Hernia (2015) (SuppI2):S3-S194

INGUINAL HERNIA: RECURRENCES, TAILORED SURGERY & PUBIC INGUINAL PAIN SYNDROME (SPORTSMAN HERNIA) © Springer-Verlag 2014

C023:01 COLLAGEN TYPES I AND III RATIO AS A PREDICTOR OF RECURRENCE RATE IN PATIENTS WITH INGUINAL HERNIA: A RETROSPECTIVE STUDY S G Shapovalyants l , AI Michalev l , M E Timofeev\ V G Polushkin l , V V Volkov l , A P Oettinger IRussian National Research Medical University, Department ofHospital Surgery 2, Moscow, RUSSIA 2Russian National Research Medical University, Institution ofApplied Medical Sciences, Moscow, RUSSIA Introduction: The choice of operation for hernia is often based on hernia's clinical and anatomical characteristics. However, pathogenesis of hernias, which can be attributed mostly to collagen tissue disease, is often ignored. It is, in line with tactical and technical pitfalls, complications and inadequate physical activity in early postoperative period, one of the risk factors for hernia recurrence. Pulling aside the underlying genetic etiology, variations in collagen types I AND III ratio are considered the main displays of connective tissue disorder. They present the tissue component of hernia and related connective tissue pathology. The aim of the study was to define tissue-associated factors, contributing to recurrence rate after inguinal hernia repair. Materials and methods: 122 patients (male 112, female 10, age 19-70, mean 53,5+ 14,01) with inguinal hernias were included in the study/ Main group of 97 patients, divided into two subgroups: with (1) hernia - 82 pts. (primary unilateral - 33, bilateral - 31, and recurrent hernias - 18) and 15 pts. with (2) primary Bassini repair without recurrence at two years follow-up. 25 patients in control group with neither hernia nor clinical signs of connective tissue disorder. In all patients specimens of skin 3x3 mm were taken using scalpel, fixed, paraffin-embedded, cut with microtome, stained with Sirius Red and analyzed with microscope using polarizer. Photos of 3 different areas were taken and their color scheme was analyzed by Image-Pro Plus® program pack. Collagen types ratio was attributed to color distribution and thus calculated. Results: Figures show statistically significant median decrease and bandwidth reduction from control group (2,92 to 12,60, mean 5,57) and patients after successful Bassini surgery (3,93 to 8,33, mean 6,50) to patients with unilateral (2,03 to 7,09, mean 4,35), bilateral (2,14 to 6,48, mean 4,00) and recurrent (2,40 to 4,90, mean 3,50) hernias. Threshold level was calculated based on confidence limit of control group - it appeared to be 4,64. Implying this to our patient group, we've found a that collagen types I and III ratio was below this level in 48% of control group, 57% - in unilateral, 64 - in bilateral and 94 - in recurrent hernia patients. Conclusion: I. Decreased collagen types I and III ratio can be a part of inguinal hernia recurrence pathogenesis. 2. Digital analysis of microscopic photos (skin samples 3x3 mm staining) is in effective way to

analyze this ratio. 3. Threshold level for collagen types I and III ratio is 4,64. All ratios below this level can possibly mark the collagen pathology. 4. Decreased ratio mostly associated not with bilateral hernia, but with hernia recurrence 5. When planning an inguinal hernia surgery, preoperative collagen types I and III ratio count can be an additional factor in choosing a procedure type.

C023:02 RECURRENT INGUINAL HERNIAS - A PERSISTENT PROBLEM IN HERNIA SURGERY? ANALYSIS OF 14640 RECURRENT CASES IN THE GERMAN HERNIA DATABASE "HERNIAMED" R Lorenzi, A Koch2 , F K6ckerling3 IHernia Center 3 Chirurgen, Berlin, GERMANY 2Surgical Practise, Cottbus, GERMANY 3Klinikfor Allgemein, Viszeral und GefiiJ3chirurgie, Vivantes Klinikum Spandau, Berlin, GERMANY Introduction: Today we have many options to treat inguinal hernias. In the past the recurrence was the only crucial point for the evaluation of the surgery. Meanwhile the problem of pain is more and more in the focus of the Hernia surgeons but the recurrence is still an ongoing problem. There is a considerable difference ofthe evaluated recurrence rates of different randomized controlled studies and metaanalysis of any technique to the results in most of the Hernia Databases. Since many years a recurrence rate of more than 10% in the registries seems to be accepted. One of the biggest issues also today is how can we prevent recurrences in inguinal hernia repair and how we can treat them sufficiently. Methods: We analyse the results of the German Hernia Database Herniamed. We are presenting the statistics comparing all since 2009 registered inguinal hernias to all registered recurrent inguinal hernias. Additional we use a multivariate analysis to answer the following questions of recurrent inguinal hernias: - What types of Hernia have most of the recurrences? - Which comorbidities? Which risk profiles are related to recurrences? - What time after primary repair develops a recurrence? - Which operation techniques are linked to most of the recurrences? - Is the treatment of recurrences more complicated than the primary repair? Results: In the database we identify 133.029 inguinal hernias. 13% (14.640) of them are recurrent cases. 1359 (9.3 %) of these had a second recurrent hernia, 294 (2.0 %) had already a third recurrent inguinal hernia and 144 (0.9 %) cases have more than 3 hernia operations in the medical history. Every technique with or without meshes has also multiple recurrences, but most of them are after an pure tissue repair 55.14% after an open - non-mesh repair, 23.86 % after open mesh repair and 20.91 % after endoscopic repair) Early recurrences are same

~ Springer

Hernia (2015) (Suppl 2):S3-S 194

S168

frequent like recurrences after years (14.18% after 1 year, 20.89% after 10-20 years) Direct Hernias are more linked to recurrences (55.18% direct or combined hernias in recurrences and 47.15% direct and combined hernias in primary cases). Males are more affected then females in recurrent cases (91.37% vs 8.63% for recurrences and 87.97% vs 12.03 % for primary cases. 56.56% of the recurrent inguinal Hernias have obesity with a BMI more than 25 . Males with an age of more than 50 years are more affected as females with the same age (74.50% vs.64.07%) Conclusion: Recurrences are an ongoing problem in the repair of inguinal hernias. Also after mostly use of meshes for inguinal hernia repair we count about 13 % recurrences in our German Hernia Database. The recurrences are influenced by biological, technical and surgical factors. To identify them and to develop an adapted tailored approach of the treatment is helpful to reduce the problem in the future . L~lsl~nhernl~: L~IZI~ Vorop~rAtlon

with a Hazard ratio of 3.1 (CI 95% 2.4 - 3.9) compared with IIH at primary operation (p < 0.001), and that laparoscopic operation gave a lower risk of recurrence with a Hazard ratio of 0.57 (CI 95% 0.43-0.75) compared with Lichtenstein's technique (p < 0.001). Conclusion: In a female nationwide prospectively gathered cohort we found that operation for a DIH resulted in a higher risk of reoperation than operation for an IIH. We found that femoral hernia recurrences exclusively existed after anterior open primary operation.

C023:04 LAPAROSCOPIC INGUINAL HERNIA REPAIR PERFORMED IN PUBLIC HOSPITALS OR LOW-VOLUME CENTERS HAVE INCREASED RISK OF REOPERATION FOR RECURRENCE K Andresen', H Friis-Andersen2, J Rosenberg' 'Department of Surgery, Herlev Hospital, University afCopenhagen, Copenhagen, DENMARK 2Department of Surgery, Horsens Hospital, Horsens, DENMARK

C023:03 DIRECT INGUINAL HERNIAS ARE DOMINATING IN FEMALE INGUINAL HERNIA RECURRENCES J Burcharth' , K Andresen' , H-C Pommergaard', T Bisgaard2• 3, J Rosenberg" 3 'Center for Perioperative Optimization, Department of Surgery, Herlev Hospital, Herlev, DENMA RK 2Department of Surgery, Hvidovre Hospital, Hvidovre, DENMARK 3The Danish Hernia Database, Copenhagen, DENMARK Purpose: The relationship between the type of inguinal hernia (direct inguinal hernia (DIH), indirect inguinal hernia (IIH)) at the primary and recurrent hernia operation procedure has not been studied in a large-scale female population. The purpose of this study was to establish the risk of recurrence after direct and indirect inguinal hernia operation, and to establish the relationship between the type of hernia at the primary and recurrent procedure. Methods: Using data from the Danish Hernia Database (DHDB) a cohort was generated: all females operated electively for a primary inguinal hernia operated by either Lichtenstein's technique or laparoscopy from 1998 to 2012. Within this prospectively collected cohort the hernia type at the primary procedure (DIH, IIH), the hernia type at the recurrent procedure (DIH, IIH, femoral hernia) and time from primary procedure to reoperation were registered. Results: A total of 5,758 females with primary elective inguinal hernia operation in the study period (62 % IIH, 38 % DIH) were included with a median follow-up time of 72 months (range 0 to 169). A total of 304 operations for recurrences were registered (56 % inguinal recurrences, 38 % femoral recurrences, 6 % not specified), which corresponded to an overall reoperation rate of 5.3 %. All femoral recurrences occurred after a previous open anterior operation. The crude reoperation rate after primary DIH operation was 9.1 %, and 3.0 % after primary IIH operation (p < 0.001). The multivariate adjusted analysis found that DIH at primary operation was a substantial risk factor for recurrence ~ Springer

Introduction: Inguinal hernia repair is traditionally carried out as either open or laparoscopic repair. Laparoscopic repair has been shown to be superior in terms of pain and discomfort, but has a higher risk of reoperation. Quality of inguinal hernia repair is related to factors, such as method of repair, characteristics of patients, and possibly the annual volume of procedures performed by a center. The aim of this study was to test the hypothesis that hospital volume and type of hospital (private versus public) could influence the reoperation rate for recurrence as a marker of surgical quality of care. Methods: This study was based on data from the Danish Hernia Database covering the period from January I, 1998 to December 31 , 2013. Hernia repairs included in this study were laparoscopic repair of primary, inguinal hernias in the elective setting, performed on adult male patients. Results: A total of 14,532laparoscopic repairs were included for analysis. Centers reporting less than 50 procedures a year had a significantly higher cumulative reoperation rate compared with centers reporting more than 50 procedures a year (9.97% versus 6.06 %) P < 0.0001. Private centers had a lower cumulative reoperation rate compared with public centers: 5.36% versus 8.53% p = < 0.0001. Type of center and center volume were both independent risk factors for reoperation in a Cox regression model. Conclusion: Hospital volume had an effect on the reoperation rate for recurrence after laparoscopic inguinal hernia repair. Furthermore, private centers performed better than public centers irrespective of volume.

C023:05 THE SURGICAL STRATEGY FOR LAPAROSCOPIC APPROACH IN RECURRENT INGUINAL HERNIA REPAIR (A REPORT OF 225 CASES) J W Li', F Le, M H Zheng 'Ruijin Hospital, Shanghai Jiaotong University School ofMedicine., Shanghai, CHINA Objective: To evaluate the surgical stragety for laparoscopic approach in recurrent inguinal hernia repair. Methods: Between January 200 I and December. 20 II, the clinical data of 213 patients with 225 recurrent inguinal hernias underwent laparoscopic repair were retrospectively analyzed in our hospital. There were

Hernia (2015) (SuppI2):S3-S194 174 TAPP, 41 TEP and 10 IPOM procedures performed with this series of patients. The follow-up period ranged from 15 to 60 months (median 42 months). No patient lost to follow-up during the investigation. Results: 48 TAPP and 26 TEP were applied to 77(32.9%) recurrent hernias after conventional suture repair; 23 TAPP and 15 TEP were utilized to 38(16.9%) recurrent hernias after Lichtenstein repair; 90 TAPP and 1 IPOM were employed for 91 (40.4%) recurrent hernias after Patch and Plug repair; and the other 22 (9.8%) recurrent hernias after preperitoneal repair were repaired by using l3 TAPP and 9 IPOM techniques. No conversion to open surgery was observed. The average operative time was 38.9 ± 14.3(15-90)min. No patients required analgesia postoperatively. The postoperative average VAS score was 2.4 ± 1.1(1.2-6.4), the average hospital stay was1.7 ± 1.5(l-9)d with the patients returned to unrestricted activities in two weeks was 99.6%. No recurrence was observed during the follow-up. The accumulative postoperative complications rates was 11.1 %(25), with one severe complication (surgical intervention was needed) as intraabdominal infection(O.4%), as well as other 24 complications including 15 cases of seroma (6.7%), 5 cases of urinary retention (2.2%), 3 cases with transient paresthesia (1.3%) and I case withparalytic ileus (0.4%). Conclusions: TAPP and TEP are both feasible and efficacious techniques to treat recurrent hernias after suture repair and Lichtenstein repair, while the choice depends on surgeons' experience. Most recurrent hernias after Patch and Plug repair could be treated successfully by TAPP but TEP technique is not encouraged. For recurrences after preperitoneal repair, the TAPP repair should be recommended as first choice, while IPOM is a good technique to cope with the cases which TAPP failed.

C023:06 LAPAROSCOPIC TAPP REPAIR FOR RECURRENT INGUINAL HERNIA: IS ACTUALLY EFFECTIVE IN HIGH-RISK PATIENTS?

F Rosciol, F Combi l, P Frattinil, F Clerici l, I Scandroglio l I Galmarini Hospital - Department of Surgery - Division of General Surgery, Tradate, ITALY

Purpose: The recurrence rate of inguinal hernia varies between 0.5 and 15%, depending on both the type of primitive hernia and the repair technique. Laparoscopic transabdominal preperitoneal (TAPP) repair provides satisfactory short-and long-term outcomes in the treatment of inguinal hernia recurrence. However, often TAPP is not considered for high-risk patients (HRP) due to their frialty and significant comorbidities. This study aims to evaluate the short-term results ofTAPP for the treatment of recurrent inguinal hernia in HRP, assuming that there are no statistically significant differences compared to low-risk patients (LRP). Methods: HRP are defined as those that have at least one characteristic between age> 80 years, ASA score> 2, a history of major abdomino-pelvic surgery and BMI > 30 kg/m2. We retrospectively considered a consecutive unselected series of39 patients who underwent TAPP at our division for recurrent unilateral inguinal hernia (Nyhus classification 4) between January 2010 and December 20l3. Of these patients, 21 (53.8%) were HRP, 18 (46.2%) LRP. Surgical technique, instrumentation, prosthesis and fixation devices have been standardized. All operations were performed by the same team. For each cohort, we analyzed demographics, disease- and surgery-related data. Comorbidity was assessed using the Charlson Comorbidity Index (CCI), complications through the Clavien-Dindo classification system. Short-term follow-up was conducted at 30 and 60 days. Continuous variables were analyzed using the Student t test, while categorical ones were analyzed by the Fischer test or Chi-square test, where appropriate. P < 0.05 were considered statistically significant.

S169 Results: HRP and LRP were comparable about the type of recurrence, whereas, by definition, age, BMI and ASA score were statistically different. A significantly higher CCI has characterized HRP (4.0 ± 2.1 vs 1.6 ±0.9, p <0.005). The operative time (77.4± 14.0vs 74.9± 11.8 min, NS), estimated blood loss (29.0 ± 28.0 vs 31.7 ± 23.2 ml, NS) and length of hospital stay (1.4 ± 0.5 vs 1.2 ± 0.4 days, NS) were statistically comparable. No conversion was recorded in the two cohorts. The complication rate was 19.0 vs 16.6%, NS and 9.5 vs 5.5%, NS respectively for Clavien-Dindo grades I and II. We did not record complications of higher grade in the two groups. We did not observe hospital readmissions within 30 days of surgery. We have not recorded cases of early recurrence during the short-term follow-up. Conclusions: The risk variables considered do not seem to significantly increase neither the operative time nor the complication rate. TAPP is safe and effective even in HRP and we believe that this category of patients may have a greater benefit from a minimally invasive treatment of recurrent inguinal hernia.

C023:07 APPLICATION OF LAPAROSCOPIC TRANSABDOMINAL PRE PERITONEAL REPAIR FOR RECURRENT INGUINAL HERNIA X Zhao l, Y Nie, J Liu, M Wang lBeijing Chao-Yang Hospital, Beijing, CHINA

Introduction: Recurrent inguinal hernia continue to be a problem, the emergence of the laparoscopic repair provides a better solution. It's necessary to explore the surgical techniques and the clinical effect of laparoscopic repair for recurrent inguinal hernia. Methods: Clinical data of 130 cases of recurrent inguinal hernia who underwent TAPP repair from Mar. 2009 to Dec. 2012 in Beijing Chao-Yang Hospital of Capital Medical University were retrospectively analyzed. Results: Operations were completed successfully in 129 cases and 1 case was converted to open surgery. The operation time was (54.5 ± 16.I)min (30-100 min) and the hospital stay was (4.5 ± 2.1) d (2-11 d). The rates of postoperative pain, hydrocele, and urinary retention were 3.8% (5/130), 11.5% (15/130), and 1.5% (2/l30) respectively. There were no complications such as foreign body sensation, wound infection, and intestinal obstruction after operation. All cases were followed-up for 7-50months [(24.3 ± 11.3) months] with no recurrence was observed. Conclusion: Laparoscopic TAPP repair for recurrent inguinal hernia has advantages of minimal invasion and few complications, it's safe and effective.

C023:08 ANTERIOR OPEN PREPERITONEAL MESH REPAIR IN RECURRENT INGUINAL HERNIA L Kuo', C C Tsai, K T Mok, S I Liu, I S Chen, N H Chou, B W Wang, Y C Chen, B M Chang, T J Liang, C H Kang, C Y Tsai lKaohsiung Veterans General Hospital-Department of General Surgery, Kaohsiung, TAIWAN Introduction: Open preperitoneal mesh repair is a traditional procedure and is still commonly performed in patients with recurrent inguinal hernia. Although recent literature reported less recurrence rate and groin pain in laparoscopic repair than open repair, similar outcomes can be achieved in some specific and large-volume institutions. Today we share our experience in Nyhus procedure with acceptable recurrence and complication rates.

~ Springer

S170 Materials and Methods: Three hundred and eighty-three consecutive patients having recurrent inguinal hernias from January 2004 to October 2014 in our hospital were included and the charts were reviewed. Among them, 206 patients (53.8%) underwent Nyhus procedure. Patients having less than one-year follow up and not being contacted by telephone were excluded. Finally, 165 patients were enrolled and were asked about complications and recurrence. Results: The patient population comprised 161 men and 4 women. The mean age of these 165 patients was 70.65 years (range, 6-92 years). No procedure-related mortality was noted. Complications were recorded, including 2 urine retention, 4 chronic groin pain, 16 seromas, one wound infection, and all of them were simply resolved after management except for groin pain. The mean time of follow up was 63.4 months. There were 10 cases of recurrence (6.0%). Three (1.8%) of them, which consisted of two missing hernias, were found within one year and we defined that as true recurrence related to failure of procedure. Conclusion: Nyhus procedure, known as preperitoneal approach from the virgin site for recurrent inguinal hernia, is less popular due to the increasing prevalence of laparoscopic hernioplasty. However, it takes less operative time and is highly effective when taking cost into consideration. It is also superior to laparoscopic procedures in some selected patients only capable of performing spinal anesthesia. As reported in our study, Nyhus procedure has a low recurrence rate and only some minor complications. Missing hernia is the leading cause of early recurrence and is thought to be resulted from misunderstanding the anatomy of groin areas. In spite of the laparoscopic generation, we still recommend that all general surgeons should be familiar to this safe and useful method as a choice of recurrent inguinal hernia repair.

C023:09 COMPLICATED GROIN HERNIA: RECURRENT, BIG, AND RISKY

MDudai l lHernia Excellence, Ramat Aviv Medical Center, Tel Aviv, Israel The debate between LaplEndo versus Open Groin Hernia repair for the average patient is not completed yet, but Complicated Hernia is much more undefined. We like to light up the variety and complexity of the treatments and to describe our outcome experience of the Complicated Hernia. Recurrent Hernia it is a real challenge for the surgeon, the patient is suffering from a failed repair and he should not confront more a risk of recurrence! Recurrent Hernia should be repair by Hernia expert and not by a surgeon that do by the others hernia repair. Failed tissue repair widely accepted that should be repaired with mesh. Known statement is that failed anterior repair has to be repair by posterior repair and failed posterior repair (Lap/Endo) by anterior one. This is because you like to repair with virgin tissue and to escape the failed mesh. This statement ignores the fact that posterior failed mesh still can trap a bowel after anterior repair. Recurrence after Lap/Endo occurs because of inaccurate mesh placement or incomplete dissection. In our experience Lap TAPP approach gives excellent view of the place and reason of the recurrence and ability to complete the repair of the pathology without the need to repeat the entire repair! Big Hernia has higher risk for recurrence, mostly because the defect in the posterior inguinal wall is big. Big defect will need a bigger size of mesh, the posterior approach will enable placement of larger mesh size. For very big defect there is a limit of the mesh size one can place and to the amount of fixation. In spite of this understanding the recurrence of Big Hernia is higher than of regular hernia. In 1994 we published in Nyhus Hernia textbook our technique of two layers of repair for big hernia; a dynamic plug "Dudai butterfly" in the defect

~ Springer

Hernia (2015) (SuppI2):S3-S194 as first layer and a wide mesh on top as a second layer. Since then to date we are using this technique with very good results similar to the regular hernias. A Risky Hernia is that one that you know that has a high chance for recurrence. The two main groups are: a) Edematous tissue surface that will cause the mesh to slip and not to incorporate. Typical two examples are: Incarcerated Hernia and protein malnutrition (not so uncommon situation!). b) Tissue healing deficiency that will affect the collagen formation process. Typical pathologies are: Smoking, Obesity and systemic Steroid treatment. For the "Edematous tissue" group you should not select the posterior approach that needs a surface for mesh incorporation. For the "Healing deficiency" group you should select the posterior TEP approach with wide mesh and extra fixation and not to be depended on the anterior tissue healing. Complicated Groin Hernia is a challenge for the surgeon and the patient and should be repair by Hernia expert. Expert experience is needed for the surgical skill but also for selecting the right surgery that has to be tailored to the patient condition. For Recurrent and Big Hernia you can have similar results as for regular hernia, for Risky Hernia you can improve the results.

C023:10 A RETROSPECTIVE ANALYSIS OF 56 RECURRENT HERNIA CASES RECEIVED TEP AFTER INGUINAL HERNIOPLASTY WITH PLUG PERFIX MESH

Y J Zeng l, T LLiu l, C M Shi', L Sunl, R Shu l 1Department of Gastroenterology and Hernia, the first affiliated hospital of Kunming Medical University, Kunming, CHINA

Introduction: To explore the feasibility and safety ofthe laparoscopic totally extraperitoneal prosthesis(TEP) in the treatment of recurrent inguinal hernia after plug perfix mesh repair. Methods: 56 TEP cases of recurrent inguinal hernia after plug perfix meshes repair were retrospectively analyzed in the Department of Gastroenterology and Hernia of the first affiliated hospital of Kunming Medical University from January 2011 to September 2013. Results: All operations were successfully performed. No injury of major structures and infection. The operative time was (43 ± 12.6) mins (31-7Imins), intraoperative blood loss of5 ± 7 ml (3-20 ml), postoperative hospital stay was 1.2 ± I d (I-3d), postoperative pain (visual analogue scale VAS> 4) incidence was 27% (15/56), seroma 30% (17/56), urinary retention 25% (14/56), scrotal emphysema 61 %(34/56). All patients were followed up for 6 months without recurrence. Conclusion: TEP is feasible and safe for patients of recurrent hernia after inguinal hernioplasty with plug perfix mesh, but good skill is required for the repairing of broken peritoneum.

C023:11 LOCKING PROCEDURE TO PREVENT RECURRENT INGUINAL HERNIA AFTER LAPAROSCOPIC HERNIOPLASTY M Kawaguchi I, Y Takahashi I, M Tochimotol, Y Horiguchi I, H Kato I, K Tawaraya l, 0 Hosokawa l 1 Yokohama Sakae Kyosai Hospital, Yokohama, JAPAN Introduction: Laparosocopic hernioplasty is widely distributed in Western world. It provides ideal fixation of the orifice and less surgical

Hernia (2015) (SuppI2):S3-S194 pain for inguinal hernia. However, randomized study has been shown higher recurrence than open procedure. Therefore, preventive procedure for recurrent inguinal hernia was an important issue. For preventing recurrence after laparoscopic hernioplasty, EHS guidelines recommended larger size of the prosthesis. However, the sufficient size of prosthesis and the reason has not been defined. Prosthesis must be important for laparoscopic hernioplasty. however, other factors could be existed. Preventing procedures of acquired inguinal hernia after prostatectomy has been developed, without using prosthesis. Authors have been reported a mechanism of the acquired inguinal hernia seemed like a swing door at the inguinal ring. Preventing procedures for inguinal hernia could be implied to lock the swing door phenomenon. Under these considerations, a locking procedure to prevent recurrent inguinal hernia was developed. This study aimed to make a preliminary study of the locking procedure for laparoscopic hernioplasty. Feasibility and safeness of the procedure were evaluated. Additionally, new laparoscopic plugging procedure with the locking method was developed. Patients and methods: April 2013 to August 2014,187 patients had inguinal hernioplasty in our institute for adult patients. Of those patients, 32 patients had laparoscopic hernioplasty. Laparoscopic hernioplasty is about 3 folds expensive than ordinary open methods in Japan. Therefore, a decision of approaches was depended on a patient's thought, after an explanation of features of the approaches. Procedure of laparosocopic hernioplasty for inguinal hernia Three procedures were performed in this study. Trans-abdominal preperitoneal method (TAPP), laparoscopic plugging for direct hernia and laparoscopic plugging for indirect hernia were performed. Alliaparoscopic approach and preperitoneal dissection were similar to TAPP approach. However, the range of preperitoneal dissection at the inguinal area was limited around a hernia orifice. Additionally, preperitoneal layers at the outer side of the deep inguinal ring were cut and dissected. Then, prosthesis was fixed to the point by absorbable tacks. All laparoscopic hernioplasty were performed this locking method at the inguinal ring. Selection of the procedures were decided by one surgeon on the intraperitoneal findings. As for plugging procedures, various types of plugs were used not to depend on the kind of the plug. Evaluation: Each patients were recorded of age, sex, diagnosis, surgical procedures and prognosis. For the diagnosis, side of hernia and type of inguinal hernia were recorded. For surgical procedure, type of surgical procedure and surgical time are recorded. In type of bilateral inguinal hernia, each side of surgical time was evaluated to be a half time. Postoperative complications and recurrences were evaluated. The primary end point of the study was recurrence and post surgical pain after I year, which were evaluated by physical exam, CT and interview. Results: Inguinal hernia were performed 176 and II in men and women, respectively. Laparoscopic hernioplasty were performed 32 patients in men. Side of inguinal hernias were right 11, left 10 and bilateral II lesions. Then, 43 lesions were performed laparoscopic hernioplasty. The type of hernia were indirect 21, direct 19 and pantaloon type 3. Among the type of hernia, surgical time was longer in the pantaloon type. On the other hand, no significant difference of surgical time was found among procedures. There was no complications and no recurrence in the study periods, especially neuralgic complications were not observed. Conclusion: On the present study, the locking procedure for the deep inguinal ring was feasible for laparoscopic hernioplasty. Laparoscopic plugging with the locking procedure could be useful for a specific inguinal hernia, however, generalization of the procedure should be dealt with carefully. Further prospective studies are demanded.

S171

C023:12 TAILORED TENSION-FREE GROIN HERNIA REPAIR BASED ON PATIENT'S MPO PATHOLOGY AND CO-MORBIDITY BURDEN C Huang 1• 2 lCathay medical center, Taipei, TAIWAN lTaipei medical university, Taipei, TAIWAN Introduction: Open tension-free repair has replaced Shouldice repair for adult groin hernia in our institution since 2001, this study is to report our experiences of tailored tension-free repair with selective usage of four types of mesh materials (onlay mesh, Plug & patch, Bi-layer, Kugel) based on each patient's MPO pathology and co-morbidity burden, the long-term results of 3473 sides of tailored repairs were analysed. Materials & Methods: A prospectively collected hernia database was established on 2999 consecutive pts with 3473 sides of tension-free groin hernia repair(including 430 repairs for recurrent groin hernia) from Feb 2001 to Jan 20l4.The database included patient's demographic characteristics, preoperative groin conditions, types of anesthesia, operative finding (Gilbert types), presence of lipoma, repair methods, types & size of the mesh used, postop stay, perioperative complications, postoperative pain scores at day I, day 6, day 90 and I to 12 years' follow-up data about chronic groin pain and recurrences. The selection of various types of mesh materials are based on individual hernia's Gilbert types, the severity of inguinal floor deterioration, pt's age and co-morbidity. Results: 3473 sides of tension-free repairs were performed including onlay mesh (103), Plug & Patch(979), Bilayer mesh(1583), Kugel or Modified Kugel mesh(808», age ranged from 19 to 103(median: 65)years old, local anesthesia was used in 15% ofpts, epidural 75%, General 10%. Gilbert types were: type 2 (6%), type 3 (41.5%), type 4 (19%), type 5 (6%), type 6 (27%), type 7 (0.5%). Cord lipoma was present in 23% of groins. Perioperative complications included superficial wound infection (0.5%), scrotal hematoma (1.5%), seroma (2%), testicular atroply (0.03%), the average postoperative pain scores (VAS; 0-5) were: day one (1.68), day 6 (0.99), day 90(0.3).6.9% ofpts had chronic inguinal discomfort(severe pain 0.8%), recurrences: 0.4% for the whole group, 2.0% for the recurrent hernia subset. Conclusions: Tailored open tension-free repair of groin hernia is simple & effective, over/ under-treatment can be avoided, however, accurate dissection of the anterior and posterior (preperitoneal) spaces in addition to selection of a proper synthetic mesh, with adequate re-enforcement of all the tripetriangles are essential for success.(2015, Milan)

C023:13 THE USE OF TABOTAMP COMPRESS IN THE INGUINAL HERNIA REPAIR A Sorgel, L Masonj2, R Magli0 3, F Di Marzo 1, C Mosconi., M Gallinella Muzi4 IOspedale S. Giovanni Bosco, Napoli, ITALY 20spedale S. Andrea, Roma, ITALY 30spedale Israelitico, Roma, ITALY 4Policlinico Universitario Tor Vergata, Roma, ITALY Introduction: The use of a non absorbable plug is controversial for related complications as reported in literature. The preliminary results of two surgical groups using TabotampR compress (TC) like a plug for inguinal hernia repair, is reported. The purpose of this clinical trial was to assess the performance ofTC as a plug, to facilitate the internal inguinal ring and posterior wall reconstruction and to reduce chronic pain and complications related to the use of a non absorbable material, maintaining the same recurrence rate. ~ Springer

SI72 Methods: Between June 2007 and September 2014 in two different Day Surgery Hospital units, a total of one hundred and seventy three adult patients underwent surgery for inguinal hernia repair. All patients were treated with an open tension-free hernioplasty with ProgripTM mesh. A completely absorbable TC was positioned in the defect to contain the sac before positioning the prosthesis. One hundred and forty six external oblique (L2-L3) and twenty seven direct inguinal hernias (M2-M3), were treated. All patients were clinically visited at one, three, six and twelve months after surgery to evaluate: infection, hematoma, seroma and chronic pain. Results: Early post-operative complications were: one case (0.57 %) of infection, two cases (1.15 %) of inguinal hematomas, one case (0.57 %) of pre-peritoneal hematoma extended by ten centimeters from the midline to the bladder with pain and fever (from five to ten post-operative days) resolved with an antibiotic therapy, no case of seroma. In no case was necessary to remove the prosthesis or to dislocate the same. At the long-term follow-up no case of chronic pain was noted or no severe complications were observed. Conclusion: TabotampR compress is an antibacterial absorbable hemostatic cellulose oxidised and regenerated at high density, that produces a fibrin tissue avoiding additional stich on the hernia port possible cause of chronic pain. Based on primary results this clinical trial demonstrates low complications rate. Moreover it has an easy reproducibility and it's a safe device for the surgeon to obtain a posterior wall and an internal inguinal ring reinforced.

C023:14 IMPACT OF HIGH BMI ON TECHNICAL DIFFICULTY OF TEP HERNIOPLASTY AMONG EXPERIENCED SURGEONS

J Katol, L Iuamoto l, A Meyer lUniversity of Sao Paulo Medical School, Sao Paulo, BRAZIL lDirector ofAbdominal Wall Repair Center - Samaritano Hospital, Sao Paulo, BRAZIL Introduction: Laparoscopic Totally Extraperitoneal (TEP) hernia repair is a technically demanding procedure though provides less postoperative pain, less complications and fast recovery. Recent studies have identified body mass index (BMI) as in independent factor for technical difficulty in the learning period. The aim of the present study is to analyze the effect of overweight and obesity on the technical difficulties ofTEP performed by experienced surgeons. Methods: Prospective study on patients who underwent a symptomatic inguinal hernia by means of the TEP technique between May 2009 and May 2014. Medical records from patients operated by senior expert surgeons were analyzed in terms of gender, BMI, previous surgery, hernia type, operative time and complications. Technical difficulty was defined by operative time, major complications and recurrence. Patients were classified into 4 groups: I) underweight, ifless than 18,5kglm2, 2) normal range ifBMI between 18,5 and 24,99kglm2, 3) overweight ifBMI between 25 and 29,99kglm2 and 4) obese ifBMI >= 30kg/m2. Results: The cohort of study had a total of 238 patients, 231 men and 7 women, who underwent 400 inguinal hernias repair by TEP technique. BMI values ranged from 16 to 36kg/m2 (average 25,8kg/m2). 0,42% were underweight patients, 41 % in normal range, 46,8% overweight patients and 11,6% obeses. 83 patients underwent previous surgery (34,87%). Direct hernias counted for 141 (35,2%) patients, indirect hernias for 254 (63,5%), femoral for 4 (1%), Spiegel for 1 (0,3%) and recurrent hernias for 48 (12%). There were 101 bilateral hernias (42,3%). Average operating time was 55,4 minutes per bilateral hernia (15-150) and 37,8 minutes per unilateral (\3-150). The time of

~ Springer

Hernia (2015) (SuppI2):S3-S194 surgery was correlated with BMI increasingly in the group of patients with unilateral surgery and no prior history of surgery (p = 0.027). Conclusion: Apart from surgeon's expertise, several clinical characteristics influence operative time. This study demonstrates a statistically significant effect of BMI on duration of TEP repair among experienced surgeons.

C023:15 IMPACT OF PREVALENCE OF PREVIOUS SURGERY ON TECHNICAL DIFFICULTY OF PATIENTS SUBMITTED TO HERNIORRHAPHY BY TEP TECHNIQUE

L Iuamoto l, J Katol, A Meyer lUniversity of Sao Paulo Medical School, Sao Paulo, BRAZIL 2Director ofAbdominal Wall Repair Center - Samaritano Hospital, Sao Paulo, BRAZIL

Introduction: The popularity of laparoscopic inguinal hernia repair technique increased over the past two decades. Total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) are the most commonly used. TEP reduces postoperative pain, shortens recovery time and avoid the need of transabdominal approach. This study aims to analyse the impact of prevalence of previous surgery on surgery difficulty of patients submitted to hernioplasty by TEP technique. Methods: A total of 238 patients underwent laparoscopic TEP herniorrhaphy by senior expert surgeons between May 2009 and May 2014. We analysed gender, age, hernia type, operation time, hospital stay and complications based on the medical records. Technical difficulty was defined by operative time, major complications and open conversion. Results: 83 patients underwent previous surgery (34,87%) with \37 hernias (83 indirect, 52 direct, I femoral, 46 recurrence, 31 bilateral, 24 mixed). The average age of patients was 51,6 years (10-85); the mean operating time was 51,2 minutes (16-150). 4 patients (4,8%) were discharged from hospital after staying more than 12 hours. There were \3 complicated cases: 5 conversions, 3 haematoma, 2 cord edema, I recurrence, I seroma, I hematuria. The previous surgery consisted in: 49 Inguinal hernia, 8 apendicectomy, 7 cholecystectomy, 6 radical prostatectomy, 5 varicoceletomy, 2 cystostomy, I cesarea, I colectomy, I hysterectomy, 2 umbilical hernia, 4 exploratory laparotomy, I nephrectomy, I pyloroplasty. Patients without previous surgery (65,12%) had 263 hernia (171 indirect, 89 direct, 3 femoral, 2 recurrence, 70 bilateral, 58 mixed). The average age of patients was 46,7 years (21-88) and the mean operating time was 38,6 minutes (20-75). 4 patients were discharged from hospital after staying more than 12 hours (2,6%). The complications were:, 2 haematoma and I left iliac venous injury. Conclusion: We suggest that patients who underwent previous abdominal wall surgery have more risk of complications and presents technical difficulties for surgeons using the TEP herniorrhaphy.

C023:16 LAPAROSCOPIC INGUINAL HERNIA AT THE ROYAL HOSPITAL IN MUSCAT. A PLATFORM FOR SERVICE AND TRAIINING IN A MAJOR CENTRE IN OMAN RAlmehdP, Y AlazrF, B Saho0 3, RAhmed<, M Nasser5 lThe Royal Hospital, Muscat, Oman Introduction: The Royal Hospital is the main tertiary referral centre in Oman. Though Open hernia repair of all types has been the trend

Hernia (201S) (Suppl 2):S3-S 194 over the years, the Laparoscopic approach had only been used sparingly. Advanced laparoscopy took a major stride in our setting around 2009. This study over a 6 year period, analyses the challenges and the evolution of this procedure in our centre. It also looks into the option of tailoring such approach depending on feasibility of resources and expertise. Material and method: Descriptive, retrospective analysis between 2006 to end 2013 of all Laparoscopic Inguinal hernia done, taken from a prospective data base. This included different surgeons-teams. The data was analysed using SPSS program. Results: There was a total of 963 inguinal hernias done. Males made up 98% of these cases. Recurrent hernia was seen in 9% of the cases. Laparoscopy (Trans Abdominal Pre Peritoneal repair (TAPP) was performed in 280(29%). Of the total, 60 (6%) were bilateral cases and 2S(40%) of these were done by TAPP. Early post operative morbidities (mainly hematomas) was seen in 9%. Recurrence was in 8%. In 2010, only one training resident did the full procedure, this chance increased to 33% in the later stages of the study. A patients' approval survey showed high satisfaction in 8S%. Conclusion: This is the first ongoing study on Laparoscopic inguinal hernia from Oman. The progress of advanced laparoscopy at our centre over the past four years was highly consolidated with the adoption of this technique in all hernia repairs. This however has been carefully tailored with success to maintain a balance between Open and Laparoscopy in all patients. Groin hernia also offered a successful testing platform to demonstrate the feasibility of laparoscopy not only for patients' service but also for surgical residents' training in advanced technique. The patients' high satisfaction with the results is evidence enough to sustain this service's growth against the odds and challenges of establishing it for the first time only recently.

C023:17 RESENT RECURRENT CASES OF INGUINAL HERNIA - RECURRENCES AND REPAIRS USING PRE PERITONEAL FLAT MESH INSERTION TECHNIQUE T InabaI, R Fukuhsima 1, YYaguchil, M Horikawa1, E Ogawa 1, YKumata 1 IDepartment a/Surgery, Teikyo University Hospital, Tokyo, JAPAN Purpose: Recently in Japan many of hernia specialists prefer to use the technique of preperitoneal flat mesh insertion (sublay technique) instead of Lichtenstein method or Mesh Plug method (onlay technique) for adult inguinal hernia repairs. The new method sometime causes curious recurrences, however the development of the new technique made it possible to repair complicated recurrent cases with tailored sub lay methods. In this study we review our recent recurrent hernia cases and present three recurrent cases, which could be repaired with case-by-case sub lay techniques. Results: We performed twenty-three recurrent hernia repairs during 2009 and 2013. At the previous surgery some kind of prostheses were used in fifteen cases, and sub lay mesh insertion had been performed in ten ofthe fifteen cases. Although recurrent hernia orifices usually were small and many cases could be repaired with Plugs in the re-operation, we need to perform tailored surgery for some patients. Case 1: Eighty-six year-old man with a small right direct inguinal hernia after four repairs with Mesh Plugs (two right hernias and two left hernias). Recurrent hernia orifice existed in the medial side ofthe two plugs in the right inguinal region. The orifice was small, however, the failure of the previous surgeries discouraged us to use Plugs for the fifth repair. We dissected preperitoneal space around the new orifice and approached to

S173 the plugs in both the right and left area. We inserted large flat soft mesh in the dissected space and sutured it to both plugs in right and left areas. Case 2: Fifty-two year-old man with a recurrent left indirect hernia after Kugel Patch repair for direct hernia. We could dissect preperitoneal space around the new orifice widely, because the new hernia orifice was intact at the first surgery. However we could not use ready-made flat patchs (i.e. Kugel patch, Polys oft Patch, et al), because it was difficult to dissect around the previous mesh (medial side of the inguinal region). We cut large flat soft mesh into the form of dissected preperitoneal space, insert it and sutured it to the previous Kugel Patch. Case 3: Eighty year-old man with a recurrent right direct hernia after indirect hernia repair with Polys oft Patch. Before the first repair this patient had undergone prostate resection, which might cause a bad fixation of the mesh. At the second repair we found that the lateral side of the patch had rotated clockwisely from lateral side of the inguinal legion to upper side of the Hesselbach triangle. But in contrast to the Case 2 we could dissect preperitoneal space widely, not only around the new orifice but also around the edge of the previous mesh, in this case. We did not need tailor made patch for this case, thus we insert another Polysoft Patch and suture it to the previous one. Conclusion: Many of recurrent inguinal hernia cases after preperitoneal repair can be repaired with additional preperitonel mesh insertion, however, some of them need tailored case-by-case technique.

C023:18 TAPP REPAIR IN ATHLETES WITH "PUBIC INGUINAL PAIN SYNDROME" (PIPS): A PROSPECTIVE CLINICAL COHORT STUDY H Pokorny!, I Fischer, C Resinger, V Lorenz, S Podar, F Langue ILK Wiener Neustadt, Wiener Neustadt, AUSTRIA Introduction: According to current literature regarding chronic groin pain in athletes defined as pubic inguinal pain syndrome (PIPS) or inguinal disruption (ID) laparoscopic mesh repair is believed to enable a faster recovery and return to unrestricted sports activities. The aim of this study was to evaluate the role of transabdominal preperitoneal mesh repair (TAPP) in athletes with PIPS/ID resistant to conservative therapy. Methods: After a multidisciplinary approach with tailored physiotherapy 39 athletes (median age 2S years) with chronic groin pain and suspected PIPS/ID were referred to surgery at our clinic. The majority of the athletes were soccer players (80%) at a professional level, tennis players, runners and triathletes. All of them were assessed with medical history, physical examination, dynamic ultrasound and pelvic MR!. In 30 athletes resistant to conservative therapy, who had a training pause on to 6 months with accompanying physiotherapy and presenting with typical symptoms of PIPS/ID a TAPP repair was performed using a polypropylene mesh (lOxlScm) and fibrin glue fixation. The outcome measures were early recovery 6 weeks postoperatively and satisfaction after one year. Data were collected prospectively and analysed retrospectively. Results: Average duration of symptoms from onset to surgical repair was 7 months. Conservative treatment improved symptoms temporarily or to some extent in 7 athletes, 2 athletes stopped their careers. 23 athletes presented with unilateral groin pain, whereas 16 had bilateral symptoms. The laparoscopy confirmed posterior wall deficiency in 24 and true inguinal hernia in 6 athletes, mild scrotal haematoma occured in 2 athletes postoperatively, all were discharged within 24 hours of surgery. 21 (70%) returned to sports activities after 6 weeks ~ Springer

S174 of convalescence. Persisting mild pain one year postoperatively was experienced in 5 athletes, which did not interfere with normal daily activity. All except 5 patients (85%) stated complete satisfaction one year after operation with full return to sports activities.

Conclusion: This series confirms that the endoscopic placement of retropubic mesh is an efficient, safe and mini- invasive treatment of PIPS lID with fast early recovery.

C023:19 SPORTSPERSON'S HERNIA- OUTCOMES AFTER STANDARD LAPAROSCOPIC TAPP MESH REPAIR, AND TACKLESS/SUTURELESS MESH REPAIR USING 'FIBRIN SEALENT' K Etherson l, KAtkinson l, S Khanl, R Pradeept, YViswanathl, PC Munipalle IJames Cook University Hospital, Department of Surgery, Middlesbrough, UNITED KINGDOM

Introduction: The "Sportsperson's hernia" is a disruption to various degrees of some or all of the components of the inguinal canal i.e.: the superficial/deep inguinal rings, the conjoint tendon, the inguinal ligament, the external oblique aponeurosis, the transversus abdominis muscle and the internal oblique muscle, but without a peritoneal protrusion into the inguinal canal. This can be difficult for the surgeon to diagnose and manage given the absence of an inguinal peritoneal sac clinically or on ultrasound scanning of the groin, the severity of pain limiting the patients' participation in sport, and the recurrent nature despite rehabilitation with physiotherapy and analgesia. Several surgical repair techniques have been described including the open six-layered Gilmore's technique (and Marsh modification), and more recently laparoscopic mesh repairs. To date there are no published high-quality controlled trials providing evidence of technique superiority, and most evidence is of single cohort, single institution and individual procedure experience. We present our experience of treating this condition over the last \0 years at a large teaching hospital in the UK. Methods: A prospective consecutive cohort database of single surgeon experiences over a decade using multiple repair techniques and materials. Data was extracted for any patient fulfilling the inclusion criteria: patients with a clinical diagnosis of Sportsperson's hernia with evidence of groin disruption and no evidence of an inguinal canal sac on ultrasound scanning pre-operatively from 2004-2014. Exclusion criteria were any patients with evidence of a canal sac on ultrasound or during surgery. Results: 93 sportspersons (median age of 30 [SD 12]) underwent 130 individual procedures, of which 118 were primary repairs and 12 recurrent repairs. 116 (98%) of the primary repairs (59 left, 57 right), and 11 (92%) of the recurrent repairs (5 left, 6 right) were using the laparoscopic trans-abdominal pre-peritoneal approach (TAPP). Standard laparoscopic TAPP mesh repair using tacks was performed in 85 procedures (42 left, 43 right- Group A). Two modifications of laparoscopic TAPP mesh repair were also used; firstly repair using Fibrin glue alone to secure the mesh and peritoneum in 40 procedures (21 left, 19 rightGroup B), and secondly a hybrid repair where the mesh and peritoneum were secured with Fibrin glue and tacks in 5 procedures (2 left, 3 right-Group C). Only 3 recurrences of Sportsperson's hernia have been noted over the cohort, and 90 (97%) had returned to their respective sports within 8 weeks of follow-up. Complications were minor with no difference in the outcome. All three recurrences were in Group A without significant statistical differences between groups. Conclusions: Most laparoscopic surgeons will be able to adequately treat Sportsperson's hernia using the standard TAPP mesh repair,

~ Springer

Hernia (2015) (Supp12):S3-S194 hybrid (tacks and fibrin glue) TAPP mesh repair, fibrin glue TAPP mesh repair, and in a minority using Gilmore's technique or other open repairs. Using a Fibrin glue alone to secure the mesh or a hybrid fixation appears to have no disadvantage in this cohort. As with most reports in this field, these results are single-surgeon, single-centre experience and possibly affected by selection and outcome assessment bias, and as such should be treated with caution. A large prospective multiple centre study with neutral outcome assessment endpoints could be designed to test the various surgical techniques which all appear to be effective and safe for Sportsperson's hernia.

C023:20 IMPACT OF INCIDENTAL INGUINAL PATHOLOGY ON OUTCOMES AFTER LAPAROSCOPIC REPAIR OF SPORTS HERNIAS J Chung l, A Schuricht l 1 University of Pennsylvania Health System, Philadelphia, USA

Introduction: Sports hernias remain a difficult to diagnose entity, with an average delay in diagnosis of 20 months, ranging from 6 weeks to 5 years (Lynch). After diagnosis, no standard of care for the management of this condition currently exists. This study seeks to analyze the effectiveness of laparoscopic inguinal hernia repair with mesh as a treatment strategy for sports hernia, as diagnosed by specific MRI fmdings, and to determine the effects of incidental, concurrent inguinal pathology (i.e. indirect inguinal hernia, cord lipoma) on outcomes after surgery. Methods: Under IRE approval, this retrospective study included subjects from a single surgeon who underwent laparoscopic inguinal hernia repair for the treatment of sports hernias between September 20 II and April 2014. Exclusion criteria included patients who underwent a concomitant adductor tenotomy. A total of 89 patients met the inclusion criteria, with 98% of diagnoses confirmed by magnetic resonance imaging (MRI) demonstrating rectus tears or injury, with a clinical history and physical exam consistent with sports hernia. Patients were then divided into a control arm - those in whom no additional pathology was discovered at the time of surgery (N = 51) - and a study arm - those in whom an intraoperative diagnosis of concurrent inguinal pathology was made (N = 38). A telephone survey was administered to determine the average length of time to full recovery, as defined by unrestricted return to athletic/physical activity; satisfaction score; and major post-operative issues. Survey responses were then compared between the study and control groups using Student's t-test, to determine if there was an association between incidental inguinal pathology and outcomes after surgery. Results: Ten subjects from the study group and 14 from the control group completed the survey. The study group included subjects with incidental findings of cord lipomas (90%) and indirect hernia sac (\0%), which were removed and/or ligated at the time of the primary procedure. The study group had an 80% return to full activity while the control group had a rate of 93% (p = 0.18). The overall difference in the average length of recovery before return to full activity was 15.5 weeks (range 2-48 weeks) for the study group and 7.0 weeks (range 2-16 weeks) for the control group (p = 0.06). There was no statistically significant difference in overall satisfaction .scores with a mean score of 3.6 for the study group and 3.8 for the control group (p = 0.2) on a four-point scale where 1 = very dissatisfied and 4 = very satisfied. Conclusions: Comparison of outcomes after laparoscopic inguinal hernia repair with mesh for sports hernia as diagnosed by specific MRI findings of rectus abdominis disruption in those with incidental

S175

Hernia (2015) (SuppI2):S3-S194 findings of additional inguinal pathology versus those with an isolated sports hernia revealed no statistically significant differences in rates of overall return to full activity or in satisfaction. The difference in average recovery times also failed to reach statistical significance though there was a trend toward longer recovery times in the study group, suggesting that despite equal efficacy in achieving eventual return to full activity, the presence of concurrent inguinal pathology in addition to a sports hernia may predict longer recovery times. A larger prospective study is necessary to determine additional factors which may affect recovery after laparoscopic repair of sports hernias.

C023:21 SPORTSMAN HERNIA - LAPAROSCOPIC TEP REPAIR - OUR EXPERIENCE C Magalhiiesl, M Marcos!' 2, A Flores!,2 lCentro Hospitalar Porto, Porto, PORTUGAL 2Instituto Cuf, Porto, PORTUGAL

Introduction: The pubic pain syndrome is a very frequent problem that sports doctors have to deal. Sportsman hernia is responsible for about 20% of the situations and most of them need a surgical solution, Methods: The authors present the experience of our Abominal Wall Hernia Unit in the last 3 years, Since 2012 we operated 78 sportsman. All athletes that were submited to surgical treatment were diagnosed a sportsman hernia using clinical evaluation and confirmation by ultrasound, performed by an experienced Radiologist. Results: In the last 3 years it were treated a total of78 athletes, 75 were male and the medium age was 24 years, The main sport was footbal, futsal and athletics and all had more than 3 months of pain syndrome that was not solved with medical treatment. The surgical aproach that was performed to all athletes, was a TEP Laparoscopic bilateral repair using a semiabsorbable mesh (UltraPro ®), Most of the athletes left the hospital the same day of the surgery, The medium time for analgesic needs was 3 days and all of them started training after 3 weeks. Only one athlete had a persisting pain syndrome and all others were totally satisfied with the surgical solution Conclusions: - Pubic Pain Syndrome and Sportsman hernia is a challenge for all sports doctors, The best treatment needs a multiprofessional aproach and the surgical treatment should be used in some situations, Laparoscopic TEP treatment is a surgical aproach that should be considered with very good outcomes in sportsman hernia,

C023:22 SURGICAL MANAGEMENT OF SPORTSMAN'S HERNIA U Sekmen 1, M Paksoy2 lAcibadem Hospital, Istanbul, TURKEY 2Jstanbul Uni, Cerrahpasa Med. School Dept. a/Gen. Surg., Istanbul, TURKEY

Introduction: Chronic groin pain in athletes and even in normally physically active people is a difficult diagnostic and therapeutic condition. Chronic groin pain in sportsman's hernia is caused by abdominal wall weakness or injury occurs without a palpable hernia. It presents with acute or chronic inguinal pain exacerbated with physical activity, Kicking and twisting movements place large forces across the bony

pelvis and its soft tissue supports, and results of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. Multiple co-existing pathologies are often present which commonly include posterior inguinal canal wall deficiency, conjoint tendinopathy, adductor tendinopathy, osteitis pubis and peripheral nerve entrapment.

Materials and methods: Between January 2011 and September 2014 in Acibadem Fulya Hospital, eighteen athletes were surgically treated for sportsman's hernia. All were male and average age at surgery was 22,5 years (range: 18-31), and average duration of symptoms from onset to surgical repair was more than 6 months. All eighteen subjects without any clinically ruled-out hernia but recurrent episodes of exercise-triggered groin pain were assessed, Results: All are diagnosed as sportsman's hernia on tenderness palpation on external ring and sometimes with slight bUlging but no palpable hernia on physical and ultrasonographic examination, And also they were evaluated by Dynamic MR!. 12 of them had visible bulging of inguinal floor under Valsalva maneover, on the other hand 6 of them had osteitis pubis and 4 of them had adductor tendinopathy and 2 of them had rectus tendinopathy as coexistent findings on MR!. Conservative treatment for 6-12 weeks could not improve symptoms in all of athletes, All athletes underwent a laparoscopic hernia repair (TEP 16 and 2 TAPP), We had 6 patients with bilateral sportsman's hernia and all were treated by laparoscopic TEP repair, All operations were performed without any complicationA weeks after operation they are allowed to run, after 6 weeks to train and after 7-8 weeks they did all sportive activities. After 4-36 months follow up, all of them are free of symptoms caused by a sportsman's hernia, Conclusion: Reinforcement of posterior inguinal wall with laparoscopic inguinal hernia repair (our choice is TEP) offers a successful treatment and restores activity in athletes with chronic groin pain who failed to improve with conservative treatment.

C023:23 INGUINAL HERNIA IN SPORTSMAN: COMPARISON OF OUTCOME BETWEEN ANTERIOR TENSION FREE REPAIR AND TAPP USING OPTOMETRIC WALKING TEST F CerianF, S Cutaia, M Canziani, F Caravati lMultimedica Santa Maria, Castellanza (Va), ITALY

Background: in Scientific Literature there are many papers comparing outcomes of different surgical tecniques for inguinal hernia repair, Evaluation in most of the studies is achieved with interview, Quality of life test and subjective simptoms, Patients and methods: In this work a prospetcic experimental single blind study was performed, comparing trans abdominal laparoscopic hernia repair (TAPP) versus open anterior tension free repair (Trabucco tecnique), Inclusion criteria for both arms were: gender male, age < 50, BMI < 28 monolateral inguinale hernia Ll-2, MI-2 according to EHS classification, Walking speed and stride lenght with walking test analisys using optometric sistem VICON were evalueted. Test was performed the day of the intervention (just before surgery), the day after the intervention (24 hours after) and 7 days after, For each patient performance between pre and post operative test was recorded and analysed The study is ongoing and results will be presented at the 1st World Conference on Abdominal Wall Hernia Surgery,

Jf) Springer