Berrevoet2 1 Maria Middelares Ghent, Surgery, Ghent, Belgium, 2University Hospital, Hepatobiliary Surgery, Ghent, Belgium, 3Heilig Hart Hospital, Surgery, Mol, Belgium Background: There is an increasing interest for patient reported outcome measurement (PROM) to evaluate hernia surgery. Several hernia specific Quality of Life (QoL) scales have been proposed, but none are constructed for preoperative assessment. Methods: The European Registry for Abdominal Wall Hernias proposed the EuraHS-QoL score for assessment pre- and postoperatively. The EuraHS-QoL was evaluated in a prospective multicenter validation study alongside the Visual Analogue Score (VAS), Verbal Rating Scale (VRS) and Carolina Comfort ScaleTM (CCSTM) (ClinicalTrials.gov NCT01936584). Results: We included 101 patients undergoing unilateral laparoscopic inguinal hernia repair with ProGripTM laparoscopic self-fixating mesh. Clinical follow-up at 12 months was 87 % complete. The EuraHS-QoL score shows good internal consistency (Cronbach’s a C 0.90), good test–retest reliability (Spearman correlation coefficient r C 0.72) and high correlation for pain with the VAS, the VRS, the CCSTM pain scale (r between 0.64 and 0.86) and for restriction of activity with the CCSTM movement scale (r between 0.65 and 0.79). Our results show significant QoL improvement at 3 weeks compared to preoperatively and further significant improvement at 12 month (p \ 0.05). No late complications or recurrences were recorded. Surgery was performed in day surgery ([75 %) or with a less than 24 h admission ([95 %) in the majority of the patients.

123

S156 Conclusion: The EuraHS-QoL score seems a valid PROM for patients after groin hernia repair. Laparoscopic inguinal hernia repair with ProGripTM laparoscopic self-fixating mesh results in a very favorable outcome and significant improvement of QoL compared to the preoperative assessment.

O076 A two-way street: teaching and learning as a volunteer hernia surgeon in the third world P. Bystricky P-P Klinika Kladno, Surgery, Kladno, Czech Republic Background: 1-in-4 men and 1-in-25 women will suffer a groin hernia during their lifetime. In low- and middle-income countries (LMIC) the majority of these patients cannot afford surgery, or it is inaccessible. In subSaharan Africa there are more than 6 million untreated inguinal hernia, many of which are large, scrotal and, incarcerated causing pain, disability and unemployment. A simple operation can reverse this suffering. Hernia International is a 100 % volunteer organisation delivering humanitarian hernia surgery in the countries of LMIC. Methods and results: As a young surgeon, I have had the chance to join 6 international voluntary teams in the years of 2011–2016, many under the leadership of Prof. A. N. Kingsnorth. More than 530 procedures were performed, including large inguinoscrotal, incisional, and paediatric hernias. The operating conditions were often very basic. Low-cost (\$2), Low Density PolyEthylene (LDPE = mosquito net) mesh was used for the Lichtenstein repair under local anaesthesia in most cases. A very low number (less than 1 %) of early (at 6 week follow-up) post-op complications (haematoma, scrotal swelling, surgical site infection) were recorded. At each local hospital, at least two surgeons were taught mesh hernioplasty and in one hospital the laparoscopic technique. Hospital staff at all levels participated in the surgery and were initiated in the WHO checklist for safe surgery. Conclusions: Hernia International provides a high-quality surgical care to the patients from developing countries. The participation in teams gives a great opportunity not only to help, but also learn a lot from other more experienced team members, and share different experiences with local surgeons.

O077-Video Using butyl-2-cyanoacrylate as non-traumatic fixation of the mesh in laparoscopic inguinal hernia repair (TEP) L.A. Vega Rojas, D. Salazar, P. Besora, R. Rodriguez, E. Fernandez, M. Molinete, L. Blay, J. Camps Hospital de Igualada, General Surgery, Igualada, Spain Objectives: To describe the use of n-butyl-2-cyanoacrylate as mesh fixation on totally extra-peritoneal inguinal hernia repair (TEP). Materials and methods: Case intervened by our team of abdominal wall surgery. Results: Surgical table at 0. We do an infraumbilical incision and anterior fascia of the rectus abdominis is cleaved, separating the muscle to access the back sheet of the rectus sheath; where the preperitoneal space is dissected with a balloon. This space is then maintained with a trocar Hasson, for CO2 insufflations at a pressure of 8–10 mmHg. We use two 5 mm trocars work. The first supra-pubic level and the second between the navel and suprapubic trocar. Cooper’s ligament and epigastric vessels are identified. Dissection of the structures is performed in bluntly through pull maneuvers and countertraction, beginning at the side portion, and then we proceed to the

123

Hernia (2016) 20 (Suppl 2):S139–S174 reduction of the hernia and the placement of polypropylene mesh 15 9 15 cm, fixed with placing a drop of n-butyl-2-cyanoacrylate level Cooper’s ligament and lateral portion Fruchaud triangle, making sure the cord is in contact with the wall. Exhaust gas and close the fascial plane Hasson trocar. Local anesthetic infiltration in the three trocars and skin closure. Discussion: Laparoscopic hernioplasty TEP is a technique associated with a low rate of complications and recurrence when it is performed by experienced surgeons; we have recently added the use of an atraumatic method of attaching order to increase patient safety.

O078 Inguinal hernia repair: the patient’s perspective W.J.V. Bo¨kkerink1, J. de Vries2, P.W.H.E. Vriens3, C.J.H.M. van Laarhoven1, G.G. Koning1 1 Radboudumc, Surgery, Nijmegen, Netherlands, 2Tilburg University, Medical and Clinical Psychology, Tilburg, Netherlands, 3Elisabeth Tweesteden Hospital, Surgery, Tilburg, Netherlands Introduction: Inguinal hernia repair is the most frequent surgical procedure in western society. Numerous papers report on the quest for the best surgical technique. Since recurrence rates dropped drastically, Patient Reported Outcome’s (PROs), such as chronic postoperative pain, are frequently taken as primary outcomes. However, the measuring instruments for PROs are hardly investigated from a patient point of view. To improve daily care and the relevance and efficiency of future research, this study attempts to indentify the true patient’s perspective on inguinal hernia repair. Methods: A qualitative research design was chosen, using a focus group discussion. Randomly, 6 to 12 patients who recently underwent an inguinal hernia repair were asked to cooperate. An independent expert clinical medical psychologist led the meeting. The study was designed and performed in line with the latest practice and insights in qualitative research methodology. The interviews were recorded, transcribed verbatim and analyzed. Results: 7 male and 1 female participants aged 30–79 took part in the focus group discussion. In the preoperative timeframe, half of the patients appeared not to have read any information regarding their upcoming surgery. Of the postoperative period, the experiences regarding the return to daily activities varied tremendously, with a wide range in time (3–28 days) and reasons. Most participants mentioned other reasons than (physical) pain co-influencing their full recovery. Most patients found chronic postoperative pain the most important complication. Of all functionalities, the sexual activities were restarted the last. Discussion: Items valuable to patients regarding their inguinal hernia repair were identified. Pain and return to daily activities appear to be highly influenced by multiple factors. These results may fuel the ongoing global discussion on improving evidence based and patient approved outcome measures. Focus group discussions may aid in the purpose of verification of PRO’s (vPRO’s).

Hernia (2016) 20 (Suppl 2):S139–S174

O079 Incisional hernia in the United States: trends in hospital encounters and corresponding healthcare charges, 2007–2011 V.S. Shubinets, J.P. Fox, S.J. Kovach, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Introduction: Incisional hernia (IH) is a challenging, highly morbid condition. We conducted this study to estimate recent trends in hospital encounters and healthcare charges associated with IH care. Methods: Using the 2007–2011 Nationwide Inpatient Sample, we identified hospital discharges for adult patients with a diagnosis of IH. Primary outcomes were annual estimates of hospital discharges, hospital charges, patient characteristics, and in-hospital outcomes. Regression models were used to test for significance in trends. Results: From 2007 to 2011, there were 583,054 hospital discharges associated with IH in the United States. 81.1 % had a concurrent procedure for IH repair. During the study period, a 12 % increase in IH discharges (2007 = 109,702 vs. 2011 = 123,034, p = 0.009) and a 52 % increase in healthcare charges (2007 = $44,587 vs. 2011 = $63,570, p \ 0.001) were observed. There was a significant trend toward increasing age (p \ 0.001) and medical comorbidity (p \ 0.001). This was accompanied by a trend toward longer hospitalization (2007 = 5.4 days vs. 2011 = 5.6 days, p \ 0.001) and an increased frequency of serious adverse events (2007 = 13.5 % vs. 2011 = 17.7 %, p \ 0.001). In 2011, the annual healthcare bill for the inpatient care of IH in the United States was $7.3 billion, a 52 % increase over 2007. Conclusions: Hospital discharges for IH are increasing in the United States and are associated with substantial charges every year. Further work is needed to identify interventions to mediate the risk of IH development.

O080-Video Laparoscopic assisted recti diastasis approximation (LARDA), experience and outcome of a novel technique S. Wijerathne, E. Sta Clara, J. Hu, W.B. Tan, D. Lomanto National University Hospital, General Surgery, Singapore, Singapore Introduction: Rectus diastasis is common in women post pregnancy and the indications for surgery are controversial. However, it is reasonable to repair it with an umbilical hernia concurrently. Many variations of abdominoplasty have been described but little has been published on the concurrent laparoscopic repair of recti diastasis and umbilical hernia. Here, we describe a novel laparoscopic technique for concurrent repair of both problems. Method: Under general anaesthesia, the patient is placed in the supine position. A 10 mm port is placed in the right flank via Hasson approach and a 5 mm port is placed on each side of the first port. Diagnostic laparoscopy is performed and then reduction of the hernia contents. Subsequently, pneumoperitoneum is reduced and the diastasis is plicated laparoscopically using a suture passer with transfacial sutures placed via stab incisions along one side of the diastasis and extra-corporeally tied. Reduction of the divertification is confirmed by manual pressure on the anterior abdominal wall. Then, the hernia defect is reinforced with mesh placement and anchored using transfacial sutures and absorbable tacks. Patients were discharged with abdominal binder for a period of 1 month following surgery. Results: Eight patients underwent the repair over a 2 year period in a tertiary institution. They were all mothers with mean age of 37 years (n: 31–50). The main presentation was an abdominal lump secondary to the umbilical hernia and rectus diastasis. The mean operation time was 90 min (n: 80–105). One patient underwent single port repair. The

S157 median length of stay post-operatively was 2 days (n: 1–3). All patients were followed up for minimum of 3 months. No complications of seroma or infection. All patients were satisfied with the cosmetic outcome. Conclusion: Our technique of concurrent management of rectus diatasis and umbilical hernia laparoscopically is feasible and reproducible with good outcomes.

O081 Ventral hernia: results of 100 robotic repairs F.M. Bianco, L.F. Gonzalez-Ciccarelli, S. Durgam, D. Daskalaki, R. Gonzalez-Heredia, P.C. Giulianotti University of Illinois at Chicago, Surgery, Chicago, USA Introduction: More than 300,000 hernias repairs are performed each year in the United States. The traditional, ‘open’ approach is still widely used, but minimally invasive surgery is becoming more popular. This technique results in less postoperative pain, shorter hospital stay and recovery time with lower wound and mesh infection rates. The robotic approach may add additional advantages; facilitating intracorporeal suturing, improving mesh fixation and advanced visualization. The purpose of this study is to show our preliminary experience with robot assisted laparoscopic ventral hernia repair (RVHR). Methods: We retrospectively reviewed data from a prospectively collected database of 95 patients. All cases were performed between June 2011 to September 2015 at the University of Illinois Hospital and Health. Results: A total of 95 patients underwent RVHR, 38 ventral, 26 umbilical, 18 incisional, 2 lumbar and 8 ventral + umbilical for a total of 100 hernias. There were 35 incarcerated and 5 recurrent hernias repairs. 64.7 % patients were discharged on the same day with in a median time of 160 min after the procedure. Post-operative complications occurred in 4.2 % of patients. They included: 2 asymptomatic seromas, 1 urinary retention and 1 pulmonary embolism. All complications resolved with conservative treatment. There was one case of recurrence, occurring 2 years after the operation, in concomitance with pregnancy. No chronic pain or infections occurred after a mean follow up of 373.1 days. Conclusion: RVHR repair is a technically feasible, safe and effective technique. The robotic platform allows advanced manual suturing, with primary closure of the fascia defect and circumferential suturing mesh fixation. These advantages could translate into decreased complication and recurrence rates, as well as reduced post-operative pain.

O082 A preliminary evaluation of absorbable and nonabsorbable fixation in laparoscopic ventral hernia repair using matched pairs with propensity scores W.W. Hope1, S. Brigman2, C. Doerhoff3, T. Tollens4, C. Romanowski5, P. Jones5 1 New Hanover Regional Medical Center, Surgery, Wilmington, USA, 2 Karolinska Institutet at Huddinge University Hospital, Surgery, Stockholm, Sweden, 3Surgicare, Surgery, Jefferson City, USA, 4 Imelda Hospital, Surgery, Bonheiden, Belgium, 5Ethicon, Clinical Development, New Jersey, USA Background: Literature suggests patients undergoing herniorrhaphy with absorbable fixation methods may have less pain postoperatively. We evaluate preliminary pain data with absorbable and nonabsorbable mesh fixation through 6 months postoperatively to estimate a sample size for future analyses.

123

S158 Methods: The International Hernia Mesh Registry, a prospective multicenter registry collects data on patient reported outcomes. Patients completed Carolinas Comfort ScaleTM (CCSTM), validated QOL questionnaire specific to herniorrhaphy at baseline and 1, 6, 12 and 24 months postoperatively. A symptomatic patient was defined as providing a response [1 to any CCSTM question. Laparoscopic incisional/ventral repair patients who received 1 mesh with tackers or tackers and sutures from October 2007 through October 2015 were queried. Propensity score matched pairs with McNemar tests were used to test the difference between outcomes. A patient pair was defined as (1 with absorbable tacker; 1 with nonabsorbable tacker) who had similar risk factors. Results: 307 tacker patients (171 absorbable; 136 non-absorbable) met the criteria. However due to missing risk factors or CCSTM outcome; data was available for 139(79; 60) patients, respectively. Pairing resulted in 102 patients (51 pairs) for symptomatic pain at 6 months with 27 similar matched pairs (5 had pain and 22 had no pain in both patients). Of the remaining pairs, 10 and 14 had pain in only absorbable or nonabsorbable tacker patient, respectively. A difference of 8 % was observed; 168 pairs (N = 336 patients) would be sufficient to establish if this difference is greater than 10 %. Conclusion: By using propensity scores in matched pairing, we can evaluate treatment differences from this registry data. This preliminary analysis enables sample size estimates to be determined for future hypothesis testing. Once sufficient data are available, statistical analysis will be completed to determine if there is a difference in pain following use of absorbable and nonabsorbable tackers.

O085 Bridging or no bridging the gap in livhr E. Chelala CHU-NDS, Belgium There is considerable controversy, as to the best approach for treating ventral and Incisional hernias (LIVHR). ‘‘IPOM Plus’’ combines transfacial transabdominal closure of the defect with the Intraperitoneal Onlay Mesh Placement, or ‘‘s-IPOM’’, which just patches the defect and overlaps it with intraperitoneal mesh as a bridging repair. Part of literature shows disappointing outcomes from s-IPOM related to inherent problems, such as seroma formation, bulging/Eventration, non restoration of abdominal wall function, infection, and higher rate of recurrence. On the other hand, several metaanalysis suggest that IPOMPlus is associated with more favorable surgical outcomes. Methods: A standardized technique of routine closure of the defect prior to intraperitoneal onlay mesh (IPOM) reinforcement was performed (Video). Results: On the overall early complications of 5.78 %, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56 %, with a low risk of infection \1 %. Through technical improvement in the suturing concept and growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24 % (VAS: 5–7), that decreased to 2.56 % on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74 %, we noticed also, that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to respectively 2.56, 1.50, and 4.72 %. Conclusion: This lecture aims to prove the feasibility and validity of IPOM-Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result. The current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect’s width and proper patient’s selection, in order to restore adequately the optimal functionality of the abdominal muscles and provide better outcomes.

123

Hernia (2016) 20 (Suppl 2):S139–S174

O086 Abdominal wall reconstruction with mesh: closing superior to bridging? T.S. de Vries Reilingh, E.H.H. Mommers, E.H.M. Berkvens, J.A. Wegdam, S.W. Nienhuijs Elkerliek Hospital, Deurne, Netherlands There are several techniques to repair ventral abdominal wall hernias. The use of mesh is proven to be superior and accepted in daily practice, though the optimal type and positioning of mesh is still heavily debated. Another question still under debate: should the mesh be used for augmentation of the abdominal wall (reinforcing and closing the gap) or used to bridge the defect. The authors strongly believe that patient’s benefit from a proper abdominal wall reconstruction reinforced with mesh. Closing the gap and reconstructing the abdominal wall should improve the patient’s core stability, physical performance, quality-of-life and cosmetic outcome. Additionally it should lead to reduced recurrence rates and mesh related complications. Despite the aforementioned advantages, reconstructive techniques might have an increased risk of post-operative (wound) complications and give a longer operation time. A multidatabase search was performed for evidence to evaluate this philosophy. There were no randomized controlled trials found comparing between reconstructive techniques and bridging. A few retrospective series where identified that suggested reconstruction is in favor to bridging. A systematic review suggested in laparoscopic ventral hernia repair an advantage of fascial gap closure although the quality of these data were considered poor. A recent report on a large case series in LVHR did not show the advantage of closure. Currently a randomized controlled trial is conducted comparing laparoscopic bridging and open reconstruction with mesh augmentation. Recent evidence suggests a positive relationship between reconstruction of the abdominal wall and the strength of the trunk flexors. There was no evidence found for improved quality-of-life after reconstruction with mesh reconstruction compared to bridging. Although the concept of abdominal wall reconstruction with mesh augmentation seems superior to bridging the defect with a mesh are is no evidence supporting this concept.

O088 The ability to assess of biocompatibility of mesh implants for hernioplasty. Experimental study K.A. Shemyatovsky1, N.M. Gevondyan2, D.L. Titarov1, A.V. Protasov1, E.D. Smirnova1 1 People’s Friendship University of Russia, Of operative surgery, Moscow, Russian Federation, 2Institute of Bio-organic Chemistry, Institute of bioorganic chemistry, Moscow, Russian Federation The use of polypropylene mesh implant is associated with a number of complications. For eliminate the negative properties of the polypropylene implants, they are covered with a layer of titanium. This improves the biocompatibility of polypropylene. Topical issue a rational assessment of humoral immunity reaction to the implanted material. The study was conducted on 40 white rats. Depending on the type of implantable material (polypropylene PP Light or titaniferous TiMesh mesh) all the animals were divided into two equal groups. The subcutaneous implantation of mesh implants were performed. The material for immunological studies were serum of venous blood. Blood was collected before and at 2, 7, 14 and 30 days after operation. The effectiveness of the immune response was evaluated on the basis of the protective activity in the immune system, which takes into account the level and quality of antibodies. Significant differences in the suppressive effect of implants on the secondary immune response depending on the material of the implant

Hernia (2016) 20 (Suppl 2):S139–S174 were identified. Polypropylene implants lead to a deep depression of adaptive immunity. They provoke increased secretion of functionally inactive high avidity antibodies. The titanium-covered polypropylene implants cause a gradual reduction of reactivity of the immune system, making them more attractive in the early stages of implantation. However, a significant decrease in the level of functionally active antibodies to the 13th day of the postoperative observation leaves no hope for the maintenance of clinical and immunologic remission. Conclusions: Definition In-protective activity of the immune system makes it possible to select the mesh implant, predict the direction of adaptation processes in the body. One month after implantation the positive properties of the titanium-covered polypropylene implant were reduced. Final conclusions should be made in the analysis of long-term follows.

O089 Translation of histological outcome after mesh implantation; are rats a good model for hernia research? L.C.L. van den Hil1, R.R. Vogels1, M.J.J. Gijbels1, M.H.F. Schreinemacher2, N.D. Bouvy1 1 Maastricht University Medical Centre, General Surgery, Maastricht, Netherlands, 2Academic Medical Center, General Surgery, Amsterdam, Netherlands Introduction: Incisional hernias are still a frequent problem in abdominal surgery. Hernia repair should consist of mesh-placement to prevent recurrences. In search of the ideal mesh, research in rats is often used, but it has never been shown that the tissue reaction in rats can be translated to the human situation. If this translation is not possible, further mesh-research in rats should be discontinued. Therefore, the aim of our study was to investigate whether the tissue reaction on meshes in rats is comparable with the reaction in humans. A second aim was to validate the use of rat models in mesh research. Methods: In a group of 10 rats, a mesh was intraperitoneally placed and removed after 3 months. Besides, a group of 8 patients with colorectal carcinoma received the same mesh, placed intraperitoneally around a temporary stoma. At the time of stoma reversal a piece of the mesh was explanted and the mesh was closed in order to prevent an incisional hernia at the former stoma site. Intra-abdominal adhesions were scored and histological and immunohistochemistry stainings were performed to assess the immune reaction. Results: Stomas were reversed after a median period of 6 months. There was no significant difference in adhesion formation between rats and humans. Both groups showed a mild tissue reaction, with the presence of macrophages, granulocytes and few giant cells. More evident fibrosis was seen in humans compared to rats. Conclusion: This is the first study that shows a comparable tissue reaction on intraperitoneally placed meshes between humans and rats. It can be recommended to use rats in future experimental mesh for incisional hernia research.

O090 Features of different composite meshes implantation in abdominal wall (experimental model) O. Ioffe, T. Tarasiuk, O. Stetsenko, I.U. Tsiura Bogomolets National Medical University, General Surgery #2, Kiev, Ukraine The widespread use of intraabdominal laparoscopic hernioplasty in ventral hernia surgical treatment makes necessary to use composite

S159 meshes. On the mesh implantation in the abdominal wall the structure and covering the implant may influence. Materials: The 27 white Wistar rats, 3–4 months of age, were used throughout the experiment. The mesh 2 9 2 cm was fixed to the peritoneum of abdominal wall. We used a composite polypropylene mesh with different types of structures and external coverage: Physiomesh (Ethicon)—9, Proceed (Ethicon)—9, C-QUR (Atrium)—9. We studied the mesh implantation in abdominal wall on 14, 30 and 90 days. Results: On 14th day the majority square of Proceed was germinated by connective tissue, thin capsule formed around the polypropylene fibers. Physiomesh showed a similar pattern, but the capsule was less pronounced. There were areas to form a continuous bilayer capsule around the mesh, without connective tissue between the filaments. C-QUR showed the total capsule formation around it, inflammation of tissues around. On 30th day Proceed was fully germinated by connective tissue. Cellulose filaments were partially absorbed. Physiomesh showed germinating by connective tissue. But the cavity between the capsule layer of polypropylene filaments and the abdominal wall was formed-seroma. C-QUR marked the formation of a capsule around the implant, with signs of mild inflammation. On 90th day the connective tissue totally germinated between polypropylene filaments of Proceed and Physiomesh. In the area of implantation Proceed mesh the layer of mesothelium was formed. The thick capsule around the mesh, with signs of mild inflammation, single impurities of detritus was determined in C-QUR case. Conclusion: The presence of absorbable layer in mesh and lack of coverage in contact with the parietal peritoneum provide shorter term of mesh implantation in abdominal wall and the formation of the mesothelium.

O091 Entering new dimensions in soft tissue reconstruction with degradable implants? Biologic silk meshes in comparison to synthetic devices S. Gruber-Blum1,3, J. Park2, O. Guillaume2, J. Scheidig2, H. Redl2, R. Fortelny1, A. Petter-Puchner2 1 Wilhelminenspital, Department of General, Visceral and Ocological Surgery, Vienna, Austria, 2Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Cluster of Tissue Regeneration, Vienna, Austria, 3Cluster of Tissue regeneration, Ludwig Boltzmann Institute of Experimental and Clinical Traumatology, Vienna, Austria Introduction: Degradable scaffolds have entered the competition with biologic devices. This entity forms a new generation of abdominal wall implants with to date only little scientific evidence. Fibroin, the silk protein is one of the oldest materials used in surgery. Modern processing is able to enhance biocompatibility and to tailor the scaffold material to the surgeon’s needs. Experimentally, self-manufactured long-term degradable meshes of biologic silk fibres have been compared to the degradable synthetic Tigr matrix and a non-resorbable polypropylene mesh. Materials: A surgical onlay model in rats was performed to compare two different macroporous meshes fabricated of degummed silk fibres, one single stranded, one doublestranded, to Tigr matrix and Optilene, serving as controls. After 7 and 60 days follow-up macroscopic, histologic and biomechanical evaluation criteria were surveyed. Results: Complete mesh integration was observed in all samples of all groups with well detectable vascularization of the mesh surface after 7 and 60 days. The moderate foreign body reaction of silk meshes decreased after 60 days, featuring good biocompatibility. Mesh shrinkage of 30 % of the mesh surface was observed in singlestranded silk samples. Force until rupture and elongation in the silk groups was comparable to native abdominal wall tissue. A fine web-like structure of collagen fibers was seen histologically in silk samples and the synthetic resorbable material, whereas the collagen bundles were more aligned and with greater pore structure in polypropylene samples.

123

S160 Conclusions: Silk meshes are derived from a natural biologic product coming in fibers. They pose the advantage of tailoring the matrix to the surgeon’s need regarding thickness and pore size. Fibroin meshes have an inherent strength comparable to native abdominal wall and are well integrated into the soft tissue. Serving as scaffold for a fine webbed collagen structure they seem suitable for 3D soft tissue reconstruction of the abdominal wall.

O092 Strength of parietal ingrowth of two different polypropylene meshes is independent of mesh properties and type of anchoring: an experimental longterm study in sheep S. Harsløf1, N. Zinther1, T. Harsløf2, C. Danielsen3, P. Wara2, H. Friis-Andersen1 1 Regional Hospital Horsens, Surgical Department, Horsens, Denmark, 2Aarhus University Hospital, Department of Endocrinology, Aarhus, Denmark, 3Aarhus University, Institute of Biomedicine, Aarhus, Denmark Background: In laparoscopic ventral hernia repair parietal ingrowth of the mesh is of crucial importance. Until significant ingrowth occurs mesh fixation depends on the interface between abdominal wall, mesh, and anchoring device. Relatively few studies have addressed the effect of mesh properties and anchoring device on long-term parietal ingrowth. Methods: In 20 sheep, using laparoscopy, we inserted two different polypropylene-based meshes, PhysiomeshTM (large pore, lightweight) and VentralightTM ST (small pore, mediumweight), anchored with ProTackTM, SecurestrapTM or GlubranTM. After 6 or 12 months, 10 sheep at each timepoint, we euthanized the animals and harvested the meshes with the corresponding fascia. Mesh with fascia was attached on an AlwetronTM tensiometer, and pulled apart registering the peel-off energy (Joule (J)). Results: We found a significant interaction between time and type of anchoring (p \ 0.001), indicating that the effect of type of anchoring on strength of parietal ingrowth depended on time. The strength of parietal ingrowth at 6 months was 5.99 ± 0.54 J (mean ± SEM), 4.94 ± 0.54 J and 7.35 ± 0.55 J when anchored with ProtackTM, GlubranTM or SecurestrapTM, respectively. At 6 months the strength of parietal ingrowth of SecurestrapTM was significantly higher than GlubranTM (p = 0.04). No significant difference was seen between any other combinations. Parietal ingrowth at 12 months was 7.05 ± 0.56 J, 7.55 ± 0.54 J and 5.73 ± 0.54 J when anchored with ProtackTM, GlubranTM and SecurestrapTM, respectively. No significant difference in strength of parietal ingrowth was seen between the three types of anchoring, (p = 1.00, p = 1.00 and p = 0.29). Conclusion: At 12 months the strength of parietal ingrowth was the same for all comparisons. The two polypropylene meshes showed equal strength of parietal ingrowth independent of anchoring devices used.

O093 Mesh shrinkage depends on mesh properties and anchoring device: An experimental long-term study in sheep S. Harsløf1, N. Zinther1, T. Harsløf2, C. Danielsen3, P. Wara2, H. Friis-Andersen1 1 Regional Hospital Horsens, Surgical Department, Horsens, Denmark, 2Aarhus University Hospital, Department of Endocrinology, Aarhus, Denmark, 3Aarhus University, Institute of Biomedicine, Aarhus, Denmark Background: The choice of mesh and anchoring device in laparoscopic ventral hernia repair is controversial. Clinically important

123

Hernia (2016) 20 (Suppl 2):S139–S174 long-term properties of mesh and anchoring device such as mesh shrinkage have been sparsely investigated. Furthermore, the effect of various anchoring devices on mesh properties has never been examined. Methods: In 20 sheep, using laparoscopy, we inserted three PhysiomeshTM (large pore, lightweight) and three VentralightTM ST (small pore, mediumweight), anchored with ProTackTM, SecurestrapTM or GlubranTM, respectively. After 6 and 12 months, 10 sheep at each time-point, we euthanized the sheep, harvested the meshes with fascia, and measured the exact size and area of the mesh, expressing mesh shrinkage as a percentage of the initial area. Results: The shrinkage of PhysiomeshTM was 35.7, 23.8 and 17.7 % when anchored with ProtackTM, GlubranTM or SecurestrapTM, respectively. Shrinkage with ProtackTM was significantly higher than with either GlubranTM or SecurestrapTM, respectively (p \ 0.01 and p \ 0.01). The shrinkage of VentralightTM ST was 19.3, 22.2 and 19.6 % when anchored with ProtackTM, GlubranTM and SecurestrapTM, respectively (p [ 0.05 for all pairwise comparisons). Overall shrinkage of PhysiomeshTM anchored with ProtackTM was significantly higher for all comparisons (p \ 0.01). Conclusion: Our results suggest that mesh shrinkage in sheep takes place within 6 months after implantation. A significant interaction between mesh and type of anchoring indicates that shrinkage depends on both mesh properties and anchoring device. The results of the current study imply that the combined effect of mesh and anchoring device on shrinkage should be evaluated in future studies.

O094 Hernia repair in the obese T.H.J. Aufenacker Radboudumc, Nijmegen, Netherlands In this presentation a case will be demonstrated and therapeutic options will be discussed. These are focussed on weight losing regimens but also the treatment of this tempting case will be discussed. What intervention can be used and how much weight loss can be expected? Also data regarding the best treatment options of an unsuspected peroperative hernia in the obese are presented.

O095 What to do with the occult hernia? A.C. de Beaux Royal Infirmary of Edinburgh, Edinburgh, UK Occult for whom? The patient, the surgeon, both? With increasing use of cross sectional imaging, asymptomatic hernias in the groin and the midline, especially from the umbilicus to the xiphisternum are being reported. With increasing obesity in the Western population, these are often not detectable on clinical examination either. Such hernias rarely require surgery at this stage. It is well recognised that in patients presenting with an inguinal hernia, up to 1 in 2 men will either present with bilateral hernias, or develop a contralateral hernia during their life time. While it is generally accepted that at open groin surgery, only the symptomatic side is repaired, there are a number of surgeons who would repair both sides at TEP or TAPP when there is a clinically detectable hernia on both sides, even if only one side is symptomatic. Some patients will have a small defect on the contralateral side at laparoscopy for TAPP which was not symptomatic or clinically

Hernia (2016) 20 (Suppl 2):S139–S174 detectable. Repair of the contralateral side is not unreasonable in this situation assuming appropriate informed consent has been obtained. There is also a view held by some surgeons that at TEP, exploration of the contralateral side (assuming no previous hernia repair, or surgical contra-indication to bilateral repair) is routine. The options on the contra-lateral side are then to insert a mesh anyway, or only if a hernia is present. Is this practice justified? Lets examine the evidence together for these treatment strategies.

O096 Symptomatic abdominal wall hernias in pregnancy: what to do? D. van Geldere Isala Hospital, Zwolle, Netherlands Abdominal wall hernias in pregnancy are very rare. Their incidence is unknown. There is no consensus on their treatment. The literature is sparse and mainly case reports are found. Groin hernias in pregnancy are extremely rare and virtually non-existent. The growing uterus in fact blocks Fruchaud’s triangle. A reducible groin swelling during pregnancy is more likely varicosity of the round ligament than an inguinal hernia. Ultrasound is essential for this diagnosis. Treatment is not necessary, unless intractable pain exists. Only one case of incarcerated inguinal hernia was described with repair during pregnancy. Elective treatment can be postponed to after delivery or in conjunction with cesarean section. Umbilical hernias are a bit more common in pregnancy. The incidence is unknown. Symptomatic hernias are rare and treated as usual; pregnancy is no contraindication for operation or anesthesia. Only seven emergency repairs were reported in a recent systematic review by Jensen et al. (Hernia, 2015). Most often a pediculated uterine fibroid is incarcerated or strangulated. Asymptomatic umbilical hernias can be safely repaired simultaneous with cesarean section. Incisional hernias are rare as well. In third world countries herniation of the gravid uterus is described with severe obstetric complications. Surgical common sense is the best guideline to treat symptomatic abdominal wall hernias during pregnancy. Treatment is the same as in non pregnant patients. Mesh repair is safe, but may give rise to abdominal wall pain during the last months of pregnancy. Known hernias are better repaired before pregnancy intervenes. Reference: 1. Augustin G (2014) Acute abdomen during pregnancy. Springer, Berlin

O097 Evidence based management of the painful groin in athletes A.J. Sheen Manchester Royal Infirmary, Manchester, UK Introduction: An elite athlete may present with groin pain as a result of the increasing forces that the groin is subjected to as a result of running, twisting and turning motions. The ideal definition for this condition is inguinal disruption as described in the Manchester 2014 Consensus Statement. Methods: An accurate history and examination eliciting at least 3 out of the 5 cardinal signs & symptoms of inguinal disruption are required for a clinical diagnosis. Imaging is essential in mainly excluding other pathologies such as hip or adductor injuries. In addition a full assessment of the athlete’s core stability and abdominal wall musculature is essential prior to the consideration of any surgical

S161 treatment. The full assessment is therefore ideally made with the help of a Multidisciplinary team (Orthopedic/Groin Surgeons, MSK Radiologist and a Physiotherapist). An active physiotherapy programme is required at first to try and improve any weaknesses in any musculature found which will be tailored to suit the affected muscles group(s). Results and further treatment: After a failure of either physiotherapy, steroid injections, hip labral tears treatment and/or physiotherapy for a noted adductor injury, then surgery to improve the integrity of the inguinal canal is considered. The choice of surgery is largely, like inguinal hernia repair, decided on the surgeon’s preference. No operation to date, whether open or laparoscopic, mesh or no mesh, has been directly compared until recently, a trial comparing open minimal repair with TEP, which is presently underway in Europe. Conclusion: A treatment algorithm can be established to manage athletes with inguinal disruption using a multidisciplinary approach in order to firstly improve the core stability and muscle groups of the athlete, as well as provide possible surgical repair as necessary. This approach will hopefully improve the time an athlete abstains from sport.

O099 Quality control in meta-analysis T.H.J. Aufenacker Radboudumc, Nijmegen, Netherlands In evidence based medicine the highest level of evidence is said to come from meta-analysis. But there is, I strongly believe, a big danger regarding metaanalysis. Meta-analysis are given to much weight and influence clinical decision making without enough critical review. Many metaanalysis are incorrectly performed or missing data and are therefore leading to the wrong conclusion. When looking at a few current topics in hernia reapir this can easily be demonstrated. This is because of faults in data extraction, incomplete literature search and incorrect use of statistical methods. Since performing and reviewing a meta-analysis is a rather tempting procedure it is not hard to state that: ‘‘The current, manuscript reviewing methods are probably not good enough to correct for these faults.’’ Unfortunately nowadays doctors rather look at meta-analysis than good RCT’s. But the doctor has to keep in mind that according to the evidence based medicine principle the key question is: ‘‘Are the results applicable to my patients’’. And since many meta-analysis are combinations of all trials on a topic this is usually not the case. Thus meta-analysis is a non-perfect technique that is no substitute for a large and well-designed randomized controlled study. In this presentation some examples are given and where possible insight are presented regarding vulnerable data/results which influence our practice every day.

O100 Quality control in surgery and data entry F. Ko¨ckerling Vivantes Hospital Berlin, Berlin, Germany In the past the majority of surgical innovations were accepted on the basis of non-randomized trials. Sir Alfred Cushieri has spoken about the introduction of laparoscopic cholecystectomy as the ‘‘greatest unaudited procedure in the history of surgery’’. Specifically hernia

123

S162 surgery has experienced rapid progress in recent years. By virtue of the ever-expanding number of medical devices used in hernia surgery, the surgical techniques are of such a broad variety that they can scarcely be evaluated in a randomized controlled trial. But by consistently recording details of the different surgical techniques in a prospective registry, any problems or complications related to particular variants of the technique can be identified at an early stage. Additionally, more than 100 different surgical techniques have been described for the treatment of inguinal hernias. The ultimate aim of a hernia registry is to improve quality across the entire spectrum of hernia surgery. It has been revealed than in Denmark, there was a significant reduction in recurrence rate after the introduction of a hernia registry. A surgeon can only become better, if he knows his own results. A further aim for hernia registries is outcome research, monitoring and evaluating how the knowledge gleaned from evidence-based science is implemented in the everyday clinical setting and, ultimately, investigate its effectiveness. In summary, there are many reasons, why quality control in hernia surgery is essential. Data entry needs the precise documentation of all patient-related risk factors and local disease findings as well as all the details of the procedure including the used products. The challenge is getting surgeons to be more clinical about the outcomes of their operations.

O104 Treatment for mesh infection with bowel erosion after open inguinal hernia repair B.S. Wang Baoshan, C.J. Chenjie, S.Y.M. Shen Yingmo Beijing Chao-Yang Hospital, Hernia and Abdominal Wall Surgery, Beijing, China Background: Hernia repairs are the most common elective abdominal wall procedures performed by general surgeons. The use of mesh has become the standard for hernia repair surgery. However, meshrelated complications have become increasingly more frequent. Few reports from the medical literature have presented severe mesh-related complications following open inguinal hernia repair. One of these complications is being mesh erosion into bowel. This study was to discuss the treatment and experience of mesh infection with bowel erosion after open inguinal hernia repair. Methods: The clinical data of 89 cases of mesh infection after open inguinal hernia repair who were treated in our clinical center from January 2013 to December 2015 were included, and 7 of them who developed mesh erosion into intestinal were retrospectively analyzed. Data of previous hernia repair, mesh, operative findings, therapeutic methods and postoperative complications were recorded. Results: Only 1 patient had diagnosed mesh infection with bowel erosion before operation, the rest of the patients clarified a diagnosis via laparoscopic exploration. Surgical treatment involved the infected mesh removal, bowel resection or repair, primary suture, and placement of abdominal and wound drainage, without replacement of a new mesh substitute. 2 patients were late healed due to the superficial infection following stitch removal. All patients were followed up for a mean period of 18 months (range 10–31 months), no wound infection, intestinal fistula, postoperative pain and recurrence were observed. Conclusions: The rate of mesh infection due to mesh erosion into bowel is 7.9 % (7/89). The diagnosis and treatment of mesh infection with bowel erosion after inguinal hernia repair is complicated. Laparoscopic technology plays a significant role in diagnosis and treatment. Using comprehensive surgical treatment, such as mesh removal, thorough debridement, bowel resection or repair, primary suture and placement of abdominal and wound drainage, can obtain a satisfactory result.

123

Hernia (2016) 20 (Suppl 2):S139–S174

O106-Best Oral INCA-trial (RCT): watchful waiting versus elective repair of mildly symptomatic or asymptomatic inguinal hernia in men aged 50 years or older B. de Goede, A.R. Wijsmuller, G.H. van Ramshorst, B.J. van Kempen, W.C. Hop, M.R. Scheltinga, G.J. Kleinrensink, J. Jeekel, J.F. Lange for the INCA Trialists Collaboration Erasmus MC, Department of Surgery, Rotterdam, Netherlands Background: The role of watchful waiting in men aged 50 years or older with mildly symptomatic or asymptomatic inguinal hernia is not well established. Methods: We randomly assigned men aged 50 years or older with mildly symptomatic or asymptomatic inguinal hernia to either elective inguinal hernia repair or watchful waiting. The primary endpoint was the mean difference in a 4-point pain/discomfort score during a follow-up period of 24 months. Using a 0.20-point difference as a clinically relevant margin, we hypothesized that watchful waiting was non-inferior to elective repair. Secondary endpoints included quality of life, event-free survival, and crossover rates during the 36-month study period. Results: From January 2006 through August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair; 262 to watchful waiting. After 24 months, the 4-point pain/discomfort score was 0.49 for watchful waiting and 0.26 for patients assigned to elective repair (mean difference (MD), -0.23, 95 % CI -0.31 to -0.14). In the watchful waiting group, 99 patients (37.8 %) eventually underwent surgery; 6 (6.1 %) because of strangulation/incarceration. Postoperative complications and recurrence rates in these 99 individuals were comparable to individuals originally assigned to the elective repair group (8.1 vs. 15.0 %; P = 0.106) and (7.1 vs. 8.9 %; P = 0.668) respectively. Conclusion: We showed non-inferiority of watchful waiting compared to elective repair of inguinal hernia in pain/discomfort during 24 months, justifying watchful waiting into daily practice.

O107-Best Oral Prevention of parastomal hernias of endcolostomies with mesh: a meta-analysis and trial sequential analysis of randomized trials M. Lopez-Cano1, H.T. Brandsma2, K. Bury3, B.M.E. Hansson2, I. Kyle-Leinhase4, J. Garcia-Alamino5, F. Muysoms4 1 Vall d´Hebron Hospital, Surgery, Barcelona, Spain, 2Canisius Wilhelmina Hospital, Surgery, Nijmegen, Netherlands, 3Klinika Kardiochirurgii i Chirurgii Naczyniowej, Gdanski Unywersitet Medyczny, Surgery, Gdansk, Poland, 4Maria Middelares Ghent, Surgery, Gent, Belgium, 5Department of Primary Health Care Sciences, Oxford University, Department of Primary Health Care Science, Oxford, UK Introduction: The incidence of parastomal hernias (PH) is very high and its prevention by mesh augmented reinforcement (MAR) at the time of stoma creation has been tested in several of randomized studies (RCT). With this meta-analysis we want to analyze the current level of evidence. Materials and methods: We performed a systematic computerized literature search in October 2015 and added data from 2 additional RCTs submitted for publication. We included only RCTs comparing MAR versus No-Mesh in the creation of end-colostomies. The primary endpoint is the incidence of PH with clinical and/or CT diagnosis. Secondary endpoints are incidence of PH with clinical

Hernia (2016) 20 (Suppl 2):S139–S174 diagnosis only, incidence with CT scan diagnosis only, PH repair rate and wound infection rate. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN (internal validity) and the GRADE methodology (external validity). Trial Sequential Analysis (TSA) is done to determine the Optimal Information Size (OIS). Meta-analysis was performed with Review Manager v5.3. Results: From 10 RCTs identified, we excluded 3 because low follow up time, inclusion of ileostomies or poor quality. The remaining 7 studies encompass 452 patients. We find a significant reduction of 57 % in the incidence of PH by prophylactic mesh (RR 0.43; 95 % CI: 0.26–0.71). The OIS for PH diagnosis (clinical or CT) is 251 patients. We find a significant higher number of patients needing a PH repair during follow-up (RR 0.28; 95 % CI: 0.10–0.78). The OIS for PH repair is 511 patients. No difference in the number of wound infections was found (RR 0.79; 95 % CI: 0.41–1.53). Conclusion: We found evidence by reaching the optimal information size in this meta-analysis that MAR when creating an end colostomy reduces significantly the incidence of PH. It also reduced significantly the risk for subsequent PH repair. No difference in wound infections was found.

O108-Best Oral A multicenter prospective randomized controlled trial comparing closure versus non-closure of hernia defects between 2 and 5 cm wide in laparoscopic ventral hernia repair F. Berrevoet1, L. Berwouts2, F. Muysoms3, T. Tollens4, A. Vanlander1 1 Ghent University Hospital, General and HPB Surgery and Liver Transplantation, Heusden, Belgium, 2Vincentius Hospital, Dept of Surgery, Deinze, Belgium, 3Maria Middelares Ghent, Dept of Surgery, Ghent, Belgium, 4Imelda Hospital, Department of Surgery, Bonheiden, Belgium Introduction: Closure of the hernia defect might reduce the risks of both mesh migration, seroma formation and eventually recurrence. This multicenter prospective randomized controlled trial compares closure versus non-closure of the hernia defect between 2 and 5 cm in width in laparoscopic ventral hernia repair. ClinicalTrials.gov Identifier: NCT01719718. Methods: All patients were treated according to a standardized technique: Group 1: Conventional laparoscopic ventral hernia repair without closure of the hernia defect (defect bridging technique). Fixation with 4 sutures Prolene 2/0 at cardinal points. Rest of fixation is by absorbable fixation device in a double crown fashion. Group 2 had the same technique with closure of the hernia defect (mesh augmentation technique). Closure of the defect was performed by PDS 0 punctures in the midline every 1 cm along the defect using endoclose with subcutaneous knotting. Results: At this analysis 92 patients were evaluated with a mean age of 61.6 years and a mean BMI of 30.6 kg/m2. Four recurrent hernias were treated as well as 33 umbilical hernias, 37 incisional hernias and 17 epigastric hernias, all between 2 and 5 cm wide. Forty-five patients had closure of the hernia defect, 47 did not. The mean mesh overlap was 6 cm. In total 13 patients had a type II or type III seroma according to Morales’ classification of which 10 occurred in the bridged group and 3 in the augmented group. Five patients had some remaining bulging, while 1 patient developed a recurrence, all in the non-closed group after 1 year follow-up in 76 out of the 92 patients included. Conclusion: This preliminary analysis shows no significant differences in outcome between closed or non-closed defects between 2 and

S163 5 cm wide in LVHR. There is a trends towards less asymptomatic seroma and bulging in the closed defect patients.

O109/P001 Pregnancy is associated with an increased risk of ventral hernia recurrence: a nationwide registerbased study E. Oma, K.K. Jensen, L.N. Jorgensen Bispebjerg University Hospital, Digestive Disease Center, Copenhagen, Denmark Background: Although ventral hernia repair is common in fertile female patients, the impact of subsequent pregnancy on the risk of hernia recurrence is unknown. Hence, consensus lacks on the timing of surgical repair for women who plan future pregnancies. The aim of this study was to examine whether pregnancy following ventral hernia repair was associated with hernia recurrence. Methods: This was a nationwide cohort study including all fertile female patients registered in the Danish Ventral Hernia Database with umbilical, epigastric or incisional hernia repair between 2007 and 2013. Obstetric data was retrieved from the Danish Medical Birth Registry. Ventral hernia recurrence was defined according to registration in the Danish National Patient Registry which holds data on all diagnoses and procedures from both public and private hospitals in Denmark. Multivariable extended Cox regression analysis was performed to assess the confounder-adjusted association between pregnancy and hernia recurrence. Results: A total of 3578 patients were included in the study, 267 (7.5 %) of whom subsequently became pregnant during follow-up. The median time from ventral hernia repair to pregnancy was 1.1 years (range 0–5.8 years) and the overall median follow-up was 3.1 years (range 0–8.4 years). After adjusting for relevant confounders, pregnancy was associated with an increased risk of ventral hernia recurrence (hazard ratio (HR) 1.56, 95 % CI 1.09–2.25, P = 0.016). Hernia type (umbilical HR 1.55, 95 % CI 1.17–2.06 and incisional HR 3.30, 95 % CI 2.42–4.51 compared with epigastric) and hernia defect size (HR per 10 cm2 increase 1.02, 95 % CI 1.01–1.04) were likewise associated with hernia recurrence. Conclusion: Pregnancy following ventral hernia repair was associated with an increased risk of ventral hernia recurrence. Planned future pregnancies should be considered for a timely repair of ventral hernia in fertile women.

O110/P002 Concurrent panniculectomy in the obese ventral hernia patient: Assessment of short-term complications, hernia recurrence, and healthcare utilization M.A. Lanni, V. Shubinets, J.P. Fox, M.N. Mirzabeigi, M.G. Tecce, R.R. Kelz, K.R. Dumon, S.J. Kovach, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Introduction: Soft-tissue interventions such as panniculectomy (PAN) are often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice have not been fully established in part due to paucity of comparative effectiveness studies. Presented herein is a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients.

123

S164 Study design: From the Healthcare Cost and Utilization Project (HCUP) database, obese patients who underwent VHR with and without concurrent PAN were identified. Multivariate cox proportional-hazards regression modeling was performed to compare outcomes between the two groups. Results: The final cohort included 1013 VHR-PAN and 18,328 VHRonly patients. The VHR-PAN patients experienced a longer adjusted length of hospital stay (6.8 vs. 5.2 days; p \ 0.001), a higher rate of in-hospital adverse events (29.3 vs. 20.7 %; AOR = 2.34 [2.01–2.74]), and a higher rate of 30-day readmissions (13.6 vs. 8.1 %; AOR = 2.04 [1.69–2.48]). The 2-year rate of hernia recurrence, however, was lower in the VHR-PAN group (7.9 vs. 11.3 %; AOR = 0.65 [0.51–0.82]). Both groups generated significant costs of care ($104,805 VHR-PAN vs. $72,206 VHR-only, p \ 0.001). Conclusions: Performing a concurrent PAN in the obese hernia patient is associated with a higher rate of early complications and greater healthcare expenditures, but overall a substantially lower incidence of 2-year hernia recurrence. The literature review presented here also highlights a significant need for further comparative effectiveness studies to create the needed framework for evidence-based guidelines.

O111/P003 Health-economic analysis of Lichtenstein in local anesthesia vs Total ExtraPeritoneal repair for inguinal hernia: preliminary data from a randomized clinical trial L.C. Westin1, S. Wollert2, M. Ljungdahl2, G. Sandblom1, U. Gunnarsson3, U. Dahlstrand1 1 Karolinska Institutet, CLINTEC, Stockholm, Sweden, 2Uppsala University, Department of Surgical Science, Uppsala, Sweden, 3Umea˚ University, Surgery and perioperative science, Umea˚, Sweden Objective: To compare cost-effectiveness of Lichtenstein under local anesthesia (LLA) and total extra-peritoneal repair (TEP) for repair of primary inguinal hernias in men. Background: Endoscopic approaches to inguinal hernia repair are often considered more costly. Endoscopic hernia repair has, however, not been compared to open inguinal hernia repair under cost-optimized settings. Methods: The study is based on a randomized controlled trial designed to compare post-operative pain between LLA and TEP performed under cost-optimized circumstances. Economic data was assembled prospectively. Information from the hospitals economic systems regarding duration of operation, cost of operating time, anesthesia duration and cost of anesthesia collected together with data on material cost. Data from the national registry for sick leave were obtained in order to include longer term social costs for these patients. Altogether 384 patients were included. Results: 374 (97.4 %) patients were analyzed, 189 patients in the LLA group and 185 in the TEP group. For 10 patients no data could be retrieved from the economic registry of the hospital. The mean operating time for LLA was 72.3 (SD 16.0) min compared to 62.7 (SD 18.6) min in the TEP group, p \ 0.001. The mean duration of anesthetic treatment was 116.9 (SD 22.7) min for LLA and 128.9 (SD 26.2) min for TEP, p \ 0.001. Conclusion: Operating time was significantly longer in the LLA group; the duration of anesthesia or anesthetic treatment in the operating room was however significantly shorter in the LLA group when compared to the TEP group. This could result in an equalization of costs. However, data from sick leave costs and materials need to be taken into account as well.

123

Hernia (2016) 20 (Suppl 2):S139–S174

O115 Open incisional herniae and fistula, my strategies M.A. Boermeester Academic Medical Center, Amsterdam, Netherlands Two-thirds of enterocutaneous fistulae (ECF) are caused by iatrogenic injuries. Immediate re-operative surgery for ECF is potentially detrimental. There should be a delay to restorative surgery and when possible they should be discharged home prior to surgery. Reconstructive surgery should not be undertaken for 6 to 12 months the time it takes for the abdomen to become softened and re-epithelialized, for nutrition to be optimised, and preferably after the patient has had a period of time at home. During reconstructive surgery segmental bowel resections of segments with a fistula are needed. When bowel is anastomosed every attempt should be made to close the abdominal wall to lower the risk of anastomotic leakage. An abdominal wall defect with a large skin defect and an infected mesh and a fistula becomes a very complicated wound, and must involve other specialties including plastic surgery. Reconstruction of the abdominal wall is an important part of these operations. Evidence on the safety and efficacy of non-absorbable mesh for open abdomen with enteric fistula is equivocal with possible increased rate of infection. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation and should be avoided. With large abdominal wall defects, it’s all about getting the midline closed. Midline fascial closure is possible in extreme, complex cases. However, use of the conventional components separation (Ramirez) technique without mesh reinforcement does not produce acceptable outcomes. Use of non-crosslinked biomesh for reinforcement reduces the need for bridging repair of large abdominal wall defects, because this biomesh can withstand high traction forces. Personal experience with a newly developed technique will be discussed: In non-contaminated extreme hernias, a double layer technique can be applied with use of an intra-abdominal sublay biomesh and retrorectus sublay synthetic mesh reinforcement.

O116-Video Huge bilateral subcostal incisional hernia solved by retromuscular repair and transversus abdominis release M. Garcia-Uren˜a1, L.A. Blazquez1, J. Lopez-Monclus2, A. Robin1, A. Cruz1, E. Gonza´lez1, N. Palencia1, D. Melero1, P. Lo´pez1, A. Moreno1, A. Galvan1, R. Becerra1, A. Aguilera1, C. Jime´nez1 1 Henares University Hospital, Surgery, Madrid, Spain, 2Puerta de Hierro University Hospital, Surgery, Madrid, Spain Background: Bilateral subcostal hernias are considered complex. The proximity of the costochondral border and the lack of aponeurosis on both lateral sides make this repair difficult. We present a complex case operated by an open approach through the previous incision solved by a bilateral posterior component separation technique and a retromuscular placement of a double mesh technique. Methods: This is a 71 old man with a history of hypertension, diabetes and chronic renal failure. He had an episode of acute necrotizing pancreatitis with several operations more than 25 years ago. A posterior attempt to repair incisional hernia was also attempted. He came to our clinic with a huge, loss of domain bilateral incisional hernia. The CT scan showed a massive abdominal wall defect, sized 20 cm vertical x 30 cm horizontal. An open approach was planned. The cranial dissection was made retromuscular in the plane between diaphragm and the fascia diaphragmatica and the peritoneum.

Hernia (2016) 20 (Suppl 2):S139–S174 Caudally a bilateral transversus abdominis release was performed to reach the plane between the posterior rectus sheath and rectus muscle. Laterally, the plane between the transversus abdominis and fascia transversalis was obtained. A big bioA absorbable mesh was placed to reinforce the posterior wall closure of fascia transversalis, peritoneum and posterior rectus sheath. A 50 9 50 polypropylene mesh was used over the bioA mesh and extended to the quadratus lumborum, retrocostal and retromuscular. Some transcostal sutures fixed the polypropylene retrocostally. No other lateral fixations were used. Results: The patient was discharged on the 7th postoperative day. After 1 year the patient is completely satisfied with the results. Conclusions: In complex bilateral subcostal lateral defects, the posterior component separation technique can be the technique of choice. The mesh should be extended in a continuous plane obtained behind the diaphragm, behind the transversus abdominis muscle and retromuscular.

O117-Video Hybrid technique used for repairing huge abdominal incisional hernia N. Nie, J. Chen Beijing Chao-Yang Hospital, Hernia and Abdominal Wall Surgery, Beijing, China This operation involve three procedure: 1. Laparoscopic procedure: Abdominal cavity adhesiolysis. 2. Open procedure: Spindle shaped incision; excision of the hernia sac; embed the patch; close the hernia ring. 3. Laparoscopic procedure: spiral tacks fix the patch.

O118 Tailored laparoscopic approach in large inguino-scrotal hernias: an institutional review S. Wijerathne, E. Sta Clara, W.B. Tan, S.W. Tang, D. Lomanto National University Hospital, General Surgery, Singapore, Singapore Introduction: Endolaparoscopic repair of inguinal hernias is becoming the widely accepted approach over the open approach since if offers lesser pain, improved convalescence, decreased length of hospital stay, improved quality of life and decreased morbidity rate. However, there is still a debate on its use in treating inguinoscrotal hernias because of the anticipated problems and complications in dissecting the extensive hernia sac even though a posterior approach has been advocate as repair of choice for complicated cases. Method: Between March 2013 and July 2015, 50 patients with inguino-scrotal hernias underwent laparoscopic inguinal hernia repair. Patient demographics, hernia characteristics, operating time, surgical technique, conversion rate, intraoperative and postoperative complications and recurrence were recorded, measured and analyzed using MS Excel software. Result: 50 patients who underwent laparoscopic inguinal hernia repair were recorded, 47 patients underwent total extraperitoneal (TEP) inguinal hernia repair and 3 patients underwent transabdominal pre-peritoneal (TAPP) inguinal hernia repair. 26 patients had unilateral hernia and 24 patients had bilateral hernias. The mean age was 45 years old. The mean operation time was 74 min for unilateral hernia and 116.5 min for bilateral hernia. Three patients (6 %) required a combined open surgery to transect the incarcerated omentum. There was no mortality. Morbidity was limited to seroma formation in 13 (26 %) patients and 2 patient of the combined laparoscopic-open approach had wound infection treated with

S165 dressing and antibiotics. Mean Follow up was 27 weeks. There were no recurrences. All patients were discharged within 23 h. Conclusion: We conclude that the laparoscopic approach can be safely employed for the treatment of complicated inguinal hernias as inguino-scrotal; surgical experience in endolaparoscopic hernia repair is mandatory with tailored technique in order to reduce to minimum morbidity and to achieve good clinical outcomes with acceptable recurrence rates.

O119 Do we need mesh in umbilical hernia surgery: The HUMP-trial R. Kaufmann Erasmus University Medical Center, Rotterdam, Netherlands Introduction: Umbilical hernias are repaired with either suture repair or the use of mesh. A multicenter, randomized, double blind, controlled trial was performed comparing mesh and suture repair in umbilical hernia. The aim of our study was to investigate the recurrence rates of both mesh and suture repair and the complications of each technique. Methods: Patients were eligible for inclusion when they were C18 years and if they had an umbilical hernia with a diameter of 1 to 4 cm. The following parameters were assessed: recurrence of hernia and postoperative complications. Patients underwent physical examination 2 weeks, and 3, 12, and 24 months after umbilical hernia repair. The primary analysis was the time to recurrence during a follow-up period of 24 months between the two treatment arms. Results: Four-hundred and three patients consented to participate in the study. A total of 300 patients was randomized during operation. One-hundred and three patients were ineligible due to variance in hernia size, the presence of more than one hernia defect, or another type of hernia (mostly epigastric hernia). After follow up of 30 months, there were significantly fewer recurrences (6 patients) in the mesh group versus 16 recurrences in the suture group, with two-year actuarial estimates of recurrence of 3.6 % versus 11.4 % (P = 0.014). This significant difference remained in the subgroup analyses grouped on diameter (1–2 cm and [2–4 cm). There was no significant difference in pain occurrence between mesh and suture repair during all time-points (P = 0.45). Postoperative infections occurred only rarely; there was no significant difference between the two groups. Conclusion: This study of mesh versus suture umbilical hernia repair in adults reveals that there is a significant advantage of mesh use. There were significantly less recurrences in the mesh group—also in smaller diameters—without an increase in postoperative pain.

O120 Mesh OR PatcH at Epigastric and Umbilical SItes; 1-year results MORPHEUS trial S.W. Nienhuijs Catharina Hospital Eindhoven, Eindhoven, Netherlands Background: Evidence is accumulating that regardless of hernia size that umbilical and epigastric hernias should be repaired with mesh, similar to others. In addition to standard flat-meshes, several devices with the option of intra-peritoneal placement have been developed. It is unclear whether these devices are associated with an equal risk of complications compared to flat-meshes. Methods: In six medical centres patients with symptomatic primary epigastric and umbilical hernias were randomised to receive a flat

123

S166 polypropylene mesh or device (Proceed Ventral Patch (PVP)) repair. Follow-up is scheduled up to 2 years with examination at 1 and 12 months and by questionnaire at 3 and 24 months. Data collected included baseline characteristics (gender, hernia type, body mass index, pre-operative pain, physical exercise, diabetes mellitus, pain syndrome and skin disease), operative details and complications (wound infection, pain and recurrence). The primary endpoint was incidence of complications requiring treatment. Completed 1-year follow-up was included in this report. Results: Between February 2011, and June 2015, 350 patients were included and treated by PVP (n = 177) and flat mesh repair (n = 173). Baseline characteristics did not differ significantly. No significant differences were seen in complications, descriptive pain and cosmetic scores. Operation time was significantly longer in the mesh repair group (p \ 0.001) as was the ease of the procedure scored significantly less (p \ 0.001). Recurrence within 1-year did not differ significantly between both groups. In both groups a rather high wound infection rate was found of nearly 18 %. Conclusion: The flat polypropylene mesh and Proceed Ventral Patch (PVP) repair for epigastric and umbilical herniorrhaphy were associated with comparable outcome up to 1 year. The PVP repair was associated with significantly shorter duration and scores on easiness. We theorize that the higher than anticipated reported rate of wound infection was related to the careful, prospective data collection of events.

O121-Video Incisional hernia of the ‘risky zone’: laparoscopic repair of subxifoid hernia L. Latham, G.B. Borroni, V.Q. Quintodei, L.L. Livraghi, M.B. Berselli, L.F. Farassino, L.U. Ungari, J.G. Galvanin, A.A. Ambrosoli, S.C. Cuffari, E.C. Cocozza A.o. di Circolo fondazione Macchi di Varese, General Surgery, Varese, Italy Background: Incisional hernias are a common pathology and its treatment is well-defined and standardized; however the management of boundary incisional hernias remains a challenge for laparoscopy. This video shows our technique for the laparoscopic repair of incisional hernia in the ‘‘risky zone’’: a big subxifoid hernia repaired with mesh by laparoscopic approach. Methods: A 79 years-old patient with a previous history of median sternotomy for cardiothoracic surgery, presents epigastric hernia. Diagnostic workout includes abdominal wall ultrasound that showed a 8 9 5 cm interruption of continuity of the abdominal wall with passage of intestinal loops and the left liver lobe. The patient underwent to laparoscopic prosthetic incisional hernia repair. Results: After the induction of pneumoperitoneum with Veress needle in left hypochondrium, optical 12 mm trocar was positioned in left hypochondrium. 10 and 5 mm operative trocars were insert in left flank and left iliac fossa respectively. Lysis of the falciform ligament and subsequently preparation of the pre-peritoneal space all around the fascial defect were firstly performed. Incisional hernia measured 8 9 5 cm. The mesh were branch-prepared and tailored in 18 9 16 cm, centered on the abdominal wall defect. Then it has been fixed with a double crown of titanium spirals and resorbable clips. In the cranial portion, in correspondence of the diaphragm, two stitch were placed and lastly biological glue was used to bind the mesh to the abdominal wall. Conclusion: The laparoscopic repair of boundary incisional hernia with prosthesis is a safe and feasible method in a high volume centre for laparoscopic surgery.

123

Hernia (2016) 20 (Suppl 2):S139–S174

O122 Use of prophylactic mesh in subcostal laparotomies: a cohort study L. Blazquez Hernando1, M.A. Garcia Uren˜a1, J. Lo´pez Monclu´s2, D. Mesero Montes1, C. Castello´n Pavo´n3, A. Robı´n del Valle Lersundi1, C. Jimenez Ceinos1, A. Cruz Cidoncha1, A. Aguilera Velardo1, N. Palencia1, R. Becerra1, A. Galvan1, E. Gonzalez1, P. Lo´pez Quindos1, A. Moreno1 1 Hospital Universitario del Henares, General Surgery, Coslada, Spain, 2Hospital Universitario Puerta de Hierro-Majadahonda, General Surgery, Madrid, Spain, 3Hospital Infanta Elena, General Surgery, Valdemoro, Spain Background: The use of prophylactic mesh to prevent incisional hernia is increasingly common in midline laparotomies and colostomies. So far no published use of prophylactic mesh in subcostal laparotomies in which although the incidence of hernias is smaller, treatment is more complex. Materials and methods: Cohort study among two groups of patients operated through a bilateral subcostal laparotomy in elective surgery. One was carried conventional layered closure with continuous extra long-term absorbable monofilament synthetic suture of poly-4-hydroxybutyrate (MonoMax n81 loop) On the other group we have used the same technique and also places polyester self-fixating mesh(Progrip) above the posterior rectus sheath and laterally in the plane between the internal oblique and traverse muscles and the external oblique muscle. Results: The conventional-group consists of 57 patients operated between 2009 and 2011 and mesh-group consists of 58 patients operated between 2011 and 2013. The majority for upper GI, hepatic and pancreatic surgery and more than 65 % for oncologic process. The two groups are statistically comparable in age, sex, BMI, history, diagnosis, type of surgery, type of surgical field and surgical time. The P-Possum, the Charlson index and the Charlson-age index are equivalent. The two groups have similar surgical time and similar admission time. The two groups have a similar rate of local and systemic complications. The wound infection was 10.34 % in the mesh-group and 15.79 % in the conventional-group. There is a statistically significant lower incidence of hernia in the mesh group (1 patient, 0.02 %) compared to conventional-group (10 patients, 17.54 %) with a follow up of 24 months. Conclusions: The use of a prophylactic polyester mesh for closing bilateral subcostal laparotomy is an effective safe technique that does not increase the incidence of local complications and decrease the prevalence of incisional hernia.

O123 Surgical correction of abdominal rectus diastasis reduces pain and improves abdominal wall muscle strength: a randomised trial comparing retromuscular mesh repair to double-row self-retaining sutures K. Striga˚rd1, P. Emanuelsson2, U. Gunnarsson1, U. Dahlstrand3, B. Stark2 1 Department of Surgical and Perioperative Sciences, Umea˚ University, Department of Surgery, Uema˚, Sweden, 2Department of Molecular Medicine and Surgery, Karolinska Institutet, Department of Plastic and Reconstructive, Stockholm, Sweden, 3 CLINTEC, Karolinska Institutet, Department of Surgery, Stockholm, Sweden Background: The primary aim of this prospective randomised clinical two-armed trial was to evaluate the risk for recurrence using two

Hernia (2016) 20 (Suppl 2):S139–S174 different surgical techniques for repair of abdominal rectus diastasis. Secondary aims were comparison of pain, abdominal muscle strength and quality-of-life and to compare those outcomes also to a control group receiving physical training only. Methods: Eighty-six patients were enrolled. Twenty-nine patients were allocated to retromuscular polypropylene mesh and 27 to double-row plication with Quill technology. Thirty-two patients participated in a 3-month training program. Diastasis was evaluated with CT scan and clinically. Pain was assessed using ventral hernia pain questionnaire (VHPQ), quality-of-life (SF-36) and abdominal muscle strength using the Biodex System-4. Results: One early recurrence occurred in the Quill group, two encapsulated seromas in the mesh group and three in the suture group. Significant improvements in perceived pain, VHPQ and quality-oflife appeared at the 1-year follow-up with no difference between the two surgical groups. Significant muscular improvement was obtained in all groups (Biodex System-4). Patient perceived gain in muscle strength assessed with a visual analogue scale (VAS) improved similarly in both surgical groups: this improvement was significantly greater than that seen in the training group. Patients in the training group still experienced bodily pain at follow-up. Conclusion: There is no difference between the Quill technique and retromuscular mesh in the effect on abdominal wall stability, with a similar complication rate 1 year after surgery. Surgery improves patient comfort and quality-of-life. Training strengthens the abdominal muscles but patients still experience discomfort and pain.

O124 The myth of the width of the linea alba in patients with abdominal aortic aneurysm: a comparative analysis J. Verhelst, J. Nieuwenhuizen, T.S. Vijfvinkel, J. Jeekel, G.J. Kleinrensink, H.J.M. Verhagen, J.F. Lange Erasmus Medical Center, Surgery, Rotterdam, Netherlands Background: Incisional hernias are frequently seen after abdominal surgery, causing decreased quality of life, morbidity and mortality. Patients with an abdominal aortic aneurysm (AAA) are more at risk to develop an incisional hernia. This increased risk in AAA patients might be attributed to a systemic connective tissue disorder, resulting in distention of both the aortic and abdominal wall. The objective of this study was to determine anatomical differences of the linea alba between patients with an AAA and a control group. Methods: A retrospective cohort study was performed. Male patients, with a virgin linea alba, who underwent elective open AAA repair were compared with patients who underwent a laparotomy for colorectal cancer. Baseline characteristics and hernia incidence were retrieved. Preoperative CT-scans were used to analyse the linea alba. The width of the linea alba was measured at six predefined points between the xiphoid process and the pubic bone. The outline of the linea alba was reconstructed and the surface was approximated. Results: Eighty patients who underwent open AAA repair were included in this study and 98 patients were included in the control group. There was no significant difference in width of the linea alba between the groups. The mean surface of the linea alba in patients with AAA was 58.7 and 58.4 cm2 in the control group, p = 0.951. Postoperatively, thirteen patients (16 %) in the AAA group developed an incisional hernia, 23 (24 %) in the control group, p = 0.264. Multivariable analyses showed that a higher BMI is associated with a wider linea alba. Conclusion: This study shows no difference in width and surface of the linea alba between patients with AAA and patients with colorectal cancer. A higher BMI is associated with a wider linea alba. There is no evidence that a wider linea alba correlates with the development of incisional hernia.

S167

O125-Video Is the current classification of inguinal hernia anatomically correct? D.J. Hehir, A. Hehir Midlands Regional Hospital, General Surgery, Tullamore, Ireland By the time Bassini presented his epic tissue repair more than 130 years ago, it was already accepted that inguinal herniation medial to the inferior epigastric vasculature was considered ‘direct’ and defects lateral to the vessels were ‘indirect’. There remains a significant failure rate despite a variety of methods of inguinal hernia repair. Video endoscopy has facilitated dynamic in vivo evaluation of the inguinal region and having performed more than fifteen hundred TEP repairs, we now believe that the inferior epigastric vessels are incidental anatomical relations in the process of herniation. We believe that pure ‘direct’ or ‘indirect’ inguinal defects are uncommon; rather there is a global defect involving the shared musculotendinous components of the anterior and posterior walls of the inguinal canal. The video utilises clinical as well as anatomical dissection to present our hypotheses that the inferior epigastric vessels are incidental in the classification of inguinal hernia and that it is not usually possible to accurately classify pre-operatively whether an inguinal hernia is ‘direct’ or ‘indirect’. The findings may have implications for the current hernia classification systems.

O126 Randomized clinical trial of tissue glue versus absorbable sutures for mesh fixation in Lichtenstein repair: 5-year outcome analysis M. Matikainen1, H. Paajanen2, J. Ko¨ssi3, S. Silvasti1, T. Hulmi1 1 Pohjois-Karjalan Keskussairaala, Surgery, Joensuu, Finland, 2 Kuopio University hospital, Surgery, Kuopio, Finland, 3Lahden keskussairaala, Surgery, Lahti, Finland Background: Lichtenstein hernioplasty has relatively low recurrence rate but chronic inguinal pain may cause harm to the patient. Pain may be related to operative trauma including mesh fixation. The aim of our study was to compare long-term results of cyanoacrylate glue vs. absorbable sutures for mesh fixation in Lichtenstein hernioplasty. Methods: Lichtenstein hernioplasty was performed under local anaesthesia in three hospitals. The patients were randomized to receive either 1 ml of butyl-2-cyanoacrylate tissue glue (Glubran; 151 hernias) or absorbable polyglycolic acid sutures (Dexon; 151 hernias) for mesh fixation (Optilene). Chronic groin pain, foreign body sensation, use of analgesics, recurrence and possible re-operations were analysed 5 years after surgery. Results: A total of 302 patients were included in the original study. Five years after surgery we reached 236 patients (78 %) to analysis. In the glue group (n = 115) there were 5 (4.3 %) recurrent hernias and in the suture group (n = 121) 3 (2.5 %) recurrent hernias. The prevalence of chronic pain (VAS C 30) was similar in the two groups: 19/115 (16 %) and 18/121 (15 %), respectively. There was no significant difference in foreign body sensation or in the need of analgesics between the two study groups. Conclusion: Both cyanoacrylate glue and suture fixation were equal in terms of chronic pain and rate of recurrences in Lichtenstein hernioplasty after 5 years follow-up.

123

S168

O127 3-D vs. 2D visualization in TEP surgery: a prospective randomized trial D. Weyhe1, H. Nerenz1, N. Tabriz1, E. Dieker2, S, Dieker2, V. Uslar3 1 Pius-Hospital, Clinic for general and visceral surgery, Oldenburg, Germany, 2Die Diekers, Oldenburg, 3Carl-von-Ossietzky University, University hospital for visceral surgery, Oldenburg, Germany Introduction: Total extraperitoneal surgery is one of the guidelines recommended types of surgery in inguinal hernia. However, it is unclear if 3-dimensional visualization (3D View) results in better subjective scores by the surgeon, and if 3D View results in fatigue and higher work load. Material and methods: 38 patients undergoing TEP were randomized for 2d or 3D View (approved by the ethics committee of the MHH, No. 2790-2015). The 2D group (n = 21) and the 3D group (n = 17) were treated equally. All surgeries were conducted by surgeons, whose bioptic vision was tested before the trial. Intraoperatively, the time needed for the placement of the mesh was measured. In addition, the subjective work load was measured via the validated NASA-TLX score. Results: 28 % of all surgeons (2/7; average age 46 ± 5.7 y) showed the need for correction of the depth of field, and one of those surgeons showed malfunctions in the perception of depth. Video quality was judged as 1.8 in 3D and 2.3 in 2D on a scale from 1 to 6 (1 = very good; 6 = insufficient). Duration of surgery and duration of mesh placement did not differ between 2D and 3D View (median surgery duration 2D: 40 min, range: 17 to 122 min; 3D: 48 min, 20 to 92 min; mesh placement 2D: 6,7 min, 2.3 to 30.9 min; 3D: 7.1 min, 1.5 to 17.9 min). Work load was judged to be lower by the assistance than by the surgeon, at least in 2D View. For 3D no difference was observed in work load. Conclusion: Surgeons should test their bioptic vision before using the 3D equipment. Video quality was judged to be better in 3D regardless of the occupational group. However, 3D view results in higher workload for all people on the team.

O128 Effects of surgery on patients with a clinically inapparent inguinal hernia, diagnosed using ultrasonography: a retrospective analysis L. van Hout, P.W.H.E. Vriens, J. Heisterkamp ETZ, Surgery, Tilburg, Netherlands Background: Chronic postoperative inguinal pain (CPIP) is the most significant long-term problem after inguinal hernia repair. Patients with an occult inguinal hernia, diagnosed with ultrasonography, but with negative clinical examination may present substantial groin pain. Our aim was to evaluate the effects of surgery on patients with a clinically inapparent occult inguinal hernia, diagnosed using ultrasonography (US). Methods: In a retrospective design, 349 patients with a positive ultrasonography for a primary inguinal hernia but negative clinical examination during the period January 2006 until May 2014 were analysed. Patients with a recurrent hernia, femoral hernia or previous surgery to the inguinal canal were excluded. For patients who received surgical treatment, information on incidence of postoperative pain was collected as primary outcome. Furthermore, data on preoperative complaints, hernia type, surgical technique and findings during ultrasonography and surgery were studied in relation to the development of CPIP. Results: Twenty-eight percent of 179 surgically treated patients reported pain for more than 3 months after surgery. This is two to three times higher when compared to the 3.5–12 % reported in the

123

Hernia (2016) 20 (Suppl 2):S139–S174 literature (P = 0.002). Female gender (P = 0.037), atypical groin pain prior to surgery (P \ 0.001) and small hernia size on US (P = 0.05) significantly increased the risk of developing CPIP within this cohort. Follow-up of patients with CPIP showed that they were treated longer and more intensively (P \ 0.001) at the outpatient clinic and were referred to other specialists more often (P \ 0.001). Conclusion: Patients with a clinically inapparent inguinal hernia diagnosed using ultrasonography have an increased risk of developing CPIP after surgical repair. Especially patients with atypical groin pain prior to surgery are likely to develop CPIP. These hernias diagnosed using ultrasonography should not be classified as symptomatic inguinal hernias. Finding an alternative diagnosis for the groin pain seems more appropriate than surgical treatment.

O129-Video Laparoscopic TEP plus laparoscopy plus TEP for laparoscopic complex inguinal hernia management M. Planells Roig, U. Ponce Villar, J.M. Bolufer, F. Peiro, F. Caro Gandia Hospital, Surgery, Gandia, Spain Background: laparoscopic inguinal repair by total extraperitoneal access is the preferred laparoscopic approach to inguinal hernia as a long peritoneal wound is avoided and morbidity associated to its closure or postoperative adhesions are excluded trough TEp repair instead of TAPP approach. The problem is that complex inguinal hernias (mainly scrotal and incarcerated) are extremely difficult or impossible to repair by the TEP approach. In these patients the usual approach is therefore TAPP and advantages of TEP repair cannot be reached. Material and method: We developed an alternative approach which includes first a standard TEP exploration and if hernia reduction is not achieved we perform through the same wounds an intraperitoneal access which allows a laparoscopic abdominal exploration and hernia reduction. After hernia content has been reduced we go back to the preperitoneal space and continue with the classical TEP approach. Video presentation: We present this video showing the TEP + LAP + TEP approach in two scrotal inguinal hernias with no possibility of preperitoneal dissection and reduction. We present another surgical application of this technique in a patient with postoperative TEP bleeding due to an injury to the corona mortis with a severe hemoperitoneum. During this particular case a first TEP approach allowed hemostatic control and in the time the LAP approach was performed the hemoperitoneum was tretaed. Conclusion: The TEP + LAP + TEP approach is a feasible technique which allows endoscopic complex inguinal hernia management avoiding the TAPP side effects. It is also a good option in patients with severe postoperative bleeding after a TEP approach.

O130 Efficacy and safety of n-butyl-2-cyanoacrylate (NBCA) medical adhesive for patch fixation in totally extraperitoneal prosthesis (TEP): a prospective, randomized, controlled trial Y.M. Shen, Y.T. Liu, J. Chen Beijing Chao-Yang Hospital, Capital Medical University, Hernia and Abdominal Wall Surgery, Beijing, China Background: Inguinal hernia is one of the most common diseases in general surgery and minimal invasive laparoscopic approach had been gradually developed. However, the methods of mesh fixation or no mesh fixation for laparoscopic inguinal hernia repair has been disputed by several surgeons which is associated with recurrence rate,

Hernia (2016) 20 (Suppl 2):S139–S174 risk for chronic pain and local foreign body sensation. In order to improve patients’ postoperative life quality, medical adhesive mesh fixation which is less invasive emerged and got satisfactory effect. We conducted this prospective, randomized, controlled study from July 2013 to July 2014 using a lightweight polypropylene mesh for totally extraperitoneal prosthesis (TEP) to assess the effectiveness and safety of n-butyl-2-cyanoacrylate (NBCA) medical adhesive for mesh fixation in inguinal hernia repair. Methods: A total of 160 patients with primary unilateral inguinal hernia were assigned randomly to receive TEP using NBCA medical adhesive for patch fixation (experimental group) and without patch fixation(control group). We evaluated operation time, visual analogue scale (VAS) pain score 24 h after surgery, postoperative duration of stay, hospital costs, postoperative complications and hernia recurrence. Results: A total of 160 cases were operated successfully. There was no significant difference in operation time, VAS pain score 24 h after surgery, postoperative duration of stay, and postoperative complications between the groups (P [ .05), but a statistical difference in hospital fees (P \ .05). Hernia recurrence was occurred in 4 cases of the control group and none of the experimental group with significant difference (P \ .05). Conclusion: The use of NBCA medical adhesive for patch fixation in TEP is effective and safe.

O131 Randomized trial comparing glue fixation, self-gripping mesh and suture fixation of mesh in Lichtenstein hernia repair (FinnMesh study): 2-year analysis of patients with chronic pain H.E.K. Paajanen1, J. Vironen2, J. Ko¨ssi3, T. Hulmi4, I. Ilves5, M. Hertsi6, K. Mustonen1 1 Kuopio University Hospital, Surgery, Kuopio, Finland, 2Helsinki University Hospital, Surgery, Helsinki, Finland, 3Kanta-Ha¨meen Keskussairaala, Surgery, Ha¨Meenlinna, Finland, 4Pohjois-Karjalan Keskussairaala, Surgery, Joensuu, Finland, 5Mikkeli Central Hospital, Surgery, Mikkeli, Finland, 6Savonlinna Central Hospital, Surgery, Savonlinna, Finland Background: Mesh fixation may influence on the incidence of chronic pain after Lichtenstein hernioplasty. Three different techniques of mesh fixation were compared to find the best outcome in regard of chronic pain. Methods: Lichtenstein hernioplasty was performed under local anaesthesia in 625 patients as day-case surgery in eight Finnish hospitals1. The patients were randomized to receive either a cyanoacrylate glue (Histoacryl, n = 216), self-gripping mesh (Parietex ProGrip, n = 202) or conventional non-absorbable sutures (Prolene 2-0, n = 207) for mesh fixation. One-year outcome analysis of wound complications, pain, recurrences and patients discomfort was reported earlier1. In the present study we performed the re-analysis of patients with chronic inguinal pain (VAS C 30) 2 years after surgery. Results: The type and size of inguinal hernias were similar in the three study groups. There were no significant differences postoperatively in pain response or need for analgesics between the study groups after one-year follow-up. Some 52 patients had pain scores C30 (0–100) 1 year after surgery (glue group n = 20, self-gripping n = 20 and suture group n = 12) and 25 patients (4.2 %) needed occasionally analgesics to relieve chronic groin pain. Outcome analysis of these patients after 2-year follow-up is presented in the meeting.

S169 Conclusion: This prospective randomized study evaluates factors affecting chronic pain after Lichtenstein hernioplasty. Reference: 1. Ro¨nka¨ K, Vironen J, Ko¨ssi J, Hulmi T, Silvasti S, Hakala T, Ilves I, Song I, Hertsi M, Juvonen P, Paajanen H (2015) Randomized multicenter trial comparing glue fixation, self-gripping mesh, and suture fixation of mesh in Lichtenstein hernia repair (FinnMesh Study). Ann Surg 262:714–720

O132 Dysejaculation: Cause for alarm? R. Bendavid1, V. Iakovlev2 1 Shouldice Hospital and St Michael Hospital, Surgery, Toronto, Canada, 2St Michael Hospital, Pathology, Toronto, Canada Dysejaculation was first described and reported in April 1992. The original series of 17 patients was culled over 10 years out of an approximate patient population of 70,000, following a Shouldice repair (incidence: 0.025 %). A subsequent series up to 1995, offered 30 cases for an incidence of 0.04 %. Today, the reported incidence following mesh repairs (laparoscopic, open, onlay and preperitoneal), is 3–4 % as gleaned from the literature. This is a one hundred fold (10,000 %) increase in the last 20 years since the sudden increase in the use of mesh in the 1990s. The pain mechanism seemed to be due, at first in pure tissue repairs, to distortion and scarring into position of convoluted segments of the vas. The latter being a hollow viscus, pain was at first thought to be due to obstruction and distension of smooth muscle fibers of the vas. Today, with the global omnipresence of polypropylene mesh, we are able to identify invasion of the vas by the mesh with attendant invasion of nerves in the vas plexus and muscle. Scarring and fibrotic replacement of the anatomical structures are seen on the path of the mesh during its transmigration. A new significant pathology is at hand and must be recognized. Explants are difficult to obtain because men are loath and ill disposed to part with their vas and/or testicles. Exceptional pathology slides will document the issue.

O133 Utility of magnetic resonance imaging to monitor meshes: Correlating imaging and clinical outcome of patients undergoing inguinal hernia repair. Experience from more than 70 MRI R.W. Wilke Klingen Nagold, General-, Viszeral- and Vascular Surgery, Nagold, Germany Background: The purpose of this study was to evaluate the efficacy of hernia repair after mesh implantation based on MRI findings (mesh coverage, visibility of hernia structures) and based on the patient’s postoperative symptoms. Materials and methods: 238 MRI-visible meshes (10 9 15 cm Endolap, Dahlhausen) were implanted in 169 patients for inguinal hernia repair via TAPP procedure. Non fixation in lateral hernias, direct hernias with glue or Strap fixation. Full physically stress allowed after surgery. MRI performed in 71 symptomatic cases (32 unilateral, 39 bilateral) within 1 week and at 3 months after surgery. Mesh position, deformation, and coverage of the hernia were visually and correlated with the respective patient’s clinical symptoms.

123

S170 Results: The indication for MRI was a mild pain in 54 cases, a recurrence was suspected in 17 cases. 21 of the 110 meshes presented an atypical mesh configuration with a short medial overlap of less than 2 cm. 89 of the 110 meshes exhibited a typical mesh configuration with lateral folding and initial overlap of more than 2 cm. Average overlap decreased in the medial and lateral direction by nearly 10 % as a result of shrinkage. No correlation between clinical symptoms and mesh position or hernia coverage was found. A slight seroma was seen in 14 cases (\5 ml), in 7 cases a symptomatic seroma ([5 ml). A correlation between postoperative physical activity or mesh fixation technique was not seen on MRI. Non recurrence was seen in all cases. After examining, 65 patients were free of pain within a week. Conclusion: The MRT representation implanted meshes enables a secure review of the inguinal region. In general, we did not find a correlation between clinical symptoms and mesh configuration or position. Shrinkage of meshes does occur, leading to reduced hernia coverage of up to -10 % in the lateral and medial directions.

O144 Where are we 10 years from now: scarless hernia surgery H.M. Tran The Sydney Hernia Specialists Clinic, Sydney, Australia Although the conversion from open to laparoscopy such as cholecystectomy was swift in the early 1990’s because of proven safety and efficacy, the uptake of laparoscopic inguinal hernia repair has been much slower, even in developed countries, varying from some 20 % in USA to over 51 % in Australia in 2015. Laparoscopic inguinal herniorrhaphy has become highly standardized over the past 2 decades with few technical improvements with the industry devoting unparalleled efforts into improving mesh prosthetics. The advent of natural orifice transluminal endoscopic surgery (NOTES) heralded potential for real innovation in minimally invasive surgery. Although single incision laparoscopic surgery (SILS) is an offshoot of NOTES, its adoption has been much more widespread. The author has adopted routine SILS in the practice of hernia surgery since 2009 and has performed over 1500 SIL hernia repairs. Many lessons were learned along the way, and countless tips and tricks will be discussed. Furthermore, SIL inguinal herniorrhaphy with telescopic dissection has been shown to be more cost-effective compared to conventional multi-port surgery with balloon dissection. Current randomized controlled studies and meta-analyses comparing single-port and multiport inguinal herniorrhaphy have not consistently demonstrated advantages, other than cosmesis, of SILS. However, there is sufficient evidence to conclude that single-port surgery is as safe as multiport surgery, and therefore it provides an acceptable alternative for those surgeons wishing to advance their laparoscopic skills. Skills developed during the performance of inguinal herniorrhaphy can easily be applied to much more complex procedures with potential for improved safety and efficacy.

O146 Genetic repair in abdominal wall defects U. Klinge University Hospital of the RWTH Aachen, Aachen, Germany Any genetic repair requires the identification of the genetic source of a disease. For the distinct patterns of abdominal wall

123

Hernia (2016) 20 (Suppl 2):S139–S174 defect (=hernia disease) we first of all have to separate- the infant hernia- the primary groin hernia of the adult-primary abdominal wall hernias (e.g. umbilical, epigastric)—the incisional hernia. Whereas any genetic repair of infant hernias seem to be illusive, it may be conceivable that the remodelling defect of the primary hernias or the wound healing defect of incisional hernias may be accessible by some interventions on the gene level. However, it is most likely that neither the problem of tissue remodelling or of wound healing is simply subject to changes in the sequences of some few gene. The abdominal wall defects more likely result from a disturbed function of widely normal genes, which are caused by a disturbed influence of some of the hundred thousands epigenetic confounders (transcriptional regulatory elements such as enhancers and promoters). Due to all the complex interactions it is doubtful that the local defect in case of an abdominal wall hernia can be compensated by simply introducing cells considered to be ‘‘genetically normal’’. In contrast, it has to be supposed that any new cell or tissue will become subject to the same epigenetic influences, which have been responsible for the formation of the origin hernia. However, we know that a pharmaco-therapy of the local tissue remodelling or of the local tissue repair mechanism is able to change the local gene function, and might be able to achieve a normalisation of the local gene function, and of the local proteins. In this respect we may come to a genetic repair of abdominal wall defects in future, but from this point of view only in this respect.

O148 Wound morbidity in abdominal wall reconstruction can be reduced using transversus abdominis release compared to anterior component separation technique G. Woeste, A. Reinisch, U. Pession, W.O. Bechstein University Frankfurt, Department of Surgery, Frankfurt, Germany Background: Repair of large ventral hernias is challenging. Closing the midline and reinforcing it with a mesh is superior to bridging. In case of wide hernias this can only be achieved performing a component separation (CS). Different techniques are described for this maneuver, the anterior CS (Ramirez et al. 1990) and the posterior CS described as transversus abdominis release (TAR) (Novitsky et al. 2012). The TAR technique avoids creation of skin flaps. In this retrospective analysis of a prospective data collection we compare the outcomes of patients who underwent abdominal wall reconstruction (AWR) for large hernias using either anterior CS or TAR. Methods: From 8/2011 to 1/2016 we performed 41 AWRs with closure of the midline and reinforcement with a synthetic mesh in sublay position: 25/41 (61 %) underwent anterior CS and 16/41 (39 %) TAR procedure. The mean body mass index (BMI) of the patients was 27.6 in the CS and 24.8 in the TAR group. The hernia size was 207.7 cm2 versus 220.3 cm2 (n.s.). The VHWG grading in the two groups was grade 1 in 16.7 and 18.75 %, grade 2 in 50 and 56.25 % and grade 3 in 33.3 and 18.75 % respectively (all n.s.). Results: Wound complications occurred in 36 % after CS with the need for NPWT in 5/25 (20 %) and none after TAR (p \ 0.01). In both groups no mesh had to be removed due to infectious problems. Length of stay was 17.7 and 9.1 days (p \ 0.05). Conclusions: In large hernias CS is needed for midline closure. In this retrospective study we showed a significant reduction of wound complication and a lower length of stay after TAR compared to anterior CS.

Hernia (2016) 20 (Suppl 2):S139–S174

O149 The ‘AbdoMAN’: a physical abdominal wall simulator for biomechanical studies on techniques for closure of laparotomy L.F. Kroese1, C. Ordrenneau2, J.J. Harlaar3, J. Verhelst1, G. Guerin2, R.H.M. Goossens4, F. Turquier2, J. Jeekel1, G.J. Kleinrensink1, J.F. Lange1 1 Erasmus Medical Center, Surgery, Rotterdam, Netherlands, 2 Medtronic, Biomechanics, Tre´voux, France, 3VU medical center, Surgery, Amsterdam, Netherlands, 4University of Technology, Industrial Design, Delft, Netherlands Background: Incisional hernia remains a frequent complication after abdominal surgery associated with significant morbidity and high costs. The purpose of this study was to use a previously developed physical abdominal wall simulator to investigate several closure modalities on the mechanical behaviour of the abdominal wall. It was hypothesized that a physical model of the human abdominal wall would give new insights in commonly used suture techniques representing a substantial alternative or predecessor for clinical and animal studies. Methods: A previously developed device was used to simulate human abdominal wall biomechanics. A synthetic abdominal wall was placed over an air filled balloon simulating the abdominal cavity. Six pneumatic cylinders (‘air muscles’) simulated the action of the lateral abdominal wall muscles and resulted in intra-abdominal pressure (IAP). The ‘AbdoMAN’ is capable to vary and measure IAP and to cough repeatable with physiological peak IAP. A fifteen centimetre incision was created and closed. 3 9 3 mm, 5 9 5 mm and 10 9 10 mm bite sizes in continuous suturing were compared. Strain patterns were captured with 3D stereo correlation software. Results: The ‘AbdoMAN’ was perfectly able to simulate physiological conditions using intact samples; mean peak IAP was 74.9 mmHg (65.3–88.3). Fifteen synthetic abdominal walls were closed after incision. Testing different closure modalities showed no significant difference in mean maximal strain at stitches (13.65 ± 1.09 % for 3 9 3 mm, 13.76 ± 1.45 for 5 9 5 mm and 15.88 ± 2.04 for 10 9 10 mm) or incision distension (0.24 ± 0.21 mm for 3 9 3 mm, 0.34 ± 0.11 mm for 5 9 5 mm and 0.32 ± 0.13 mm for 10 9 10 mm). Conclusion: Intact sample testing demonstrated repeatable testing conditions. Strain and incision distention analysis showed no significant differences between bite sizes. However, decreased variance when decreasing bite size might explain the better clinical outcomes. The ‘AbdoMAN’ might be a promising alternative or precursor for animal and clinical studies on abdominal wall related aspects of abdominal surgery. Using human cadaveric abdominal walls could validate the device even more.

O150 Modified single-port laparoscopic herniorrhaphy for pediatric inguinal hernias: based on 3,507 cases in China B. Li, D. Gong, Y. Mo, Z. Xie, Y. Peng, H. Xie, X. Nie Hexian Memorial Affiliated Hospital of Southern Medical University, General Surgery, Guangzhou, China Background: Laparoscopic surgery is an alternative procedure for pediatric inguinal hernia (PIH), with a major trend toward increasing use of extracorporeal knotting and decreasing use of working ports.

S171 We report our experience with the modified single-port laparoscopic herniorrhaphy for repair of PIH and retrospectively evaluate a consecutive series of 3507 cases in our institution. Methods: Between February 2006 and June 2015, 3507 children with indirect inguinal hernia were treated by laparoscopic surgery. All patients underwent high ligation surgery with a modified single-port laparoscopic technique, mainly performed by extracorporeal suturing with an ordinary taper needle (1/2 Arc 11 9 34). The clinical data were retrospectively analyzed. Results: All surgery was successful without any serious complications. During the operations, contralateral patent processus vaginalis was found and subsequently repaired in 1072 cases (30.6 %). The mean operative time was 10 (range 4–16) min in 2435 cases of unilateral repair and 17 (range 11–25) min in 1072 cases of bilateral repair. The mean of postoperative hospital stay was 25 (range 16–51) h. Complications occurred in 20 cases (0.57 %) and were properly managed, with no major impact on outcome of the operations. There were 15 recurrent cases (0.43 %) in the patients who had been followed-up for 3–115 months. There was no obvious scaring visible in any patients after treatment. Conclusions: The modified single-port laparoscopic technique for the repair of PIH is a safe and reliable procedure with minimal invasion and satisfactory outcome. It is easy to perfect and to perform and therefore is a worthy choice for PIH.

O151-Video Midline and parastomal hernia. Posterior component separation and double mesh repair A. Robin1, L. Blazquez1, D. Melero1, J. Lo´pez-Monclu´s2, A. Cruz1, N. Palencia1, A. Moreno1, P. Lopez-Quindo´s1, A. Aguilera1, M.A. Garcı´a-Uren˜a1 1 Hospital del Henares, General Surgery, Coslada (Madrid), Spain, 2 Hospital Universitario Puerta de Hierro, General Surgery, Madrid, Spain Background: Parastomal hernias associated with midline incisional hernias are common in colon cancer patients with a colostomy. Lateral and ventral hernias are difficult to treat and are associated with a certain percentage of hernia relapse. We present a case of a ventral hernia treated by the means of an open approach and a right retrorectal and left posterior component separation and a polypropylene and Bio-A mesh repar. Methods: We present a 75 years old male who was operated on for an adenocarcinoma of the rectum T3N0M0 in may 2012 after receiving neo-adjuvant QT + RT. We performed a low anterior resection of the rectum without primary anastomosis through a suprasub umbilical laparotomy and a colostomy in left iliac fossa. Closure of the laparotomy was made with prophylactic polypropylene mesh. During follow-up the patient had no recurrence of the tumor but presented a ventral hernia, both clinically and radiologically (CT scan). We performed a retro-rectal dissection in both sides and posterior component separation in the left side in order to overlap the colostomy. We used a polypropylene mesh to repair the abdominal wall defect and a Bio-A mesh to prevent contact with the intestinal loops. Results: The patient was discharged on postoperative day 5 and presents no relapse of the hernia during follow-up. Conclusions: In parastomal and ventral hernia defects, a posterior component separation seems to be a good technique to perform the abdominal wall repair. The mesh is anchored to the abdominal wall cranially and caudally preventing lateral sutures and reduce postoperative abdominal pain.

123

S172

O152-Video Laparoscopic L3W3 lateral incisional hernia repair with rectus diastasis associated J. Bellido Luque1, A. Bellido Luque2, J. Guadalajara Jurado1, J.M. Suarez Gra´u1, J. Gomez Menchero1, J. Garcı´a Moreno1, M. Sanchez Ramirez2, I. Alarco´n del Agua2, A. Tejada Gomez2 1 Riotinto Hospital, Surgical Department, Huelva, Spain, 2Quiro´n Sagrado Corazo´n Hospital, Surgical Department, Seville, Spain We present a 65 years old woman, with previous appendectomy and cesarean, who went to the hospital due to right iliac fossa painful mass. After the explorations, a postappendectomy incisional hernia L3W3 was diagnosed. The CT scan showed a 12 9 11 cm size incisional hernia in right iliac fossa with right colon and ileal loop inside the hernia sac. The scan identified a infraumbilical rectus diastasis due to the previous cesarean. the patient underwent to laparoscopic surgery. After the rectus plication using continuous v-loc suture, Cooper’s and iliopectineous ligaments are identified. A PTFE-c mes is used to cover the hernia defect and the rectus plication to reinforce the suture. The mesh is placed intraabdominally in order to overlap 5 cm the defect and covering the complete rectus plication. Inferiorly the mesh is fixed to coopers and iliopectoneous ligaments using helicoidal sutures and fibrin glue above the iliac vessels. Postoperatory course was without complications. After 6 months follow-up the patients remains asymptomatic conclusions when lateral incisional hernia and rectus diastasis are identified, complete abdominal wall repair should be recommended. Laparoscopic approach, using the same mesh to repair the hernia defect and reinforce the rectus plication, is a good alternative to solve both pathologies.

O153 Analysing the rate of parastomal herniae following pelvic exenterative surgery T.M. Noone, N.J. Smart, I.R. Daniels Royal Devon and Exeter NHS Foundation Trust, Exeter Surgical Health Services Research Unit, HeSRU, Exeter, UK Background: Pelvic exenterative surgery is technically challenging and associated with significant morbidity and mortality. These patients with advanced pelvic malignancies will have either an ileostomy/colostomy, with or without a urostomy. The aim of this study is to assess the rate of parastomal herniae (PH), predisposing risk factors and complications in patients following pelvic exenteration. Methods: A retrospective review was carried out of prospectively collected data for patients who have undergone pelvic exenteration from September 2005–September 2014. Patient demographics, patient-related risk factors, histopathology, operative details, stoma type, complications, follow up imaging and outcomes were documented. PH severity was classified according to European Hernia Society (EHS) and Moreno-Matias (M-M) Classifications. Results: 45 patients underwent pelvic exenteration; 2 were excluded due to restoration of gastro-intestinal/urinary tract with colo-anal pouch/neo-bladder formation. 77 % (33) had two stomas (1 end ileostomy/32 end colostomies with 33 urostomies). 23 % (10) had one stoma (9 end colostomies/1 urostomy). During a median time to first follow-up with CT imaging of 10 months (range 3–37 months), 21 % (7) with two stomas developed a PH (18 % para-colostomy—9 % EHS IV, 9 % EHS II; 9 % para-urostomy EHS II; 6 % double EHS

123

Hernia (2016) 20 (Suppl 2):S139–S174 II), compared to 10 % (1) with one stoma (para-colostomy EHS II). Overall rate of PH was 19 % and concomitant incisional herniae (cIH) was 30 % (33 vs. 20 % with two/one stoma(s) respectively). All were M-M III. Significant risk factors included: male gender, recurrent cancer resection, neoadjuvant chemoradiotherapy and blood transfusions. 44.4 % (20) patients died within the timeframe of the study, with a median survival of 733 days (range 114–3383 days). Conclusions: Para-colostomy rates were highest and all occurred with cIH (EHS II or IV/M-M III), however all were managed conservatively.

O154 Structured introduction of TAP Y. Cengiz, L. Israelsson Umea˚ University, Surgical Department, Umea˚, Sweden Background: The learning curve for a surgeon is with laparoscopic transabdominal inguinal hernia repair (TAP) regarded to be 50–100 operations before complication rates comparable with open surgery are achieved. With a structured introduction based on the knowledge accomplished at expert centers the learning curve may possibly be shorter. Methods: Before introducing the TAP experienced laparoscopic surgeons visited a Swedish expert center to be initiated into the details of the technique and one expert later participated in the first 8 TAP operations performed. The first 48 elective TAP operations were compared to 50 consecutive open anterior mesh repairs during the same period. Patient- operative- and postoperative data were collected. Complications were retrieved from patients’ medical records. At a telephone interview after 2 years patients with any complaints were offered a clinical examination. Results: 4 laparoscopic surgeons were involved and 16 surgeons performed the open procedures. With a TAP 9 patients had bilateral hernias and 10 a recurrent hernia, while with an open technique all hernias were unilateral and primary (p \ 0.01). With a TAP patients mean age was 60 years and 67 with an open repair (p = 0.03). 26 (54 %) females had a TAP and 3 (6 %) an open repair (p \ 0.01). The mean operation time was 43 min with a TAP and 68 min with an open repair (p \ 0.01). Early complications were few in both groups. In 50 hernias operated openly 1 recurrence occurred and in 58 hernias operated with a TAP 2 recurrence occurred (p [ 0.05). Conclusions: The TAP operations were faster and not associated with an increased rate of complications or recurrences compared with the standard open anterior mesh repair. With a structured introduction based on the knowledge accomplished at expert centers the learning curve can be very short for experienced laparoscopic surgeons.

O155 HerniaSurge guidelines: Mesh fixation in open and laparo-endoscopic inguinal/femoral hernia repair R.H.F. Fortelny1, D.S. Sanders2, A.M. Montgomery3, M.S. Simons4 1 Wilhelminenspital, General, Visceral and Oncological Surgery, Vienna, Austria, 2Royal Cornwall Hospital, Department of Upper GI Surgery, Truro, UK, 3Malmo¨ University Hospital, Department of surgery, Malmo¨, Sweden, 4Onze Lieve Vrouwe Gasthuis Hospital, Department of Surgery, Amsterdam, Netherlands Introduction: Mesh fixation in both open and laparo-endoscopic hernia repair involves a consideration of the strength of fixation versus the risk of trauma to local tissues and nerve damage through entrapment. A number of randomized controlled trials have compared

Hernia (2016) 20 (Suppl 2):S139–S174 different mesh fixation methods such as tacks, staples, self-fixing, fibrin sealants, glues and sutures in open and laparo-endoscopic inguinal hernia repair. The HerniaSurge guidelines committee, a group of international hernia experts aimed to achieve an evidence based consensus in this special topic as a part of the world guidelines for management of groin hernia. Method: A systematic literature search of Pubmed and Cochrane databases on the subject of mesh fixation in primary open and endo/ laparoscopic inguinal hernia repair using GRADE approach was performed. After applying strict inclusion criteria (SIGN methodology) papers were reviewed concerning short term outcomes, pain and recurrence rate and for quality. Results: After open inguinal/femora hernia surgery no differences in recurrence, surgical site infection rates or length of stay between different fixation methods was identified. Fixation with glue (fibrin sealant or cyanoacrylate) may reduce early postoperative and chronic pain. Atraumatic mesh fixation techniques are recommended to reduce early postoperative pain. Fixation of the mesh in TEP and TAPP is unnecessary, except in large direct medial hernias (MIII EHS classification), in order to reduce the risk of recurrence. When fixation is used, glue is recommended (MIII EHSclassification) in TAPP and TEP to decrease early postoperative pain. Conclusions: In laparo-endoscopic inguinal/femoral hernia repair mesh fixation is recommended only in patients with large direct hernias (M3-EHS classification) to reduce recurrence risk. Atraumatic fixation methods in inguinal/femoral hernia repair like fibrin glue, cyanoacrylate or self-fixating meshes replaces conventional penetrating devices leading to an improved early outcome for both open and laparo-endoscopic techniques.

O156 Herniasurge guidelines: Are clinical outcomes in TEP/ TAPP influenced by mesh weight? a systematic literature analysis D. Weyhe1, U. Klinge2, M. Simons3 1 Pius-Hospital, Clinic for general and visceral surgery, Oldenburg, Germany, 2RWTH Aachen and University Clinic Aachen, Clinic for gen. visc. and transpl. surgery, Aachen, Germany, 3Onze Lieve Vrouwe Gasthuis Hospital, Department of Surgery, Amsterdam, Netherlands Introduction: There is an ongoing debate about the mesh type best suited for laparo-endoscopic inguinal hernia repair. So-called Lightweight Meshes (LWM) are said to result in higher recurrence rates than so-called Heavyweight Meshes (HWM). However, LWMs might cause less chronic pain and foreign body sensation. The analysis presented below intends to clarify the issue. Material and method: Three meta-analyses reviewing various aspects of TEP/TAPP laparo-endoscopic surgery have been published recently. Here we present a systematic review of those meta-analyses and other recent RCTs. Results: Results varied with regard to various endpoints. Currie (2012) concluded that short- and long-term results following surgery with LWM or HWM are comparable across all endpoints. Li (2012) concluded that there are probably higher recurrence rates with LWM but less groin pain and foreign body sensation. Sajid (2013) concluded that LWM are associated with less groin pain and foreign body sensation but found no increase in recurrence rate. However, selection criteria for relevant literature vary between the three meta-analyses. E.g., Li (2012) did not take into account some prospective randomized trials, and included case control studies instead. Sajid (2013) enclosed the aforementioned studies, but also include a surgeon choice randomized study that was mistakenly indicated as computer

S173 generated. According to all reviews and our own research, no studies are available that consider only weight as the single predictive factor for surgical outcomes. Discussion: Published meta-analyses and RCTs do not support the contention that LWMs in groin hernia surgery are associated with better postoperative outcomes. Subset analyses did not find higher recurrence rates for LWMs in laparoscopic inguinal hernia repair. No clearly defined weight limit exists for LWMs and HWMs. Therefore, the effect of weight differences alone on surgical outcomes is unknown and mesh selection based on weight alone is neither recommended nor supported by available literature.

O157 Surgical treatment combined with debridement and vacuum sealing drainage for mesh infection after prosthetic patch repair of inguinal hernia L. Sun, Y. Shen, J. Chen Beijing Chao-Yang Hospital, Capital Medical University, Hernia and Abdominal Wall Surgery, Beijing, China Background: This study is aimed at discussing the surgical treatment and experience of infection after prosthetic patch repair of inguinal hernia for 56 cases. Methods: the clinical date of 56 cases mesh infection after inguinal herniorrhaphy in our department from January 2013 to June 2014 were retrospectively analyzed. This group of patients whose wound were not healed after placement of prosthetic patch and local place festered, patch exposed or sinus tract formed after 3–12 months of wound consistently dressing change. They were treated with surgical operation in our department, including removing the infected mesh and surrounding tissues, primary suture and a placement of wound drainage,without replacement of a new patch substitute. After that we recorded and analyzed the wound healing daily. Results: All patients accepted affected mesh removal successfully. 38 patients got primary healed and the other 18 patients healed delayed after local dressing change and vacuum sealing drainage(VSD) due to the superficial infection following stitch removal. The result showed 100 % postoperative follow-up of patients over a 6-month period, with no recurrence in this 56 patients. Conclusions: the treatment of infection after inguinal hernia repair is very complicated, Initial debridement and the temporary VSD cover followed after several days is a reliable treatment for mesh infection after prosthetic patch repair of inguinal hernia.

O158 Sexual dysfunction after inguinal hernia repair with Onstep versus Lichtenstein technique: a randomized clinical trial K. Andresen1, J. Burcharth1, S. Fonnes1, L. Hupfeld1, J.P. Rothman1, S. Deigaard1, D. Winther1, M.B. Errebo2, R. Therkildsen2, D. Hauge3, F.S. Sørensen4, J. Bjerg5, J. Rosenberg1 1 Herlev Hospital, Department of Surgery, Copenhagen, Denmark, 2 Horsens Hospital, Department of Surgery, Horsens, Denmark, 3 Bispebjerg University Hospital, Department of Surgery, Copenhagen, Denmark, 4University Hospital Aalborg, Dagkirurgisk Center Hobro, Hobro, Denmark, 5Sygehus Lillebælt, Kolding Hospital, Department of Surgery, Kolding, Denmark Background: Sequelae following inguinal hernia repair includes pain related impairment of sexual function. Pain during intercourse can

123

S174 originate from the scar, scrotum, penis, or be during ejaculation. The aim of this study was to investigate if the Onstep technique resulted in better results than the Lichtenstein technique regarding pain related impairment of sexual function. Methods: This study was part of the randomized ONLI-trial (NCT01753219), Onstep versus Lichtenstein for inguinal hernia repair). Separate reporting of pain related impairment of sexual function was planned before the study start, with a separate sample size calculation. Participants were randomized to Onstep or Lichtenstein technique for repair of their primary inguinal hernia and followed up at 6 months postoperative with the use of a questionnaire specific for pain related impairment of sexual function. Results: A total of 259 patients completed the 6 months follow-up, 129 in the Lichtenstein group and 130 in the Onstep group. Among the patients operated with the Onstep technique, 17 experienced pain during sexual activity 6 months after surgery compared with 30 patients operated with the Lichtenstein technique, p = 0.034. The Lichtenstein technique resulted in new pain in 14 patients whereas the Onstep procedure gave new pain in seven patients, p = 0.073. Conclusion: The Onstep technique was superior to the Lichtenstein technique in terms of pain during sexual activity 6 months after operation.

O159 Endoscopic-mini/less open sublay technique (E-MILOS) R. Bittner, W. Reinpold, J. Schwarz Hernia Center Rottenburg, Rottenburg A.N., Germany The ideal operative therapy of primary and secondary hernias of the abdominal wall is still in discussion. The open techniques are burdened with a high rate of infection and seromas, whereas a laparoscopic repair (IPOM) requires a special and expensive mesh and carries the risk of lesions to the bowel. Furthermore in IPOM special fixation devices are needed which are expensive as well and may cause severe pain in the later postoperative course. In order to avoid these disadvantages we developed a technique which combines the MILOS (MiniLessOpenSublay) approach with a subsequent endoscopic dissection of the complete retromuscular space (upper and lower abdomen), thus the implantation of a huge mesh without any opening of the abdominal cavity and without any fixation is possible as well as the direct closure of the hernia defect. The ideal indication for this new operation technique are primary ventral hernias in patients having an additional significant rectus diastasis. In these patients for prevention of a recurrence an augmentation of the whole linea alba is recommended. The E-MILOS technique allows the implantation of a 40/30 9 20 cm mesh but only performing a 4–10 cm skin incision. In video clips the steps of the operation are demonstrated and preliminary results reported.

123

Hernia (2016) 20 (Suppl 2):S139–S174

Hernia (2016) 20 (Suppl 2):S175–S249

ABSTRACTS

Posters P001/O109 Pregnancy is associated with an increased risk of ventral hernia recurrence: a nationwide registerbased study E. Oma, K.K. Jensen, L.N. Jorgensen Bispebjerg University Hospital, Digestive Disease Center, Copenhagen, Denmark Background: Although ventral hernia repair is common in fertile female patients, the impact of subsequent pregnancy on the risk of hernia recurrence is unknown. Hence, consensus lacks on the timing of surgical repair for women who plan future pregnancies. The aim of this study was to examine whether pregnancy following ventral hernia repair was associated with hernia recurrence. Methods: This was a nationwide cohort study including all fertile female patients registered in the Danish Ventral Hernia Database with umbilical, epigastric or incisional hernia repair between 2007 and 2013. Obstetric data was retrieved from the Danish Medical Birth Registry. Ventral hernia recurrence was defined according to registration in the Danish National Patient Registry which holds data on all diagnoses and procedures from both public and private hospitals in Denmark. Multivariable extended Cox regression analysis was performed to assess the confounder-adjusted association between pregnancy and hernia recurrence. Results: A total of 3578 patients were included in the study, 267 (7.5 %) of whom subsequently became pregnant during follow-up. The median time from ventral hernia repair to pregnancy was 1.1 years (range 0–5.8 years) and the overall median follow-up was 3.1 years (range 0–8.4 years). After adjusting for relevant confounders, pregnancy was associated with an increased risk of ventral hernia recurrence (hazard ratio (HR) 1.56, 95 % CI 1.09–2.25, P = 0.016). Hernia type (umbilical HR 1.55, 95 % CI 1.17–2.06 and incisional HR 3.30, 95 % CI 2.42–4.51 compared with epigastric) and hernia defect size (HR per 10 cm2 increase 1.02, 95 % CI 1.01–1.04) were likewise associated with hernia recurrence. Conclusion: Pregnancy following ventral hernia repair was associated with an increased risk of ventral hernia recurrence. Planned future pregnancies should be considered for a timely repair of ventral hernia in fertile women.

P002/O110 Concurrent panniculectomy in the obese ventral hernia patient: Assessment of short-term complications, hernia recurrence, and healthcare utilization M.A. Lanni, V. Shubinets, J.P. Fox, M.N. Mirzabeigi, M.G. Tecce, R.R. Kelz, K.R. Dumon, S.J. Kovach, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Introduction: Soft-tissue interventions such as panniculectomy (PAN) are often performed concurrently with ventral hernia repair (VHR) in the obese patient. However, the effectiveness and safety profile of this common practice have not been fully established in part

due to paucity of comparative effectiveness studies. Presented herein is a comparative analysis of early complications, long-term hernia recurrence, and healthcare expenditures between VHR-PAN and VHR-only patients. Study design: From the Healthcare Cost and Utilization Project (HCUP) database, obese patients who underwent VHR with and without concurrent PAN were identified. Multivariate cox proportional-hazards regression modeling was performed to compare outcomes between the two groups. Results: The final cohort included 1013 VHR-PAN and 18,328 VHRonly patients. The VHR-PAN patients experienced a longer adjusted length of hospital stay (6.8 vs. 5.2 days; p \ 0.001), a higher rate of in-hospital adverse events (29.3 vs. 20.7 %; AOR = 2.34 [2.012.74]), and a higher rate of 30-day readmissions (13.6 vs. 8.1 %; AOR = 2.04 [1.69–2.48]). The 2-year rate of hernia recurrence, however, was lower in the VHR-PAN group (7.9 vs. 11.3 %; AOR = 0.65 [0.51–0.82]). Both groups generated significant costs of care ($104,805 VHR-PAN vs. $72,206 VHR-only, p \ 0.001). Conclusions: Performing a concurrent PAN in the obese hernia patient is associated with a higher rate of early complications and greater healthcare expenditures, but overall a substantially lower incidence of 2-year hernia recurrence. The literature review presented here also highlights a significant need for further comparative effectiveness studies to create the needed framework for evidence-based guidelines.

P003/O111 Health-economic analysis of Lichtenstein in local anesthesia vs Total ExtraPeritoneal repair for inguinal hernia: preliminary data from a randomized clinical trial L.C. Westin1, S. Wollert2, M. Ljungdahl2, G. Sandblom1, U. Gunnarsson3, U. Dahlstrand1 1 Karolinska Institutet, CLINTEC, Stockholm, Sweden, 2Uppsala University, Department of Surgical Science, Uppsala, Sweden, 3Umea˚ University, Surgery and perioperative science, Umea˚, Sweden Objective: to compare cost-effectiveness of Lichtenstein under local anesthesia (LLA) and total extra-peritoneal repair (TEP) for repair of primary inguinal hernias in men. Background: Endoscopic approaches to inguinal hernia repair are often considered more costly. Endoscopic hernia repair has, however, not been compared to open inguinal hernia repair under cost-optimized settings. Methods: The study is based on a randomized controlled trial designed to compare post-operative pain between LLA and TEP performed under cost-optimized circumstances. Economic data was assembled prospectively. Information from the hospitals economic systems regarding duration of operation, cost of operating time, anesthesia duration and cost of anesthesia collected together with data on material cost. Data from the national registry for sick leave were obtained in order to include longer term social costs for these patients. Altogether 384 patients were included. Results: 374 (97.4 %) patients were analyzed, 189 patients in the LLA group and 185 in the TEP group. For 10 patients no data could be retrieved from the economic registry of the hospital. The mean operating time for LLA was 72.3 (SD 16.0) min compared to 62.7 (SD 18.6) min in the TEP group, p \ 0.001. The mean duration of anesthetic treatment was 116.9 (SD 22.7) min for LLA and 128.9 (SD 26.2) min for TEP, p \ 0.001.

123

S176 Conclusion: Operating time was significantly longer in the LLA group; the duration of anesthesia or anesthetic treatment in the operating room was however significantly shorter in the LLA group when compared to the TEP group. This could result in an equalization of costs. However, data from sick leave costs and materials need to be taken into account as well.

P004 Trocar-site hernia after diagnostic laparoscopy B. Agca, B. Karip, Y. Iscan, Y. Ozcabi, T. Aydin, K. Celik, K. Memisoglu Fatih Sultan Mehmet Training and Research Hospital, General Surgery, Istanbul, Turkey Trocar-site hernias occur due to various reasons and may cause lifethreatening complications. Early diagnosis and treatment reduces morbidity and mortality rates. In this paper, we present a 43-year-old patient who presented to our emergency department with the complaints of nausea, vomiting, distention and inability to defecate occurred after a diagnostic laparoscopy for an abdominal stab wound. A computed tomography revealed a trocar-site hernia involving a small bowel segment. Trocar site was evaluated under general anesthesia and, after reduction of the bowel, the defect was closed primarily. On the first postoperative day, he was discharged uneventfully. Immediate mechanical bowel obstruction after laparoscopic surgery should be kept in mind to deal with these complications.

P005 Ten years results in modified plug-patch inguinal hernia repairs A. Stefanopoulos, M. Psarologos, I. Massalis, G. Efthymiou, E. Lazaridou, S.M. Iliopoulou, P. Gkanas General Hospital of Nafplio, Department of Surgery, Nafplio, Greece Background: To evaluate the clinical results and complications of inguinal hernia with modified plug-patch repair in our hospital. Methods: 428 consecutive patients with inguinal hernia were evaluated in the period between 1/1/2006 and 31/7/2015 retrospectively. All operations were done by three surgeons. A modified technique using a plug and an onlay light polypropylene patch was performed under general anesthesia. One to three stitches was used to attach the plug to the transverse fascia in order to prevent patch migration. The nerves were routinely identified, registered and preserved. Patients were evaluated for postoperative complications following observation in the outpatient’s clinic after 1, 4 and 24 weeks. Results: 390 patients operated electively and 38 operated as acute cases. The mean age of the patients was 65 years with male: female ratio of 374:54. Inguinal hernia was indirect in 243 patients, direct in 157 and ‘‘pantaloon hernia in 28 patients. Urinary retention was the commonest complication occurred in 8 patients. Wound hematoma observed in 10 cases all treated conservatively. 12 patients developed seroma mainly related to complementary inguinal gland resection the heavy polypropylene meshes utilized in the first year of our study 5 patients developed acute postoperative neuralgia and they reoperated within 48 h. We didn’t observe wound infection observed. We didn’t diagnose any testicular atrophy and 10 patients experienced hypaesthesia. All patients were discharged within 48 h after surgery. The average recovery time was 12 days. No recurrences were recorded. Conclusion: The modified plug-patch technique is a safe and effective procedure for inguinal hernia repair. The complications are acceptable in regard of the incidence of postoperative chronic pain.

123

Hernia (2016) 20 (Suppl 2):S175–S249

P006 Mesh infection after incisional hernia repair- personal experience S. Jovanovic Center for Minimally Invasive Surgery, CC NIS, Nis, Serbia Objectives: The incidence of incisional hernia after previous operation in the abdomen varies, from 3.8–11.5 %. In 90 % of cases they occur during the first 3 years after operation. Due to high recurrence rate after conventional repairs (Mayo- repair, direct suture), after the year 1999 we started to use prosthetic material for the repair of large incisional hernias. The aim of this study is to show our experience with mesh infection after repair of incisional hernia. Methods: At Clinic of Surgery, Clinical Center Nis, from 1999–2015 we have operated 432 patients with incisional hernias using mesh repair (Rives-Stoppa, Trabucco, Chevrel), ASA (I, II and III). The mean age of patients was 65 (28–74 years). There were 142 men (32.73 %) and 290 women (67.27 %). All operations were done under general anesthesia. We have analyzed the correlation between size of the defect and occurrence of infection and its microbiological cause. Results: Majority of patient received preoperative one-shot prophylaxis. Average was 8.5 days (2–45). 64.55 % of cases we have used 1–2 drains, which were extracted after 2–5 days. The rate of infection was 8.18 % (9 patients) caused with: Staphylococcus aureus, Proteus mirabilis, E. coli, Bacteroides fragilis. All of infections occurred among abdominal wall defects that were larger then 10 cm. In those cases we were obliged to use large size meshes. Infections were treated with antibiotics and daily wound care. In 2 cases (1.81 %) the mesh was extracted. Conclusion: Tissue trauma, duration of operation as well as mesh size, increase the risk of infection. Infections were caused by intrahospital species. Taking all of this into consideration we could conclude that laparoscopic repair is superior to open repair.

P007 Emergency surgery due to diaphragmatic hernias A. Girardi, S. Lafranceschina, R.M. Isernia, F. Fragassi, G.M. de Luca, M. Testini University of Bari, Department of Biomedical Sciences and Human Oncology, Bari, Italy Background: Congenital diaphragmatic hernia (CDH) is a congenital anomaly with a frequency of 1/2500 newborns. Incomplete formation of the diaphragm allows abdominal contents to herniate into the chest creating a mass effect that impedes lung development. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diaphragmatic rupture may occur during falls or vehicle accidents, in about 5 % of those. Methods: From May 2013 to December 2015, four cases (3 females, 1 male; mean age 56 years) of diaphragmatic hernia arrived to our Emergency Department with respiratory and abdominal symptoms. No breath sounds were detected in the left chest area. Chest X-ray, barium studies and CT scan were performed. Results: The first patient presented left diaphragmatic hernia containing transverse and descending colon. The second showed left CDH which allowed passage of stomach, spleen and colon. The third had stomach and spleen in left hemitorax and multiple rib fractures. The last one presented left CDH containing colon, spleen. Emergency laparotomy was always performed. In the second case a combined chestabdominal approach because of dense intrathoracic adhesions was performed. The hernia contents were reduced and defect was closed

Hernia (2016) 20 (Suppl 2):S175–S249 with primary repair or mesh. Postoperative course was uneventful, and the medium postoperative stay was 20 days (range 7–45). Conclusion: A diagnosis of diaphragmatic hernia should be kept in mind for patients with overlapping abdominal and respiratory symptoms with or without an history of trauma. Chest X-ray CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents, before planning any surgical intervention. Emergency surgical approach is mandatory for reducing morbidity and mortality. The use of mesh is recommended where the defect proved too large for primary closure, but the use of tension free mesh is vital to the success of the procedures.

P008 De Garengeot hernia: Case report and review D. Rivera Alonso, I. Domı´nguez Serrano, G. Sanz Ortega, P. Sa´ez Carlin, L.M. Estela Vila, M.J. Pen˜a Soria, J.J. Cabeza Go´mez, D. Jime´nez-Valladolid Condes, A.E. Pe´rez Jime´nez, V. Mun˜oz Lo´pezPela´ez, J.L. Garcı´a Galocha, E. Blesa Sierra, A.J. Torres Garcı´a Hospital Clı´nico San Carlos, General Surgery, Madrid, Spain Background: Garengeot’s Hernia is a rare entity which consists in the presence of the cecal appendix into a femoral hernia sac. There are about 100 cases described and due to this low incidence, there is no consensus about the optimal treatment for it. Patient and methods: We present a case of an 84 year old woman who arrived to the emergency room with an 8 h right groin pain. On physical examination, a 3 cm painful mass suggestive of an incarcerated femoral hernia was shown, therefore urgent surgical treatment was decided. An incision was made on the tumor, exhibiting a trapped hernia sac at the femoral hole level. The sac was dissected and opened, showing the vermiform appendix with congestive signs and part of the cecum. Appendectomy was performed and, after checking the feasibility of cecum, an hernioplasty with a polypropylene plug was carried out. Pictures of the procedure are presented. Results: Histological examination of the appendix confirmed congestive appendicitis. The patient was discharged on the third postoperative day and 3 months after the procedure there is no evidence of recurrence. Conclusion: Garengeot’s hernia is an exceptional entity that is usually diagnosed intraoperatively, so it is important for the surgeon to know and take into consideration the different surgical options for its treatment. Appendectomy and prosthetic repair of the defect is a procedure that, in our case, was performed with good results.

P009 Outcomes of surgical treatment of mesenteric thrombosis masquerading as a strangulated ventral hernia S.R. Mykytiuk Khmelnytskyi Regional Hospital, Surgical Department, Khmelnytskyi, Ukraine Background: Incarceration of ventral hernia may be the consequence of increased intraabdominal pressure due to abdominal emergencies such as mesenteric thrombosis. Aim: to emphasize the necessity of differential diagnosis in patients with strangulated ventral hernia. Methods: Clinical data of 3 patients with false strangulated postoperative ventral, umbilical and femoral hernias due to mesenteric thrombosis were evaluated retrospectively. All patient were women with average age 74 ± 10 years.

S177 Results: At examination all patients showed an enormous strangulated hernia with clinics of acute abdomen, obstruction or peritonitis accompanying with cardiac failure and history of atrial fibrillation. The correct diagnosis was made during emergency surgery for hernia repair only in one patient, whereas the primary pathology was identified postoperatively in other two patients. Mesenteric thrombosis producing ischemia and gangrene of the bowel as content in different abdominal wall hernias are rarely reported in the medical literature. So, while dealing with an hernia with gangrenous small intestine or colon as the content, one should keep in mind a rare possibility of mesenteric thromboembolism as the cause. Moreover, the surgeon should consider general abdominal exploration if contradictory findings are encountered during the exploration of the hernia sac, even if preoperative diagnostic studies reveal no gross pathology or non-specific findings. Treatment should be individualized based on the extent of thrombosis and the presence of intestine ischemia. In our cases, small bowel necrosis was detected in all patients, but in one patient only postmortality. A near-total resection of small bowel with single terminal stomas was performed in 2 patients. Laparostomy was established in 2 patients. Direct hernia repair with prosthetic mesh were performed in 2 patients. Conclusion: Therapists, surgeons and emergency medicine personnel should be aware of the possibility of mesenteric thromboembolism masquerading as a strangulated or incarcerated abdominal wall hernia in patients with known history of fibrillation.

P010 The impact of the site of mesh implantation on postoperative seroma formation in tension free hernioplasty of ventral hernia repair S. Mansor, R. Bendardaf, A. Algasi, M. Moftah Aljala Hospital, General Surgery, Benghazi, Libya Aim of this study was to assess and analyze the difference between Onlay, Inlay and Sublay mesh implantation techniques in terms of postoperative seroma formation. Also to determine whether these differences are clinically and statistically of significance to the extent that making one technique superior to the others. Method. The Cohort study was carried out in 91 Consecutive patients of ventral abdominal hernia, primary and incisional hernia. Admitted as elective cases in our department from 1st January 2010 to 31st December 2014. Patients important information that were recorded from history as gender, age, chronic cough, constipation, prostatism, diabetes mellitus, steroid therapy, smoking status, and any previous abdominal surgery. And from the clinical examination we recorded the body mass index and size of the defect. Postoperative observations were made with regards to seroma formation, that diagnosed by clinical examination and confirmed with ultrasound examination, which form a primary end point of study, while the secondary end point is complete 1 year postoperative follow up. Result. During the study period of 91 cases, 54 (59 %) were females and 37 (41 %) were males. The mean age was 43.35 years. 37 patients had incisional hernia, 37 had paraumbilical hernia and 17 had epigastric hernia. In the first group were 53 patients (58 %) operated by onlay mesh repair method. In the second group were 21 patients (23 %) operated by inlay. And in the third group were 17 patients (19 %) operated by sublay method. As postoperative complications, seroma formation was occurred in 17 patients (32 %) were in onlay group, 11 patients (52 %) were in inlay group. And 2 patients (12 %) had postoperative seroma in sublay group. Conclusion. In our study we have concluded an evidences show that, the Sublay mesh repair hernioplasty is superior to onlay and inlay mesh repair in terms of seroma formation.

123

S178

P011 Rectus abdominis hematoma. Experience at our University Hospital P. Garcı´a-Pastor, N. Carvajal, R. Garcia-Dominguez, A. Torregrosa, S. Bonafe, J. Iserte, J. Bueno University Hospital La Fe, Abdominal Wall Surgery Unit, Valencia, Spain Introduction: Rectus Abdominis hematoma is a risky entity. This paper is to describe our experience (diagnosis, treatment) to obtain an algorithm, and a focus on identifying patients at increased risk (including death). Materials and methods: Retrospective analysis of rectus abdominis hematoma treated in our hospital during the past 10 years. Results: 76 patients were included in our review. Initial symptoms were mainly abdominal pain with sudden onset and increasing intensity, abdominal mass and acute anemia. 62 patients (81.6 %) received antiplatelet or anticoagulant therapy; warfarin-type were often associated (55.6 %). In all cases, imaging tests were performed for diagnosis (US, CT scan). The most common triggers were cough (44.7 %) and trauma injections of LMWH (29 %), consistent with the published series; in 28.9 % the cause was undetermined. The median hospital stay was 10 days; 62 % of patients required transfusion, with a median of 2 HCU per patient. Most cases (77.6 %) were treated conservatively, although 17 needed active measures: 9 (12 %) inferior epigastric embolization, 8 cases (10.5 %) surgical treatment due to instability or expanding hematoma; in these patients the triggering factor was injection of LMWH (52.9 vs 29 % in the total group). 8 patients died due to cardiopulmonary instability; trauma for LMWH injection is a trigger risk in 5 of them (62.5 %). Conclusions: The rectus abdominis hematoma is a serious condition that should be suspected in elderly women, who receive anticoagulant/antiplatelet therapy and presenting with abdominal sudden pain increasing intensity, especially in relation to coughing or injections (usually self-administered) of LMWH. In most cases conservative treatment is enough; diagnostic arteriography with selective arterial embolization is the first choice in case of failure, whereas surgery should be exceptional. Although the sample size is small, our results suggest relationship between LMWH-injection and failure of conservative treatment. It’s also a clear risk factor for mortality.

P012 Giant pseudocyst in abdominal wall: an underreported entity. Our experience A.E. Pe´rez Jime´nez, M.J. Pen˜a Soria, V. Mun˜oz Lo´pez Pelaez, L.M. Estela, E. Blesa Sierra, J.L. Garcı´a Galocha, A. Garcı´a Fernandez, J. Cabeza Go´mez, A.J. Torres Garcı´a Clı´nico San Carlos, General Surgery, Madrid, Spain First described by Waldrep et al. in 1993, giant pseudocyst is a complication of incisional hernia repair, whose ignorance makes it underdiagnosed. Defined as a big collection of fluid limited by a capsula without epithelium that appears in the abdominal wall; most of cases described after incisional hernia repaired with a supraaponeurotic synthetic mesh, but also cases of mature cyst have been described after performing liposuction or abdominoplasty. Although some theories have been suggested, its etiology remains unknown, and the low number of reported cases provides low knowledge about this entity, which incidence is estimated at 0.8 % of all incisional hernia repair. Several maneuvers have been applied, but the complete excision of the lesion is the only successful treatment

123

Hernia (2016) 20 (Suppl 2):S175–S249 accepted; not being well handled by evacuation due to the rapid recurrence of the lesion. In this report, we are introducing the largest number of cases of giant pseudocyst described in the literature to our days, which brings together all the cases observed in our abdominal wall unit from January of 2002 to December of 2015, making a descriptive analysis of the sample, analyzing factors such as gender, age, smoking, hypertension, diabetes or obesity, using a SPSS statistical program; that is vital for the characterization of this late complication of incisional hernia repair, which remains a challenge for the general surgeon.

P013 Posttraumatic bilateral lumbar hernia; a case report and review J.L. Garcı´a Galocha, M.J. Pen˜a Soria, V. Mun˜oz Lo´pez Pelaez, M. Sa´nchez Garcı´a, D. Jimenez Valladolid Condes, J.J. Cabeza Gomez, D. Rivera Alonso, E. Blesa Sierra, A.E. Perez Jimenez, A.J. Torres Garcı´a Clı´nico San Carlos, General Surgery, Madrid, Spain Backgrounds: Posttraumatic hernias are a rare pathology. Since the first episode, described by Shelby in 1906, only 140 episodes have been reported in the literature. We present a case of this infrequent pathology treated in our center, Hospital Clı´nico San Carlos. Case report: We report a case of a 56 year old woman who suffered rectum muscles disruption and sigma perforation after a car accident with traumatic abdominal injury. On physical examination she had bilateral hematoma. Midline laparotomy was required and sigmoidectomy with primary anastomosis was performed. After 5 months, the patient came back to our hospital presenting a bilateral abdominal tumor which was correlated with a posttraumatic hernia identified in a CT scan and located on both flanks with colon on right side and preperitoneal fat in the other side. Sublay polypropylene mesh was used to repair the posttraumatic defect in both cases. No recurrence was observed 6 months after surgery. Discussion: Traumatic abdominal hernias are rare type of hernia, with an incidence estimated 0.07 to 0.2 % of all the cases of abdominal trauma. There are only two diagnostic criteria: suffering a trauma and the absence of a previous hernia in the same location. Advanced age, muscular weakness and hematoma in acute episode are risk factors for its development. In the context of a high energy abdominal trauma, it is necessary to confirm the presence or absence of hernia, since it is likely to be under-diagnosed. In this case, CT scan is the gold standard diagnostic test. Mesh repair decreases the rate of recurrence. Carrying out a multidisciplinary approach is the best way to optimize the surgical results.

P015 Over 20 years’ experience in use of polypropylene sutures in hernia´s surgery J.M. Goderich Lalan1, L. Luna Vazquez2, E.J. Molina Fernandez3 1 Hospital Juan Bruno Zayas, Surgery, Santiago De Cuba, Cuba, 2 Hospital Ambrosio Grillo Portuondo, Nursery, Santiago De Cuba, Cuba, 3Hospital Manuel Fajardo, Surgery, La Habana, Cuba The modern hernia surgery has the use of the meshes among its fundamental pillars and so, the use of modern surgical sutures. The basic component suture of the polypropylene monofilament is a

Hernia (2016) 20 (Suppl 2):S175–S249 stereoisomer, an hydrocarbonate linear polymer, blue, stained with alcian, ASSUPRO, which possess the advantages of the stainless steel. But its handling is easier, it is not fragmented until lapse enough time, its strength of tension is high and is well maintained with only a minimal loss of strength after 18 to 24 months, is stronger than silk and cotton, similar to nylon or something stronger, it requires of a careful knot and is unlikely its break due to its capacity of being deformed and extended when is used. Objective: To evaluate the work results in 20 years with this suture in hernias surgery. Method: A clinical and observational study of all the patients attended and follow up from November 30, 1993 to December 31, 2014, based on the registers of the institution. The universe were Inguinals Hernias 13 611, Incisionals Hernias 6003, Femorals Hernias 677, Umbilicals Hernias 968, Epigastric Hernias 456, Other hernias 115, in Total 21 830 operations carried out. Results: The rates of postoperatories complications, and 3.8 % recurrences by type, and nine variables for patient, the analysis social and economical carried out. The number of attributable complications to the suture was minimum and no reject reported. All the patient were controlled in follow up visits for the benefits of the Cuban health system. Recurrences in Inguinals Hernias 3.1 %, Incisionals Hernias 4.2 %, Femorals Hernias 1.2 %, Umbilicals Hernias 4.3 %, Epigastrics Hernias 3,0 %. Conclusions: The benefits in hernia surgery of the ASSUPRO of Assut Europe suture, its cost, social impact and the early return to work with minimum of complications is reaffirmed.

P016 Synergistic effect of topology and mechanical properties on the performance of hernia prosthesis and its fixation system G. Vozzi, C. de Maria, F. Montemurro University of Pisa, Research Center ‘‘E. Piaggio’’, Pisa, Italy Background: The ventral hernia affects more than 20 millions of people in the world. In the last years, several types of meshes have been produced and commercialized, making difficult the choice in the clinical practice. The mismatch of mechanical properties between the mesh and the surrounding tissues can induce discomfort and pain, until the failure of the implant. Methods: In this study, six different meshes with different topologies were uniaxial mechanically tested, in dry and wet conditions, and classified using two different indexes, the anisotropy and safety index. Moreover the force of detachment of a most compliant hernia prosthesis fixed in different ways on rat abdominal wall was analysed. Results: The mechanical analysis performed on the different prostheses has allowed to classify them and select the most suitable one for clinical applications (CMC prosthesis, Dipromed srl, Italy). Its mechanical behaviour is comparable with that of the human. We also demonstrated that human and rat abdominal wall tissue have similar mechanical properties, so the animal tissue model for the detachment test of hernia prosthesis. This last analysis has allowed to classify the different fixation system (glues, tags or their combinations) to allow to the clinicians to select the best solution on the basis of clinical case. Conclusions: Our work may represent the basis to asses the performance of a mesh and its fixation methods in order to minimize production costs for the companies and gave valid instruments to the surgeons to choose the optimal mesh to use for their clinical needs.

S179

P017 Low agreement in operation indication and planned technique for incisional hernia repair among hernia experts D. Kokotovic, I.G. Go¨genur, F.H. Helgstrand Køge University Hospital, Dept. of Surgery, Køge, Denmark Background: Benign discretionary procedures give rise to heterogeneity in operation indication and surgical technique among specialized surgeons in a variety of surgical fields. The purpose of this study was to analyse agreement in incisional hernia repair between expert hernia surgeons when evaluating the same patient in a standardized setting. Methods: Five Danish hernia experts answered questions concerning operation indication and surgical technique for 25 real-life clinical cases. A standardized clinical consultation in line with daily clinical practice was conducted for 25 patients. A video of the consultations including full medical history, clinical interview, clinical hernia examination, and CT-scan of the hernia were produced. The experts evaluated the videos by a standardized questionnaire. The questionnaire asked questions on operation indication, operation type, component separation, mesh fixation and mesh positioning. Results: All surgeons were experienced in incisional hernia repair and members of the Steering group of the Danish Hernia Database, with a median of 253 repairs (range 164–450 repairs) throughout their career. Perfect overall agreement among all the surgeons in both indication, operation type, component separation and mesh position was only found in 5 cases (20 %). In separate sub-analyses of indication and different surgical approaches, the following results were found. Agreement in operation indication among the surgeons was present in 14 cases (56 %). The most common reason not to operate was comorbidities. Agreement in operation type (open vs. laparoscopic) was present in 10 cases (40 %). Agreement in mesh fixation method was also present in 10 cases (40 %). Agreement in mesh position was found in 40 % of cases. The highest overall agreement between the surgeons was present in regard to whether patients needed component separation (21 cases, 84 %). Conclusion: In a standardized setting, agreement in treatment strategy for patients with incisional hernias is very low among experienced surgeons that form national guidelines.

P018 Prophylactic mesh use during primary stoma formation to prevent parastomal hernia: a systematic review and meta-analysis J.B. Cornille1, S. Pathak2, I.R. Daniels2, N.J. Smart2 1 Leuven, Abdominal surgery, Leuven, Belgium, 2Royal Devon and Exeter Hospital, General surgery, Exeter, UK Purpose: Parastomal herniation is a common and debilitating problem following stoma formation, with up to 30 % of patients requiring further surgical intervention. The optimal surgical technique for stoma formation is yet to be defined though recent randomised trials have focussed on whether prophylactic mesh placement at the time of stoma creation can reduce the rate of PSH. The aim of this study was to systematically review use of prophylactic mesh versus no mesh with regard to (a) occurrence of PSH and (b) peristomal complications.

123

S180 Methods: A systematic search was performed using PubMed, Medline, Embase and the Cochrane Library to identify randomised controlled trials that analysed placement of prophylactic mesh versus no mesh at time of initial surgery to prevent parastomal herniation. Meta-analysis was performed using the random effects methods. The primary outcomes of interest were PSH occurrence and peristomal complications. Results: A total of 506 studies were identified by our search strategy. Eight studies were included, involving 430 patients (217 mesh vs 213 no mesh). Prophylactic mesh placement resulted in a significantly lower rate of parastomal hernia formation 19.4 % (42/217) versus 43.2 % (92/213). The combined risk ratio was 0.40 (95 % CI 0.21–0.75, p = 0.004). Placement of prophylactic mesh did not result in increased peristomal complications 6.9 % (15/218) versus 7 % (16/ 227). The combined risk ratio was 1.0 (95 % CI 0.49–2.01, p = 0.99). Conclusions: Prophylactic placement of mesh at primary stoma formation appears to reduce the incidence of PSH, without an increase in peristomal complications. However, the overall quality of RCTs included in the meta-analysis is poor and should prompt caution regarding the applicability of the findings of the individual studies and the meta-analysis to everyday practice. The optimal type of mesh, location for mesh placement and cost effectiveness still needs to be defined.

P019 Factors influencing the costs of laboratory and radiologic tests in hernia patients: results of an eight hospital study G. Halmerbauer1, C. Ausch2, R. Rieger2, R. Haslinger1, N. Kamptner1, T. Ko¨nigswieser2, K. Arthofer1, M. Ehrenmu¨ller1 1 University of Applied Sciences of Upper Austria, Department of Process Management in Health Care, Steyr, Austria, 2OO¨. Gesundheits- und Spitals-AG, Department of Surgery, Steyr, Linz, Austria Background: The routine use of laboratory and radiologic investigations in patients undergoing hernia repair is considered an important element of care. Differences in costs concerning laboratory and radiologic tests exist between individual patients. The aim of this retrospective study was to examine laboratory and radiologic costs concerning Hernia patients before, during and after their hospital stay as well as to identify associated risk factors. Methods: Resource use for laboratory as well as radiologic investigations was analyzed in a random sample of 2317 patients undergoing hernia repair in eight medium to small sized Austrian hospitals. Potential risk factors were analyzed using regression analysis. Results: Overall laboratory costs caused by the tests were between a median (Q1–Q3) of 19.8 (0–77.6) € to 134.8 (117.3–156.4) € and overall costs for radiologic investigations were between a median (Q1–Q3) of 0 (0–0) € to 233.2 (0–364.6) € per patient in different hospitals. Age (0.6 €/a; p \ 0.001), risk factor (6.2 €/risk factor; p \ 0.001), ASA class II (7.5 €; p \ 0.001), ASA class III (43.3 €; p \ 0.001), 5 out of 8 departments (31.7 €–83.0 €; p \ 0.001)) and complication y/n (56.6 €; p \ 0.001) were significantly associated with laboratory costs. Age (2.6 €/a; p \ 0.001), risk factor (42.3 €/ risk factor; p \ 0.001), 7 out of 8 departments (57.5 €–212.9 €; p \ 0.001)) and complication y/n (225.2 €; p \ 0.001) were significantly associated with radiologic costs. Conclusion: We were able to demonstrate several associated risk factors for laboratory and radiologic costs in surgical patients. Most of these factors are patient specific and cannot be influenced by the physicians. However, complications add significantly to costs as well

123

Hernia (2016) 20 (Suppl 2):S175–S249 as individual prescription patterns in the participating hospitals. Processes of care could be improved and costs decreased by collaborative initiatives to adopt evidence-based best practices.

P020 Surgical records and sanitary reimbursement S.S.A. Dalila Patrizia Greco1, F. Amatucci2, G. Padula2, M. Pulito2 1 S.S.ASST Grande Ospedale Metropolitano Niguarda, Day Surgery Centralizzata, Milan, Italy, 2CERGAS University Bocconi, Milan, Italy A five-year-analysis of the data on abdominal wall treatment at ‘‘ASST Grande Ospedale Metropolitano Niguarda’’ (Milan, Italy) supports the thesis that the analysis of the reimbursement system in Italy (DRGs) points out an unfair economic coverage of the treated cases, and it does not take into account continuous technologic improvements and variability of cases. The analysis of the 5 years records shows which are the variables, in the surgical treatment of the hernia surgery that can be useful in redetermination of reimbursement.

P021 Abdominal wall hernia surgery in Tuscany: 2013 data and final crosslinked analysis between clinical and hospital discharge record databases F. di Marzo1, V. Mingarelli2, C. Galatioto3, L. Cobuccio3, L. Gia1, L. Felicioni4, L. Salvischini4, A. Marioni3, S. Forni5, S. d’Arienzo5, P. Ipponi6, F. Medi7, P. Buccianti3, A. Vannucci5 1 ASL 1 Massa Carrara, General Surgery, Pontremoli, Italy, 2 Universita` Sapienza, General Surgery, Rome, Italy, 3Azienda Ospedaliero Universitaria Pisana, Emergency Surgery, Pisa, Italy, 4 ASL9, General Surgery, Grosseto, Italy, 5ARS, Quality Control, Firenze, Italy, 6ASL10, General Surgery, Florence, Italy, 7Barbantini Hospital, General Surgery, Lucca, Italy Background: First report about this retrospective observational study has been presented last year in Milan, this second paper summarize the whole process and the final step. The aim is to detect and sort out coding errors in abdominal wall hernia repair surgery, to propose guidelines about coding system (based on ICD-9-CM) and implement it. Methods: A retrospective observational study was performed on patients treated for abdominal wall hernia in 2013, excluded those with an inguinal hernia repair. Eight General Surgery Departments (two from the same University Hospital, 5 from general hospitals e 1 from private hospital) joined the study. Every single center received and reviewed a list of clinical records selected from Hospital Discharge Abstract (HDA), focusing on two different pathways (from operative report to diagnosis and procedure coding on any different computer system and from this to Hospital Discharge Record-HDR) and chasing errors (frequency, reiteration, inter-hospital difference). Results: We reviewed 315 clinical records. In 117 cases (40.3 %) the operative report did not match with the code: the surgeon described a procedure and coded for a different one. For the diagnosis the error rate was 26.6. Laparoscopic procedure was incorrectly specified in 84.9 % of cases. Computer System coding and HDR do not match in 18 % (both for procedures and diagnosis). Codes accounting for more errors are: 553.1, 553.20/1, 553.8 (other hernias) and 53.69, 53.59 (other hernias with and without mesh), 53.61 (incisional hernia with mesh).

Hernia (2016) 20 (Suppl 2):S175–S249 Conclusion: We highlighted a two-level error-prone iter: Different surgeons are in charge of filling in the operative report, related codes and HDR (filled in without operative report’s double check). ICD-9-CM is not up-to-date for Abdominal Wall Hernia Surgery and its continuous evolution (laparoscopic, endoscopic, complex hernia repair). Regional guidelines and a proposal for new codes are meant to simplify the whole process.

P022 Should we place a radiological marker into the mesh to control positioning, contraction, twisting or displacements, in hernioplasty and eventroplasty? A. Torregrosa, P. Garcı´a Pastor, J. Sancho Muriel, B. Argu¨elles, J. Iserte, S. Bonafe Diana, J. Bueno Lledo´ La Fe University and Polytechnic Hospital, Valencia, Spain, Abdominal Wall Surgery Unit, Valencia, Spain Introduction: Prosthetic mesh implants are widely used in hernia surgery. To show long-term mesh-related complications such as shrinkage, displacements or adhesions visualization of meshes and their vicinity in vivo is important. We have already described a protocol using multislice CT to control Polysoft patch after inguinal hernia repair. Thereafter, there are studies with Magnetic Resonance Imaging (MRI) to control meshes supplemented with ferro-particles (MRI delineates the mesh itself). The purpose of our study was to assess the reliability of multislice CT and MRI in depicting these memory-ring patches after hernia surgery and in ventroplasty Rives-type with a superparamagnetic iron-oxides-mesh (DynaMesh IPOM). Materials and methods: We controlled ten patients with Polysoft patch; exams were carried out with a 64-channel multidetector CT device (VCT GE Healthcare) in the supine position, without no oral nor intravenous contrast media. Ten patients with midline incisional hernia were operated by Rives-type ventroplasty using retromuscular DynaMesh IPOM-superparamagnetic iron-oxides-mesh; these patients were controlled with MRI. Results: CT technique allowed the detection of all the memory-ring patches examined. The oval-shaped polyester fibers were identified as a fine line more dense than the surrounding tissues. The shape and location of all the patches was accurately depicted. We could easily identify the normal positioned as well as the twisted patches, even measuring their areas and displacements. 3D MIP reconstructions showed to be the best technique to demonstrate the patches. Otherwise, MRI could achieve the positioning, shrinkage, twisting and displacements in the ventroplasty iron-oxides-mesh. We got these information quite accurately in all our 10 patients-control. Conclusions: These marked-meshes have been well-controlled by simple and safe radiologic examinations. Maybe we should mark all meshes, just to be able to control them in case we need it.

P024 Gastric dilatation: a cause of hepatic portal venous gas secondary to incisional ventral hernia. A case report and literature review H. Bermingham St Helens and Knowsley Hospital Trust, General Surgery, Liverpool, UK Background: Hepatic portal venous gas (HPVG) has been reported in the literature since 1955. Recent studies show mortality has reduced from 75 % to 29–35 %.

S181 The aetiology of HPVG can be categorised into intestinal wall alterations, bowel distension, intra-abdominal sepsis and unknown causes [2, 5], mesenteric ischaemia being the most serious cause. We report a case of hepatic portal venous gas (HPVG) with acute gastric dilatation secondary to an incarcerated incisional ventral hernia, in an obese lady, BMI 56.1. Methods: A 57 year old super obese Caucasian lady presented as an emergency admission with crampy abdominal pain around a large incisional ventral hernia. She had previously undergone an emergency operation for an incarcerated ventral hernia in 2008. Results: CT scan showed porto-mesenteric gas throughout the liver, mesenteric gas was seen in the Superior Mesenteric Vein and vasculature within the left upper quadrant. There was marked dilatation of the stomach and small bowel to the level of the large hernia, where there was a clear transition point. She developed a lactate acidosis suggesting GI ischaemia. The patient underwent a laparotomy, relief of small bowel obstruction, repair of her massive incisional hernia with mesh and was discharged home 8 days later. Conclusions: This is the first reported case of HPVG caused by an obstructed hernia. We hypothesis the small bowel became obstructed by the ventral hernia, which resulted in acute gastric dilatation. The stomach became ischaemic giving a lactic acidosis (which was relieved by decompression). Patients with a radiological finding of HPVG require further investigation and treatment of the underlying cause. The main condition that needs ruling out is mesenteric ischaemia which is still associated with a poor prognostic outcome. Patients with the serious finding of HPGV, high lactate and acidosis should not necessarily be seen as a premorbid event.

P025 Rives stoppa method for massive complex ventral hernia repair A. Rapoport, S. Biswas, A. Bukin, O. Efremov, O. Efremov, E. Solomonov Ziv Medical Centre, Surgery, Galilee, Israel Background: The Rives-Stoppa method for repair of massive incisional hernia repair is well established. However, patients with stoma or faecal fistulae may require staged procedures in order to avoid contamination and mesh infection. Closing the abdomen after restoring continuity of the bowel at first stage surgery still leaves the problem of bridging a massive abdominal wall defect; therefore, a single stage procedure including laparotomy, bowel anastomosis and hernia repair is ideal. We present four complex cases of incisional hernia after multiple surgical procedures. All patients had colostomies or faecal fistulae which were closed in a single stage procedure with simultaneous Rives-Stoppa massive incisional hernia repair. Methods: Four patients (age range 41 to 82 years) with co-morbidities including cardiorespiratory and thromboembolic disease underwent laparotomy and massive incisional hernia repair using the Rives-Stoppa technique with Ultra-pro mesh (30 9 30 cm). Original surgery resulting in massive incisional hernia included: laparotomy, small bowel resection and transverse end colostomy formation for mesenteric ischemia with postoperative anticoagulation; bariatric surgery complicated by leakage and peritonitis, with multiple relaparotomy procedures, lavage and small bowel fistula secondary to transphysio mesh repair; Crohns disease and severe perianal sepsis managed by defunctioning loop sigmoid colostomy complicated by large parastomal hernia; and, right hemicolectomy complicated by anastomotic leakage requiring relaparotomy and, ileostomy and mucus fistula formation.

123

S182 Results: All patients had uneventful postoperative recoveries with minor wound infections in two patients which resolved promptly on opening of a small section of the wound. At follow up (mean 4 months) there was no recurrence and excellent functional and cosmetic outcomes. Conclusion: Single stage closure of colostomy and resection of fistula with Rives Stoppa massive incision hernia repair has been shown to be safe and effective in contaminated surgical sites with no incidence of mesh infection, no fluid collection and no recurrence.

P026 Associated postoperative hernias of anterior abdominal wall: case report

Hernia (2016) 20 (Suppl 2):S175–S249 tackers. 90 % of all surgical procedures were performed laparoscopically. We performed 28 incisional hernia repair, 4 primary hernia repair (1 umbilical, 2 epigastric and 1 lumbar hernia) and 2 parastomal hernia repair. The median operation time was 65.3 min for elective procedures and 81.2 min for urgencies. We had two complications (6.4 %) one case of intraoperative bleeding and one case of post-operative prolonged ileus successfully treated conservatively. We had no recurrences. According to QoL we can state that postoperative pain felt on the whole and in the site of the hernia is mild at 6 weeks of follow up, while at 12 months patients do not complain about pain or discomfort for esthetic result. Laparoscopic treatment with the use of composite mesh in polypropylene fixed with absorbable devices is feasible and safe. More data are needed in order to confirm the results of this our preliminary experience.

P. Milosevic, M. Kolinovic, M. Babovic General Hospital Danilo I, Department of Surgery, Cetinje, Montenegro The authors report a case of associated postoperative hernias of anterior abdominal wall, emphasizing the most efficient way of their repair. The patient was a 60-year old man who decided to visit the outpatient clinic of the General Hospital ‘‘Danilo I’’, Cetinje, Montenegro, in November 2014. Hernias initially appeared at the operative sites, a year after appendectomy which was performed 3 years ago and 1 year after surgical treatment of perforated ulcer of duodenal bulb which was done 5 years ago. The surgery was performed under general anesthesia, through right subcostal cut. The both hernial sacs were prepared and opened. Their content was repositioned into the abdominal cavity and the sacs were sutured. The muscles and fascia between two hernial sacs were left intact and each hernia was repaired separately. Monofilament polypropylene meshes were placed preperitoneally and fixed. At the site of appendectomy, the lateral and lower portions of the mesh were attached to internal oblique muscle while the medial portion was attached to intact rectus abdominis fascia. At the site of previous duodenal ulcer surgery, both lateral portions and lower portion of the mesh were attached to rectus abdominis fascia. The upper portions of the mesh at both hernia sites were attached to costal arch. In this case of associated anterior abdominal wall hernias, the surgery was performed through one cut but each hernia was repaired separately, leaving intact the area of muscles and fascia between them and using it to achieve the optimal reconstruction of anterior abdominal wall.

P027 Repair of primary and incisional hernias using composite mesh: our experience with 34 cases M.A. Marzetti, S.A.M. Vigna, D. Prando, F. Agresta Santa Maria Regina degli Angeli Hospital, General surgery, Adria, Italy We evaluated in a prospective observational study a cohort population which underwent primary and incisional hernia repair using a composite mesh in polypropylene fixed with absorbable devices. We focused on feasible and safety of the procedures performed by experienced surgeons in laparoscopy analyzing our data trough the EuraHS registry. A total of 79 procedures of primary and incisional hernia repair were performed from July 2013 to December 2015 at Santa Maria Regina degli Angeli Hospital in Adria (RO); we analyzed 34 of these procedures which were performed using a composite mesh the CMC ‘‘Clear Mesh Composite’’(Dipromed) fixed with absorbable

123

P028 A single-center report in the management of open surgery of incisional hernia repair with mesh J. Tang1, L. Huang2 1 Shanghai Huadong Hospital, Surgical Department, China, 2 Shanghai Huadong Hospital, Hernia Surgery and Training Center, China Objective: To analyze and assess the clinical efficacy of open primary incisional hernia mesh repair. Methods: Clinical data of 601 cases of open primary incisional hernia mesh repair from Dec. 2002 to Dec. 2013 in Huadong Hospital were analyzed. According to the different types of incisional hernia, using different patches on 601 cases of incisional hernia repair. Recurrence,wound infection, chronic pain, patch infection with intestinal fistula and seroma and other complications were observed and analyzed. Results: There were 5 deaths (0.8 %) after operation. After a mean follow-up of 3 years, 23 cases (3.8 %) of recurrence, 40 cases (6.7 %) of wound infection or fat liquefaction, 5 cases (0.8 %) of chronic pain, patch infection in 10 patients (1.7 %), intestinal fistula in 12 patients (2.0 %), seroma in 6 cases (1.0 %). Compared using PROCEED, Using GORE-TEX DualMesh or Composix Kugel Patch patch had high incidence of wound infection (P \ 0.01), while using Composix E/X Mesh patch had no difference in incidence of wound infection (P > 0.05). Incidence of patch infection of GORE-TEX DualMesh was significantly higher than PROCEED (P\0.01). Conclusion: Open primary incisional hernia mesh repair for incisional hernia treatment is safe and effective technique. We recommend using different patchs for different patients for the best effective.

P029 Parastomal hernia is an independent risk factor for incisional hernia in patients with end colostomy J.I. Jorge Barreiro1, I. Garcia Bear1, A. Rodriguez Infante1, N. Gutierrez Corral1, G. Minguez Ruiz1, V. Sanchez Turrion2, J.L. Otero Diez1 1 San Agustin, Department of General Surgery, Aviles, Spain, 2 Hospital Puerta de Hierro, Department of General Surgery, Madrid, Spain Background data: Incisional hernia (IH) is the most frequent complication after abdominal surgery with an incidence of 11–20 % and

Hernia (2016) 20 (Suppl 2):S175–S249 up to 35 % in risk groups. Our hypothesis is that parastomal hernia (PH) might also be a risk factors can help determine the need for preventive measures like primary mesh augmentation. Methods: All patients who were operated between 2001 and 2013 by means of a Hartmann procedure or abdominoperineal resection were invited for a follow-up visit to our outpatient clinic. Primary outcome measures were the prevalences of IH and PH: All possible risk factors for IH were scored. A physical examination was performed and, when available, CT scans were scored for IH and PH. Results: A total of 180 patients were seen in the outpatient clinic. The median follow-up was 43 months. IH had a prevalence of 38.1 % and PH had a prevalence of 54.3 %. Both hernias were present in the same patient in 28 %. PH was found to be a statistically significant risk factor for IH in univariate and multivariate logistic regression analyses of variance, with an Odds Ratio (OR) of 7.6 (95 % CI 3.5–16.7). This effect can possibly be attributed to a shift of the midline or rectus muscle atrophy after colostomy creation. In addition, an emergency operation was found to be a risk factor for IH with an OR of 6.2 in the multivariate analyses. Conclusions: Patients with a PH have a 6 times higer chance os developing an IH compared to patients without PH.

P030 Previous trial: Mesh-augmented reinforcement of midline laparotomy with an absorbable mesh. Preliminary results S. Valverde, M. Lo´pez Cano Hospital Vall d’Hebron, General Surgery, Barcelona, Spain Background: Incisional hernia (IH) can occur after laparotomy in up to 30 % of the cases, with an onset shortly after surgery. It worsens life quality and represents a cost to our health systems. There is a lack of consistent evidence regarding the prevention of IH. Objective: Testing whether midline laparotomy augmentation with an absorbable mesh decreases the incidence of IH and, secondarily, finding differences in operative and postoperative outcomes. Methods: From September 2014 to September 2015 patients who underwent an emergent or elective midline laparotomy were included in a randomized prospective trial. The experimental group (group A) underwent mesh-augmented reinforcement of midline laparotomy with an inlay polyglycolic acid-trimethylene carbonate (BIO-A) mesh and an absorbable continuous suture. The control group (group B) received a conventional laparotomy closure with an absorbable continuous suture without prosthetic mesh. Preoperative demographic data. Operative details and postoperative complications were collected. Follow-up was done by a post-operative physical examination 3 months after surgery and a computerized tomography scan (CT) 6 months postoperatively. Outcomes: 95 patients were randomized, 48 in group A and 47 in group B. 60 % were male and the average age was 65. Emergent cases represented 33.7 % overall. Demographic and operative data were homogeneous. No significant differences were found in postoperative complications or mortality. There was 1 suspected incisional hernia in group A and 2 suspected incisional hernias in group B on physical examination. The CT on the 6th month showed 4 cases of incisional hernia; 2 of them in each group (10.9 % incidence of IH overall). Conclusion: IH after elective or emergent laparotomy may be reduced by midline reinforcement with an inlay absorbable mesh such as BIO-A with no significant differences in morbidity and mortality. However, no differences have been showed in this study. A wider sample is needed for conclusive results.

S183

P031 The methods of reducing postoperative complications in the treatment of incisional ventral hernias N. Petrovsky Alexandr Regional Clinical Hospital named after Prof. S.V. Ochapovsky, General Surgery, Krasnodar, Russian Federation The incisional ventral hernias of the abdominal wall are observed in 20–22 % of patients with a history of abdominal surgery. Despite the introduction of modern technologies, materials and improvement of technical approaches, the level of postoperative complications in the treatment of the incisional ventral hernias remains the same. The goal of our work was the analysis of the frequency of postoperative complications after plastic on-line and in various kinds of separation repair the anterior abdominal wall. Retro- and prospective review of different types of hernia repair on the occasion of incisional ventral hernias, performed in our clinic between 26.12.2013 and 12.25.2015, were analysed total 746 interventions were performed, of which, according to the SWRclassification 194 operations-R1, 78-R2, 40-R3; hernias of 90 patients, because of size hernial ring refer to the level W1, 102-W2, 97-W3, 23-W4; 28 patients had lateral hernia gate location, in 284 cases there was a medial location of the hernial ring. 236 patients had multi-chamber hernial sac, among them 175 cases were the presence of herniate accompanied by the loss of the domain. 110 patients underwent hernia repair using onlay-plastic—24 patients in the postoperative period had postoperative wound infection, 16 had supraaponeurotic seromas. Posterior separation repair in various versions had made to 112 patients—postoperative wound infection was noted in 3 cases, the postoperative bleeding was not observed. 90 patients underwent anterior separation hernia repair— postoperative wound infection was noted in 2 cases, the postoperative bleeding formation was not observed. Lethal outcomes and hernia recurrence were not observed after our surgical treatment in all groups of hernia repair. So, our study report demonstrates the advantages of separation methods for recovery of the abdominal wall.

P032 Occurrence of hernia and abdominal bulging after open partial nephrectomies A.I. Aapo Inkila¨inen, K.S. Karin Striga˚rd, B.L. Bo¨rje Ljungberg University Hospital of Umea˚, Urology and Andrology, Umea˚, Sweden Keywords: Flank bulge, Incisional hernia, Renal cell carcinoma, Open partial nephrectomy. Background: Abdominal bulging and incisional hernia are known complications after open partial nephrectomies (OPN) in a flank incision. There is a lack of knowledge in the field of the exact occurrence rate of bulging or hernia after surgery. Objective: To determine the prevalence and potential risk factors of bulging and hernia after OPN in a flank incision. Design, setting and participants: A retrospective review of the medical records of 197 consecutive patients that had been treated with OPN in a flank incision during 2004–2014 at the University Hospital of Umea˚ and Sundsvall–Ha¨rno¨sand County Hospital. Medical records and radiological images from preoperative work-up and follow-up after surgery at 3, 12 and 24 months were reviewed for the occurrence of bulging or hernia. Bulges were graded and measured using a newly developed scoring system. Outcome measurements and statistical analysis: Chi square and Fischer’s exact tests were used to compare categorical values. T test and Mann–Whitney U test were used to compare means.

123

S184 Results and limitation: After exclusion 186 patients remained for analysis. Clinical bulge was noted in 36 patients (19 %) and radiological changes perceived as bulging were seen in 50 patients (26 %). Clinical hernia was reported in 5 patients (3 %) and radiological hernia was seen in 10 patients (5 %). BMI [ 26 was a statistically significant risk factor for hernia (p = 0.03). Patients with clinical bulging had a mean 47.4 min longer surgery time (p = 0,0002). Other demographic variables showed no statistic significance. Conclusion: Rates of hernia after a flank incision is comparable to the rates after other abdominal surgery. Bulging is a common complication after flank incisions. Further studies are required to evaluate psychological and physiological effects of bulging.

P033 A risk model and cost analysis of post operative incisional hernia following 4,608 open hysterectomiesdefining indications and opportunities for risk reduction M.A. Lanni, M.G. Tecce, M.N. Basta, V. Shubinets, M.N. Mirzabeigi, S.J. Kovach, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Purpose: Incisional hernia (IH) is a major complication following open abdominal hysterectomy. The purpose of this study is threefold: (1) to assess the incidence and health care cost of surgically repaired IH after open abdominal hysterectomy; (2) identify actionable, perioperative risk factors; and (3) create a predictive risk model. Methods: We conducted a retrospective review of patients who underwent open hysterectomy through an open abdominal approach between 1/2005 and 6/2013 within the University of Pennsylvania Health System. The primary outcome of interest was posthysterectomy IH. Univariate and multivariate cox proportional hazard analyses were performed to identify perioperative risk factors. Patients with prior hernia, less than 1 year followup, or emergency surgeries were excluded. Cox hazard regression modeling with bootstrapped validation, risk factor stratification, and assessment of model performance was performed. Results: A total of 4608 patients underwent open abdominal hysterectomy during the study period. Eighty-four patients (1.82 %) required IH repair and generated significantly higher costs of care ($68,077 vs. $22,107, p \ 0.001). Ten risk factors were identified and included in the final adjusted risk model, the strongest of which were acute intraabdominal inflammatory process (HR = 3.75 [1.46 9.63]) and liver disease (HR = 2.61 [1.554.40]). Extreme risk patients experienced the highest incidence of surgically repaired IH after hysterectomy (21.7 %), followed by the high risk group (7.3 %), moderate risk group (2.3 %), and low risk group (0.6 %) (C statistic = 0.81). Conclusion: This study identifies perioperative risk factors for IH and provides a risk prediction instrument to accurately stratify patients, augment preoperative counseling, and potentially imply risk reduction techniques.

P034 Parastoma hernia repair: Modified Sugarbaker procedure with components separation technique vs modified Rives sublay with components separation technique M. Zuvela, D. Galun, I. Palibrk, N. Bidzic, A. Bogdanovic, S. Miric University Clinic for Digestive Surgery, HPB Unit, Belgrade, Serbia Background: The study objective is to compare the modified Sugarbaker and modified Rives procedure both combined with

123

Hernia (2016) 20 (Suppl 2):S175–S249 components separation technique (CST) in the management of parastomal hernia. Methods: From June 2011–January 2016 we managed 18 patients with parastomal hernia using two operative techniques. The modified Rives technique with CST was performed in 13 patients: (a) rectus muscle dissection from posterior rectus sheath on the opposite side of stoma location; (b) dissection external from internal oblique muscle on the side of stoma location; (c) sewing posterior rectus sheath and internal oblique muscle around the stoma on the side of stoma location; (d) complete reconstruction of the posterior miofascial layer is achieved by stitching both posterior rectus sheaths at the midline; (e) polypropylene mesh is cut like in ‘‘keyhole-technique’’ and positioned to rectus muscle on the opposite side of stoma location and to external oblique muscle on the side of stoma location; (f) complete reconstruction of the anterior miofascial layer is achieved by stitching anterior rectus sheath and external oblique muscle around the stoma on the side of stoma location and both anterior rectus sheaths at the midline. The modified Sugarbaker technique was performed in 5 patients: (a) dissection of external from internal oblique muscle on the side of stoma location; (b) sewing rectus muscle and internal oblique muscle around the stoma on the side of stoma location; (c) Sugarbaker intraperitoneal mesh hernioplasty with mesh/tissue overlapping for 5–7 cm and covering midline incision with mesh. Results: Complications: 1(7.7 %) mesh infection and 1(7.7 %) hernia recurrence after the modified Rives technique with CST and 1(20 %) mesh infection resulting in hernia recurrence after the modified Sugarbaker technique with CST during mean follow-up of 18 (2–54) months. Conclusion: Both operative techniques can be used for the management of patients with parastomal hernia.

P035 Development of a clinically-actionable, longitudinal incisional hernia risk model following colectomy surgery using all-payer claims data M.A. Lanni, M.G. Tecce, Y. Hsu, R.R. Kelz, J.P. Fox, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Objective: Incisional hernia (IH) remains a persistent and costly complication. Prophylactic mesh augmentation (PMA) is an effective, risk reductive technique but guidelines are lacking. We aim to use claims data to develop an actionable risk model of IH following colectomy. Methods: State in-patient HCUP datasets (NY, CA, FL; 25 % allpayer US) were used to identify colectomy cases hernia risk was calculated with multivariable hierarchical logistic regression modeling and validated using bootstrap techniques. Exclusion criteria included: concurrent hernia, metastasis, mortality, and \18 years. Inflation-adjusted expenditure estimates were calculated. Results: 30,865 patients underwent colectomy (1/3 laparoscopic and 70 % for cancer). 24 % of patients were smokers, 12 % were obese, and 3 % had prior hernia repair. IH occurred in 5.5 % (30 month follow-up). Open repair was performed in 80 % costing $58,000/case and translating into inflation-adjusted national costs of -billion per year. 16 risk factors were identified, including: open (OR = 1.9), obesity (OR = 1.7), cancer (OR = 2.0), Hispanic race (OR = 2.6), and prior hernia (OR = 1.8). A simple risk model was created: 2 to 20 % (C-statistic = 0.7). Conclusions: We present a clinically-actionable model of IH using all-payer claims following colectomy. Hernia risk can be identified based upon preoperative co-morbidities, procedural characteristics, and adjusted for surgeon and hospital characteristics. The data

Hernia (2016) 20 (Suppl 2):S175–S249 presented can structure preoperative risk counseling, inform decisions for PMA, and advance the field of risk prediction using claims data.

P036 The current state of prophylactic mesh augmentation: Outcomes, risk modeling, barriers to adoption, and the future of risk M.A. Lanni, M.G. Tecce, V. Shubinets, M.N. Mirzabeigi, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Introduction: With the high incidence and insufficient treatments leading to disproportionately high morbidity and cost associated with the incisional hernia after laparotomy, it is crucial to investigate hernia prevention. Prophylactic mesh augmentation (PMA) is the implantation of mesh at index laparotomy to decrease a patient’s risk for developing incisional hernia (IH). The current body of evidence lacks standard guidelines for patient selection, mesh placement, and material choice. The purpose of this study is to identify areas of research needed to formulate a clinical framework and to foster responsible and appropriate of use of new technology and surgical techniques. Study design: We conducted a comprehensive literature search of Scopus and PubMed and a search of clinicaltrials.gov for articles and trials related to using PMA for incisional hernia risk reduction. Our review was further supplemented by including select papers on biomechanical properties of mesh, animal models, cost-practicality, patient-reported outcomes, risk-modeling, surgical techniques, and available materials related to PMA. Results: Five-hundred-fifty-one unique articles and 288 trials were reviewed. Multiple studies report that there was significant decrease in IH incidence with PMA compared to suture closure, although seromas have been associated with onlay mesh positioning. No multicenter randomized control trial (MCRCT) has been conducted in the United States to date. Only two such trials are currently active, but they are inconsistent in examining PMA variables or defining IH. Conclusions: There are clear indications for the use of PMA, with evident cost-utility and models for selecting high-risk patients, but treatment guidelines are lacking. Widespread adoption of PMA requires large scale pragmatic MCRCT research and CPT coding. The first step in breaking down the barriers preventing the use of PMA in a high-risk cohort of patients will be gaining awareness to build momentum for PMA adoption worldwide.

P037 A systematic review of operative techniques for kidney transplant recipients: conventional techniques show unacceptable rates of abdominal wall relaxation and incisional hernia S. Wagenaar, J.H. Nederhoed, A.W.J. Hoksbergen, H.J. Bonjer, W. Wisselink, G.H. van Ramshorst VU medical center, Surgery, Amsterdam, Netherlands Background: Conventional kidney transplantation surgery can cause abdominal wall relaxation and incisional hernia. Our aim was to systematically review available literature and to compare conventional and minimally invasive operative techniques for kidney transplant recipients. Methods: A systematic review was conducted in Pubmed-medline, EMBASE and Cochrane library. Articles were included and scored by

S185 two independent reviewers using Group Reading Assessment and Diagnostic Evaluation scale (GRADE), Newcastle Ottawas quality assessment Scale (NOS) and Oxford Guidelines. Main outcomes were incisional hernia, cosmetic result, surgical site infection (SSI) and graft survival. Results: In total, 16 out of 1823 identified publications were included and assessed. One RCT, two cohort studies and 13 case–control or case-series were found describing 15 different techniques. In general, quality of evidence was low: GRADE range 1–3; NOS range 0–4; Oxford level range 2–4. Four subgroups were distinguished: conventional open techniques, minimally invasive open techniques, laparoscopic techniques and robotically assisted techniques. Hockey-stick incisions showed higher rates of abdominal wall relaxation (24 %) compared to Gibson incisions (8 %). Incisional hernia rates were 9–16 % for hockey-stick incisions, 0–4 % for Gibson incisions and 0–6 % for minimally invasive techniques. Conventional techniques showed higher SSI rates (2–29 %) with worse cosmetic result (mean incision length 14.2–21.2 cm) and slower postoperative recovery in terms of pain and hospitalization. Reported disadvantages included prolonged cold and warm ischemia time (0.5–14 h and 2–67 min, respectively) and operation time (118–257 min). No differences were found for graft or patient survival. Conclusion: Conventional techniques, and the hockey-stick incision in particular, show unacceptable rates of postoperative abdominal wall complications. Although the level of evidence was generally low, minimally invasive techniques showed promising results with regard to complications and recovery and should be considered to use. For open surgery, authors recommend using the smallest possible Gibson incision.

P038 Open repair of large incisional hernia with Progrip self gripping mesh-2 Year long term results S.B. Hopson, L. Miller TPMG Hernia Center, Surgery, Newport News, Virginia, USA Purpose: Secure mesh fixation in incisional hernia repair is mandatory to prevent mesh dislocation. Traditional fixation methods such as sutures and tacks have been implicated as a source of chronic postoperative pain as well as possible points of recurrence. We report 2-year outcomes with a self-gripping mesh for repair of open incisional hernia. Methods: This prospective case series enrolled 20 patients (10 female, 10 males, mean age 62 ± 12 years, mean body mass index 35 ± 9 kg/m2) with incisional hernia (mean defect size: 84 ± 28 cm2). Patients were treated using a polyester mesh with resorbable polylactic acid microgrips (Parietex ProGrip[TRADEMARK], Covidien, Mansfield, MA, USA) using open onlay technique. Components separation was included if necessary. Outcomes included pain severity (0 to 10 scale), Carolinas Comfort Scale (CCS), complications, and hernia recurrence. Patients returned for follow-up at 1, 3, 6, 12, and 24 months. Results: Median mesh fixation time was 2 min. Mean operative time was 38 min. Patients were discharged same day (n = 15) or next day (n = 5). Minor seroma occurred postoperatively in one patient. Patient follow-up compliance through 2 years was 100 %. Mean pain score was 1.8 ± 2.0 at discharge, 0.9 ± 1.7 at 1 month, 0.7 ± 1.7 at 1 year, and 0 at 2 years. At 2-year follow-up, all patients were very satisfied with treatment and hernia-specific quality of life was excellent (mean CCS score = 0). No infection, mesh removal, or hernia recurrence were observed during follow-up.

123

S186 Conclusions: Open repair using a self-gripping mesh is a viable treatment option in patients with incisional hernia. This study shows immediate mesh fixation facilitates a safe and durable tension-free repair with no serious complication. This technique may be an improved method than other reported open techniques. Further studies comparing this procedure to other hernia procedure are suggested. The simplicity, adaptability and potential reduced cost of this procedure make it very attractive.

P039 Surgical treatment of incisional hernias in the patients with excessive subcutaneous fat on the abdominal wall B.S. Gogia, R.R. Alyautdinov A.V.Vishnevsky Institute of Surgery, Plastic Surgery, Moscow, Russian Federation Background: Excess deposition of fat in the abdominal wall contributes to the further relaxation of muscular aponeurotic elements of the abdominal wall which is already compromised in the patients with incisional hernias. Methods: Dermolipectomy combined with hernia repair was performed in 74 patients (female 73, male 1). Incisional hernia in 64 (86.5 %) on the abdominal wall were localized midline, in 7 (9.5 %)—laterally and in 3 (4.0 %) cases both localizations were observed. 6 (8.1 %) patients had a small hernia, 15 (20.3 %)—average, 35 (47.3 %)—large and 18 (24.3 %)—a giant one. The age of patients was 51.9 ± 1.2 years, weight—96.9 ± 1.9 kg (maximum weight—150 kg), BMI—37.4 ± 0.7 kg/m2 (maximum—53.8 kg/ m2). In 36 patients hernia repair was performed autoplastically, in 38—by using Prolene mesh in the ‘Onlay’ position. Incisions for dermolipectomy were performed depending on the location of the hernia in the abdominal wall by the method: Thorek, Grazer, Castanares or Kelly. Results: In the group of patients, undergone dermolipectomy in autoplasty, the rate of local postoperative complications was 16 (44.4 %), in prosthetic repair—18 (47.4 %) (P [ 0.05). Seroma was the most frequent complication: after autoplasty it occurred in 8 (22 %) cases, after prosthetic repair—in 11(29.0 %) cases (P [ 0.05). Edge necrosis occurred in 2 cases after incisions by Castanares. In the long-term period recurrence in patients after autoplasty observed in 6 (16.7 %) cases, after prosthetic repair—in 2 (5.3 %). Conclusions: In patients with incisional hernias and obesity combined removal of excess subcutaneous fat is both one of the links in the prevention of hernia recurrence and goal to achieve satisfactory cosmetic results. In addition, in hernia repair using a polypropylene mesh dermolipectomy does not increase the incidence of local postoperative complications.

P040 Recurrent incisional hernia repair with open ventral hernia repair with mesh (OVHR) S. Tahir1, A. Nikolovski1, G.J. Stavridis1, A. Devaja1, T. Baldjiev2, D. Mladenovik1 1 University Surgical Clinic-St.Naum Ohridski, Abdominal, Skopje, Macedonia, 2General Hospital Strumica, Abdomen, Strumica, Macedonia Introduction: Incisional hernias show recidivism in more than 20 %, seroma occur in 25–45 %, infection of the surgical wound/incision SSI 15–30 %, eventration in 5–15 % of the cases. Materials and methods: Over the period 2003–2013, 254 patients were operated. 55 % of the patients were previously operated at our

123

Hernia (2016) 20 (Suppl 2):S175–S249 clinic (all with mesh) and 45 % at various hospitals (suturing and mesh techniques). Correspondingly, 52 (20 %) were previously operated with suturing and 202 (80 %) with mesh technique. OVHRM was used on all of the patients. From the total, 158 (62 %) were operated with median laparotomy incision, 41 (16 %) with subcostal incision, 30 (12 %) with post appendectomy (Gridiron’s) and 25 (10 %) with lumbotomy incision. All patients were operated under GEA. Pre-surgical prophylactic dose of antibiotic was given to all patients. Generally used materials were PROLENE mash or dual mash (PROLENE and VICRYL). Commonly used mesh size: 20 9 30 cm–148 pat(58 %), 15 9 15 cm–78(31 %). Retromuscular preperitoneal mesh was placed in 139 patients (55 %), Chevrel technique of the premuscular placement used with 74 patients (29 %) and in 41 patients (16 %) intraperitoneal dual mesh was placed (Parietene). In 152 patients (60 %) that were operated single and double vacuum drainage was inserted. Outcome: In 65 (25 %) patients seroma occurred more than 10 days, 49 (19 %) had retromuscular mesh, 16 (6 %) patients had intraperitoneal. In 15 (4 %) patients inflammation of the incision site occurred and were treated with antibiotics, 9(3 %) retromuscular and 3 (1 %) intraperitoneal mesh. Only 2 (0.7 %) retromuscular mesh patients needed mandatory removal of the mesh by using component separation technique. Hospitalization was 7.4 days (min 3, max 35 days). Follow-ups for a year postoperatively. Recidivism occurred in 10 (4 %) patients. Conclusion: On the basis of the study we conclude that Chevrel’s technique in incisional hernia with midline incisions and Retromuscular mesh repair technique with all the remaining incisional hernias demonstrate best results respectively.

P041 Laparoscopic incisional and ventral hernia repair (LIVH): a single-center experience with ePTFE/PP mesh fixed with absorbable fixation device M. Origi, M.R. Moroni, P. Veronesi, M. Gerosa, W. Zuliani Humanitas Mater Domini Clinical Institute, Surgery, Castellanza (Varese), Italy Background (aim): Evaluation of results using a standardized technique, unique surgical equipe and single type of lightweight laparoscopic dual-mesh (Herniamesh-Relimesh) fixed with absorbable strap fixation device (Ethicon-Securestrap). Methods: 70 patients underwent laparoscopic treatment of incisional hernia between 2011–2015. We evaluate hernia recurrences, seroma (clinical evaluation and ultrasound at 2 weeks, 3–6 months after surgery from single surgeon), post-operative pain (Carolinas Comfort Scale [TRADEMARK]—CCS). In case of suspected recurrence or in defects [10 cm, a CT-scan was performed. Results: The mean follow-up was 11.68 (±19.8) months. Mean age was 65.96 (±11.3) years, mean BMI 28.60 (±11.3), mean ASA score was 2. Two conversion to laparotomy (1.4). No evidence of intraoperative mesh damage or dislocation due to the fixation system was observed. The mean operative time was 75.72 (±48) minutes. The overall morbidity rate was 15 %. None major complications, including post-operative peritonitis (bowel injury) and surgical site pain or ileus implied revisional surgery. One case of mesh infection in umbilical defect of 3 cm in obese patient required mesh removal (0.7 %). Three patients developed non-infected seroma (2.1 %). The mean duration of hospitalization was 2.24 (±2.3) days. The recurrence rate was 2.8 %. The average interval to onset of recurrence was 45.8 (±31.1) months. The post-operative pain assessment (3 and 6 months) evaluated with CCS showed that 87 % of patients were satisfied, without impairment of activities of daily-living, coughing or deep breathing and exercise.

Hernia (2016) 20 (Suppl 2):S175–S249 Conclusion: LIVH repair using intra-peritoneal mesh fixed with absorbable straps is a safe technique with satisfactory outcomes, even in large hernia defects [10 cm and obese patients. Laparoscopic approach such be considered in all such patients since it seems to guarantee both encouraging short term and long term results with decreased risk of abdominal wall infection than is observed in open repair.

P042 Abdominal wall reconstruction improves pulmonary expiratory function: A prospective clinical study of patients with giant incisional hernia K.K. Jensen, V. Backer, L.N. Jorgensen Bispebjerg University Hospital, Digestive Disease Center, Copenhagen, Denmark Background: One-fifths of patients undergoing abdominal wall reconstruction (AWR) due to giant incisional hernia—develop respiratory complications, which is hypothesized to be partly due to increased postoperative intraabdominal pressure. It is unknown if long-term pulmonary function is affected by AWR. We sought to address this from measurement of pulmonary function and subjective changes in pulmonary symptoms in patients who underwent AWR for giant incisional hernia. Methods: Consecutive patients scheduled to undergo open AWR for giant incisional hernia (horizontal fascial defect [10 cm) aided by endoscopic anterior component separation were examined pre- and 1 year postoperatively. Examinations included pulmonary spirometry, measurement of maximal in- and expiratory mouth pressure, St. George respiratory questionnaire (SGRQ), and a modified COPD assessment test (CAT). This study was registered at clinicaltrials.gov (NCT02011048). Results: A total of 18 patients were included in the study, and 17 were available for one-year follow-up. Compared with preoperative results, predicted peak expiratory flow (84 % preop vs 91 % postop, P = 0.036) and maximal expiratory pressure were significantly increased (95 cmH2O preop vs. 102 cmH2O postop, P = 0.049), whereas maximal inspiratory pressure showed insignificant changes (102 cmH2O preop vs 103 cmH2O postop, P = 0.306). Spirometric examination revealed no significant change in predicted forced vital capacity (92 % preop vs. 0.91 % postop, P = 1.00). There were no significant changes in the patient-reported respiratory quality of life questionnaires on SGRQ (vs. 12.92 preop vs 9.31 postop, P = 0.190) and CAT (. 8.5 preop vs 7.0 postop, P = 0.270). Conclusion: AWR for giant incisional hernia increased the peak expiratory flow and maximal expiratory pressure without compromising other pulmonary volumes or respiratory quality of life 1 year postoperatively.

P043 A cohort study of 54 patients with port-site incisional hernia A.L. Lambertz1, B.O. Stu¨ben2, R.M. Eickhoff1, U.P. Neumann1, C.J. Krones2, C.D. Klink1 1 RWTH Aachen University Hospital, Department of General, Visceral and Transplantation Surgery, Aachen, Germany, 2Katholische Stiftung Marienhospital Aachen, Department of General and Visceral Surg, Aachen, Germany Background: Port-site incisional hernia (PIH) is an ongoing surgical problem especially due to the increased use of laparoscopic

S187 approaches. Whether the question if port-site closure should be performed by fascia suture or not, nor the optimal treatment strategy in PIH (suture vs. mesh) is yet not clarified. To contribute to these questions, the aim of this study was to describe our experience presenting a series of 54 patients with PIH operated in two surgical centres during 10 years and to derive possible treatment strategies from these results. Methods: 54 patients were operated due to port-site incisional hernia in two surgical centres between 2003 and 2013. Depending on surgical technique of port-site hernia repair (Mesh repair group, n = 13 vs. Suture only group, n = 41) their data were collected and retrospectively analyzed. Results: In 96 % (52 patients), PIH occurred after the use of trocars with 10 mm or larger diameter. Body mass index (BMI) was significantly higher in patients treated with mesh repair (32 ± 9 vs. 27 ± 4; p = 0.023) and these patients had significantly higher rates of cardiac diseases (77 vs. 39 %; p = 0.026) than patients in the Suture only group. In the Mesh repair group, mean fascial defect size was significantly larger (31 ± 24 vs. 24 ± 32 mm; p = 0.007) and mean time of operation was significantly longer (83 ± 47 vs. 40 ± 28 min; p \ 0.001). Concerning mean hospital stay (3 ± 4 days; p = 0.057) and hernia recurrence rates (9 %; p = 0.653), there were no significant differences between study groups. Mean time of follow up was 32 ± 35 months. Conclusions: Fascia should be closed by suture in port sites of 10 mm and larger diameter. PIH repair by sublay mesh in cases of higher risk patients and larger fascial defects leads to similar outcomes like suture only repair in lower risk patients with smaller fascial defects.

P044 Fourier transform infra-red (FTIR) microscopy contribution for monitoring the in vivo degradation of bioresorbable meshes used for hernia repair Y. Bayon1, A. Alves2, C. Grossiord3, C. Brunon3 1 Medtronic-Sofradim Production, R&D, Tre´voux, France, 2NAMSA, ˆ ne, France, 3Science and Surface, Science NAMSA, Chasse/Rho and Surface, Ecully, France Background: Poly-L-Lactic acid (PLLA) and related polyester polymers are widely used materials in different clinical indications, including hernia repair, because of their biocompatible and biodegradable properties. The history and changes of such polymers after implantation as medical devices should be characterized since they condition their tissue repair functions by providing mechanical and/or scaffolding properties. In this study, PLLA degradation has been investigated, after subcutaneous implantation in rabbits. The extent and mapping of PLA degradation within selected medical devices was documented by a novel approach combining FTIR (Fourier Transform Infra-Red) spectroscopy and image analysis, from tissue explant sections. Materials and methods: 18 New Zealand White male rabbits received each, 8 subcutaneous implants: 4 PLLA test meshes and 4 control meshes (TIGR Matrix Surgical) (Novus Scientific). The follow-up period was 4, 26 and 52 weeks (n = 6 animals/time-period). Both the test and control meshes were implanted in 3 configurations: native, partially and highly pre-degraded. FTIR microscopic analyses were made directly on tissue explant sections. Standard histology staining was carried out in parallel. Results: FTIR analysis of reference PLLA yarns revealed peak shifts and intensity changes for bands at 1209 and 1130 cm-1. The intensity of these bands is linked to the crystallinity of PLLA, increasing with lower molecular weights of PLA as a result of hydrolysis progression.

123

S188 FTIR maps of PLLA yarn degradation were processed, in the overall tissue explant sections. Discussion and conclusions: FTIR microscopy has been used to image the degradation of PLA from explanted tissues. It mapped out, at the lm scale, the progression of degradation of PLA and related polymers in meshes and inside yarns. This helped in better understanding the foreign body reaction kinetics and hernia tissue repair throughout the in vivo life of the degradable polymers, by confronting FTIR and standard histology results.

P045 Use of the hernia sac as peritoneal flap in the repair of large incisional hernias C.S. Schoonjans, P. Leyman, M. Huyghe St-Augustinus Hospital, General and Abdominal Surgery, Antwerp, Belgium Background: Standard open repair of incisional hernia uses a mesh in the retromuscular position. In large hernias, fascial closure can’t always be achieved, leaving the mesh exposed in the subcutaneous tissue with a risk of developing wound complications. We present our experience with use of the peritoneal sac to bridge the fascial gap, to overcome this problem. Methods: We retrospectively reviewed the medical records of 17 patients who were operated by the senior author for midline incisional hernias between 2012 and 2014. In 7 patients, a peritoneal flap was used to bridge the fascial gap. All patients had a preoperative CTscan. Clinical follow-up was done at 6 weeks and 6 months after the procedure. Results: Transverse diameters in the peritoneal flap group ranged from 7–17 cm. In 6 patients the hernia sac was used in a sandwich way, covering the sublay mesh anteriorly and posteriorly. In one of the patients, we combined the technique with a Ramirez procedure because of the large size of the hernia (17 cm). In one additional patient, the technique was used without the interposition of mesh. None of the patients developed wound problems. There were no clinical recurrences. In one patient, we detected a small asymptomatic recurrence at the occasion of a laparoscopy for cholecystectomy. Conclusion: In our experience, the peritoneal flap technique is a useful tool in the repair of large incisional hernias, when primary fascial closure is not achievable without undue tension. The technique avoids unnecessary subcutaneous dissection, protecting the blood supply to the overlying skin which contributes to the prevention of wound complications.

P046 Ileoclose trial B. Villanueva-Figueredo, M. Lopez-Cano, F. Vallribera Valls, E. Espı´n Bassany H.U. Vall d´Hebro´n, General Surgery, Barcelona, Spain Background: Development of incisional hernia on loop ileostomy closure site is an unstudied frequent complication. This paper presents the design for a study protocol of a randomized controlled trial, the aim of which was to evaluate the efficacy and safety of prophylactically placing a bioabsorbable synthetic mesh for reinforcement of loop ileostomy closure site. Methods: The ILEOCLOSE trial (ILEOstomy CLOsure trial) is a unicentric randomized controlled trial in which adult patients undergoing elective ileostomy closure operations are assigned to one of two groups: an intervention group in which a continuous polydioxanone (PDS) suture is reinforced with a commercially available GORE

123

Hernia (2016) 20 (Suppl 2):S175–S249 BIO-A Tissue Reinforcement prosthesis (W. L. Gore & Associates, Flagstaff, AZ, USA), or a control group with continuous PDS suture only. Both groups are followed over 1 year. Outcomes: The primary outcome is the appearance of incisional hernias assessed by physical examination at clinical visits and radiologically (CT scan) performed at the end of follow-up. Secondary outcomes are the rate of complications, mainly infection, hematoma, burst abdomen, pain, and reoperation. The ILEOCLOSE trial has the potential to demonstrate that suture plus prosthetic mesh insertion for routine loop ileostomy closure is effective in preventing incisional hernias. This would avoid the effects on those affected, such as poor cosmesis, social embarrassment, or impaired quality of life, and to save costs potentially associated with incisional hernia surgical repair. Preliminary results will be presented.

P047 Abdominal wall reconstruction for large abdominal wall hernias along with restoration of intestinal continuity: is this two in one approach safe? S. Anwar, I. Rajput Calderdale and Huddersfield NHS Trust, General Surgery, Huddersfield, UK Aims: Reconstruction of large, complex abdominal wall hernias remains challenging. We aimed to assess the outcomes of abdominal wall hernia repairs, using component separation technique. In particular, we looked at a smaller subgroup that also had a simultaneous restoration of intestinal continuity; to assess the safety of a combined approach. Methods: We carried out a retrospective analysis of a prospectively maintained database of patients having abdominal wall reconstruction using a component separation technique. One-third of these patients had a concomitant restoration of intestinal continuity for a stoma along site a large abdominal wall defect with major loss of domain. Results: Twenty patients were identified between the periods of 2011 and 2015. Male to female ratio was 10:5. Median age was 65 (32–77). Seven patients also had a restoration of intestinal continuity. Median BMI was 32. There were 18 anterior component separations, 1 posterior component separation and 1 patient had both. Biological mesh was used in 12 patients, 8 had composite mesh. Median length of stay was 10 days. There were 10 seromas (only two required drainage), 5 wound infections (only one major). One patient had an anastomotic leak that settled successfully with conservative management. After a mean follow up of 14 months, we had 2 recurrences and no other hernia related complications. Conclusion: Although the incidence of seromas is high in this complex group it is compatible with other reported literature. Our data suggest that large incisional hernias can be repaired using a component separation technique whilst restoring intestinal continuity simultaneously with good results.

P048 A novel polylactide-caprolactone composite mesh used for ventral hernia repair: A first 2-year clinical observation Y.M. Shen, J. Chen, Q. Li, L. Sun, F.Q. Chen Beijing Chao-Yang Hospital, Capital Medical University, Hernia and Abdominal Wall Surgery, Beijing, China Background: Composite surgical mesh is widely used in laparoscopic repair of ventral hernia but may carry the risk of postoperative

Hernia (2016) 20 (Suppl 2):S175–S249 adhesion and more serious complications. The present study was undertaken to demonstrate the clinical outcomes of a new composite polypropylene mesh coated with poly L-lactide-co-e-caprolactone (EasyProsthesTM). Methods: Data was prospectively gathered with a database. This study included 100 patients who underwent laparoscopic ventral hernia repair (with or without the hybrid technique) using EasyProsthes composite mesh (EPM) in our institute. Hernia recurrence, chronic pain, seroma formation, intestinal fistula and obstruction, wound or abdominal infection, and ultrasound evidence of viscera adhesion were evaluated at 2 years post-operative follow up. Results: All patients completed 24 months of follow-up. 2 patients in EPM group (2 %) developed mesh-viscera adhesions after surgery. No patients developed intestinal fistulas or obstructions. 40 patients in EPM group (40 %) developed post-surgical seromas in the operative area. 1 patient developed postoperative wound infection. There were no cases of mesh infection and no reports of chronic pain or hernia recurrence. Conclusions: Despite a small cohort of patients, the results provide promising outcomes for the patients who underwent laparoscopic ventral hernia repair using EPM. A larger-size comparative study is urgently necessary to ascertain whether such a composite surgical mesh is comparable or superior to other intraperitoneal meshes.

P049 Posterior component separation for the treatment of complex abdominal wall problems L. Blazquez Hernando1, M.A. Garcia Uren˜a1, D. Mesero Montes1, J. Lo´pez Monclu´s2, A. Robı´n del Valle Lersundi1, P. Lo´pez Quindos1, C. Jimenez Ceinos1, N. Palencia1, R. Becerra1, A. Galvan1, A. Aguilera Velardo1, A. Cruz Cidoncha1, E. Gonzalez1, A. Moreno1 1 Hospital Universitario del Henares, General Surgery, Coslada, Spain, 2Hospital Universitario Puerta de Hierro-Majadahonda, General Surgery, Madrid, Spain Background: The complex incisional hernias are a serious health problem. These hernias may lead to severe complications and it also causes symptomatology that impair physical activity and quality of life. Surgical treatment is difficult and is accompanied by non-negligible morbidity and high recurrence rate. The posterior components separation helps in the treatment of these patients. Materials and methods: Prospectively maintained database was used to identify all patients with complex abdominal wall undergoing posterior component separation technique between 2012 and 2015. Briefly we identify complex abdominal hernias by size, localiizacio´n, the existence of contamination and some characteristics of the patient. Usually we performed a TAR and a we use a Carbonell component separation only when we can not dissect the preperitoneal space. We do not use lateral fixations. Results: 66 patients (62 % males) were operated with a mean age 61 years and BMI 32.3. 36 % diabetic and 41 % smokers. Hernias included: 16 midline hernias, 14 lateral, 15 medial + lateral, 11 medial + parastomal and 10 parastomal. Mean hospital stay: 9 days. The mean hernia defect was 11.3 (4–40). Complete closure of anterior layer was achieved in 38 %. 18 % needed an intestinal resection. 3 cases were operated in emergency situation and 4 had simultaneous dermolipectomy. The VHWG classification was: 16 type I, 24 type II, 22 type III and 4 type IV. Wound morbidity was: 7.5 % seromas, 4.5 % hematomas, 7.6 % superficial SSI, 6.1 % deep SSI. Abdominal and systemic complications: Paralytic ileus 13.6 %, 2 enteric fistulas from anastomosis, respiratory insufficiency 9.1 %, cardiac failure 4.5 %. With a mean follow-up of 18 months there was 8 recurrences (12.1 %) and 3 bulging (4.5 %).

S189 Conclusions: The posterior component separations is a very good solution for the complex abdominal wall problems with very acceptable rates of morbidity and recurrence.

P050 IPOM technique in district general hospital: first experience with Relimesh D.D. Dabic, B.M. Maric General Hospital Cacak, Surgery, Cacak, Serbia Background: Recent technical and technological achievements couldn’t outflank hernia surgery because general surgeons frequently get involved with it during their praxis. Introducing laparoscopic surgery into hernia surgery was a step forward. Methods: From October 2014 till May 2015 17 patients with ventral/ incisional hernia have been operated. Results: 17 have been operated, 9 with incisional and 8 patients with ventral/umbilical hernia. Average size of hernia aperture was 8.2 cm (4–12); in average, the operation lasted for 98 min (62–136); average duration of the hospitalization was 3.4 days (2–5). Average age of the patients was 56.4 years (38–71); 7 men and 4 women have been operated. Follow up period lasted for 6 months and the checks were held after 7 days, 1, 3, 6 months and 1 year. Intraoperative complications didn’t appear at all. 2 (11.76 %) patients had seroma complications and a pain that persisted for 3 months after the surgery. During the follow up period, further complications weren’t noticed. Tacker was used for fixation when it comes to all the patients. Conclusion: IPOM technique is already an appreciated method when it comes to ventral/incisional hernia surgery with use of various types of mesh for intraperitoneal placement. During this brief follow up period, Relimesh has proved to be a mesh that is easy handling, adequate for placement and fixation. It’s also quite competitive, if you take it’s price into account. When it comes to possible complications, they can be related to various things such as wrong ways of fixing, as well as the experience and the qualification of a surgeon. We can’t exclude complications that could appear as a consequence of mesh characteristics, but time will show.

P051 Laparoscopic incisional and ventral hernia repair. Our experience on 222 patients with 5-years follow-up M.J.R. Nardi, P. Millo, A. Usai, R. Brachet Contul, R. Lorusso, M. Grivon, E. Ponte, F. Persico, P. Bocchia, R. Allieta Regional Hospital ‘‘U. Parini’’, Aosta, Surgery, Aosta, Italy Background: Laparoscopic incisional and ventral hernia repair (LIVHR) is widely used although its clinical indications are often debated. The aim of this study is to describe our experience in order to establish the safety, efficacy, feasibility of LIVHR using composite mesh and to determine highlight the factors related to the surgical technique that influence the risk of hernia recurrence. Materials and methods: Between January 2007 and December 2015, 222 patients were admitted to General Surgery Division of Aosta (Italy), with the diagnosis of incisional or primary abdominal wall hernia and underwent laparoscopic repair. The type and size of surgical defects, mean operative time, morbidity, mortality, type of the mesh positioned, type of fixation means used, and rate of recurrence at 5 years follow-up retrospectively analysed. Results: We performed 222 LIVHR: 128 (58 %) for incisional hernia and 94 (42 %) for abdominal wall hernias. Mean age was 62.5; mean operative time was 48 min, conversion rate was 2.7 %. The mean size of abdominal defect was 3.5 (2–20), mean BMI was 30 kg/m2. The

123

S190 mean value of the overlap of the mesh was 5 cm in all directions. The mortality rate was 0 %; overall morbidity was 10.3 %. At 5-years follow-up we observed 19 (9 %) hernia recurrences. Conclusions: LIVHR using composite mesh is an effective and safe procedure with very low morbidity and low rates of postoperative pain and recurrence; the treatment is indicated especially in patients with median and paramedian abdominal defect with a diameter between 5 and 15 cm and in case of obesity. The fixation technique more secure in terms of reduction of recurrence seems to be the double crown of absorbable tacks associated with the positioning of 4 transparietal sutures, respecting and overlap of the mesh in all directions at least 5 cm. Key words: laparoscopy, incisional hernia, ventral hernia.

P052 Posterior component separation technique in incisional hernia repair V.V. Parshikov Nizhny Novgorod State Medical Academy, Hospital Surgery named after B.A.Korolyov, Nizhny Novgorod, Russian Federation Background: Prosthetic repair is commonly used procedure in patients with incisional hernias. In cases with wide hernia orifices the reconstruction of abdominal wall by standard sublay technique is not possible. The bridging repair is a known approach in such situation. Another hands the reconstruction is probably better for patients and developed higher life quality. Component separation technique (CST) is effective surgery for abdominal wall reconstruction but relatively difficult approach. CST to date is not common accepted procedure in big hernia repair. Methods: 122 patients with big incisional hernias were divided to two groups in prospective study and operated. In all cases used open mesh repair. In the first group (n = 76) used bridging technique. In the second group (n = 46) were performed abdominal wall reconstruction with posterior components separation and retromuscular mesh position according Carbonell (2008) or Novitsky (2013) approach. In the first group operations were made by different surgeons, in the second group all procedures were performed by single surgeon. Between the groups were no significant differences in hernia orifice sizes, ASA status, concomitant pathology and mesh type. The endpoints of study were hospital stay duration, re-operations, complications, recurrent hernia development and life quality. Follow-up in 2 years with clinical and ultrasonic study, MOS SF-36 QoL research. Results: No mortality in all patients was noted. Two deep infection (ns) and two re-operation (ns) in first group, one hematoma in both groups, 3 recurrent hernia (ns) in first group were observed. Hospital stay duration was lower in the second group. The life quality was better in second group. Conclusion: The abdominal wall reconstruction with posterior components technique and prosthetic repair is reliable and safety surgical procedure in patients with big incisional hernias.

P053 Laparoscopic giant abdominal hernia repair: results, complications and follow-up after 15 years of experience M. Uccelli, S. Olmi, G. Cesana, F. Ciccarese, G. Castello, V. Reggiani, G. Legnani San Marco Hospital, General Surgery Department, General Surgery Department, Zingonia (BG), Italy Background: The purpose of this study is to show safety, reproducibility and results of laparoscopic techniques in treatment of huge

123

Hernia (2016) 20 (Suppl 2):S175–S249 abdominal wall hernias. A further object is to compare the results related to the different fixing systems used. Methods: From January 2001 to December 2014, 500 unselected patients (280 females, 220 males), age 56 years (range 42–73), mean BMI 30 (range 26–58) were included in the study. All abdominal wall hernias recruited had a minimum dimension of 9 cm; average size: 12.5 cm (range 9–28). All patients underwent laparoscopic repair with composite mesh (Parietex PCO-Covidien) and all meshes have been fixed by the double crown technique, using 3 different fixing systems (EMS, Protack, Absorbatack). Results: Mean operative time: 68.5 min (range 38–120 min). Three different fixing devices: EMS (260 patients), Protack (210 patients) and Absorbatack (30 patients). We recorded in 8 cases (1.6 %) an intraoperative intestinal lesion, treated by suturing, with subsequent positioning of mesh. We recorded one case (0.20 %) of postoperative intestinal perforation treated laparoscopy without removal of the prosthesis. Average hospital stay: 2.5 days (range 2–4), with a return to normal activities within 28 days. Mean follow-up: 112 months (range 12–168). We recorded 20 seroma (4.0 %), 10 cases of chronic pain at 6 months (2.0 %) of which in 3 cases we proceeded to laparoscopic tacks removal. We recorded a total of 12 recurrences (2.4 %) distributed as follows: EMS 4 (1.5 %), Protack 5 (2.4 %), Absorbatack 3 (10 %). Conclusions: The encouraging results that we collected support the safety and effectiveness of the technique. Laparoscopic repair of huge abdominal wall defects is safe and effective when performed in centers with adequate experience, with excellent postoperative results. The follow-up showed, with significant differences with respect to the different fixing devices used, excellent results in terms of chronic pain and recurrences.

P054 Treatment costs of complex abdominal wall reconstruction with biological tissue matrix F.A. Philipszoon1, P.C. Philipszoon1, T.M.J. van Bakel2, M.R. Toorenvliet2, W.J. Vles2 1 PhilMed, Health Economy, Riel, Netherlands, 2Ikazia Hospital, General Surgery, Rotterdam, Netherlands Background: Exact cost data of complex abdominal wall reconstruction (CAWR) remain insufficient. The aim of this study was to estimate treatment costs of CAWR with Strattice[TRADEMARK] biological porcine tissue matrix, using the results of an analysis performed at a Dutch hospital. Methods: Patient-level data was collected from the Ikazia hospital in Rotterdam, The Netherlands. All patients undergoing complex abdominal wall reconstruction (N = 13) at the hospital between March, 2010 and July, 2014 were included in this study. Costs were measured per patient and included all direct treatment-related costs; consisting of ambulatory pre-operative nutrition costs, inpatient hospital care costs, and costs of post-operative clinical stay until hospital leave. Costs were calculated by multiplying the units of health utilization by their cost price according to the 2013 Ikazia hospital costs. Results: A total of thirteen patients underwent abdominal wall reconstruction between March, 2010 and July, 2014. All patients were treated successfully, of which one patient was treated repeatedly. Mean total treatment costs per patient were €54,313, mainly caused by the following items: outpatient pre-operative nutrition (€11,019) of which 85 % of all patients received and varying between 26 and 265 days, surgery (€13,225) including the biological mesh (€8500 p.p.) with a mean surgery time of 270 min, intensive care (€9727) was required for all patients with a mean stay of 5.8 days, followed by post-operative hospital stay (€7333) for all patients with a mean stay

Hernia (2016) 20 (Suppl 2):S175–S249 of 19.5 days including parental nutrition of which 54 % of the patients received with a mean duration of 17 days. Other costs were caused by diagnostics, laboratory research and other treatment supporting events. Conclusion: Based on this study, the total treatment costs of complex abdominal wall reconstruction are €54,313 per patient. Accurate costing data is necessary to obtain cost-covering reimbursement.

P055 Quality of life following abdominal reconstruction and repair of incisional hernias with loss of abdominal wall domain S.E. Miller1, A. Bhargava2 1 Queen Mary University of London, Medicine, London, UK, 2King George Hospital, General Surgery, Essex, UK Loss of abdominal wall domain is associated with reduced abdominal wall functionality that impacts on patient’s quality of life (QoL). Surgical repair of such hernias is possible using an open component separation technique and abdominal reconstruction, but few studies have evaluated the impact of this intervention on a patient’s QoL. This study aimed to investigate QoL outcomes following repair of incisional hernia with loss of abdominal domain, focussing on the impact of hernia symptoms and abdominal wall function, and cosmetic appearance. Twenty-two patients were retrospectively identified from operative records as having undergone incisional hernia repair with abdominal reconstruction between January 2007 and December 2015. All were sent a postal questionnaire in January 2016 based upon the Carolinas Comfort Scale, regarding their basic demographics and comorbidities, pre- and post-operative function level, self-perceived physical and mental health, and cosmetic satisfaction. Patients were also asked whether a stoma was present. Scores were reviewed and interpreted to provide a QoL comparison for each patient pre- and post-operatively. Of the 11 patients that participated in the survey (further data awaited), seven (64 %) reported an improvement in overall health postoperatively. Six (55 %) reported improved physical health, and eight (73 %) had improved mental health and cosmetic satisfaction. Activities with greatest symptom improvement following surgery were walking and lying down (change in median score from 4 preoperatively to 1 postoperatively; minimum severity 1 (no symptoms), maximum 5 (disabling). Of the factors contributing to functional impairment, greatest improvement was seen in scoring of hernia weight and movement impairment (preoperative median score 5/5 and 4/5 respectively, and postoperative 1/5 for both). Cosmetic satisfaction increased from a median score of 1 to 8 (range 0–10). Patients with loss of abdominal wall domain due to incisional hernia experience improved QoL and cosmetic satisfaction following incisional hernia repair with abdominal wall reconstruction.

P056 Laparoscopy reduces incisional hernia operations!: a comparative study of laparoscopic and open surgery for cholecystectomy M.G. Golling, Z.Z. Zielska, S. Felbinger Das DIAK, General and visceral surgery, Schwa¨bisch Hall, Germany Background: While laparoscopic benefit focusses around short term benefits (pain, mobilisation, hospital stay), the IH incidence should be

S191 substantially lower when the operation is performed laparoscopically. Aim of our study was a comparative analysis of the IH-incidence following cholecystectomy our patients following emergency or elective laparoscopic, converted or conventional cholecystectomies. Late follow up data on Incisional hernia complications following laparoscopic or conventional cholecystectomies are scarce. Methods: We analyzed all patients between 2007 and 2011 who had undergone a laparoscopic (LCCE) or open cholecystectomy (OCCE). The patient specific data included relevant risk factors, intra- and postop parameters like surgical site infection and occurrence (SSI/ SSO) and length of stay (LOS). The postop follow up is presently only based on a questionnaire and reoperation data for IH. Statistics involved the Chi2-/ANOVA and Mann–Whitney Test. Results: Overall 715 patients (56 ± 14 years, m: 250;35 %), w: 465;76 %) were included. A LCCE was performed in 92 % (n = 658), an OCCE in 8 % (n = 57), while a conversion (CCCE) was necessary in 6 % (n = 42). Risk profile (BMI, diabetes, cardiovasc. etc.) was comparable between the groups. Emergency CCE (EmCCE) was required in 18 % and then were only completed laparoscopically in 63.3 % (elective cases: 95 %). Conversion rate was significantly different (EmCCE: 12 %, ElCCE: 3.4 %). So was SSI (OCCE: 26 %, CCCE: 12 %, LCCE: 4 % p \ 0.01) and LOS. During the follow up of 3.2 ± 1.4 years. the IH-Operation rate was significantly higher in the OCCE patients (14 % (8/57) than in the CCCE (9.5 % (4/42) or the LCCE (1.1 % 7/616; p \ 0.01). Conclusion: Despite the bias in the groups (emergency vs elective, acute cholecystitis), which has to be finally analysed in the multivariate Cox regression analysis, the results show a lower symptomatic IH and reoperation rate, when laparoscopy was performed.

P057 Initial experience in the laparoscopic abdominal wall repair in a day surgery M. Giaccone, A. de Matteis, F. Evola, F. Currado, S. Sandrucci Azienda Ospedaliera Citta` della Salute e della Scienza, General Surgery, Turin, Italy Background: The debate between hospitalization or Day surgery in LIVHR is open. The objective of the current study was to evaluate the safety and effectiveness of laparoscopic repair of hernias and incisional hernias in a Day Surgery (D.S). Methods: Data were gathered for all laparoscopic hernia and incisional hernia repairs from January 2013 to December 2015. A total of 52 patients (24 male and 28 female) 27 incisional hernia repair, 25 primary hernia repair were performed in a Day Surgery Unit. The meshes implanted were a not absorbable dual layer totally in polypropylene mesh, composed by polypropylene light weight mesh sewn with a polypropylene smooth film to minimize the adhesions (Clear Mesh Composite Dipromed srl, Torino, Italy). n. 25 prosthesis (diameter 12 cm), n. 05 (diameter 15 cm), 13 (size 10 9 15 cm),n 09 (size 15 9 20 cm) were implanted and fixed by absorbable tacks. The patients’ clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied. Results: Two patients required readmission to the hospital for 2 days for a canalization delayed and n. 01 re-operated for peritonitis. During follow-up we detected n. 01 recurrence after 2 years for a mesh displacement and re-operated laparoscopically. The mean time of return to normal activity was less than 10 days and all the patients expressed their satisfaction with the procedure they received. The statistical study showed no significant differences between the hospitalized patients and those treated on a D.S basis with regard to morbidity and recurrence rate.

123

S192 Conclusions: Laparoscopic repair of incisional hernias can be performed as a highly efficient in a D.S, following a careful patients selection, with equal morbidity and recurrences than hospitalized patients and with economic advantage.

P058 Laparoscopic primary ventral and incisional hernia: 7 years of a single center experience M. Giaccone, A. de Matteis, F. Evola, F. Currado, S. Sandrucci Azienda Ospedaliera Citta` della Salute e della Scienza, General Surgery, Turin, Italy Background: The laparoscopic approach for Incisional ventral, primary hernias is widely used while for its clinical indications the debate is still open. The aim of this study is to describe our 7 years’ experience in our center in order to establish the safety, efficacy and feasibility of LIVHR using a Composite mesh totally in polypropylene double side. An independent retrospective cohort study has been conducted, comparing the data obtained from our experience with those described in literature. Methods: 145 patients, have undergone to laparoscopic treatment for abdominal wall hernia: 43 patients were affected by primary ventral hernia, while 102 patients were affected by incisional hernia. In all procedures a not absorbable composite mesh has been placed, fixing it with absorbable clips, glue or both. A dual mesh totally in polypropylene not absorbable called CMC (Dipromed SRL Torino) has been placed in 90 patients, other marketed prosthesis semi absorbable (OTHERS) have been placed in 55 patients. Surgical technique has been the same for all patients. Complications have been divided into two categories: pre- or intraoperative and postoperative. Disease recurrences have been considered separately. Follow up has taken from -6 to 12-months. Results: In this study we have not observed post-operative mortality. Nobody has presented wound infection or systemic complications after prosthesis placement. The most frequent complication we have observed has been 7 seroma. Long time follow up has showed only 5 cases of disease recurrence. Also a case of a fecal fistula occurred within 3 months after laparoscopic hernioplasty that has required a surgical remove of prosthesis. The statistical study of the patients characteristics showed a significant trend between the number of defects and post-operative complications: these were higher in patients with multiple defects. Conclusions: Laparoscopic surgery for abdominal wall defects, when performed correctly, produces effects comparable to those obtained with classic approach, reducing complication rate and length of hospital stay and reducing recurrence.

P059 Perineal hernia repair: a combined abdominoperineal approach F.A. Bulca, G. Varsa, M. Beuran Emergency Hospital Bucharest, General Surgery, Bucharest, Romania Background: Perineal hernias occurring after abdominoperineal resection (APR) for inferior rectal cancer are secondary or incisional perineal hernias and considered very rare. Methods: Case presentation We are reporting the case of a 75 year old man, subject to an abdominoperineal resection for inferior rectal cancer, in august 2013. One year after the operation the patient

123

Hernia (2016) 20 (Suppl 2):S175–S249 presented with a midline perineal bulge, 9 cm in diameter, painful but reducible. The patient underwent CT scan and colonoscopy. The CT scan revealed no signs of recurrence, but evidenced the perineal hernia defect with small bowel loops within the hernia sac. Treatment We chose a combined abdominoperineal approach. We started with the abdominal step, using a low midline incision. The adhesions of the small bowel were freed and the perineal hernia sac was emptied. For rebuilding the pelvic floor we used a double sided non resorbable parietal reinforcement implant—Intramesh T1. The anatomical landmarks used in the fixation of the mesh were: Waldeyer’s fascia and sacral periosteum (S3 level)—posteriorly, prostatic capsule— anteriorly, levator ani muscle remnants and the pelvic fascia—laterally. The perineal step consisted in resection of the redundant skin and hernia sac and skin suture. Intraperitoneal and perineal drainage was used. Results: The patient had a very good evolution, without any major complication, with no signs of hernia recurrence in the last 6 months. Conclusions: A combined approach for the repair of a perineal hernia seems to be the method of choice for reconstructing the pelvic floor, as the abdominal step of the abdominoperineal approach allows: good dissection of the small bowel adhesions. -Confirmation of the absence of abdominal cancer recurrence- proper identification of the anatomical landmarks for a better mesh fixation.

P060 Postoperative outcome and complications after stoma reversal surgery with cicatricial hernia prophylaxis by mesh augmentation in sublay technique using GOREÒ BIO-AÒ mesh versus DynaMeshÒ-CICAT mesh M. Ceno1, D. Paul2, D. Berger1 1 Klinikum Mittelbaden Baden-Baden, Surgery, Baden-Baden, Germany, 2Klinikum Mittelbaden Rastatt, Surgery, Rastatt, Germany Introduction: At the department of surgery of Klinikum Mittelbaden in Baden-Baden (Prof. Dr. Dieter Berger) stoma reversal surgery was performed on 127 patients in the time from Nov. 15, 2010 to Mar. 11, 2015. All 127 patients were treated with a resorbable synthetic mesh (GORE BIO-A mesh) in sublay technique to close abdominal wall incisions. Primary wound closure was carried out in all cases. In order to evaluate the rate of postoperative hernias, which literature reports to be over 30 percent and a common complication, all 127 patients were included in a prospective study. Methods: In total, 104 of the included patients (n = 127) took part in the follow-up examinations. The follow-up examination took place after a median time span of 87 weeks (8–218 weeks). The stoma was worn for a median time span of 24 weeks (3–1501 weeks). Results: The total herniation rate of 7.7 % (n = 8/104) in the examined patient population was thus much lower than described in the literature. However, the rate of perioperative wound infections in the overall population of patients amounted to 33.0 % (n = 42/127). The wound infection rate of patients included in the follow-up examinations was at 32.7 % (n = 34/104). Conclusion: According to our own prospective analysis, we were able to register a very low herniation rate compared to the literature when the resorbable synthetic mesh (GORE BIO-A- Mesh) was applied in sublay technique for stoma reversal.

Hernia (2016) 20 (Suppl 2):S175–S249 One disadvantage could lie in the increased perioperative wound infection rate. The correlation between infection and hernia resulted in a followup study using a non-resorbable mesh-with DynaMesh CICAT. Since Mar. 19, 2015 our patients were treated with DynaMesh CICAT.

P061 Tension-free abdominal wall reconstruction for a large incisional hernia: 5 years’ experience C. Rizzetto1, L. Fei2, M. Schiano di Visconte1, D. Da Ros1, G. Munegato1, R. Del Giudice1, T. Cipolat Mis1 1 S. Maria dei Battuti ULSS7, General Surgery, Conegliano, Italy, 2 Second University of Naples, Gastrointestinal Surgery, Naples, Italy Background: No single approach has emerged as the best way to close large incisional hernia that poses a demanding surgical management. The aim of this report is to present the long term results of two-institutional study on a new surgical approach with a new (Free Lateral double layer prosthesis totally in polypropylene), in order to avoid dangerous increase in the abdominal pressure. Methods: The present study is a prospective cohort study comprising 29 patients treated from April 2010 to December 2015 in two different hospitals for large abdominal wall defects using the new prosthesis. Results: In this study population, there was no postoperative mortality. After placement of the prosthesis one patient (3.4 %) presented wound infection, two patients (6.9 %) experienced a postoperative seroma and one patient had an haematoma (3.4 %). At a median follow-up of 28.5 months (IQR 22–36) no hernia relapse occurred. Conclusions: A tension-free abdominal wall reconstruction can be easily achieved by the application of free lateral double layer prosthesis totally in polypropylene mesh and film barrier. It is a safe and feasible option that can be employed to manage Rives repair in cases of abdominal wall defects with difficult closure of posterior peritoneal-aponeurotic plane where conventional prosthetic meshes could be unsuitable and without occurring to components separation.

P062 Prophylactic mesh placement to avoid stoma related hernias: a systematic review L.C.L. van den Hil1, S. van Steensel1, M.H.F. Schreinemacher2, N.D. Bouvy1 1 Maastricht University Medical Centre, General Surgery, Maastricht, Netherlands, 2Academic Medical Center, General Surgery, Amsterdam, Netherlands Introduction: Temporary stomas are created frequently and are an important cause of complications. Yet, even after closure of a temporary stoma, incisional herniation at the stoma site may occur, with a reported incidence of up to 30–48 %. Incisional hernias are at risk of causing pain, deformity and incarceration. These hernias often require surgical repair with a mesh. Preventive measures are therefore urgently needed. Prophylactic mesh placement might be one technique to reduce the incidence of stoma related hernias. The aim of this study was to perform a systematic search of the literature that will focus on prophylactic mesh placement to prevent incisional hernias at the site of stoma reversal. Methods: A literature search of Pubmed, MEDLINE and EMBASE was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search

S193 terms and synonyms for stoma, enterostomy, mesh, prophylaxis and hernia were used as MeSH and free text terms. The primary outcome was the incidence of incisional hernia formation during follow-up. Secondary outcomes were mesh related complications. Results: In total, four articles with 194 patients were included. A prophylactic mesh was placed in 94 patients to prevent incisional hernias. In one study, the mesh was placed during stoma formation, while in the other studies the mesh was placed during stoma reversal. Physical examination and ultrasonography or CT-scans were performed to detect incisional hernias. Only four patients developed an incisional hernia (4 %), while in the control groups 28 out of 100 patients (28 %) developed a hernia. No mesh related complications were observed. Conclusion: All selected studies showed a reduced risk in hernia formation when a prophylactic mesh was used. In addition, the reported lack of any mesh related infection seems to justify the routine use of a prophylactic mesh to prevent incisional hernias after stoma reversal.

P063 Laparoscopical treatment of parastomal hernia with defect closure and use of physiomesh and securestrap S. Papajikolaou, P. Daikou, O. Tsimpoukidi, L. Dritsoulas, E. Kalogridaki, A. Dounavis Sismanogleio-AM FLemig G.H., Surgical, Athens, Greece The aim is to present a case of laparoscopic treatment of parastomal hernia with the Sugarbaker technique using new materials. A 68 years old female patient underwent laparoscopic abdominoperitoneal resection elsewhere for carcinoma of the rectum. Two years postoperatively the patient noticed a swelling around the stoma, that gradually increased over time. On computer tomography a big parastomal hernia was detected. At operation a hernia 7 cm in diameter was observed. The defect was closed with transabdominal sutures and a 20 9 20 cm physiomesh was placed according to Sugarbaker. The mesh was fixed with securestrap. Postoperative analgesics were given for 3 days. The pain was due to the tension at the defect closure. Within a month postoperatively the residual swelling around the stoma disappeared completely. Of notice is the easy handling of the mesh that is see-through and the very good function of the tacks that had minimal peritoneal surface. In conclusion, a case of laparoscopic Sugarbaker operation for parastomal hernia is presented. New materials were used that had excellent handling properties.

P064 Progressive preoperative pneumoperitoneum in the treatment of hernias with loss of domain J. Comas, J. Robres, J. Barri, M.C. Buqueras, M.A. Vasco, H. Subirana, J. Catala`, P. Barrios Consorci Sanitari Integral, Cirugı´a General y Digestiva, Sant Joan Despı´, Spain Introduction: Patients presenting giant hernias with ‘‘loss of domain’’ require a proper surgical plan given their comorbidity and potential postoperative complications. Part of this comorbidity is due to abdominal hyperpression due to reintroduction to abdominal cavity of all abdominal viscera of herniary sac, producing hyperpression abdominal syndrome.

123

S194 Progressive preoperative Pneumoperitoneum (PPP) allows an increase of abdominal cavity capacitance and a better physiologic adaptation of the patient to abdominal hyperpression. Despite the long time since the introduction of this technique, we believe it is still useful for surgeons who must treat these challenging cases. Objectives: The aim of this retrospective study was to analyze our experience in the treatment of hernia with loss of domain using PPP. Methods: Between January 2005 to March 2015, 24 patients underwent repair of large hernias previously prepared with PPP in our center. Results: 20 patients presented incisional hernia, 3 patients inguinal hernia and 1 patient umbilical hernia. Mean age was 69 years. Mean time of insufflation was 11 days and mean total volume of insufflation was 9900 cc. Mean size of abdominal Wall transverse defect was 16.7 cm. In 10 cases previous reparation were performed. Complications occurred in 4 cases, 1 decompensation of previous respiratory disease and 3 cases of subcutaneous emphysema. In the patient with respiratory complication PPP was suspended. An open technique with mesh implantation was performed in the 20 cases of incisional hernia (component separation in 14 cases) and in the 2 cases of umbilical hernia. In the 3 cases of inguinal hernia a preperitoneal repair was performed. In the follow-up 1 case of recurrence was detected. Conclusions: This technique is a secure and effective tool in the preoperative preparation of the patients presenting complex hernias with ‘‘loss of domain’’. This technique helps surgeons to achieve tension free abdominal wall reparation.

P065 An evaluation of parastomal hernia repair using the Americas Hernia Society Quality Collaborative (AHSQC) W.W. Hope1, R. Janczyk2, J.A. Warren3, A.M. Carbonell3, B.K. Poulose4, M.J. Rosen5 1 New Hanover Regional Medical Center, Surgery, Wilmington, USA, 2 Beaumont Hospital, Surgery, Royal Oak, USA, 3Greenville Hospital System, Surgery, Greenville, USA, 4Vanderbilt University, Surgery, Nashville, USA, 5Cleveland Clinic, Surgery, Cleveland, USA Introduction: The purpose of this review was to evaluate outcomes relating to parastomal hernia repair. Methods: Data from the multicenter, prospective AHSQC were used to identify patients undergoing parastomal hernia repair from 2013–2015. Wound events were defined as surgical site infections (SSIs), surgical site occurrences (SSOs), and surgical site occurrences requiring procedural intervention (SSOPIs). Parastomal hernia repairs were compared to other repairs using Pearson test and Wilcoxon test with a p value \0.05 considered significant. Results: Parastomal hernia repairs were performed in 199 patients. Techniques of repair include open in 86 %, laparoscopic in 12 %, and robotic in 2 %. Mesh was used in 92 % with keyhole in 41 %, flat mesh in 33 %, and Sugarbaker in 18 %. Mesh types used were permanent synthetic in 78 %, biologic in 15 %, absorbable synthetic in 6 %, and hybrid synthetic/biologic in 1 %. Most common location for mesh was sublay in 85 % followed by onlay in 13 % and inlay in 3 % with 63 % of patients undergoing a myofascial release. Ostomy disposition included ostomy left in situ in 40 %, moved to a new site in 24 %, taken down in 21 %, and re-matured in same location in 15 %. Outcomes related to parastomal hernia repair included 10 % SSI, 21 % SSO, and 13 % SSOPIs with a 15 % readmission rate and 7 % reoperation rate. Average length of stay was 6 days. When comparing

123

Hernia (2016) 20 (Suppl 2):S175–S249 parastomal hernias to other ventral hernia repairs parastomal hernias had a significantly higher SSI, SSO, SSOPIs, readmission, reoperation rate, length of stay, OR time, and were less commonly performed laparoscopically (p \ 0.05). Conclusion: The majority of parastomal hernias are being repaired open with synthetic mesh in the sublay position. Wound complications remain high after parastomal hernia repair. Less favorable outcomes of parastomal hernia repair when compared to other ventral hernia repairs are likely related to the complexity of parastomal hernia repair.

P066 Recovery time improvement and morbidity rate decrease using a modified-rives-stoppa technique S. Lafranceschina, A. Girardi, R.M. Isernia, F. Fragassi, G. Piccinni, M. Testini University of Bari, Department of Biomedical Sciences and Human Oncology, Bari, Italy Background: Rives-Stoppa procedure for incisional hernia shows low recurrence rates, excellent long-term results, and low morbidity rate. However it is not free from complications, such as stiffness of the wall with reduction of its dynamic, chronic pain and foreign body sensation. The aim of this study was to compare a modified-RivesStoppa technique with traditional one to verify results. Methods: During the period 2003–2009, we selected 49 patients with median incisional hernia (area from 20 to 30 cm2): 32 submitted to our modified-Rives-Stoppa operation without component separation technique (Group 1); 17 treated with conventional technique (Group 2). In Group 1, the posterior rectal sheath was closed with single U-fashion stitches of Prolene-0. A soft mesh was left in place (Parietex tridimensional TET) fixed with six polyester (Ti-Cron-2/0) stitches and sprayed with fibrin glue (Tisseel 5 of 10 ml). Anterior rectal sheat was rebuilt with coated-Vicryl-1 running sutures. Tisseel was then sprayed in the subcutaneous space too. The medium follow up length was 9 years (range 7–12 years). Demographic data, hospital stay and complications were recorded. Results: Mean age was 60.1 years (range 41–82), with no difference between the two groups. 25 patients were females (51 %), equally distributed in the two groups. A statistically significant difference (all P \ .05) between Group 1 and Group 2 was found in terms of hospital stay (12.0 ± 3.8 vs 17.9 ± 15.1 days), wound infection rate (3.1 vs 29.4 %), pleural effusion (15.6 vs 41.2 %), recurrence rate (3.1 vs 23.5 %), pain/foreign body sensation/rigidity of the wall (0 vs 47.1 %). Conclusion: Rives-Stoppa seems to be the most physiological and long-lasting reconstruction of defects in incisional hernia. This proposed modified technique seems to improve recovery time and to reduce postoperative morbidity rate. Further multicenter prospective studies with larger series are required.

P067 A reproducible method for detection of incisonal hernias on CT C.R. Williams, B. Rees, R.E. Owen, C.R. Parry, R. Harries, J. Torkington University Hospital of Wales, Radiology, Cardiff, UK Background: Incisional hernia is a common complication following surgery for colo-rectal cancer both laparoscopic and open. Incisional hernias can range from asymptomatic to being a cause of serious

Hernia (2016) 20 (Suppl 2):S175–S249 morbidity. Hernias may be detected on clinical examination or on imaging. Our centre is part of a trial study looking at the Cardiff method of abdominal wall closure which may have an effect on the incidence of incisional hernia. During a pilot phase of this study we found significant inter-observer discrepancies on the detection of incisional hernia. There is no published guidance on what is classified as an incisional hernia on CT imaging grounds and as a result there is considerable variation in the reporting of incisional hernias. Methods: Patients have been recruited to a study of abdominal hernias following colo-rectal cancer surgery with regular clinical and radiological follow up (with CT). We demonstrate the inter-observer variability of detection and description of abdominal wall hernias. Using a consensus method to classify the discrepancies and with arbitration from senior radiologists and a senior colo-rectal surgeon we devised a system of detecting hernias on CT. Results: Following the use of our method for description and detection of abdominal wall hernias we collated the results to look for inter-observer concordance. The method is straightforward to learn, easy to implement using standard PACS software and shows much improved inter-observer variability compared to standard CT reading. Conclusion: We demonstrate a novel method for detection of incisional hernias on CT which is both reproducible and straightforward in order to aid future evaluation of surgical closure techniques to prevent incisional hernias.

P068 Hughes abdominal repair trial (HART): Review of feasibility study R.L. Harries, J. Cornish, D. Bosanquet, B. Rees, I. Rusell, J. Torkington University Hospital of Wales, General Surgery, Cardiff, UK Introduction: Incisional hernias are common complications following major abdominal surgery and cause significant morbidity, impaired quality of life and significant financial burden. HART is a multi-centred, pragmatic, randomised controlled trial comparing two methods of closure (mass closure and the Hughes Repair) in midline wounds in colorectal cancer patients with a view to reducing the incidence of incisional hernias. We present data from the feasibility study. Methods: The study has been registered with the current controlled trials registry (ISRCTN Number: 25616490) and has ethical approval (MREC 12/WA/0374). Inclusion criteria are patients aged 18 years or older with colorectal cancer undergoing a midline incision of at least 5 cm for colorectal cancer surgery (open or laparoscopic). Patients underwent computerised randomisation, through a telephone randomisation service, to either mass closure or Hughes repair. Primary outcome: Incidence of incisional hernia (clinical and radiological at 1 year). Secondary outcomes: C-POSSUM, complications of surgery, quality of life analysis (SF-12 and FACT-C), and cost analysis (Client Service Receipt Inventory). Tertiary outcomes: Incidence of incisional hernia at further follow-up (2–5 years) and comparison of sensitivity and specificity of CT vs. clinical examination in the diagnosis of incisional hernia. Results: 43 patients were consented; of which 30 patients had a midline incision and were randomised. This included 27 elective patients, 23 male patients, median age 72.6 years (range 53–85). There were 14 mass closures and 16 Hughes repairs performed. Primary endpoint data will be presented for the first time. Conclusions: Analysis of the data has confirmed acceptability and feasibility of the protocol and commencement of the study was approved in September 2014.

S195

P069 Incisional lumbar hernia; two cases and review V. Mun˜oz Lo´pez-Pela´ez, M.J. Pen˜a Soria, J.L. Garcı´a Galocha, E. Blesa Sierra, D. Rivera Alonso, A.E. Pe´rez Jime´nez, M. Sa´nchez Garcı´a, D. Jimenez-Valladolid, A. Torres Garcı´a Clı´nico San Carlos, Dept. of General Surgery, Madrid, Spain Background: Lumbar hernias occur infrequently. They can be congenital, posttraumatic or incisional. They are bounded by the 12th rib, the iliac crest, the erector spinae and the external oblique muscle. Incisional lumbar hernia have been associated with urologic and lumbar procedures. Methods: We present 2 patients who had lumbar surgery and subsequent develop significant bulging in this area. Results: The first case is a 72 years-old male and the second a 70 years-old male. They had a lumbar surgery in the previous year. They were referred to surgery because they developed a bulge above incision area. The physical examination showed a smooth, reductible and tender tumor in the lower back. CT scan confirmed the diagnosis and located the hernia. The first patient had a 6 cm left incisional lumbar hernia and second one had a 8 cm right lumbar hernia. In both cases the hernia sac containing colon. A polypropylene selfgripping mesh was placed in sublay position. After 6 months no recurrences were reported. Conclusion: Incidence of incisonal lumbar hernias is low. Symptoms are variable, it could be from asymptomatic to lower back pain with o without palpable flank mass. The diagnosis is clinical although a CT scan should be considered for preoperative evaluation in all patients. Surgery must be indicated as early as possible. There are two possible surgical approaches: the open lumbar surgery and laparoscopic approach. Open reconstruction may include a onlay or retroperitoneal mesh. There is low evidence about which approach is the best.

P070 Perineal hernia: hernia repair using rectus abdominis muscle flap M. Bockova, J. Hoch, L. Frajer Motol University Hospital, Department of Surgery, Prague, Czech Republic A perineal hernia is defined as a protrusion of intra-abdominal viscera through a defect in the pelvic floor. Primary hernias are extremely rare, secondary (postoperative) hernias following pelvic surgery, especially abdominoperineal resection or pelvic exenteration, are more common. Impaired perineal wound healing and neoadjuvant chemoradiotherapy in cancer patients are defined as main risk factors. A growing incidence of this complication is expected in connection with an increasing use of laparoscopic approaches and ELAPE. Despite the considerable time since the first described secondary perineal hernia in literature, patient series, prospective studies and treatment guidelines are still missing. The authors present a case of a 66-year-old man with a secondary perineal hernia following a previous laparoscopic abdominoperineal rectum cancer resection undergoing a surgical intervention. This was performed through an abdominal approach using a rectus abdominis muscle flap to repair the pelvic floor defect.

123

S196

P071 Minimally invasive components separation for midline incisional hernia repair: an observational study implementing a new technique F. di Marzo1, V. Mingarelli2, L. Cobuccio3, C. Galatioto3, L. Felicioni4, A. Marioni3 1 ASL 1 Massa Carrara, General Surgery, Pontremoli, Italy, 2 Universita` Sapienza, General Surgery, Rome, Italy, 3Azienda Ospedaliero Universitaria Pisana, Emergency Surgery, Pisa, Italy, 4 ASL9, General Surgery, Grosseto, Italy Background: Large midline incisional hernia repair is challenging for surgeon, risky for patients and highly expensive for hospitals. We decided to implement a new technique (Minimally Invasive Components Separation-MICS) creating a group of surgeons from different hospitals in Tuscany and centralizing our patients. The aim of the study is to evaluate clinical outcomes after 10 months. Methods: A retrospective observational cohort study was performed on patients treated for midline incisional hernia (classified W2 to W4, according to EHS Classification) from January 2014 to January 2016 in 4 different General Surgery Units. We set patients into two different groups (Open and Minimally invasive) and followed them over the 2 years span in which we implemented a new technique. Results: 18 patients were selected and put into two homogenous groups for gender distribution (5 males, 4 females per group), age (median 67 and 70 years), BMI (median 29.3 and 29.2) and defects classification (M, N, W); ASA score was higher in Open group, recurrences (R) and previous meshes (P) are more in M group. Median follow-up was 11 (2–24) and 3 (2–9) months. Median Operative time was 200 min (for both groups), length of stay 6 and 5 days (2–25). Most used mesh was 30 9 30 cm (6 in O group and 2 cases in M group). No intraoperative complications were reported. Post operative complications were 6 in both groups (3 in O group and 2 in M group classified as 3b according to Clavien-Dindo). Conclusion: To implement a new technique in Abdominal Wall Hernia Repair is difficult for low case-load, long learning curve and complications management. This study highlights how inter-hospitals co-operation and surgeons’ will to teamwork allow to maintain a good level in term of clinical outcomes during a process of technical evolution.

P072 IPOM technique: injury of small bowel: Finish intraperitoneal onlay mesh procedure or not? L.K. Kohoutek, P.P. Plechacova, J.M. Musil Hospital Frydlant, EUC Group, Surgery, Frydlant, Czech Republic Background: Incisional hernia is a common complication of previous abdominal surgery. IPOM (intraperitoneal onlay mesh) procedure is one of approach how to repair that. We can use IPOM technique when it occurs small bowel injury in case that accepted some recommendations. Method: Authors present case report of 67 year old female. Anamnestic’s data included some surgery, hysterectomy with adnexectomy—the main after with created incisional hernia. Motivated patient lost weight by 14 kg before surgery. It was chosen IPOM technique to repair incisional hernia. During surgery iatrogenic injury of small bowel caused a need small laparotomy and revision of bowel, resected bowel dephect and sutured by anastomosis end to end, continuing laparoscopic procedure with mesh implantation, everything with protected coagulum. Postoperative period was complicated by paralytic ileus subsided by conservative therapy.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Results: In spite of iatrogenic injury of small bowel by aseptic surgery with using hernia mesh we chose to repair hernia by IPOM technique. The process was without postoperative infectious complications. It depends on current patient´s status, local finding in abdominal cavity, choosing individual approach, selecting correct mesh, prophylaxis and suitable technique of surgery. Conclusion(s): Hernia repair surgery is challenging and complex. IPOM technique has benefits for patient but it requires losts of experiences by specialized surgeons and team of specialists across the medicine.

P073 In search of the perfect closure: lumbar incisional hernias! O. Ginghina, A. Spanu, C. Birlog, R. Munteanu, R. Iosifescu, N. Iordache Saint John Hospital, Surgical Oncology, Bucharest, Romania Background: Lumbar incisional hernias represent a rare entity. No guidelines are available till today regarding them. Methods: During the last 5 years a number of 5 cases were operated in our Department. We analysed the technique used and also the problems encountered during and after the procedures. The closure of the defect was done using an prosthetic mesh (polypropylene) and the placement was in 3 cases supra-aponeurotic and in 2 cases underlay meshes. Results: The onlay plasty showed a higher rate of post-surgical complications such as post-surgical pain, large seroma and increasing the number of hospitalization days. Conclusion: Incisional lumbar hernia is a challenging operation because there is no standard procedure in the literature. The surgeon experience in abdominal wall defects is also a primordial factor.

P074 Feasibility and effectiveness of midline large incisional hernia repair with a new FlaPp mesh F.M. Moccia Francesco1, G.M. Munegato Gabriele2, G.R. Rossetti Gianluca1, O.M. Manto Ottavia1, C.R. Rizzetto Christian2, L.F. Fei Landino1 1 Second University of Naples, School of Medicine, Unit of Gastrointestinal Surgery, Naples, Italy, 2Conegliano Hospital, Unit of General Surgery, Treviso, Italy Background: In this prospective non-randomized observational cohort study we evaluated the feasibility and effectiveness of midline large incisional hernia open repair using a new Free Lateral Polypropylene prosthesis (FlaPp mesh) in order to avoid dangerous increase in the abdominal pressure without having to perform the anterior component separation technique. Methods: Forty-three consecutive patients (27 women and 16 men), mean age 63.3 years (range 35–89), were treated in two different hospitals using a new mesh, between April 2010 to February 2016. The first part of the operation is performed according to Rives retromuscular repair. The new mesh is made up by two overlapping prostheses: the upper layer, composed by macroporous monofilament polypropylene mesh (PM) in order to promote tissue growth and optimize colonization, is joined to a thin smooth layer of not-absorbable polypropylene film (PF) that can be used in contact to the bowel. The PF layer is fixed to the peritoneum + posterior muscular sheet and the PM layer is placed in the retromuscular space with an adequate overlap (C5 cm).

Hernia (2016) 20 (Suppl 2):S175–S249 Results: The mean patient body mass index (BMI) was 29.7 (range 18–42); according to the EHS classification, of 43 incisional hernias 35 were W2 and 8 were W3. Seroma was reported in three patients (7 %),one patient (2.3 %) presented partial wound infection and another one (2.3 %) experienced a relevant haematoma requiring surgical intervention. In a patient we have removed the mesh in the early postoperative period for biliary peritonitis for unrecognized intestinal lesion during a difficult adhesiolysis; the patient was then treated with a negative-pressure therapy. At a median follow-up of 27.2 months (IQR 20–37) recurrence rate was 2.3 % (1/43). Conclusion: The new mesh seems to be a safe and reliable device for repairing large midline incisional hernia with a good patient satisfaction, and that is an alternative to other more complex operations.

P076 TIPP superior to Lichtenstein-repair? B. Stechemesser Hernia Center Cologne, Hernia, Cologne, Germany TIPP superior to Lichtenstein Repair? Lichtenstein repair is currently the best studied method in the open treatment of hernias. The disadvantage of the Lichtenstein method is a high number of chronic postoperative pain. The TIP process could constitute an alternative procedure to open supply of inguinal hernias. Advantages are obvious mainly in the treatment of women. The lack of direct mesh/nervecontact would show a lower postoperative pain rate. The poster shows the own results compared to the total database Herniamed.

P077 Self-gripping meshes for Lichtenstein repair. Do we need additional suture fixation? G. Ko¨hler1, M. Lechner2, F. Mayer2, F. Ko¨ckerling3, R. Schrittwieser4, R. Fortelny5, K. Emmanuel1 1 BHS Linz, General and Visceral Surgery, Linz, Austria, 2PMU University Salzburg, Surgery, Salzburg, Austria, 3Vivantes Klinikum Spandau, Surgery, Berlin, Germany, 4LKH Bruck a.d. Mur, Surgery, Bruck A.D. Mur, Austria, 5Wilhelminenspital, Surgery, Wien, Austria Background: The Lichtenstein repair is a frequently used treatment of inguinal hernias. In recent years, there has been an increasing tendency to apply self-gripping meshes (s.g). In many cases, additional suture of the mesh is carried out; however, it is uncertain what the benefits or potential risks of this actually are. Methods: The evaluation was undertaken on the basis of the Herniamed register, and covered all unilateral Lichtenstein operations between 01.09.2009 up to 30.09.2013. The analysis only included patients with whom s.g. meshes with resorbable micro hooks had been used (Progrip, Covidien) and who had undergone a full 1-year followup examination (80.15 %). Results: In total, 2095 patients were suitable for analysis, of which 816 (38.95 %) cases received an additional suture fixation (Fix). With increasing hernia size, more frequent fixation took place (29.97 % of hernias \1.5 cm vs. 46.65 % of hernias [3 cm, p \ 0.001). The recurrence rates 1 year after surgery did not show any significant differences (Fix. 0.86 % vs. No Fix. 1.17 %; p = 0.661) with and without fixation, even when being adjusted for covariables. Likewise, no differences were noted in terms of postoperative complications (Fix. 5.15 % vs. No Fix. 5.08 %; p = 1.0). In addition, the numbers of patients needing to be treated after 1 year for chronic pain were also comparable (Fix. 2.33 % vs. No Fix. 2.97 %; p = 0.411). Conclusion: Within the group that did not have additional suture fixation of self-gripping meshes (No Fix.), the length of operations

S197 was on average 8 min shorter (p \ 0.001). No differences could be observed in terms of postoperative complications, treatment requiring chronic pain and recurrence rates.

P078 Medical humanitarian mission to Tanzania in 2016: groin hernia repair in the setting of low availability to surgical care K. Mitura1, S. Koziel2, M. Pasierbek3 1 Siedlce Municipal Hospital, General Surgery, Siedlce, Poland, 2 Beskid Oncology Center, General Surgery, Bielsko-Biala, Poland, 3 Silesia Medical University, Pediatric Surgery Department, Zabrze, Poland Availability of surgical care in Africa is severely limited. This is due to the lack of surgeons and a small number of public hospitals. Only 25 out of 100,000 patients with inguinal hernia undergo a surgical treatment with groin hernia incidence reaching 60–175/100,000 Africans. There is a deep deficit in the treatment options for this disease. As many as 65 % of inguinal hernia repairs are performed urgently because of incarceration, with a high percentage of bowel resection—24 %. In these cases, the postoperative mortality reaches 6 %. Among patients with incarceration who don’t reach the hospital there’s recorded as many as 87 deaths per 100 cases. In order to improve the availability of treatment of inguinal hernia in Africa, humanitarian medical missions involving surgeons from Europe are organized. During regular visits to selected centers in Africa, they also carry out intensified treatment of patients and training of the local staff. We present the experience of Polish surgeons from the humanitarian medical mission in Kiabakari in northern Tanzania undertaken in January of 2016. Surgical repair was planned in 100 patients, as it was during previous mission to Ghana in 2014. All necessary equipment, including surgical instruments, drapes, antiseptics, suturing materials, meshes, dressings, analgesics and antibiotics, was delivered by three surgeons engaged in the mission. The surgery was performed in local anesthesia in two parallel teams with no access to electrocautery. The mission was planned for 3 weeks. Inguinal hernia commonly found in Tanzania is a major issue for the inefficient health care system. Humanitarian medical missions can help to improve the treatment results, as long as they are carried out periodically and allow for training of local personnel. Scarce equipment of medical facilities in Tanzania is not a significant difficulty in performing the Lichtenstein repair under the local anesthesia.

P079 TAPP groin hernia repair with 3D mesh fixed with histoacrylic glue: early and long term results of 55 patients K. Mitura Siedlce Municipal Hospital, General Surgery, Siedlce, Poland The aim of this prospective study was to evaluate the impact of transabdominal preperitoneal repair (TAPP) with implantation of a lightweight 3D mesh fixed by histoacrylic glue on the chronic pain in hernia patients. Patients were examined before procedure, early and late postoperatively. Furthermore, the patients were asked about the frequency of the pain.

123

S198 We included 55 patients in the study. Chronic pain with significant impairment of daily activities was experienced by 38 % of patients before the operation, which decreased to 7.5 % after TAPP. We present detailed data on reported pain in visual analog scale and patients’ satisfaction after procedure. The TAPP procedure with implantation of a lightweight mesh fixed with glue is a highly effective option for preventing chronic pain in inguinal hernia repair. Glue fixation seems superior to other forms of fixation during the early postoperative period. However, for confirmation of results, a randomized study is recommended.

P080 Comparison between partially-absorbable lightweight mesh and heavyweight mesh during inguinal hernia repair: Multicenter randomized pilot study S.D. Lee1, T.I. Sohn2, J.B. Lee1, Y.S. Jang2 1 Daehang Hospital, Surgery, Seoul, South-Korea, 2Eulji General Hospital, Surgery, Seoul, South-Korea Background: Prosthetic mesh is widely used for hernia repair because of its excellent adhesiveness and persistency. However, pain and stiffness can be occurred after surgery because of heavy weight (more or less 100 g/m2) and non-absorbability. Methods: The study is a prospective, multicenter, single-blind, randomized, pilot trial to assess pain and quality of life according to type of mesh. 47 patients with unilateral inguinal hernia underwent Lichtenstein repair with partially absorbable lightweight mesh (group 1, Proflex) and heavyweight mesh (group 2, Marlex). Data were collected by validated questionnaires at screening, day 1, 7, 90, and 120. Demographics, disease-associated data (prevalence, location and type, severity), and effectiveness assessment [Visual analogue scale (VAS), the Carolinas Comfort ScaleTM (CCS), and Activities Assessment Scale (AAS)] are recorded. Foreign body sensation and stiffness were also checked. Results: 47 patients, with 24 hernias repaired with lightweight mesh, completed follow up at 120 days. 31 hernias were indirect. VAS at 90 days were significantly low in group 1 (group 1: 1.88 ± 2.29 ? 0.46 ± 0.78, group 2: 2.17 ± 2.89 ? 0.96 ± 0.82, p = 0.0265). CCS was significantly lower in group 1 at day 1(51.33 ± 20.29 vs. 64.65 ± 22.64, p \ 0.05), however there was no difference at day 7, 90, 120. AAS between the two groups was also lower significantly in group 1 at day 1 (39.83 ± 9.88 vs. 46.43 ± 7.82, p \ 0.05). There was no recurrence during follow-up period in both groups. Foreign body sensation and stiffness were lower significantly in group 1 at day 90, 120 [p-value: 0.0226 (D120), 0.0116, 0.0219 (D90, 120), respectively]. Conclusions: Hernia repair with lightweight mesh improves functional outcome significantly. There were no statistical difference in recurrence and safety. Therefore, lightweight mesh can be used safely and effectively during hernia repair.

P081 Small bowel intestinal obstruction post total extraperitoneal (TEP) laparoscopic inguinal hernia repair D. Aw, W.H. Chan, K.W.E. Lim, W.K. Wong, H.S. Ong, K.H. Eng Singapore General Hospital, General Surgery, Singapore, Singapore Introduction: Laparoscopic hernioplasty is a frequently performed operation. Although it has some advantages over open hernia repair,

123

Hernia (2016) 20 (Suppl 2):S175–S249 laparoscopic hernioplasty is not without complications. There have been case reports of intestinal obstruction post Transabdominal Preperitoneal (TAPP) hernioplasty. We here present a case of small bowel obstruction through a peritoneal defect after Total Extraperitoneal (TEP) hernioplasty. A review of the literature is performed and techniques to avoid this complication are discussed. Case report: A 80 year old gentleman presented with bilateral inguinal hernias of 3 months. There were no obstructive symptoms. He was healthy with no medical history except for previous right open hernioplasty 10 years ago. Bilateral TEP hernia repair was performed with the patient under general anesthesia. A recurrent right indirect hernia with sac containing small bowels and a left indirect hernia was noted. Both hernias were repaired with mesh in the usual fashion. During the dissection, there was a small peritoneal breach and was repaired with clips. The patient was discharged the next day. The patient presented again on postoperative day 4 with obstructive symptoms of abdominal distention and pain of 2 days. No evidence of a recurrent hernia was demonstrated on examination. Computed tomography suggested internal hernia with small bowel volvulus in the right illac fossa. The patient underwent laparotomy and we found a 3 cm peritoneal defect with a loop of ileum herniating through the defect into the preperitoneal space posterior to the mesh. This was repaired with absorbable sutures. The patient recovered well after surgery and was asymptomatic when reviewed again 3 months later. Conclusion: Awareness of peritoneal defects, adequate repair of defects and evacuation of pneumoperitoneum prior to preperitoneal space closure may help reduce the incidence of bowel entrapment. Recognition of the presentation of small bowel herniation through peritoneal defects could facilitate more rapid surgical intervention.

P082 External hernia of the supravesicalis fossa: a misidentified protrusion. More frequent than imagined, riskier than perceived G. Amato, A. Agrusa, G. di Buono, V. Sorce, E. Gulotta, G. Romano University of Palermo, General Surgery and Urgency, Palermo, Italy Background: Protrusions of the supravesical fossa deemed to be rare, maybe erroneously. Probably, being misidentified with direct hernias, these hernia types are not enlisted in existing classifications. Underlining its specific characteristics can facilitate an early diagnosis, thus reducing risks of serious complications. Methods: 100 consecutive open anterior inguinal hernia repairs consecutively carried out represents the body of the research. The Nyhus classification was used to categorize the protrusions detected in the cohort of patients. True hernias of the supravesicalis fossa were considered a subgroup of direct hernias. Combined protrusions showing a dual component structure composed by direct hernia + supravesicalis fossa protrusion were also taken into account. Results: Among the patients collect were detected 5 true hernias of the supravesicalis fossa and 7 bi-component combined hernia showing a direct hernia component together with a protrusion of the supravesical fossa. All hernias of the supravesicalis fossa presented same distinctive elements: a diverticular outline with tightened basis. Occasionally, the stricture was so tight to provoke incarceration. Actually, signs of incarceration were evidenced in 2 true hernias of the supravesical fossa. In two other patients with bicomponent combined protrusion, the herniated element of the supravesical fossa revealed incarceration of the visceral content. Conclusions: External hernias of the supravesicalis fossa seem to be more frequent than imagined. Actually, these hernia types, both in the

Hernia (2016) 20 (Suppl 2):S175–S249

S199

uncombined as in the combined version, show an incidence of above 10 %. The diverticular shape of these protrusions together with the stricture at its basis, seems to explain the apparently high trend to incarceration that affects this hernia type. Consequently, if a midsized protrusion with intermittent pain and/or irreducibility is present, the occurrence of a hernia of the supravesicalis fossa should be taken into account. In these cases, the indication for a surgical treatment in the short term is recommended.

Material and method: This is a prospective study of 60 Elements of the army operated for inguinal hernia by laparoscopy. Result: We have had excellent results for the early resumption of activities after 15 days of convalescence and post operative pain in the conventional technique anterior way, no recurrence and complication only know Seroma post opeatoire in a single patient Conclusion: Laparoscopy represents an excellent indication in the treatment of hernias of the groin in military activity.

P083 The septum inguinalis: a neglected feature of the inguinal backwall showing significant implications in hernia genesis

P085 The effect of proflor 3D mesh on post-operative pain and well being: a highest case series of 342 patients from India

G. Amato, A. Agrusa, G. di Buono, V. Sorce, E. Gulotta, G. Romano University of Palermo, General Surgery and Urgency, Palermo, Italy

A. Porwal, P. Gandhi Healing Hands Clinic, General surgery, Pune, India

Background: Increasing understanding about physiopathology of the inguinal region can result helpful in addressing the unresolved issue of hernia genesis. At this regard, the divisor diaphragm that separates a double ipsilateral inguinal hernia, composed of a direct and indirect hernia, shows interesting characteristics. It is composed anteriorly by the fibers of the internal oblique and transverse muscle, and posteriorly by the epigastric vessels and its sheath. This septal arrangement seems to embody noteworthy features in updating the functional anatomy of the groin. Methods: The structural characteristic of the divisor septum of the inguinal backwall detected in case of double ipsilateral inguinal hernia composed by indirect and direct hernia is the subject of the investigation. Said occurrence was recognized in 8 % of patients who underwent inguinal hernia repair. In 6 individual the septum was removed for histological study. Gross anatomic and histological data were collected and analyzed. Results: The detected septi of the inguinal backwall showed different degrees of structural modifications. Macroscopically, an evident reduction of the muscular component was almost a constant finding. Related to the muscular disbanding, the epigastric vessels were often evident from the anterior perspective. In one patient, the septum was manifestly fibrotic altered and neither muscles nor vascular structures were detectable. All degrees of structural damage until final disbanding was confirmed by histological examination. Conclusions: The septum inguinalis is not a new, previously undetected, anatomical structure, but the result of functional modification of the inguinal backwall following degenerative insult. Gross anatomic modifications and histological evidence demonstrate that the injuries of the septum inguinalis own the typical trait of chronic compressive damage. In this area, there is no source of chronic compression other than the visceral impact against the abdominal wall. Therefore, visceral impact can be deemed as a significant factor in the genesis of hernia disease.

Background: Inguinal hernia repair is the most frequently performed procedures worldwide in general surgery. Our study objective was to evaluate pain score, mesh sensation and treatment satisfaction using ProFlor 3D mesh in inguinal hernia repair. Methods: A prospective pilot study was performed from 2012 to 2015 at a single center in India. Total 355 patients with inguinal hernias were enrolled for Proflor 3D mesh repair. Visual Analogue Scale and Inguinal Pain Questionnaire were used for scoring pain and treatment satisfaction was assessed on a 4 point Likert scale. Results: Out of 355 patients 12 (3.38 %) patients were lost to follow up. Age ranged from 18 to 65 years with 48.74 ± 6.97 mean age. The mean hospital stay was 18.17 ± 3.59 h and operating time was 16.94 ± 2.14 min. The mean time taken to return to normal activity was 3.21 ± 0.62 days. There was significant reduction in pain at rest, on coughing, rising from lying to sitting and climbing one step on the staircase and 30 min indoor walk from post-operative Day 1 to Day 7, 15, month 1, 6, 1 year and 3 years. Only 6.76 % (n = 24) patients required analgesic beyond 7 days. At month 6 only 2 patients had a feeling of a foreign body in their groin. In the total study population, 5 (1.41 %) patients experienced chronic groin pain, 3 (0.85 %) patients had wound infection, which was treated conservatively and 2 (0.56 %) patients had a collection of seroma at wound site they underwent debridement. 86 % patients were highly satisfied with the treatment. No recurrence seen after long term follow up of 3 years. Conclusion: The use of a 3D Proflor mesh was found to be promising regarding groin pain, mesh sensation and treatment satisfaction at 3 years long term follow up in patients with inguinal hernia.

P084 Contribution of laparoscopy in the treatment of inguinal hernias in the military: about 60 cases S. Zatir, A. Selmani, R. Koudjeti Military Hospital of Oran, Surgery, Oran, Algeria Introduction: The military environment needs a young and active population, inguinal hernias are a real problem of public health care more precisely in the military, our study is based on the contribution of laparoscopy in the treatment of hernias of the groin to the military population.

P086 Two-year results from the use of n-butyl-2cyanoacrylate in Lichtenstein inguinal hernia repair L.A. Vega Rojas, P. Besora, R. Claveria, D. Salazar, R. Rodriguez, D. Carmona, M. Molinete, J. Camps Hospital de Igualada, General Surgery, Igualada, Spain Background: Long-term effectiveness of the use of n- butyl-2cyanoacrylate in Lichtenstein inguinal hernia repair type and its effect on post- operative pain. Materials and methods: A prospective randomized trial of patients who underwent primary unilateral, types I, II and III clinical trial EHS inguinal hernia; comparing the binding of the polypropylene mesh lightweight, with n-butyl-2-cyanoacrylate versus non-absorbable (polypropylene 3-0) suture. Results: We included 120 patients (60 in each group), from 11/26/2013 until 09/02/2015. Average age of 61.12 years (18–84 years). 91 % men,

123

S200 9 % women. We have collected the patient’s own variables as well as those inherent in the operation. The assessments were performed by a first outpatient visit within 30 days after the surgery, 6 months follow-up, 12 months and 2 years. The incidence of recurrence after 2 years of follow-up was 2/60 (3.33 %) in the cyanoacrylate group and 1/60 (1.66 %) in the suture group. No statistically significant differences in the incidence of chronic pain or foreign body sensation assessed a maximum of 2 years were observed. Conclusions: The results of this trial show that both methods are equivalent fixation of prostheses from the point of view of the quality of repair. Besides their use is associated with lower operating time and a reduction in the incidence of acute pain evaluated a month after, no statistically significant differences in chronic pain evaluated at 6 months, 1 and 2 years.

P087 Safety of the use of n-butyl-2-cyanoacrylate in elective inguinal hernia repair by open approach L.A. Vega Rojas, E. Fernandez, R. Claveria, P. Besora, X. Vin˜as, R. Rodriguez, M. Molinete, J. Camps Hospital de Igualada, General Surgery, Igualada, Spain Background: Patient safety of mesh fixation with n -butyl-2cyanoacrylate in the inguinal hernioplasty Lichtenstein compared with the conventional technique. Materials and methods: Clinical, prospective, randomized trial. Including 120 patients (60 in each arm). Group I, mesh fixation with n-butyl-2-cyanoacrylate (study group). Group II, mesh fixation with polypropylene 2/0 (control group). From November 2013 to February 2015. Results: Average age of 61.12 years (18–84 years) 91 % men, 9 % women and have collected demographic and variables inherent in the operation. All of our patients have been operated during operation without income and with spinal anesthesia. There were no intraoperative complications in either group. It has conducted telephone control at 24 h intervention and 2–4 weeks in outpatients. Scale use Clavien et al. to determine the clinical impact of complications. The incidence of complications in the cyanoacrylate group was 11/60 (18.33 %) whereas in the group of polypropylene fixation was (10/60) 16.66 %, without observing these statistically significant differences. A decrease in the secondary target operating time for the n-butyl-2cyanoacrylate (36.39 vs. 42.22 min p \ 0.05). No early recurrences were observed in either group. Conclusions: The use of n-butyl-2-cyanoacrylate as a method of fixing mesh in Lichtenstein inguinal hernia repair is a safe method. It has been observed secondarily decreased operative time (p \ 0.05) but the amount of this reduction has little clinical relevance. We conclude that both methods are equivalent from this point of view.

P088 Open inguinal hernia repair using a self-gripping suture less mesh in one hundred cases: our experience after 24 months follow-up

Hernia (2016) 20 (Suppl 2):S175–S249 Materials and methods: One hundred primary inguinal hernia were managed by open self-gripping mesh repair (Parietex Progrip Covidien). About these 97 were unilateral and 3 bilateral, in 17 female and 80 male patients. The patients age ranging from 36 to 90 years, 31 hernias were direct and 69 were indirect. We find 52 inguinal right hernia and 48 left inguinal hernia. Operative surgical time was included between 20 to 60 min. Results: Median operative time was 35 min for unilateral hernias and 60 min for bilateral ones. All the patients were discharged home at the same date of surgical intervention. We had three cases of relapses at the time of operation; one of them had a relapse too at 18 months but it was the only case of our study. Two of all patients had postoperative pain and minimal discomfort after 18 months. One of them suffered from chronic pain after inguinal hernia repair with conventional polypropylene mesh. No cases of wound infections, seromas or hematomas. Conclusions: Open inguinal hernia repair using a self-gripping suture less mesh (Parietex Progrip Covidien) represents an alternative and viable surgical way respect to classic Lichtenstein suture procedure.

P089 Post-operative pain after TAPP: impact of mesh fixation methods A.M. Belousov1, T.V. Horobryh2, R.E. Izrailov1 1 Moscow Clinical Scientific Center, Surgery, Moscow, Russian Federation, 2First Moscow State Medical University named by I.M. Sechenov, Surgery, Moscow, Russian Federation Background: The TAPP is a frequently used treatment of inguinal hernias. The role of fixation of the mesh is important in the endoscopic technique. Use staples, screws, sutures is associated with a significantly increased risk of developing a post-operative pain syndrome. Methods: Data analysis included 115 patients with inguinal hernia. This patients underwent standard TAPP. We compared four groups of patients: a group of 23 patients treated with sutures (I group), a group of 34 patients treated with non- absorbable tacks (II group), a group of 33 patients treated with absorbable tacks (III group), a group of 25 patients treated with autologous fibrin glue (IV group). We evaluated: duration of surgery, post-operative pain, return to normal activity, and early and late complications. Results: Mean duration of surgery was significantly higher for I group and minimal in IV group (71 ± 4.5 min, 44.03 ± 1.81 min, respectively). Post-operative pain (7 h, 24 h, 7 days) was higher in I group (VAS 4–8); in II and III group were no significant difference (VAS 3–6); minimal post-operative pain was in IV group (VAS 0.5–4). Time to return to normal activity depended on post-operative pain and was higher in I group minimal in IV group (10 vs. 4, respectively). Two patients with chronic postoperative pain were reported in I group. Two recurrence were noticed in III group. Conclusion: This study demonstrates that autologous fibrin glue lead to good results during initial follow-up and in long term data.

L.D. Luigi d’Ambra, E.M. Muzio, S.B. Bruno, E.F. Francone, S.B. Berti S. Andrea, Chirurgia Generale, La Spezia, Italy

P090 Elective and emergency inguinal hernia repair in the geriatric age group

Background: We describe our experience about open inguinal hernia repair using a self-gripping mesh (Parietex Progrip Covidien) applied in a series of one hundred cases followed for a period of 24 months, analyzing early and late post-operative complications as acute and chronic pain, seroma, hematoma, infection and relapse.

S. So¨zen, S. Emir Namik Kemal University, General surgery, Tekirdag, Turkey

123

Purpose: In this study morbidity and mortality rates of inguinal and femoral hernia repair operations carried out under emergency and

Hernia (2016) 20 (Suppl 2):S175–S249 elective conditions on patients of 65 years and older ages are evaluated. Materials and methods: Seventy-eight patients of 65 years and older, who were operated on under emergency and elective conditions for inguinal and femoral hernia within the 5 years period between 2008 and 2013, were included in this study. Of these patients, 48 were operated on under emergency conditions while the other 28 were operated on under elective conditions. We compared chronic diseases (e.g. Chronic obstructive pulmonary disease, diabetes mellitus), which may cause postoperative recurrence, gender, recurrence, the development of postoperative seroma, receiving postoperative drainage and postoperative length of hospital stay were compared. Results: There was no significant difference between the groups in terms of co-morbid diseases (p = 0.1). While no mortality was seen among patients operated on under emergency and elective conditions, There was not any significant difference between groups in terms of the duration of the surgery, postoperative morbidity and mortality rates (p [ 0.05). While the patients who were operated on under emergency conditions spent an average time of 7 days in hospital, this time was 3 days for those operated on under elective conditions (p \ 0.001). Conclusion: We conclude that elective and emergency inguinal hernia repair can be done in the geriatric age group after a careful preoperative preparation.

P091 The use of prolene mesh in incarcerated inguinal hernia repair: Is it a safe and feasible procedure on patients of 65 years and older ages? S. So¨zen Namik Kemal University, General surgery, Tekirdag, Turkey Aim: The aim of this study was to analyze the outcomes of mesh use in incarcerated inguinal hernias on patients of 65 years and older ages. Methods: Seventy-eight patients of 65 years and older, who were operated on under emergency conditions for inguinal and femoral hernia within the 5 years period between 2008 and 2013, were included in this study. Patients were allocated into two groups according to the operation type as; Lichtenstein repair (Group 1:40) and primary repair (Group 2:38). The two groups were compared in accordance to their pre and post operative characteristics. Results: There was no significant difference between the groups in terms of co-morbid diseases (p = 0.1). While no mortality was seen among patients operated on under emergency conditions, There was not any significant difference between groups in terms of the duration of the surgery, the hospital stay, postoperative morbidity and mortality rates (p [ 0.05). Bowel resection was performed mostly in women patients. In addition, patients having bowel resection had longer hospital stay times. The risk of having a complication and a recurrent hernia was higher in these patients. While the patients having bowel resection on under emergency conditions spent an average time of 9 days in hospital, this time was 3 days for those operated on under elective conditions (p \ 0.001). Conclusion: Monofilament polypropylene mesh use for strangulated inguinal hernia repair is safe and feasible. Generally mesh usage is accepted but in case of peritonitis primary repairing should be preferred.

S201

P092 Retrospective comparison of 3D mesh devices (UHS and PHS) in inguinal repair J.I. Jorge Barreiro1, I. Garcia Bear1, A. Rodriguez Infante1, G. Minguez Ruiz1, V. Sanchez Turrion2, C. Ildefonso Cienfuegos1, P.I. Fernandez Mun˜iz1 1 San Agustin, General Surgery, Aviles, Spain, 2Hospital Puerta de Hierro, General Surgery, Madrid, Sri Lanka Introduction: We retrospectively compare the 3d mesh devices, ultrapro hernia system (UHSOV1) and prolene hernia system (PHSE) in the management of inguinal hernia. 3D mesh devices consist of onlay and underlay patch which are connected together. They have the benefit of a posterior and anterior repair via an anterior approach. Methods: PHS hernia repairs performed between January 2006 and June 2010 were compared with UHS mesh hernia repairs performed between August 2009 and June 2013. Demographic data such as age, gender as well as comorbid conditions such as COPD, heart disease, diabetes, hypertension, prostatism, and chronic cough were collected. Complications such as seroma, hematoma, urinary retention, orchitis and wound infection were recorded. Recurrences in each group were also recorded. A student test and Chi square analysis were used for statistical analysis. Results: 200 valid cases entered the study. UHS 117 and PHS 73. All patients were followed up to February 2014. There was no significant differences with regards to age, gender or comorbidities. In general the trend for chronic pain and recurrence appeared to be decreasing with UHS. When we measured satisfaction ratio as being pain free, recurrence or discomfort, then the PHS group shows 74.7 % satisfaction as opposed to 85.5 % with the UHS group. Conclusion: Our study shows, UHS is significantly better when compared to PHS in terms of recurrence and chronic groin pain. UHS may be better alternative to PHS in inguinal hernia repair suggesting that light weight mesh may be the way ahead.

P093 Actual costs of Lichtenstein and laparoscopic inguinal hernia repairs S. Kouhia1, E. Aro2, H. Paajanen3 1 Helsinki University Hospital, Department of Vascular Surgery, Helsinki, Finland, 2North Karelia Central Hospital, Department of Surgery, Joensuu, Finland, 3Kuopio University Hospital, Department of Surgery, Kuopio, Finland Background: There is limited evidence of the actual societal costs of Lichtenstein and laparoscopic inguinal hernia repair, when current guidelines on inguinal hernia treatment are followed. The aim of this study was to compare the total costs of Lichtenstein and laparoscopic repairs of inguinal hernia in clinical setting, outside an RCT. Methods: Between 2002 and 2011, consecutive 458 patients undergoing laparoscopic inguinal hernia surgery in one hospital were compared to 528 patients operated with Lichtenstein technique. Actual costs were calculated for all hospital visits, admissions, surgical procedures, complications and convalescence for employed patients until June 2015, providing a minimum follow-up of 3.5 years. Patients were operated respecting the current EHS guidelines of inguinal hernia treatment.

123

S202 Results: Laparoscopic repairs were more often performed for complicated hernias (bilateral and recurrent). There were no statistically significant differences in complications between the groups. The laparoscopic repair was significantly more expensive from the hospital perspective ($3069 vs. $1948, p \ 0.001), and also the complications after laparoscopic surgery were more expensive ($1874 vs. $971 per complicated case, p = 0.003). However, laparoscopic repair was a more attractive option from the societal perspective (total costs for employed patients $7684 vs. $8073, p \ 0.001). For nonworking patients, laparoscopy was more expensive (total costs $3325 vs. $2188, p \ 0.001) without the balancing effect of shorter convalescence. These results remained consistent in the subgroup analyses for bilateral, recurrent, and unilateral primary hernias. Conclusion: This clinical non-randomized audit confirmed, that laparoscopic inguinal hernia repair has lower total societal costs compared to Lichtenstein repair in employed patients.

P094 The value of transabdominal preperitoneal patch plasty(TAPP) treatment of complicated inguinal hernia B. Li, D. Gong, Y. Mo, Z. Xie, Y. Peng, H. Xie, X. Nie Hexian Memorial affiliated hospital of Southern Medical University, General Surgery, Guangzhou, China Background: The treatment of complicated inguinal hernia which is defined as hernia with large defect or recurrent hernia, is a common problem that vexes all general surgeons. It is accompanied with higher recurrences and more postoperative complications. Which is the best treatment still remain contravasial. Transabdominal preperitoneal patch plasty (TAPP) seems to be a preferred alternative. We report our experience with the TAPP surgery for repair of complicated inguinal hernia and retrospectively evaluate a consecutive series of 77 cases in our institution. Methods: Between November 2012 and June 2015, 77 cases of complicated inguinal hernia were treated by laparoscopic surgery. All patients underwent transabdominal preperitoneal patch plasty. The clinical data were retrospectively analyzed. Results: All surgery was successful without any serious complications. The mean operative time was 61 (range 40–189) min in 31 cases of recurrent hernias and 53 (range 37–162) min in 46 cases of hernias with large defect. The mean of postoperative hospital stay was 70 (range 36–144) h. Complications including urinary retentions, urinary infections, scrotal hematomas and seromas occurred in 21 cases (27.3 %) and were properly managed, with no major impact on outcome of the operations. Complications associated with mesh was not detected. No serious acute or chronic pain occured postoperatively. There were one recurrent case (1.2 %) in the patients who had been followed-up for 3–34 months. Conclusions: The TAPP surgery for repair of complicated inguinal hernia is a safe and reliable procedure with minimal invasion and satisfactory outcome, but the technique should be reserved for surgeons with extensive experience in the TAPP technique.

P095 TAPP with combined ULTRAPRO mesh fixation at inguinal hernias Y.P. Feleshtynskyi, A.V. Kokhanevych, V.F. Vatamaniuk P.L. Shupyk National Medical Academy of Postgraduate Education, Surgery and proctology, Kyiv, Ukraine Introduction: The relapse rate of inguinal hernia after TAPP is 3.5–10 %. The main reason for recurrence of inguinal hernias after

123

Hernia (2016) 20 (Suppl 2):S175–S249 TAPP is the lack of mesh fixation on the site of iliopubic tract and iliac vessels. In our opinion, the use of mesh fixation combined with TAPP will help to reduce the frequency of relapses. The aim of the research: Was to improve the results of surgical treatment of inguinal hernias using TAPP. Materials and methods: Analysis of surgical treatment of inguinal hernias using TAPP in 106 patients aged from 25 to 75 was performed. All patients were male. Depending on the method of TAPP, patients were divided into two groups. In group I (52 patients) the classical method of TAPP was performed. In group II (54 patients) the advanced techniques of TAPP, the area of iliopubic tract and iliac vessels was fixed with glue «Acril» . «Ultrapro» 10 9 15 cm was used in both of groups. Results and discussion: In the early postoperative period among patients of group I, seroma was observed in 2 patients (3.8 %), scrotal hematoma in 3 patients (5.7 %); in 3 patients (5.5 %) and in 2 patients (3.7 %) of group II respectively. Long-term results of treatment were studied in the period of 1 to 5 years. Among the 42 examined patients of group I relapsed inguinal hernia were observed in 3 patients (7.1 %), and among the 41 examined patients of group II the recurrence of hernia was not observed. Conclusion: Combined fixation of «Ultrapro» mesh at TAPP using stapler «Protack» at typical points and glue «Acril» on the site of iliopubic tract and iliac vessels significantly reduces the recurrence rate of inguinal hernias.

P096 Prothesis and sealants: two different approaches for a better standard of living in inguinal hernia repair T.L. Lubrano1, C. Vidotto2, E. Ponte1, E. Mazza1, M. Morino1 1 Citta` della Scienza e della Salute, Chirurgia Universitaria 1, Turin, Italy, 2Universita` degli Studi Guglielmo Marconi, Dip. Scienze e Tecnologie Applicate, Rome, Italy Aim: The use of synthetic macroporous low-weight prothesis combinate with atraumatic fixation systems, provide effective treatment, better performance and tolerability especially in young, dynamic and regular-weight patients. Methods: This research takes into account 200 male patients, mean age 52 years, ASA I-III, BMI \ 28, with primary inguinal hernia (P EHS 1-2 LM), submitted in the period November 2012, December 2014 to tension-free hernioplasty sutureless, under local anesthesia, and a Day/1-day-surgery. The study relies on the random blind distribution in a group A (100 pcs using a macroporous light-weight polypropylene mesh and fibrin glue fixation spray and 1/100 of elements of human thrombin 5 U/ml) and group B (100 pcs using a macroporous light-weight polypropylene monofilament mesh covered with pvp and peg sealants). Both groups were monitored at 7, 30, 90, and 360 days. Results: By this data we can see that the cure rate is similar in two groups, valued at more than 98 % of cases. Complications are reduced in both. Seromas were more evident in the initial period in group A, related to incorrect dilution or improper distribution of the glue with the consequent creation of dead space, then reduced to about 6 %, similar in two groups. Hematomas were about 0.2 % in group A and B. No infections in all cases. We haven’t seen chronic pain (VAS scale, 30 to 365 days) due to the accurate identification of inguinal nerves, the lack of sutures (single assorbible point on pubis), and for the affinity of the materials used in comparisons of nerve tissue. Conclusions: This devices are of comparable effectiveness. The use of macroporous light-weight prothesis allows better cellular colonization, tissue integration and physiological tensile strength.

Hernia (2016) 20 (Suppl 2):S175–S249 Biological glue and synthetic idrolitic sealants avoids meshes dislocation in a better way than a classical Lichtenstein technique. Guaranteeing a superior comfort, greater safety and better performance than standard prothesis.

P097 MRI visible meshes: A diagnostic solution if the hernia repair complicated ¨ z1, E. O ¨ zveri1, E. Yildiz1 H. Go¨k1, M. Ertem2, A. O 1 Acibadem Kozyatagi Hastanesi, General Surgery, Istanbul, Turkey, 2 Istanbul Uni., Cerrahpasa School of Medicine, General Surgery, Istanbul, Turkey Background: Radiological imaging methods in order to detect problems such as mesh shrinkage, migration and meshoma formation after inguinal hernia repair sometimes are inadequate. MRI visible meshes has been produced over past years. If the hernia repair is complicated; such meshes may provide ease to the physician. Here we present the our case series which we applied MRI visible meshes. Methods: 82 laparoscopic inguinal hernia repairs in 57 patients (53 male, 4 female) were done by using MRI visible meshes. Mean age was 46.3 (range 21–83), BMI 26 (range 20–37). TEP repair was done to 28 patients unilaterally and to 22 bilaterally. TAPP repair was done to 3 patients unilaterally and 3 bilaterally. 1 unilateral TAPP case and 2 unilateral TEP cases were recurrent ones. Three dimensional type of the mesh was used in 45 cases. Results: Meshes were fixed with protack in the all patients. Tissue adhesive was used in addition to protack at 17 patients. All patients except 2 ones were discharged first postoperative day. MRI was obtained from 2 patients after 3 and 12 months. There were no recurrences or any other complications during follow up period, mean 12 months (range 1–31). Conclusion: Over the past decades, the incidence of implant-related complications such as shrinkage, deformation, migration with erosion of adjacent organs, fistula formation has increased in parallel with the increasing clinical use of mesh implants. Because all imaging methods fail to visualize regular surgical implants, to capable to visualize a mesh in the body would provide valuable information if the hernia repair complicated. In order to accomplish this, integration of iron particles in the mesh base material allows MRI visualization of meshes. In clinical practice, detection of possible mesh migration, mesh fractures, or deformation is facilitated with iron particles integrated mesh implants.

P098 Short and mid-term outcomes of inguinal hernioplasty in the Belgrade Hernia Service: a prospective evaluation V. Cijan, M. Scepanovic, P. Bojovic, M. Gencic, A. Durkovic Clinical Hospital Center ‘‘Zvezdara’’, Surgery Clinic, Belgrade, Serbia Background: Inguinal hernioplasty has a huge impact on health-care expenditure and working disability. Dedicated hernia centres significantly improved the outcomes of inguinal hernioplasty achieving an cost-effective procedure with low morbidity and recurrence and rapid return to daily activity. In 2012, Belgrade Hernia Service, a department devoted to hernia surgery within teaching hospital was established. Our aim was to evaluate the short and mid-term outcomes of inguinal hernioplasty in Belgrade Hernia Service compared with those in General Surgical Clinic.

S203 Methods: A prospective database of patients who underwent Lichtenstein inguinal hernioplasty between 2012–2016 was created. Demographic data, American Society of Anesthesiologists (ASA) classification, type of anaesthesia, antibiotic prophylaxis, operating time, early and late complications, hospitalisation and return to daily activities were collected. Patients were evaluated before discharge, at 7, 28 days and annually. Operative characteristics and short-term outcomes were compared with General Surgical Clinic data. Results: 650 patients of mean age 66.3 were operated under local anaesthesia, with 57 min median operation time and 24-h hospitalisation. ASA-type 2 was the most common. Antibiotic prophylaxis was recorded in 9.84 %, postoperative haematoma 2.31 %, wound seroma 6 %, superficial infection 3 %, urinary retention 0.3 % and readmission in 5 patients, with return to activities in 5 days. Two patients developed deep infection and inguinodynia which required mesh removal. Recurrence rate was 0.77 % at follow-up. Comparing with General Surgical Clinic, significant differences were noticed in antibiotic prophylaxis 9.84 vs 93.2 %, local anaesthesia 100 vs 20 %, spinal anaesthesia 0 vs 80 %, urinary retention 0.3 vs 2 % and hospitalisation 1 vs 3.3 days. Conclusion: This study has highlighted beneficial effects of Belgrade Hernia Service operating within an teaching hospital. The good overall results signifies that our institutional protocols improved all aspects of patient care in the field of inguinal hernioplasty.

P099 Lightweight non-absorbable meshes versus lightweight partially-absorbable mesh (HybridmeshÒHerniameshÒ). Randomized clinical trial comparing Lichtenstein inguinal hernia repair with anterior approach. Results after 18 months after surgery M. Origi, M.R. Moroni, P. Veronesi, M. Gerosa, W. Zuliani Humanitas Mater Domini Clinical Institute, Surgery, Castellanza (Varese), Italy Background (aim): Compare different types of lightweight-mesh by tension-free hernia repair: HerniameshHertra6, HerniameshHertra9 and HerniameshHybridmesh. Determination of the meshes on treatment results. Methods: From June–October 2014 we observed 150 consecutive male patients affected by primitive inguinal hernia. Lichtensteintechnique was performed (absorbable sutures). Controlled follow-up appointments took place for 18 months from operation using ultrasound and clinical examination (average analgesic consumption, return to everyday activities, chronic pain occurrence, discomfort, seroma, recurrence, pain intensity). Results: No significant influence of the type of mesh on the risk of early complications (\15 days), pain intensity, length of hospital stay, time of recovery or patients satisfaction with treatment was observed. No presence of seroma was observed patients in HY group, even in those with BMI [ 30 and with hernia duration [2 years. None of the patients with isolated lateral and medial hernia developed a recurrence. After 18 months we observed no statistically significant differences between groups with regard to ‘‘foreign body sensation’’ (H6vsH9 OR = 0.30, 5 % CI 0.72–1.241, p = 0.091—H6vsHY OR = 0.35, 95 % CI 0.69–1.199, p = 0.074—H9vsHY OR = 0.32, 95 % CI 0.77–1.219, p = 0.253). Subjective differences (p = 0.217) in return to everyday activities were observed in HY-H6 groups with hernia duration \12 months from onset of symptoms to operation compared with H9 group. Mean follow-up 17 ± 1.418 months (range 15–19).

123

S204 Conclusions: 18 months follow-up results confirm the effectiveness of the Lichtenstein technique for hernia repair with every types of meshes we used. In particular the use of partially absorbable mesh Hybridmesh, with higher compliance and reduced ‘‘foreign-bodysensation’’, may ensure excellent results in selected patients. It appears the use of partially absorbable mesh is connected with lower risk of postoperative complications and in a faster return to everyday activities at 18 months.

P100 Open inguinal hernia repair with local anesthesia in patients treated with antiplatelet therapy S. al Mogrampi, A. Polyzos, E. Demertzidou, M. Verroiotou, A. Krexi, D. Michalakis, P. Tsanidis, I. Fardellas Naousa General Hospital, Surgical, Naousa, Imathia, Greece Background: The number of patients, who are eligible for elective surgery and concurrently receiving antiplatelet agents for secondary prevention in cardiovascular disease or vascular stenting, is increasing. Pre- and perioperative management of these patients is of great concern, as discontinuation of antiplatelet therapy due to increased bleeding risk exposes patients to thrombotic events. The aim of this study is to evaluate the safety of open inguinal hernia repair with local anesthesia in patients treated with antiplatelet therapy. Methods: From January 2008 to December 2015, a total of 812 patients were operated for inguinal hernia. The data that were collected regarded the patients who had an elective inguinal hernia repair with local anesthesia and who were on antiplatelet drug as a lifetime therapy for secondary prevention or vascular stents. Antiplatelet treatment was not discontinued at all throughout the admission. Anesthesia included local infusion of xylocaine. All patients underwent open inguinal hernia repair with mesh-plug fixation. Results: The number of patients under study was 118 and the average age was 56 years with an approximate 13:1 male to female ratio. All patients were dismissed the 1st post operative day. In the follow-up, two patients presented inguinal hematoma on the 3d post operative day. Hematomas resolved spontaneously approximately 25 days later. The complication rate was 1.7 % (2/118). Conclusions: Open inguinal hernia repair with local anesthesia can be safely performed on patients taking antiplatelet agents. Risk of hemorrhage is of minor importance as long as proper hemostasis is performed during the surgical operation. Moreover, patients have an early dismission from the hospital and they do not need to interrupt the antiplatelet therapy.

P101 An interesting case of strangulated littre hernia in a 88year- old patient A. Permekerlis, S. Filiou, S. Petousis, I. Orfanakos, P. Kouridakis General Military Hospital, 2nd Surgical Department, Thessaloniki, Greece Background: Littre is the type of hernia in which Meckel’s diverticulum, embryologic remnant of the vitelline duct, occurring approximately in 1–3 % of the adult population and located at the antimesenteric part of the small intestine, at a distance of 30–90 cm from the ileocecal valve, is present in the hernia sac. We report a highly interesting case of Littre hernia, since there are few articles concerning these types of hernias published in the international literature. Material and methods: All medical data were thoroughly reviewed regarding the patient’s preoperative and postoperative period. Images were obtained from surgical procedure findings.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Results: A 88-year-old patient presented in the emergency department of 424 military hospital in Thessaloniki (Greece) with clinical signs and radiologic findings of strangulated inguinal hernia. The emergency surgery revealed the presence of strangulated but vital part of small intestine and Meckel’s diverticulum within the hernia sac. Consequently, resection of Meckel’s diverticulum as well as appendectomy were performed, followed by the placing of a polypropylene mesh in the orifice of the abdominal wall (Lichtenstein method). There were no postoperative complications related to the surgery and the patient was excharged on the 7th postoperative day due to comorbidity and cardiac problems. Conclusion: Littre hernias, although rare, can be presented as abdominal hernias and resection of Meckel’s diverticulum as well as repair of the fascial defect are crucial in avoiding complications related to the diverticulum in the future, such as obstruction, infection, bleeding or herniation.

P102 Inguinal abscess in a strangulated Littre’s hernia S. Al Mogrampi, A. Krexi, A. Polyzos, M. Verroiotou, E. Demertzidou, D. Michalaki, P. Tsanidis, I. Fardellas Naousa General Hospital, Surgical Clinic, Naousa, Imathia, Greece Background: Littre’s hernia is the type of hernia, where the sac contains Meckel’s diverticulum, which is associated with various kinds of complications. Strangulation of Meckel’s diverticulum and consequent rupture represents a serious and life-threatening condition. Aim of this study is to present the case of a female patient, who had an inguinal abscess, which was attributed to a strangulated Littre’s hernia. Methods: A 62-year old woman, with a 10-days history of abdominal pain, presented in the emergency department referring deterioration of the abdominal pain in the past 48 h, accompanied by fever and vomit. Clinical examination revealed diffuse abdominal pain and an inflammatory mass on the right groin. Laboratory tests were positive for leukocytosis and abdominal X-ray revealed multiple air fluid levels. Given the clinical and laboratory findings the patient was taken in the operating room. Results: Diagnostic laparoscopy revealed Littre’s hernia accompanied by rupture of Meckel’s diverticulum and abscess formation. Due to multiple adhesions and distension of the small bowel, the operation proceeded with open laparotomy, performing a subumbilical midline incision. Enterectomy and side-to-side anastomosis was performed and the abscess was drained. The post-operative period was uneventful and in 2 months follow-up the patient was symptoms-free. Conclusions: An inguinal abscess can represent the first manifestation of a strangulated Meckel’s diverticulum in Littre’s hernia. It should be taken into account in the differential diagnosis of acute abdomen. Prompt diagnosis and therapy is essential. The treatment of choice is surgical operation and consists in enterectomy and primary anastomosis.

P103 Ten-year experience in treating inguinal hernias by Desarda technique V.V. Vlasov1, I.V. Babii1, P.V. Prosvitliuk1, S.R. Mykytiuk1, O.V. Vlasova2 1 Khmelnytskyi Regional Hospital, Department of Surgery in FPE of Pyrohiv Vinnytsia NMU, Khmelnytskyi, Ukraine, 2Bukovinian State Medical University, Pediatrics and Infectious Disease, Chernivtsi, Ukraine More than 10 million operations for inguinal hernias (IH) are performed over the world annually. They are predominantly allografts.

Hernia (2016) 20 (Suppl 2):S175–S249 However, young people often prefer autografting in the treatment of IH. Objective: To study the results of autografting by Desarda technique in patients with IH. We treated 586 patients with IH (523 men and 63 women aged on 51.4 ± 14.6). According to the classification by EHS pL1 type IH was diagnosed in 42 cases, pL(M)2–270, pL(M)3–254, rL(M)3–13, rM2–7. Allografting technique was applied in 399 patients. To treat 187 patients with IH (127 men, 60 women aged on 42.8 ± 17.8) we used Desarda technique. We observed the right-side localization of IH in 130 patients and the left-side—57. Primary IH, strong aponeurosis of the abdominal external oblique muscle or that with medium stiffness, height of the inguinal interval \2.5 cm, the patient’s refusal to have allografting, young men and women regardless of their age serve as indicators for using M. P. Desarda technique. In all cases it was necessary to sew up the transverse fascia by forming a deep inguinal ring to normal anatomical size (about 1 cm). In order to fix the aponeurotic strip we used an uninterrupted suture. The pre- and post-operative antibiotic prophylaxis was used. In the early postoperative period in 4 patients operated by M. P. Desarda technique we observed infiltration of soft tissues in the postoperative wound, swelling of the scrotum—2, spermatic cord hematoma—2, orchitis—1. All complications were eliminated conservatively. Conclusions: (1) It is technically simple to perform, can be used due to refusal of the patient to have allografting and the absence of a meshed autograft. (2) Operation by M. R. Desarda can effectively close the hernia defect of primary IH and to avoid any complications associated with the use of synthetic material.

P104 ‘Sutureless’ in groin hernias F.A. Abbonante, F. Manno Catanzaro City Hospital, Chief of plastic surgery/surgery department, Catanzaro, Italy Ermanno Trabucco was the first surgeon in the world who understood sutureless technique was the unique tension free technique in groin hernia like in incisional hernias. After his death this work who explain integral Trabucco’s technique is necessary to avoid world to forget this important concept.

P105 Prosthetic inguinal hernia repair with semi-rigid Polypropylene mesh (HertraÒ2–HerniameshÒ) under local anesthesia: in short and long term results and quality of life valuation G. Brancato, M. Donati, M. Ristagno, G. Basile A.O.U. Policlinico-OVE, Chirurgia, Catania, Italy Background: The purpose of this study is to demonstrate the validity of the semi-rigid Polypropylene mesh (Hertra2, Herniamesh) in the treatment of inguinal hernia and evaluate the short and long term results and quality of life. Methods: From January 1994 to December 2015, 3312 patients underwent prosthetic inguinal hernioplasty under local anesthesia. Of these, 813 were treated with Hertra2 mesh using tension-free sutureless technique. No exclusion criterion was considered. Results: All the operations were performed under local anesthesia and without opening the hernia sac, as well as in respect of the

S205 defense mechanisms that protect from increased intra-abdominal pressure. No intra-perioperative complication noteworthy was observed. All patients walked immediately after the operation, they were fed after about an hour and were discharged in the early afternoon. 58 % of them needed an analgesic treatment during hospitalization and only 34 % have used it at home. 74 % of patients drove the car within 5 days and self-employed in 63 % of cases have resumed their activities 4–5 days after surgery. Even those who practiced sport were able to start again it in a light way within 20–30 days. The clinical and ultrasound follow-up at 6 months showed an abdominal wall perfectly consolidated and valid also under coughing. Conclusions: In our experience the semi-rigid Polypropylene prosthesis Hertra2 is a safe device, reliable and, for its physical characteristics, allows an early healing of the abdominal wall and rapid recovery of normal daily activities without pain. References: 1. Donati A, Cardı` F, Brancato G, Privitera A, Gandolfo L, Donati M (2001) Day surgery for primary inguinal hernia: personale experience. Atti del 4 Congresso Internazionale di Chirurgia Ambulatoriale. Ginevra 22-25 Aprile 2001. Amb Surger 9(S):S44 (A) 2. Novitsky YW, Harrell AG, Hope WW et al (2007) Meshes in hernia repair. Surg Technol Int 16:123–127

P106 Two variants of the Guarnieri’s technique for inguinal hernia give a tension free repair without any prosthetic material F. Guarnieri1, F. Moscatelli1, W. Smaldone1, C. Nwamba1, C. Durazzo2 1 Clinica Guarnieri, General Surgery, Rome, Italy, 2Universita’ La Sapienza, General Surgery, Rome, Italy The Guarnieri’s technique for inguinal hernia repair is a well consolidated technique that gives now 0.5 % of recurrence rate in expert hands. This technique can be used with or without mesh. In recent years we are limiting the mesh use because we can obtain the same results in terms of recurrence in both cases (with or without using the mesh). In this paper we debate on how it is possible to substitute the prosthetic material with the local biological resources giving a perfect pure tissue repair without tension. In our institution we have now developed a protocol to change some technical steps of the Guarnieri’s technique. The basic steps remain the same while the type of hernia and the anatomical variants shape different steps. To do this, we have to consider the anatomical differences among the inguinal hernia population. The architecture of the inguinal canal is evaluated and re-designed on the basis of the internal oblique muscle variations and the distance between the inguinal ligament and the rectus muscle lateral border. The rectus muscle can be lateralized with a relaxing incision on the rectus muscle fascia and the fascia itself can be used as a natural prosthesis. The incised lateral flap of the external oblique aponeurosis can be sutured on the rectus muscle aponeurosis over or under the plane of the internal oblique muscle. This is performed on the base of the internal oblique muscle trophic status along its path inside the inguinal canal towards the pubic tubercle. All this new technical variants aim to reduce the passive areas lacking of musculature, to avoid the lateral tension of sutures, to reinforce the defective areas without using any prosthetic material. Our results do not show any difference in terms of recurrence rate between the original technique and the new technical variants.

123

S206

P107 Laparoscopic transabdominal preperitoneal repair of inguinal hernia with small intestinal submucosa F.Q. Chen, Y.M. Shen, J. Chen, B.S. Wang Beijing Chao-Yang Hospital, Hernia and abdominal Wall Surgery, Beijing, China Background: Biologic mesh is now increasingly considered as an additional option for open inguinal hernia repair with acceptable outcomes, especially in contaminated field. Laparoscopic technique has recently played a more and more important role in inguinal hernia repair, while poor experience of biologic mesh in laparoscopic herniorrhaphy were documented in the literature. Aim of this study was to show the clinical outcomes of biologic mesh following transabdominal preperitoneal (TAPP) hernia repair. Methods: A retrospective study of patients who underwent TAPP repair using a small intestinal submucosa (SIS) was conducted in a single clinical center from January 2013 to February 2015. Patient’s demographic data, intraoperative details, recurrence and postoperative complications were recorded and analyzed. Results: A total of 21 patients (23 hernias) who underwent TAPP repair with biological prosthesis were enrolled in this study (16 male, 5 female; mean age 29.6 years). Of these, 19 were unilateral hernia while 2 were bilateral hernias, including two emergency cases of incarcerated hernia. Mean operative time was 40 min (range 28–60 min) for unilateral hernia, 60 min (range 40–80 min) for bilateral hernias. Mean length of hospitalization stay was 3.5 days. Major postoperative complications were scrotal seroma (7/23) and pyrexia (T [ 38, 4/21). During mean follow up of 12 months (range 10–23 months), no recurrence, chronic pain, foreign body sensation or mesh infection were noted. Conclusion: On the basis of our initial experience, TAPP repair with the SIS biologic mesh is feasible and effective, without gaining any risk of recurrence. It looks like that postoperative seroma and selflimited fever are not uncommon following this clinical practice. Evidence of superior procedure and optimum candidates for biologic mesh are still needed to be investigated further.

P108 Fourth trocar in TAPP complex inguinal hernia repair. Preliminary experience and technical notes F. Velluti, F. Ghiglione, S. Marola, F. Caciolo, A. Bona, S. Manfredi, P. de Paolis Humanitas Gradenigo Hospital, General surgery, Turin, Italy Objective: TAPP inguinal hernia repair is a well defined surgical procedure, with significant advantages for patients. In our experience, compared to literature, laparoscopic alloplastic is associated with a lower postoperative pain, less complications of surgical site and faster recovery. The surgical technique presents difficult steps that in some patients may extend operating time losing laparoscopic benefits. Results and methods: We performed from 2006 to 2016 about 350 TAPP with 50 min and 90 min of mean operating time in unilateral and bilateral inguinal hernia repair respectively. In 40 % cases bilateral hernia was diagnosed preoperative and 10 % cases contralateral hernia was detected during the exploration. At the beginning of our experience we had an increased operating time in patients with not favorable anatomical feature or previous lower abdominal surgery. The main critical steps reported were: exposure of the peritoneal layer to allocate the mesh hernia sac reduction.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Mesh placement and peritoneal flap reconstruction. Our approach: Preoperative vesical voiding; initial exploration of the abdominal cavity by 10 mm optical trocar in umbilicus; Two trocars placed on right and left transversal umbilical line. In 70/350 selected patients a fourth 5 mm trocar was placed in the median line between umbilicus and pubic bone or laterally on the more complex hernia side. Conclusions: In our experience use a fourth 5 mm trocar is useful for flap preparation, surgical exposure with significantly reduced operating time with not increased surgical invasivity or complication.

P109 Improvement of mini-invasive approach. Laparoscopic totally extraperitoneal alloplastic with 3 mm trocar S. Marola F. Velluti, F. Ghiglione, F. Caciolo, C. Filippa, F. Ferri, P. de Paolis Humanitas Gradenigo Hospital, General surgery, Turin, Italy In recent years laparoscopic treatment of inguinal hernia has gained popularity around the world and showed its potential benefits. Totally extraperitoneal approach (TEP) for inguinal hernia repair provides attractive aspects in terms of minimal incisions, more favorable postoperative course, less pain and faster recovery and return to normal activities. However this technique requires specific anatomical knowledge, and a certain number of operating trocar. In recent years, laparoscopic surgeons have attempted to improve cosmesis with surgery using various techniques. This case report describes the use of 3-mm trocar in totally extraperitoneal repair of an inguinal hernia. A 45 years-old patient with BMI = 22 affected by inguinal hernia (PM2) underwent surgery. The technique has provided an incision of 10 mm on umbilical cord and two 3 mm trocars on median line, between umbilicus and pubis bone. Operative time was 40 min, comparable to the TEP conventional technique. The mesh, folded with microgrip layer inside, has been placed in abdomen by umbilical trocar with the aid of grasper inserted in the suprapubic trocar. There were no intraoperative or postoperative complications. The patient was discharged 24 h after surgery. Many surgeons, to reduce parietal damage and to improve esthetic results, in a more and more minimally invasive prospective, performed TEP hernia repair with disposable instruments with higher costs and technical difficulties (i.e. single-incision). In our experience the umbilical incision associated to two 3 mm trocars is effective and provides an excellent wound result. The use of this technique, as the traditional TEP, is safe, doesn’t result in increased operating time and is cost effective thanks to re-usable device.

P110 Inguinal bilateral hernia tep repair with parietex ProGripTM self-fixating mesh F. Caciolo, F. Velluti, F. Ghiglione, S. Marola, A. Borasi, D. Borreca, P. de Paolis Humanitas Gradenigo Hospital, General Surgery, Turin, Italy Inguinal hernia is a common disease. Recently laparoscopic treatment has been widely used. It is very widespread in the common practice to use a mesh placed in the preperitoneal space secured especially in bilateral hernias to reduce the risk of his malpositioning or migration. There is no agreement on methods of mesh fixing. The fixating device determines itself a risk of increased postoperative or chronic pain.

Hernia (2016) 20 (Suppl 2):S175–S249 We report our experience in an inguinal bilateral hernia repair with totally preperitoneal technique using self-fixating ProGrip[TRADEMARK] mesh. We performed a primitive bilateral inguinal hernia repair in a 50 years-old patient with left PM2 and right PL2 (according to EHS hernia classification) BMI = 26. The technique is carried out with a sub-umbilical 10 mm incision to place the optical trocar and two 5 mm trocars positioned under vision in suprapubic and in the middle between navel and pubic bone. The operating time was 60 min. We placed two Parietex ProGrip[TRADEMARK] (15 9 9 cm) pre-shaped, folded with the microgrips layer inside, inserted through the umbilical trocar by rendezvous with the aid of the laparoscopic grasper inserted in the suprapubic trocar. We had no difficulties in mesh placement, intraoperative or postoperative complications. The patient was discharged 24 h after surgery. TEP procedure in bilateral hernias with self-fixating mesh is effective, safe and feasible. In literature use of mesh without fixation device is associated with a slight increased rate of recurrence. However, mesh fixation is associated with increased incidence and severity of postoperative chronic pain and higher costs. Surgeons should be able to perform different techniques to achieve best result tailored to the patient. Our choice of self-fixating mesh, avoiding glue and other fixation device, may provide a useful way to ensure better comfort to the patients with no significantly increased recurrence rate and costs.

P111 TAPP inguinal hernia repair with parietex ProGripTM self-fixating mesh F. Ghiglione, F. Velluti, S. Marola, F. Caciolo, M.P. Bellomo, M. Bossotti, P. de Paolis Humanitas Gradenigo Hospital, General Surgery, Turin, Italy Inguinal hernia is a common disease in general surgery. Various treatments in hernia repair are described. Recently the laparoscopic approach is widely used. The routine procedure is based on the use of a mesh placed in the preperitoneal space. A debated topic is the risk of malposition or migration which could necessitate the fixation of the mesh although many device to fix the mesh are related to increased postoperative or chronic pain. We describe our experience in TAPP inguinal hernia repair using self-fixating parietex ProGripTM mesh. We conducted a retrospective review of medical records of all patients undergoing laparoscopic preperitoneal alloplastic technique with parietex ProGripTM from 2012 to 2015. A total of 200 patients underwent TAPP for unilateral/bilateral inguinal hernia. The mean operative time was 50 min (25–60 min) in unilateral 90 in the bilateral (70–120 min). Two patients were converted for parietal peritoneum weakness. There were no major complications. All patients were discharged 24 h after surgery. There were no infectious complications of the surgical site or of the prosthesis. Only 4 hematoma and 8 seroma were reported. There were no cases of chronic pain with 6 months followup. There were a total of 4 recurrence detected at 3-years-follow-up. Conclusions: In our experience we don’t report an increased rate of recurrences or intraoperative and postoperative complications whit less chronic pain compared to the literature whit fixating device. In several randomized prospective trials TAPP repair has a strong potential in selected patients. Use of a self-fixating mesh, avoiding glue and other fixation device, is a useful way to ensure better comfort to the patients with no significantly increased recurrence rate and costs. Further improvements in the surgical technique can be obtained

S207 with the use of new materials that can simplify as much as possible the surgical act maximizing the results.

P112 Laparoscopic hernia repair in case of appendicitis within the hernia sac (Amyand’s hernia); is use of mesh contraindicated? H. Scheidbach Rho¨n Kreisklinik, General and Visceral Surgery, Bad Neustadt, Germany Background: Amyand´s hernia is defined as an appendicitis within the hernia sac of the ipsilateral groin. The occurrence of this specific type of hernia is extremely low, clinical presentation is preoperatively characterized by symptoms of an incarcerated hernia. There is a controversial debate on the use of mesh-based hernioplasty, the majority of surgeons reject it in such cases. In the age of endoscopic and predominantly prosthetic mesh repair, this question has to be raised again. Methods: Based on the approximately 150 published cases so far, and their detailed analysis this controversial issue in Amyand´s hernia is reassessed also on the basis of our own experience in the treatment of two representative cases. Results: Even in the case of coincident finding of appendicitis within the sac of an inguinal hernia, laparoscopic inguinal hernia repair using alloplastic meshes appears possible in the majority of cases. Conclusion: In case of prosthetic mesh repair of an Amyand’s hernia it is recommended to resect the adhesive hernia sac and only low weight and large-porous meshes should be used.

P113 Safety and efficacy of laparoscopic transabdominal preperitoneal herniorrhaphy using a partially absorbable polypropylene mesh for recurrent femoral hernias Y.M. Shen, J. Chen, F.Q. Chen, S. Yang Beijing Chao-Yang Hospital, Capital Medical University, Hernia and Abdominal Wall Surgery, Beijing, China Background: Femoral hernias are relatively scarce in clinic, but the patients frequently present as emergency or recurrent cases, especially, in a specialized hernia center. Open surgery is still the most common procedure, but its standard technique and approach have not yet reached. We present our preliminary experience of laparoscopic transabdominal preperitoneal (TAPP) repair with a partially absorbable polypropylene flat mesh in recurrent femoral hernias. Methods: In this retrospective study, 18 patients who had a previous open herniorrhaphy repair (simple suture or mesh repair) underwent laparoscopic TAPP repair using a partially absorbable polypropylene mesh (EasyProsthesis MESH 15 9 15, TransEasy Medical Technology Co., Ltd., China) in our institution from 2013 to 2015. Data was collected regarding patients’ demographics, prior surgery, recurrence rate, duration of hospital stay, and complications. Results: In this series, the mean patient age was 54.4 (range 35–78) years. The patients (15 females, 3 males) had an average of 1.3 prior repairs. 3 patients had simple suture repair, 4 had both suture repair and mesh repair, and 2 had undergone twice mesh repairs. Other 9 patients had once mesh repair previously. The mean operating time was 95.0 min (range 80–130 min). After at least 6 months follow-up,

123

S208 there were no recurrences or infections. 3 cases (16.7 %) of seroma occurred after operation. No postoperative pain (visual analogue score [4, lasted 3 months) was observed. Conclusions: The treatment of femoral hernia which has previous open hernia surgery is a challenge practice in the clinical practice. Laparoscopic preperitoneal herniorrhaphy using partially absorbable polypropylene mesh appears to be a safe and effective procedure in the repair of recurrent femoral hernias.

P114 Inguinal hernia after pelvic fracture surgery: report of two cases K.T. Katayama Teikyo University Hospital, Surgery, Tokyo, Japan Case 1: The patient, a 66-year-old male, had undergone surgery 10 months previously for right acetabular fracture and central fracture-dislocation of the right hip joint caused by a traffic accident. The patient presented due to observing gradual swelling of the right groin region postoperatively. The patient was diagnosed with right inguinal hernia and a surgery was performed with the anterior approach (before transabdominal preperitoneal hernioplasty [TAPP] was introduced at our hospital). Postoperative changes including adhesion made it difficult to determine anatomical position. However, the preperitoneal space was separated and the mesh was deployed with no problems (UHS-L used). A diagnosis of external inguinal hernia I-2 was made. Operative time was 1 h and 35 min, there was little bleeding and the patient progressed well postoperatively. Case 2: The patient, a 72-year-old male, presented with swelling in the right groin region that had appeared from 2 months previously. The patient had undergone surgery 6 months previously for right acetabular fracture. The patient was diagnosed with right inguinal hernia and underwent a surgery with TAPP. A clear intraperitoneal visual field was achieved. However, heteromorphic thickening of Cooper’s ligament that may have been due to postoperative adhesion was observed, and it took time to expose Cooper’s ligament. Other problems experienced including a trouble with the V lock closure made surgery take longer. A 3DMaxTM medium mesh was used. The patient was diagnosed with external inguinal hernia I-2. Operative time was 2 h and 46 min, there was little bleeding and the patient progressed well postoperatively. This report discusses surgical procedures for inguinal hernia following pelvic fracture with examining cases treated at our hospital and available literature.

P115 What is the right choice in inguinal hernia surgery: flat mesh (Hermesh) vs. 3D mesh (PHS/UHS) D.D. Dabic, B.M. Maric General Hospital Cacak, Surgery, Cacak, Serbia Background: Introduction of modern technology and application of new prosthetic materials opened a new chapter in hernia surgery. Methods: From January 2006 till January 2015, 1156 elective unilateral inguinal hernia operations in ambulatory surgery conditions have been done. We used flat mesh (HERMESH 8x15 cm; Herniamesh S.r.l. Italy) in the Lichtenstein technique and PHS/UHS (Ethicon J&J company, USA). Results: 683 (59.08 %) patients were operated by using Lichtenstein technique, and 473 (40.92 %) by using PHS/UHS. Average age of the patients was 63.7 years (20–91). Average duration of the

123

Hernia (2016) 20 (Suppl 2):S175–S249 hospitalization was 2.8 h (2–5). 39 (3.37 %) patients had intraoperative problems such as perioperative pain, bradycardia, hypotension and swelling (22 Lichtenstein and 17 PHS/UHS). Average duration of the operation when it comes to Lichtenstein technique was 49 min (29–66) and when it comes to 3D devices 37 min (23–54). In 60 month average follow up period, 44 (3.81 %) patients had complications. Seroma had occured in 9 (0.78 %) cases, 3 after Lichtenstein and 6 after PHS/UHS; haematoma on 16 (1,38 %) patients, 10 after Lichtenstein and 6 after PHS/UHS. 8 (0.69 %) patients had superficial wound infection, 5 after Lichtenstein and 3 after PHS/UHS. 6 (0.52 %) patients had chronic pain, 4 after Lichtenstein and 2 after PHS/UHS. Recurrence occurred in 5 (0.43 %) patients, 4 after Lichtenstein and 1 after PHS/UHS. None of the patients had need for urinary catheterisation. Conclusion: Both operation techniques, as well as both types of mesh give excellent results and there were not any significant differences related to the number of complications and postoperative recovery. The advantage of using 3D devices in inguinal hernia treatment is not vital, so a logical question appears, is using of 3D devices which are 109 (3D vs. flat mesh) more expensive justifiable. From my point of view, this question will remain unanswered for a long time.

P116 Outcomes of Lichtenstein inguinal hernioplasty in patients on chronic anticoagulation therapy V. Cijan, M. Scepanovic, P. Bojovic, M. Brankovic, M. Gencic Clinical Hospital Center ‘‘Zvezdara’’, Surgery Clinic, Belgrade, Serbia Background: The periprocedural management of patients receiving long-term oral anticoagulant therapy who require inguinal hernioplasty is a common but complex clinical problem. The optimal perioperative anticoagulation management is currently controversial and still a matter of debate. The aim was to review our protocol and outcomes in patients on chronic oral anticoagulant therapy who underwent inguinal hernioplasty. Methods: A database of xx patients who underwent Lichtenstein inguinal hernioplasty using 15 9 8 cm polypropylene mesh—Hermesh 3 (Herniamesh S.r.l. Italy), between 2012–2015 was maintained. A standard 3-day bridging therapy protocol with lowmolecular-weight heparin (LMWH) was used. Demography, American Society of Anesthesiologists (ASA) classification, indication for anticoagulation, international normalized ratio (INR), type of anaesthesia, operating time, complications, hospitalisation and return to normal activities were recorded. Patients were evaluated before discharge, at 7, 28 days and annually. Results: 38 chronic anticoagulated patients of median age 64,6 were evaluated; of these 20 have chronic atrial fibrillation, 5 mechanical cardiac valve, 10 history of deep venous thrombosis or pulmonary embolism and 3 other diseases. ASA-type 3 was the most common. The average INR on the operation was 1.4. All patients were operated under local anaesthesia, median operation time was 67 min and hospitalisation 4.5 days with return to normal activities in 5.5 days. Postoperative haematoma developed in 10.5 % patients, 3 were managed conservatively and 1 required surgical evacuation. 7.89 % wound seroma and 2.63 % superficial infection were recorded. No thromboembolic events and recurrence occurred at follow-up. Conclusion: Lichtenstein inguinal hernioplasty under local anesthesia can be done safely in patients on chronic oral anticoagulation therapy using a standardised bridging protocol. In our study this technique had excellent results, with minimal morbidity and prompt recovery. 3-day bridging therapeutic LMWH protocol has a low incidence of major bleeding and thromboembolic complications.

Hernia (2016) 20 (Suppl 2):S175–S249

P117 Transinguinal preperitoneal groin hernia repair using a preperitoneal mesh preformed with a permanent memory ring: Our results as alternative to Lichtenstein’s technique A. Torregrosa1, N. Payma Armas2, P. Garcı´a Pastor1, J. Balanya´ Vidal2, S. Cachaldora Alejo2 1 La Fe University and Politechnic Hospital, Valencia, Spain, Abdominal Wall Surgery Unit, Valencia, Spain, 2Military Hospital, General Surgery, Valencia, Spain Purpose: The transinguinal preperitoneal technique with a preformed mesh with a permanent memory ring has become as alternative to Lichtenstein´s technique making a preperitoneal repair similar to Rives’ technique. The purpose of this retrospective study was to evaluate our primary results by systematic clinical evaluation. Methods: This study includes all consecutive adult patients treated with surgery for a groin hernia by the same team using the same technique between January 2007 and March 2009. Any patient who participated in this study had a systematic clinical control between 6 months and 9 years after surgery. Results: In this study, we performed 190 hernia repairs in 146 patients. There was no infection of the mesh 1 recurrence; chronic pain in 2 cases, one of them require section of genitocrural branches and 1 hydrocele. Conclusions: It is feasible to correct a groin hernia using a preperitoneal preformed mesh with a permanent memory ring. This technique confirms the results of Pellisier et al., Berrevoet et al. and Maillart et al., presenting a low rate of complications including recurrence, chronic pain. As we describe this technique combines the benefits of the anterior approach (easy technique, short learning curve, low cost) and the preperitoneal placement of the mesh (less recurrence, less pain). This procedure is a good alternative to Lichtenstein’s technique and laparoscopic procedures like TEP (Totally extraperitoneal).

P118 Bilateral obturator hernia repair with transabdominal preperitoneal technique: case presentation E.H. Engin Hatipoglu, S.D. Suleyman Demiryas, V.U. Veysel Umman, F.D. Fatih Dal, M.E. Metin Ertem Istanbul University Cerrahpasa Medical Faculty, General Surgery, Istanbul, Turkey Obturator hernia is rare among all abdominal wall hernias. The incidence is between 0.05–1.4 % (1). Here we report an 84 year old female patient, who was diagnosed with bilateral obturator hernia and underwent surgery with transabdominal preperitoneal (TAPP) surgery. She presented with complaints of nausea, vomiting, and right hip pain to our emergency department and was evaluated with an initial diagnosis of acute mechanical intestinal obstruction. She had chronic renal failure and hypertension in her medical history. Standing abdominal x-ray showed dilatation of all small intestinal segments. CT scan revealed that distal ileal loop was herniated to the obturator canal and proximally there was a dilatation of 3.5 cm. The patient was taken to the emergency operation with a diagnosis of bilateral incarcerated obturator hernia. Diagnostic laparoscopy showed that distal ileal loops were herniated to the obturator canal bilaterally (stage III) No signs of ischemia, or perforation were seen. The defects were repaired using the laparoscopic TAPP technique with polypropylene mesh. At 12th hour postoperatively patient received oral regimen and at 48th hour drain was removed. The patient stayed at the intensive care unit for 4 days and at the surgery service for 5 days for a

S209 total of 9 days and was discharged uneventfully. In the 6 month follow up there was no complication or recurrence. Obturator hernia is among the differential diagnoses of acute abdomen presentations that requires early diagnosis and surgical intervention. Early CT scan is crucial and it is shown to decrease morbidity and mortality as well as being the indispensable modality for choosing the operative approach. TAPP technique is less invasive compared to the open surgery and it can be a feasible technique in cases with no signs of ischemia since it allows the control of intraabdominal pathologies and viability of the intestines.

P119 Hernioplasty using Desarda’s technique: single surgeon experience O.M. Kharyshyn Central District Hospital, Department of Surgery, Slavuta, Khmelnitsky Region, Ukraine Background: Inguinal hernia repair is probably the most common procedure in general surgery. Desarda’s technique was presented in 2001 as an original tissue-based repair method using an undetached strip of external oblique aponeurosis which strengthens the posterior wall of the inguinal canal. Aim of the study: Evaluation of the treatment results of patients, who underwent inguinal hernioplasty by Desarda’s technique-n general surgical department. Materials and methods: From 2007 to 2015, among 760 patients who underwent hernioplasty, 107 patients with 113 inguinal hernias (male 90.65 %, female 9.35 %) were operated by single surgeon using Desarda’s method at Surgery Department of Slavuta Central District Hospital. The following options were analyzed: age, type and location of hernia, duration of a surgical procedure, postoperative pain (evaluated by VAS) and complications. Results: The average age of patient 52.9 ± 16.7 years. There were 75 indirect and 32 direct hernias. Desarda’s method was used for treatment of 3 recurrent, 2 strangulated inguinal hernias. In 6 cases, bilateral hernias were operated. The average duration of operation was 49.17 ± 12.8 min. 90 patients were operated using local anesthesia (79.6 %), 10 (8.84 %)—under spinal and other 7 (6.19 %)— under general anesthesia. 5 patients (4.42 % of the whole quantity) suffered from postoperative complications (among them 2 cases of seroma, 1 case of superficial hematoma, 1 case of orchitis and one patient was operated under spinal anesthesia with observed urinary retention). The postoperative pain score was low (43–3 mm). After operations, there were no recurrences within the period of the next 3–96 months. Conclusions: The above mentioned method is simple in technical terms and is universal for various types of hernias. The results showed that in case of the correct performance, this technique is effective for inguinal hernia repair with good short and long-term results.

P120 Surgical treatment of strangulated inguinal hernias T. Gvenetadze Aversi Clinic, Surgery, Tbilisi, Georgia Background: Treatment of strangulated inguinal hernia remains important as emergency surgeries are frequently required. However, emergency surgeries are characterized by high rates of recurrence, complications and mortality. Serious comorbidities in the elderly which cannot always be properly evaluated and managed in the emergency situations, contribute to this problem.

123

S210 Objective: To analyze the reasons for recurrences and complications. Materials and methods: 592 patients with strangulated inguinal hernias who were operated in our clinic during 2009–2013 were included in the analysis. Primary hernias 309, once recurrent 176, multiply recurrent 107. Mostly occurred strangulation of small intestine—in 254 patients, loop of the small intestine and the greater omentum—in 126, greater omentum—165, other organs—in 47 patients. Method of surgical treatment for strangulated inguinal hernias were hernioplasty by Liechtenstein—97, by Gvenetadze—495. Results: In early postoperative period were observed following complications: suppuration of wounds—35, hematoma of wounds— 65, wound seroma—86, wound infiltration—17. All complications were cured by conservative methods—dressings, punctures, physiotherapies. From 592 strangulated hernia operated patients—16 died during postoperative period. Reasons of death in 9 of them were peritonitis, in 5—cardiac insufficiency, in 2—pneumonia. Long-term results were studied from 2 to 5 years in 423 patients. Recurrencies after Inguinal hernias treated by Lichtenstein—6 patients, from them during primary hernias—1, in multiply recurrences 5. After operation by Gvenetadze there were no cases of recurrences. Conclusion: In order to improve outcomes of surgical treatment of strangulated inguinal hernias it is necessary to prevent strangulation. In multiple recurrent inguinal hernias with destroyed tissues it is advisable to accomplish hernioplasty by creating three-layer back wall of inguinal channel by Gvenetadze.

P121 Sutureless inguinal hernia repair: a comparison between laparoscopic and open technique M. Uccelli, S. Olmi, G. Cesana, F. Ciccarese, R. Giorgi, G. Castello, V. Reggiani, G. Legnani San Marco Hospital, General Surgery Department, General Surgery Department, Zingonia (BG), Italy Background: Sutureless inguinal hernia repair avoid chronic groin pain. Since many years our group perform both laparoscopic and anterior inguinal hernia repair with sutureless techniques. In this study we compare laparoscopic and anterior sutureless hernia repair. Methods: This is a retrospective study on 300 patients with groin hernia who underwent sutureless surgical repair between July 2005 and July 2006. 150 patients were treated laparoscopically (trans-abdominal pre-peritoneal), 150 patients with open technique. A complete follow up of 60 months was collected. Results: No chronic groin pain was observed in both groups. Less post-operative pain and discomfort were observed in the laparoscopic group. A significant larger number of complications in the first 6 months after surgery were noted in the open repair group. Relapses were observed only in the open repair group. Conclusions: Sutureless inguinal hernia repair is feasible without a significant increase in complications and relapses; the laparoscopic technique seems to be the best choice for a quicker return to daily activities.

P122 Role of selective mesh fixation in TEP repair of inguinal hernia R. Sarangi, J. Nanavati Sir Ganga Ram Hospital, General and Laparoscopic Surgery, New Delhi, India The totally extraperitoneal (TEP) endoscopic repair of inguinal hernia combines the advantage of minimal access surgery with tension free

123

Hernia (2016) 20 (Suppl 2):S175–S249 prosthesis mesh repair. Many surgeons believe that mesh fixation is essential to reduce the recurrence of hernia. But it has been reported that mesh fixation is associated with certain specific complications apart from adding to the over all cost of the procedure. We present our experience of 1201 T E P repair over a period extending from 01.01.95 to 31. 12.15. We do not routinely fix the mesh and follow a policy of selective mesh fixation. We normally put a polypropylene mesh of size 15 9 8 cm for defect of \2 cm and 15 9 10 or 11 cm for defect more than 2 cm. During the period extending from 01.01.95 to 31.12.04 out of 874 hernia fixation was done in 72 cases where as in the later part between 01.01.05 to 31.12.15 out of 1201 hernia fixation was done 351. We followed a policy of mesh fixation in large direct and indirect inguinal hernia, sliding hernia and in TEP or TAPP repair for recurrent hernia following TEP repair. Patients were followed up after 2, 6, 12 and 24 months after the surgery and subsequently to report in case of doubt of recurrence. In the first half the recurrence rate was 1.94 % where as in the later half it was 0.72 %. Prevention of recurrence of hernia can be achieved in majority of cases with adequate space creation for the mash to be placed flat and selectively applying fixative device one or more depending on the necessity for the mesh to be placed properly.

P123 Surgical treatment of direct inguinal hernia large sizes I.V. Babii, V.V. Vlasov, M.E. Prystupa, V.V. Zagoruyko, V.P. Romanovsky Khmelnitsky Regional Hospital, Department of Surgery, Khmelnitsky, Ukraine Background: Inguinal hernia is mainly men of working age with a frequency of about 5 % of all surgical diseases, plastic of hernia is the most common (10–15 %) in the planned surgery operation. Purpose: Improve technique of direct inguinal hernia treatment of large sizes. Methods: The analysis of treatment of 201 patients with inguinal hernias operated alloplastic methods. Among operated the majority were male—187 (93 %). Patients were aged 18 to 87 years. According to the classification EHS pL1 type of inguinal hernia was diagnosed in 10 cases (4.5 %), pL2—41 (18.5 %), pL3—in 55 (24.9 %), rM1—3 (1.36 %), rM2—in 49 (22.2 %), PM3—in 41 (18.5 %), rS1—in 1 (0.45 %), rS2—2 (0.9 %), rS3—4 (1.8 %), rL3— in 3 (1.4 %), rM2—in 6 (2.7 %), rM3—5 (2.3 %), rS3—in 1 (0.45 %). Results: In 46 (20.8 %) patients completed plastic hernia defect on direct inguinal hernia of large size. Plastic hernia defect by Lichtenstein performed 9 (4.1 %) open preperitoneal alloplasty of hernia defect performed 37 (16.7 %) patients with direct inguinal hernias large size. Transverse fascia has been circumcised circularly at base hernial sac. Transverse fascia not separated. Hernial sac immersed in the abdominal cavity. The defect in the transverse fascia was sewn. This technique reduces the operation time, bleeding warned of hernial sac. Patients after preperitoneal alloplastic had complications: postoperative scar infiltrate (2), wound hematoma (1), which did not require surgical correction. Patients after surgery by Lichtenstein had complications: hydrocele testis membranes (1), postoperative scar infiltrate (1), hematoma wound (2). Patients examined in terms of 3 years—the patient after surgery by Lichtenstein had recurrence. Conclusions: 1. Patients with direct inguinal hernia better perform large open preperitoneal alloplastic. This technique reduces processing hernial sac of an operation.

Hernia (2016) 20 (Suppl 2):S175–S249

P124 Individualisation in groin hernia surgery K. Talboom VU medical center, Surgery, Amsterdam, Netherlands Background: The last few decades groin hernia surgery has changed significantly. New techniques have been introduced and are still emerging. Up till now it is unclear whether one technique suits all indications and patients, or if a tailored approach is indicated. We therefor designed a questionnaire to reveal the practice of hernia experts throughout the world. Methods: The questionnaire contained 22 questions concerning specific patient, hernia and situation related factors, e.g. females, obese, smokers, recurrent hernias etc. The questionnaire was distributed amongst the hernia surgeons of Hernia Surge during the 1st World Conference on Abdominal Wall Surgery. The surgeons were asked to indicate which technique they mostly practiced and which technique they preferred in these specific situations. Results: The questionnaire was filled out by 32 surgeons. A clear preference for an endoscopic approach was observed in patients with collagen disease (66 %), with a recurrence after an anterior approach (66 %), athletes (69 %), workers (72 %) and young patients (69 %). A preference for an open approach was observed in patients who underwent a prostatectomy (88 %) and patients with ascites (84 %). Subsequently we analysed whether technique preference was influenced by the technique the questioned surgeon mostly performed. A clear relation was found in laparoscopic surgeons who preferred a minimal invasive technique in case of female gender (OR 3.8; 95 % CI 1.04–13.5), athletes (OR 6.1; 95 % CI 1.3–28.6) and patients with a collagen disorder (OR 11.6; 95 % CI 1.46–93.3). Further on, choice of technique was not influenced by the surgeons mostly performed technique. Conclusion: The expert hernia surgeons of Hernia Surge tailor their surgical technique depending on patient, hernia and situational factors. It is concluded that individualization of groin hernia surgery is indicated and that there is no one technique that suits all indications.

P125 Open hernioplasty with Progrip technique: our experience about 3 years follow up of three hundred patients M.G.M. Marco Gallinella Muzi, C. Mosconi, M.C. Marco Colella, A. Cianfarani, F. Lanzuisi, F. Saraceno, E. Picone Tor Vergata University Hospital, General Surgery, Rome, Italy Background: Parietex ProgripTM is a self-gripping partially resorbable polypropylene mesh. It’s traditionally used in abdominal wall surgery, in particular for inguinal hernia repair. In literature a lot of studies demonstrate that inguinal hernia Progrip technique repair (IHPTR) is feasible procedure and in particular recent meta-analysis (Zhang et al. 2014) shows not statistically significant difference between Progrip technique and Lichtenstein technique in term of outcomes. The aim of our study was to evaluate the recurrence rate (RR) chronic pain (POCP) of inguinal hernia Progrip technique repair (IHPTR) and it was to compare our results to other literature data. Methods: Three hundred and eleven adult patients were scheduled for surgery for inguinal hernia between 2006 and 2009 in Day-case surgery of Tor Vergata University Hospital, in Rome. All the patients underwent to open tension-free inguinal hernioplasty with Progrip technique (IHPTR) under local anesthesia with Naropine 2 mg/ml and a single intravenous dose of antibiotics was performed by the same surgeon (M.G.Muzi).

S211 Our study was a retrospective-study with 3 years follow-up. All the patients were contacted by phone submitting survey about recurrence and chronic pain; they fill a questionnaire on pain based on VAS scale (zero to ten). The patients with suspicious of hernia recurrence were evaluated in out-patients-clinic. Results: At the long-term follow-up, the outcomes were two cases of recurrence (0.66 %) and no case of chronic pain (0 %). Conclusions: Our results currently encountered seem encouraging the self-gripping mesh and to enlarge number of our cases to investigate the open tension-free Progrip hernioplasty outcomes.

P126 The first use of progriptm such a plug for a lacuna vasorum femoral hernia 1

M.G.M. Marco Gallinella Muzi, 1C. Mosconi, 1M.C. Marco Colella, A. Cianfarani, 1R. Pezzuto, 1F. 1Saraceno, 1E. Picone, 2F. Rulli 1 Tor Vergata University Hospital, General Surgery, Rome, Italy, 2 Universita` cattolica nostra signora del buon consiglio, Tirana Albania 1

Background: ProgripTM is a self-gripping partially resorbable polypropylene mesh that is traditionally used in the abdominal wall surgery, especially designed for the inguinal hernia repair. Here we report our experience about the use of self-gripping ProgripTM mesh such a plug in a case of lacuna vasorum femoral hernia. Methods: A 67 years old man underwent surgery for inguinal hernia repair in 2001 in another hospital, but a no-prosthesis surgical technique had been used. He came to our hospital in 2015 for a suspicion of inguinal hernia recurrence. At the time of USS suspicion of femoral hernia had been raised. Patient’s comorbidities were hypercholesterolemia, benign prostatic hypertrophy and congenital unilateral renal agenesis. Patient underwent open inguinal hernioplasty in daycase surgery under local anesthesia with Naropine 2 mg/ml and received a single dose of intravenous antibiotics just before the skin incision. After the left inguinal incision we found vascular-lacunar femoral hernia; the hernia sac was isolated and preperitoneal space was prepared. The hernia sac contained fat, therefore it wasn’t opened. We used a non previously shaped ProgripTM mesh cutting it like a square and rolled it like a cigarette, with micro-hooks towards the other side. We implanted the mesh in the crural region such a plug between the inguinal and Cooper ligaments. We used four stitches (Prolene 3/0) for safer fixation. Results: On 3 months follow up the patient didn’t showed secondary outcomes such post-operative pain; wound infection; seroma; hematoma; vascular complications; recurrence; chronic pain and especially the patient has not vascular complications and recurrence. Conclusion: For the first time a ProgripTM has been used for the treatment of femoral hernia. Its use has been proved safe and without complications for the patient. The procedure is easy for surgeon and can be performed under local anesthesia without any additional costs.

P127 A combination of Bromelain and Boswellia Serrata Casperome in SibenÒ: effects on post-operative course of inguinal hernioplasty with prosthesis A. Sorge1, M. Gallinella Muzi2, P. Maida3 1 Ospedale San Giovanni Bosco, General surgery, Naples, Italy, 2 Policlinico Universitario Tor Vergata, General surgery, Rome, Italy, 3 Evangelical hospital ‘‘Villa Betania’’, General Surgery, Naples, Italy Background: Aim of this study is to investigate the potential benefits about post-operative complications and outcomes (pain; bruising;

123

S212 edema; hydrocele; abnormal healing; reduced function of the limb ipsilateral; paresthesia; return to working daily activities), of inguinal hernia repair with prosthesis, using a combination of Bromelain (200 mg) and Boswellia Serrata Casperome (200 mg), Siben and compare responses with control patients (placebo). This surgery do not normally involves the subministration of common antiinflammatory agents. Methods: One hundred patients (24 females, 76 males) underwent open tension-free hernioplasty with Progrip and were divided into two groups. Group A (fifty patients, case) took one tablet of Siben every 12 h for 11 days on an empty stomach, starting the first postoperative day. Group B (fifty patients, control) took a placebo following the same schedule. All patients fill a questionnaire on pain: at rest, during normal activities and during exercise; based on VAS scale (from zero to ten) The two groups were homogeneous (mean age 57 years, BMI 27 kg/m2). Results: The perception of pain, assessed in rest condition, is similar in the two groups at baseline, while it is significantly reduced in Siben group compared to the group B, both at seven (p \ 0.05) and eleven post-operative day (p \ 0.05). The perceived pain during daily activities and during physical exertion was significantly reduced (p \ 0.05) in group A. In addition, all patients using Siben, resume daily activities and return to work earlier than control group. Improvements were reported on all other outcomes talking about in the background. Conclusions: The results of this preliminary study, show an important improvements about open inguinal hernioplasty outcomes. The treatment with Siben, allow to the patients a return to daily and working activities up to a week earlier than the placebo group.

P128 Laparoscopic transabdominal pre-peritoneal hernia repair (TAPP): a retrospective analysis concerning a day surgery setting and patients’ safety U. Wirth, S.K. Schopf, H.M. Schardey Agatharied Hospital, General and Vascular Surgery, Hausham, Germany Background: According to EHS guidelines on the treatment of inguinal hernia every patient should be considered for day surgery procedure. In Germany TAPP procedures are rarely performed as day surgeries, but should increasingly be transferred to day surgery setting. Primary objective is to determine the implications of this transfer for a secondary referral center by evaluating the amount of patients with an indication for inhospital observation. Methods: We present a retrospective analysis on 522 TAPP procedures performed in a certified center for hernia surgery (inpatient setting). We evaluate the quantity and type of comorbidities, the postoperative need of special analgesic therapy, the rate of perioperative complications, the rate of recurrent hernia surgery and billing information. Results: Median age was 55.3 years; median BMI was 25.2 kg/m2. 46 % of patients had relevant comorbidities (n = 242). 17 % of patients (n = 88) required analgesic therapy by i.v. line or opioids. 14 % of patients (n = 74) had minor complications. No major complications occurred. 7 % of patients (n = 36) had surgery for recurrent hernia. 83 % of patients left the hospital on 1st postoperative day. Considering the overlap between these factors, in sum 61 % of patients (n = 321) had a reason for inpatient observation after TAPP procedures. A new possible distribution between inpatient and day surgery can result in a deficit of about 90.000€/year for a single surgical department.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Conclusion: TAPP procedures could safely be performed as day surgery in a subgroup of patients (39 %). Nevertheless, the risk for major complication is given in transabdominal surgery; this might be potentially life threatening. The German day surgery setting is not yet flexible enough to postpone the decision about day surgery to a time after the procedure, dependent on patients’ well-being and individual risk factors. In addition, the German health system creates a false incentive due to inadequate payment for outpatient procedures.

P129 Novel surgeon-designed glue applicator in laparoscopic inguinal hernia repair ¨ zveri1 H. Go¨k1, M. Ertem2, E. O 1 Acibadem Kozyatagi Hastanesi, General Surgery, Istanbul, Turkey, 2 Istanbul Uni., Cerrahpasa School of Medicine, General Surgery, Istanbul, Turkey Background: Acute or chronic post-operative pain after laparoscopic inguinal hernia repair may be linked to staplers used for mesh fixation. Adhesives appear to be a viable alternative to staplers; fibrin and cyanoacrylic-based versions are being used since a few years. Methods: Histoacryl, manufactured by B. Braun Melsungen AG, consisting of n-Butyl-2 Cyanoacrylate and supplied in 0.5 ml single use plastic ampoules, is a fast-acting synthetic glue that provides excellent mesh-tissue fixation. We have designed a novel laparoscopic applicator that easily allows for drop-wise application of Histoacryl through a 5 mm trocar and found it to be more practical compared to alternatives, especially when addressing areas that are difficult to access. Pictures and illustrations can be seen in the poster. Results: This surgeon-designed, novel device offers ergonomic convenience for the surgeon and potentially better outcomes for both the surgeon and the patient. Histoacryl can be relatively easily applied in the desired amount and in difficult-to-address areas using this applicator. Adhesive usage may also benefit the patient in the form of potentially reduced post-op pain, which may be related to staplers. Conclusion: Studies indicate that open or laparoscopic inguinal hernia repair using tissue adhesives may be associated with less postop pain although there seems to be no difference in terms of recurrence rates compared to staplers. Adhesives may be preferred over staplers due to this incremental, yet seemingly important benefit. Devices that make sealant application more practical, effective and efficient such as our novel applicator may play a significant role in better overall outcomes and result in enhanced surgeon and patient satisfaction.

P130 Transabdominal preperitoneal (TAPP) laparoscopic hernia repair with self-adhering mesh: our initial experience M.R. Gonc¸alves, J. Lomba, A.C. Rodriges, L. Calais, D. Gomes, F. Barbosa, A. Mido˜es, T. Brito Hospital de Viana do Castelo, Cirurgia, Viana Do Castelo, Portugal Introduction: Transabdominal preperitoneal (TAPP) laparoscopic hernia repair is growing as a procedure for inguinal hernia repair, by its reproducibility, low recurrence rate and complications. One of the main concerns about the technic is fixating the mesh, which is related with chronic pain.

Hernia (2016) 20 (Suppl 2):S175–S249 Materials and methods: We reviewed the literature and are presenting our initial experience with the TAPP procedures using a novel self-gripping mesh. Twelve patients were included in the study: inguinal bilateral hernia (n = 8), recurrent inguinal bilateral hernia (n = 1) and recurrent inguinal unilateral hernia (n = 3). ASA CLassification was ASA I (n = 10) and ASA II (n = 2). Our actual follow-up time is 1 month (n = 3), 2 months (n = 3), 6 months (n = 3) and 8 months (n = 3). Results: We have registered 3 cases with Clavien Dindo grade 1 complications (1 scrotal hematoma, 1 scrotal seroma and 1 pelvic hematoma). All patients, except 1 (pelvic hematoma) were discharged the same day of operation. Discussion: Self-adhering are recent in our daily procedures. At our Hospital, we started to use these meshes on 2015, with 12 cases until the end of the year. We have more patients planned for 2016. Preliminary results indicate that this procedures, using this type of mesh, in an ambulatory basis, seems secure, reproductible and with few and minor complications, making it possible to decrease admission days and hospital bed occupation.

P131 A challenging repair of a giant inguinoscrotal hernia; case report L.M. Hickey, M. Chadwick Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, General Surgery, Prescot, UK Background: Giant inguinoscrotal herniae are rare in developed countries, requiring complicated lengthy surgery often associated with significant morbidity and mortality. Preoperative planning, and intra/post-operative monitoring is essential to secure a sound recurrence-free repair, avoid abdominal compartment syndrome, excise compromised/necrotic tissue and secure a cosmetically acceptable and functional reconstruction. Methods: A 68 year old man with a longstanding left groin lump, presented with intestinal obstruction, an irreducible inguinoscrotal hernia, and painful scrotal bruising. Contrast CT confirmed a large direct left-sided inguinoscrotal hernia, with left scrotal skin oedema, containing viable, faecally-loaded sigmoid colon (non-ischaemic). Mechanical obstruction appeared just proximal to the hernia. Intraoperative findings corroborated the CT findings. The giant inguinoscrotal hernia contained the whole viable sigmoid colon and two-thirds of a megarectum loaded and obstructed with hard stool. A large cord lipoma and grossly distorted cord and fascia were noted. A large fluid collection in the tunica around an apparently viable left testicle with infarcted epididymis and thrombosed cord vessels was seen with two-thirds of the scrotum bruised with ischaemia. The hernia defect was 4 cm. Results: He underwent emergency high anterior resection (stapled off), mesh hernia repair, left orchidectomy, then fascial lower midline laparotomy and end-to-end colorectal stapled anastomosis after raising a fasciocutaneous flap, then scrotal reconstruction. He recovered well with no complications. No recurrence was seen at 5 month follow up and scars had healed well. Conclusions: Careful planning of the management of these hernias is prudent. This case highlights difficulties in dealing with a chronically obstructed rectosigmoid colon in an inguinoscrotal hernia sac plus a potentially compromised testicle and cord structures with ischaemic scrotal skin. Incisions were adapted to facilitate access, debride damaged and redundant tissue, avoid abdominal compartment syndrome, avoid contamination of the hernia repair—separate from the bowel anastomosis—and permit reconstruction.

S213

P132 Recurrence in groin hernia: how to treat? Own experience and Review of literature C. Wurst Agaplesion Bethesda Hospital Stuttgart, Department of Generaland Visceral Surgery, Stuttgart, Germany Introduction: On grounds of development within laparoscopic surgery the recurrence rate in groin hernias could be tremendously reduced. Today the question seems to be which kind of surgery could be the favored one for recurrent hernias after minimal invasive surgery. We reviewed our own data and did a review of literature. Methods: We evaluated all groin surgeries between 2000 and 2015 in our institution. Therefore we could also use the data of the national hernia register. Furthermore we did a database enquiry on pubmed. (References have been: recurrence, reoperation, groin hernia, inguinal hernia). 451 publications concerning this topic could be found. Only a few of the literature found occupied themselves with the question which method could be safe and practical in case of recurrence. Results: Between 2000 and 2015 270 recurrence’s have been treated. 236 firs recurrence’s, 30 s and 4 third recurrence’s underwent surgery. The primary methods have been 196 direct sutures, 32 Lichtenstein procedures and 42 TAPP procedures. 123 hernia recurrence’s have been treated with a TAPP procedure. From this 40 recurrence´s after TAPP have been treated again with the transabdominal preperitoneal patch procedure. Discussion: The European hernia society recommends the surgical care in case of recurrence due to the previous method. In case of TAPP as the primary operation a anterior approach is the favored method. In the literature minimal invasive procedures are looked as secure option. Also the recurrence rates are statistically lower. There are only less investigations concerning transabdominal preperitoneal patch plastic following this procedure. Within the poor data concerning this topic there does not seem to be higher rates of complications, hospital resting time or recurrences. Therefore transabdominal preperitoneal patch plastic seems to be a good alternative. Especially in the hands of experienced surgeons.

P133 Method Trabucco modified by new prosthesis S.M. Massa, M. Sorge Angelo, M. Gianluca Cassese G.H.Caserta, Chirurgia, Caserta, Italy Background: The Trabucco’s technique for the inguinal hernia repair, together with Lichtenstein technique, is the most practiced in the world. The original method has been modified over time by the same author thanks to research design and implementation of new generation prosthesis, but has always maintained its basic principles. The multi-center study we are doing is aimed to test the use of different prosthetic devices for the Trabucco’s technique depending on whether it is necessary to repair a direct or indirect inguinal hernia. Methods: For direct inguinal hernia HybridMesh (Herniamesh) semiabsorbable prosthesis has been utilized. The preshaped prosthesis, according to the dimensions specified in the original Trabucco’s method, is positioned sutureless in the retro-fascial position of the external oblique muscle, where it remains flat thanks to its own rigidity. It is a semi-absorbable prosthesis knitted by a quadriaxial technology with 25 % of Polypropylene and 75 % of Polylactic acid. For the treatment of indirect inguinal hernia a different Polypropylene prosthesis was used which is NeT Plug & Patch (Herniamesh): it

123

S214 has the characteristic to have an innovative plug extruded directly from the mesh. During the last year (2015), 110 patients were treated with the modified Trabucco’s technique. Results: All patients have been operated under local anesthesia and discharged within four hours from surgery. The surgical results were assessed positively. At 1 year follow-up we found no hernia recurrence, chronic pain or significant complications. Conclusions: The use of different prostheses for the direct and indirect inguinal hernia appears to be a requirement according to the criteria of ‘tailored surgery’. The two prostheses used in the multicenter study we conduced, HybridMesh and NeT Plug & Patch, judging by the first results, offer significant advantages in the treatment of inguinal hernia early in accordance with the principles underlying the Trabucco’s technique.

P134 Quality of life before and after inguinal herniotomy O.V. Ogurtsov1, O.V. Lukavetskyy1, T.M. Ivankiv1, O.M. Lerchuk2 1 Danylo Halytsky Lviv National Medical University, Surgery Department, Lviv, Ukraine, 2Lviv Regional Clinical Hospital, Surgery Department, Lviv, Ukraine Background: One of important things about evaluating the effectiveness of treatment is patient’s quality of life after surgical intervention. Furthermore, social aspects are inseparable, so far as most of the patients are at the working age. Methods: We have made prospective study the group of 56 patients. Patients underwent Liechtenstein hernia repair. Polypropylene mesh and ultrapro were used. Questioning was conducted: at admission, in 1 after surgery (AS), 10 months AS. Results: The average age was 56.2 years (4 women; 52 men). The first symptoms appeared, in average, 19.1 months before surgery. Pain lasted from 1 min to 1 h in 78.6 % cases, from 1 to 5 h in 3.6 %; during day and night, 8.9 %; pain in the missing 7.1 %. In 84 % of patients pain limited physical activity. 76.7 % of patients reduced hernia on their own, the remaining 23.3 % did not need reducing. In a week before the operation reduced hernia: repeatedly 50 % of patients; 2 to 5 times 5.4 %; daily 8.9 %; once 1.8 %; did not reduce a hernia 33.9 %. In 1 months AS, none of the patients observed recurrence of hernia; 17.9 % patients noted feeling of a foreign body in the post-operative area, another 8 patients were not sure whether these feelings were caused by the implanted mesh. 29 patients noted numbness in the postoperative area: 25 (heavy mesh), light mesh (4). No one in the study group complained of pain in the postoperative area, and it wasn’t necessary to take painkillers. No erectile disorders were noted. 78.6 % of the patients returned to normal physical activity, on average, in 40 days AS. Conclusion(s): Quality of life of patients AS is a major criterion of the effectiveness of treatment of a hernia. Using light meshes for the treatment of inguinal hernias is more efficient and provides a high quality of life AS.

P135 Effectivity of laparoscopic inguinal hernia repair (TAPP) in daily clinical practice: early and long-term result R. Bittner1, F. Muschalla2, J. Schwarz1 1 Hernia Center Rottenburg, Rottenburg A.N., Germany, 2Klinikum rechts der Isar der TU Mu¨nchen, Surgical Clinic, Munich, Germany Introduction: The aim of the study was to investigate effectiveness of laparoscopic inguinal hernia repair in daily clinical practice.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Patients and methods: All patients admitted to the hospital for surgery of an inguinal hernia during a 1 year period were prospectively documented and included in a follow-up study. The follow-up was performed at least 5 years after surgery and consisted of a clinical examination, ultrasound investigation and a questionnaire. Results: From January 2000 to January 2001 a total of 1208 inguinal hernias in 952 patients were consecutively operated by a total of 11 general surgeons in daily clinical routine. 98.02 % of the patients were operated laparoscopically with the transabdominal preperitoneal patch plasty technique (TAPP) and 1.98 % of the patients had an open repair. The frequency of intra- and early postoperative complications was 2.8 %. The complication rate in the patients presenting a complex hernia was not higher than in patients with uncomplicated unilateral hernias. Live-threatening complications were seen in 4 patients (bowel lesion—0.4 %), but all four patients presented extensive adhesions in the abdominal cavity after previous abdominal surgery. The follow-up rate after 5 years was 85.3 %. After 5 years the recurrence rate was 0.4 % and the rate of severe chronic pain 0.59 %. None of the patients took analgesics or had to change his occupation. Conclusion: Laparoscopic repair can be applied to all types of inguinal hernia as a daily routine procedure with low rates of recurrences and chronic pain. Limiting factor may be extensive adhesions after previous major surgery in the lower abdomen.

P136 High incidence of inguinal hernias in laparoscopic cholecystectomy patients O. Tsimpoukidi, C. Loumpias, M. Vasulaki, E. Anastasiou, I. Konstantinidis, A. Dounavis Sismanogleio-AM FLemig G.H., Surgical, Athens, Greece The aim of this study was to detect the incidence of asymptomatic inguinal hernia in a laparoscopic cholecystectomy population. In a 5 months period 47 laparoscopic cholecystectomies were performed by the same surgeon. Prior to the cholecystectomy both inguinal areas were inspected laparoscopically. The presence or absence of hernias was recorded and photos of the field were taken. Twenty-one patients were male and 26 were female. In 20 patients the anatomy of both inguinal regions seemed normal without hernias. In 7 occasions the area could not be inspected mainly because of extensive adhesions. Among the remaining patients 5 had indirect and 6 had direct hernias. Bilateral hernias were found in 9 patients (six direct and three indirect). One patient had a coexistent femoral hernia. A few of these hernias were either incompetent internal ring or loose transversalis fascia but still the irregularity was present even at this early stage. Consultation was given to the patients with hernias concerning their body weight and exercise. In conclusion, it seems that the incidence of asymptomatic inguinal hernia is higher than reported. Proper investigation must be performed during laparoscopy and if hernia is found the patient must be informed accordingly.

P137 Bilateral varicocele in vena cava duplication. Laparoscopical treatment X.O. Oikonomou, E. Anastasiou, N. Nikolopoulos, S. Adamopoulos, A. Dounavis Sismanogleio-AM FLemig G.H., SURGERY, Athens, Greece The aim is to present a rare case of bilateral varicocele that was due to venous anatomical variation. A 22 years old male patient was presented at the clinic with bilateral varicocele and poor semen quality. The diagnosis was made

Hernia (2016) 20 (Suppl 2):S175–S249 by clinical examination and ultrasound. The scrotal veins were mildly dilated on palpation. The patient underwent further investigation to rule out other pathologies. The abdominal MRI was normal. A suspicion of vein irregularity was reported therefore an MRA was ordered. Duplication of the inferior vena cava below the renal veins was noticed and so the bilateral pathology was explained. The patient underwent a laparoscopic ligation of the spermatic veins in both sides. The postoperative period was uneventful. In conclusion, in this young patient a rare venous anatomical variation was the cause of bilateral varicocele, which was treated successfully laparoscopically.

P138 Is preoperative withdrawal of aspirin necessary in patients undergoing inguinal hernia repair? S. Wijerathne, W. Ong, S. Tong, W.B. Tan, E. Sta Clara, D. Lomanto National University Hospital, General Surgery, Singapore, Singapore Aging population worldwide and increasing incidence of cardiovascular disease makes anti-platelets such as aspirin widely used to reduce thrombotic events in these patients. Continuing aspirin through major non-cardiac surgery has been shown to reduce risk of major adverse cardiac events (MACE). However, this may lead to higher bleeding complications. All patients that underwent elective primary inguinal hernia repair from 2007 to 2014 and were on aspirin pre-operatively were identified. The patients were divided into 2 groups: those who continue aspirin through the morning of the operation and those who have been advised to stop aspirin therapy 3 to 7 days prior to operation. Among 1841 patients who underwent elective primary inguinal hernia mesh repair, 142 (7.7 %) patients were on preoperative aspirin. 57 patients underwent laparoscopic repair while 85 underwent open mesh repair. 27/57 (47.3 %) from the laparoscopic group and 55/85 (64.7 %) from the open group, were instructed to stop aspirin (p = 0.040). There were no significant differences between those who stopped aspirin and those who continued in terms of intraoperative blood loss (Lap 2.5 vs 8.5 ml p = 0.157; Open 10.1 vs 8.2 ml s p = 0.638) and operative timing (Lap: 92.8 vs 96.2 min p = 0.761, Open 88.1 vs 78.5 min p = 0.337). Immediate post-operative bleeding complications (Lap: 18.5 vs 13.3 % p = 0.592, Open: 5.5 vs 6.7 % p = 0.820) and follow-up wound complications (Lap 11.1 vs 10.0 % p = 0.891, Open 10.9 vs 16.7 % p = 0.450) were also similar between the two groups. Overall there was no MACE among those who underwent laparoscopic repair. 3 MACE were recorded in the open group (2 stopped aspirin vs 1 continued aspirin; p = 0.943). Our findings suggest that aspirin continuation is unlikely to increase blood loss or complications in both primary laparoscopic and open inguinal hernia repair. Continuation of aspirin is safe and should be preferred in patients with higher cardiovascular risk.

P139 A comparative experimental study of sutureless fixation techniques using lightweight surgical meshes of different polymers G.V. Khachatrian1, M.V. Anurov1, S.M. Titkova1, P. Velangi2, A.P. Oettinger1, M.D. M.d. Polivoda1 1 Russian National Research Medical University, Experimental surgery, Moscow, Russian Federation, 2Peoples Friendship University of Russia, Student, Moscow, Russian Federation Background: The recent widespread growth of endoscopic inguinal hernia repair has been accompanied by the appearance of new

S215 lightweight surgical meshes made up of different polymers and fixation techniques. Therefore, the choice of prosthesis and the method of its fixation have gained importance. The purpose of study is to compare the efficacy of different sutureless fixation techniques using light surgical meshes made of polypropylene (PP) and polyester (PET) in the early postoperative period. Methods: In 18 male rats weighing 350 ± 35 g two symmetrical lateral musculo-fascial defects (20 9 30 mm in size), preserving the peritoneum were made in the anterior abdominal wall under general anesthesia. In the 1st group (n = 6), the defects were covered by Progrip self-gripping meshes. In the 2nd group (n = 6)—by glue fixation (n-butyl-2-cyanoacrylate) was used. In the 3rd group (n = 6) no fixations were used. After 5 days, mesh dislocation with respect to the defect and the pararectal line was macroscopically evaluated. The fixation strength was determined by a sliding rupture test using the universal texture analyzer (TA.XT Plus). The maximum shear force, distance and the work required to rupture the mesh was measured. Results: Dislocations were detected only in the 3rd group (n = 3 for PP, n = 2 for PET). The strength of fixation in 3rd group was 3.1 ± 1.2 N (PP) and 5.8 ± 2.6 N (PET), and was significantly lower than the 1st group (13.98 ± 3.0 N for PP, 23.6 ± 5.8 N for PET) (P \ 0.05) and 2nd group (17.2 ± 5.1 N for PP, 20.5 ± 7.04 N for PET) (P \ 0.05). The strength of fixation in all the groups was higher for PET than PP meshes. Conclusions: Sutureless techniques greatly increase the strength of lightweight surgical meshes and help to reduce the risk of a mesh dislocation. Better results in the PET polymer group may be related to the surface properties of PET fibers.

P140 A preliminary report of a randomized controlled trial comparing two polypropylene meshes in laparoscopic inguinal hernia repair W.W. Hope, Z. Williams, A. Adams, A. Lapid, W.B. Hooks Iii New Hanover Regional Medical Center, Surgery, Wilmington, USA Introduction: Multiple mesh choices are available for use in laparoscopic inguinal hernia repair. Several considerations must be taken into account by the surgeon when choosing a mesh for hernia repair including clinical efficacy, cost, and ease of use. The purpose of this study was to compare two different polypropylene based meshes for use in laparoscopic inguinal hernia repair. Methods: Subjects were randomized by a random number generator, sealed in an opaque envelope, and opened directly before surgery. Data were reported in N(%) and median [Q1–Q3], comparisons of mesh insertion time were tested using a 2 9 2 ANOVA on the ranked times, comparisons between categorical variables were tested with Fisher’s Exact, and all data were analyzed using SAS 9.4. Results: Between January 2015 and January 2016, 27 subjects were enrolled. One subject was excluded. Of the 26 eligible subjects, most were Caucasian (N = 23. 88.5 %), male (N = 17, 65.4 %), with a median age of 60 years and randomized evenly between 3DMax and Ultrapro. Subjects with a higher ASA and VSA were more likely to have been randomized to the Ultrapro group (p = 0.03 and p = 0.0002). Robotic repair was more likely to be used on subjects randomized to the 3DMax group (0.049). The use of robot significantly increased the mesh insertion time regardless of mesh used (p \ .0001). However, the type of mesh did not significantly impact the mesh insertion time, regardless of robot use (p = 0.13). Conclusion: Preliminary data from our RCT shows that mesh insertion times between two different polypropylene meshes were similar when performed laparoscopically. Increased mesh insertion times associated with robotic repair are likely due to the use of

123

S216 suturing and likely reflect the learning curve associated. Further information on clinical efficacy and ease of use will be forthcoming as the trial continues.

P141 One surgeon, one centre: 3 years of experience for glue mesh fixation in TAPP hernia repair V.G. Radu, M. Lica, A. Radu, S. Ene Life Memorial Hospital, Dept. of Surgery, Bucharest, Romania Background: Minimally invasive procedures increased in popularity over time as the surgical expertise became available in many centres. Methods: We present the surgical experience in laparoscopic inguinal hernia repair of the same surgeon in a single centre over the past 3 years. The medical records of all patients operated by laparoscopic approach (TAPP) using the same mesh and cyanoacrylate glue for fixation, were analysed in a retrospective manner. Results: 323 patients were operated from January 2013 to December 2015. Most of the cases were male (92.6 %), mean age of 49.6 years (SD 14 years). 75 % of patients had unilateral hernia, and 10 % of cases were operated for recurrent inguinal hernia. Surgical procedure takes a mean of 55 min (range 35 to 180 min) and no major complication were encounter during surgery or hospital stay; no conversion to open surgery. Patients were scheduled for clinical follow-up at 1 month (5 % lost) and 1 year after surgery (70 % lost). Long term results include 0.4 % clinical seroma formation, no chronic pain and two cases (0.65 %) of hernia recurrence. Conclusions: TAPP hernia repair using light mesh and glue fixation is a safe and effective procedure.

P142 Sutureless repair of inguinal hernias by mesh plug Y.S. Sunagawa, T.H. Hachisuka, N.T. Takeda, M.S. Shizuku, Y.S. Suenaga, K.S. Sakata, H.T. Teramoto, T.S. Shikano, K.H. Hattori, Y.M. Mizuno, H.M. Maruyama, T.M. Mori Yokkaichi Municipal Hospital, Surgery, Yokkaichi, Japan Background: The plug method is one of the most widespread methods for repairing inguinal hernias. In 1992 and 1997, Gilbert et al. reported on sutureless repair of inguinal hernias using the plug method; however, this method has not spread due to a high rate of hernia recurrence. Currently, the understanding of the anatomical structures in groin has progressed, and the tissue compatibility of hernia meshes has dramatically improved. Therefore, we attempted sutureless repair of inguinal hernias. Methods: The enrolled subjects, who were relatively sedentary and aged 70 years or older, had indirect inguinal hernias with hernia orifices B3 cm in size. For the repair, we used a Light PerFix Plug, which has high tissue compatibility. High dissection of the hernia sac was completed by detachment at the entire periphery of the transversalis fascia and superficial preperitoneal fascia, and subsequently, the plug was inserted without any sutures. Results: In the 52 cases, from 2012–2014, no recurrence was observed, and the average postoperative hospital stay was 1.02 days. Additionally, no significant complications resulting in delayed hospital discharge were observed. A post-operative questionnaire yielded favorable results. Conclusion: Sutureless repair is a useful method that avoids tissue damage and tissue tension caused by stitches. In our study, we obtained favorable short- and long-term results for sutureless repair

123

Hernia (2016) 20 (Suppl 2):S175–S249 by using precise surgical technique with recognition of the involved anatomical layers.

P143 Elective Lichtenstein inguinal hernioplasty in male patients aged 75 years: a 5 year experience P. Bojovic, V. Cijan, M. Scepanovic, Z. Bokun, R. Duraki Clinical Hospital Center Zvezdara, Surgery Clinic, Belgrade, Serbia Background: During the past decades surgical care of elderly has been paid growing attention. Inguinal hernia in elderly patients is a common pathological condition because of the abdominal wall weakness and conditions which increase intraabdominal pressure. In addition, herniorrhaphy in the elderly has been associated with disturbingly high morbidity and mortality rates which increases significantly with emergency operations. Because of that, the open tension-free Lichtenstein hernioplasty constitutes the current gold standard for the elective repair of inguinal hernia in men. The aim of this study was to compare the outcomes of the elective Lichtenstein hernioplasty performed patients aged 75 years or older in a district general hospital for a 5-year period. Methods: Prospective-retrospective study of male patients aged 75 years or older undergoing elective Lichtenstein inguinal hernioplasty at a district teaching hospital. Results: From January 1st 2010–December 31st 2014, all male patients aged 75 years or older who underwent elective Lichtenstein inguinal hernioplasty were recorded. All patients who underwent repair of inguinal hernia with the Lichtenstein technique were operated by using polypropylene macroporus flat mesh different size (Herniamesh, Italy). Data regarding demographics, co-morbidity, type of hernia, complications, hospitalization postoperative pain and use of analgetics and return to normal daily activities were recorded in oneyear follow up. Patient satisfaction following the operation was also assessed (short-follow up—1 year). Conclusion: Lichtenstein inguinal hernioplasty under local anesthesia is a simple, comfortable and effective method, with prompt recovery and low complications and can be done safely in patients over 75 years. It has better outcomes than operation under spinal anesthesia. It is possible to achieve excellent results with this technique in general surgical unit.

P144 Transabdominal preperitoneal inguinal hernia repair in elderly L. Latham, V. Quintodei, V. Raveglia, M. Berselli, L. Livraghi, L. Farassino, G. Borroni, I. Ceriani, J. Galvanin, L. Ungari, E. Cocozza A.o. di Circolo fondazione Macchi di Varese, General surgery, Varese, Italy Background: Inguinal hernia repair is the most common operations performed worldwide. Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair is an evolving technique associated with advantages of a minimally invasive approach. The present manuscript aims to evaluate the impact of recurrence and surgical complications after TAPP repair in the elderly versus younger patients. Methods: A consecutive series of patients who underwent to TAPP repair from July 2009 to December 2014 were divided in 2 groups according to their age (group A C65, group B \65 years old) and retrospectively analyzed. The primary end-point was the recurrency

Hernia (2016) 20 (Suppl 2):S175–S249 rate; the secondary end-point was the analysis of the postoperative complications. Results: 86 patients (Group A 49, Group B 37, 3.4 % women and 96.6 % men), underwent to TAPP repair for unilateral (29 %), bilateral (71 %) and recurrent (35 %) hernia. The recurrence rate, registered after 6-months of follow-up, was 4 % in group A and 8 % in group B (p = 0.806). Hematoma occurred in 4/86 patients (4.7 %), a case in group A and three cases in group B with no statistical correlation (p = 0.186). Inguinal chronic pain (lasted longer than 6 months after surgery) occurred in 3/86 (3.5 %) with non significantly differences between groups (p = 0.422). Conclusions: Results suggest that age does not represent an absolute contraindication to TAPP repair for groin hernias. The indications for laparoscopic approach in elderly have to be carefully evaluated because of the higher risk of general complications than in traditional open techniques. The increasing in life expectancy and the necessity to offer, also to young- and middle-old patients an optimal quality of life, make to consider this surgical approach in a tailored surgery.

P145 TAPP versus Lichtenstein for inguinal hernia repair: a protocol for a systematic review with meta-analysis and trial sequential analyses W.J.V. Bo¨kkerink1, C.J.H.M. van Laarhoven1, J. Wetterslev2, F. Keus3, G.G. Koning1 1 Radboudumc, Surgery, Nijmegen, Netherlands, 2Centre of Clinical Intervention Research, Copenhagen Trial Unit (CTU), Copenhagen, Denmark, 3University Medical Center Groningen, Critical Care, Groningen, Netherlands Introduction: On inguinal hernia repair multiple systematic reviews with or without meta-analysis have been conducted. Previously, most reviews compared combinations of different techniques with one or more other techniques. However, it is problematic to claim the superiority of one specific technique for inguinal hernia repair based on the evidence including groups of interventions. Of the currently popular herniorrhaphy techniques, the Lichtenstein’s method and the endoscopic techniques (TEP or TAPP) have been evaluated in several randomized trials. For the comparison TEP versus Lichtenstein a systematic review with meta-analysis exist, but for TAPP versus Lichtenstein’s hernioplasty this is still lacking. Methods: All randomized clinical trials (RCT’s) comparing TAPP with Lichtenstein’s hernioplasty for primary unilateral inguinal hernias will be included. The methodology from the Cochrane Handbook for Systematic Reviews of Interventions will be followed. Risk of bias assessment will be applied and a trial sequential analysis will be performed to assess the risk of type-I-errors. Primary outcomes are mortality, recurrence rate, chronic postoperative pain and severe adverse events. Secondary outcomes are conversions, time to return to usual activity, length of stay and the duration of operation. Prior to start of the review process the protocol was clearly defined and published on the Prospero registration (accessible via http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD4 2014013927). Conclusion: The aim of this review is to contribute in the search for the inguinal hernia repair technique with the best results considering benefits and harms. In this particular study, RCT’s on TAPP versus Lichtenstein’s hernioplasty will be reviewed. Composing a detailed protocol, publishing this protocol prior to the start of the process and performing trial sequential analyses are thought to be important aspects to improve the quality of the systematic reviews and metaanalysis on inguinal hernia repair.

S217

P146 The TREPP repair for recurrent inguinal hernia W.J.V. Bo¨kkerink1, A.M. Persoon2, W.L. Akkersdijk2, C.J.H.M. van Laarhoven1, G.G. Koning1 1 Radboudumc, Surgery, Nijmegen, Netherlands, 2St. Jansdal Hospital, Surgery, Harderwijk, Netherlands Introduction: Recurrent inguinal hernias after initial repair with mesh are preferably treated via an alternative route (e.g. posterior after anterior and vice versa). For recurrent inguinal hernias after an anterior repair such as Lichtenstein’s, an endoscopic approach such as the total extraperitoneal- or transabdominal preperitoneal technique (TEP or TAPP) is recommended if expertise is present. The TransREctus Sheath PrePeritoneal (TREPP) technique may be a promising open posterior technique and could be an alternative to the endoscopic methods. This retrospective study aims to evaluate the results of the TREPP technique for recurrent inguinal hernia repair. Methods: Consecutive patients who underwent a TREPP repair after initial anterior, onlay mesh repair (Lichtenstein’s) with at least 1 year of follow-up after TREPP were included. Exclusion criteria were previous non-mesh repair, unknown initial surgical technique and previous preperitoneal surgery. Benefits and harms were evaluated. Results: Between January 2006 and December 2013 fifty-two patients were eligible for inclusion of which 38 patients were clinically evaluated. The mean follow-up of these 38 was 65 months in which 2 patients had developed a re-recurrence. In total, 7 of the 38 patients (18.4 %) reported chronic postoperative inguinal pain (CPIP), of which four patients experienced this pain since the primary inguinal hernia repair. Peri-operative and \30 day complications were rare and no severe adverse events occurred. Discussion: TREPP seems a feasible alternative for recurrent inguinal hernia repair after an initial Lichtenstein’s method. It may yield extra advantages compared to endoscopic repairs, such as spinal anesthesia and lower costs.

P147 De Garengeot’s hernia- case report K.V. Kulic Vojkan General Hospital Krusevac, Surgery, Krusevac, Serbia Background: De Garengeot’s hernia is quite rare entity with an incidence of 5 % and is defined as the presence of the vermiform appendix within a femoral hernia sac. Rene Jacques Croissant de Garengeot, a Parissian surgeon, as it states in literature, is the first to have described this situation back in 1731, as a case where a femoral hernia sac contains an appendix. Methods: We present the case of an elderly male, operated last year in our hospital, who noticed a non-painful lump, with no obstructive symptoms a week before. An ultrasound scan showed a lymph node in the right groin with surrounding fluid and an unusual appearance, not typical for the hernia. Results: Via a groin crease incision, during local anaesthesia, we found an incarcerated femoral hernia sac with the appendix inside. There were no signs of inflammation of the vermiform appendix. That being the case, we’ve made a decision to convert the local anaesthesia into a general endotracheal anaesthesia. Through the new typical incision, we performed an appendectomy. Hernia repair, with plug T2 Herniamesh, was done simultaneously. After the operation, we used antibiotics as therapy. Postoperatively, he recovered well and he was discharged without any complication. Conclusion: The incarceration of the vermiform appendix within a femoral hernia sac is possible as option.

123

S218

P148 Multidisciplinary team assessment and laparoscopic surgical treatment with a self-gripping mesh for Groin pain Syndrome in athletes: a prospective case series F. di Marzo1, G.N. Bisciotti2, V. Mingarelli3, L. Gia1 1 ASL 1 Massa Carrara, General Surgery, Pontremoli, Italy, 2 Orthopaedic and Sport Medicine Hospital, Sport Medicine, Doha, Qatar, 3Universita` Sapienza, General Surgery, Rome, Italy Background: The purpose of this prospective case-series study was to evaluate clinical outcomes after laparoscopic inguinal repair using a self-fixating mesh (Laparoscopic ProgripTM) in a population of soccer players affected by Groin Pain Syndrome (GPS). Methods: 13 consecutive athletes with GPS were selected by a multidisciplinary team and underwent laparoscopic inguinal (TAPP) repair between May 2014 and December 2015. The Italian validated version of Copenhagen Hip And Groin Outcome Score (HAGOS) was used to assess pre and postoperative pain. All patients had the same physical therapy protocol supervised by the same team until their return to play (RTP). Results: 10 patients (77 %) are professional athletes. There were 2 intraoperative (15.4 %) complications (bleeding managed with temporary gauze compression). 12 patients (92.3 %) had intraoperative findings of bilateral M defect. 3 patients (23 %) had localized rectus abdominis muscles pain (transitory and related to muscular overload). Median follow-up was 10 months. HAGOS showed improvement from pre-op median 41.6 (23.4–66.8) to post-op 98.7 (97.2–100). All patients (11/13), but 2 (still recovering from surgery at time of abstract), returned to play with a median time of 49 days. Conclusion: A multidisciplinary patient-centered approach (also based on patient reported outcome measure-HAGOS) is mandatory to assess and treat athletes affected by GPS, avoiding partial resolution of symptoms, relapse and prolonged absence from sport activities. A self-fixating partially resorbable mesh avoid chronic pain, delay of recovery from surgery and physical therapy discontinuation; it is a safe and feasible option ensuring a homogenous forces distribution all over the covered surface.

P149 Inguinal hernia: results of 227 robotic repairs F.M. Bianco, L.F. Gonzalez-Ciccarelli, S. Durgam, D. Daskalaki, R. Gonzalez-Heredia, P.C. Giulianotti University of Illinois at Chicago, Surgery, Chicago, USA Background: Open and minimally Invasive repair are currently accepted options for treatment of inguinal hernias. Both approaches present risk of recurrence and chronic pain which in different series can be as high as 10 and 60 %.A clear correlation between the incidence of complications and learning curve has been established for the laparoscopic approach. We present our experience after a robotic inguinal hernia training model was implemented at our institution for residents training. Methods: A retrospective review was conducted in 195 patients that underwent robotic inguinal hernia repair (RIHR). All cases were performed at different levels by residents and fellows under the supervision of a single attending, between the months of July 2012 to January 2016. All unilateral and bilateral inguinal hernias were included and each procedure was analyzed separately.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Results: A total of 195 patients underwent RIHR, 163 unilateral and 32 bilateral, for a total of 227 hernias repairs. There were 153 indirect, 60 direct, 4 femoral and 10 recurrent hernia repairs. Same day discharge occurred for 84.18 % of patients, with a median time of 133 min after the procedure. Post-operative complication in 5.6 % of patients. Namely, 7 seromas, 2 hematurias, 1 urinary retention and 1 incisional hernia. The incidence of hernia recurrence and chronic pain was nil at a mean follow-up of 12 month. Conclusion: RIHR is a feasible, safe and effective technique, even when performed during the early steps of the learning curve. The potential advantages of the robot may include: lower complication rates, recurrence rates and chronic pain. Further prospective randomized studies will be needed to draw definitive conclusions.

P150 HerniaSurge Guidelines: open anterior inguinal hernia repair and type of anesthesia A.R. Wijsmuller1, P. Nordin2, M.P. Simons3 1 University Hospital Strasbourg, IRCAD/EITS, Department of General, Digestive and Endocrine Surgery, Strasbourg, France, 2¨ Ostersund Hospital, General Surgery, O¨stersund, Sweden, 3Onze Lieve Vrouw Gasthuis Hospital, General Surgery, Amsterdam, Netherlands Background: Different types of anesthetic techniques are used to facilitate open anterior inguinal hernia surgery. The ideal anesthetic technique provides good peri- and postoperative analgesia, produces optimal operating conditions by immobility, is associated with few complications, facilitates early patient discharge, is cost effective and above all, is safe for the patient. Methods: In the context of the development of a global directive on the treatment of inguinal hernia, a systematic review was executed, comparing general, regional and local anesthetic techniques applied during open inguinal hernia repair with respect to the above mentioned outcome parameters. Databases used was Cochrane, Medline and Scopus. Quality of studies was assessed using the GRADE guidelines which were developed according to Scottish Intercollegiate Guidelines Network (SIGN) principles. Results: When compared with general anesthesia, local is associated with faster mobilization, earlier hospital discharge, lower hospital and total healthcare costs, and fewer complications such as urinary retention and early postoperative pain. When compared with regional anesthesia, local is associated with earlier hospital discharge, lower hospital and total healthcare costs, and a lower incidence of urinary retention. However, when surgeons inexperienced in its use administer local anesthesia, more hernia recurrences might result. When compared with regional anesthesia, general offers no clear advantages regarding the incidence of postoperative pain, postoperative nausea, cost, or patient satisfaction. Its use allows for faster patient discharge, which is of uncertain clinical significance. Some studies report a higher incidence of urinary retention with regional anesthesia. When compared with general anesthesia, regional in patients aged 65 and older might be associated with a higher incidence of medical complications like myocardial infarction, pneumonia and venous thromboembolism. Conclusion: Local anesthesia is recommended for open anterior repair of primary reducible inguinal hernias provided that the surgeon is familiar with administering local anesthesia.

Hernia (2016) 20 (Suppl 2):S175–S249

P151 Results in inguinal hernia repair: open versus laparoscopic method I.O. Avram, F. Schu¨tze, S. Ro¨hr, C. Lamberty, D. Borces, D. Feuerstake, A. Meier, R. Metzger CaritasKlinikum Saarbrucken, Klinik fu¨r Allgemein-, Viszeral-, Thorax- und Tumorchirurgie, Saarbrucken, Germany Background: The repair of inguinal hernia is the most common surgical procedures performed yearly. While there is a general consensus regarding the usage mesh repair, there is still an ongoing debate regarding the surgical technique of choice, open or laparoscopic. Aim: Aim of the study is to compare the outcome of conventional mesh repair (Lichtenstein technique) to laparoscopic TEP repair used to treat inguinal hernia. Methods: All hernia patients operated in our clinic since 03.2014 were prospectively recorded in a database, a follow-up was done at 1 year postoperatively. The risk factors, intra- and postoperative complications, OR duration, rate of recurrence, rate of reoperation and chronic pain was recorded. Using SPSS v. 21.00 all data was analyzed retrospectively. Results: Out of the 598 hernia patients operated in our clinic in the last 2 years we selected the 369 patients operated for inguinal hernia. 106 patients were operated for bilateral inguinal hernia (28.72 %), 127 for left side hernia and 137 for right side hernia. All bilateral inguinal hernias were operated endoscopically. Only 98 out of the 173 patients summoned for the 1-year follow-up were examined (56.65 %). We recorded 3 recurrences (3.06 %), 2 after TEP repair (2.04) and 1 after Lichtenstein repair (1.02 %). All 2 recurrences after TEP occurred during the first 30 days. Conclusions: The recurrence rate for both TEP and Lichtenstein repair was similar, and recurrences after TEP occurred earlier postoperatively. No significant difference regarding postoperative complication rate was found. The postoperative VAS pain score was significantly lower in the case of TEP repair.

P152 Low BMI and small waist circumference as a risk factor for groin hernia repair A. Hemberg, P. Nordin Umea˚ Universitet, Department of Surgical and Perioperative Sciences, Helsingborg, Sweden Background: Overweight and obesity have been connected to certain types of herniation. Intra-abdominal pressure has been suggested as a cause. Some studies have however showed that groin hernias has a diminished incidence among overweight and obesity individuals. Present study aims to determine the connection between body mass index (BMI), waist circumference (WC) and groin hernia repair. Data on elective and acute operated patients as well as a comparison between diagnosed and operated patients will be evaluated. Method: A register based cohort study including 109,678 participants from the county of Va¨sterbotten, Sweden and recorded in an Interventions Program was cross linking with the Swedish Hernia Register and the National Patient Register. Overweight and obesity measured as both BMI and WC.

S219 Results: (preliminary) Participants with a registered groin hernia repair had lower median BMI and WC. Overweight and obesity decreased the risk for groin hernia repair, BMI 25–30 OR 0.72 (95 % CI 0.66–0.79), BMI [ 30 OR 0.27 (95 % CI 0.22–0.32). Abdominal obesity measured as WC expressed an OR of 0.43 (95 % CI 0.33–0.51), intermediate WC showed no significant difference to normal WC. Higher education decreased the risk for groin hernia repair while differences in light or heavy physical work showed no significant difference. Conclusion: Overweight and obesity defined by BMI and abdominal obesity defined by WC decreases the risk for groin hernia repair.

P153 Adequacy of written consent in open inguinal hernia repair: a North West research collaborative audit C.G.V. Slawinski1, N. Heywood2, P. Coe3, R. Basson4, R. Fish5, J. Barker1, Nw Research Collaborative6 1 Blackpool Victoria Hospital, General Surgery, Blackpool, UK, 2 University Hospital of South Manchester NHS Foundation Trust, General Surgery, Manchester, UK, 3East Lancashire Hospitals NHS Trust, General Surgery, Blackburn, UK, 4Bolton NHS Foundation Trust, General Surgery, Bolton, UK, 5Salford Royal NHS Foundation Trust, General Surgery, Manchester, UK, 6North West Research Collaborative, Research Collaborative, Manchester, UK Background: Consent issues are the cause of litigation in 10 % of groin hernia repairs. Testicular/cord injury, chronic pain and visceral injury are the most commonly litigated complications. We assessed the adequacy of written consent for open inguinal hernia repair across Health Education North West (HENW). Methods: A multicentre retrospective audit of patients undergoing primary open inguinal hernia repair between 1st August 2013 and 31st July 2014 was conducted involving nine sites across HENW. Consent forms were reviewed against the complications stated in the European Hernia Society guidelines used as audit standards. Adequacy of consent was calculated as the proportion of complications consented for, from a total of fifteen (13 in females). Results: 673 cases were included. The median age was 65 years (range 17–96) and 92 % were male. The side of repair was: left 43 %, right 54 % and bilateral 3 %. The grade of the consenting clinician was: consultant 46 %, ST3 and above 14 %, associate specialist 13 %, trust SpR 13 %, CT1/2 7 %, nurse practitioner 4 % and FY1/2 1 %. Explanation of procedure benefits was documented in 94 %. Median adequacy of consent was 40 % (0–87 %), varying 27–47 % per trust (Trust D vs. Trusts B and G, p \ 0.0001), and 25–47 % per clinician (FY2 vs. nurse practitioner, p = 0.0831). The most commonly consented complications were: bleeding (93 %), wound infection (92 %) and recurrence (90 %). Less commonly consented complications included: chronic pain (63 %), testicular complications (38 %), cord injury (24 %), bowel (12 %) and bladder injury (6 %). Conclusions: Written consent for open inguinal hernia repair was inadequate across HENW, including the complications most frequently associated with litigation. A standardised consent form may improve adequacy of consent. Further study will be required to identify if this will reduce litigation.

123

S220

P154 Adequacy of written consent in laparoscopic inguinal hernia repair: A North West Research collaborative audit C.G.V. Slawinski1, P. Coe2, N. Heywood3, R. Fish4, R. Basson5, J. Barker1, Nw Research Collaborative6 1 Blackpool Victoria Hospital, General Surgery, Blackpool, UK, 2East Lancashire Hospitals NHS Trust, General Surgery, Blackburn, UK, 3 University Hospital of South Manchester NHS Foundation Trust, General Surgery, Manchester, UK, 4Salford Royal NHS Foundation Trust, General Surgery, Manchester, UK, 5Bolton NHS Foundation Trust, General Surgery, Bolton, UK, 6North West Research Collaborative, Research Collaborative, Manchester, UK Background: Consent issues are the cause of litigation in 10 % of groin hernia repairs. Testicular/cord injury, chronic pain and visceral injury are the most commonly litigated complications. We assessed the adequacy of written consent for laparoscopic inguinal hernia repair across Health Education North West (HENW). Methods: A multicentre retrospective audit of patients undergoing primary laparoscopic mesh inguinal hernia repair between 1st August 2013 and 31st July 2014 was conducted involving nine sites across HENW. Consent forms were reviewed against the complications stated in the European Hernia Society guidelines used as audit standards. Adequacy of consent was calculated as the proportion of complications consented for, from a total of 19 (17 in females). Results: 347 cases were included. The median age was 57 years (range 18–85) and 95 % were male. The side of repair was: left 27 %, right 39 % and bilateral 33 %. The grade of the consenting clinician was: consultant 44 %, ST3 and above 20 %, trust SpR 19 %, nurse practitioner 8 %, CT1/2 4 %, associate specialist 2 % and FY2 2 %. Explanation of procedure benefits was documented in 94 %. Median adequacy of consent was 37 % (0–74 %), varying 5–47 % per trust (Trust C vs. Trust A, p \ 0.0001) and 29–53 % per clinician (consultant vs. nurse practitioner, p = \ 0.0001). The most commonly consented complications were: bleeding (86 %), wound infection (88 %) and recurrence (81 %). Less commonly consented complications included: chronic pain (58 %), cord injury (54 %), testicular complications (28 %), bowel (43 %) and bladder (28 %) injury. Conclusions: Written consent for laparoscopic inguinal hernia repair was inadequate across HENW, including the complications most frequently associated with litigation. A standardised consent form may improve adequacy of consent. Further study will be required to identify if this will reduce litigation.

P155 Open inguinal hernia repair with self-gripping ProGripTM mesh: results of a prospective analysis of 132 consecutive patients in a tertiary university teaching hospital P.O.L. Guarner Piquet, J.C. Baanante, J.J. Espert, S. Delgado, A.M. Lacy Hospital Clinic Barcelona, gastrointestinal surgery, Barcelona, Spain Background: Self-gripping mesh is proposed as an efficient and safe product for open inguinal hernia repair, with good short and long-term outcomes. We describe the results of a consecutive series of patients

123

Hernia (2016) 20 (Suppl 2):S175–S249 with inguinal hernia, treated by open repair with self-gripping mesh fixation in a Tertiary University teaching Hospital, with a considerable percentage of the surgeries performed by surgeons in training. Methods: This is a prospective analysis of a consecutive series of 132 patients surgically treated by this technique, with self-gripping ProGripTM (CovidienTM) mesh repair, at the Major Ambulatory Surgery service of Hospital Clinic of Barcelona between 2012 and 2014. Variables included demographic, disease-related and surgery-related data, and short and mid-term outcomes (pain at 1d, 1w, 1m and 6m, recurrence and foreign body sensation and QoL measured by SF-36 questionnaire). Statistical analysis was performed with SPSS II program (SPSS, Inc., Chicago, IL). Results: 132 consecutive patients (123 males and 9 females), with a mean age of 58.10 years, underwent open inguinal hernia repair with self-gripping ProGripTM mesh: 68 right, 61 left and 3 bilateral. Mean operative time was 40.5 min, being performed 68.9 % of them by general surgery residents. 77.3 % of patients were discharged within 6 h after the procedure. During at least 12-month follow-up, one patient presented recurrence, properly repaired with no further complications. 9.1 % of patients presented pain at 1 week, 5.3 % at 1 month and 3 % at 6 months after surgery; and 6 % presented foreign body sensation after 1 year. There was no mortality and the overall complication rate was 7.6 %. SF-36 assessment at one-year follow-up showed a very good status. Conclusions: This study shows that inguinal hernia repair with ProGripTM mesh placement is safe and feasible, with very good short and mid-term outcomes (chronic pain and recurrence related) in our Tertiary University Teaching Hospital experience.

P156 Partially absorbable mesh versus non absorbable mesh for incisional hernia sublay repair: a comparative study M. Antor, L. Schwarz, V. Bridoux, E. Huet, J.J. Tuech, H. Khalil Rouen University Hospital, Digestive Surgery, Rouen, France Background: Ultrapro is a macroporous partially absorbable mesh designed for hernia repair. The aim of this retrospective study was to compare results of incisional hernia repair using sublay partially absorbable mesh (ultrapro) versus non absorbable mesh (prolene). Methods: From January 2008 to June 2015, 115 patients underwent surgery for incisional hernia using sublay mesh. Ultrapro was used in 57 patients (group I) and prolene mesh in 58 patients(group II). All patients had physical examination 3 months after surgery and were contacted by phone for long term follow-up. Results: The median age of patients was 62 years (range 33–87) with a median BMI of 30 (range 17–55). The median parietal defect was 8 cm in diameter in group I (range 2–30) and 6 cm in the group II (range 3–20). The mean hospital stay was 6 days in the both groups. Postoperative complications included seroma (group I: n = 1, group II: n = 4), hematoma (group I: n = 1, group II: n = 4), or abscess (group I: n = 4, group II: n = 6). Two patients described chronic post operative pain in the group I and 7 patients in the group II. The median follow up was 48 months (range 6–95). Recurrence rate was the same in the both group (group I: 7 %, group II: n = 8.5 %). Conclusions: Ultrapro has the same post operative complications (recurrence and abscess), but less chronic post operative pain and seroma. A prospective study is necessary for complete the results.

Hernia (2016) 20 (Suppl 2):S175–S249

P157 Laparoscopic approach of direct inguinal hernia-is there a perfect way to close the defect? O. Arnautu1, O. Ginghina2, R. Iosifescu2, R. Munteanu1, N. Iordache2 1 Euroclinic Hospital-Regina Maria Private Healthcare Network, General Surgery, Bucharest, Romania, 2Sf Ioan Emergency Hospital, General Surgery, Bucharest, Romania Background: During TEP/TAPP approach in direct inguinal hernias, closing the big defect is always challenging and raises the risk of recurrence. Methods: We have studied 274 patients with inguinal hernia, who were operated by laparoscopic approach between 2012 and 2015, in two different hospitals, with 7 surgeons involved. There were 57 patients diagnosed intraoperatively with direct inguinal hernia, and the defect was treated by 3 different techniques: small anterior abdominal incision with resection of the sac, posterior abdominal laparoscopic purse-string and treatment of the sac only by parietalisation. Results: From the 57 patients with direct inguinal hernia treated laparoscopically, there were 3 recurrences, one conversion due to intraoperative bleeding and 4 patients with moderate post-operative pain, who were controlled by usual pain-killers within the first month. Conclusions: The rate of post-operative complications is not technique-dependant but it is related only with the dimensions of the parietal defect.

P158 Rarely seen and often missed: Lumbar hernia, a case report and review of the literature S. van Steensel, A. Bloemen, L.C.L. van den Hil, N.D. Bouvy Maastricht University Medical Centre, Department of Surgery, Maastricht, Netherlands Background: The lumbar hernia is a rare hernia in which the abdominal contents protrude through a defect in the posterior abdominal wall. Two anatomical locations of primary lumbar hernia are known: the superior (of Grynfeltt) and the inferior lumbar triangle (Petit’s triangle). Lumbar hernias develop from a congenital abdominal wall weakness, through iatrogenic or traumatic injury. Case: We present the case of a 54-year-old woman who presented with a mass in the right lumbar fossa. Computed Tomography (CT) scanning showed an inferior lumbar hernia with a diameter of 10 cm. Open operative reduction and mesh fixation was performed. An early recurrence was treated by laparoscopic mesh repair. Review: Only 300 cases of lumbar hernias are reported and the diagnosis is often missed due to unfamiliarity. CT scanning should be performed during pre-operative workup. Occurrence is highest in the superior lumbar triangle (55 %), although traumatic hernias following seatbelt injury most affect the inferior triangle. Risk factors are related to increased intra-abdominal pressure, similar to other hernias. An increased size and shape of the triangle is a risk factor, as seen in short and obese people. The treatment is challenging due to weakness of the abdominal wall and bony structures bordering the location. The limited evidence favours laparoscopic mesh reinforcement, saving open repair for larger lumbar hernias. Conclusion: Pre-operative Computed Tomography and laparoscopic mesh repair are the suggested standard for diagnosis and treatment. However, research is limited by the low incidence of lumbar hernias resulting in scarce experience and a lack of consensus in the literature.

S221

P160 CMC prosthesis: an example of smart combination of the design and physico-mechanical properties for a successful implant G. Vozzi, C. de Maria, F. Montemurro University of Pisa, Research Center ‘‘E. Piaggio’’, Pisa, Italy Background: It is well kwon that mismatch of mechanical properties between the mesh and the surrounding tissues can induce discomfort and pain, until the failure of the implant. The stiffness of a complex structure, such as mesh for surgical repair, depends on the building material, on the mesh geometry, on its porosity and permeability, and of course it may vary after exposition to biological fluids. Methods: In this study, we focused on a particular hernia prosthesis (CMC prosthesis, Dipromed srl, Italy). It was modelled using finite element analysis software to analyse its mechanical behaviour. The CMC prosthesis was also characterised in terms of mechanical properties (elastic modulus, strain and stress failure) and of its permeability to the biological fluids. Results: The comparison of results obtained by FEM analysis and experimental section has shown a good correspondence between the two analyses. Moreover, the measured mechanical properties and permeability of this mesh were similar to those of natural tissue. This last parameter it is really important to measure because it ensure not only a perfect integration but also a perfect perfusion of natural tissue after the implantation favouring a more rapid healing process. Conclusions: This study has shown how a smart and focused selection of a well defined topology and of biomaterial, combined with a precise finite element analysis can forecast the mechanical and biological performance of a prosthesis once implanted. The CMC prosthesis is an innovative medical device that combines in itself all the requirements necessary for a successful implant.

P161 Botulinum toxin as adjuvant therapy in giant inguinoscrotal hernia: case report M.J. Pen˜a Soria, C. Gonzalez Perrino, M.B. Josa Martinez, J.J. Cabeza Go´mez, D. Jime´nez -Valladolid Conde´s, A.J. Torres Garcı´a Hospital Clı´nico San Carlos, Servicio de cirugı´a General. Unidad de Pared Abdominal, Madrid, Spain Introduction: Giant inguinoscrotal hernia is a rare condition that supposes a challenge for the surgical team. It is defined when the hernia sac reaches or exceeds the middle third of the thigh or contains up to one-third of the abdominal viscera, without spontaneous or forced reduction any of them. Botulinum toxin A, has been used as adjuvant treatment of large anterior abdominal wall defects. We describe our first case in which we applied this treatment in a patient with giant inguinoescrotal hernia. Method: We describe the clinical case in which we performed preoperative treatment with botulinum toxin A. We also describe the infiltration technique and clinical results. Results: A 66 years old male with the diagnosis of giant inguinoscrotal hernia. Before performing a definitive surgery we decided to make neuromuscular block with botulinum toxin A (Botox) in order to avoid complications such compartmental syndrome after reduce a lost domain hernia. Under local anesthesia and sedation we proceeded to infiltrate toxin botulinum A. The application points were scored and symmetrically equidistant between the costal margin and the iliac crest: 2 points level of the mid-axillary line and 3 points between the

123

S222 axillary line anterior and middle clavicular line. Lateral to the midline supraumbilicales apply 2 points and 2-level infraumbilical rectus muscle. Using ultrasound guidance we infiltrated with 22 IU of botulinum toxin in each point. After 6 weeks we performed a bilateral Lichtenstein repair. No complications were recorded during postoperative period. After 6 months of follow-up no recurrence were recorded. Conclusion: Adjuvant treatment with botulinum toxin A might be a useful tool for giant inguinoscrotal hernias surgery.

P162 Chronic pain after inguinal hernia repair with Lichtenstein versus the Onstep method, results of a randomized clinical trial K. Andresen1, J. Burcharth1, S. Fonnes1, L. Hupfeld1, J.P. Rothman1, S. Deigaard1, D. Winther1, M.B. Errebo2, R. Therkildsen2, D. Hauge3, F.S. Sørensen4, J. Bjerg5, J. Rosenberg1 1 Herlev Hospital, Department of Surgery, Copenhagen, Denmark, 2 Horsens Hospital, Department of Surgery, Horsens, Denmark, 3 Bispebjerg University Hospital, Department of Surgery, Copenhagen, Denmark, 4University Hospital Aalborg, Dagkirurgisk center Hobro, Hobro, Denmark, 5Sygehus Lillebælt, Kolding Hospital, Department of Surgery, Kolding, Denmark Background: The Onstep technique for the repair of inguinal hernia was presented some years ago, with promising initial results regarding chronic pain. We have conducted a randomized clinical trial investigating the Onstep technique versus the Lichtenstein technique with focus on postoperative pain. The aim of this paper was to report the results regarding chronic pain from the 6 and 12 months follow-up for the participants in the Onstep versus Lichtenstein trial. Methods: This study was conducted as a randomized double-blind clinical trial in male participants with primary unilateral hernias. At surgery participants were allocated to the Onstep repair or the Lichtenstein technique. Participants were followed up with questionnaires after 6 and 12 months. The primary outcome was the proportion of patients with substantial pain related impairment of daily functions, at 6 and 12 months follow-up. Results: From April 2013 to May 2014 a total of 290 male patients were included in the study. Regarding follow-up for pain, a total of 259 patients completed the 6 months follow-up and a total of 236 patients completed the 12 months follow-up. Regarding pain at the 6 and 12 months follow-ups, no difference was found between groups. Two patients operated with the Lichtenstein technique developed severe disabling chronic pain postoperatively, which was not seen in the Onstep group. Conclusion: The Onstep technique was equal to the Lichtenstein technique regarding chronic pain following repair of primary inguinal hernias in males.

P163 The effectiveness of cyanoacrylate usage for polypropylene mesh fixation A. Uzunkoy Harran University School of Medicine, General Surgery, Sanliurfa, Turkey Aim: This study was planned to investigate the efficacy of cyanoacrylate usage for polypropylene mesh fixation. Materials and methods: Twenty-one Wistar albino rats were divided into three groups. All the rats were operated on under ether

123

Hernia (2016) 20 (Suppl 2):S175–S249 anaesthesia. 1.5 cm diameter tissue piece from the front wall of the abdomen was removed. In the first group, 3 9 3 cm polypropylene mesh was placed on the defect and this mesh was fixed with 4.0 polypropylene sutures and abdominal skin was closed with 5.0 polyglactin sutures. In the second group, mesh was fixed by using 2-octyl cyanoacrylate in the third group, abdominal facial defect was closed with 2.0 polypropylene sutures. The rats were sacrificed in the 21st day after the operation. The rats were sacrificed in the 14th day after the operation. Intra-abdominal adhesions and tissue breaking strength were evaluated. Results: In the primary closed group, tissue tensile strength significantly decreased compared to other groups (p \ 0.05). Tissue tensile strength was not significant difference between the other two groups (p [ 0.05). Intra-abdominal adhesions were significantly higher in the first and second groups than third group (p \ 0.05). In terms of adhesions was not significantly difference between first and second group (p [ 0.05). Conclusion: The results of cyanoacrylate mesh fixation are comparable the results of polypropylene mesh fixation. So cyanoacrylate can be used for mesh fixation. Using cyanoacrylate mesh fixation appears to be safe under experimental conditions but it is needed additional and experimental studies.

P164 Botox supported abdominal wall reconstruction in IPOM technique (BUBI): our solution for difficult cases N. Bohnert, A. Ba¨r, B.J. Lammers Lukaskrankenhaus Neuss, Department of General, Visceral and Hernia Surgery, Neuss, Germany Background: Sometimes it s difficult to achieve reconstruction of the linea alba in cases of big/loss of domain hernias. In those cases the Ramirez Operation (CST) (open or laparoscopic) for example is a technique to gain more material for the closure of the midline. We were looking for a feasible, less invasive method to solve this problem. Methods: Using the examples of two cases of multimorbid patients with big abdominal wall hernias we describe our new method of Botox supported abdominal wall reconstruction in IPOM technique (BUBI). In both cases the patients were treated with sonography supported abdominal wall Botox injections 2–3 weeks before surgery. After the Botox effect has been proved by low dose CT scan, surgery was done. In both cases the patients got a midline reconstruction and a mesh augmentation in IPOM technique. Results: In both cases the reconstruction was successful. No early complications like burst abdomen or wound infection occured. So far both patients are free from hernia recurrence. Conclusion: BUBI seems to be a feasible, safe method to gain reconstruction of the mildline in cases of big/loss of domain abdominal wall hernias.

P165 Echography estimation of muscles in men with inguinal hernia and COPD A. Lemeschewskij, S. Lemiasheuskaya, A. Makarevich, S. Alekseev Belarusian State Medical University, General Surgery, Minsk, Republic of Belarus Background: Advanced Chronic obstructive pulmonary disease (COPD) is often associated with systemic extra pulmonary effects

Hernia (2016) 20 (Suppl 2):S175–S249 such as degenerate-dystrophic changes of skeletal muscles. The Aim our work was to investigate the muscles status by echography and compare results with histological data of bioptic material of these muscles. Methods: The peak histogram of the internal oblique abdominal muscle was detected by ultrasonic scanner HONDA HS-2000. We obtained the following indices: homogeneity, structural density, echogenicity and dispersion. Histological research of bioptic muscular material of internal oblique abdominal muscle received during herniotomy. All patients gave written, informed consent, which had been approved by the Ethics Committee of our university. Microscopical and echodensitometry research was made in 32 patients: 1st group (10—1st COPD stage; mean: age—55 years; FEV1— 79 %; BMI—24 kg/m2); 2nd group (10—2nd COPD stage, age—59 years; FEV1—59 %; BMI—24 kg/m2). Control group was formed of 12 comparable healthy subjects. Results: Progression of COPD severity was associated with increase indices echogenicity and dispersion and decrease indices homogeneity and structural density. Increasing of COPD severity was associated with significant enhancing of ‘‘contractions’’ (r = 0.72), destruction of myofibrils (r = 0.69) and proliferation of fibroblasts (r = 0.52). We detected the presence of negative correlations between indices homogeneity, structural density and intensity of sclerosis manifestations (r = -0.39 and r = -0.51 respectively; p \ 0.05). Conclusion: The proposed ultrasonic indices reflect the degenerative processes occurring in the muscles in men with inguinal hernia during COPD progression. Identified changes in the internal oblique muscle in men with COPD can be seen as rationale for the use of mesh prosthesis when choosing a method of hernia in patients with stage II COPD or higher.

S223 cases were operated in emergency situation and 5 had simultaneous dermolipectomy. The VHWG classification was: 15 type I, 16 type II, 19 type III and 3 type IV. Wound morbidity was: 5.7 % seromas, 7.5 % hematomas, 7.5 % superficial SSI, 1.9 % deep SSI, 13 % partial skin necrosis. Abdominal and systemic complications: Paralytic ileus 15 %, 2 enteric fistulas from anastomosis, respiratory insufficiency 9 %, cardiac failure 5.7 %. With a mean follow-up of 18 months there was 5 recurrences (13.5 %) and 2 bulging (5.6 %). Conclusions: The possibility of using an absorbable mesh as reinforcement and 3-dimensional configuration of PP mesh helps to manage challenging incisional cases in both midline and lateral abdominal wall.

P167 A simple technique to facilitate the installation of prosthesis during correction of parastomal hernias by the Sugarbaker laparoscopic technique G. Brochu1, G. Bergeron-Gigue`re2 1 CHU de Que´bec-Universite´ Laval, Surgery, Quebec, Canada, 2 Universite´ Laval, Surgery, Quebec, Canada

P166 BIOA mesh as reinforcement and 3-dimensional configuration of polypropylene meshes avoids lateral fixation in complex incisional hernias

The correction of parastomal hernias is a major challenge. Many techniques exist but the recurrence rate remains high. The last few decades have seen the development of different procedures and prostheses. Sugarbaker’s method—laparoscopic repair with prosthesis by the creation of a ‘chicane’—seems to distinguish itself from others by its low recurrence rate. However, numerous procedural steps need to be followed as intestinal loop manipulation in stoma creation is a serious undertaking. We present a simple procedure that facilitates placement and installation. A transparietal suture encircles the intestine about 10 cm from the stomal opening. Once placed under tension, the suture affixes the intestine against the abdominal wall, which permits better delimitation of installed prosthesis margins and tension. Furthermore, intestinal loop placement against the abdominal wall greatly facilitates prosthesis fixation. The temporary suture is easily removed at the end of the procedure.

M. Garcia-Uren˜a1, L.A. Blazquez1, A. Robin1, A. Cruz1, D. Melero1, J. Lopez-Monclus2, P. Lo´pez1, E. Gonza´lez1, R. Becerra1, C. Jime´nez1, A. Galvan1, A. Moreno1, N. Palencia1, A. Aguilera1 1 Henares University Hospital, Surgery, Madrid, Spain, 2Puerta de Hierro University Hospital, Surgery, Madrid, Spain

P168 A novel approach for parastomal hernia repair: a technical note and first results

Background: Retromuscular mesh reinforcement and posterior component separation techniques are increasingly being used in lateral and midline complex incisional hernias. The introduction of a bioabsorbable mesh in combination with a permanent mesh may help in difficult cases. Materials and methods: A prospectively maintained database was used to identify all patients undergoing open retromuscular approach or posterior component separation technique with a double mesh technique of bioA mesh and polypropylene mesh, between 2012 and 2015. The bioA mesh was used in all cases to reinforce posterior layer closure and separate the peritoneum from medium density polypropylene (PP) mesh that was only fixed cranially and caudally without any lateral fixations. The initial rigidity of bioabsorbable mesh helped to extend and maintained the PP mesh in place. Results: 53 patients (31 males) were operated with a mean age 53 years and BMI 32.5. 41 % diabetic and 45 % smokers. Hernias included: 19 midline hernias, 12 lateral, 7 medial + lateral, 7 medial + parastomal and 7 parastomal. Mean hospital stay: 10 days. The mean hernia defect was 11.3 (4–40). Complete closure of anterior layer was achieved in 37 %. 22 % needed an intestinal resection. 5

J.D.G. de Gols1, G.V. Vangertruyden2, J. Knol2 1 SFZ Heusden-Zolder, Abdominal Surgery, Heusden-Zolder, Belgium, 2Jessa, Abdominal Surgery, Hasselt, Belgium Background and aims: Although a variety of surgical repairs exist for treatment of a parastomal hernia (PSH), in general, use of a prosthesis results in a lower recurrence rate when compared to local repair. Basically, two techniques are used to repair parastomal hernias with an intraperitoneally placed mesh: the ‘‘Sugarbaker’’ technique and the Keyhole repair. The first technique is difficult to standardize and implements a risk of bowel kinking or erosion, while the latter has an unacceptable high recurrence rate. We therefore modified the Keyhole-approach by reinforcing the centre of the mesh with a handmade funnel, directed in-to-out. Methods: The central opening in a simple flat prosthesis for PSHrepair has a tendency to become bigger as a result of shrinkage and therefore often leading to a recurrence. On the other hand when adding a tubular part to the prosthesis the risk of stenosis occurs. Therefore, in our model, we aim to create an adaptable inner diameter by cutting triangular shaped flaps in the central opening. These flaps are directed in-to-out, so according to the direction of bowel

123

S224 peristalsis. By attaching a resorbable tubular prosthesis on the inside of these flaps chance of mesh erosion is minimized, the position is maintained and scarring on the flaps is allowed while normal tissue bridges are created inbetween the flaps. This way dilatation even remains possible when needed. Results: Ten patients were treated by using this Modified KeyholeMesh-Repair: six patients underwent a laparoscopic repair and four an open procedure. Median follow up is 24 months with a range of 6–72 months. The recurrence rate was 20 %. Conclusion: The Modified Keyhole-Mesh-Repair is feasible with an acceptable recurrence rate in this small series. The results of a larger group of patients will be reported in the near future.

P169 Accuracy of ultrasound diagnosis of recurrent inguinofemoral hernia in the post-op groin: a study P.J. Mullaney, J. Torkington University Hospital of Wales, Department of Radiology, Cardiff, UK Background: Ultrasound (US) imaging of the groin is a rapidly growing discipline in the management of suspected inguinofemoral hernia. Although current European Hernia Society guidelines (2009) do not recommend US for the assessment of suspected groin hernia, a recent metanalysis demonstrated the efficacy of US in the diagnosis of inguinofemoral hernia where the clinical diagnosis is uncertain (Overall sensitivity 96.6 %, Specificity 84.8 %, Positive Predictive Value 92.6 %). The size of each published cohort used in the analysis is variable (20–440 groins, average 145 groins). To the authors knowledge there is no published data on the efficacy of US in the diagnosis of suspected recurrent inguinofemoral hernia, where previous groin surgery has been performed. The presence of indwelling mesh confers challenges to visualisation of the inguinal canal, but accurate preoperative diagnosis in such cases may have greater clinical value due to the increased technical difficulty of surgical exploration and revision repair. Methods: 80 cases of suspected recurrent inguinofemoral hernia were scanned by a single operator (Consultant Musculoskeletal Radiologist, PM). Scan findings are compared to surgical records, or clinical follow up (mean follow up time 36.6 months, range 10.1–80.7 months). The patients presented are a subset of 952 consecutive groin scans performed by the operator over 6 years, with data prospectively gathered over this time. Results: US accuracy for the diagnosis of recurrent inguinofemoral hernia is as follows: sensitivity: 96.2 %, specificity 83.3 %, positive predictive value 75.3 %, negative predictive value 97.8 %, accuracy 87.5 %. Conclusion: The results in this series compare favourably to published results for US diagnosis of primary inguinofemoral hernia, and demonstrate the value of US even in the post-op groin. To the authors knowledge, this is the first series of this kind, part of the largest adult series of groin scans yet published.

P170 Successful reconstruction of complex abdominal wall defects using a ‘sandwich’ procedure B.J.M. Bustos Jimenez, V. Pino Dı´az, V. Dura´n Mun˜oz Cruzado, J. Tinoco Gonzalez, I. Alarcon del Agua, J. Martin Cartes, M.J. Tamayo Lopez, F. Docobo Durantez, F. Padillo Ruiz H.U. Virgen del Rocio, Cirugı´a General, Sevilla, Spain Reconstruction of large, complex abdominal wall hernias is an interesting challenge. There is little agreement about the most

123

Hernia (2016) 20 (Suppl 2):S175–S249 appropriate technique or prosthetic to repair these defects, in spite the fact of the prevalence of ventral hernias. In an attempt to reduce recurrences, we frequently added a biologic underlay mesh and a lightweight polypropylene on-lay mesh to the traditional CST. Our objective was to determine biologic mesh practice patterns of reconstructive surgeons with regard to indications, most appropriate technique, choice of prosthetics and experience with complications in order to work those hernias out. Methods: Seventy-one consecutive patients who underwent abdominal wall reconstruction by means of a component separations associated with non-cross-linked porcine dermal scaffolds (NCPDS) or a synthetic tissue scaffold (STS) reinforcement between November 2010 and December 2015 were retrospectively reviewed. Analysis of demographics, indications for NCPDS or STS placement, surgical technique, complications and follow-up data were performed. They underwent a ‘sandwich’ procedure with a biologic underlay mesh and a lightweight polypropylene on-lay mesh added to the traditional CST. Results: A ‘sandwich’ procedure was used for abdominal wall repair in 71 patients. In all of them, NCPDS or STS was positioned using an intraperitoneal technique associated to a lightweight polypropylene on-lay mesh and the CST. At a mean follow-up time of 30.1 months, most patients had successful outcomes. Occurrences 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 occurrences. Moreover, repair of large, complex abdominal wall hernias by CST augmented with a biologic underlay mesh and a lightweight polypropylene on-lay mesh results in lower recurrence rates compared with historical reports of CST alone.

P171 New perforator flap reconstruction techniques lead to new types of incisional hernias F. Berrevoet, S. van Cleven, K. van Landuyt, K. Claes Ghent University Hospital, General and HPB Surgery and Liver Transplantation, Heusden, Belgium Introduction: Autologous breast reconstruction with a perforator flap has become increasingly popular. The free lumbar artery perforator (LAP) flap has recently been described as a good alternative for autologous breast reconstruction. The LAP flap is a fasciocutaneous flap based on a single artery. Methods: We present a case of a lumbar incisional hernia after LAP flap for breast reconstruction in a 53-year-old patient. The patient had previously been treated for cancer in both breasts with a bilateral mastectomy. Secondary breast reconstruction was performed with a bilateral DIEP (Deep Inferior Epigastric Perforator) flap. Reoperation was necessary because of a failed DIEP flap at the left side. A new reconstruction was performed with a free LAP flap. Results: The patient was referred for evaluation of a right lumbar swelling at the donor-site of the LAP flap. A CT-scan confirmed a lumbar incisional hernia with herniation of small bowel and colon. An open dorsal repair was performed with a retroperitoneal large pore polypropylene mesh. The thoracolumbar fascia was closed in 2 layers with a running suture. Postoperative CT scan showed a solid repair with some residual seroma that resolved spontaneously. Conclusion: The possible reconstruction methods using perforator flaps increase over the years. The lumbar artery perforator is a relatively new fasciocutaneous flap based on a single artery. It does not sacrifice any muscle and its donor-site can be closed primarily, with minimal donor-site morbidity. We present here the first case of a

Hernia (2016) 20 (Suppl 2):S175–S249 successfully treated lumbar incisional hernia repair after LAP flap breast reconstruction.

P172 Abdominal wall’s neoplasms and their treatment B.J.M. Bustos Jimenez, A.C. Maya Aparicio, V. Pino Dı´az, L. Aguilar Romero, M. Fernandez Ramos, I. Alarcon del Agua, J. Martin Cartes, M.J. Tamayo Lopez, F. Docobo Durantez, F. Padillo Ruiz H.U. Virgen del Rocio, Cirugı´a General, Sevilla, Spain Background: Malignant tumors of the abdominal wall are rare tumours with a prevalence of about 1 case for 2000. In the medical literature studies that we encounter regarding this theme are scarce, with a small number of patients and most are studies with a low level of evidence. The purpose of this study is to provide data on these types of tumours at our institution and our experience in their treatment. Methods and results: We performed a retrospective study based on data collected from surgeries performed in our unit specialized in advanced abdominal wall. We collected information from the database that contains the surgeries performed in our unit specialized in advanced abdominal wall in the range of dates between 21/02/2009 and 01/08/2013, in a total of 1193 interventions, finding a total of 13 surgical interventions in malignant tumours of abdominal wall. Conclusion: When we speak of malignant tumours of the abdominal wall, we have to classify them into two groups, those called primary tumours, within which we find desmoid tumours and sarcomas, but we can also find other more infrequent as the Dermatofibrosarcoma protuberans; and those called secondary malignant tumours, the most frequent are metastases or tumour implants in the abdominal wall. The selected treatment for all these tumours is surgery, making a direct closure or using a PPL or a PTFE prosthesis to repair the defect of the wall.

P173 Resorbable prosthesis Bio-A usefulness in the surgical treatment of complex hernias P. Garcı´a-Pastor, A. Torregrosa, J. Sancho-Muriel, J. Iserte, S. Bonafe, J. Bueno University Hospital La Fe, Abdominal Wall Surgery Unit, Valencia, Spain Introduction: The abdominal wall repair requires handling of multiple elements; surgeon must know and master various techniques and materials to suit every clinical case and provide adequate alternative solution to each patient. We report our experience with the Posterior Component Separation-TAR (PCS-TAR) associated with use of BioA absorbable prosthesis (Gore) in the management of large hernias. Material and method: Since its description by the Rosen–Novitsky team, we have progressively implemented this surgical technique in our work group. Until January 2016, we have performed a total of 25 PCS-TAR, in 11 cases (those in which the hernia defect or quality of musculoaponeurotic component remaining in the abdominal wall was worse) have implanted resorbable prosthesis Bio A associated with a PPL permanent prosthesis. We present our series data: demographic data, origin and type of hernia (study by dynamic CT-Valsalva, location and size of the hernia ring, volumetry, visceral content and adhesions), preoperative management of complex cases (3 cases with Botulinum toxin-A infiltration followed by Progressive pneumoperitoneum), details of the intervention and postoperative immediate and medium-term evolution (CT tracking control as protocol).

S225 Results: Our experience in using Bio-A prosthesis on the PCS-TAR, although still initial, has been very positive. It has been especially useful in addressing large lateral hernias (lumbotomy, pararectal for kidney transplantation) and peristomal, with the advantage of allowing a firm preperitoneal plane on which the definitive mesh extends safely. The initial consistency of repair attributable to absorbable prosthesis is highly valued by the patient. There’s no complications related to its use, and development of repair (maximum 17 months) is positive, with no relapses till the moment.

P174 Synthetic glue: cyanoacrylate for mesh fixation in Rives-style ventral hernia repair P. Garcı´a-Pastor, A. Torregrosa, J. Sancho-Muriel, B. Argu¨elles, S. Bonafe, J. Iserte, J. Bueno University Hospital La Fe, Abdominal Wall Surgery Unit, Valencia, Spain Introduction: Despite numerous studies support the safety and effectiveness of synthetic tissue adhesives as a means of attachment for inguinal hernia repair, it has not been described so far for ventral hernia repair. It’s probably due to high abdominal pressure that these procedures are subjected. The aim of the present study is to show the step by step technique and our results obtained by performing conventional Rives technique for ventral hernia repair using retrorectal mesh fixated with only four transmuscular stitches and the use of synthetic tissue adhesive-cyanoacrylate (Glubran) in order to validate this fixation method applied in this surgical technique. Material and method: Our usual alternative for repairing midline small and moderate-size hernias (type W1 and W2 in EHS classification) is Rives technique. Our protocol is opening the rectus sheath, comprehensive dissection of retrorectal space for primary closure of the hernia defect by continuous monofilament of long-life suture, placement of prostheses PPL-dual (IPOM, Dynamesh) which is fixed by only four transmuscular stitches; and the rest of its surface is fixed by synthetic cyanoacrylate-adhesive glue (Glubran). We present the results of our technique over 5 years: descriptive demographic data of patients, the hernias characteristics and their origin and size, technical intraop details, immediate evolution and follow-up in short and medium time (5 years–5 months). Results: In our team, the Rives technique is of choice for midline hernias of small-moderate size. With the amendment to the standard technique and the introduction of bonding with cyanoacrylate-glue for mesh fixation, we managed to shorten the time of surgery and reduce local complications (pain, hematoma) without impairing safety, because the recurrence rate has not increased.

P175 Percutaneous laparoscopy: new Teleflex equipment: first experiences C. Wurst Agaplesion Bethesda Hospital Stuttgart, Department of Generaland Visceral Surgery, Stuttgart, Germany Introduction: Since laparoscopic surgery started the surgical landscape changed a lot. Many new ways and techniques were described. We had the opportunity to be the first hospital in Germany to work with this new set of Teleflex instruments. Our experience was limited to the initial generation without electrocautery functionality. A minimal learning curve was noted.

123

S226 Methods: Within this first generation it was possible to use several instruments. There is a reusable handle combined with a single use shaft and single use tooltip. At present there is a 2.9 mm diameter shaft which is 29 cm long. It is possible to attach different tooltips at the end. To bring the instrument into the abdomen a blunt tip introducer is used. Following the insertion the instrument exits the abdominal cavity through the optic trocar and the introducer tip is exchanged with a tool tip. At present, two graspers, one dissector and a scissors are available. Until now we used the instruments during various surgeries: groin hernia, cholecystectomy, fundoplication and bariatric procedures. The small incisions have been closed just with glue. Results: The shaft has the required stiffness while providing some flexibility that allows for angulation without too much of a bend. The different tooltips allow gentle handling of sensitive tissues as well as firm grip, comparable to standard instruments. All surgeries could be performed in a safe manner without conversion to conventional instruments. Discussion: At present important tooltips are under development and not yet available. At the time of introduction on the market of the Percuvance System an electrocautery hook and spatula tooltip and a Hem-o-lokTM clip applier tooltip will be available, as well as longer shafts for use in bariatric surgery. In terms of cosmesis and safety the presented set of instruments provides very good results and a practicable approach.

P176 A porcine animal model for intraperitoneal mesh prosthesis in stoma surgery R.M. Eickhoff1, L. Ernst2, A. Lambertz1, U. Klinge1, U.P. Neumann1, R.H. Tolba2, C.D. Klink1 1 RWTH Aachen University Hospital, Department of General, Visceral and Transplantation Surgery, Aachen, Germany, 2RWTH Aachen University, Institute for Laboratory Animal Science, Aachen, Germany Background: Parastomal herniation is a frequent complication in colorectal surgery, occurring with a prevalence of 30–80 %. The simulation of a stoma animal model is challenging. The aim of the study was to establish an animal model for intraperitoneal colostoma mesh prosthesis. Methods: We performed open terminal sigmoid colostomies with a 10 9 10 cm IPST mesh (n = 5 elastic, vs. n = 5 non elastic) in a total of 10 female minipigs. For dissection of the colon we used a gia[TRADEMARK] stapler (DST-series, Covidien) and colostomy was placed paramedian in the left lower abdomen. IPST was fixed intraperitoneal with absorbable tacks (AbsorbaTac[TRADEMARK], Covidien). Postoperative care comprised daily examinations, physiotherapy, digital palpation and cleaning of colostoma, and special soaked diet. After 8 weeks the animals were euthanized after laparoscopic exploration and the stoma site was resected. Results: No parastomal hernia appeared in any animal with n = 8 animals survived till the endpoint. In turn, one animal died during anesthesia on day 33 by aspiration and one was euthanized due to an obstructive ileus on day 14. A wound infection occurred in one pig. Two main problems were detected during the study: A tendency to obstipation due to low and thickened stoma output (n = 8) and granulation with constriction of the stoma at skin level (n = 5), which required incision of the parastomal skin (median 31st postoperative day (POD)). As a consequence we performed active exercise therapy (n = 10; POD 2–15), administered soaked food 1 week before stoma surgery for preconditioning (n = 6) and added raps oil and movicol after surgery.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Conclusions: We successfully established a porcine animal model for intraperitoneal mesh prosthesis in stoma surgery. However, the model required substantial time and effort to guarantee the wellbeing of the animals.

P177 4 year long term follow up of a new MRI visible hiatal mesh in a pig R.M. Eickhoff1, D. Busch1, A. Lambertz1, A. Ciritsis1, N.L. Hansen1, N.A. Kra¨mer1, F.A. Granderath2, C.D. Klink1, U. Klinge1, U.P. Neumann1, J. Otto3 1 RWTH Aachen University Hospital, Department of General, Visceral and Transplantation Surgery, Aachen, Germany, 2Neuwerk Hospital, Department of Surgery, Mo¨Nchengladbach, Germany, 3MZ Sta¨dte Region Aachen, Department of General and Visceral Surge, Aachen, Germany Background: The use of textile prostheses for the repair of laparoscopic hiatal hernia still is under discussion. Erosion, migration and stricture might occur with a delay of months or even years after implantation. The aim of the study was to demonstrate the effectiveness and safety of a new, MRI visible, laparoscopic implanted hiatal mesh for long term surveillance. Methods: We laparoscopically implanted an MRI visible mesh prosthesis with a circular distance of [5 mm to the esophagus in a Go¨ttingen minipig. The prosthesis was made of PVDF as a flat mesh of 12 9 7 cm size, with a central squared 3 cm 9 3 cm opening. The mesh was fixed with absorbable tacks. Following implantation, free passage was established and documented by endoscopy. MRI examination and endoscopic control was performed after 7 days, 36 and 50 months. After 50 months the animal was finalized and the mesh prosthesis explanted. Results: The minipig tolerated all procedures very well. Neither a hiatal herniation nor any mesh complication, e.g. erosion, migration or stricture, were observed. Accurate position of the prosthesis could be verified in all three MRI examinations, and the mesh area could be calculated. The central squared opening of the mesh prevented any stenosis or any damage of the oesophagus wall. Endoscopically there was no stenosis or proximal dilatation, which was corroborated by the normal food intake and continuous body weight. All these findings were confirmed by the macro- and microscopic investigations after euthanasia. Conclusions: We demonstrate the feasibility and effectiveness of a new, MRI visible, laparoscopic implanted hiatal mesh in a long term follow up porcine model. Following this proof-of-principle, larger cohorts, however, are needed to establish the prevalence of potential complications for this procedure.

P178 Single incision laparoscopic intraperitoneal onlay mesh repair (SIL-IPOM) vs. conventional laparoscopic IPOM for midline ventral hernia repair: a casematched comparative analysis J. Schulte-Ma¨ter, J. Raakow, M. Kilian, M. Biebl, J. Pratschke Charite´ Berlin, Surgery, Berlin, Germany Introduction: In recent years, single incision laparoscopic surgery (SILS) has been introduced as a less invasive alternative to conventional laparoscopy but little is known about the efficiency and safety of SIL-IPOM. The aim of this study was to compare the single incision approach with the multiport technique for laparoscopic IPOM repair regarding surgical and postoperative outcome.

Hernia (2016) 20 (Suppl 2):S175–S249 Methods: Prospective data was collected on 11 consecutive patients undergoing SIL-IPOM repair between August 2014 und July 2015. Those patients were matched by age (±5 years), BMI (±3 kg/m2) and hernia size in a 1:2 ratio with 22 patients who underwent multiport laparoscopic IPOM repair. Comorbidities were documented. Operative technique and operating time, postoperative pain as well as recurrence rate were recorded. Results: In the group of SIL-IPOM the mean BMI was 30.4 (25.1–37.7) kg/m2. The median hernia size was 4.2 (2–8) cm. 9 patients had an umbilical hernia, one a combined umbilical/epigastric and one patient presented with an incisional hernia. All patients were operated without additional trocars used or conversion to open repair. The mean operating time for SIL-IPOM was 70 (37–99) min compared to 93 (65–180) min for conventional laparoscopy. No perioperative complications in both groups were seen. The length of hospital stay was 3.3 (2–6) days compared to 3.4 (2–7) days, respectively. Mean follow-up was 7.6 (3–13) months. There were no recurrent hernia in the SIL-IPOM group. Two recurrent hernia were documented in conventional IPOM group. Conclusion: The SIL-IPOM is safe and easy for the repair of ventral abdominal wall hernias with comparable surgical and postoperative results. Further studies with more patients and longer follow-up are needed to further evaluate the technique and define its position of SIL-IPOM.

P179 Early fascia closure using unilateral rectus abdominal sheath turnover flap method and the Separation of anatomic components technique, in patients with ACS D.D. Diklic, K.D. Koprek, V.D. Vujcic General Hospital Bjelovar, Abdominal Surgery, Bjelovar, Croatia Background: The acute intra-abdominal hypertension causes profound physiologic abnormalities, both within and outside the abdomen. Just as in compartment syndrome in the extremities, gut mucosal ischemia begins long before clinical signs are evident, explaining the name of ‘abdominal compartment syndrome’ given to the acute, markedly increased intra-abdominal pressure. The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and non-traumatic surgical conditions. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. Methods: Our case was the patient who was operated two times due to obstruction of small intestine and developed abdominal compartment syndrome (CSA). The decision was an indication for emergency laparotomy. Unilateral anterior rectus abdominal sheath turnover flap where created by longitudinal incisions along the lateral edge of the anterior rectus sheath, which where mobilized medially and approximated and the separation of anatomic components technique. The skin was closed primary. Results: Unilateral anterior rectus abdominal sheath turnover flap and approximated and the separation of anatomic components technique have led to improvements of physiology function and better condition of a patient. Conclusion: Early laparotomy with fascia closure of unilateral anterior rectus abdominal sheath turnover flap and the separation of anatomic components technique at abdominal compartment syndrome have led to improvements of physiology function and better condition of a patient. This approach can be considered as an alternative technique in the early management of patient with ACS.

S227

P180 Laparoscopic repair of diaphragmatic hernia with propylene pledgets and toupet fundoplication: superior, safe and cheap A. Mamound, C.H.M. Clemens, W.R. ten Hove, W.E. Hueting Alrijne Zorggroep, Surgery, Leiden, Netherlands Background: Laparoscopic repair of diaphragmatic hernia is accepted as the gold standard. To reduce the relapse rates, the use of prosthetics for improving the crural repair has been suggested. This study aimed to asses the results of laparoscopic repair of diaphragmatic hernia in two groups: group with propylene pledgets for the strengthening of the cruroraphy and group without propylene pledgets. Methods: A retrospective study was performed on all patients with diaphragmatic hernia repair, in our hospital between January 2011 and November 2015. Preoperative and operative variables, complications and anatomical recurrence were evaluated. Postoperative data were gathered using GERD-HRQL, dyspnea-index, Visick-score and subjective patient opinion. Results: Until November 2015, 176 patients; 125 females, median age 60 years (18–92) underwent repair of diaphragmatic hernia with complete hernia sac resection. 104 patients had a reinforcement of the cruroraphy with prolene pledgets, 46.2 %, for a type I, 8.7 % for a type II, 14.4 % for a type III and 30.8 % for a type IV hernia diaphragmatica. From the 72 patient in the group without prolene pledgets, 41.7 % had a type I hernia diaphragmatica, 26.4 % a type II, 11.1 % a type III and 20.8 % had a type IV. The total anatomical recurrence rate was 7/176 (3.98 %), 2/104 (1.9 %) in group with propylene pledgets and 5/72 (6.9 %) in group without propylene pledgets. In these 5 years of follow-up (median 23 months) no cases of complications related to the propylene pledgets were observed. Mortality rate was zero. Conclusions: In our regional referral center a decrease of recurrence and postoperative symptoms was observed in patients after laparoscopic repair of hernia diaphragmatica with propylene pledgets compared to a group without propylene pledgets. An improved, safe and cheap method according to the basic principles of hernia surgery.

P181 Giant ventral hernia: compartment preparation technique and atypical flap reconstruction L. Bilianskyi1, S.P. Galych2 1 National Medical University after O.O.Bogomolets, General surgery, Kiev, Ukraine, 2National institute of surgery after O/ O.Shalymov, Kiev, Ukraine, Plastic Surgery, Kiev, Ukraine The purpose of this study is to define the approach to the surgical treatment of patients with full or significant absence of support of abdominal wall muscles particularly in cases of intraabdominal hypertension hazard. Methods: The retrospective study was conducted in 2006–2015, and included two arms of the patients: 47 patients (26 females and 21 males) were operated on followed by progressive preoperative pneumoperitoneum (PPP) as a special volume preparation of the compartment; another arm—21 consecutive patients (18 males and 3 females) were treated with conventional surgical technique. Different types of prosthesis were used and the final phase of the surgery includes the transposition of the atypical musculocutaneous flaps— the transposition of tensor fasciae latae in 19 patients and rectus femoris muscle in 2 patients. Results: Patient compliance was adequate. PPP technique was maintained for an average of 21.3 ± 5.7 days and there were no

123

S228 serious complications relating to the procedure in the PPP arm. After PPP procedure a tension-free hernioplasty was successful in all patients. In the second arm all the patients had seromas, which were treated conservatively during the following 25.5 ± 7.4 days after the surgery. There were no major morbidity and no mortality. Conclusion: The PPP procedure is the useful technique for the compartment preparation in the patients with giant hernias. The transposition of the femoral musculocutaneous and fascial flaps were the key point of reconstruction in the cases of the full or significant absence of the abdominal wall support.

P182 Injecting botulinum toxin in the abdominal wall prior to the surgical repair of the giant hernias of the abdominal wall B.M. Josa Martinez, M.J. Pen˜a Soria, A. Garcia Fernandez, A.E. Perez Jimenez, M. Florez Gamarra, D. Jimenez Valladolid, J.J. Cabeza Gomez, A.J. Torres Garcia Clı´nico San Carlos, Cirugia General, Madrid, Spain Introduction: Patients with giant hernias with loss of domain require proper planning of surgical repair, because of the high associated comorbidity. The injecting of botulinum toxin technique described by M. C ¸ akmak allows a more physiological adaptation of the patient and the abdominal cavity to the reinstatement of the viscera to the abdomen, enabling adequate surgical repair. The objective of this study was to analyze our experience in the treatment of this type of hernia. Materials and methods: We carried out a retrospective study that included 22 patients with major abdominal wall defects and loss of domain who were treated with this technique by the Abdominal Wall Unit at the Clinical Hospital San Carlos in Madrid from 2013 to 2016. Results: We infiltrated the botulinum toxin in 3 points in the midaxillary line between the costal margin and the external iliac crest on the edge of the external oblique muscle. All patients were injected on an outpatient basis and under sterile conditions by the surgical equipment, and infiltration 50 UI of the toxin per point is guided by ultrasound. We analyzed if after injection of the botulinum toxin was achieved primary closure of the abdominal wall, as well as the use of meshes. An important point to analyze is the appearance of complications, mainly respiratory, produced by increased abdominal pressure. Patients were followed periodically in order to diagnose recurrences early. Conclusions: The technique of injecting botulinum toxin remains safe to prepare patients with giant hernias with loss of domain in our case serie. We believe that this procedure can reduce the morbidity caused by the increase in abdominal pressure after abdominal wall repair.

P183 Mesh shrinkage in hiatal hernia repair: One-year Follow up of MRI- visible meshes D. Weyhe1, V. Uslar2, A. Kluge1, A. Grewe3, U. Klinge4 1 Pius-Hospital, Clinic for General and Visceral Surgery, Oldenburg, Germany, 2Carl-von-Ossietzky University, University hospital for visceral surgery, Oldenburg, Germany, 3FEG Textiltechnik, FEG Textiltechnik, Aachen, Germany, 4RWTH Aachen and University Clinic Aachen, Clinic for Gen. Visc. and Transpl. Surgery, Aachen, Germany Introduction: Usage of mesh in hiatal hernia surgery is discussed controversially because of potential foreign body reaction with subsequent mesh shrinkage and the risk of mesh penetration or postoperative dysphagia. German as well as US guidelines do not give any recommendations regarding this issue, and therefore no

123

Hernia (2016) 20 (Suppl 2):S175–S249 agreements exists on the minimal hiatial surface area (HSA) indicating mesh augmentation. Materials and methods: Eleven patients undergoing surgery because of symptomatic hiatal hernia entered this prospective clinical trial. Indication of mesh implantation was given if HAS was [5 cm2. All patients were implanted with an MRT-visible mesh (Dynamesh mrivisible) with absorbable fixation. Immediately perioperatively as well as 1 year postoperatively a MRT measurement was conducted. MRT sequences were edited with the photo-editing software ImageJ. Points on the mesh border surrounding the esophagus were marked. The size of the area build by the hole in the mesh surrounding the esophagus was calculated numerically (Finite-elements method). Results: For n = 11 patients (9 female, 2 male; median age: 71 years; range: 53 to 86 years) both MRT examinations are analyzed. Mean intraoperatively measured HSA was 8.9 cm2 with a range from 5.0 to 17.5 cm2. Overall, there was no clinically relevant shrinkage between the perioperative MRT measurement (median mesh hole: 264 mm2; range: 124 to 438 mm2) and the one year postoperative measurement (median: 261 mm2; range: 132 to 474 mm2). Four patients revealed a clinically not relevant shrinkage (B63 mm2). Five patients showed an increase of the hole (between 2 and 36 mm2). The increase seems to coincide with large HSA. Discussion: Mesh shrinkage and mesh elongation was observed in most cases. Neither was clinically relevant. Register studies should be used to clarify if a HSA value [5 cm2 is indeed a good threshold for the indication of mesh augmentation.

P184 Recall bias in pain scores evaluating abdominal wall and groin pain surgery: a meta-analysis W.A.R. Zwaans1, J.A. de Bruijn1, J.P. Dieleman1, E.W. Steyerberg2, M.R.M. Scheltinga1, R.M.H. Roumen1 1 Ma´xima Medical Center, General Surgery, Veldhoven/Eindhoven, Netherlands, 2Erasmus Medical Center, Public Health, Rotterdam, Netherlands Background: To determine whether preoperative pain as recalled by a patient in the postoperative phase is possibly overestimated or underestimated compared to prospectively scored pain. If so, a subsequent misclassification may induce recall bias that may lead to a different effect outcome. Materials and methods: Data of seven retrospective cohort studies on surgery for abdominal wall and groin pain using three different pain scores (VRS, verbal rating score; VAS, visual analogue score; NRS, numerical rating scale) were systematically evaluated. Firstly, it was assessed whether retrospectively acquired preoperative pain levels, as scored by the patient in the postoperative phase, differed from prospectively acquired preoperative pain scores. Secondly, it was determined if errors associated with retrospectively obtained pain scores potentially lead to a misclassification of treatment outcome. Thirdly, a meta-analysis established whether recall misclassifications, if present, affected overall study conclusions. Result: A total of 313 surgical patients were evaluated. The overall prevalence of misclassification due to a recall error was 13.7 %. Patients not benefitting from surgery (‘failures’) judged their preoperative pain level as more severe than it actually was. In contrast, patients who were pain free after remedial surgery (‘successes’) underestimated preoperative pain scores. Recall misclassifications were significantly more present in a failures than in successful patients (odds ratio 2.4 [95 % CI 1.2–4.8]). Conclusion: One in seven patients is misclassified on the basis of retrospectively obtained preoperative pain scores (success instead of failure, or vice versa). Misclassifications are significantly more

Hernia (2016) 20 (Suppl 2):S175–S249 present in failures which leads to an overestimation of beneficial effect size of a therapy most of the time.

P185 Chronic postoperative groin pain requiring remedial surgery: spinal or general anaesthesia? W.A.R. Zwaans1, L.H.P.M. Le Mair1, M. van Kleef2, M.R.M. Scheltinga1, R.M.H. Roumen1 1 Ma´xima Medical Center, General Surgery, Veldhoven/Eindhoven, Netherlands, 2Maastricht University Medical Center, Anaesthesiology/Pain Medicine, Maastricht, Netherlands Background: Conservative treatments for chronic pain following open inguinal hernia repair are often to no avail. Remedial surgery such as a neurectomy may be considered but success rates are suboptimal. Type of anaesthesia may influence outcome. Aim of the present study was to determine whether remedial surgery for inguinodynia is more successful if performed under spinal anaesthesia compared to general anaesthesia. Methods: Patients who underwent open remedial surgery between 2000 and 2014 in a single centre of expertise on chronic abdominal wall and groin pain syndromes (SolviMa´x) were identified by a database search. Evidence-based confounding patient characteristics and specifics of surgery were extracted from the hospital’s electronic information system. An univariate binary logistic regression analysis identified factors possibly predicting treatment outcome. Significant variables (p B 0.1) were included in a multivariate logistic regression analysis to correct for potential confounders. Success was determined by patient satisfaction as documented in the electronic file. Results: A total of in 339 patients (63 % males, median age 50, range 18–88,) were eligible for study. Surgerywas performed under spinal anaesthesia in 41 %. Overall success rate was 66 %. After correction for confounders, spinal anaesthesia showed a significant positive association with a successful outcome (OR 2.1, 95 % CI 1.2–3.8). This effect was most evident in patients who underwent a neurectomy (OR 2.3, 95 % CI 1.3–4.1). Conclusion: Remedial surgery for chronic postoperative groin pain syndromes is twice as successful if the procedure is performed under spinal anaesthesia. This effect is most evident if a neurectomy is involved.

P186 Local anesthesia in inguinal hernia hernioplasty with sutureless technique: our experience S. Jovanovic, V. Pejcic, N. Filipovic, A. Pavlovoc, B. Jovanovic Center for Minimally Invasive Surgery, CC NIS, Nis, Serbia Objective: Specialized centers use local anesthesia in hernia surgery with concept of 1 day surgery. Local anesthesia represents standards in surgery of inguinal hernia. Objective of this study is presentation of local anesthesia technique in hernia surgery (our experience). Methods: Administrating combination of local anesthetics we active anesthesia of ilioinguinal, iliohipogastric, genitofemoral and outer femoral cutaneous nerve. Anesthetic is given gradually and until circular administration of anesthetic around hernia sack before resection. In period from 2007 until 2015 year (period of 9 years) we operated 1356 patients in local anesthesia, with inguinal hernia, 1132 male and 224 female patients. All patients were treated with one of tension sutureless free techniques (Trabucco technique). All patients had antibiotic prophylaxis (Cephasoline 2.0 g I.V.). We analyzed: operating time, intraoperative and postoperative complications,

S229 hospitalization period and time patients need to return to normal activities. Results: Good anesthesia of skin, subcutaneous tissue and all four nerves, provides safe condition for operating aware patients. Possibility to perform ‘‘cough’’ test for verifying adequacy of hernia repair, gives comfort to surgeon and patient. The age of patients was ranging from 28 to 76 years. Average operating time was 35 min (from 25 to 65 min). There wasn’t intraoperative complications. Postoperatively we had 78 hematomas and 29 seromas, which were treated conservatively. All patients were dismissed same or next day. All patients get back to normal activities in 7 days (5–7 days). Conclusions: Reasons such as bad general state, age, bad cardiovascular function, liver disease, kidney failure, good intraoperative comfort of patients and surgeons, and minimal complications, makes local anesthesia the most convenient one in surgery of inguinal hernia with tension free technique.

P187 Local injections for abdominal wall neuralgia in childhood M. Siawash, R.M. Roumen, M.R. Scheltinga Ma´xima Medical Center, Surgery, Veldhoven, Netherlands Background: Anterior Cutaneous Nerve Entrapment Syndrome (ACNES) is characterised by severe neuropathic pain originating from the abdominal wall. Best treatment is neurectomy of the affected nerve. Less successful but also a less invasive intervention is subfascial administration of a local anesthetic or steroids. Aim of the present report is to inform on the outcome of this treatment in children suffering from abdominal pain due to ACNES. Method: Pro- and retrospective observation of treatment outcome and adverse events in children receiving abdominal wall injections during 7 consecutive years at a single center. Results: 108 of the total 114 children were included. Median age was 15 years (range 8–17) and 76 % was female. A single abdominal wall injection using lidocaine was successful in 15 children. Additional 1–3 injections combined with steroids was successful in another 24 children. At median 22 months follow up (range 4–81) an overall success rate of 36 % was found. Age B12 years was associated with success (p \ 0.02). In contrast, physician’s experience, pain localisation, -intensity or delay in diagnosis as well as gender did not affect treatment outcome. Conclusion: Subfascial injections using a local anesthetic and steroids can avert surgery in one of three children with chronic abdominal pain due to ACNES.

P188 Open inguinal sutureless hernia repair with a novel preformed folded polypropylene mesh M. Uccelli, S. Olmi, G. Cesana, F. Ciccarese, V. Reggiani, G. Castello, R. Giorgi, G. Legnani San Marco Hospital, General Surgery Department, General Surgery Department, Zingonia (BG), Italy Background: Lichtenstein tension-free hernioplasty began in 1984, and it become the standard technique since the last decade of the past century. In contrast to recurrence, chronic pain has been reported in high rates varying from 0 to 63 %. The aim of this retrospective study was to compare the outcome after open inguinal sutureless hernia repair with a new type of mesh (Angiologica Folded Mesh) with

123

S230 respect to postoperative course, complications, and postoperative chronic pain. Methods: Between 01/2002 and 01/2014 all patients scheduled for open monolateral inguinal hernia repair undergo to open groin hernia repair with Angiologica Folded Mesh. This mesh has a dual preformed reinforcement that allows easy use and easy positioning, with sutureless technique. We enrolled a total of 850 patients. Patients were discharged the day of surgery. Day tenth was done outpatient visit. Subsequent examinations: 1-3-6-12-24 months. Results: Average time: 40 ± 16 min (range 15–60 min), in absence of intra and postoperative complications. Study population is predominantly male (95.91 %); mean age: 68.50 ± 13.45 years. With a complete follow-up of 24 months, we recorded 16/850 recurrences (1.88 %), 22/850 hematoma (2.59 %), 26/850 seroma or scrotal ecchymosis (3.06 %), 4/850 chronic inguinal pain (0.47 %). Conclusions: Since reported recurrence rates have declined to 1–2 % during the last decades, more interest has been focused on chronic groin pain after inguinal hernia repair, that has been reported in high rates varying from 0 to 63 %. Although not yet fully confirmed, remaining mesh and fixation material with excessive scarring, or nerve injuries due to surgical exploration and entrapment by sutures or clips, have also been suggested as possible explanations. Our results demonstrates the feasibility and effectiveness of sutureless inguinal hernia repair with a particular type of mesh, associated with an improvement in the incidence of chronic pain and a comparable recurrence rate.

P189 Prevention from neuralgia following inguinal hernia repair: What should we know? M.N. Narita, K.M. Moriyoshi, K.H. Hanada, R.M. Matsusue, H.H. Hata, T.Y. Yamaguchi, T.O. Otani, I.I. Ikai National Hospital Organization, Kyoto Medical Center, Surgery, Kyoto, Japan Background: Postoperative neuralgia after inguinal hernia repair can be managed with conservative therapy in most cases, while it sometimes becomes chronic and refractory to treatment. The aim of this study is to discuss what we should know to prevent from neuralgia from the pathological point of view. Methods: In the present study, pathological specimens were obtained from two surgical cases with refractory neuralgia. Case 1 is a 43-yearold male with persistent inguinal and testicular pain who underwent triple neurectomy and mesh removal. Case 2 is a 73-year-old male patient with persistent right orchialgia who underwent triple neurectomy, mesh removal, and orchiectomy. Both patients achieved pain free after surgery. Results: Gross appearance of resected specimens in case 1 showed that ilioinguinal nerve (IIN) was entrapped by wrinkled-mesh. Iliohypogastric nerve (IHGN) was considerably thick, which was inadequately resected at previous surgery. The genital branch of the genitofemoral nerve (GBGFN) was intact. In case 2, the wrinkled mesh was integrated with the spermatic cord. Both IIN and IHGN were intact. Microscopically, massive fibrosis due to foreign-body reaction was observed around IIN and GBGFN in case 1 and 2, respectively. Endoneurium of these nerves were compressed by fibrosis. Traumatic neuroma was observed in IHGN of case 1. These findings might lead to chronic neuralgia. There were many nerve bundles beside the vas deference. The wrinkled mesh was situated close to the vas deference and massive fibrosis compressed these nerves, which might be also associated with neuralgia. Conclusions: To prevent from postoperative neuralgia, the following issues are important:

123

Hernia (2016) 20 (Suppl 2):S175–S249 1. Do not put the mesh close to the nerve as much as possible. 2. Injured nerves should be resected adequately. 3. Unnecessary dissection surrounding the vas deference should be avoided. During parietalization, dissection should be performed more to the peritoneum than to the vas deference.

P190 Intraoperative regional anesthesia prevents persistent postsurgical pain onset. Analysis of outpatient procedures at University Hospital Varese (Italy) A.L. Ambrosoli, L. Latham, E. Cocozza, J. Galvanin, I. Ceriani, M. Binda, C. Lanza, S. Cuffari, L. Guzzetti Varese Hospital, Anesthesia and Intensive Care Department, Varese, Italy Background: Inguinal hernia repair (IHR) is a common surgical intervention worldwide. Despite minimal postoperative morbidity, Persistent Postsurgical Pain (PPSP) is still the most common and serious long-term problem after herniorrhaphy that influences patients’ quality of life. The incidence of PPSP after IHR is reported to be approximately 10 % and the data could be underestimated. Methods: We have analysed 151 patients who underwent open groin hernia repair with Mesh that received intraoperative Transversus Abdominal Plane block (TAP) anesthesia. In our clinical practice we inject Levobupivacaine 0.5 % 20 ml between internal oblique and transversus abdominis muscles under ultrasound view to perform TAP block. Oral Paracetamol and Tramadol is given as postoperative analgesia. Our principal endpoint is postoperative pain rate and PPSP onset. We usually register intraoperative data (surgical and anethesiological data), discharge success (discharge criteria), readmission rate and our standard follow up consist of three phone calls: first day, 1 and 3 months after dimission. We have called patients 6 months after the procedure for a phone interview about pain rate. Results: No patients required rescue analgesics in day surgery unit after operating room discharge. During phone interview we asked to the patients the pain value (NRS value) and analgesics consume. We registered ongoing acute pain on first postoperative day in 25 patients (16.5 %), in 12 cases PPSP after 1 and 3 months (7.9 %) and 7 cases at 6 months (4.6 %) of chronic pain. Conclusion: In our analysis we observed an incidence of chronic postoperative pain after IHR lower than previous data (4.6 % vs at least 10 %). The preventing role of regional anaesthesia to diminish the PPSP onset is well documented in recent manuscripts. As PPSP is the first step to generate chronic pain, TAP block, which is an effective analgesic procedure, could be the real key to prevent chronic pain.

P191 The controversial role of lidocaine patch treatment in neuropathic pain developed after open groin hernia repair; analysis of our early data L. Guzzetti, E. Cocozza, L. Latham, L. Ungari, S. Binda, M. Binda, M. Sambuco, M. Oggioni, G. Selmo, A.L. Ambrosoli Varese Hospital, Anesthesia and Intensive Care Department, Varese, Italy Background: After groin hernia repair 10 to 20 % of patients develop neuropathic chronic pain and its management results in a postoperative challenge. In WHO drugs list for neuropathic pain treatment, topical lidocaine is included as second- line drug classes and some individual studies reveal its effective pain-relief rule.

Hernia (2016) 20 (Suppl 2):S175–S249 Material: In our University Hospital in Varese ITALY we perform at least 200 outpatient open groin repair annually. We have created a registry to analyze the development of postoperative chronic neuropathic pain (assessment through pain detect scale) and we have developed a systematic multidrug pain approach including lidocaine patch. Results: Seven patients, from March to October 2015, described a neuropathic pain with a pain detect value major to 13. These patients received lidocaine patch therapy at incision site plus vitamin B and pregabalin for 2 weeks. Four patients had a complete pain regression, one developed a controlled nociceptive pain and two had not pain improvement. Conclusion: Our clinical experience support the lidocaine patch effectiveness with some exceptions. Recent manuscripts ascribe the differences in treatment success to phenotype type patient. Intraoperative anesthesiological and surgical management are essential factors to investigate in chronic pain onset. Our initial data are inconclusive and a randomized controlled study is necessary.

P192 Chronic pain after inguinal hernia repair: multidisciplinary approach L. Latham, V. Quintodei, G. Borroni, L. Guzzetti, A. Ambrosoli, S. Cuffari, M. Berselli, L. Farassino, L. Livraghi, V. Raveglia, E. Cocozza A.o. di Circolo fondazione Macchi di Varese, General surgery, Varese, Italy Background: Chronic pain (CP) is defined as pain lasting more than 3 months after surgery and represent an important complications occurring after inguinal hernia repair. CP following herniorrhaphy is related to several factors as preemptive analgesia, type of anesthesia, preservation of nerves, entrapment of the ilioinguinal, iliohypogastric or genital branch of the genitofemoral nerve in sutures, mesh or scar tissue. We ideate a protocol to identify and treat CP. Methods: Working group, composed by surgeons and anesthesiologists, evaluate quality of CP before surgery and after 1 week, 1, 6 and 12 months using Visual Analogue Scale and the Pain Detect questionnaire which analyse intensity, course and radiating of pain, presence and perceived severity of seven somatosensory symptoms of neuropathic pain. For diagnostic purposes, an algorithm is used to calculate a score ranging from 0 to 38 based on the answers. Results: Based on score results’ we distinguish patients in two branches. In case of score [13 we start the application of lidocaine 5 % patch for 2 weeks; if pain persists acetaminophen 1 g twice a day and pregabalin 75 mg are associated. If the score is less than 13 we suggest an association of acetaminophen (1 g, 3 times a day) and ketoprofen (80 mg, twice a day) for 1 week; if there’s no answer acetaminophen is replaced by tapentadol (50 mg, twice a day) for 3 days; it can be increased till 100 mg every 12 h. Nonresponder patients, after 1 months of therapy, required interventional procedure as ultrasound-guided ilioinguinal and iliohypogastric nerves block potentially associated with genitofemoral nerve block. Conclusions: CP following herniorrhaphy is an important surgical aspects due to the benign characteristics of the disease. In order to decrease this post-operative condition a multidisciplinary approach, including surgeons ad anesthesiologists, is suggest.

S231

P193 Post-operative pain with ventral hernia hernioplasty: tension-free vs tension techniques S. Dencic, A. Lilic, N. Velickovic, S. Ilic, B. Ciric, S. Velkov, Z. Todorovic General Hospital Pirot, Department of General Surgery, Pirot, Serbia Introduction: Medicine is a science that is constantly changing and whose history is a constant struggle against the disease, pain and suffering. Methods: A retrospective study, we analyzed the results of 50 consecutive tension-free hernioplasty (TFH) and 50 tension hernioplasty (TH) ventral hernias. The patients we sent a questionnaire regarding operational outcomes, including: the duration and intensity of pain VAS, the duration of the temporary inability to work and complications. Results: The pain score of 0 to 2 on a scale of 0 to 10: (A) TFH group—56 % during the first postoperative week, 72 % during the second week, 90 % in the third week, 95 % at week, after the fifth week—chronic pain in one patient, 2.3 %; (B) TH group—41 % in the first postoperative week, 64 % in the second week, 77 % in the third week, 90 % in the fourth week, after the fifth week—chronic pain in 2 patients, 5.1 %. Average time of temporary inability to work was 16 days (7 to 34) in the TFH group and 28 days (14 to 45). Major complications: TFH—removal mesh due to chronic cutaneous fistula in one patient. Minor complications: TFH—minimal infection welded line, in 3 patients; TH—minimal infection welded line, in 5 patients, and urinary retention, in one patient. Conclusion: Tension-free hernioplasty with the use of prosthetic material, on the basis of our experience, successful in relation to the tension techniques, the advantages are evident: less intense and shorter lasting postoperative pain, shorter hospitalization, less convalescent period, fewer complications. On the basis of this conclusion, we can say that the tension-free hernioplasty really ‘a friend of the patient’ and increasingly takes the place of tension hernioplastics. If possible, one should prefer laparoscopic repair of double-layer mesh, biomaterial ePTFE (Bi-material Relimesh)’.

P194 12-month patient reported outcomes following hernia repair with an absorbable fixation device J.A. Redan1, C. Doerhoff2, H. Bougard3, W. Hope4, M. Chudy5, J. Murdoch6, S. Bringman7, P. Jones6 1 Florida Hospital-Celebration Health, Minimally Invasive General Surgery, Celebration, USA, 2Surgicare of Missouri, Department of Surgery, Jefferson City, USA, 3New Somerset Hospital, General Surgery, Cape Town, South Africa, 4New Hanover Regional Medical Center,, Department of Surgery, Wilmington, USA, 5Ayr Hospital, Department of Surgery, Ayr, Scotland, UK, 6Ethicon, A Johnson & Johnson Company, Clinical Development, Edinburgh, UK, 7 Karolinska Institutet, So¨derta¨lje Hospital, Department of Surgery, So¨derta¨lje, Sweden Introduction: Various methods are utilized to enable mesh fixation during hernia repair, including: sutures, mechanical fixation, fibrin sealants and combinations thereof. The 12-month postoperative clinical outcomes following hernia mesh repair with an absorbable fixation device are reported.

123

S232 Methods: The International Hernia Mesh Registry is a prospective multi-center registry, sponsored by ETHICON, designed to collect patient reported, longitudinal data on hernia mesh products and fixation methods. Data collection includes baseline characteristics, perioperative details and adverse events. Patients complete Carolinas Comfort Scale[TRADEMARK] (CCS), quality of life questionnaire specific to hernia repair at baseline to 24-months post-operatively. Data was analysed using 12 month outcomes for hernia mesh repairs with ETHICON SECURESTRAP Absorbable Strap Fixation Device (Somerville, NJ). Statistical significance using McNemar’s test was denoted as p B 0.05. Results: Patients (n = 188) were enrolled at 16 sites, of these 77 have 12 month data. Mean [SD] age 53.9 [13.5] years and mean [SD] BMI 32.7 [7.4] kg/m2. Higher proportion of patients were female (52.3 %). Smoking history was self-reported: current 21.9 %; previous 31.4 %. Main hernia types (%): incisional/ventral (60.1 %), umbilical (17.0 %), epigastric (7.4 %), trocar (3.7 %). Most cases were laparoscopic (97.9 %), 82.4 % were primary repairs. All procedures utilised general anaesthesia. Median length of hospital stay (range) of 1 (0–8) night. Fixation methods used (%): mechanical fixation only (46.8 %); mechanical fixation and sutures (52.1 %); mechanical fixation, sutures, fibrin sealant (1.1 %). Patients with symptomatic CCS pain and movement limitations scores, improved from baseline (70.9 %; 61.1 %) to 12 months (29.9 %; 19.7 %) respectively (p \ 0.001). Seroma was the most common reported adverse event (13.3 %). Eight (5.8 %) patients had hernia recurrence; of these five were medically confirmed. Conclusions: Patients, who underwent hernia mesh repair using the absorbable fixation device, exhibited a statistically significant improvement at 12 months in symptomatic CCS pain and movement limitations compared to baseline. Follow-up continues until 24 months post-surgery.

P195 Endoscopic totally extraperitoneal (TEP) hernia repair for inguinal disruption: rationale and design of a prospective observational cohort study M.M. Roos1, E. Goedhart2, E.J. Verleisdonk1, F. Sanders1, D. Naafs1, C.E. Voorbrood1, J.P. Burgmans1 1 Diakonessenhuis, Chirurgie, Utrecht, Netherlands, 2KNVB, Sportgeneeskunde, Zeist, Netherlands Background: Chronic inguinal pain is a frequently occurring problem in athletes. Inguinal disruption is defined as groin pain when no other obvious pathology exists to explain the symptoms of inguinal pain. Until now, conservative management is considered the primary treatment for this condition. Relevant prospective studies regarding treatment of inguinal disruption are limited; however, recent studies have shown the benefits of the totally extraperitoneal patch (TEP) technique. This study provides a complete assessment of the inguinal area in athletes with chronic inguinal pain before and after treatment with the TEP hernia repair technique. Methods: The study is conducted in a high-volume, single centre hospital with specialty in Totally Endoscopic Preperitoneal (TEP) hernia repair in collaboration with the Sports Medical Centre of the Royal Dutch Football Association (KNVB). Patients over 18 years, suffering from inguinal pain for at least 3 months during or after playing sports whom have not undergone previous inguinal surgery and have received no benefit from physiotherapy and sport rest, are eligible for inclusion. All patients are physically examined and inguinal ultrasound, X-pelvis/hip and MRI are performed. Patients without obvious other causes of groin pain are selected for TEP repair. The primary outcome is pain reduction after 3 months,

123

Hernia (2016) 20 (Suppl 2):S175–S249 measured by a Numeric Rating Scale (NRS). Secondary outcomes are resumption of sport (in frequency and intensity), pain reduction and physical functioning. Results and conclusion: Based on our calculated sample size, 32 patients are needed for inclusion. Up to now, we have included 26 patients. The study is ongoing and the results will be presented at the 38th International Congress of the European Hernia Society.

P196 Postherniotomy pain and the use of targeted spinal cord stimulation: a novel concept in the care continuum of postoperative intractable pain G.B. Bara, G. Matis, A. Chatzikalfas, R. Richter, V. VisserVandewalle, A. Koulousakis University Hospital Cologne, Stereotaxy and Functional Neurosurgery, Cologne, Germany Background: Spinal cord stimulation (SCS), in which mild electrical stimulation is applied to the dorsal columns of the spinal cord, has become a standard treatment option for chronic otherwise intractable neuropathic pain syndromes for meanwhile 40 years. However, some anatomical pain distributions were known to be difficult to cover with traditional spinal cord stimulation due to lack of necessary stimulation induced paraesthesia coverage or stimulation side effects, so in postoherniotomy pain. This has led to the common practice to proceed from local anesthetic infiltration straight to neurectomy, missing less-invasive options completely and resulting in often insufficient pain reduction. With recent technological advancements and the ability to target the dorsal root ganglion (DRG) specifically, neuromodulation has become a viable treatment option in otherwise intractable pain syndromes. Here we present a novel concept of how neurostimulation of the dorsal root ganglia could benefit and support the care continuum of post-herniotomy pain patients. Methods: Patients with groin pain due a variety of etiologies but most commonly post-herniorrhaphy underwent trial therapy across multiple centers where specifically designed leads were implanted at the target DRGs between T12 and L4. Patients who had a successful trial ([50 % improvement) received the fully implantable neuromodulation system. Pain scores were captured on a visual analog scale (VAS) at baseline and at regular follow-up visits. Results: 43 patients trialed, 39 (90.6 %) had a successful trial and received fully implantable neurostimulators. At follow-up (mean: 26 weeks; SD: 21), 31 of 39 patients (79.5 %) had [50 % pain reduction. Conclusion: DRG stimulation is a viable treatment option for chronic postherniotomy pain, minimal invasive, allowing the retention of neural anatomy unlike destructive interventions. This aligns the care continuum for post-herniorrhaphy pain with best-practice guidelines. It is expected that cross-disciplinary awareness for non-surgical pain management options will contribute to better clinical outcomes.

P198 Desmoid tumors during pregnancy: A review of two cases M. Kraft, I. Tapiolas, C. Semeraro, S. Bergamini, M. Armengol, M. Lo´pez University Hospital Vall d’Hebron, General and Abdominal Surgery, Barcelona, Spain Desmoid tumors (DT) are uncommon soft-tissue tumors. Despite they are histologically benign the natural history of DT is poorly

Hernia (2016) 20 (Suppl 2):S175–S249 understood and they could have aggressive local invasive growth and a high recurrence rate after resection. On the other hand, growth stabilization or even spontaneous regression has been described. Moreover, surgery has been related with increased incidence of recurrences. Management of pregnancy-associated desmoid tumors (PADT) is not well defined too. We present two cases of PADTs with different approaches. In the first case a 33 years old women presented a 8x6x4,5 cm mass in contact with the left rectus abdominis muscle at 12th gestation week. A voluntary scheduled abortion was performed and a resection with abdominal wall reconstruction with retromuscular and prefascial polypropylene meshes was realized. The second case is about a 32 years old woman who during her pregnancy follow up was diagnosed of abdominal wall DT and a wait and see strategy was made. The patient gave birth without complications. Different strategies could be done after a complete patient information about natural history and therapeutic options of this kind of tumors. This allows a share decision making process.

P199 Prophylactic negative pressure wound therapy to reduce the risk of surgical site infections. A systematic review and meta-analysis F.E.E. de Vries1, E.D. Wallert1, J.S. Solomkin2, B. Allegranzi3, M. Egger4, E.P. Dellinger5, M.A. Boermeester1 1 Academic Medical Center, Surgery, Amsterdam, Netherlands, 2 University of Cincinnati College of Medicine, Surgery, Cincinnati, USA, 3World Health Organization, Health Systems and Innovation, Geneva, Switzerland, 4University of Bern, Institute of Social and Preventive medic, Bern, Switzerland, 5University of Washington, Surgery, Seattle, USA Background: First introduced in orthopaedic surgery in 2006, prophylactic negative pressure wound therapy (NPWT) has been suggested as a new method to prevent wound complications, specifically surgical site infections (SSI) by its application on a closed incisional wound. Methods: This review was conducted in line with the development of the Global Guidelines for prevention of surgical site infections commissioned by World Health Organisation (WHO) in Geneva. Pubmed, Embase, CENTRAL, Cinahl, World Health Organisation database and African Index Medicus between 01-01-1990 and 07-102015 were searched. Inclusion criteria were randomized controlled trials and observational studies comparing prophylactic NPWT with conventional wound dressings and reporting on the incidence of SSI. Meta-analyses were performed with a random effect model. Results: Nineteen articles describing 21 studies (6 RCTs and 15 observational) were included. We found 9 studies on abdominal surgery of which four involved ventral hernia repair surgery, six studies on orthopaedic or trauma surgery, two studies on cardiac surgery and two studies on vascular surgery. One study included both abdominal and breast surgery. Either dry gauze, conventional-, occlusive- or absorbent dressings were used in the control group. Summary estimate showed a significant benefit of prophylactic NPWT over standard wound dressings in reducing surgical site infections in both RCTs and observational studies, respectively OR 0.56 (95 % CI 0.32–0.96), p = 0.04 and OR 0.30 (95 % CI 0.21–0.41), p \ 0.00001. A subgroup meta-analysis of nine observational studies in abdominal surgery including ventral hernia repair also revealed a significant benefit of pNPWT (OR 0.31(95 % CI 0.19–0.49), p B 0.00001). Conclusion: Prophylactic NPWT seems a promising solution to prevent SSI. More randomized controlled trials are needed to identify the group of patients in who pNPWT is cost-effective. This answers is

S233 most likely to be found in patients at high risk of surgical site infections due to contamination or patient characteristics.

P200 Wound-VAC assisted delayed primary closure (DPC) in the contaminated field S. Groene, S.W.R. Samuel Ross, B.O. Bindhu Oommen, M.K. Mimi Kim, T. Prasad, A. Lincourt, R.F.S. Ronald Sing, S.G. Stanley Getz, B.T. Heniford, V. Augenstein Carolinas Medical Center, Department of Surgery, Charlotte, USA Introduction: Determining the best way to manage skin and subcutaneous tissue closure in contaminated surgical procedures plays an important role in postoperative outcomes yet it has been poorly studied. The objective was to evaluate the outcomes of patients who underwent DPC at our institution. Methods: Review of our institutional surgical database as well as retrospective chart review for patients undergoing DPC from 2012-June 2015 was performed. Patient demographics, operative characteristics, complications and charges were analyzed using standard statistical methods. Results: Thirty-nine patients underwent DPC. The mean age was 55.6 ± 12.4 years, BMI 33.2 ± 9.4 kg/m2, and 56.4 % were female. The mean number of comorbidities was 4.4 ± 2.4, with hypertension (71.8 %), tobacco use (23.1 %), diabetes (20.5 %), and morbid obesity (18.0 %) being the most prevalent. Majority of the patients had infected mesh (61.5 %), 30.8 % had a fistula and 12.8 % had an ostomy involved at the time of their hernia repair. Eighteen (46.2 %) received antibiotics preoperatively. The majority (59.0 %) had a clean-contaminated wound, while 38.5 % had dirty wounds. There was a mean of 5.3 ± 1.4 days of VAC therapy before DPC. The rate of wound complication was 18.0 %; 10.3 % developed a seroma. Total OR costs were $26,187 ± 9788. Overall, 6 patients (15.4 %) required re-opening of the wound and outpatient VAC use. These 6 patients were more obese (43.5 ± 12.1 vs 31.3 ± 7.6 kg/m2; p = 0.03) and had significantly higher OR costs ($24,636 ± 9809 vs 34,723 ± 3004; p = 0.003) Although the rates of diabetes (33.3 vs 18.1 %) and tobacco use (33.3 vs 21.2 %) were higher, they did not reach statistical significance. Conclusion: DPC with wound-VAC assistance was successful for closing clean-contaminated and dirty wounds in 85 % of patients; therefore, it should be strongly considered as an option to decrease long term wound care and risk of primary closure. Morbidly obese patients have a higher risk of failure.

P201 Diaphragmatic herniation of abdominal contents: a rare postoperative complication J. Raakow, J. Schulte-Ma¨ter, M. Biebl, M. Kilian, J. Pratschke Charite´-Universitaetsmedizin Berlin, Department of General, Visceral, Vascular and Thoracic Surgery, Berlin, Germany Background: Diaphragmatic hernias are divided into congenital and acquired hernias, most of which are congenital. An Enterothorax with herniation of abdominal contents through a diaphragmatic defect is a rare postoperative complication. Diaphragmatic herniation is either an early postoperative event or it can occur after several months or even years. When it is acute, emergency laparotomy is mandatory to prevent bowel obstruction or strangulation. The aim of the present study was to describe a larger case series and therapy-relevant features of a rare postoperative complication.

123

S234 Methods: A retrospective analysis of all patients undergoing an operative therapy due to a postoperative Enterothorax at a single center was performed. Especially the time of occurrence of clinical symptoms, surgical therapy and post-operative morbidity were analyzed. Results: Between March 2007 and October 2014 twenty patients presented with a postoperative Enterothorax. In 6 cases (30 %) the diaphragmatic herniation occured within the early postoperative course, in 14 patients (70 %) the diagnosis was made delayed, in the mean 42 months after the primary operation. Patients mainly present with abdominal pain or dyspnea. For diagnosis, a computed tomography was performed in 70 % (n = 14), a thoracic radiograph in 30 % (n = 6), an immediate laparotomy in 15 % (n = 3) of the cases. The diaphragmatic defect involved the left side in 75 % of cases (n = 15). The closure oft the defect was achieved with primary suture in 70 % of the patients (n = 14), in six patients (30 %) a mesh augmentation was necessary. The postoperative morbidity was 60 %. Conclusion: A postoperative diaphragmatic hernia with an Enterothorax is a rare complication and it can occur early after the primary operation or even after several months or years. Surgical treatment should be performed promptly even in asymptomatic forms to avoid further complications like bowel obstruction or strangulation.

P202 Hernia surgery in CAPD patients: No need to switch to hemodialysis F.X. Felberbauer, G. Prager Medical University of Vienna, Department of Surgery, Vienna, Austria Background: Continuous Ambulatory Peritoneal Dialysis (CAPD) patients are prone to the development of abdominal wall hernias. In addition to the effects of uremia, this is mainly due to increased intraperitoneal pressure during CAPD. Therefore any nephrologists still favor switching to hemodialysis for several weeks after hernia repair in CAPD patients. This strategy, however, may induce additional complications such as catheter sepsis and hematomas. At the Medical University of Vienna, we developed a regimen of continuing CAPD perioperatively in 2008. This regimen included careful pre-operative exclusion of peritoneal infection, high frequency and low-volume in-patient CAPD sessions and special attention to normal albumin levels. Methods: In this study, we compare 38 (30 male, 8 female) CAPD patients who underwent repair before from 2001 to 2007 under hemodialysis with 42 (38 male, 4 female) patients operated under the modified CAPD regimen since 2007. The 38 patients before 2008 displayed 46 hernias (38 inguinal, four bilateral, and 8 umbilical) whereas the 42 operated after 2008 had 36 inguinal (three bilateral) and 6 umbilical hernias (including one strangulated Richter hernia). The preponderance of inguinal hernias in this study is due to their higher risk of incarceration. The 38 hernia patients before 2008 underwent hemodialysis via a large-bore central venous catheter up to 8 weeks after surgery. Under antibiotic prophylaxis, open repair was done in all patients using a prosthesis in all inguinal and umbilical hernias [4 cm. Results: In patients switched to hemodialysis, three recurrencies (one inguinal and two umbilical) were observed, in CAPD patients, two umbilical hernias recurred (p = 0.3). Four hematomas were drained in hemodialysis patients, no complication was seen under the CAPD regimen (p = 0.05). Discussion: In this study comparing Peritoneal can safely be taken up again shortly after hernia surgery without increase in recurrencies and with a significantly lower complication rate.

123

Hernia (2016) 20 (Suppl 2):S175–S249

P203 Trabucco technique in complex inguinal hernia M.A. Miguel Aguirre Irma Lourdes Tzanetatos, Surgery, Panama Background: Many surgical techniques for the inguinal hernia repair are nowadays performed with or without the use of meshes. Since Lichtenstein introduced the tension free repair, this has been the approach for most surgeons in this surgery. In 1995, Dr. Ermanno Trabucco introduced the sutureless inguinal hernioplasty, by placing the mesh without suture into the ‘Inguinal Box’. This technique is standardized, easy to learn and to reproduce in all patients. In Latin America we have patients with big inguinal hernias mainly due to very long waiting lists. In our hospital, we introduced the Trabucco’s technique in 2013, and we are now able to perform this surgery in all our patients with excellent results. Methods: The video reports the case of a 45 years old patient with right inguinal hernia lasting 4 years of evolution. According to the Nyhus classification the patients hernia can be classified as type III (direct hernia with destroyed floor of the inguinal canal). As described by the Trabucco technique, the sac is freed and reduced into the peritoneal cavity. The floor of the inguinal canal is reconstructed with a polyglactin running suture and a preshaped mesh Herniamesh Hertra6 is placed as a ‘sandwich’ of three layers (the external oblique muscle fascia, the same mesh and the transversalis fascia) leaving the spermatic cord above the external oblique fascia, in the subcutaneous tissue. Results: The patient was discharged the same day of surgery with satisfactory results. In 6 months of postsurgical follow-up there was no recurrence. The pain control and the recovery were optimal. Conclusion: In our Country we handle many cases of patients with big and complex inguinal hernias. In these patients we can use the Trabucco’s technique, that combines the tension-free and the sutureless principles with very good results.

P204 Best clinical outcome and cost-effective anesthetic technique for resident training in open inguinal hernia repair: a randomized controlled trial B. Nuntasunti, T. Akaraviputh, C. Phalanusitthepha Siriraj Hospital, Minimally Invasive Surgery Unit, Department of Surgery, Bangkok, Thailand Background: Open inguinal hernioplasty is a requirement in surgical resident training program. However, the procedure may increase operative time (OT), require more anesthetic drug, cause more postoperative complications and add cost, leading to lower patient satisfaction. Methods: A randomized controlled trial of different anesthetic methods in open hernioplasty was conducted. The procedure was performed by surgical residents under staff supervision. Clinical outcome, anesthetic technique, patient satisfaction and cost-effectiveness were analyzed. Results: Seventy- five cases of open inguinal hernioplasty were randomly divided into three groups: 25 general anesthesia (GA), 27 spinal blocks (SB) and 23 local anesthesia (LA). The post-operative pain, total post-operative opioids use and hospital stay were not different. But the patient satisfaction in LA group was significantly lower than the others (p \ 0.05). The average operative cost of LA group (440.61 $) was significantly lower than SB (509.47 $) and GA group (633.54 $). Minor complications were equally found in all groups while none revealed either mortality or major complication.

Hernia (2016) 20 (Suppl 2):S175–S249 Conclusion: All anesthetic techniques can be practically applied in hernioplasty. Interestingly, while LA has lower patient satisfaction with the lowest cost SB is the most cost-effective method due to its low cost and high patient satisfaction.

P205 Transmesosigmoid hernia: a case report K.Y. Kumata Teikyo University Hospital, Surgery, Tokyo, Japan A 41-year-old man with no history of prior surgery presented with the chief complaint of abdominal pain at another hospital. Plain computed tomography (CT) of the abdomen revealed marked distension of the stomach, and thus, duodenal stenosis was suspected, and conservative treatment was initiated with insertion of a nasogastric tube. Fever and vomiting subsequently appeared on hospital day 3. Because plain CT of the abdomen revealed extensive distension of the small intestine, an ileus tube was inserted. Despite this, a further rise in body temperature and symptoms of peritoneal irritation were observed on the same day; strangulated ileus was suspected, and therefore, the patient was transferred to our hospital. CT results indicated marked distension of the small intestine continuing from the stomach. Ascites was also observed, and it was noted that the pelvic small intestine had been collapsed. Fever and symptoms of peritoneal irritation were also observed, and we decided to perform emergency surgery because strangulated ileus was suspected. Exploratory laparotomy of the peritoneal cavity revealed that the small intestine protruded through a hiatus of the sigmoid mesocolon, and the patient was diagnosed with small intestine ileus because of incarcerated internal hernia of the same site. Because none of the findings indicated intestinal necrosis of the incarcerated small intestine, intestinal resection was not performed. Surgery was concluded with release of the incarceration and closure of the hiatus. The patient progressed well after surgery and was discharged on postoperative day 10. We hereby report a relatively rare case of transmesosigmoid hernia together with a brief discussion of the literature.

P206 Cyst of Nuck’s canal, clinic, radiologic and intraoperatory findings P. Anaya-Reig1, P. Garcı´a-Pastor2, S. Pe´rez-Bru1, J.L. MolinaRodriguez1, J. Garcı´a del Can˜o1, M. Dı´az-Tobarra1, A. CarbonellTatay1, V. Casp-Vanaclocha1 1 General H. Onteniente, General surgery, Valencia, Spain, 2La Fe Hospital, Abdominal Wall Surgery Unit. Gral and Di, Valencia, Spain Introduction: Cyst of Nuck’s canal is a rare cause of inguinal swelling in women. This entity should be present in the differential diagnosis of irreducible inguinal or femoral masses in female patients. We present a case report that shows us all the process: clinical suspicion, radiologic diagnosis and surgical findings and correct treatment. Methods: Present an obese 41 years old female, previously operated of right inguinal hernia. She developed a painful swelling in right

S235 groin, below the inguinal scar. Clinically seems a femoral hernia or a serum collection. The US study revealed a cyst of Nuck, immediately below the inguinal scar, measuring 8 9 3 9 4 cm. We completed the study with a CT Scan and Magnetic Resonance Imaging. As the correct treatment is surgery, we did a cyst resection. The patient didn’t present any postoperative problem; in the follow-up 6 months later, she is asymptomatic. Discussion: Cyst of Nuck’s canal was first described by Anto´n Nuck, in ‘‘Adenographı´a curiosa et uteri foeminei anatome nova’’ such a cystic structure with fluid collection inside that could be an evagination of the parietal peritoneum (processus vaginalis) that undergoes obliterated soon after birth. If this obliteration is not completed, causes a cyst. Clinically appears as a fluctuant irreducible mass in the inguinal region. The differential diagnosis includes inguinal-femoral hernia. For diagnosis, US is the choice. In case of doubts, CT scan and MRI can help us. Treatment is surgical excision. Cyst aspiration can be performed in patients who refuse surgery.

P207 Mesh fixation with liquid or viscous cyanoacrylate glues: experimental study in animals P. Garcı´a-Pastor1, A. Poli2 1 University Hospital La Fe, Abdominal Wall Surgery Unit, Valencia, Spain, 2Pisa University, Veterinary Department, Pisa, Italy Introduction: Current studies show the safety and effectiveness of the glue fixation of mesh to repair abdominal wall. We propose to study the behaviour of a liquid and viscous cyanoacrylate-glue when fixing a PVDF mesh through macroscopic, histopatologic and immunohistochemical investigations. Materials and methods: We used 32 white Wistar rats. We made hernia defects in the abdominal wall, which were prepared with PVDF-mesh fixed by a liquid or viscous cyanoacrylate-glue. Subjects were sacrificed at 1, 7, 15 and 30 days post-fixation. Abdominal wall was analyzed to determine mesh integration and tissue reactions. Histopathology. Formalin fixed, paraffin embedded, HaematoxylinEosin stain, Mallory trichrome-stain for connective tissue, Perls-stain for hemosiderin. Morphometric analysis. Semiautomatic system (LAS V4.3 Leica). Three non-overlapping fields from each section using 109 or 209 magnification, 20 counts per field. Statistical analysis using SPSS 21. Immunohistochemistry. Streptavidin–biotin peroxidase method: monoclonal mouse anti-vimentin antibody dilution 1:100, anti-human Ki-67 monoclonal mouse polyclonal antibody dilution 1:100, mouse anti-human CD34 monoclonal 1:50 dilution. Results: Macroscopic. Rare omental adhesions easily reducible in both groups at 15 and 30 days post-implant. Mesh was always found to be adhered to the peritoneum regardless of glue used. Microscopic. Statistically significant differences in favor to liquid glue in terms of: thickness of inflammatory reaction, tissue damage and fibrotic reaction induced by glue; presence of mast-cells, eosinophils, macrophages and fibroblasts in inflammatory reaction induced by glue deposits. Conclusions: Viscous glue induced a stronger inflammatory reaction and fibrosis than liquid glue In early phase, tissue response was perimysial (muscle edema and regressive changes—mast cells and eosinophils infiltrate—) and more severe with viscous glue. Late inflammatory reaction (macrophage infiltration, fibroblastic proliferation) was more severe in viscous glue deposits.

123

S236

P208 Centre Hospitalier du Sedhiou-Senegal: a new place for surgeons in action and hernia international foundations for carrying out humanitarian camps T. Butro´n Vila1, E. Rubio Gonza´lez1, B. Revuelta Alonso2, M.C. Santiago Martin3, M. Fanjul4, J.A. Pascual Montero5, E. Bilbao6, A. Kingnsnorth7, I. Dominguez1, V. Vieiro1, M. Lopez Vizcayno8 1 ‘‘12 de Octubre’’ University Hospital, General and Digestive Surgery, Madrid, Spain, 2Complejo Asistencial Universitario de Leo´n(CAULE), Servicio de Anestesiologia y Reanimacio´n, Leo´N, Spain, 3Hospital Universitario Principe de Asturias, Servicio de Urologia, Alcala´ De Henares, Spain, 4Hospital Universitario Gregorio Maran˜on, Servicio de Cirugı´a Pedia´trica, Madrid, Spain, 5 Clı´nica CEMTRO, Departamento de Cirugı´a, Madrid, Spain, 6 Igualatorio, Departamento de Cirugı´a, Bilbao, Spain, 7Hernia International Foundation, Department of Surgery, Plymouth, UK, 8 Hospital Universitario Clinico S Carlos, Servicio de anestesiologia y Reanimacio´n, Madrid, Spain Background: ‘‘Surgeons in Action’’ and ‘‘Hernia International’’ Foundations in mutual collaboration carry out missions in developing countries to operate patients without resources with abdominal wall pathologies and others. We also teach local professionals to use mosquito net meshes in hernioplasties. The region of Sedhiou (Senegal) has 400,000 inhabitants, and it has only a general surgeon, a gynecologist, and two anaesthetists. We thought this would be a good place for new camps, so we sent a team to find out whether it would be good for camps once or twice every year. Methods: In January 2016 a team of doctors (3 general surgeons, 1 paediatric surgeon, 1 urologist, 1 anaesthetist, 1 gynecologist) went to the Centre Hospitalier Sedhiou during 1 week. It has two operating theaters, one respirator and one diathermic generator. We brought with us two diathermic generators. We arranged three operation tables to operate three patients at a time. All the local professionals were working with us. Results: We operated 74 patients (13 children), 51 males, 23 females with 87 procedures in 6 days. Adults: 37 inguinal hernias (24 right and 13 left, 7 recurrent, 6 bilateral—26 Lichtenstein and 11 Rubcow hernioplasties (all except 7 with mosquito net meshes), 1 umbilical and 6 epigastric hernias; others: 9 hydroceles, 1 bladder-vaginal fistula, 4 lipomas, 1 anal fissure, 8 miomatosis uterus (4 hysterectomies, 3 myomectomies). Children: high ligation of the sac in 1 inguinal hernia, 1 strange body (gauze), high ligation of the sac in 2 hydroceles, herniorrhaphies in 5 umbilical hernias, circumcision in 3 phimosis, orchidopexy in 1 cryptorchidie. The local general surgeon and gynecologist learned to use the mosquito net meshes and operated as first surgeon some patients with inguinal hernia—Lichtenstein hernioplasty. Conclusion: The Centre Hospitalier Sedhiou is suitable for carrying out camps of our foundations.

P209 Learning TEP: what is the real learning curve? O. Ginghina, F. Turcu, N. Iordache Saint John Hospital, Surgical Oncology, Bucharest, Romania Background: Till today limited data exists over the learning curve in TEP approach to inguinal hernia. Methods: We studied 458 cases operated between 1994 till 2011 with a follow up that continued until 2014. Only the first 100 cases per surgeon were included. The analysis was based on 20 cases We

123

Hernia (2016) 20 (Suppl 2):S175–S249 related the target events to the surgeon experience—first 20 cases, following 20 cases and so on. Results: Conversion rate was 2.4 and recurrence rate was 1.9 %. Following the first 60 cases the complication rate decreased dramatically. Also the first surgeons starting to perform TEP in the 90’s, had a longer time to perform the first 60 cases and also more incidents during the period. Conclusions: 60 cases represent a base for a good learning curve in TEP procedure. Also the learning curve is easier to overcome if you start under supervision of trained surgeons.

P210 Changes in the surgical management of parastomal hernias over 15 years: Results of 135 cases G. Ko¨hler1, F. Mayer2, H. Wundsam1, R. Schrittwieser3, K. Emmanuel1, M. Lechner2 1 BHS Linz, General and Visceral Surgery, Linz, Austria, 2PMU University Salzburg, Surgery, Salzburg, Austria, 3LKH Bruck a.d. Mur, Surgery, Bruck A.D. Mur, Austria Background: Over the years, various open and laparoscopic approaches toward the repair of parastomal hernias (PSH) have been described. The variety of published techniques itself can be seen as an indicator for the often low level of satisfaction reached with the surgical procedures. Methods: From January 1999 to January 2014, we assessed all cases of PSH repair performed at the three participating surgical departments in a retrospective analysis. The results were evaluated with regard to different surgical techniques focusing on complications and recurrences. Results: One hundred and thirty-five individuals could be included in the analysis. They were operated on with eight different surgical techniques. Laparoscopic procedures were carried out in 46.7 % (63/135) of the cases. Median follow-up was 54 months (12–146 months). We found 44 cases of recurrence (32.6 %) and 24 (17.8 %) of the patients experienced perioperative complications and 12 of them needed to return to theater. Fourteen of the 135 patients (10.4 %) were operated as emergency cases which were associated with a mortality of 28.6 % (4/14). In case of elective PSH repair, no mortality occured. Conclusion: The results achieved by direct suture or the use of incised flat meshes for the repair of PSH were poor with these procedures having unacceptably high recurrence rates. With regard to the latter ostomy revision through three-dimensional funnel-shaped meshes and the laparoscopic sandwich technique showed the best results. Emergency procedures were linked to a dramatic increase in morbidity and mortality (p \ 0.001).

P211 Outcome analysis of light weight large pore polypropylene mesh in complex open ventral hernia in clean contaminated and contaminated fields J.I. Jorge Barreiro1, I. Garcia Bear1, A. Rodriguez Infante1, N. Gutierrez Corral1, G. Minguez Ruiz1, V. Sanchez Turrion2 1 San Agustin, general surgery, Aviles, Spain, 2Hospital Puerta de Hierro, General Surgery, Madrid, Sri Lanka Background: There is no consensus for a reinforcing mesh material in complicated open VH. Have suggested that open VH repairs utilizing bio-prosthetic mesh in clean contaminated and contaminated

Hernia (2016) 20 (Suppl 2):S175–S249 fields may have hernia recurrence rates of more than 30 %. The use of light weight, large pore (LWLP) polypropylene mesh may be considered an alternative. We aimed to analyze the outcome of implanting LWLP mesh in the pre-peritoneal space for OVH repairs in clean contaminated and contaminated fields. Methods: We retrospectively examined. Patients with OVH repair and component muscle separation with al least 1500 cm2 of LWLP polypropylene mesh in the pre-peritoneal space that were clean contaminated and contaminated were included. Outcome parameters included length of hospital stay, surgical site occurrence, mesh removal, and hernia recurrence. Results: 77 patients (33 male, 44 female) with a mean age of 62 ± 16 years and a body mass index (BMI) of 39 ± 15 kg/m2 were evaluated. There were 47 clean contaminated and 30 contaminated patients. Mean hospital stay was 10 ± 5 and 9 ± 11 days respectively. There were a total of 33 (42 %) surgical site occurrences in the 30 day post-operative period for a clean contaminated group and 11 (33 %) for the contaminated group. No mesh removal and no hernia recurrences were noted during the follow up of 30 ± 10 months for both groups. Conclusion: Interestingly, BMI was more predictive of surgical site occurrence than mesh placement in a contaminated field, p \ 0.05. Early analysis of LWLP polypropylene mesh is favorable, not justify its use of the bio-prosthetic mesh.

P212 The modified Chevrel method for large ventral incisional hernia repair: long term results and critical appraisal of literature E.H.H. Mommers1, B. Leenders2, W.K.G. Leclercq2, S.W. Nienhuijs3, T.S. de Vries-Reilingh1, J.A. Charbon2 1 Elkerliek Hospital, Surgery, Helmond, Netherlands, 2Ma´xima Medical Center, Surgery, Veldhoven, Netherlands, 3Catharina Hospital, Surgery, Eindhoven, Netherlands Purpose: Evaluate the short and long-term results after the modified Chevrel technique (onlay) for midline incisional hernia repair regarding surgical technique, hospital stay, wound complications, postoperative quality of life, and recurrence rate. These results will be compared to literature derived reference values regarding the original and modified Chevrel techniques. Methods: In this large retrospective, single surgeon (J.C), single institution (Maxima Medical Centre) cohort all modified Chevrel hernia repairs between 2000 and 2012 were identified. Results were evaluated by reviewing patients medical charts. Postoperative qualityof-life was prospectively measured using the Carolina Comfort Scale. A literature review of PubMed and Embase was conducted to compare the results of our series to literature based reference values. Results: 158 patients (86 male) were identified for follow-up. 58 % percent were large incisional hernia’s according the definition of the European Hernia Society. 16 patients (10 %) underwent a concomitant procedure. Of the 142 patients without concomitant procedures 34 patients had a mild Clavien Dindo 1–2 postoperative complication within 30 days, only three patients had a severe (CD 3–4) postoperative complication. Wound complications rate was 18 % (28 patients), however 15 of these patients had a small seroma that was treated conservatively or with needle aspiration. Median length-ofstay was 5 days. There was no mortality within 30 days. Recurrence rate was only 2 % after median follow-up of 51 months (113 patients, follow-up of 12–128 months). Postoperative quality-of-life was excellent (7/115 Carolina Comfort Scale). Conclusions: The modified Chevrel method for midline ventral hernias proves a reliable repair with remarkably few recurrences and excellent postoperative quality-of-life.

S237

P213 Should hernia repair and panniculectomy be performed concomitantly: A systematic meta-analysis of outcomes performed at single institutions M.A. Lanni, M.G. Tecce, V. Shubinets, S.J. Kovach, J.P. Fischer University of Pennsylvania, Division of Plastic Surgery, Department of Surgery, Philadelphia, USA Purpose: Over one-quarter of adults in the U.S. identify as obese. Morbid obesity increases risk for hernia after abdominal surgery with an incidence as high as 25 % and a recurrence rate greater than 20 %. Current literature supports hernia repair (HR) with panniculectomy (PAN) both concomitantly and as separate procedures. The purpose of this systematic review and meta-analysis is to compare outcomes of HR with and without PAN. Methods: A comprehensive literature search was conducted using several online databases for MeSH terms ‘‘hernia’’, ‘‘herniorrhaphy’’, ‘‘hernia repair’’, ‘‘abdominoplasty’’ and/or ‘‘panniculectomy’’ yielding 1,412 papers. These results were reviewed to include prospective and retrospective studies performed at single institutions. The primary outcomes of interest included reoperation, hernia recurrence, length of stay, infection, fluid collection, and wound complications. Results: Four studies involving 172 patients were included with 75 patients receiving HR and 97 patients receiving HR and PAN. Wound complications were higher with HRPAN as opposed to HR alone (p \ 0.001), as was the reoperation rate (p = 0.041). There were no differences in reported hernia recurrence (p = 0.97) or length of stay (p = 0.239). Conclusion: The results of our meta-analysis support the notion that likelihood of wound complications and reoperation is higher with HRPAN, while hernia recurrence remains the same regardless of procedure. The amount of data available on the subject is both limited and conflicting with a lack of standardized outcome reporting parameters which make comparisons difficult or impossible in many instances. Future studies should contain clear language that defines what variables are included in outcomes.

P214 Mesh fixation in abdominal wall reconstruction using fibrin or cyanoacrylate glue G. Woeste, A. Reinisch, U. Pession, W.O. Bechstein University Frankfurt, Department of Surgery, Frankfurt, Germany Background: The use of mesh is mandatory in abdominal wall reconstruction for treatment of incisional hernias. For large meshes fixation is standard of care. Different fixation techniques are used depending on the positioning of the mesh and the type of material. In this retrospective analysis of a prospective data collection we analyzed two different mesh fixations using either fibrin glue or cyanoacrylate glue. Methods: From 4/2015 to 1/2016 we performed 24 open repairs of midline incisional hernias using glue fixation. The size of the hernias was W1 (3/24), W2 (10/24), W3 (11/24) according to the EHS classification. The technique used for hernias repair included component separation (CS) in 16/24 cases with transversus abdominis release (TAR) in 14/24 (58.3 %), anterior CS according to Ramirez in 1/24 (4.2 %) and Rives-Stoppa in 9/24 (37.5 %). In all cases the midline was closed and a synthetic mesh was used: 18 Soft Mesh (Bard), 4 Optilene (BBraun), 3 Ultrapro (Ethicon). The mesh was placed in the retromuscular space. For fixation of the mesh glue was used in all cases, in 13/24 (54.2 %) using fibrin glue (Tisseel, Baxter) in 10/24 (441.7 %)

123

S238 cyanoacrylate glue (Histoacryl, BBraun), and in one case a combination with both was used. Results: Postoperative wound complications occurred in 2/24 (8.3 %) patients showing a superficial surgical site infections (SSI). One mesh was removed during relaparotomy due to small bowel leakage. It was replaced in sublay position at the end of the relaparotomy. There was no complication caused by the mesh or the fixation. No early recurrence due to mesh dislocation was observed. Conclusion: Mesh fixation with either fibrin or cyanoacrylate glue is safe for fixation of large pore polypropylene meshes placed in the retromuscular space.

P215 Surgery outcomes after open umbilical hernia repair Z. Demetrashvili, T. Metreveli Tbilisi State Medical University, Surgery, Tbilisi, Georgia Background: Repair of Umbilical hernias in adults is still under consideration. The aim of our study was to compare short and longterm outcome of open Umbilical hernia repair. Methods: We conducted a retrospective study of 59 patients who underwent open Umbilical hernia repair from January 2009 to December 2014. Patients were divided for 2 groups: There were 27 patients in the first group, who underwent hernioplasty without mesh (Mayo procedure); in the second group, there were 32 patients, who underwent hernioplasty with mesh. All of the operations were elective and were performed under general anesthesia. In the second group we used polypropylene mesh. We analyzed the short-term (Surgical Site Infection (SSI) and seroma) and long-term (hernia recurrence) outcomes of surgery. Results: For 59 patients, women were 39 (66.1 %). The average age was 54.7 ± 12.5 years, mean BMI was 28.9 ± 8.1 kg/m2, the average diameter of hernia was 8.7 ± 6.4 . All hernias were primary. There was no difference in SSI between 1st and 2nd groups (3.7 versus 9.9 %, P = 0.62). Seroma was more common in patients, who underwent hernioplasty with a mesh (25 versus 3.7 %, P = 0.03). The hernia recurrence developed in 6 patients (22.2 %), who underwent hernioplasty without mesh, and in 1 patient (3.1 %), who underwent hernioplasty with mesh (P = 0.04). We expressed two opinions about hernia recurrence: (1) The total of seven recurrences, six were patients, who had BMI [ 30 kg/m2; (2) In suture repair group, all of the six patients who developed the recurrence originally had hernias more than 3 cm. Conclusion: Mesh repair has a reduction in recurrence rates compared with suture repairs for primary umbilical hernias, but an increased risk of seroma was observed. Suture repair can be used when the size of umbilical hernia is less than 3 cm. Umbilical hernias, more than 3 cm, needs hernia repair with a mesh.

P216 Polypropylene prosthesis in a composite form as a microenvironment favourable for all cells involved in abdominal wall reconstruction: outcome of 10 years of research G. Muzio, V. Festa, F. Festa, R.A. Canuto University of Turin, Clinical and Biological Sciences, Turin, Italy Background: Repair of abdominal wall is a complex and dynamic process requiring both a framework supporting the reconstruction of extracellular components, and the proliferation/activity of the several types of cells, epithelial, mesothelial and muscle cells, and fibroblasts. The coordinated work of these cells is important in maximizing the

123

Hernia (2016) 20 (Suppl 2):S175–S249 possibility of a successful outcome and reducing recurrences. It is evident that the ability of prosthesis in creating a microenvironment favourable for cellular infiltration is critical for its integration and reconstruction. For these reasons, since 10 years our research aimed to investigate the ability of a polypropylene prosthesis in a composite form in stimulating the growth/activity of cells involved in abdominal wall reconstruction. Methods: CMC prosthesis (Clear Mesh Composite DIPROMED srl Torino -Italy), comprised of two polypropylene layers, one macroporous light meshes (parietal side) and one thin transparent film (visceral side), was used. Human fibroblasts BJ, keratinocytes NCTC 2544, mesothelial cells isolated from omentum specimens (approved protocol by Ethics Committee), and murine muscle myoblasts were seeded on CMC (meshes side) or on film, basing on their natural location in abdominal wall. Cell growth, viability, inflammation mediators, and specific markers of cell activity were examined. Results: Growth evaluation evidenced that all cell types well colonized the CMC side facing abdominal wall, whereas only mesothelial cells increased on film facing viscera. No cell death was observed. Muscle cells well differentiated on side facing abdominal wall, as evidenced by myosin production and myotube formation. A precocious and transient increase of pro-inflammatory molecules occurred. The expression of activity markers was maintained in all cells. Conclusions: The CMC side facing abdominal wall represents a microenvironment able to be colonized by cells, that maintain their physiological activity. Differently, only mesothelial cells grow on side facing viscera, being this very important in favoring peritoneum regeneration, avoiding adherence formation.

P217 A comparative study of the mechanical properties of human abdominal fascial structures M. Anurov, S. Titkova Pirogov Russian National Research Medical University (RNRMU), Experimental surgery, Moscow, Russian Federation Background: Prosthetic hernia repair seeks to restore the anatomy and function of abdominal wall. To achieve this, a modern surgical mesh should closely resembles the fascial structures in properties, so the aim of this study was to investigate the mechanical properties of human anterior and posterior rectus sheaths depending on gender and the direction of stretching. Methods: The samples for the study were collected from 5 male and 5 female cadavers of 30–60 years, not later than 2 days after the death. One strip (60 9 30 mm) of anterior and posterior rectus sheaths along and across the linea alba on both sides were dissected. After stabilization in saline at T + 60 for 3–4 h samples of 25 mm 9 10 mm were cut out. Tensile tests were performed using the ‘TA.XTplus Texture Analyser’ at a speed of 0.2 mm/s until failure. The breaking strength and strain, and the elastic limit and deformation were determined. The modulus of elasticity was calculated as a ratio of elastic limit and deformation. Results: Both sheaths had maximal strength across the linea alba, and the highest elasticity and extensibility along. Breaking strength in perpendicular directions differed more than twice, and moduli of elasticity in 4–7 times. In the corresponding directions the strength and stiffness of the anterior sheath was significantly higher than that of the posterior sheath (from 30 to 60 %). The strength of both sheaths in men in the transverse direction was about 50 % higher than in women, and longitudinally—difference reaches 100 %. Conclusion: When choosing a mesh for particular technique of midline hernia repair marked differences between mechanical properties of fascial structures should be considered. In any technique surgical mesh should have maximum flexibility along the linea alba, and maximum stiffness and strength across.

Hernia (2016) 20 (Suppl 2):S175–S249

P218 TEP approach is the best procedure for spigelian hernia repair when associated to inguinal hernia M. Planells Roig, U. Ponce Villar, F. Peiro, A. Ban˜uls Matoses, N. Krystek, N. Orozco, R. Dietmar, J.M. Bolufer, F. Caro Gandia Hospital, Surgery, Gandia, Spain Background: Spigelian hernia (SH) is nowadays approached through a laparoscopic procedure, although there is still debate on which procedure is better, the laparoscopic transabdominal approach or the totally extraperitoneal approach. TEP approach specially if inguinal hernia is associated to SH has not been reported yet. Objective: We present a patient with bilateral inguinal hernia, one recurrent and the other primary, associated both to a symptomatic SH with recurrent incarceration episodes. Patient and method: A 60 year old male patient presented with a symptomatic, SH with recurrent episodes of abdominal pain and incarceration. During exploration a bilateral inguinal hernia was also diagnosed. He had been operated for unilateral inguinal hernia 3 years before and a Lichtenstein procedure was performed. The CT scan confirmed clinical diagnosis of a right SH with a synchronous right inguinal hernia and left recurrent inguinal hernia. The patient underwent a laparoscopic totally extraperitoneal approach. We first approached the right side and the SH which was easily reduced and dissected. The second step was the right inguinal hernia repair, performed as usual and finally we performed the left inguinal repair, retrieving a plug from the previous surgery. The right side inguinal hernia mesh was large enough to cover the myopectineal area and also the SH defect. Conclusions: Laparoscopic TEP is an excellent procedure for SH treatment and should be the selected procedure in case of inguinal hernia association.

P219 Abdominal wall insufflation used in laparoscopic VHRs impacts acute post-op reinforcement performances: a case study using a physical model T. Belzacq, A. Vegleur, F. Turquier Medtronic, Surgical Innovations, Tre´voux, France Background: In laparoscopic VHRs, meshes are fixed against inflated abdominal walls. Deflation can lead to significant change in initial conformity. An experimental method has been developed to assess mesh fixation distribution at deflated state and evaluate the acute postop reinforcement provided by meshes. Methods: A 20 cm 9 15 cm rectangular mesh has been fixed at 5 mmHg pressure equivalent on the inner surface of an intact calibrated abdominal wall physical model ‘‘AWPM’’. A regular single crown distribution has been implemented with tacks 10 mm away from the edge and 16 mm apart from each other. Mesh/ abdominal wall conformity has been ensured. The tack displacements during deflation have been captured by 2 cameras. Final tack positions have been worked out by a 3D digital image correlation software. The post-op AWPM with mesh has been submitted to tensile tests in longitudinal and transversal directions up to 10 % deformation. Its behavior has been compared to an intact AWPM without mesh. Results: The distance between tacks has decreased from 16 mm at inflated state down to 12 mm at deflated state on average. The mesh has shrunk by 15 and 13 % respectively in longitudinal and transversal directions. No difference has been found in tensile behavior between the AWPMs with and without mesh.

S239 Conclusion: This case study has demonstrated how deflation in laparoscopic VHRs could lead to significant loss of mesh conformity and result in lack of acute post-op reinforcement. In clinical practice, fixing meshes by trans-facial sutures prior to tacking when the abdominal wall is partially deflated could reduce the highlighted phenomena. An assisting system for personalized fixation distribution could also be imagined in the future to optimize laparoscopic VHRs.

P220 Sigmoid obstruction due to spigelian hernia: presentation of a rare case A. Ioannidis Sismanoglion G.H.A., 2nd Surgical Ward, Athens, Greece Background: Spigelian hernia is a relatively rare entity with a wide variation in clinical presentation. Aim: To notify that a rare complication like this may exist and could be life threatening. Material and method: We present a rare case of a complicated Spigel hernia with obstruction of sigmoid colon. Result: The case of a 76 y.o. female patient who presented in the ER complaining about flatulus and a mass on the left lower quadrand of the abdomen. Colonoscopy revealed full obstruction of sigmoid colon and CT noticed a portion of the sigmoid that was trapped in a gap of a Spigelian hernia. During the operation we found a double barrel-like sigmoid trapped in a gap of a left spigelian hernia. The operation and post-operative period had no complications. Conclusion: Spigelian hernia can sometimes cause life-threatening conditions that an experienced surgeon could manage.

P221 The retrospective case analysis and individualized treatment strategy for complex ventral hernia J. Chen, S. Yang, Y.M. Shen Beijing Chao-Yang Hospital, Hernia and Abdominal wall surgery, Beijing, China Background: Ventral hernia is common in clinic. However, the defined standard of complex ventral hernia (CVH) has no consensus in the literature. It usually involves with defect size, location, contaminated/infection risk and comorbidity, etc. The clinical results are varied and treatment is challenge. No single procedure will be suitable for all kinds of CVHs. Methods: A total of 235 cases of CHV admitted in our institution between January 2011 and June 2015 were divided into several subgroups with different procedures. Giant ventral hernia with loss of domain (Group A, n = 43) were performed with prophylactic volume reduction and monitored with intra-abdominal pressure after operation to prevent abdominal compartment syndrome (ACS). Multiple hernias (n = 35) or recurrent hernias (n = 38) in Group B were performed with IPOM. Irreducible/incarcerated hernia (Group C, n = 54) underwent hybrid technique (open plus laparoscope) with part-absorbable meshes to prevent potential infection. Hernia complicated with infection/intestinal fistula (Group D, n = 28) were performed with debridement, and with/without part-absorbable meshes replaced. Hernia located in specific positions (marginal hernia) (Group E, n = 37) were applied with multiple mesh fixation (tacks and sutures). Results: All cases were operated successfully without death and unexpected organ injury. Duration of follow-up ranged from 6 to 40 months. One recurrent hernia (trocar hernia) was occurred in group B, and one recurrence of lumbar hernia developed in group E.

123

S240

Hernia (2016) 20 (Suppl 2):S175–S249

Five cases of wound infection were occurred in group A (n = 2) and group C (n = 3) without mesh infection, all of them recovered after debridement. Hematoma and seroma were 15 cases including 8 in group A, 5 in group B, 2 in group D. All recovered by puncture treatment. Conclusion: Individual therapy strategies for CVH are rational and feasible to prevent and cure the complications.

fixation method used in our department and examine better fixation methods. Two patients in our department underwent additional suture fixation with stomach wall fixtures used for percutaneous endoscopic gastrostomy. No particular postoperative problems with this method have been observed without recurrence. As stomach wall fixtures pose a problem in that they are not covered by health insurance, different methods are currently under consideration.

P222 Spigelian hernia: analysis of personal experience in the management of a rare disease

P224 Influence of primary laparotomy wound closing with synthetic prosthesis on life quality of patients

F.G. Ghiglione, F. Velluti, S. Marola, F. Caciolo, D. Borreca, A. Borasi, P. de Paolis, F. Ghiglione Humanitas Gradenigo Hospital, General surgery, Turin, Italy

B.S. Sukovatykh1, N.M. Valuiskaya1, N.N. Zherdev1, E.V. Gerasimchuk2 1 Kursk State Medical University, General surgery, Kursk, Russian Federation, 2City Clinical Emergency Hospital, General surgery, Kursk, Russian Federation

Objective: Spigelian hernia is a rare abdominal wall defect which arises on the semilunar line laterally of the rectus abdominis muscle. Between 2000 and 2013 we treated 34 patients from Spigelian hernia. We report the technical, surgical findings. Patients and methods: We treated 34 patients, 24 female and 10 male (67 years average age). Most frequently Spigelian hernia was detected on the right side (71 %). In 8 % we discovered other abdominal wall defect susceptible of intervention. The diagnosis was achieved using ultrasound or CT. The surgery was performed in emergency conditions in 15 % and in 95 % we placed preperitoneal polypropylene mesh. In 6 % we had a laparoscopic approach. Results: The mean hospital stay was 2 days, no major complication were reported. At 3 years follow-up only one recurrence were reported in an emergency intervention with no mesh placement possibility. Conclusions: The most frequent presentation is an atypical painful abdominal syndrome. A correct diagnosis of Spigelian hernia is often difficult, the potential complications can be serious and is challenging for the surgeon because requires smart diagnostical ability. There are few references in the literature, the disease involves general practitioners, gastroenterologists, radiologists and surgeons. In our experience ultrasound or CT is useful diagnostic tools. The treatment is surgical, with excellent results. We suggest, when possible, the laparoscopic approach to treat hernia sac and eventual ischemic intestinal tract has proven effective in reducing hospital stay and wound complications. Mesh use improves results in terms of recurrence without increase post operative complication and pain.

P223 Original approach to laparoscopic abdominal wall hernia surgery procedures H.M. Horikawa Teikyo University Hospital, Surgery, Tokyo, Japan Laparoscopic abdominal wall hernia repair was introduced to our department in 2012. The basic procedure in our department involves the following: (1) mesh size is tailored to overlap the entire margins of the hernia orifice by approximately 5 cm; (2) the mesh is subcutaneously suture fixed to the abdominal wall with non-absorbable sutures in four directions; and (3) a double crown technique is finally used to secure the mesh to the abdominal wall using tackers. However, in some obese patients with thick preperitoneal fat, tacker fixation may appear to be inadequate. We hereby report on the

123

Background: Determination of the effect of the primary laparotomy wound closing with polypropylene prosthesis on the life quality of patients. Methods: It was carried the retrospective analysis of indications for implantation of the prosthesis in the laparotomy wound of 200 patients in the main group after operations on the abdominal organs and retroperitoneal space. The control group consisted of 200 patients compared for age, sex, main and concomitant diseases with patients of the main group, which the abdominal wall is sutured in conventional manner. The life quality of patients studied using the SF-36 questionnaire. Results: On the first place in frequency it was sharply-xpressed anatomical and functional failure of the abdominal wall with laxity, ptosis of the abdomen with the presence of suprapubic-inguinal fold as apron for women, dome-shaped abdomen with a diastasis of the rectus muscles in men. On the second place it was obesity of patients with body mass index more than 30 kg/m2 without or with the metabolic syndrome. On the third place was old and senile age patients in combination with other risk factors: constipation, difficulty of urination, chronic respiratory failure, abdominal aortic aneurysm. On the fourth place was laparotomy wound closing in patients with general peritonitis, whose treatment was programmed sanation of abdomen. There were not eventration and post-operative hernias after preventive prosthetics. In 10 (5 %) patients in the control group it was eventration in the immediate postoperative period, and in 48 (24 %)—post-operative hernias in the long-term period. The physical component of health in the main group was 81.3 ± 1.7, psychological—61.8 ± 1.6, while in the control group it was respectively 53.8 ± 2.2 and 35.5 ± 2.1. Conclusion: Primary laparotomy wound closing with synthetic prosthesis increases the physical component of the health by 27.5 %, and psychological—by 26.3 %.

P225 The component separation technique: evolution and experience E. Blesa Sierra, M.J. Pen˜a Soria, V. Mun˜oz Lo´pez-Pela´ez, A. Ruano Campos, D. Rivera Alonso, A.E. Perez Jimenez, J.L. Garcı´a Galocha, D. Jimenez-Valladolid, A.J. Torres Garcı´a, J.J. Cabeza Gomez Clı´nico San Carlos, Abdominal Wall Department, Madrid, Spain Background: The Component Separation Technique (CST) was described in 1990 and it meant a great advance into the complicated abdominal wall defects management. The association with meshes

Hernia (2016) 20 (Suppl 2):S175–S249 has resulted in a low recurrence rate. New possibilities, like the botulism toxin infiltration (BTI), are contributing in the repairing of large abdominal wall defects. The aim of this study is to analyze the advances of these techniques and the results of our own experience. Methods: We retrospectively reviewed patients that underwent CST between April 2013 to May 2015. We analyzed clinical results such as midline primary closure, postoperative complications (compartimental syndrome, respiratory and local complications) and recurrence. The technical approach used was an open CST modified by Carbonell-Bonafe´, combined or not with preoperative BTI. Results: We analyzed results from 36 patients. All patients underwent an open CST. In 9 patients we used 1 onlay polypropylene mesh and in 27 patients 2 meshes; the first one was a composite or biological intraperitoneal mesh, and the second one was a polypropylene supraaponeurotic mesh. Prosthesis were fixed by reabsorbible stitches and fibrin sealant. The rectus abdominis muscle width was 5–10 cm in 13 patients and 10–20 cm in 23 patients. BTI infiltration was performed in all those patients with a defect of over 10 cm. The midline closure of the abdomen was achieved in 30 patients. No compartmental syndrome was reported. Six patients suffered from respiratory complications. 22 local complications were detected (3 haematomas; 8 wound infection/ local necrosis; and 11 cases of seroma). One case of recurrence was detected in the follow-up. Conclusion: The CST is a new technique in constant development. The association with other tools might allow surgeons to perform a tailored surgery for those patients with complex abdominal wall defects to achieve a tension-free reconstruction.

P226 The choice of polypropylene implants for preventive endoprosthetics of abdominal wall B.S. Sukovatykh1, N.M. Valuiskaya1, E.V. Gerasimchuk2 1 Kursk State Medical University, General surgery, Kursk, Russian Federation, 2City Clinical Emergency Hospital, General surgery, Kursk, Russian Federation Background: To determine the most appropriate material for preventive prosthetics we decided to study later tissue reaction of the abdominal wall for the implantation of the various polypropylene prosthetics. Methods: We analyzed results of the experiment of 45 rabbits divided into 3 groups with 15 animals in each. The standard polypropylene prosthesis (the filament diameter is 120 microns) was implanted on the muscles of the abdominal wall for the first group animals, the filament diameter of the prosthesis for the second group—90 microns, for the third group—70 microns. Animals were sacrificed in 30, 60 and 120 days after operation. It was morphological study of full-thickness flap of anterior abdominal wall, including the implant material. Results: Studies the later tissue reaction of the abdominal wall for the implantation of the various polypropylene prosthetics showed that the biocompatibility of prosthesis depends on the thickness of the filament. In the later stages of implantation in the first group of animals coarse-fibered deformed capsule with a predominance of the cellular elements by giant cells of foreign bodies formed around a standard polypropylene prosthesis. It was established that the prosthesis is fully overgrows with connective tissue in 2–4 months after implantation in the second group. Connective tissue capsule around this prosthesis had the same foreign body giant cells, but to a lesser extent than with the standard prosthesis implantation. The presence of foreign body cells under the abdominal wall tissues strengthening caused an inflammatory response. In the third group super-light prosthesis with 70-micron thickness was surrounded by a very thin connective

S241 capsule with the minimum number of cell elements and with a predominance of fibrous structures. It didn’t cause inflammatory changes in the abdominal wall. Conclusion: The best material for preventive endoprosthetics of the abdominal wall is a super-light polypropylene prosthesis.

P227 Ventral hernia repair RIVES type: Non-randomized prospective comparative study with 2 types of fixation systems A. Torregrosa, P. Garcı´a Pastor, B. Argu¨elles, J. Sancho Muriel, J. Iserte, S. Bonafe Diana, J. Bueno Lledo´ La Fe University and Polytechnic Hospital. Valencia, Spain, Abdominal Wall Surgery Unit, Valencia, Spain Objectives: Despite numerous studies supporting the safety and effectiveness of the synthetic tissue adhesives as a means of attachment to the inguinal hernia repair, has not been described so far for ventral hernia repair RIVES type due to high abdominal pressure that these procedures are subjected. The aim of this study is to compare the results obtained by performing conventional RIVES type ventral hernia repair using mesh fixation retrorectal with transmuscular suture, with the use of synthetic tissue adhesives and validate the use thereof as effective method of fixation. Methods: A prospective non randomized comparative study of a group of 24 patients with midline hernia in ventral hernia repair has been made RIVES type using as fixation method a synthetic tissue adhesive (n-butyl-cyanoacrylate-a-Glubran) with a control group of the 23 patients and same technique retrorectal-fixing by preperitoneal mesh sutured with polypropylene (PPL) transmuscular. Univariate statistical analysis of demographic characteristics, risk factors and comorbidity, intra-, peri- and postoperative variables and complications in the short and medium term. Control of postoperative abdominal pain as VAS scale. Results: Both groups are homogeneous in terms of the variables studied. BMI is comparable in both groups. There has been an average postoperative follow-up of between 6 and 29 months median: 16.8 months in all patients. We found no significant differences in hospital stay, abdominal pain according to VAS, hernia recurrence, and postoperative complications such as hematoma and infection, except seroma which was higher in the control group. In our experience, the use of cyanoacrylate is safe and effective in such repair. Even as a medium follow-up, given the absence of complications and recurrence, we believe it can be an alternative to the transmural fixation technique. It would be advisable to carry out a randomized study with more patients to confirm our results.

P228 To the algorithms of diagnosis and treatment of patients with primary linea alba hernia S.V. Kalinovskyi1, V.V. Vlasov2, O.O. Pidmurnyak2, O.M. Kharyshyn1, K.V. Vlasova3 1 Central District Hospital, Department of Surgery, Slavuta, Khmelnitsky Region, Ukraine, 2Khmelnitsky Regional Hospital, Department of Surgery, Khmelnitsky, Ukraine, 3Bukovinian State Medical University, Department of Surgery, Chernovtsy, Ukraine General information: The results of treatment of linea alba (LA) hernias don‘t meet surgeons’ requirements due to the high number of recurrences happen.

123

S242 Methods: The results of treatment of 276 patients (54.7 ± 12.5 years) with LA hernia, distributed by size of the hernia defect (by EHS, 2009) and methods of surgical intervention, have been studied. Results: Most hernia defects observed were of average (47.11 %) and small size (31.24 %). Ultrasound investigation and CT allowed us to measure the size of hernia defect and LA and to detect additional defects in it. 39 % of patients had normal LA. Diastasis recti of a different degree were found along all of the length of LA (23 %) or along some of its separate levels (38 %). Based on the collected data, the complex algorithm diagnosis of LA hernia, which enabled to identify and consider all factors that could cause recurrence of hernia has been developed. Analyzing the results of closing hernia defect method for each patient, the algorithm of treatment has been developed. Autoplastic methods (69 cases) were used for patients with small size defects, the absence of diastasis recti and with normal body weight. In all other cases the alloplastic methods were used. Using the preperitoneal alloplasty (168 cases) was recommended for patients with the defect of small and medium size and the presence of diastasis recti of I degree only. Retromuscular alloplasty (35 cases) was used for the patients with diastasis recti of II–III degree. Patients were examined within the 3 years period. After the closure of the hernia defect with autoplastic methods, the recurrence was detected in 11.59 %, and after alloplasty—in 0.48 %. Conclusions: Algorithm of diagnosing the linea alba hernia provides the optimization of their examination. Algorithm of treatment allows choosing the way of closing the hernia defect individually.

P229 7 year clinical experience with laparoscopic ventral hernia repair using the Parietextm composite mesh in morbidly-obese and non-morbidly-obese patients: a single centre cohort study S.A.H. Jeurie¨ns-van de Ven, D.P.J. Smeeing, H.J. Lourens, P.M. Kruyt, R.M.H.G. Mollen, H.S. de Vries Gelderse Vallei, Surgery, Nijmegen, Netherlands Background: The treatment of incisional and ventral hernias is associated with significant perioperative morbidity and recurrences. Recent studies showed a reduction in complications in morbidlyobese patients undergoing a laparoscopic ventral hernia repair. The aim of our study was to describe the clinical experience in terms of efficacy and safety with laparoscopic ventral hernia repair using the ParietexTM Composite mesh in morbidly-obese patients (BMI C 35) compared with non-morbidly-obese patients. Methods: All patients with a primary ventral or incisional hernia admitted to Gelderse Vallei Hospital Ede from January 2006 until December 2012 who underwent a laparoscopic repair with the ParietexTM Composite mesh were included in this study. Patient data were retrospectively collected. Pain scores by numeric rating scale were prospectively collected 24 to 48 h postoperatively by an independent physician. Patients were stratified in 2 groups by BMI:\35 and C35 . Results: 213 consecutive patients were included in the study. 176 patients had a BMI \ 35 and 37 patients had a BMI C 35. The baseline characteristics of these two groups were comparable, except the morbidly-obese group contained more women (p = 0.002). There

123

Hernia (2016) 20 (Suppl 2):S175–S249 were no statistically significant differences with regards to operation time or hospital stay. The use of analgetics was comparable between the two groups. There was no statistically difference in postoperative recurrence (13 % in the non-obese and 16 % in the obese group). In other complications such as seroma, pneumonia or small bowel perforation no statistically significant differences were observed between the two groups. Conclusion: Laparoscopic repair with the ParietexTM Composite mesh is safe and feasible to perform in morbidly-obese patients. The recurrence rate in longterm follow up of 14 % in non-morbidly and 19 % is in morbidly patients, which is relatively high but within the range given in the literature.

P230 An integrated surgical-biomechanical approach to characterize surgical meshes for abdominal wall repair N. Baldan1, S. Merigliano2, P.G. Pavan2, S. Todros2, P. Pachera2, A.N. Natali2 1 Padova General Hospital, General Surgery, Padua, Italy, 2 University of Padova, Department of Oncologic and Gastroentero, Padua, Italy Background: Abdominal wall surgery entails the use of surgical meshes, currently available in a variety of materials and structural conformations. Physicochemical and mechanical properties, as elastic, time dependent and anisotropic response, play a crucial role, affecting mesh interaction with surrounding biological tissues and mechanical biocompatibility. The aim of this study is to provide integrated experimental and computational approach to define biomechanical characteristics in direct correlation with surgical practice, aiming at a definition of suitable surgical meshes for the use in specific abdominal wall repair. Methods: Physicochemical characterization of polymers used in the manufacturing of surgical meshes and morphological analysis is carried out. Mechanical test are performed, according to suitable loading protocols. Mesh mechanical response is investigated, evaluating appropriate constitutive models and parameters through the analysis of experimental data. A virtual solid model of the abdomen is developed based on MR images, tissue histological analysis, mechanical testing and constitutive modeling. The numerical model of the abdominal wall is exploited to evaluate the biomechanical performance of surgical meshes and their interaction with biological tissues. Results: A numerical model of the abdominal wall is provided, including main muscular (rectus and lateral sheaths), fascial (rectus, posterior and transversalis fascia) and aponeurotic structures. An elliptical post laparotomy hernia is represented in the sovra-umbilical region and virtual surgical repair is carried out with different prostheses. The increment of intra-abdominal pressure is simulated up to a maximum physiological value and the corresponding mechanical behavior of the abdominal wall is evaluated. Conclusion: Numerical analyses of the interaction phenomena between surgical meshes and abdominal wall represent a valid support to interpret different aspects of surgical repair. A correlation is established with surgical procedures, to evaluate the influence of mesh material and structural conformation on surgical outcome.

Hernia (2016) 20 (Suppl 2):S175–S249

P231 The feasibility of laparoscopic management of incarcerated obturator hernia J.L. Liu, J.C. Chen Beijing Chao-Yang Hospital, Hernia and abdominal wall surgery, Beijing, China Background: Obturator hernia (OH), a rare cause of acute small bowel obstruction, requires immediate surgical intervention to prevent serious complications and mortality. We assessed the safety and efficacy of laparoscopic surgery in patients with incarcerated OH presenting with acute abdomen in an emergency setting. Methods: Data pertaining to patients diagnosed with incarcerated OH between June 2011 and June 2015 at our hospital were reviewed. Patients characteristics, operation details and postoperative outcomes were retrospectively analyzed. Results: All eight patients diagnosed with incarcerated obturator hernia during the reference period were females (average age: 72.1 ± 11.8 years; average weight: 43.2 ± 7.4 kg; average body mass index: 17.8 ± 2.1 kg/m2; average operating time: 62 ± 15 min; average hospital stay: 7.1 ± 6.4 days). Seven occult hernias, including four contralateral OHs, one ipsilateral femoral hernia and one bilateral femoral hernia were detected in four patients (50 %), which were simultaneously repaired after laparoscopic exploration. Seven patients (87.5 %) were successfully treated with synthetic mesh by laparoscopic technique. Only one case required intraoperative conversion to open surgery due to strangulated intestine with perforation. Wound infection was reported in one patient who had undergone bowel resection, but with an eventual complete recovery. Post-operative period was uneventful in the other seven patients. No recurrence or complications were reported on follow-up (mean duration of follow-up: 6 to 50 months). Conclusion: In this study, laparoscopic technique was associated with a reduced duration of hospital stay and fewer complications. It allowed for simultaneous diagnosis and treatment of occult hernias during the same procedure. The approach is safe and feasibility for the treatment of incarcerated obturator hernia and may be a better option in selected patients.

P232 Giant ventral hernia: relationship between abdominal wall muscle strength and hernia area K. Striga˚rd1, B. Stark2, L. Clay3, U. Gunnarsson1, P. Falk4 1 Department of Surgical and Perioperative Sciences, Umea˚ University, Department of Surgery, Uema˚, Sweden, 2Department of Molecular Medicine and Surgery, Karolinska Institutet, Department of Plastic and Reconstructive, Stockholm, Sweden, 3 CLINTEC, Karolinska Institutet, Department of Surgery, Stockholm, Sweden, 4Institute of Clinical sciences, Sahlgrenska Academy, at University of Gothenburg, Fibrinolysis Laboratory/Tissue Centre, Gothenburg, Sweden Background: Symptoms arising from giant ventral hernia have been considered to be related to weakening of the abdominal muscles. The aim of this study was to investigate the relationship between the area of the abdominal wall defect and abdominal wall muscle strength measured by the validated BioDex system together with a back/abdominal unit. Methods: 52 patients with giant ventral hernia ([10 cm wide) taking part in a randomized study comparing reinforcement with either full thickness skin graft or synthetic mesh, underwent CT scan, clinical

S243 measurement of hernia size and BioDex measurement of muscle strength prior to surgery. The areas of the hernia derived from CT scan and from clinical measurement were compared with BioDex forces in the modalities extension, flexion and isometric contraction. The Spearman rank test was used to calculate correlations between area, BMI, gender, age, and muscle strength. Result: The area calculated from clinical measurements correlated to abdominal muscle strength for all modalities (p-values 0.015–0.036), whereas there was no correlation between the area calculated from CT scan and BioDex results. No relationship was seen between BMI, gender, age and the area of the hernia. Conclusion: The inverse correlation between BioDex abdominal muscle strength and clinically assessed hernia area, seen in all modalities, was so robust that it seems safe to conclude that the area of the hernia is an important determinant of the degree of loss of abdominal muscle strength. Results using hernia area calculated from the CT scan showed no such correlation and this would seem to concur with the results from a previous study by our group on patients with abdominal rectus diastasis. In that study, defect size assessed clinically, but not that measured by CT scan, was in agreement with the size of the diastasis measured intra-operatively.

P233 Contaminated complex recurrent ventral hernia repair using posterior components separation with NegativePressure Wound Therapy, biosynthetic mesh and botox preparation: experiences from 3 cases R.W. Wilke Klingen Nagold, General-, Viszeral- and Vascular surgery, Nagold, Germany Background: Components separation provides a useful option among closure choices for complex ventral hernia repairs. However, the management of contaminated large hernias is difficult in the point of abdominal wall closure and right mesh choice. We present the operative management of three similar cases with complex recurrence hernias in a contaminated field after multiple synthetic mesh implants and active small intestinal fistulae. Methods: The conditions were in all three patients exactly the same. All had developed a small bowel fistula with a large incisional hernia recurrence. Previously, multiple reparations with synthetic meshes have been conducted in all abdominal wall layers as onlay, sublay and Ipom implantation. The goal was to remove the implanted infected meshes. Further to resect the intestinal fistula and to close the abdominal wall without any synthetic meshes. Results: All patients (mean age 69 years, BMI 30 kg/m2) were pretreated with 200 units of Botox 2–4 weeks in advance. The first operation was the completely mesh removal and the fistula refurbishment with bowel resection. In all cases, the meshes had grown into the intestine. The next operations were a posterior component separation and a vacuum therapy for 1 week. All smears showed a bacterial infection. In a third operation, a 20 9 30 cm large biosynthetic mesh (BIO A, Gore) was implanted and the vacuum therapy continued for a minimum of 2 weeks. All patients were discharged after 5–8 weeks with closed abdominal wall. The follow-up was up to 1 year and showed no wound infections, seroma, recurrences or bowel fistulas. Conclusions: The surgical treatment of contaminated hernias requires a strategic approach and patience on the part of the surgeon and the patient. The addition of biosynthetic mesh when performing components separation in repairing contaminated complex ventral hernias is a successful and safe procedure.

123

S244

P234 Open primary ventral hernia repair with ParietexTM composite ventral patch: 1 year results of the Panacea prospective, multi-centre trial S. Nienhuijs1, S. Hopson2, L.N. Jørgensen3, E. Kullman4, T. Tollens5, M.G. Muzi6, F. Muysoms7, C. Doerhoff8, K. Leblanc9, M. Schwartz10, F. Berrevoet11 1 Catharina Hospital, Department of Surgery, Eindhoven, Netherlands, 2Mary Immaculate Hospital, Bon Secours Hernia Center, Newport News, USA, 3University of Copenhagen, Bispebjerg Hospital, Copenhagen, Denmark, 4Medicinskt Centrum Linko¨ping, Sweden, 5Imelda Hospital, Imelda Hospital-General Surgery, Bonheiden, Belgium, 6University Hospital Tor Vergata, Rome, Italy, 7 AZ Maria Middelares, Department of Surgery, Ghent, Belgium, 8 Surgicare of Missouri, Surgicare of Missouri, Jefferson City, USA, 9 Our Lady of Lakes Regional Medical Center, Baton Rouge, USA, 10 Monmouth Medical Center, Long Branch, USA, 11University Hospital Ghent, Department of General and Hepatobiliary Surgery, Ghent, Belgium Background: The ParietexTM Composite Ventral Patch (PCO-VP) is an innovative monofilament polyester mesh for ventral hernia repair that has fixation points in four directions and absorbable expanders to assist with mesh placement. The PANACEA study is a prospective international non-comparative study designed to assess clinical outcomes following open intraperitoneal implantation of PCO-VP. The 1 year results are presented here. Methods: Primary ventral hernias were repaired openly using PCOVP. Follow-up assessments were performed at 1, 6, 12, and 24 months measuring pain, comfort and complications. The primary endpoint is recurrence at 24 months. Results: 126 patients (110 with umbilical hernia and 16 with epigastric hernia) were treated with PCO-VP. Mean hernia diameter was 1.8 ± 0.8 cm. At this interim analysis, 114 and 106 patients have reached their 6 and 12 month post-surgery follow-up, respectively. Cumulative hernia recurrence rates within 6 and 12 months were 1.8 % (2/114) and 2.8 % (3/106), respectively. Numeric Rating Scale pain scores showed improvement from 2.1 ± 2.0 at baseline to 0.5 ± 0.7 at 1 month (P \ 0.001), and a low pain level was maintained at 12 months post-surgery (P \ 0.001). The mean global Carolina’sTM Comfort Scale score improved from 3.8 ± 6.2 at 1 month post-surgery to 1.4 ± 4.3 (P \ 0.001) at 12 months post-surgery. All patients except one were satisfied with the procedure at their last assessment. Conclusions: These promising 1 year results reveal low postoperative pain levels and high patient satisfaction. The low 12 month recurrence rate suggests long-term efficacy of PCO-VP in primary open ventral hernia repair.

P235 Application of absorbable anti adhesions barrier membrane for creation composite mesh in intraperitoneal implantation: experimental study G.V. Khachatrian, V.A. Gorsky, M.D. M.d. Polivoda, A.P. Oettinger, A.V. Volenko, A.S. Sivkov, S.O. Shadsky Russian National Research Medical University, Experimental Surgery, Moscow, Russian Federation Background: In treatment of ventral and incisional hernia remains a lot of unsolved problems. Laparoscopic IPOM technique operation show good result, but surgeons haven’t ‘‘ideal’’ mesh to decrease recurrent of hernia and adhesions in peritoneum at the same time. The aim of study is create antiadhesions barrier membrane (antiABM) over mesh with using ‘CollaGUARD’ for intraperitoneal mesh implantation.

123

Hernia (2016) 20 (Suppl 2):S175–S249 Methods: In 20 Wistar rats with average weight 330 ± 30 g, under general anesthesia, made midline laparotomy and was implanted on the peritoneum 2 polypropylene mesh (Premilene) size 20 9 15 mm, covered by absorbable collagen antiABM size 25 9 20 mm. AntiABM fixed to mesh using to glue n-butyl-2-cyanoacrylate (Histoacryl). On the hepatic side implanted created mesh fix to peritoneum by glue, on the splenic side—four interrupted suture Prolene 5/0. Animals was killed after 7 and 30 days. Results: No wounds infection, no rats died. In gluing side 70 % cases found isolated adhesions along the edges of composite mesh, no adhesions in center of antiABM. Area of adhesions less 20 %. In sutured side only 2 rats (20 %) had isolate adhesions to suture, no adhesions in center of created mesh. Adhesions area less 9 %. After 30 days antiABM absorb completely. In gluing side found isolated adhesions along the edges, adhesions area less 15 %. In suture side only 1 rat had isolated adhesion to suture. Adhesions area less 5 %. Conclusion: In this way, polypropylene mesh with gluing antiABM show in experimental study good antiadhesions properties. Absorbable collagen membrane can be considered as an alternative to the other composite meshes. Both intraperitoneal methods of fixation (gluing and suturing) had convenient for fixation. However suture fixation in experimental study show less significant adhesion formation.

P236 Ventral hernia repair with SymbotexTM composite mesh: Interim results of a prospective consecutive registry M. Lepere1, J.F. Gillion2, C. Barrat3, A. Bonan4, O. Cas2, A. Dabrowski5, G. Fromont6, F. Jurczak7, H. Khalil8, C. Zaranis9 1 Clinique St Charles, General Surgery, La Roche Sur Yon, France, 2 ˆ pital Prive´ d’Antony, Unite´ de Chirurgie visce´rale et Digestiv, Ho ˆ pital Jean Verdier, Bondy, France, 4Ho ˆ pital Antony, France, 3Ho Prive´ d’Antony, Surgery, Antony, France, 5Clinique de Saint-Omer, ˆ pital Prive´ Bois Bernard, Rouvroy, France, Blendecques, France, 6Ho 7 ˆ pital Clinique Mutualiste de l’Estuaire, Saint Nazaire, France, 8Ho Charles Nicolle, Chirurgie Digestive, Rouen, France, 9Clinique du Mail, La Rochelle, France Background: SymbotexTM composite mesh features an innovative three-dimensional monofilament textile and an absorbable collagen barrier on one side to minimize tissue attachment. The objective of this registry study is to assess patient outcomes and surgeon satisfaction with SymbotexTM composite mesh in ventral hernia repair. Methods: The SymCHro study is a multicentric observational registry study of 100 consecutive patients in the Club Hernie database who underwent ventral hernia repair using SymbotexTM composite mesh. The primary objective is to evaluate recurrences and complications within 2 years of surgery. The secondary objective is to assess the use of SymbotexTM composite mesh, including patient and surgeon satisfaction. Results: One hundred patients from the Club Hernie database were treated for a total of 103 hernias (37.9 % primary, 62.1 % incisional; 79.2 % repaired laparoscopically) and were enrolled in this study from 4 July 2014 to 13 May 2015. At this analysis, 100 and 27 patients have completed 1 and 12 month follow-up assessments, respectively. Median follow-up is 46.5 (0–425) days. The median hospital stay was 1.0 day (range 0–7 days). Six low-grade seromas (1 perioperatively; 5 within 2 months postoperative) unrelated to the mesh occurred. Three incidents of low-grade transitory ileus (2 perioperative; 1 within 1 month) were identified. No recurrence, sepsis, nor serious adverse event were reported. For surgeries reporting satisfaction data, surgeon satisfaction with regard to mesh flexibility and ease of insertion was 100 %. At 1 year postoperative, 92.6 % (25) patients assessed the hernia operation

Hernia (2016) 20 (Suppl 2):S175–S249 results as ‘‘good’’ or ‘‘excellent.’’ Patient pain assessed by a Visual Analog Scale was significantly reduced at day 1, day 8, month 1, and month 3 following the operation. Conclusions: These interim results show minimal pain, low complication rates, and high patient and surgeon satisfaction associated with SymbotexTM composite mesh use in primary and incisional ventral hernia repair.

P237 Outcomes following emergency abdominal wall hernia repair: a single-centre experience L.M. Hickey, S. Semple, M.H. Scott Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, General Surgery, Prescot, UK Background: Terminology describing presenting emergency hernias varies. We aimed to identify outcomes and correlation between clinical diagnosis and operative findings for emergency hernia repair. Methods: A single-centre retrospective study of emergency hernia repairs over 12 months. Results: 34 males and 29 females presented (median age = 67, IQR = 49–77). Hernias included 14 inguinal, 12 femoral, and 38 others. 11 required laparotomy. 17 cases had strangulation intraoperatively, 10 bowel resections being required, with 5 (29 %) initially clinically diagnosed correctly. One patient died 6 days postoperatively (2 %). Early postoperative morbidity was recorded in 20 patients (31 %). Median inpatient stay was 3 nights (IQR = 1–10). There was no difference in the proportion of consultant-led procedures during daytime hours (18/38) compared with out-of-hours (10/26)-v2, p = 0.48. Preoperative descriptions of clinically diagnosed hernias included 8 strangulated, 30 incarcerated, 4 obstructed, 6 ‘irreducible and tender’, and remainder had variable terminology. 18 (28 %) cases underwent CT and 3 (5 %) ultrasound. Of those with adequate documentation, clinical diagnosis and operative findings had 65 % positive correlation and imaging findings and operative findings had 95 % positive correlation. Median time for hernias clinically diagnosed as strangulated versus non-strangulated from admission to operation was 5.8 (IQR = 4.1–9.3) hours and 10.4 (IQR = 4.9–20.1) hours respectively. Conclusions: Hernia description prior to emergency surgery is often inadequate with variable accuracy compared with operative findings. This can lead to operative delay and poor outcomes.

P238 A comparative study to assess the efficacy of absorbable and non-absorbable fixation devices in laparoscopic ventral hernia repair S. Wijerathne, E. Sta Clara, W.B. Tan, D. Lomanto National University Hospital, General Surgery, Singapore, Singapore Introduction: One of the controversial topics related to laparoscopic ventral hernia repair is the technique for mesh fixation. Method: This is a retrospective study of a prospectively collected database of patients who underwent laparoscopic ventral hernia repair in a single institution. Data such as patients’ demographics, presenting symptoms, intra-operative findings and post-operative complications were collected. Group A has mesh fixation with absorbable tackers (AbsorbaTack, Covidien) while Group B has mesh fixation using non absorbable tackers (ProTack, Covidien).

S245 Results: The mean operating time was 107.7 min (31–272) in Group A vs 98 min (35–199) in Group B. The mean size of hernia defect was 3.74 cm in Group A vs 4.26 in Group B. All patients had a mesh inserted and fixed in the same manner except with regards to the type of tackers used. The average length of stay was 2.7 days in both groups. Post-operatively, 81 % of patients from Group A and 72.9 % of patients from Group B developed acute pain where acute pain is defined as pain requiring more than 1 type of analgesia during the hospitalisation. Seroma was found in 0 % of patients in Group A vs 10.8 % in Group B. All patients were followed up for a mean of 44.1 weeks (range 0–244). Recurrence rates of ventral hernia were 3.4 % in Group A vs 2.7 % in Group B. Conclusion: Both absorbable and non-absorbable tackers are feasible options as method of mesh fixation in laparoscopic ventral hernia repair.

P239 Laparoscopic transabdominal preperitoneal ventral hernia repair with self-adhesive mesh. Preliminary results after first year follow-up J. Bellido Luque1, J.M. Suarez Gra´u1, J. Gomez Menchero1, J. Guadalajara Jurado1, J. Garcı´a Moreno1, A. Bellido Luque2, A. Tejada Gomez2, I. Alarco´n del Agua2, M. Sanchez Ramirez2, S. Morales Conde2 1 Riotinto Hospital, Surgical Department, Huelva, Spain, 2Quiro´n Sagrado Corazo´n Hospital, Surgical department, Seville, Spain Introduction: Laparoscopic ventral or incisional hernia repair requires intraperitoneal mesh placement. It’s associated with an increase of adhesions, bowel obstruction and enterocutaneous fistula. Intraabdominal meshes are laparoscopically fixed using traumatic fixation as helicoidal or transfascial sutures that increase acute, chronic pain and adhesions to bowel loops. Aim: Prospectively check the safety and effectiveness of the laparoscopic approach in small and medium size ventral or incisional hernia, using a self-adhesive mesh in the preperitoneal space without traumatic fixation (tackers or transfascial sutures) and objectively assess its benefits and complications. Materials and methods: Patients aged 18–67 years old with medial, lateral ventral and incisional hernias 3 and 8 cm size are included in this prospective Cohort study. 50 patients were included in the study, from January 2013 to March 2015. The average length of surgery was 55.6 ± 10.7 min (110–31 min range). The average hospital stay was 1.1 ± 0.4 days (1–2 days range).The average time for back to work was 9 ± 2.44 days (4–16 days range). The most common postoperative complication was seroma, 13 patients (27.6 %), all type 1 in the Morales et al. classification. Other complications (Clavien-Dindo grade 1:1 ileus and 1 Haematoma abdominal wall. The average follow-up was 13.68 ± 3.2 months (22–10 months range). There were 3 lost during this period. There was no hernia recurrence during examination nor in CT scan, in the follow-up period. The average visual analogical scale before surgery was 4.12 ± 1.15 (2–6 range). After surgery were as follows: 3.03 ± 0.73 (2–4 range) on the first day after surgery, 0.8 ± 0.62 (0–2 range) after the first week. 0 after the first month. No patient showed chronic pain. Conclusions: The use of self-adhesive meshes during laparoscopic transabdominal preperitoneal approach in small and medium size ventral or incisional hernias is safe and effective, with low postoperative pain and quick functional recovery after the surgery without increasing recurrences in short-term.

123

S246

P240 Laparoscopic IPOM using hydrophobic polyacrylic endoprosthesis in surgical treatment of median hernias of anterior abdomen wall W. Trukhalev, M. Kukosh Nizhny Novgorod State Medical Academy, Clinic of surgery, Nizhny Novgorod, Russian Federation Actuality: IPOM is one of the variants of tension-free repair of abdominal wall hernias. Endoprosthesis with hydrophobic polyacrylic coating is developed, that causes minimal commissural process in postoperative period. Target: To decide on the role of laparoscopic IPOM in surgical treatment of median hernias of anterior abdomen wall. Methods: The analysis of near-term treatment results was produced in 248 patients. The median age appeared to be 60 year. Laparoscopic operations on primary ventral hernias took place in 11 of 155 patients, on postoperative ventral hernias—in 10 of 118 cases. Laparoscopic surgery was performed at aponeurosis defect width of B4 cm in primary ventral hernias, and at defect width of B10 cm in postoperative ventral hernias. Two groups of patients were formed. The 1st group is presented with 210 patients, who have undergone open operations on primary ventral hernias. The 2nd group consists of 21 patients, who have been operated using laparoscopic IPOM method with hydrophobic polyacrylic covered endoprosthesis. The groups are comparable. Results: The median surgery duration in the 1st group was 55 min, where as in the 2nd group it was 55, 45 and 75 min correspondingly. No statistically significant difference was defined (T = 2676.5, p = 0.411). Median duration of hospital stay was surely less in the patients, having laparoscopic operations, than in those who underwent open surgery (5 vs 7, T = 1063.5, p = 0.0001). No statistically reliable difference in local complications frequency was marked. Need in narcotic painkillers in short-term postoperative period was found authentically lower in patients after laparoscopic operations. Conclusions: Laparoscopic IPOM in ventral hernias, using mesh endoprosthesis with hydrophobic polyacrylic coating, reduces presence duration at the clinic and decreases the need in narcotic painkillers in short-term postoperative period. Open and laparoscopic operations are comparable in surgery duration and short-term postoperative complications frequency.

P241 Preclinical study of cyanoacrylate-based tissue adhesives for intraperitoneal mesh fixation G. Pascual1, M. Rodrı´guez1, S. Sotomayor1, B. Pe´rez-Ko¨hler1, A. Ku¨hnhardt1, M. Ferna´ndez-Gutie´rrez2, J. San Roma´n2, J.M. Bello´n1 1 University of Alcala´, Medicine and Medical Specialities, Alcala De Henares, Spain, 2Consejo Superior de Investigaciones Cientificas, Institute of Polymer Science and Technol, Madrid, Spain Introduction: During laparoscopic/endoscopic hernia repair, the use of a tissue adhesive to fix a prosthetic material is a feasible option. However, scarce data exist for the use of a synthetic adhesive in this setting. This study examines the intraperitoneal behavior of two cyanoacrylate tissue adhesives: Ifabond and a new, non-marketed octyl cyanoacrylate adhesive (OCA) used for the intraperitoneal fixation of an expanded polytetrafluoroethylene (ePTFE) mesh. Materials and methods: In 36 New Zealand White rabbits, 3 9 3 cm (n = 24) or 1.5 9 3 cm (n = 12) fragments of ePTFE

123

Hernia (2016) 20 (Suppl 2):S175–S249 mesh (Preclude, Gore, Flagstaff, USA) were fixed to the parietal peritoneum using OCA or Ifabond. Peritoneal fluid was obtained at the time of implant and at 2 weeks postimplant for cytokine determinations (IL-6 and TNF-a). At 14 or 90 days postsurgery, the animals were euthanized and the meshes excised en bloc with the anterior abdominal wall to assess host tissue incorporation (light microscopy and scanning electron microscopy), the macrophage response (immunolabeling with the rabbit monoclonal anti-RAM 11 antibody), apoptosis (TUNEL) and fixation strength (T-peel tensiometry). Results: Peritoneal fluid IL-6 and TNF-a concentrations were similar in the OCA and Ifabond groups. Both adhesives gave rise to adequate mesothelialization of the ePTFE and their degradation was visible at 90 days. Macrophage counts were similar for the two study groups, but a significantly increase in macrophage response was observed from 14 to 90 days for Ifabond. At 90 days postimplant, apoptotic cell counts was lower for the implants fixed with OCA (p \ 0.05) and a fixation strength was significantly lower for OCA (p \ 0.0001). Conclusion: Despite similar cytokine levels at 2 weeks and similar host tissue incorporation observed for the meshes fixed with the two adhesives, the use of Ifabond gave rise to a greater apoptosis rate, although this adhesive provided a stronger fixation bond. Financial support: SAF2014-55022-P.

P242 Simultaneous abdominal hernia repair in patients undergoing laparoscopic bariatric surgery M.M. Matyja, M.P. Pedziwiatr, M.M. Matlok, A.P. Pasternak, A.B. Budzynski University Hospital, II Department of General Surgery, Cracow, Poland Background: The number of patients undergoing minimally invasive bariatric surgery is growing every year. Since obesity is an important risk factor for abdominal hernia- its coexistence is relatively common in patients undergoing weight loss surgery. The aim of this study was to assess the effectiveness of simultaneous hernia repair during laparoscopic sleeve gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB) Methods: A retrospective study of patients that underwent LSG or LRYGB between 2009 and 2015 in our department was conducted. We analyzed patients demographics, the rate of concomitant hernia, methods of treatment and postoperative outcomes. Results: Out of 445 patients that underwent weight loss surgery concomitant abdominal hernia was present in 12 cases (7 females, 5 males). Average BMI of patients with a hernia was 50.09 kg/m2. In 3 cases previously qualified for delayed hernia repair incarceration of hernia in postoperative period was noted and they required immediate surgery. 1 postoperative mortality in 30-day postoperative period was noted—a patient (BMI 64 kg/m2) that underwent LRYGB developed umbilical hernia strangulation subsequent small bowel necrosis. In 7 cases synchronous hernia repair was performed and no complications in postoperative period were observed. Conclusions: Although based on a small number of patients, we observed an evident risk of complications that may occur in postoperative period in cases of delayed hernia surgery. Moreover, simultaneous hernia repair is feasible and may lower the incidence of hernia incarceration in early postoperative period. However, synchronous hernia repair with bariatric surgery requires long-term observation before becoming a method of choice.

Hernia (2016) 20 (Suppl 2):S175–S249

P243 Abdominal wall hernias repair in cirrhotic patients and resistant ascites: Utility of abdominal drainage S. Pisarenco1, G. Anghelici1, O. Crudu1, M. Danu1, I. Pirtac2, G. Lupu1 1 State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’, Department of Surgery N2 ‘‘C.Tibirna’’, LCS Hepatosurgery, Chisinev, Moldova, 2Municipal Clinical Hospital Nr.3 ‘‘Sf.Treime’’, Department of Surgery 2, Chisinev, Moldova Background: Management of abdominal wall hernias in patients with liver cirrhosis with massive resistance ascites is still under debate. The objective of this study was to compare the outcome in our series of urgently versus scheduled operated treatment of these patients. Methods: In the period between 2011 and 2015, 102 patients with an abdominal wall hernias combined with liver cirrhosis and ascites were identified from our hospital database. I group: 48 cirrhotic patients operated on urgently, including 36 (75 %)—with hernia sac erupts with ascites fluid overflow and 12 (25 %) with strangulated hernias. 9 (18.8 %) patients was performed endoscopic hemostasis simultaneously for variceal bleeding. In 85 % cases ascites fluid was present bacterial microflora. In all cases was installed abdominal drainage, for drainage ascites and lavage abdominal cavity. Group II: 54 cirrhotic patients with massive ascites and spontaneous eruption risk of hernia, operated scheduled after a thorough preoperative preparation, laparoscopic drainage of abdominal ascites and abdominal cavity lavage with antibacterials. In 55 % cases ascites fluid was present bacterial microflora. Plasty method—‘tension-free no mesh’. Sealing prophylactic endoscopic variceal was performed in 29 (53.7 %) patients. Results: The first group died postoperatively 7 (14.6 %) patients with hepatic insufficiency, including 4 with variceal bleeding and 3 ascitesperitonitis. In group II was 1 (1.9 %) death—hepato-renal failure. Postoperative eventration 3–6 months: I group—10 (20.8 %); II group—2 (3.7 %). Suppuration of postoperative wound: I group—8 (16.7 %), II group without complications. Conclusions: Abdominal wall hernias in cirrhotic patients with ascites preferable operated planned. Laparoscopic abdominal drainage and lavage with antibacterials reduces the risk of ascitesperitonitis, improves wound healing. The preferably solution is hernioplastia ‘tension-free no mesh’.

P244 Prospective comparison of outcomes and cost between primary and recurrent open ventral hernia repairs (OVHR) S. Groene, V. Augenstein, P.C. Paul Colavita, T. Prasad, A. Lincourt, K. Kercher, B.T. Heniford Carolinas Medical Center, Department of Surgery, Charlotte, USA Introduction: OVHR for recurrence is a difficult and costly problem. Our goal was to compare outcomes and costs between primary (POVRH) and recurrent (R)OVHR. Methods: A prospective study of patients undergoing primary and recurrent OVHR at a single institution over 3 years was performed. Demographics, operative details, complications, outcomes and costs were statistically evaluated. Results: One-hundred ninety-seven patients had a POVHR, 303 a ROVHR. Both groups were similar in age, but POVHR had a significantly lower BMI (31.4 ± 9.0 vs 34.3 ± 7.9 kg/m2; p \ 0.001). POVHR patients had a higher rate of preoperative CHF (5.1 vs 1.0 %; p = 0.005) but lower rate of diabetes (18.8 vs 27.1 %; p = 0.03).

S247 They were also less likely to have ongoing wound complications (12.7 vs 36.3 %; p \ 0.001). Other co-morbidities were similar. Intraoperatively, ROVHR were less likely to have a panniculectomy (26.4 vs 35.3 %; p = 0.003) or advancement flaps (43.7 vs 54.1 %; p = 0.02), less use of biologic mesh (5.6 vs 14.8 %; p = 0.003), less EBL (125.3 ± 208.6 vs 165.6 ± 162.8 mL; p \ 0.001) and a smaller defect (121.1 ± 154.1 vs 250.2 ± 336.6 cm2; p \ 0.001) in those undergoing POVHR. POVHR had a significantly lower rate of seroma formation (15.2 vs 25.7 %; p = 0.005), cellulitis (15.2 vs 26.7 %; p = 0.003), wound breakdown (12.2 vs 18.8 %; p = 0.049), 30-day readmission (12.2 % vs 19.8 %; p = 0.03) and recurrence (2.0 vs 7.9 %; p = 0.005). They had a shorter LOS (6.5 ± 10.4 vs 7.2 ± 5.1 days; p \ 0.001) and fewer follow-up visits (p \ 0.001). Overall costs were significantly lower in the primary repair group ($51,1186 ± 79,974 vs $56,196 ± 48,448; p \ 0.001). After controlling for panniculectomy, preop wound complications, and biologic mesh, ROVHR was no longer associated with higher rates of seroma, wound breakdown or recurrence. Conclusion: Patients undergoing ROVHR were more obese and more likely to have a chronic wound issues at the time of surgery. When controlling for pre-op wound issues, panniculectomy and contamination, ROVHR had similar outcomes compared to POVHR. ROVHR can be performed with comparable outcomes to POVHR.

P245 Long-term assessment of surgical and quality of life (QOL) outcomes in ventral hernia repair (VHR) in patients with and without an intraoperative enterotomy S. Groene, C. Huntington, L. Blair, T. Cox, T. Prasad, A. Lincourt, K. Kercher, B.T. Heniford, V. Augenstein Carolinas Medical Center, Department of Surgery, Charlotte, USA Introduction: An enterotomy during a VHR is an unfortunate complication with obvious but poorly studied outcomes implications. Our goal was to compare surgical and QOL outcomes between patients with and without an enterotomy during VHR. Methods: A prospective, single-institutional database was assessed for VHR performed from 1999-–une 2015 with group selection based on enterotomy. Demographics, operative details and complications were evaluated. QOL outcomes were evaluated at 2 and 4 weeks and 6, 12, 24 and 36 months as measured by the Carolinas Comfort Scale (CCS); any score C 2 on the 5-point scale was considered symptomatic. Results: There were 75 enterotomies in 4,065 VHR (1.84 %). Those in the enterotomy group were significantly older (58.0 ± 11.5 vs 54.2 ± 13.7 years; p = 0.01), more obese (35.3 ± 8.9 vs 32.7 ± 10.8 kg/m2; p = 0.002) and had more comorbidities (3.5 ± 2.3 vs 2.8 ± 2.0; p = 0.005), including diabetes (28.2 vs 17.2 %; p = 0.02). OR time and EBL were higher in the enterotomy group (both p \ 0.001), and there was significantly greater biologic mesh use in this group (58.3 vs 8.5 %;p \ 0.001). Fistulae (20 vs 0.7 %; p = 0.004) or stomas (11.1 vs 4.4 %; p = 0.01) were also more common. Overall complications were higher in the enterotomy group (63.2 vs 31.4 %; p \ 0.001), with a significantly higher rate of wound infections (18.6 vs 8.0 %; p = 0.003) and recurrence (16 vs 3.4 % p \ 0.001). Patients with an enterotomy had significantly worse QOL scores at 6 months, (mesh sensation, pain and movement limitation; p B 0.04 for all), though by 12 months and thereafter, there was no difference in QOL between the groups. Conclusion: Patients who had an enterotomy during VHR were more comorbid, had more failed hernias with previously placed mesh.

123

S248 Enterotomies resulted in overall worse surgical outcomes with more frequent wound infections, hernia recurrence and mesh infections. QOL was also significantly impacted at 6 months. Preventing enterotomy in hernia repair can significantly improve outcomes.

P246 New collagen composite mesh device for laparoscopic intraperitoneal onlay mesh repair of midline hernia: early results of a multicentric study J. Lemaire1, T.B. Barthes2, O. Merlier3, E. Magne4, A. Valverde5, J.P. Cossa6, T.H. Delaunay7, P. Ledaguenel8, S. Auvray9, P. Marchand10, A. Bellouard11, C.L. Bertrand1 1 CHU UCL Namur, Digestive, endocrine and general surgery, Yvoir, Belgium, 2Barthes Thierry, Surgery, Poitiers, France, 3Merlier, Surgery, Valenciennes, France, 4Magne, Surgery, Bordeaux, France, 5 Valverde, Surgery, Paris, France, 6Cossa, Surgery, Paris, France, 7 Delaunay, Surgery, Rouen, France, 8Ledaguenel, Surgery, Bordeaux, France, 9Auvray, Surgery, Caen, France, 10Marchand, Surgery, Vire, France, 11Bllouard, Surgery, Olivet, France Background: intra-abdominal use of meshes has growth with the development of composite meshes. Covamesh R is a new material using ultra-resistant resorbable high purification collagen biomaterial for the inner layer. The results of a multicentric experience for midline hernia repair are reported. Methods: From May 2013 to November 2014, a serial of 125 consecutive patients with laparoscopic intraperitoneal onlay repair using a CovameshR for a primary or incisional hernia of the midline was prospectively recorded. Patient, hernia and technical parameters, procedure duration and complications, hospital stay length, post-operative morbidity and recurrence, in the early and medium (6 months) postoperative period, were analyzed. Results: Among the 125 patients, there were 54 umbilical, 40 incisional and 31 others (epigastric or combination) hernia. The mean largest diameter was 3.5 cm. The peritoneal sac was resected in 103 patients, the defect closed in 74. Mean operative time was 34 min. Mean hospital stay was 1.9 days. In-hospital surgical morbidity was 7 cases (5.6 %) Cumulative surgical morbidity at 6 months was 4 hematoma (one with sepsis requiring drainage without prothesis explantation), 6 seroma, 1 bowel obstruction (11 patients—8.8 %) and 1 recurrence (0.8 %). Conclusions: With a medium term follow-up, the safety and the efficacity of the new COVAMESH R combining a collagen biomaterials with a polyester mesh was at least comparable with other materials. The theoretical advantage of a biological material imposes its consideration in the future choice of a composite mesh. Other large scale studies will be necessary to evaluate an eventual advantage of this type of mesh.

P247 Alloplasty of troacar hernias in periomphalic region combined with diastasis of abdominal rectus muscles Y.P. Feleshtynskyi, V.A. Dadaian, V.V. Smishchuk, V.V. Prepodobnyi P.L. Shupyk National Medical Academy of Postgraduate Education, Surgery and proctology, Kyiv, Ukraine Introduction: Trocar hernias of periomphalic region in 60–65 % are associated with diastasis of abdominal rectus muscles. In elimination of trocar defect with a mesh, diastasis of abdominal rectus muscles is

123

Hernia (2016) 20 (Suppl 2):S175–S249 often not eliminated on the top and bottom edges of the mesh fixation, forming a weak point, which leads to relapse. The aim of the research: Was to improve the results of alloplasty of trocar hernias in periomphalic region combined with diastasis of abdominal rectus muscles. Materials and methods: Allohernioplasty using «Ultrapro» mesh was conducted in 108 patients with trocar hernias of periomphalic area combined with diastasis of abdominal rectus muscles. The average age was 54.3. There were 77 women (71.3 %), and 31 men (28.7 %). Depending on the method of alloplasty, patients were divided into 2 groups. In group I, 55 patients underwent preperitoneal alloplasty without elimination of diastasis of abdominal rectus muscles. In group II, 53 patients underwent the «sublay» technique with elimination of diastasis of abdominal rectus muscles. Results and discussion: The results of treatment in the early postoperative period were comparable in both groups. Long-term results in the period of 6 to 48 months showed that out of 34 patients in group I, hernia recurrence was observed in 4 patients (11.8 %). In 33 patients of group II, hernia recurrence was not observed. Conclusion: Alloplasty by the «sublay» method with the elimination of diastasis of abdominal rectus muscles in trocar hernias of periomphalic area combined with diastasis of abdominal rectus muscles has been displayed, which improves the results of treatment. Improved results of treatment of trocar hernia combined with diastasis of abdominal rectus muscles are achieved by using the «sublay» technique with elimination of diastasis of abdominal rectus muscles.

P248 How to manage resistant mesh infection: hydrofiber dressing with silver, NaEDTA and BeCl M. Zuvela, D. Galun, S. Miric, N. Radojicic, N. Bidzic, I. Palibrk University Clinic for Digestive Surgery, HPB unit, Belgrade, Serbia Background: The study objective was to demonstrate a role of hydrofiber dressing with silver, natrium ethylenediaminetetraacetic acid—NaEDTA and benzethoniumchloride—BeCl (designed to disrupt biofilm) in the treatment of resistant mesh infection. Methods: Between January 2015–January 2016 10 patients with mesh infection following abdominal wall hernioplasty were managed using hydrofiber dressing with silver, NaEDTA and BeCl. Eight patients had 20–30 9 30 cm sublay heavy-weight polypropylene mesh infection and 1 patient had 30 9 30 cm intraperitoneal composite mesh infection. Staphylococcus aureus in 7 patients, staphylococcus aureus and acinetobacter in 1, proteus mirabilis and klebsiella/enterobacter in 1, and pseudomonas aeruginosa in 1 patient was isolated from the wound. The treatment included wound opening, mesh exposure and hydrofiber dressing with silver-NaEDTA-BeCl. Previous local treatments of mesh infection and specific antibiotic therapy were unsuccessful during mean follow-up of 84 (9-242) days. Results: Hydrofiber dressing with silver, NaEDTA and BeCl led to complete resolving of mesh infection and wound healing in all patients during the mean period of 123 (23–268) days and was achieved at average of 95 (12–215) wound bandaging. The bacteria in high number were present in the wound till the end of the treatment contrary to good clinical course of wound healing. In 6 patients 1-2 cm of mesh excision was done to stimulate wound closure and in 4 patients it was not necessary. There was 1 small asymptomatic hernia recurrence at the site of partial mesh excision and no mesh reinfection during the mean follow-up of 4.3 (1–10) months. Conclusions: Hydrofiber dressing with silver, NaEDTA and BeCl can be one of solutions in the management of resistant mesh infection following abdominal wall hernioplasty.

Hernia (2016) 20 (Suppl 2):S175–S249

P249 Experimental prosthetic repair with ultralight mesh use in contaminated wound V.V. Parshikov1, A.A. Mironov2, E.A. Anikina3, M.I. Zaslavskaya1, A.I. Alyokhin4, A.A. Kazantsev4 1 Nizhny Novgorod State Medical Academy, Hospital Surgery named after B.A.Korolyov, Nizhny Novgorod, Russian Federation, 2 Lobachevsky State University of Nizhny Novgorod, Neurotechnology, Nizhny Novgorod, Russian Federation, 3Hospital 35, Anesthesiology, Nizhny Novgorod, Russian Federation, 4Central Clinical Hospital of Russian Academy of Sciences, Scientific Work, Moscow, Russian Federation Background: The possibility of mesh use in contaminated area is discussed. Prosthetic repair associated with some risk of inflammatory complication. Which mesh is better for compromised wound is to date not defined. What surgical methods are optimal is yet not described. Need of mesh removal in cases developed inflammatory complications is also not confirmed. Ultralight materials use in contaminated fields are not studied. Methods: In Central Scientific Research Laboratory onlay and sublay repair are modeled in rats in contaminated conditions. Polypropylene, titanized polypropylene and titanium mesh were used. All meshes consider to ultralight category. In study groups operations area was infected with Escherichia Coli and Staphylococcus Aureus 108 CFU. In control group was no contamination in implantation zone. All rats were observed and inflammatory process was measured with special scale. Results: In sublay group we noted low inflammatory count than in onlay group in 2–10 days after surgery. In E. coli series the inflammation was higher than in S. aureus series. Maximal inflammation was marked in 3 day after operation in S. aureus series and in 4 day in E. coli series. In 14 days after surgery we noted no significant differences between basic and control groups. Nearly all meshes remains in situ. Conclusion: Prosthetic repair in contaminated area associated with high risk of inflammatory complications. Sublay position of endoprosthesis is some better than onlay. The mesh use in bacterial infected wound is common not recommended. Prosthetic repair in presence of infection is possible but requires the experience of such operations by surgeon. The mesh should be placed not in area of maximal contamination.

S249

P250 The adhesions formation challenge and the importance to choice the right mesh in the abdominal wall defects surgery. Experimental background and clinical report S. Cuccomarino Chivasso General Hospital, Surgery, Chivasso, Italy Background: Peritoneal reaction and adhesions formation are the main problems in the laparoscopic and open surgery of the abdominal wall defects. We present an experimental study on the adhesions formation after implanting six different meshes (Gore Dualmesh, Ethicon Proceed, Bard Composix, a Polypropylene + glycolic and lactic acid copolymer mesh, a Polypropylene + collagen mesh, and Herniamesh Relimesh) in 40 New Zealand rabbits, sacrificed at 48 h and at 4 weeks after surgery. By analyzing the macroscopic and microscopic data using the Zhlke scale we found that the collagen mesh induces a scarce adhesions amount; ePTFE alone produces adhesions and shrinkage. The adhesions induced by Relimesh are comparable to those of the collagen + polypropylene mesh. The difference between the Composix and Relimesh is possibly due to the evenness of its visceral side. Methods: Following that, we started to use Herniamesh Relimesh in our clinical activity. Since June 2008, we used that mesh in 212 patients (incisional hernia = 126, recurrent incisional hernia = 33, epigastric/umbilical hernia = 48, Spiegel hernia = 5; ratio M:F = 1:1 and the mean age = 51, 66 years, range 38–71, S.D. 12,258). Of the 212 meshes, 183 were implanted by laparoscopy and 29 in open surgery. All meshes were marked by two radiopaque clips in the cephalic extremity, to study its displacement in the follow-up. Results: The follow up was carried out at least for 2 years after surgery. We obtained an abdominal Rx to set the initial position of the mesh before discharging the patients. A week after surgery, all patients were in absolute wellness. At 6 months and 1 and 2 years they were free of recurrence and asymptomatic. We obtained a control Rx, to verify the clips positions that were unchanged respect the first Rx in all cases. Conclusions: Herniamesh Relimesh is manageable both in laparoscopic and open settings, is well tolerated and safe to use.

123

Hernia (2016) 20 (Suppl 2):S250–S258

ABSTRACTS

Author Index

 Springer-Verlag France 2016 Aasvang E.K., O026, S144 Abbonante F.A., P104, S205 Acosta S., O071, S154 Adamopoulos S., P137, S214 Adams A., P140, S215 Agca B., P004, S176 Agresta F., P027, S182 Agrusa A., P082, S198, P083, S199 Aguilar Romero L., P172, S225 Aguilera A., O043, S147, O116, S164, O151, S171, P166, S223 Aguilera Velardo A., O122, S166, P049, S189 Ahmed W.B., O073, S155 Akaraviputh T., P204, S234 Akkersdijk W.L., P146, S217 Al Mogrampi S., P100, S204, P102, S204 Alarco´n del Agua I., O152, S172, P170, S224, P172, S225, P239, S245 Alekseev S., P165, S222 Algasi A., P010, S177 Allegranzi B., P199, S233 Allieta R., P051, S189 Alves A., P044, S187 Alyautdinov R.R., P039, S186 Alyokhin A.I., P249, S249 Amato G., P082, S198, P083, S199 Amatucci F., P020, S180 Ambrosoli A.A., O121, S166, P192, S231 Ambrosoli A.L., P190, S230, P191, S230 Anastasiou E., P136, S214, P137, S214 Anaya-Reig P., P206, S235 Andresen K., P162, S222, O158, S173 Angelo Sorge A.S., P127, S211 Anghelici G., P243, S247 Anikina E.A., P249, S249 Anselmino M., O074, S155 Antor M., O052, S149, P156, S220 Antunes C., O048, S148 Anurov M., P217, S238 Anurov M.V., P139, S215 Anwar S., P047, S188 Argudo Aguirre N., O018, S143 Argu¨elles B., P022, S181, P174, S225, P227, S241 Armengol M., P198, S232 Arnautu O., P157, S221 Aro E., P093, S201 Arthofer K., P019, S180

123

Atema J.J., O024, S144, O053, S150 Aufenacker T.H.J., O094, S160, O099, S161 Augenstein V., O050, S149, P200, S233, P244, S247, P245, S247 Ausch C., P019, S180 Auvray S., P246, S248 Avram I.O., P151, S219 Aw D., P081, S198 Aydin T., P004, S176 Baanante J.C., P155, S220 Babii I.V., P103, S204, P123, S210 Babo A., O048, S148 Babovic M., P026, S182 Backer V., P042, S187 Balanya´ Vidal J., P117, S209 Baldan N., P230, S242 Baldjiev T., P040, S186 Ban˜uls Matoses A., P218, S239 Ba¨r A., P164, S222 Bara G.B., P196, S232 Barbosa F., P130, S212 Barker J., P153, S219, P154, S220 Barrat C., O049, S148, P236, S244 Barri J., P064, S193 Barrios P., P064, S193 Barthes T.B., P246, S248 Basile G., P105, S205 Basson R., P153, S219, P154, S220 Basta M.N., P033, S184 Bastiaansen-Jenniskens Y.M., O072, S154 Bayon Y., O072, S154, P044, S187 Becerra R., O043, S147, O116, S164, O122, S166, P049, S189, P166, S223 Bechstein W.O., P214, S237, O148, S170 Bellido Luque A., P239, S245, O152, S172 Bellido Luque J., P239, S245, O152, S172 Bellini R., O074, S155 Bellomo M.P., P111, S207 Bello´n J.M., P241, S246 Bellouard A., P246, S248 Belousov A.M., P089, S200 Belzacq T., P219, S239 Bendardaf R., P010, S177 Bendavid R., O032, S145, O132, S169 Bergamini S., P198, S232 Berger D., P060, S192

Hernia (2016) 20 (Suppl 2):S250–S258 Bergeron-Gigue`re G., P167, S223 Berkvens E.H.M., O064, S152, O086, S158 Bermingham H., P024, S181 Berrevoet F., O075, S155, O108-BO, S163, P171, S224, P234, S244 Berselli M., O121, S166, P192, S231, P144, S216 Berta R.D., O074, S155 Berti S.B., P088, S200 Bertrand C.L., P246, S248 Berwouts L., O108-BO, S163 Besora P., P086, S199, P087, S200, O077, S156 Beuran M., P059, S192 Bhargava A., P055, S191 Bianco F.M., O051, S149, O081, S157, P149, S218 Bidzic N., P248, S248, P034, S184, O055, S150 Biebl M., P178, S226, P201, S233 Bilbao E., P208, S236 Bilianskyi L., P181, S227 Binda M., P190, S230, P191 S230 Binda S., P191, S230 Bindhu Oommen B.O., P200, S233 Birlog C., P073, S196 Bisciotti G.N., P148, S218 Bisgaard T., O021, S143 Biswas S., P025, S181 Bittner R., O065, S153, O159, S174, P135, S214 Bjarnason T., O071, S154 Bjerg J., O158, S173, P162, S222 Bjo¨rck M., O071, S154 Blair L., O050, S149, P245, S247 Blay L., O077, S156 Blazquez L., O151, S171 Blazquez L.A., O043, S147, O116, S164, P166, S223 Blazquez Hernando L., O122, S122, P049, S189 Blesa Sierra E., P008, S177, P013, S178, P069, S195, P225, S240 Bloemen A., P158, S221 Boateng-Duah B., O062, S152 Bocchia P., P051, S189 Bockova M., P070, S195 Boermeester M.A., O024, S144, O053, S150, O115, S164, P199, S233 Boersema G.S.A., O072, S152 Bogdanovic A., P034, S184, O055, S150 Bohnert N., P164, S222 Bojovic P., P098, S203, P116, S208, P143, S216 Bo¨kkerink W.J.V., O078, S156, P145, S217, P146, S217 Bokun Z., P143, S216 Bolufer J.M., O129, S168, P218, S239 Bona A., P108, S206 Bonafe S., P173, S225, P174, S225, P011, S178 Bonafe Diana S., P227, S241, P022, S181 Bonan A., P236, S244 Bonjer H.J., O065, S153, P037, S185 Borasi A., P110, S206, P222, S240 Borces D., P151, S219 Borreca D., P110, S206, P222, S240 Borroni G., O121, S166, P192, S231, P144, S216 Bosanquet D., P068, S195 Bossi M., O049, S148 Bossotti M., P111, S207 Bougard H., P194, S231 Bouvy N.D., O089, S159, P062, S193, P158, S221 Brachet Contul R., P051, S189 Bradley T., O050, S149 Brancato G., P105, S205 Brandsma H.T., O107-BO, S162 Brankovic M., P116, S208 Bridoux V., O052, S149, P156, S220 Brigman S., O082, S157 Bringman S., P194, S231 Brito T., P130, S212

S251 Brochu G., P167, S223 Bruno S.B., P088, S200 Brunon C., P044, S187 Buccianti P., P021, S180 Budzynski A.B., P242, S246 Bueno J., P011, S178, P173, S225, P174, S225 Bueno Lledo´ J., P022, S181, P227, S241 Bukin A., P025, S181 Bulca F.A., P059, S192 Buqueras M.C., P064, S193 Burcharth J., P162, S222, O158, S173 Burgmans J.P., P195, S232 Burgmans J.P.J., O003, S139 Bury K., O107-BO, S162 Busch D., P177, S226 Bustos Jimenez B.J.M., P170, S224, P172, S225 Butro´n Vila T., P208, S236 Buyne O., O066, S153 Bystricky P., O076, S156 Cabeza Go´mez J.J., P008, S177, P013, S178, P161, S221, P182, S228, P225, S240 Cachaldora Alejo S., P117, S209 Caciolo F., P108, S206, P109, S206, P110, S206, P111, S207, P222, S240 Calais L., P130, S212 Campanelli G., O030, S145 Camps J., P086, S199, P087, S200, O077, S156 Canuto R.A., P216, S238 Carandina S., O049, S148 Carbonell A.M., P065, S194 Carbonell-Tatay A., P206, S235 Carmona D., P086, S199 Caro F., O129, S168, P218, S239 Carvajal N., P011, S178 Cas O., P236, S244 Casp-Vanaclocha V., P206, S23 Castello G., P053, S190, P121, S210, P188, S229 Castello´n Pavo´n C., O122, S166 Catala` J., P064, S193 Celik K., P004, S176 Cengiz Y., O154, S172 Ceno M., P060, S192 Ceriani I., P144, S216, P190, S230 Cesana G., P053, S190, P121, S210, P188, S229 Ceulemans R., O075, S155 Chadwick M., P131, S213 Chan W.H., P081, S198 Charbon J.A., P212, S237 Chatzikalfas A., P196, S232 Chelala E., O085, S158 Chen F.Q., P048, S188, P107, S206, P113, S207 Chen J., O130, S168, O117, S165, O157, S173, P048, S188, P107, S206, P113, S207, P221, S239, P231, S243 Chen D.C., O005, S140, O029, S145 Chenjie C.J., O104, S162 Chudy M., P194, S231 Cianfarani A., P125, S211, P126, S211 Ciccarese F., P053, S190, P121, S210, P188, S229 Cijan V., P098, S203, P116, S208, P143, S216 Ciric B., P193, S231 Ciritsis A., P177, S226 Claes K., P171, S224 Claveria R., P086, S199, P087, S200 Clay L., P232, S243 Clemens C.H.M., P180, S227 Cobuccio L., P021, S180, P071, S196 Cocozza E., O121, S166, P144, S216, P190, S230, P191, S230, P192, S231 Coe P., P153, S219, P154, S220

123

S252 Colavita P., O050, S149 Comas J., P064, S193 Cornille J.B., P018, S179 Cornish J., P068, S195 Cossa J.P., P246, S248 Cox T., O050, S149, P245, S247 Crudu O., P243, S247 Cruz A., O043, S147, O116, S164, O151, S171, P166, S223 Cruz Cidoncha A., O122, S166, P049, S189 Cuccomarino C., P250, S249 Cuccurullo D., O065, S153 Cuffari S., O121, S166, P190, S230, P192, S231 Currado F., P057, S191, P058, S192 Da Ros D., O000, S139, P061, S193 Dabic D.D., P050, S189, P115, S208 Dabrowski A., P236, S244 Dadaian V.A., P247, S248 Dahlstrand U., O123, S166 Dahlstrand U., O111, S164, P003, S175 Daikou P., P063, S193 Dalila Patrizia Greco S.S.A., P020, S180 Daniels I.R., O153, S172, P018, S179 Danielsen C., O092, S160, O093, S160 Danu M., P243, S247 d’Arienzo S., P021, S180 Daskalaki D., O051, S149, O081, S157, P149, S218 De Beaux A.C., O015, S142, O095, S160 de Bruijn J.A., P184, S228 de Goede B., O106-BO, S162 de Gols J.D.G., P168, S223 de Luca G.M., P007, S176 de Maria C., P016, S179, P160, S221 de Matteis A., P057, S191, P058, S192 de Paolis P., P108, S206, P109, S206, P110, S206 , P111, S207, P222, S240 de Ridder V., O037, S146 de Vries F.E.E., O024, S144, P199, S233, O053, S150 de Vries H.S., P229, S242 de Vries J., O078, S156 De Vries Reilingh T.S., O086, S158, P212, S237 Deerenberg E.B., O014, S141 Deigaard S., P162, S222, O158, S173 Delaunay T.H., P246, S248 Delgado M., O048, S148 Delgado S., P155, S220 Dellinger E.P., P199, S233 Demertzidou E., P100, S204, P102, S204 Demetrashvili Z., P215, S238 Dencic S., P193, S231 Devaja A., P040, S186 di Buono G., P082, S198, P083, S199 di Marzo F., P021, S180, P071, S196, P148, S218 Dı´az-Tobarra M., P206, S235 Dieleman J.P., P184, S228 Dietmar R., P218, S239 Diklic D.D., P179, S227 Dillemans B., O059, S151 Docobo Durantez F., P170, S224, P172, S225 Doerhoff C., O082, S157, P194, S231, P234, S244 Dominguez I., P208, S236 Domı´nguez Serrano I., P008, S177 Donati M., P105, S205 Dounavis A., P063, S193, P136, S214, P137, S214 Dritsoulas L., P063, S193 Dumon K.R., O110, S163, P002, S175 Duraki R., P143, S216 Dura´n Mun˜oz Cruzado V., P170, S224 Durazzo C., P106, S205

123

Hernia (2016) 20 (Suppl 2):S250–S258 Durgam S., O051, S149, O081, S157, P149, S218 Durkovic A., P098, S203 East B., O025, S144 Efremov O., P025, S181 Efthymiou G., P005, S176 Egger M., P199, S233 Ehrenmu¨ller M., P019, S180 Eickhoff R.M., P043, S187, P176, S226, P177, S226 Ekberg O., O057, S151 Emanuelsson P., O123, S166 Emir S., P090, S200 Emmanuel K., P077, S197, P210, S236 Ene S., P141, S216 Eng K.H., P081, S198 Engin Hatipoglu E.H., P118, S209 Ernst L., P176, S226 Errebo M.B., O158, S173, P162, S222 Ertem M., P097, S203, P129, S212 Espert J.J., P155, S220 Espı´n Bassany E., P046, S188 Estela Vila L.M., P008, S177 Evola F., P057, S191, P058, S192 Falk P., P232, S243 Fanjul M., P208, S236 Farassino L., O121, S166, P144, S216, P192, S231 Fardellas I., P100, S204, P102, S204 Fatih Dal F.D., P118, S209 Fei L., O000, S139, P061, S193 Fei Landino L.F., P074, S196 Felberbauer F.X., P202, S234 Felbinger S., O017, S142, P056, S191 Feleshtynskyi Y.P., P095, S202, P247, S248 Felicioni L., P021, S180, P071, S196 Fernandez E., O077, S156, P087, S200 Fernandez Mun˜iz P.I., P092, S201 Fernandez Ramos M., P172, S225 Ferna´ndez-Gutie´rrez M., P241, S246 Ferri F., P109, S206 Festa F., P216, S238 Festa V., P216, S238 Feuerstake D., P151, S219 Filiou S., P101, S204 Filipovic N., P186, S229 Filippa C., P109, S206 Fischer J.P., O079, S157, O110, S163, P002, S175, P033, S184, P035, S184, P036, S186, P213, S237 Fish R., P153, S219, P154, S220 Florez Gamarra M., P182, S228 Fonnes S., P162, S222, O158, S173 Forni S., P021, S180 Fortelny R., O014, S141, O091, S159, O155, S172, P077, S197 Fox J.P., O079, S157, O110, S163, P002, S175, P035, S184 Fragassi F., P007, S176, P066, S194 Frajer L., P070, S195 Francone E.F., P088, S200 Friis-Andersen H., O092, S160, O093, S160 Fromont G., P236, S244 Galatioto C., P021, S180, P071, S196 Galun D., O055, S150, P034, S184, P248, S248 Galvan A., O043, S147,O116, S164, O122, S166, P049, S189, P166, S223 Galvanin J., O121, S250, P144, S216, P190, S230 Galych S.P., P181, S227 Gandhi P., P085, S199 Garcia Bear I., P029, S182, P092, S201, P211, S236 Garcıa del Can˜o J., P206, S235 Garcia Fernandez A., P182, S228

Hernia (2016) 20 (Suppl 2):S250–S258 Garcı´a Galocha J.L., P008, S177, P013, S178, P069, S195, P225, S240 Garcı´a Moreno J., P239, S245, O152, S172 Garcı´a Pastor P., P022, S181, P117, S209, P227, S241, P011, S178, P173, S225, P174, S225, P206, S235, P207, S235 Garcia Uren˜a M.A., O122, S166, P049, S189 Garcia-Alamino J., O107-BO, S162 Garcia-Dominguez R., P011, S178 Garcia-Uren˜a M., O043, S147, O116, S164, O151, S171, P166, S223 Gencic M., P098, S203, P116, S208 Gerasimchuk E.V., P224, S240, P226, S241 Gerosa Martino G.M., P041, S186, P099, S203 Gevondyan N.M., O088, S158 Ghiglione F., P222, S240 Ghiglione F., P109, S206, P110, S206, P111, S207, P108, S206, P222, S240 Gia L., P021, S180, P148, S218 Giaccone M., P057, S191, P058, S192 Gianluca Cassese M., P133, S213 Gijbels M.J.J., O089, S159 Gillion J.F., P236, S244 Ginghina O., P073, S196, P157, S221, P209, S236 Giorgi R., P121, S210, P188, S229 Girardi A., P007, S176, P066, S194 Giulianotti P.C., O051, S149, O081, S157, P149, S218 Gkanas P., P005, S176 Goderich Lalan J.M., P015, S178 Goedhart E., P195, S232 Go¨genur I.G., P017, S179 Gogia B.S., P039, S186 Go¨k H., P097, S203, P129, S212 Golling M., O017, S142, P056, S191 Gomes D., P130, S212 Gomez Menchero J., P239, S245, O152, S172 Goncc¸alves M.R., P130, S212 Gong D., O150, S171, P094, S202 Gonza´lez E., O043, S147, O116, S164, O122, P049, S189, P166, S223 Gonzalez Perrino C., P161, S221 Gonzalez-Ciccarelli L.F., O051, S149, O081, S157, P149, S218 Gonzalez-Heredia R., O051, S149, O081, S157, P149, S218 Goossens R.H.M., O149, S171 Gorsky V.A., P235, S244 Grande L., O018, S143 Granderath F.A., P177, S226 Grewe A., P183, S228 Grivon M., P051, S189 Groene S., P200, S233, P244, S247, P245, S247 Grossiord C., P044, S187 Grotenhuis B., O037, S146 Gruber-Blum S., O091, S159 Guadalajara Jurado J., P239, S245, O152, S172 Guarner Piquet P.O.L., P155, S230 Guarnieri F., P106, S205 Guerin G., O149, S171 Guillaume O., O091, S159 Gulotta E., P082, S198, P083, S199 Gunnarsson U., O111, S164, O123, S166, P003, S175, P232, S243 Gutierrez Corral N., P211, S236, P029, S182 Guzzetti L., P190, S230, P191, S230, P192, S231 Gvenetadze T., P120, S209 Hachisuka T.H., P142, S216 Halmerbauer G., P019, S180 Hamel S., O052, S149 Hanada K.H., P189, S230 Hansen N.L., P177, S226 Hansson B.M.E., O107-BO, S162 Harlaar J.J., O149, S171 Harries R., P067, S194, P068, S195 Harsløf S., O092, S160, O093, S160

S253 Harsløf T., O092, S160, O093, S160 Haslinger R., P019, S180 Hata H.H., P189, S230 Hattori K.H., P142, S216 Hauge D., O158, S173, P162, S222 Hehir A., O125, S167 Hehir D.J., O125, S167 Heisterkamp J., O128, S168 Helgstrand F.H., P017, S179 Hemberg A., P152, S219 Heniford B.T., O050, S149, P200, S233, P244, S247, P245, S247 Henriksen N.A., O014, S141 Hertsi M., O131, S169 Heywood N., P153, S219, P154, S220 Hickey L.M., P131, S213, P237, S245 Hlavacek C., O050, S149 Hoch J., O025, S144, P070, S195 Hoksbergen A.W.J., P037, S185 Holmberg H., O033, S146 Hooks Iii W.B., P140, S215 Hop W.C., O106-BO, S162 Hope W.W., O082, S157, P065, S194, P140, S215, P194, S231 Hopson S., P038, S185, P234, S244 Horikawa H.M., P223, S240 Horobryh T.V., P089, S200 Hsu Y., P035, S184 Hu J., O080, S157 Huang L., P028, S182 Huet E., P156, S220 Hueting W.E., P180, S227 Hulmi T., O126, S167, O131, S169 Huntington C., O050, S149, P245, S247 Hupfeld L., P162, S222, O158, S173 Huyghe M., P045, S188 Iakovlev V., O032, S145, O132, S169 Ikai I.I., P189, S230 Ildefonso Cienfuegos C., P092, S201 Ilic S., P193, S231 Iliopoulou S.M., P005, S176 Ilves I., O131, S169 Inkila¨inen A., P032, S183 Ioannidis A., P220, S239 Ioffe O., O090, S159 Iordache N., P073, S196, P157, S221, P209, S236 Iosifescu R., P073, S196, P157, S221 Ipponi P., P021, S180 Iscan Y., P004, S176 Isernia R.M., P007, S176, P066, S194 Iserte J., P011, S178, P022, S181, P173, S225, P174, S225, P227, S241 Iskra Marco M.P., O018, S143 Israelsson L., O154, S172 Ivankiv T.M., P134, S214 Izrailov R.E., P089, S200 Jacobs I., O075, S155 Jairam A., O012, S141, O016, S142 Janczyk R., P065, S194 Jang Y.S., P080, S198 Jeekel J., O106-BO, S162, O124, S167, O149, S171 Jensen K.K., O058, S151, O109, S163, P001, S175, P042, S187 Jeurie¨ns-van de Ven S.A.H., P229, S242 Jime´nez C., O116, S164, P166, S233, O043, S147 Jimenez Ceinos C., O122, S166, P049, S189 Jimenez Valladolid D., P182, S228 Jime´nez -Valladolid Conde´s D., P008, S177, P013, S178, P161, S221 Jimenez-Valladolid D., P069, S195, P225, S240, P182, S228 Joachimova M., O025, S144 Jones P., O082, S157, P194, S231

123

S254 Jorge Barreiro J.I., P029, S182, P092, S201, P211, S236 Jørgensen L.N., O109, S163, O058, S151, P001, S175, P042, S187, P234, S244 Josa Martinez B.M., P182, S228 Josa Martinez M.B., P161, S221 Jovanovic B., P186, S229 Jovanovic S., P006, S176, P186, S229 Jurczak F., P236, S244 Kalinovskyi S.V., P228, S241 Kalogridaki E., P063, S193 Kamptner N., P019, S180 Karip B., P004, S176 Katayama K.T., P114, S208 Kaufmann R., O119, S165 Kazantsev A.A., P249, S249 Kelz R.R., O110, S163, P002, S175, P035, S184 Kercher K., P244, S247, P245, S247 Keus E., O034, S146 Keus F., P145, S217 Khachatrian G.V., P235, S244, P139, S215 Khalil H., O052, S149, P156, S220, P236, S244 Kharyshyn O.M., P119, S209, P228, S241 Kilian M., P178, S226, P201, S233 Kingnsnorth A., P208, S236 Kjaer M., O058, S151 Kleinrensink G.J., O106-BO, S162, O124, S167, O149, S171 Klinge U., O035, S146, O146, S170, O156, S173, P176, S226, P177, S226, P183, S228 Klink C.D., P043, S187, P176, S226, P177, S226 Kluge A., P183, S228 Knol J., P168, S223 Ko¨ckerling F., O010, S141, O016, S142, O060, S152, O100, S161, P077, S197 Ko¨hler G., P077, S197, P210, S236 Kohoutek L.K., P072, S196 Kokhanevych A.V., P095, S202 Kokotovic D., O042, S147, P017, S179 Kolinovic M., P026, S182 Ko¨nigswieser T., P019, S180 Koning G.G., O078, S156, P145, S217, P146, S217 Konstantinidis I., P136, S214 Koprek K.D., P179, S227 Kops N., O072, S154 Ko¨ssi J., O126, S167, O131, S169 Koudjeti R., P084, S199 Kouhia S., P093, S201 Koulousakis A., P196, S232 Kouridakis P., P101, S204 Kovach S.J., O079, S157, O110, S163, P002, S175, P033, S184, P213, S237 Koziel S., P078, S197 Kraft M., P198, S232 Kra¨mer N.A., P177, S226 Krejci T., O025, S144 Krexi A., P100, S204, P102, S204 Kroese L.F., O149, S171 Krones C.J., P043, S187 Kruyt P.M., P229, S242 Krystek N., P218, S239 Ku¨hnhardt A., P241, S246 Kukosh M., P240, S246 Kulic Vojkan K.V., P147, S217 Kullman E., P234, S244 Kumata K.Y., P205, S235 Kyle-Leinhase I., O016, S142, O075, S155, O107-BO, S162 Lacy A.M., P155, S220 Lafranceschina S., P007, S176, P066, S194

123

Hernia (2016) 20 (Suppl 2):S250–S258 Lamberty C., P151, S219 Lambertz A., P043, S187, P176, S226, P177, S226 Lammers B.J., P164, S222 Lange J.F., O037, S146, O072, S154, O106-BO, S162, O124, S167, O149, S171 Lange J.F.M., O034, S146 Lanni M.A., O110, S163, P002, S175, P033, S184, P035, S184, P036, S185, P213, S237 Lanza C., P190, S230 Lanzuisi F., P125, S211 Lapid A., P140, S215 Lapid O., O024, S144 Latham L., O121, S166, P144, S216, P190, S230, P191, S230, P192, S231 Lazaridou E., P005, S176 Le Mair L.H.P.M., P185, S229 Leblanc K., P234, S244 Lechner M., P077, S197, P210, S236 Leclercq W.K.G., P212, S237 Ledaguenel P., P246, S248 Lee J.B., P080, S198 Lee S.D., P080, S198 Leenders B., P212, S237 Legnani G., P053, S190, P121, S210, P188, S229 Lemaire J., P246, S248 Lemeschewskij A., P165, S222 Lemiasheuskaya S., P165, S222 Lepere M., P236, S244 Lerchuk O.M., P134, S214 Leyman P., P045, S188 Li B., P094, S202, O150, S171 Li Q., P048, S188 Lica M., O054, S150, P141, S216 Lilic A., P193, S231 Lim K.W.E., P081, S198 Lincourt A., P244, S247, P200, S233, P245, S247 Lincourt A.E., O050, S149 Liu J.L., P231, S243 Liu Y.T., O130, S168 Livraghi L., O121, S166, P192, S231, P144, S216 Ljungberg B., P032, S183 Ljungdahl M., O111, S175, P003, S164 Lomanto D., O080, S157, O118, S165, P138, S215, P238, S245 Lomba J., P130, S212 Lo´pez M., P198, S232 Lo´pez P., O043, S147, O116, S164, P166, S223 Lo´pez Cano M., P030, S183 Lo´pez Monclu´s J., O116, S164, O043, S147, O151, S171, P166, S223, O122, S166, P049, S189 Lo´pez Quindos P., O122, S166, P049, S189 Lopez Vizcayno M., P208, S236 Lopez-Cano M., O016, S142, O018, S143, O107-BO, S162, P046, S188 Lopez-Quindo´s P., O151, S171 Lorenz R., O010, S141 Lorusso R., P051, S189 Loumpias C., P136, S214 Lourens H.J., P229, S242 Lubrano T.L., P096, S202 Luigi d’Ambra L.D., P088, S200 Lukavetskyy O.V., P134, S214 Luna Vazquez L., P015, S178 Lundstrom K.J., O033, S146 Lupu G., P243, S247 Magne E., P246, S248 Makarevich A., P165, S222 Mamound A., P180, S227 Mancini R., O074, S155 Manfredi S., P108, S206 Manno F., P104, S205

Hernia (2016) 20 (Suppl 2):S250–S258 Mansor S., P010, S177 Manto Ottavia O.M., P074, S196 Marchand P., P246, S248 Marco Colella M.C., P125, S211, P126, S211 Marco Gallinella Muzi M.G.M., P125, S211, P126, S211, P127, S211 Maric B.M., P050, S189, P115, S208 Marioni A., P021, S180, P071, S196 Marola S., P108, S206, P109, S206, P110, S206, P111, S207, P222, S240 Martin Cartes J., P170, S224, P172, S225 Maruyama H.M., P142, S216 Marzetti M.A., P027, S182 Massa S.M., P133, S213 Massalis I., P005, S176 Matikainen M., O126, S167 Matis G., P196, S232 Matlok M.M., P242, S246 Matsusue R.M., P189, S230 Matyja M.M., P242, S246 Maya Aparicio A.C., P172, S225 Mayer F., P077, P210, S236, S197 Mazza E., P096, S202 Medi F., P021, S180 Meier A., P151, S219 Melero D., O043, S147, O116, S164, O151, S171, P166, S223 Memisoglu K., P004, S176 Merigliano S., P230, S242 Merlier O., P246, S248 Mesero Montes D., O122, S166, P049, S189 Metin Ertem M.E., P118, S209 Metreveli T., P215, S238 Metzger R., P151, S219 Meyer V.M., O034, S146 Michalakis D., P100, S204, P102, S204 Michiels M., O075, S155 Mido˜es A., P130, S212 Miguel Aguirre M.A., P203, S234 Miller L., P038, S185 Miller S.E., P055, S191 Millo P., P051, S189 Milosevic P., P026, S182 Mimi Kim M.K., P200, S233 Mingarelli V., P021, S180, P071, S196, P148, S218 Minguez Ruiz G., P029, S182, P092, S201, P211, S236 Miric S., P034, S184, P248, S248 Mironov A.A., P249, S249 Mirzabeigi M.N., O110, S163, P002, S175, P033, S184, P036, S185 Miserez M., O014, S141 Mitura K., P078, S197, P079, S197 Mizuno Y.M., P142, S216 Mladenovik D., P040, S186 Mo Y., P094, S202, O150, S171 Moccia Francesco F.M., P074, S196 Moftah M., P010, S177 Molegraaf M.J., O037, S146 Molina Fernandez E.J., P015, S178 Molina-Rodriguez J.L., P206, S235 Molinete M., P086, S199, P087, S200, O077, S156 Mollen R.M.H.G., P229, S242 Mommers E.H.H., O086, S158, P212, S237 Mommers E.M.M., O064, S152 Montemurro F., P016, S179, P160, S221 Montgomery A., O046, S148, O057, S151, O071, S154, O155, S172 Morales Conde S., P239, S245 Moreno A., O043, S147, O116, S164, O122, S166, O151, S171, P049, S189, P166, S223 Moretto C., O074, S155 Mori T.M., P142, S216 Morino M., P096, S202 Moriyoshi K.M., P189, S230

S255 Moroni Maurizio Renato M.M.R., P041, S186, P099, S203 Moscatelli F., P106, S205 Mosconi C., P125, S211, P126, S211 Mullaney P.J., P169, S224 Munegato G., O000, S139, P061, S193, P074, S196 Munim K., O058, S151 Mun˜oz Lo´pez Pelaez V., P008, S177, P013, S178, P069, S195, P225, S240 Munteanu R., P073, S196, P157, S221 Murdoch J., P194, S231 Muschalla F., P135, S214 Musil J.M., P072, S196 Mustonen K., O131, S169 Muysoms F.E., O014, S141, O016, S142, O075, S155, O107-BO, S162, O108-BO, S163, P234, S244 Muzi M.G., P234, S244 Muzio E.M., P088, S200 Muzio G., P216, S238 Mykytiuk S.R., P009, S177, P103, S204 Naafs D., P195, S232 Nanavati J., P122, S210 Nardi M.J.R., P051, S189 Narita M.N., P189, S230 Natali A.N., P230, S242 Nederhoed J.H., P037, S185 Nerenz H., O127, S168 Neumann U.P., P043, S187, P176, S226, P177, S226 Nie N., O117, S165 Nie X., O150, S171, P094, S202 Nienhuijs S.W., O064, S152, O086, S158, O120, S165, P212, S237, P234, S244 Nieuwenhuizen J., O124, S167 Nikolopoulos N., P137, S214 Nikolovski A., P040, S186 Noone T.M., O153, S172 Nordin P., O033, S146, P150, S218, P152, S219 Nuntasunti B., P204, S234 Nwamba C., P106, S205 Obdeijn M.C., O024, S144 Oettinger A.P., P139, S215, P235, S244 Oggioni M., P191, S230 Ogurtsov O.V., P134, S214 Oikonomou X.O., P137, S214 Olmi S., P053, S190, P121, S210, P188, S229 Oma E., O109, S163, P001, S175 Ong H.S., P081, S198 Ong W., P138, S215 Oppong F.C., O063, S152 Ordrenneau C., O149, S171 Orfanakos I., P101, S204 Origi M., P041, S186, P099, S203 Orozco N., P218, S239 Otani T.O., P189, S230 Otero Diez J.L., P029, S182 Otto J., P177, S226 Owen R.E., P067, S194 ¨ z A., P097, S203 O Ozcabi Y., P004, S176 ¨ zveri E., P097, S203, P129, S212 O Paajanen H., O126, S167, O131, S169, P093, S201 Pachera P., P230, S242 Padillo Ruiz F., P170, S224, P172, S225 Padula G., P020, S180 Palencia N., O043, S147, O116, S164, O122, S166, O151, S171, P049, S189, P166, S223 Palibrk I., P248, S248, P034, S184, O055, S150 Papajikolaou S., P063, S193

123

S256 Park J., O091, S159 Parry C.R., P067, S194 Parshikov V.V., P052, S190, P249, S249 Pascual G., O069, S154, P241, S246 Pascual Montero J.A., P208, S236 Pasierbek M., P078, S197 Pasternak A.P., P242, S246 Pathak S., P018, S179 Paul D., P060, S192 Paul Colavita P.C., P244, S247 Pavan P.G., P230, S242 Pavlovoc A., P186, S229 Payma Armas N., P117, S209 Pedziwiatr M.P., P242, S246 Peiro F., O129, S168, P218, S239 Pejcic V., P186, S229 Pen˜a Soria M.J., P008, S177, P013, S178, P069, S195, P161, S221, P182, S228, P225, S240 Peng Y., P094, S202, O150, S171 Pera M., O018, S143 Pereira Rodriguez J.A., O018, S143 Pe´rez Jime´nez A.E., P008, S177, P012, S178, P013, S178, P069, S195, P182, S228, P225, S240 Pe´rez-Bru S., P206, S235 Pe´rez-Ko¨hler B., P241, S246 Permekerlis A., P101, S204 Persico F., P051, S189 Persoon A.M., P146, S217 Pession U., O148, S170, P214, S237 Petersson U., O071, S142 Petousis S., P101, S204 Petrovsky Alexandr N., P031, S183 Petter-Puchner A., O040, S147, O091, S159 Pezzuto R., P126, S211 Phalanusitthepha C., P204, S234 Philipszoon F.A., P054, S190 Philipszoon P.C., P054, S190 Piccinni G., P066, S194 Picone E., P125, S211, P126, S211 Pidmurnyak O.O., P228, S241 Pierie J.R.E.N., O034, S146 Piero Maida P.M., P127, S211 Pino Dıaz V., P170, S224, P172, S225 Pirtac I., P243, S247 Pisarenco S., P243, S247 Piza-Katzer H., O023, S143 Planells Roig M., O129, S168, P218, S239 Plechacova P.P., P072, S196 Pletinckx P., O075, S155 Ploeg J.R., O034, S146 Poli A., P207, S235 Polivoda M.D., P139, S215, P235, S244 Polliand C., O049, S148 Polyzos A., P100, S204, P102, S204 Ponce Villar U., O129, S168, P218, S239 Ponte E., P051, S189, P096, S202 Porwal A., P085, S199 Poulose B.K., P065, S194 Prager G., P202, S234 Prando D., P027, S182 Prasad T., O050, S149, P200, S233, P244, S247, P245, S247 Pratschke J., P178, S226, P201, S233 Prepodobnyi V.V., P247, S248 Prosvitliuk P.V., P103, S204 Protasov A.V., O088, S158 Prystupa M.E., P123, S210 Psarologos M., P005. S176 Pulito M., P020, S180

123

Hernia (2016) 20 (Suppl 2):S250–S258 Quintodei V., O121, S166, P192, S231, P144, S216 Raakow J., P178, S226, P201, S233 Radojicic N., P248, S248 Radu A., O054, S150, P141, S216 Radu V.G., O054, S150, P141, S216 Rajput I., P047, S188 Rapoport A., P025, S181 Raveglia V., P144, S216, P192, S231 Redan J.A., P194, S231 Redl H., O091, S159 Redwan A.A., O073, S155 Rees B., P067, S194, P068, S195 Reggiani V., P053, S190, P121, S210, P188, S229 Reinisch A., O148, S170, P214, S237 Reinpold W., O010, S141, O159, S174 Revuelta Alonso B., P208, S236 Reynvoet E., O059, S151 Ribas S., O048, S148 Richter R., P196, S232 Rieger R., P019, S180 Ristagno M., P105, S205 Rivera Alonso D., P008, S177, P012, S178, P013, S178, P069, S195, P225, S240 Rizzetto C., O000, S139, P061, S193, P074, S196 Robı´n A., O043, S147, O116, S164, O151, S171, P166, S223 Robı´n del Valle Lersundi A., O122, S166, P049, S189 Robres J., P064, S193 Rodriges A.C., P130, S212 Rodrı´guez R., O077, S156, P086, S199, P087, S200 Rodrı´guez M., P241, S246 Rodriguez Infante A., P029, S182, P092, S201, P211, S236 Rogmark P., O057, S151, O071, S154 Ro¨hr S., P151, S219 Romano G., P082, S198, P083, S199 Romanovsky V.P., P123, S210 Romanowski C., O082, S157 Ronald Sing R.F.S., P200, S233 Roos M.M., P195, S232 Rosen M.J., P065, S194 Rosenberg J., P162, S222, O158, S173 Rossetti Gianluca G.R., P074, S196 Rothman J.P., P162, S222, O158, S173 Roumen R.M., O031, S145, P187, S229 Roumen R.M.H., P184, S228, P185, S229 Ruano Campos A., P225, S240 Rubio Gonza´lez E., P208, S236 Rusell I., P068, S195 Sa´ez Carlin P., P008, S177 Sakata K.S., P142, S216 Salazar D., O077, S156, P086, S199 Salvischini L., P021, S180 Sambuco M., P191, S230 Samuel Ross S.W.R., P200, S233 San Roma´n J., P241, S246 Sa´nchez Garcı´a M., P013, S178, P069, S195 Sanchez Ramirez M., P239, S245, O152, S172 Sanchez Turrion V., P029, S182, P092, S201, P211, S236 Sancho Insenser J.J., O018, S143 Sancho Muriel J., P022, S181, P227, S241, P173, S225, P174, S225 Sanders D.S., O155, S172 Sandblom G., O111, S164, P003, S175 Sanders F., P195, S232 Sandrucci S., P057, S191, P058, S192 Santiago Martin M.C., P208, S236 Sanz Ortega G., P008, S177 Saraceno F., P125, S211, P126, S211

Hernia (2016) 20 (Suppl 2):S250–S258 Sarangi R., P122, S210 Sawilah A., O074, S155 Scepanovic M., P098, S203, P116, S208, P143, S216 Schardey H.M., P128, S212 Scheidbach H., P112, S207 Scheidig J., O091, S159 Scheltinga M.R., O031, S145, O106-BO, S162, P184, S228, P185, S229, P187, S229 Schiano di Visconte M., O000, S139, P061, S193 Schoonjans C.S., P045, S188 Schopf S.K., P128, S212 Schreinemacher M., O068, S153, O089, S159, P062, S193 Schrittwieser R., P077, S197, P210, S236 Schulte-Ma¨ter J., P178, S226, P201, S233 Schu¨tze F., P151, S219 Schwartz M., P234, S244 Schwarz J., O159, S174, P135, S214 Schwarz L., O052, S149, P156, S220 Scott M.H., P237, S245 Selmani A., P084, S199 Selmo G., P191, S230 Semeraro C., P198, S232 Semple S., P237, S245 Serlie M.J.M., O053, S150 Shadsky S.O., P235, S244 Sheen A.J., O097, S161 Shemyatovsky K.A., O088, S158 Shen Y., O157, S173 Shen Y.M., O130, S168, P048, S188, P107, S206, P113, S207, P221, S239 Shen Yingmo S.Y.M., O104, S162 Shikano T.S., P142, S216 Shizuku M.S., P142, S216 Shubinets V., O110, S163, P002, S175, P033, S184, P036, S185, P213, S237 Shubinets V.S., O079, S157 Siawash M., O031, S145, P187, S229 Silvasti S., O126, S167 Simons M., O156, S173 Simons M.P., P150, S218 Simons M.S., O155, S172 Sivkov A.S., P235, S244 Slawinski C.G.V., P153, S219, P154, S220 Smaldone W., P106, S205 Smart N.J., O153, S172, P018, S179 Smeeing D.P.J., P229, S242 Smietanski M., O016, S142 Smirnova E.D., O088, S158 Smishchuk V.V., P247, S248 Sohn T.I., P080, S198 Sokratous A., O056, S150 Solomkin J.S., P199, S233 Solomonov E., P025, S181 Sorce V., P082, S198, P083, S199 So¨relius K., O071, S154 Sørensen F.S., O158, S173, P162, S222 Sorge Angelo M., P133, S213 Sotomayor S., P241, S246 So¨zen S., P090, S200, P091, S201 Spanu A., P073, S196 Sta Clara E., O080, S157, O118, S165, P138, S215, P238, S245 Stanley Getz S.G., P200, S233 Stark B., O123, S166, P232, S243 Stavridis G.J., P040, S186 Stechemesser B., O010, S141, P076, S197 Stefanopoulos A., P005, S176 Stetsenko O., O090, S159 Steyerberg E.W., P184, S228 Striga˚rd K., O123, S166, P032, S183, P232, S243 Stu¨ben B.O., P043, S187

S257 Suarez Gra´u J.M., O152, S172, P239, S245 Subirana H., P064, S193 Suenaga Y.S., P142, S216 Sukovatykh B.S., P224, S240, P226, S241 Suleyman Demiryas S.D., P118, S209 Sun L., O157, S173, P048, S188 Sunagawa Y.S., P142, S216 Svensson M., O071, S154 Swank D.J., O037, S146 Tabbara M., O049, S148 Tabriz N., O127, S168 Tahir S., P040, S186 Takeda N.T., P142, S216 Talboom K., P124, S211 Tamayo Lopez M.J., P170, S224, P172, S225 Tan W.B., O080, S157, O118, S165, P138, S215, P238, S245 Tang J., P028, S182 Tang S.W., O118, S165 Tapiolas I., P198, S232 Tarasiuk T., O090, S159 Tassinari D., O074, S155 Tecce M.G., P033, S184, P035, S184, P036, S185, O110, S163, P002, S175, P213, S237 Tejada Gomez A., O152, S172, P239, S245 Ten Cate T.H.J., O001, S139 Ten Cate Hoedemaker H.O., O007, S140 Ten Hove W.R., P180, S227 Teramoto H.T., P142, S216 Testini M., P007, S176, P066, S194 Therkildsen R., O158, S173, P162, S222 Tinoco Gonzalez J., P170, S224 Titarov D.L., O088, S158 Titkova S., P217, S238 Titkova S.M., P139, S215 Todorovic Z., P193, S231 Todros S., P230, S242 Tolba R.H., P176, S226 Tollens T., O082, S157, O108-BO, S163, P234, S244 Tong S., P138, S215 Toorenvliet M.R., P054, S190 Torensma B., O037, S146 Torkington J., P067, S194, P068, S195, P169, S224 Torregrosa A., P011, S178, P022, S181, P117, S209, P173, S225, P174, S225, P227, S241 Torres Garcı´a A.J., P008, S177, P013, S178, P069, S195, P161, S221, P182, S228, P225, S240 Tran H., O065, S153 Tran H.M., O144, S170 Trukhalev W., P240, S246 Tsanidis P., P100, S204, P102, S204 Tsimpoukidi O., P063, S193, P136, S214 Tsiura I.U., O090, S159 Tuech J.J., O052, S149, P156, S220 Turcu F., P209, S236 Turquier F., O149, S171, P219, S239 Uccelli M., P053, S190, P121, S210, P188, S229 Ungari L., O121, S166, P144, S216, P191, S230 Usai A., P051, S189 Uslar V., O127, S168, P183, S228 Utomo L., O072, S154 Uzunkoy A., P163, S222 Vallribera Valls F., P046, S188 Valuiskaya N.M., P224, S240, P226, S241 Valverde A., P246, S248 Valverde S., P030, S183 Van Bakel T.M.J., P054, S190

123

S258 Van Cauwenberge S., O059, S151 Van Cleven S., P171, S224 Van den Hil L.C.L., O089, S159, P062, S193, P158, S221 Van der Harst E., O072, S154 Van Geldere D., O096, S161 Van Hout L., O128, S168 Van Kempen B.J., O106-BO, S162 Van Kleef M., P185, S229 Van Laarhoven C.J.H.M., O078, S156, P145, S217, P146, S217 Van Landuyt K., P171, S224 Van Langenhove K., O059, S151 Van Ramshorst G.H., O065, S153, O106-BO, S162, P037, S185 Van Ruler O., O053, S150 Van Steensel S., P062, S193, P158, S221 Van Wingerden J.P., O022, S143 Vangertruyden G.V., P168, S223 Vanlander A., O075, S155, O108-BO, S163 Vannucci A., P021, S180 Varsa G., P059, S192 Vasco M.A., P064, S193 Vasulaki M., P136, S214 Vatamaniuk V.F., P095, S202 Vega Rojas L.A., O077, S156, P086, S199, P087, S200 Vegleur A., P219, S239 Velangi P., P139, S215 Velickovic J., O055, S150 Velickovic N., P193, S231 Velkov S., P193, S231 Velluti F., P108, S206, P109, S206, P110, S206, P111, S207, P222, S240 Venclauskas L., O014, S141 Verhagen H.J.M., O124, S167 Verhelst J., O124, S167, O149, S171 Verleisdonk E.J., P195, S232 Veronesi Paolo V.P., P041, S186, P099, S203 Verroiotou M., P100, S204, P102, S204 Veysel Umman V.U., P118, S209 Vidotto C., P096, S202 Vieiro V., P208, S236 Vigna S.A.M., P027, S182 Vijfvinkel T.S., O124, S167 Villanueva-Figueredo B., P046, S188 Vin˜as X., P087, S200 Vironen J., O131, S169 Visser-Vandewalle V., P196, S232 Vlasov V.V., P103, S204, P123, S210, P228, S241 Vlasova K.V., P228, S241 Vlasova O.V., P103, S204 Vles W.J., P054, S190 Vlieger E.J.P., O008, S140 Vogels R.R., O089, S159

123

Hernia (2016) 20 (Suppl 2):S250–S258 Volenko A.V., P235, S244 Voorbrood C.E., P195, S232 Voropai D.A., O034, S146 Vozzi G., P016, S179, P160, S221 Vriens P.W.H.E., O078, S156, O128, S168 Vries Reilingh T.S., O064, S152 Vujcic V.D., P179, S227 Wagenaar S., P037, S185 Wallert E.D., P199, S233 Wang B.S., P107, S206 Wang Baoshan B.S., O104, S162 Wara P., O092, S160, O093, S160 Warren J.A., P065, S194 Wegdam J.A., O064, S152, O086, S158 Westin L.C., O111, S164, P003, S175 Wetterslev J., P145, S217 Weyhe D., O127, S168, O156, S173, P183, S228 Wijerathne S., O080, S157, O118, S165, P138, S215, P238, S245 Wijsmuller A.R., O034, S146, O106-BO, S162, P150, S218 Wilke R.W., O133, S169, P233, S243 Williams C.R., P067, S194 Williams Z., P140, S215 Winther D., O158, S173, P162, S222 Wirth U., P128, S212 Wisselink W., P037, S185 Woeste G., O016, S142, O148, S170, P214, S237 Wollert S., O111, S164, P003, S175 Wong W.K., P081, S198 Wundsam H., P210, S236 Wurst C., P132, S213, P175, S225 Xie H., O150, S171, P094, S202 Xie Z., O150, S171, P094, S202 Yamaguchi T.Y., P189, S230 Yang S., P113, S207, P221, S239 Yildiz E., P097, S203 Zagoruyko V.V., P123, S210 Zaranis C., P236, S244 Zaslavskaya M.I., P249, S249 Zatir S., P084, S199 Zherdev N.N., P224, S240 Zielska Z.Z., P056, S191 Zinther N., O092, S160, O093, S160 Zuliani Walter Z.W., P041, S186, P099, S203 Zuvela M., O055, S150, P034, S184, P248, S248 Zwaans W.A.R., P184, S228, P185, S229