Hernia (2017) 21 (Suppl 2):S139–S207 DOI 10.1007/s10029-017-1595-x

ABSTRACTS

Oral and video presentations

Ó Springer-Verlag France 2017

01 Hernia prevention O1.2 Risk of hernia in single-incision and multiple incision laparoscopic surgery S. Antoniou1, F. Muysoms2, The EHS Guidelines Development Group on Prevention and Treatment of Parastomal Hernias 1 Heraklion, Greece, 2Department of Surgery, Maria Middelares Hospital, Ghent, Belgium Background: International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society implemented a Clinical Practice Guideline development project. Methods: The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. Results: End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomata. Clinical examination is necessary for the diagnosis, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic nonabsorbable mesh upon construction of an end colostomy is strongly recommended. No such recommendation can be made for other types of stomata. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient evidence on specific techniques, open or laparoscopic surgery, and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. Conclusion: An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicentre trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

O1.3 Open access: where and how to close? F. Muysoms1, N. Henriksen2, D. Cuccurullo3, F. Berrevoet4 1 Maria Middelares Gent, Gent, Belgium, 2Digestive Disease Center, Bispebjerg Hospital and Department of Gastroenterology, Hvidovre Hospital, Copenhagen, Denmark, 3Department of General and Laparoscopic Surgery, Monaldi Hospital, Azienda Ospedaliera dei Colli, Napels, Italy, 4Department of General and Hepatobiliary Surgery and Liver Transplantation Service, University Hospital, Gent, Belgium Background: Laparotomy incisions can be classified as midline, transverse, oblique or paramedian incisions. There is evidence that the risk of incisional hernia is increased with the use of a midline laparotomy. Methods: A search for systematic reviews and/or meta-analyses was performed in Medline, Embase, NIHR CRD, NICE and The Cochrane library. Results: Six systematic reviews have compared midline laparotomies to alternative incisions, but only two were considered High Quality. Bickenback et al. compared midline, transverse (including oblique) and paramedian incisions. This review identified studies published until 2009 and 24 RCT’s directly comparing different laparotomy incisions were included in the analysis. The incisional hernia rates after non-midline incisions were significantly lower compared to the incisional hernia rates after midline incisions, for both transverse incisions (RR = 1.77; 95% CI: 1.09–2.87) and paramedian incisions (RR = 3.41; 95% CI: 1.02–11.45). A Cochrane review by Brown et al. published in 2005 and updated in 2011, compared transverse versus midline incisions, but excluded studies comparing paramedian incisions. A decreased incisional hernia rate after transverse incisions was reported compared to midline incisions (OR = 0.49; 95% CI: 0.30–0.79). Both reviews concluded that non-midline incisions significantly reduced the risk of incisional hernia compared to midline incisions, but did not influence the risk of burst abdomen. Conclusion: Non-midline incisions are recommended where possible.

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O1.4 It’s just a hernia T. Heniford1,2 1 Charlotte, NC, USA, 2Carolinas Medical Center, Charlotte, NC, USA For many years in the United States, hernia repair was, in general, delegated to junior surgical trainees or to fairly senior attending surgeons who no longer or never performed complex operations. It was a means to learn basic skills or to fulfill surgical quotas. Little reliable information was available concerning recurrence, complications, or cost, and there was no consideration for patient quality of life. Over the last 15–20 years, however, things have significantly changed. The techniques have wholly transformed, including development of major reconstructive procedures, the meshes have mutated, our understanding and consideration of ‘‘success’’ has expanded, surgical cost has been defined, and the data concerning outcomes has demonstrated that we have much to improve. All of this has converted hernia surgery from ‘‘it’s just a hernia’’ to a true specialty practice. These additional considerations of science, data, bodily function, quality of life, and cost has generated significant avenues of research and excitement and promoted true generational improvement in hernia care. A hernia specialist is no longer the young, old or functionally poor surgeon. Twenty-first century hernia surgery has inspired the best of us to commit to quality hernia care.

02 The strength of registry data O2.1 Registries as a tool to perform prospective multicenter studies I. Kyle-Leinhase1, F. Muysoms2 1 EuraHS, Gent, Belgium, 2Maria Middelares, Gent, Belgium Background: No other surgical discipline utilises so many different techniques and materials and is continually evolving in development as hernia surgery. Consequently, prospective observational research of surgical outcome is important in understanding the postoperative course for patients undergoing hernia repair. Methods: Besides case control studies, randomised controlled trials (RTCs) and meta-analyses are the gold standard in evidence-based hernia research. RTCs are mostly performed in hernia expert centres for specific questions relating to techniques, materials or patients outcome. While RTCs carry an outstanding internal power, they may lack applicability into the wider surgical community. The first large European hernia registries were established in Sweden and Denmark in 1992. By collecting numerous data from very large patient populations, complications which rarely occur can be detected earlier by such registries. Registry-based results can provide real-world data for the effectiveness of specific techniques and surgical materials in broader hernia society. Moreover, registry-based data can confirm the findings of RTCs and meta-analyses. Results: Prospective observational studies using these hernia registers have already resulted in numerous findings that have been incorporated in hernia guidelines and classification. Subsequently, more than 100 scientific articles have been published resulting from prospective registry based studies. Moreover, registry-based outcome can stimulate ideas for the implementation of new RCTs.

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Hernia (2017) 21 (Suppl 2):S139–S207 Conclusion: Therefore, we strongly recommend the use of the established European registries for standardized documentation of surgical outcome including: risk factors, co-morbidities, surgical techniques and materials and effective long-term follow-up, when performing prospective multicentre studies.

O2.2 Registries as a tool for post-marketing surveillance of meshes F. Ko¨ckerling Vivantes Hospital Berlin Department of Surgery and Centre of Minimally Invasive Surgery, Berlin, Germany To date surgical meshes are classified as group II medical devices requiring only demonstration of substantial equivalence to another legally U.S.or European Union marketed device. Class II devices did not require premarket clearance by clinical studies. The importance of register data for post-marketing surveillance of meshes has been demonstrated in a study of the Herniamed Hernia Register, with similar findings in the Danish Hernia Database. Together, this has led a manufacturer to the decision of a voluntary market withdrawal of a composite mesh for laparoscopic IPOM. This mesh had in the German and Danish registers in laparoscopic IPOM repair for incisional hernias a markedly higher recurrence rate in comparison to other composite meshes. Europe‘s new Medical Device Regulation (MDR) will bring substantial changes to the European market. Surgical meshes are added to class III devices and need clinical investigations for approval. The manufacturer of surgical meshes is obliged to monitor products placed on the market. The post market surveillance plan must be constantly updated, and this also includes a plan for the post-market clinical follow-up. The new MDR introduces the requirements for periodic safety update reports for manufacturers of devices in class IIa, IIb and III. These will summarise the results and conclusions of the analyses of the gathered post-market surveillance data. Considering the increased demands for the manufacturers of surgical meshes concerning clinical data hernia registers will become an important tool for pre-and post-marketing surveillance of surgical meshes.

O2.3 Registries as a tool for quality improvement and benchmarking B. K. Poulose1, W. W. Hope2, D. C. Chen3, M. J. Rosen4 1 Vanderbilt University Medical Center, Nashville, TN, USA, 2New Hanover Regional Medical Center, Wilmington, NC, USA, 3 University of California, Los Angeles, Los Angeles, CA, USA, 4 Cleveland Clinic, Cleveland, OH, USA As the management of hernia disease becomes increasingly complex, the systematic collection of information offers a unique opportunity to improve the quality of care delivered to patients. This application of registry data involves a continuous and coordinated process implemented at a local level. Key concepts include integration of data collection into the delivery of care and minimizing delay in returning risk-adjusted information back to clinical care teams. We discuss both the challenges and successes of implementing this model within the Americas Hernia Society Quality Collaborative.

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O2.5 Registries as a tool to identify risk factors for bad outcomes 1

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03 Prevention of chronic pain 3

J. Pereira Rodriguez , M. Lo´pez Cano , P. Herna´ndez Granados , Members of Group EVEREG 1 Parc de Salut Mar, Barcelona, Spain, 2Hospital Vall d’Hebron, Barcelona, Spain, 3Hospital Fundacio´n de Alcorco´n, Madrid, Spain Background: Registries are a very strong tool to identify factors predicting bad results. Our objective was to analyse the data of the Spanish Register of Incisional Hernia (EVEREG) to detect risk situations for the development of complications and recurrences. Methods: We analyse the data of the cohort of hernias registered in EVEREG during the period from July 2012 to December 2014. We have compared the data between complicated and no complicated patients in the short and long term follow-up. Data compared were: Patient demographics, comorbid condition, hernia defect characteristics and technical data of operations to determine which of them may be predictors of poor outcomes. Results: During the period of study we have collected data of 1309 patients (43.7% males; 56.3% females) with a median age of 63.6 years (SD 12.4) and BMI of 30.44 (SD 5.4). In the univariant analysis, factors obtaining statistical signification (p \ 0.05) were: age [70 year, male sex, ASA III-IV, Previous neoplasm, emergency repair, previous repair, median laparotomy and parastomal hernias, transversal and longitudinal diameters more than 10 cm, Components separation, dermolipectomy, and bowel resection. Using a nominal logistic regression analysis, risk factors predictors for complications were: age [70, previous neoplasm, hernia length [10 cm. Previous repair and Bowel resection. Conclusion: In our study risk factors associated with postoperative complications were: age; previous neoplasm; hernia length [10 cm, previous repair and bowel resection.

O2.6 Registries as a tool to monitor long term outcomes T. Bisgaard Hvidovre Hospital, Hvidovre, Denmark Background: Well-designed randomized controlled trial carries a high internal validity to comprise the highest available evidence. However, when to detect long-term and perhaps even minor but perhaps serious outcome differences (such as mesh-related surgical complications and/or and recurrence etc.) between surgical treatment modalities, registries may provide evidence as good as it gets. Methods: A clinical hernia registry serves as a method for long-term monitoring and quality assurance based on a high national coverage data to elucidate daily life surgical results. Results: More than 75 per reviewed articles have been lounged Danish Hernia Database during a 20 years period since it’s start in 1996. Several ‘‘highlights’’ over the past years with special reference to the previous 5 years will be presented. Conclusion: In conclusion, the Danish Hernia Database is still active in it’s 20th years. The database provides data based on external validity for the sake of improving surgical outcome after a hernia repair.

O3.1 Chronic pain after non-mesh repair of inguinal hernias: a systematic review and network meta-analysis of randomized controlled trials ¨ berg1, K. Andresen1, T. W. Klausen2, J. Rosenberg1 S. O 1 Center for perioperative optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark, 2 Department of Hematology, Herlev Hospital, University of Copenhagen, Denmark., Herlev, Denmark Background: Chronic pain affects 10–12% after inguinal hernia repair. The etiology is not well understood, but less foreign material may theoretically prevent pain. Non-mesh repairs have a higher recurrence rate compared with mesh repairs, but studies suggest that pain is similar after 3–4 years. However, if chronic pain is lower after non-mesh repairs, selected hernias might be repaired without mesh. The aim with this study was to review chronic pain after inguinal hernia repair by mesh versus non-mesh techniques. Methods: Systematic searches were conducted in five databases. Primary outcome was chronic pain reported minimum six months after repair of a primary inguinal hernia in adult patients. Only randomized controlled trials (RCTs) were included. Chronic pain was compared with both meta-analyses and network meta-analyses. Results: A total of 23 RCTs with 5444 patients were included. The median follow up was 1.4 years (range 0.5–10). Twenty-one studies reported crude pain rate, and when considering moderate/severe pain, non-mesh and mesh repairs were similar, median 3.7% (0–16.2%) vs. median 4.0% (0–27.6%), respectively. Both the meta-analyses and the network meta-analysis showed no significant difference in chronic pain rate when comparing Shouldice and other non-mesh repairs with laparoscopy, Lichtenstein, and Prolene Hernia System (PHS). Conclusion: The network meta-analysis and the regular meta-analyses showed no difference in chronic pain rate for non-mesh versus mesh repairs of inguinal hernia.

O3.2 Why do inguinal hernia patients have pain? Histology points to compression neuropathy R. C. Wright1, D. E. Born2, N. D’Souza3, L. Hurd3, R. Gill4, D. Wright5 1 Cascade Hernia Institute, Puyallup, WA, USA, 2Stanford University, Palo Alto, CA, USA, 3Pacific Northwest University of Health Sciences, Yakima, WA, USA, 4Creighton University, Omaha, NE, USA, 5University of Denver, Denver, CO, USA Background: Enlargement of the ilioinguinal nerve occurs in up to 63% of patients with primary inguinal hernia; compression neuropathy has similar gross features. Histological features associated with compression neuropathy are here studied in relation to the incidence of preoperative primary inguinal hernia pain. Methods: 35 patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. Routine inguinal neurectomy performed and nerve segments were sampled for

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S142 histologic evaluation. 35 patients completed pain questionnaires pertaining to preoperative pain and the quality of pain experienced. Routine inguinal neurectomy performed and nerve segments were sampled for histologic evaluation. Results: 22 thickened nerve segments (63% of total) with proximal and distal specimens were resected for examination and comparison. A quantitative description of various histologic indicators (nerve diameter, fascicle count, myxoid content within the epineurium, perineurium and endoneurium) was undertaken. Increased preoperative patient pain scores correlate with increased nerve diameter, increased fascicle count and increased myxoid material both within the perineurium and endoneurium. Conclusion: These findings support the concept that preoperative hernia pain is consistent with compression neuropathy.

O3.3 Port site infiltration and extra-peritoneal instillation of ropivacaine in TEP: a randomised controlled trial N. Sharma, S. Jain, A. Tyagi University College of Medical Sciences, Delhi, India Background: Infiltration of port sites and instillation ropivacaine in the extraperitoneal space may decrease postoperative pain after TEP. Methods: 18–60 year old men with unilateral inguinal hernia were randomized to either ropivacaine group (30) or placebo group (30) using a randomization sequence generated online. Port sites and extraperitoneal space received either 0.75% ropivacaine or 0.9% saline (placebo). Primary outcome was NRS pain score at 6 h after surgery. Secondary outcomes were NRS at 2, 24 h, and total analgesic requirement during the first postoperative week. The same surgeon using the same type of mesh performed all procedures using 3 midline ports and without mesh fixation. The patient, surgery team and observer were blinded. Results: All patients underwent allocated procedure. There were no conversions. The baseline parameters were comparable in the two groups. The mean NRS at 6 h was 2.53 ± 1.70 in the ropivacaine group compared with 2.73 ± 1.95 in the placebo group (p = 0.693, Mann–Whitney test). Similar comparable pain scores were obtained at 2 and 24 h. No Significant difference was noted in analgesic requirement in 1st 24 h, till post-operative day 7, time to ambulation or micturition between groups. Only 13 patients complained of groin pain at day 7, almost equally in the 2 groups. Conclusion: Infiltration of port sites and extraperitoneal space with ropivacaine does not decrease postoperative pain of analgesic requirement in TEP.

O3.4 TEP under combined spinal epidural anaesthesia vs general anaestheia: a pilot study N. Sharma, A. K. Kundu, B. K. Jain, M. Mohta University College of Medical Sciences, Delhi, India Background: TEP is usually performed under general anaesthesia (GA). Some reports have confirmed feasibility for performing TEP under regional anaesthesia. This randomized pilot study has compared ease of performing TEP under combined spinal and epidural anaesthesia (CSEA) with GA.

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Hernia (2017) 21 (Suppl 2):S139–S207 Methods: 41 patients were randomized to undergo TEP either under GA or CSEA.The outcome measures evaluated were ease of performing TEP, total duration of surgery, patient’s satisfaction with the overall procedure and postoperative pain. Patients were followed for a period of seven days by a personal interview. Neither patient nor surgeon was blinded. Results: 39 patients were analyzed, 19 in the CSEA group, and 20 in the GA group.The median ease of surgery NRS was 9 (6–10) for the CSEA group compared to 10 (9–10) for the GA group (p = 0.02, Mann–Whitney test). The mean operative time was 92 min in the CSEA group and 72 min in the GA group. 10 out of 19 (52.6%) patients in the CSEA group had to be converted to GA due to severe pain in chest and shoulder, excessive straining, and breathing difficulty. The median score for patient satisfaction using NRS was 9/10 (8–10) in the CSEA group and 10/10(10–10) in the GA group and was statistically significant (p = .006, Mann–Whitney). Conclusion: It is more difficult to perform TEP under CSEA than GA. Use of GA results in higher patient satisfaction compared to CSEA.

O3.5 Mesh fixation technique comparison in Lichtenstein hernioplasty, preliminary results of a prospective randomized study A. Garcı´a Ferna´ndez, M. Pen˜a Soria, D. Jime´nez-Valladolid, J. Cabeza, A. Pe´rez Jime´nez, M. Florez Gamarra, L. Estela, P. del Pozo, J. Garcı´a Galocha, J. Romera Martinez, M. Rojo Abecia, R. Avellana, A. Torres Garcı´a Hospital clinico san Carlos, Madrid, Spain Background: Licthtenstein hernioplasty technique is the gold standard procedure in the groin hernia repair.Traditionally, the polipropilene mesh has been fixed with different sutures.Recently, many new methods have been designed in order to reduce the chronic pain.There are no quality studies comparing results between the gold standard against new techniques. This is a prospective, randomized, double blind trial not concluded yet. Methods: We compare the recurrence outcomes in three groups of patients. Suture fixation technique was chosen for the first group. For the second, fibrin glue was employed, whereas in the third group, the chosen technique was a self-fixing mesh. All patients were followed for a 6-months to 2-years period. From the calculated sample size of 530 patients, 250 were analyzed for this preliminary control. Results: Out of the original 250 patients, 244 were analyzed. 72 patients were assigned to the first group, 4 of whom (5.55%) presented recurrence. 65 patients were assigned to the second group, 6 of whom (9.23%) recurred. Finally, 87 patients were assigned to the third group, 4 of whom (4.59%) recurred. The recurrence rate comparison between groups showed a P value of 0.519, not statistically significant. No significant differences were found between groups. Conclusion: Once analyzed almost half of our target sample in the comparison of three mesh fixing techniques in Lichtenstein hernioplasty, we cannot, as of today, set a recommendation for the use of one of this techniques looking at the recurrence outcomes.This study will be further developed in order to get statistically significant results.

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O3.6 Lightweight non-absorbable mesh versus lightweight partially-absorbable mesh in the treatment of groin hernia with anterior approach: a randomized clinical trial D. Chiari, M. Origi, M. R. Moroni, P. Veronesi, M. Platto, D. Tornese, G. Borroni, V. Quintodei, W. Zuliani Humanitas Mater Domini, Castellanza, Italy Background: We compared three different types of lightweight mesh for groin hernia repair: HerniameshÒ HertraÒ6 (48 g/m2), HerniameshÒ HertraÒ 9 (88 g/m2) and HerniameshÒ HybridmeshÒ (80 g/ m2). Methods: From June 2014 to March 2016 we observed 225 consecutive male patients affected by primitive or combined groin hernia. Lichtenstein technique was performed using absorbable sutures. Patients were randomized to three comparable trial groups (H6–H9– HY). Controlled, scheduled follow-up appointments took place for 24 months from operation using ultrasound combined with clinical examination, in order to evaluate the clinical outcome. Results: The three groups did not present statistically significant differences in terms of early complications (\15 days), severe pain intensity, length of hospital stay, time of recovery, patients’ satisfaction and ‘‘foreign body sensation’’ (after 24 months). No presence of seroma was observed patients in HY group at US evaluation, even in those with BMI [30 and with hernia duration [2 years. Only 1 (1.5%) patient (group H9) with combined hernia had recurred at 20-month follow-up. Difference in return to everyday activities was observed between the patients of the HY and H6 groups (with hernia duration \12 months) compared with H9 group, regardless of age (p = 0.217). Conclusion: Two-years follow-up results confirm the effectiveness of the Lichtenstein technique for groin hernia repair with every type of mesh we used. In particular, the use of partially absorbable mesh HybridmeshÒ, with his higher compliance and reduced ‘‘foreign body sensation’’, may ensure excellent results in selected patients.

O3.7 Significant clinical and patient reported outcomes at 6 months following hernia repair with an absorbable fixation device H. Bougard1, C. Doerhoff2, S. Bringman3, M. Chudy4, C. Romanowski5, P. Jones6 1 New Somerset Hospital, Cape Town, South Africa, 2Surgicare of Missouri, Jefferson City, MO, USA, 3Karolinska Institutet, So¨derta¨lje Hospital, So¨derta¨lje, Sweden, 4Ayr Hospital, Ayr, UK, 5 Ethicon, Somerville, NJ, USA, 6Ethicon, Livingston, UK Background: Surgeons utilize various mesh fixation methods during hernia repair which may include tacks/straps and/or sutures. One of these tack/strap choices, is an absorbable fixation device, SecurestrapÒ (ETHICON, Somerville, NJ), consisting of polydioxanone and L (-)-lactide/glycolide copolymer. The 6 month clinical results and patient outcomes with SecurestrapÒ fixation are reported. Methods: The International Hernia Mesh Registry, prospective multicenter registry, designed to collect patient reported, longitudinal data on hernia mesh products and fixation methods. Patients completed the Carolinas Comfort ScaleTM (CCS). Symptomatic patient defined as responding [1 to any CCSTM question. P-values obtained by McNemar test and Kaplan–Meier methods used to estimate the recurrence rate up to 183 days.

S143 Results: Patients enrolled at 17 centers with data on 101 of the 216 patients who had reached the 6 month time point. Demographics were: mean age 53.0(13.2 SD); mean BMI 33.0(7.7 SD) kg/m2; females (51.4%); nonsmokers (46.4%). Majority of hernias were incisional/ventral (57.9%) and most were laparoscopic (98.1%). Mesh fixation was with tacks/straps (50.5%) or tacks/straps and sutures (49.5%). Symptomatic CCSTM pains scores improved from baseline to 1 month and improved significantly from 1 month to 6-months (69.1–60.6%, p = 0.0858; 60.6 to 22.8%, p = 0.0002), respectively. Similar results were observed with symptomatic CCSTM movement limitations. The recurrence rate was 1.8% (0.6–5.4%); 2 medically confirmed; 1 had not yet been assessed. Conclusion: Mesh fixation using absorbable tacks/straps with or without additional sutures results showed statistical significant improvement in patient reported outcomes at 6 months as compared to baseline. Follow-up continues.

O3.8 A complete suturless hernia repair to reduce inguinodynia: our experience F. Abbonante, G. Tomaino Hospital Pugliese-Ciaccio, Catanzaro, Italy Background: With the introduction of mesh and plug, the treatment of inguinal hernias has made a great progress in terms of hospitalization and recurrence. Nevertheless, with tension-free repair recurrence is still present and old and new complications, strictly related to prosthetic material and its fixation, affect the lives of patients after surgery. The most important is inguinodynia, chronic groin pain reported by the patient beyond 3 months after surgery, ranging from 0 to 62.9%. The study analyzes the results of the technique conceived by Ermanno Trabucco and defines it as sutureless, witch not required any system of anchorage to the tissues. Methods: From January 2008 to December 2015, we analyzed a case series of 850 patients treated for inguinal hernia. We used a sutureless hernioplasty with a T4 Plug, and/or, pre-shaped Polypropylene heavy mesh. Results: No intraoperative complications occurred. Inguinodynia was reported in 19 patients (2.24%). At 12 months after surgery, only 2 patients reported paresthesia (0.35%), but we not reported any case of difficulty in walking. In summary, 70.94% of patients report having started to perform regular daily life activities after 1–2 days (603 patients). Conclusion: In our study, follow-up shows that the technique is feasible, with good comfort for the patient, low rate of risk of damage due to the mesh suture and low recurrence rate compared to other existing techniques. No sutures to fix the mesh, reduces the risk of nerves damaging and of inguinodynia.

O3.9 NBCA (n-butyl-2-cyanoacrylate) medical adhesive for mesh fixation in inguinal herniorrhaphy (Lichtenstein, TAPP or TEP) Y. Shen, J. Chen, C. Qin, S. Yang Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: With the aim of reducing these complications, such as postoperative pain, chronic pain, and hematoma or hydrops formation, some researchers have adapted medical adhesives in tension-free herniorrhaphy and have achieved satisfactory results. We conducted

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S144 this study using a novel lightweight polypropylene mesh that has been proven to be associated with fewer complications for inguinal herniorrhaphy to imply the effectiveness of n-butyl-2-cyanoacrylate (NBCA) glue for mesh fixation in Lichtenstein tension-free herniorrhaphy and laparoscopic herniorrhaphy for inguinal hernias. Methods: A total of 2136 patients with primary unilateral inguinal hernia were included. In 893 cases, NBCA adhesive (Compont Medical Adhesive, 1.5 ml/tube; Beijing Compont Medical Devices Co., Ltd., Beijing, China) was used during Lichtenstein herniorrhaphy while the left 1243 cases was used in the fixation of the mesh during the laparoscopic herniorrhaphy (TAPP or TEP). Operation time, postoperative length of stay, visual analogue scale (VAS) score, incidence of chronic pain and hematoma formation, and hernia recurrence were evaluated. Results: The operative time was 36.2 ± 10.3 min and the postoperative length of stay was 1.2 ± 0.6 days. The minimum follow-up was 24 months, there were no hernia recurrence or wound infection in either group. The postoperative VAS score was 1.6 ± 0.7, there was no postoperative pain occurred (visual analogue score [4, lasted 3 months). Thirteen (1.5%) hematomas occurred in the open cases and 17 (1.4%) cases occurred in the laparoscopic group. Conclusion: Application of chemical medical adhesive in tensionfree herniorrhaphy for inguinal hernia appears to be a safe and effective approach.

04 Patience selection in incisional, ventral and parastomal hernia surgery O4.1 EuraHS Class of 2013‘‘: results of the first multicentric study of the EHS-registry U. Dietz1, F. Muysoms2, I. Kyle-Leinhase2 1 University of Wuerzburg, Wu¨rzburg, Germany, 2Maria Middelares, Ghent, Belgium Background: The main objective of EuraHS is to collect prospective data regarding the surgical treatment of ventral hernias and the implantation of meshes by means of a post market surveillance registry. The preliminary results of the first EuraHS multicentric study, ‘‘Class of 2013’’, will be presented. Methods: The study was approved by ethic votes from Universities in Germany, Belgium and the Netherlands and fulfills the requirements of privacy data protection. Procedures for the treatment of ventral and incisional hernias from 8 European centers were prospectively collected from January of 2013 to June of 2013. Results: ‘‘EuraHS Class of 2013’’ recruited a total of 382 procedures, 258 incisional hernias, 115 ventral hernias and 9 parastomal hernias. Mean age was 54.97 ± 15.63 for ventral-, 60.45 ± 13.71 for incisional and 62 ± 7.63 for parastomal hernias. Width of the hernia gap was 2.23 ± 1.61, 8.31 ± 5.83 and 6.53 ± 4.94, respective. Duration of the operation in minutes was 50.97 ± 26.17 for ventral and 129.30 ± 46.00 for parastomal hernias, 141.43 ± 67.42 for open incisional repairs and 84.97 ± 43.70 for incisional laparoscopic procedures. The follow-up rate at 6 weeks was 64.92% (248 patients). The final evaluation of the comprehensive data volume will be available in Vienna. Conclusion: The participants experienced a quick familiarization with the tool. EuraHS proved to be a singular platform for highly standardized datacollection across all Europe with multilingual access. We expect to win a large number of new participants in the next months. As this preliminary data shows, low follow up is a main bias to be improved.

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O4.2 Experiences in creating a registry for inguinal hernia repair in styria/austria and first results R. Schrittwieser1, T. Auer2, M. Jagoditsch3 1 LKH Hochsteiermark/Standort Bruck an der Mur, 8600 Bruck an der Mur, Austria, 2Universita¨tsklinik fu¨r Chirurgie Graz, Graz, Austria, 3 LKH Judenburg/Knittelfeld, Judenburh, Austria Background: Registries are gaining more and more importance in hernia surgery. In some countries nationwide registries were established to evaluate outcome of the different techniques in different institutions. In 2010 the board of management of the styrian KAGes decided to introduce a registry for inguinal hernia repair for all nonprivate hospitals in styria/austria. Methods: It is described how the registry was built and the first results of 5057 cases from december 2011 until December 2015 are shown. Results: The current status quo in inguinal hernia surgery in all nonprivate hospitals in styria (1, 2 million inhabitants) is presented. First results of 5057 cases are presented. Conclusion: For quality control reasons it is important to collect data in registries. In terms of compliance it is very helpful to create the process of data input as easy as possible and also to acquire as much data as possible from the information system of the institution. From the beginning the registry should be prepared for later delivery of the data to a nationwide or international registry.

O4.3 Determining risk factors in ventral hernia repair M. E. Lindmark1, K. Strigard2, U. Dahlstrand3, T. Lo¨wenmark4, U. Gunnarsson2 1 Umea University, Skelleftea˚, Sweden, 2Umea University, Umea˚, Sweden, 3Karolinska University Hospital, Stockholm, Sweden, 4 Umea University, Stockholm, Sweden Background: The aim was to identify risk factors for adverse events as early surgical complications, need of ICU and readmission in ventral hernia repair. The hypothesis was that there are specific determinants that increase the complication rate in ventral hernia repair. Such proposed factors are hernia size, BMI over 35, concomitant bowel surgery and method of hernia repair. Methods: A prospective hernia database at two Swedish university hospitals with 408 patients operated due to primary or secondary ventral hernia from 2007 to 2014 was analysed. A follow up of complications, need of intensive care and readmission was executed through a review of medical records three months after surgery. The association between specified risk factors and complication were calculated. Results: 81 of 408 patients had a complication registered. 58 of these were Clavien I–III a. In total 19 patients had Clavien IIIb–IV where five complications resulted from leakage, fistulas and infection. 7/42 onlay repairs had serious complications. Larger hernia size and age at operation were associated with increased risk for early complications in ventral hernia repair. There was a proportional relationship between hernia size and Clavien outcome class analysed by the Kendall Tau test. Morbid obesity, ASA, onlay repair, operation for hernia recurrence and concomitant bowel surgery did not reach statistical significance as predictors of adverse events. Gender did not affect the result. Conclusion: Hernia aperture size is of great importance in preoperative evaluation of the patient before ventral hernia surgery.

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O4.4 The Post INCisional Hernia repair-Phone (PINCHPhone): a new method of follow-up after incisional hernia repair N. Van Veenendaal1, M. Poelman2, B. Van den Heuvel3, B. Dwars4, H. Schreurs5, J. Stoot6, J. Bonjer1 1 VU University Medical Center, Amsterdam, The Netherlands, 2Sint Franciscus Gasthuis, Rotterdam, The Netherlands, 3Jeroen Bosch Hospital, Den Bosch, The Netherlands, 4Slotervaart Medical Center, Amsterdam, The Netherlands, 5NoordWest Ziekenhuisgroep, Alkmaar, The Netherlands, 6Zuyderland Medical Center, Sittard/ Heerlen, The Netherlands Background: 10–15% of the patients after incisional hernia repair develops a recurrence. Reliable follow-up is, therefore essential. Previous follow-up studies showed that physical examination is the only reliable method of follow-up to detect recurrences. However, physical examination is laborious and time consuming. We designed a telephone questionnaire as method of follow-up after incisional hernia surgery; the PINCH-Phone (Post-INCisionalHernia repair-questionnaire by telePhone). Aim of this study is to validate the PINCH-Phone for detecting both asymptomatic and symptomatic recurrences. Methods: This multicenter prospective study contained 210 patients after incisional hernia repair. All patients were contacted by telephone and the PINCH-Phone was carried out. The PINCH-Phone contains four elements; 3 questions regarding symptoms and a do-it-yourself Valsalva manoeuvre. Additionally, all patients were seen at the outer patient clinic and physical examination was done. Results: Fifty percent was male and the mean age was 58 years old (range 20–83). The mean interval between surgery and study inclusion was 38, 7 months (range 12–356). In 34 patients (16%) a recurrence was found. A majority of them replied positively to one or more elements of the PINCH-Phone. 73 patients replied negatively to all elements and 6 of them had a recurrence. The overall sensitivity was 79%. Although overall specificity was 38%, negative predictive value was 91%. Conclusion: This study aimed to validate the PINCH-Phone. However, patient-reported outcomes, interviews and physical examination seem to be the best way to assess the outcomes of hernia surgery and detect recurrences.

O4.5 Tailored approach to diastasis recti with or without a concomitant midline hernia J. Vironen1, T. Jahkola2 1 Helsinki University Hospital, Dept of GI- and general surgery, Espoo, Finland, 2Helsinki University Hospital, Dept of plastic surgery, Espoo, Finland Background: Linea alba diastasis alone or in combination with midline hernia is a common consequence after pregnancies. A novel method of repair using a narrow strip of mesh is presented in this patient series. Methods: Altogether 23 patients (median age 36, body mass index 23.5) were treated for symptomatic diastasis with or without concomitant umbilical/epigastric hernia. Linea alba repair with permanent suture enforced with a narrow piece of mesh (tails of an umbilical mesh or a strip of self-gripping mesh) was done in 18 cases. The mesh was buried inside the duplicated midline without opening

S145 the rectus sheath. Five patients were treated with a retromuscular selfgripping mesh. Thirteen patients had plastic surgery combined: abdominoplasty or a four-aisle-star figure of skin de-epithelization around navel saving the healthier skin of lower abdomen. Results: The width of the diastasis was 4–7 cm and length 6–18 cm. No major complications or breakdowns of the midline suture during the follow-up time occurred. At one month and one year after surgery the patients were free of back pain and very satisfied with the functional and cosmetic results. Conclusion: Simple plication or plication with an onlay mesh or mesh placed in retrorectus space are known to be effective in diastasis repair. Here a narrow strip of mesh was placed inside the plication avoiding subcutaneous placing or opening of the retromuscular plane. The method was feasible and effective in diastasis alone or in connection with small midline hernias. A larger study with quality of life evaluation is ongoing.

O4.6 The accuracy of preoperative imaging in the diagnosis of spigelian hernia D. Light1, L. Horgan2, S. Bawa2 1 Royal Infirmary of Edinburgh, Edinburgh, UK, 2 Northumbria NHS Trust, Newcastle, UK Background: The diagnosis of spigelian hernia can be difficult preoperatively. A number of patients may proceed to surgery unnecessarily if the diagnosis is incorrect. We evaluated the accuracy of radiological investigation against clinical evaluation in spigelian hernia. Methods: This study is a retrospective analysis of patients who presented from 1998 to 2016. All patients were assessed by a consultant general surgeon in outpatients’ clinic or on the surgical admissions ward. Patients were included who presented with a history suggestive of a spigelian hernia and a palpable lump or equivocal clinical examination. All patients proceeded to surgery, which was used as the reference standard. Results: 58 patients were included. 44 underwent a laparoscopic repair. 27 had a preoperative CT. 16 had a preoperative USS. 15 proceeded to surgery without preoperaive imaging. Overall correlation with operative findings showed CT to have a sensitivity of 100% and PPV of 100%. Ultrasound had a sensitivity of 90% and a PPV of 100%. Clinical assessment alone had a sensitivity of 100% and a PPV of 36%. Conclusion: This study shows that ultrasound and CT have a high sensitivity and PPV in relation to occult spigelian hernias. When no obvious spigelian hernia is present, patients should be evaluated with radiological investigation to establish a diagnosis. Owing to diagnostic uncertainty, a laparoscopic approach should be favoured.

O4.7 Spigelian hernia and laparoscopy: the experience of dedicated team S. Mandala`1,2, C. Callari1, C. La Barbera1,2, M. Lupo3, V. Mandala`1,2 1 Buccheri La Ferla Hospital, Palermo, Italy, 2Noto-Pasqualino Hospital, Palermo, Italy, 3Villa Sofia-Cervello Hospital, Palermo, Italy Background: Spigelian hernia is a defect in the anterior abdominal wall in the ‘‘linea semilunaris’’, in proximity to the external margin of

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S146 the rectus muscle. The clinical presentation often is variable: intermittent abdominal pain, rare cases of acute abdominal pain, some asymptomatic cases diagnosed during other surgical procedures. The diagnosis is often difficult, particularly in case of obesity and not palpable mass. The imaging is crucial in the diagnosis: ultrasonography and, especially, computed tomography. Today, laparoscopic approach has gained the consent of many surgeons being a tool of unquestionable diagnostic and therapeutic value. Methods: A retrospective review of twelve cases performed by laparoscopy. Nine female and three male. The average age is 60.7 years. Seven in the left side, four in the right side and one bilateral, eight in a typical position and four in an atypical low site. There was an incidental diagnosis in three cases. No emergency case. Results: Mean operative time was 73.2 min. There was no conversion. Mean hospital stay was 2.9 days. The minor complication rate was 16.6%. No early or late major complications and no case of recurrence occurred in a mean follow-up period of 43.7 months. Conclusion: Laparoscopy is important for an easy diagnosis and associated treatment in selected patients; it is safe and advantageous especially in doubtful cases (not typical symptoms, intermittent pain, not palpable mass) with a complete evaluation of abdominal wall and viscera. According to the Authors, the use of anatomical classification is essential for a tailored approach and treatment.

O4.8 Surgical treatment versus watchful waiting in patients with parastomal hernia: a retrospective cohort study D. P. V. Lambrichts, L. F. Kroese, J. Jeekel, G. Kleinrensink, W. A. Bemelman, J. F. Lange Erasmus MC, Rotterdam, The Netherlands Background: Parastomal hernia (PSH) is the most common complication after stoma construction, with incidences up to 50%. Surgical treatment (ST) is chosen over watchful waiting (WW) in 15–70% of patients, but clear arguments are described infrequently. This study is the first to compare outcomes of ST and WW to support treatment choice. Methods: Patients diagnosed with PSH between January 2007 and December 2012 were included. Patient characteristics, surgical data, stoma type, hernia symptoms and characteristics, and crossover rates between groups were collected retrospectively, as well as stoma related readmissions, ER admissions and outpatient clinic visits. For ST, postoperative complications and recurrences were collected. Results: Seventy-two patients were included; 50 (69.4%) and 22 (30.6%) in the ST and WW group respectively. Median follow-up was 60 months (interquartile range, 29.0–90.3). 42 patients (58.3%) had an end colostomy, 1 (1.4%) a loop colostomy, 18 (25.0%) an end ileostomy, 3 (4.2%) a loop ileostomy, and 8 (11.1%) an ileal conduit. Reasons for WW were comorbidities in 8 (36.4%), absence of symptoms in 5 patients (22.7%), rectal stump problems in 1 (4.5%) and in 8 patients (36.4%) reasons were unknown. 7 patients (31.8%) crossed over from WW to ST, of which 2 needed emergency surgery. In 28 patients (56.0%) PSH recurred after ST, of which 26 (92.9%) underwent additional repair. Conclusion: Given the high recurrence and additional repair rates associated with PSH repair, and the relatively low emergency surgery rate after WW, WW might be feasible for patients without complaints or with comorbidities.

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O4.9 Clinical outcomes after parastomal hernia repair with a monofilament polyester mesh: a consecutive series of 79 patients E. Oma, B. Pilsgaard, L. N. Jorgensen Digestive Disease Center, Bispebjerg Hospital, Copenhagen, Denmark Background: Different techniques and mesh materials are used in parastomal hernia repair with recently reported recurrence rates ranging from 10 to 28%. The aim of this study was to examine the risk of recurrence and chronic pain after Sugarbaker or keyhole parastomal hernia repair with ParietexTM Composite (PCO PM) Parastomal Mesh. Methods: Data on all patients undergoing parastomal hernia repair with ParietexTM Composite (PCO PM) Parastomal Mesh at our institution during a four-year period were collected. Patients with urostomy were excluded. All repairs were performed by a team of three experienced surgeons. Follow-up was performed after 10 days, 6 and 12 months including physical examination, and hereafter as annual structured telephone interviews. Patients suspected of hernia recurrence were offered computed tomography scan. Chronic pain was defined as pain requiring out-patient visit(s) and/or use of analgesics. Results: Seventy-nine patients (colostomy, n = 60; ileostomy, n = 19) were included. Sixty-nine and 10 patients underwent Sugarbaker and keyhole repair, respectively. Seventy-two and 7 procedures were performed laparoscopically and open (one converted procedure), respectively. Two patients were reoperated within 30 days with removal of the mesh. In total, seven (9%) patients had parastomal hernia recurrence (reoperation, n = 3; conservative management, n = 4) during follow-up of median 11.9 months (interquartile range 6.1–23.7 months). In univariable logistic analyses, only type of stoma was associated with recurrence (ileostomy 28% vs colostomy 3%), p = 0.007. Three (4%) patients reported chronic pain. Conclusion: In this study, we found a low recurrence and chronic pain rate following parastomal hernia repair using ParietexTM Composite (PCO PM) Parastomal Mesh.

05 Pain prevention O5.1 Preoperative pain assessment E. K. Aasvang Rigshospitalet, Copenhagen University, Copenhagen, Denmark Background: In order to assess the effect from hernia surgery and advance knowledge on how to minimize acute and persistent pain, a thorough assessment of preoperative pain is essential both in case of a primary, recurrent or surgical procedure for persistent postherniotomy pain. The details are essential for any subsequent comparison between postoperative pain and the possibility of preoperative pain or new surgery related postoperative pain, with consequences for treatment options. Methods: Assessment should include a detailed description of pain from the hernia/surgical area, but also description of any other pain syndromes from other body areas (e.g. low-back pain, headache etc.), including current analgesic treatment. Pain description should as a minimum include: location (preferably using a body chart), intensity,

Hernia (2017) 21 (Suppl 2):S139–S207 frequency, pain at rest or during activity and what activities that aggravate pain. Any consequences of pain on daily activities should be assessed using validated questionnaires. For research purposes, a description of sensory disturbances should be added to the information, both self-reported, sensory mapping and/or quantitative sensory testing, preferably using the same protocol to allow comparison across research centers. Results: The presentation will give examples on the findings from the suggested assessment modalities and the importance of preoperative pain description with relation to diagnostic of acute and persistent herniotomy related pain, and the effect of surgery including surgery for persistent postherniotomy pain. Conclusion: Detailed assessment of pre-operative pain is critical for assessment of the results of an individual herniotmy procedure as well as for evidence based advancement to minimize future acute and persistent postherniotomy pain.

O5.2 Prophylactic analgesia W. Jaksch1,2,3 1 Vienna, Austria, 2Wilhelminenspital, Wien, Austria, 3Austrian Pain Society, Wien, Austria Depending on the risk of the individual patients there exist some options for preventive analgesia. There is evidence that some analgesic interventions have an effect on postoperative pain and/or analgesic consumption that exceeds the expected duration of action of the medicine, defined as preventive analgesia. In patients at very high risk the medical indication for surgery is to call into question. If the procedure in high risk patients is absolutely essential the first option should be regional anaesthesia may be in combination with an NMDA receptor antagonist. Possible techniques are spinal or epidural anaesthesia, ultrasound guided blockade of the nervus ilioinguinalis and also local anaesthesia with or without general anaesthesia. There is new evidence for a preventive analgesic effect of perioperative intravenous lignocaine after a wide range of operations. Other systemic drugs which should be considered for multimodal analgesia in high risk patients are the NMDA receptor antagonist ketamine or the a-2-d ligands gabapentine and pregabaline. Different meta-analysis show positive effects on postoperative analgesia, postoperative morphine consumption but even on pain prevalence 3 or 6 month after surgery. As long-term economic consequences from the progression of acute to chronic pain can be significant identification of high risk patients is crucial. Especially for these patients different methods of multimodal analgesia should be considered.

O5.4 Fixation in inguinal open and endoscopic repair W. Reinpold1,2 1 Hamburg, Germany, 2Gross Sand Hospital, Hamburg, Germany Background: The two most frequent complications after open and laparoendoscopic inguinal hernia repair are chronic postoperative groin pain and recurrences. In order to prevent both burdensome complications the operating surgeon must know the current evidence of mesh fixation in groin hernia repair. Methods: A systematic review of the literature which included the update of the EHS guidelines and the international guidelines on groin hernias (HerniaSurge) was performed.

S147 Results: In open primary inguinal/femoral hernia repair beyond the use of sutures (non- or late-resorbable) for mesh fixation new atraumatic devices (e.g. fibrin glue, cyanoacrylate, self-fixating meshes) are safe in terms of recurrence and reduce the risk of acute and chronic postoperative pain. The use of self-fixing meshes is feasible in all hernia types and sizes without raising the risk for recurrence, whereas glue fixation in the Lichtenstein technique can be performed in hernias limited to MII or LII types (EHS classification). In TEP and TAPP inguinal/femoral hernia repair non-fixation of mesh is recommended in almost all hernia types except large medial defects (M3 EHS classification) where mesh fixation is recommended. If fixation is used, atraumatic fixation techniques (fibrin glue, cyanoacrylate) should be considered to minimize the risk of acute postoperative pain. Conclusion: While atraumatic mesh fixation in open inguinal hernia repair does not lead to more recurrences traditional suture repair in Lichtenstein does not seem to be associated with more chronic pain. In TAPP and TEP repair mesh fixation is only necessary in large direct hernias (MIII). More long term results are needed.

06 The brave new world of translational hernia research O6.1 Lessons learned from a mesh explant data base-status quo and demands for the future H. Dirschmid, R. Stockinger, F. Offner Institute of Pathology, Feldkirch, Austria Mesh implantation is the most common surgical procedure after cataract operation in the Unites States. Complications and consecutive explantation range from 2 to 10% and include recurrence, mesh infection, pain, bowel obstruction, enterocutanous fistula and shrinkage of the mesh. We prospectively analyzed meshes irrespective of the reason for explantation from 14 Austrian hernia centers beginning with January 2015. Each mesh was divided by the surgeon into two parts, one in formalin for histopathological work-up, the other as a native mesh in a sterile container without any supplements for sonication and subsequent culture of the sonication fluid. Furthermore we received a swab of the intraoperative situs for routine culture. We then put these results into a database to correlate the histopathological outcomes with microbiological work-up and also to compare routine microbiological examination (swabs) with sonication fluid of the meshes. Until March 2017 69 meshes of 66 patients were sent to us in the same manner as described above. While the causes and mechanisms of complications associated with meshes are still incompletely understood it is still surprising that meshes are seldom routinely sent to the pathologist although these implants would represent a huge study material for getting a more comprehensive view on the pathophysiology of mesh complications.

O6.4 Experimental data-reliable information and guidance for clinicians? D. L. Sanders North Devon District Hospital, Barnstaple, UK Background: Medical knowledge, now, has a doubling time every 18 years. The bench to bedside process is founded on the principle of

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S148 translating findings in basic science into therapeutic interventions for patients. Methods: This presentation discusses the role of translational research in hernia surgery Results: This ‘‘process’’ has been fundamental to the implementation of remarkable achievements, such as statins for dyslipidemia and targeted cancer therapy. Yet so many more bench-side success stories have found themselves stranded on the road to translation with negligible impact in the clinical environment. The diversity of devices suffers as companies continue to recycle ‘‘old’’ materials to streamline the FDA approval process and meet their financial goals. New materials continue to be developed and vetted, yet the clinical impact is not felt as many clinicians rely on a handful of devices for tissue reconstruction. Polypropylene was invented over 60 years ago and still remains the most commonly used material in abdominal wall repair, although in use since the 1950s. Conclusion: As we move into an era where scientific discovery and advancement occur more rapidly every year, the question lingers: why aren’t the advances at the bedside commensurate with the advances on the bench?

O6.5 The scope of tissue engineering in hernia research

Hernia (2017) 21 (Suppl 2):S139–S207 guidelines. Few RCTs are available comparing these techniques in this constellation. Therefore there is a need for more comparative data. Methods: 57,906 patients with a primary unilateral inguinal hernia and one-year follow-up operated on between September 2009 and February 2015 were included in further analysis of the Herniamed registry. Using propensity score matching, 12.564 matched pairs were used for comparing of Lichtenstein/TEP, 16.375 for Lichtenstein/ TAPP and 14.426 for TEP/TAPP. Results: Comparing Lichtenstein/TEP disadvantages for the Lichtenstein with regard to the postoperative complications (3.4 vs 1.7%; p \ 0.001), reoperations (1.1 vs 0.8%; p = 0.008), pain at rest (5.2 vs 4.3%; p = 0.003) and pain on exertion (10.6 vs 7.7%; p \ 0.001). Likewise, comparison of Lichtenstein/TAPP showed disadvantages for Lichtenstein with regard to the postoperative complications (3.8 vs 3.3%; p = 0.029), reoperations (1.2 vs 0.9%; p = 0.019), pain at rest (5 vs 4.5%; p = 0.029) and on exertion (10.2 vs 7.8%; p \ 0.001). Comparing TAPP/TEP showed almost equal results excepting a higher rate of postoperative complications in the TAPP-group (3.0 vs 1.7%; p \ 0.001) due to more seroma (treated conservatively) and more postoperative haemtoma in the TEP-Group. Conclusion: TAPP/TEP show considerable advantages over the Lichtenstein procedure in the treatment of primary unilateral inguinal hernia as stated in the HerniaSurge-guidelines.

A. Petter-Puchner Vienna, Austria Background: Hernia repair has become a fascinating translational playground and is a pioneering field for various tissue engineering applications, such as complex scaffolds, sophisticated fixation devices and high-end operation techniques. Methods: The presentation will present the most urgent and promising examples of tissue engineering in hernia repair, e.g. absorbable scaffold materials, cell seeding therapies, antiadhesive strategies and new approaches to achieve a mesh/fixation entity. Conclusion: Hernia repair is on the forefront of technical development in surgical medicine. Potential and limitations of tissue engineering techniques shall be discussed.

07 Patients selection in groin hernia surgery O7.1 Results of 57.906 patients from the Herniamed registry compared for the treatment of primary unilateral inguinal hernia by Lichtenstein, TAPP and TEP using propensity-score-matching F. Mayer1, M. Lechner1, K. Emmanuel1, M. Kofler1, R. Bittner2, A. Kuthe3, W. Reinpold4, B. Stechemesser5, F. Ko¨ckerling6 1 University Hospital Salzburg, Department of Surgery, Salzburg, Austria, 2Winghofer Medicum, Hernia Center, Rottenburg am Neckar, Germany, 3Department of General and Visceral Surgery, German Red Cross Hospital, Hannover, Germany, 4Department of Surgery and Hernia Center, Wilhelmsburg Hospital Gross-Sand, Hamburg, Germany, 5Hernia Center Cologne, PAN-Hospital, Cologne, Germany, 6Department of Surgery and Center for Minimally Invasive Surgery, Vivantes Hospital Spandau, Berlin, Germany Background: Lichtenstein, TEP and TAPP are recommended for repair of primary unilateral inguinal hernia in the new HerniaSurge-

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O7.2 Low reoperation rates in young males after sutured repair of indirect inguinal hernia: arguments for a tailored approach E. Haastrup, K. Andresen, J. Rosenberg Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark Background: Younger males have higher risk of developing chronic pain after open inguinal hernia repair with mesh compared with older patients. Avoiding mesh among younger patients could be justified, if they have an acceptable low risk of recurrence compared with other groups and compared with Lichtenstein repair. The aim of this study was to investigate the reoperation rates after open indirect inguinal hernia repair with and without mesh in young males and other age groups. Methods: Data were extracted from the nationwide Danish Hernia Database which is recording prospectively. Included were males with primary indirect inguinal hernia, repaired with Lichtenstein or annulorrhaphy from the period January 1, 1998 to December 31, 2015. Reoperation rate for recurrence was used as outcome. Results: In total 52,281 primary repairs of open indirect inguinal hernia were included of which 49,951 were Lichtenstein repairs and 2330 were annulorrhaphies. The overall reoperation rates increased year after year in both groups but the 18–29 year old males had a significant lower risk of reoperation after annulorrhaphy compared with all other age groups (cumulative reoperation rate 8.1 versus 12.5%, log rank p = 0.001). Conclusion: The cumulative reoperation rate after annulorrhaphy for 18–29 year old males was significantly lower compared with other age groups. When taken into consideration, that young males have the highest risk of developing chronic pain after mesh repair the results indicate, that annulorrhaphy could be a valid option for young men with indirect inguinal hernias. Thus, we propose a tailored approach for this patient group.

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O7.3 Shouldice vs. Lichtenstein, TAPP and TEP in female inguinal hernias R. Lorenz1, A. Koch2, F. Ko¨ckerling3 1 3+CHIRURGEN Hernia Center, Berlin, Germany, 2Chirurgische Praxis Cottbus, Cottbus, Germany, 3Vivantes Klinikum Spandau, Berlin, Germany Background: In the HerniaSurge Guidelines is recommended that all female hernia patients should be operated endoscopicly. Accordingly the Shouldice technique is not recommended anymore and should be used only in scientific studies. Despite this the Shouldice hospital has excellent results, which are proved currently by an independent analysis of helath insurance data. In this study we compare the Hernia Database Herniamed results of the Shouldice technique with them of the Lichtenstein technique TAPP and TEP in groin hernias in females. Methods: In total, 7457 female patients were selected between September 1, 2009 and February 1, 2015. We include in this study 857 Shouldice-, 2226 Lichtenstein-, 1722 TEP- und 2652 TAPP-operations with a complete 1-year follow-up. These patients were analyzed with a propensity-score-matching to compare homogenous groups. Results: The Shouldice-group was younger and had smaller hernia sizes with EHS I and II of 89.38%. There are not any significant differences in the recurrence rates and in intraoperative and postoperative complications between the Shouldice technique and Lichtenstein, TEP or TAPP. The only significant difference (p \ 0.1) in the 1-year follow-up was between the Shouldice and the Lichtenstein group in case of pain at rest and pain at exertion with favor to the Shouldice technique. Conclusion: In selected female patients with primary unilateral inguinal hernias and small and midrange hernia sizes the Shouldice technique could be used with comparable results to the Lichtenstein-, TEP- and TAPP repair.

O7.4 Long-term outcomes of groin hernia repair in octogenarians and nonagenarians: the French club hernie database results M. Soler1, J. Gillion2, French Club Hernie 1 Clinique saint jean, cagnes sur mar, France, 2Antony private Hospital, Antony, France Methods: The French ‘‘club hernie’’ collects data since 2011. The surgeons must give the data for all the patients operated consecutively during a given period 14,254 groin hernias (12,089 patients) have been operated between September 2011 and 15 of April 2016: (18–101) years old—10,287 patients [18–79] years old is the control group—1504 patients were octogenarians, (80–89) years of age—289 were nonagenarians and more (90–101) years of age. Results: The Female rate is increasing with the age There were more unilateral, lateral, femoral hernias with the age There were less laparoscopic procedure with the age There were more medical and local complications with the age Post-operative pain at 8, 30, (90–180) days and 2 years decrease with the age The rate in an ambulatory setting is decreasing with the age About the emergency surgery: (incarcerated hernia with or without intestinal obstruction): The emergency surgery, women and femoral hernias rate increase with the age. The laparoscopic procedure and ambulatory setting rate decrease with the age. Conclusion: In the elderly patients there are more female, more femoral hernias and more emergency surgery In elderly patients,

S149 surgeons prefer not to do laparoscopic procedure even in scheduled surgery or in emergency surgery The authors recommends to operate sooner the female, and specifically the femoral hernias A complete statistical evaluation will be given.

O7.5 Who cares if you are old? The walk-in walk out hernia service N. Rajaretnam1, R. Bhutiani2 1 Royal Devon and Exeter Hospital, Exeter, UK, 2Northwick Park Hospital, London, UK Background: Herniae cause significant morbidity which results in a reduced quality of life. Approximately 78% of surgical repairs are performed under general anaesthesia (GA). Repair under local anaesthesia (LA) is more cost-effective and life-changing for an increasing number of patients who are refused surgery due to their comorbidities. This approach is likely to become increasingly necessary as our population ages and co-morbidities rise. Methods: Retrospective analysis of a prospective database of hernia repairs performed under LA of 696 operations between May 2006 and December 2013 under supervision of a single consultant in the WalkIn-Walk-Out (WIWO) hernia service in one NHS Trust. Data collected included patient demographics, co-morbidities, operation details and complications. Cost-effectiveness analysis performed using hospital payment tariffs. Results: Of the total 696 repairs, there was zero mortality and five recorded complications. Cost-effectiveness analysis showed that with open hernia repair under LA, our institution saved £411.00 per patient; £561.00 if overnight stay; and £861.00 when compared to overnight stay under GA. Conclusion: As our aging population develops co-morbidities which are high risk of morbidity/mortality from surgery under GA, open hernia repair under LA is not only cost-effective and safe but is considered the only option. Due to present demands of offering laparoscopic surgery (only possible under GA) in training future surgeons, we feel trainees are inexperienced to manage the needs of the comorbid population unless surgical training is modified to offer operations under LA. Combining priorities of training and cost-effectiveness makes the WIWO hernia service desirable for any healthcare institution.

O7.6 Comparison of spinal anesthesia and general anesthesia methods in open and laparoscopic extraperitoneal inguinal hernia repair T. Donmez1, O. Sunamak2, D. Yildirim3, A. Hut3, V. M. Erdem4, D. A. Erdem4, I. H. Ozata5, M. Cakir3, S. Uzman6 1 Lutfiye Nuri Burat State Hospital, Istanbul, Turkey, 2Haydarpasa Numune Training and Research Hospital, General Surgery, Istanbul, Turkey, 3Haseki Training and Research Hospital, Department of General Surgery, Istanbul, Turkey, 4Lutfiye Nuri Burat State Hospital, Department of Anesthesiology, Istanbul, Turkey, 5Lutfiye Nuri Burat State Hospital, Department of General Surgery, Istanbul, Turkey, 6Haseki Training and Research Hospital, Department of Anesthesiology, Istanbul, Turkey Background: Mesh placement is the main standard in repair of inguinal hernia. Laparoscopic repair gets popular in recent years. Although open repair has been performed under general (GA), spinal (SA) or local anesthesia, laparoscopic repair was performed only

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S150 under GA. Today, spinal, epidural or combined anesthesia promises for laparoscopic repair. We aimed to compare open and laparoscopic TEP repairs under GA and SA. Methods: Forty hundred forty inguinal hernia patients hernia were analyzed. There were 4 groups: Group 1:TEP under GA (n:111); group 2: Open mesh repair under SA (n:116); group 3: Open mesh repair under GA (n:117); group 4: TEP under SA (n:96). Age, BMI, duration of operation, hospital stay, post operative VAS scores, drain use, hypotension, vomiting, conversion, recurrence, seroma formation, scrotal edema, wound infection, post operative pain, urinary retention and headache and likert scores were compared. Results: Duration of operation was longer for TEP groups; longer in spinal one, but hospital stay was shorter in TEP group; shortest in spinal TEP. Recurrence rates were higher in both of the open repair groups. Pain scores (VAS) were also significantly higher in open surgery groups for all months and it was also significantly different in between open groups.VAS didn’t show significant difference between TEP groups. Urinary retention and headache were also higher in spinal groups; they were also higher in spinal open group than spinal TEP group. Conclusion: Laparoscopic TEP under SA is superior to open repair in hospital stay and pain feeling. Urinary retention and headache is the main problems of SA.

O7.7 Groin hernia repair after radical prostatectomy and adenomectomy: 498 cases. Long term outcome versus long term outcome for patient without prostatectomie, French database results M. Soler Clinique Saint Jean, Cagnes sur Mer, France Background: Club Hernie, the French data base. Methods: From September 1st 2011 to April 15th 2016, 14.254 groin hernias in 12,089 patients (18–101 years old) have been operated on including—10,287 patients (18–79 years old) in the ‘‘control’’ group—498 patients (36–96 years old) in the prostatectomy and open adenomectomy group—335 after radical prostatectomy—163 after open adenomectomy. Results: There were more bilateral hernias in the prostatectomy group There were less laparoscopic procedure in the prostatectomy group but the percentage of TAPP procedure is more important The rate of medical and local complications is the same in the two groups The rate of the per operative complications is the same in the two groups Post-operative pain at 8, 30, (90–180) days is the same in the two groups At two years the satisfaction rate is the same in the two groups There were less ambulatory setting in the prostatectomy group The emergency surgery rate is the same in the two groups. Conclusion: In the prostatectomy group there are more bilateral hernias. The surgeons preferred not to do laparoscopic procedure, but if they choose laparoscopy, they prefer the TAPP technique. We can observe less ambulatory setting in the prostatectomy group The groin hernia repair after prostatectomie don’t give more postoperative pain or more complication. The two years follow up is as good in both groups. A complete statistical evaluation will be given.

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O7.8 A prospective comparison of preperitoneal tension-free open herniorrhaphy with laparoscopic preperitoneal herniorrhaphy for the treatment of femoral hernias Y. Shen, S. Yang, J. Chen Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: Though many techniques exist for hernia repair, controversy still exists as to the best management of femoral hernias. Thus, we compare the open preperitoneal approach with the laparoscopic technique for the surgical treatment of femoral hernias. Methods: In this prospective study, 70 patients with primary unilateral femoral hernias were assigned randomly to a open preperitoneal group (n = 35; 8 males, 27 females) and a laparoscopic group (n = 35; 10 males, 25 females). EasyProsthesis MESH-D10 and EasyProsthesis MESH 15 9 15 (TransEasy Medical Technology Co., Ltd., China) were used, and all operations were performed by the same surgical team. Patients demographics, recurrence rate, duration of hospital stay, and complications were recorded. The duration of follow-up ranged from 6 to 24 months. Results: There were no differences between the groups with respect to surgical time, recurrences, postoperative duration of stay, or wound infection rate. There were no postoperative pain (visual analogue score [4, lasted 3 months) in the laparoscopic group, whereas there were 3 cases (8.6%) in the open group. In the laparoscopic group, there were 5 cases (14.3%) of seroma that occurred 3 and 7 days after operation and lasted 1 month. In the open group, 1 cases (2.9%) of seroma occurred 7 days after operation. Conclusion: Laparoscopic preperitoneal herniorrhaphy appears to be associated with a decreased postoperative pain and a major incidence of seroma formation compared with the open technique in the repair of femoral hernias.

O7.9 Groin pain characteristics and recurrence rates: Longterm results of a RCT comparing self-gripping mesh and sutured polypropylene mesh for open inguinal hernia repair W. A. R. Zwaans, T. Verhagen, L. Wouters, M. J. A. Loos, R. M. H. Roumen, M. R. M. Scheltinga Ma´xima Medisch Centrum, Veldhoven, The Netherlands Background: Some patients develop chronic pain following mesh insertion for an inguinal hernia. A recent trial comparing a semiresorbable, self-gripping ProgripÒ mesh with a standard sutured polypropylene mesh found that postoperative pain at three months was attenuated following the ProgripÒ. However, it is unknown if long-term pain levels and hernia recurrence rates are different between the two techniques. Methods: Patients [18 years undergoing an open primary hernia repair were randomized to receive a ProgripÒ mesh or a standard polypropylene sutured repair according to Lichtenstein. Pain was measured using a Visual Analogue Scale (VAS, 0–100) at timed intervals over a three years period. A hernia recurrence was determined using physical examination in the outpatient department.

Hernia (2017) 21 (Suppl 2):S139–S207 Results: Results of 274 patients were available at the final three year follow-up point (75% follow up rate). Pain levels were greatly attenuated over time in both groups (p = 0.05), without differences between the groups. However, altered groin skin sensation persisted after three years in both groups. Moreover, one of five patients receiving a standard mesh reported a foreign body feeling compared to one of seven with a ProgripÒ (p = 0.06). The hernia recurrence rate was higher in the ProgripÒ group (11.5 vs. 5%, p = 0.05). Conclusion: Pain levels three years after insertion of a self-gripping ProgripÒ mesh or a sutured polypropylene mesh for an open primary inguinal hernia repair are low, although altered skin sensation and foreign body feeling is not unusual. A ProgripÒ hernia repair is associated with a higher recurrence rate.

08 Prevention of complications in ventral & incisional hernia repair 1 O8.1 Vacuum assisted delayed primary closure (DPC) in very high risk ventral hernia repair (VHR) patients improves outcomes V. A. Augenstein, S. Groane, K. Coakley, J. Helm, P. D. Colavita, T. Prasad, S. Getz, B. T. Heniford Carolinas Medical center, Charlotte, NC, USA Background: Wound complications are very strongly associated with VHR failure. Our objective was to evaluate complex, contaminted VHRs treated VAC-assisted DPC. Methods: Prospective, single institution, DPC study in contaminated VHRs was performed. Risk of wound-related complication was calculated by applying Carolinas Equation for Determining Associated Risks (CeDAR) app. Outcomes were analyzed using standard statistical methods. Results: Sixty-six high risk hernia patients underwent DPC. Patient specifics include: mean age—59.8 ± 12.3 years, mean BMI— 32.4 ± 8.4 kg/m2, female—50%, mean number comorbidities— 4.7 ± 2.3. The most common indication for DPC was infected mesh (59.1%), followed by enterocutaneous fistula (33.3%), and ostomy at the time of repair (21.2%). Average risk of wound-related complication was 69.7% (25.4–95.1%) based on CeDAR scoring. There was a mean of 5.3 ± 1.4 days of VAC therapy before DPC. Nine patients (13.6%) failed DPC, requiring outpatient VAC treatment. DPC failures were more obese (40.3 ± 11.0 vs 31.1 ± 7.3 kg/m2; p = 0.02), had more comorbidities (7.3 vs4.5; p = 0.03), higher HgA1C (6.9 ± 0.9 vs 5.9 ± 0.6; p = 0.008), and longer length of stay (15.22 ± 6.4 vs 9.9 ± 6.1 days, p = 0.008). The 2 active smokers failed DPC. Hernias recurred in 4 patients (6%), 3 of which had wound complications. Conclusion: DPC with VAC was successful in 86.4% of patients with enteric-mesh fistulas, mesh infections or open intestine in the field. DPC should be considered in high risk patients to decrease the rate of long-term wound care or risk of complications from primary closure. Morbidly obesity, increased HgA1C, and smoking increase the risk of DPC failure.

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O8.2 Incisional hernia prophylaxis after stoma reversal surgery: a challenge for surgery: presentation of the early-postoperative course of two patient groups M. Ceno1, D. Paul2, T. Kottmann3, D. Berger1 1 Klinikum Mittelbaden Baden–Baden Balg, Baden–Baden, Germany, 2 Klinikum Mittelbaden Rastatt, Rastatt, Germany, 3Clinical Research Organisation, Hamm, Germany Background: Incisional hernia prophylaxis after stoma reversal surgery: Presentation of the early-postoperative course of two patient groups after prophylactic mesh augmentation of the abdominal wall using two different meshes: GOREÒ BIO-AÒ mesh vs. DynaMeshÒCICAT: Primary mesh augmentation followed by primary wound closure is the ideal concept for our patients. However, it has been demonstrated that primary mesh augmentation distinctly reduces the incidence rates of incisional hernias (Ceno et al. Poster EHS 2016 Rotterdam). Methods: All patients have been primarily treated since November 2010 according to the study inclusion and exclusion criteria with mesh augmentations applied in sublay technique and subsequent primary wound closure. From November 2010 to March 2016, we treated 127 patients with GOREÒ BIO-AÒ mesh, a synthetic resorbable mesh. From March 2015 to September 2016, we implanted the synthetic, non-resorbable mesh DynaMeshÒ-CICAT in a total of 46 patients. Results: A correlation between access and wound healing disorder was determined with a statistical significance of p = 0.017 in Fisher’s test. Primary wound healing occurred in 74.4% (n = 92) cases with GOREÒ BIO-AÒ mesh implants versus 84.8% (n = 39) cases with DynaMeshÒ-CICAT implants. In 4.7% (n = 6) of the cases GOREÒ BIO-AÒ meshes had to be removed because of deep wound infections versus 0% (n = 0) of cases with DynaMeshÒ-CICAT meshes. Conclusion: The challenge remains to treat the patients with the ideal mesh and the ideal surgical method. Match-pair analyses and randomized studies of all our patients with mesh augmentation with respect to the incidence rates of incisional hernias are in a state of preparation.

O8.3 Incisional hernia repair concomitant to stoma reversal increases the risk of anastomotic leakage N. N. Baastrup, M. F. S. Hartwig, P. Krarup, L. N. Jorgensen, K. K. Jensen Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, København NV, Denmark Background: Stoma reversal (SR) in patients with an incisional hernia represents a clinical challenge because of the subsequent closure of the abdominal wall. It remains unknown whether hernia repair should be concomitantly employed. We therefore examined the risk of complications and mortality in patients undergoing SR with or without concomitant hernia repair. Methods: This study included all patients subjected to SR between 2010 and 2016 at our institution. Patients undergoing or not undergoing concomitant incisional hernia repair were grouped accordingly.

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S152 The primary outcome was anastomotic leak (AL). Secondary outcomes included surgical site occurrences (SSO), overall surgical complications, and three-year mortality. Results: 142 patients undergoing SR were included, of which 18 (13%) underwent concomitant hernia repair. The incidence of AL was significantly higher in patients subjected to concomitant hernia repair [four out of 18 (22.2%)] compared with patients undergoing SR alone [three out of 124 (2.4%), P = 0.002]. Additional variables associated with AL were duration of surgery (P \ 0.001) and ischemic heart disease (P = 0.039). Twenty-two patients (15.5%) developed an SSO: eight (44.4%) in the hernia repair group and 14 (11.3%) in the nonhernia repair group (P \ 0.001). In the multivariable analysis, concomitant hernia repair remained associated with development of postoperative complications (OR = 5.92, 95% CI = 1.54–25.96, P = 0.012). There was no difference in three-year mortality between the two groups (P = 0.708). Conclusion: Incisional hernia repair concomitant with SR was associated with a higher incidence of AL and other complications compared with SR alone. These findings suggest that SR with concomitant hernia repair should be avoided.

O8.4 Incisional hernia repair in patients after liver transplantation with poly-4-hydroxybutyrate mesh T. S. Auer, N. Homfeld, J. E. Waha, P. Schemmer, D. Kniepeiss Univ.Klinik fu¨r Chirurgie Graz, Graz, Austria Background: Incisional hernia is a common problem after liver transplantation (LT). Permanent mesh implantation has a risk of chronic infection in immunosuppressed patients. Poly-4-hydroxybutyrate (P4 HB) commonly used as ultra-slow absorbable suture material is now considered for new generation of absorbable synthetic mesh. Most recently excellent results with P4 HB mesh in complex infected hernia have been observed. Thus incisional hernia repair after LT with P4 HB mesh in patients after LT has been implemented. Methods: In 2016 five patients after LT underwent onlay-enforcement closure of incisional hernia with P4HB mesh together with P4HB thread in a running suture and small bites technique. Results: All patients had uneventful wound healing, supported by a negative pressure suction device of -100 mmHg applied on the closed wound for 5 days. The follow-up period was between four and eleven months. All patients remained without complications and discomfort. Conclusion: Onlay-enforced closure of incisional hernia after LT is a safe procedure. To confirm our data a RCT should be performed. Based on this observational trial a RCT would be warranted.

O8.5 Visceral obesity as a predictor of incisional hernia recurrence N. N. Baastrup, L. N. Jorgensen, K. K. Jensen Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, København NV, Denmark Background: High body mass index (BMI) is a risk factor for both postoperative complications and recurrence after repair of giant incisional hernia (GIH). However, BMI is an anthropometric measure that does not distinguish between amounts of different tissues. We

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Hernia (2017) 21 (Suppl 2):S139–S207 hypothesized that visceral fat volume (VFV), measured on computed tomography (CT) scans, was a better predictor than BMI for recurrence after repair of GIH. Methods: Consecutive patients undergoing repair of GIH at our institution from 07.10.2010 to 05.12.2016 were included in this study. Data was collected from a database and all patients were summoned for clinical follow-up. We measured VFV from preoperative CT scans using an automatic segmentation tool. The primary and secondary outcomes were hernia recurrence and 30-day postoperative complications. Results: 126 patients were included, 25 (19.8%) of whom presented with hernia recurrence. Neither VFV nor BMI were significantly different between patients with and without recurrence (VFV: 5142 vs 4336 cm3, P = 0.119, and BMI: 29.5 vs. 28.0 kg/m2, P = 0.226). VFV was significantly higher among patients with a complication [VFV (complication): 5066 cm3 vs. VFV (no complication): 3830 cm3, P = 0.002]. In the subgroup of patients with BMI \ 30 kg/ m2, VFV was the only significant risk factor for recurrence [VFV (recurrence): 4944 cm3 vs. VFV (no recurrence): 3486 cm3, P = 0.022]. Conclusion: Contrary to BMI, VFV was significantly predictive of both post-operative complications in the entire cohort and hernia recurrence in non-obese patients. VFV may serve as a stronger preoperative risk factor than BMI in GIH repair.

O8.6 Special consideration for the use of botulinum toxin in abdominal wall reconstruction V. A. Augenstein, J. Helm, R. Lopez, R. Raible, K. Kercher, P. D. Colavita, B. T. Heniford Carolinas Medical center, Charlotte, NC, USA Background: Fascial closure may pose challenges in AWR but is associated with decreased rates of hernia recurrence, surgical site infection and mesh infection. Preoperative Botulinum toxin A(BTA) injection causes temporary muscle paralysis and may be used as an adjunct in AWR. There are few published reports on this subject. We describe four unique, complex examples in which BTA can successfully be used to facilitate abdominal wall closure. Methods: Preoperative image-guided BTA injections were administered to the lateral abdominal wall musculature. Demographics, hernia characteristics, imaging, surgical technique, complications and outcomes were evaluated. Results: Among the four unique patients, the average BMI was 29.15 ± 3.9 kg/m2, age 58 ± 14.8 years, and they had 1.3 ± 0.4 previous hernia repairs. Three patients had large ventral hernias, and one had a flank hernia. One patient had a previous external oblique component separation. Average operative data included: time to surgery from BTA injection: 29.3 ± 2.7 days, operative time: 252.8 ± 101.4 min, defect size: 397 ± 279.3 cm2, mesh size: 1104.8 ± 365.2 cm2. Mid weight polypropelene mesh was used in all cases and primary fascial closure was achieved in all patients. There were no postoperative complications. With an average follow up time of 18 ± 12.8 months, there are no recurrences. Conclusion: BTA injection into the lateral abdominal wall musculature should be considered in certain challenging AWR cases in order to reapproximate the midline fascia. Preoperative BTA injection should be considered in facilitating primary fascial closure in cases where component separation may not be adequate, possible, or previously failed.

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O8.7 No stitch, no pain: quality of life and recurrence with suturless technique for incisional hernia F. Abbonante, G. Tomaino, M. Della Corte Hospital Pugliese-Ciaccio, Catanzaro, Italy Background: Mesh application is considered standard procedure for incisional hernia, but, nevertheless, there is no consensus as to which mesh provides the best possible repair and what type of its application is more comfortable for the patients. Most techniques involve sutures to anchor a mesh, thinking to prevent migration, wrinkling or curling. These are blamed for extensive tissue tension and nerve entrapment leading to prolonged postoperative pain. In this study, we performed an evaluation of clinical outcomes of Ermanno Trabucco’s suture-less hernioplasty technique. Methods: From January 2007 to December 2015, 215 patients underwent surgery for incisional hernia, with the sutures-less sliding mesh hernioplasty technique. The hernias were measured and classified according to EHS classification. Based to the defect size and patient characteristics, two different type of monofilament of polypropylene heavy mesh are used. Results: Patient follow-up was performed at 2 weeks, 6 months, 1 and 2 years. We analyzed rate of recurrence, freedom of movement of the patient and presence of pain after surgery. Lower recurrence rates and greater well-being of the patients were found. Conclusion: Heavy mesh, used in this study, remain flat and well distributed, without the application of points and not shrinked or wrinkled as would happen with lighter meshes, that require synthesis sutures to stay flat, with an altered distribution of forces resulting in pain and muscle rupture during the action of contraction, functional limitation and frequent recurrence. Patients resulting in total freedom of movement and well-being, without major risks of recurrence.

O8.8 Retromuscular incisional hernia repair: feasible and safe in ambulatory surgery: a prospective cohort study E. Delgado Oliver, J. Espert, M. Ribal, G. Dı´az-DelGobbo, R. Corcelles, B. Martin, A. Lacy Hospital Clinic, Barcelona, Spain Background: Development of an incisional hernia after abdominal surgery is a common complication following laparotomy and it’s approached from different techniques nowadays. We believe retromuscular mesh repair is the best option for medium-sized incisional midline hernias decreasing SSOs and recurrences. In the absence of contraindications, this procedure may be feasible and safe in Ambulatory Surgery. Methods: This was a prospective study assessing 200 patients operated in an outpatient surgery unit between 2011 and 2016. Inclusion criteria included is midline defects of 4–10 cm. Patient’s characteristics, hernia size, postoperative outcomes as surgical site occurrences (SSO) or surgical site infection (SSI), and recurrence were analyzed. All patients were followed up at discharge, 2 weeks, 3 months and 12 months postoperatively and then annually. Results: Mean age and body mass index (BMI) were 56 years and 26.7 kg/m2. A 29% were recurrent incisional hernias, 30% diabetics and 24% smokers. Mesh fixation was performed with Fibrin until September 2014 and with Glue since October 2014. Patient satisfaction were excellent and more than 70% of patients return to their activity in less than 2 weeks. There were SSOs in 27 patients (13%): cellulitis (5%), seroma (3%), and Fail fascia (4%). Median follow-up

S153 was 27.1 months (interquartile range 7–60 months) and we detected 8 recurrences (4%). Conclusion: Retromuscular mesh repair for midline incisional hernia of moderate size is safe and feasible, with low SSO and recurrence. This approach is a valid option, in the absence of contraindications, in an outpatient surgery unit.

O8.9 Improved results with a retromuscular mesh instead of an intraperitoneal mesh in endoscopically components separation technique J. M. M. Thoolen1, J. A. Wegdam1, E. H. H. Mommers2, S. W. Nienhuijs3, T. S. de Vries Reilingh1 1 Elkerliek Hospital, Helmond, The Netherlands, 2Maastricht University Medical Centre, Maastricht, The Netherlands, 3Catharina Hospital, Eindhoven, The Netherlands Background: Complex ventral hernia repair with endoscopic Components Separation Technique (eCST) preserves skin vascularization and reduces wound surface compared to open CST. Hernia repair is completed with an intraperitoneal onlay mesh (IPOM) or a sublay retromuscular mesh. For reasons of quality improvement, institutional policy changed in 2015 from eCST with IPOM to eCST with sublay mesh. Aim of this study was to evaluate Surgical Site Occurrences (SSO), cardiopulmonary and gastrointestinal complications between IPOM and sublay patients. Methods: All patients with a 10–15 cm ventral hernia that underwent repair with eCST between 2012 and 2016 were prospectively registered. ECST was performed by dilating the intramuscular space under direct endoscopic vision and dividing the aponeurosis of the external oblique from costal margin to inguinal ligament. In IPOM, a VentralightÒ mesh was used, in sublay a SoftmeshÒ or PhasixmeshÒ. Results: In 49 eCST patients, 23 had IPOM and 26 sublay. Between both groups, patient characteristics and Hernia-Patient-Wound classification were similar: 65% males, median age 60 years, body mass index mean 28 ± 4 kg/m2, mean hernia size 182 ± 160 cm2, comorbidities in 53% and contaminated wounds in 10%. No differences between groups were demonstrated in operation time (median 146 ± 60 min), hospital stay [median 6.5 (1–67) days] or in SSO (overall 16%). Cardiopulmonary and/or gastrointestinal complications occurred in 48% in IPOM versus 15% in sublay (p = 0.03). After a follow-up of median 9 (0–44) months, 3 (6%) patients experienced a recurrent hernia. Conclusion: ECST with a retromuscular mesh led to significantly less complications than with an intraperitoneal mesh.

09 Recurrence prevention: 5 crucial procedural steps O9.2 TEP F. Ko¨ckerling Vivantes Hospital Berlin Department of Surgery and Centre of Minimally Invasive Surgery, Berlin, Germany The ‘‘World Guidelines for groin hernia management’’ recommend Lichtenstein, TAPP and TEP as the best evidence-based techniques for the repair of inguinal hernias. The present review focuses on the surgical risk factors for recurrence after primary inguinal hernia

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S154 repair. This has identified several risk factors for recurrence which can be influenced by the surgeon. Mesh size: The standard mesh size recommended in the guidelines for TEP is 15 9 10 cm. Under no circumstances should a smaller mesh be used. For larger direct ([3–4 cm) and indirect ([4–5 cm) inguinal hernias even larger meshes (12 9 17 cm) should be used. Management of the indirect sac: Wherever technical feasible in laparo-endoscopic techniques the indirect hernia sac should be completely excised from the inguinal canal. Management of the direct sac: For larger direct/medial hernias in laparo-endoscopic techniques the fixed hernia sac should be reduced to prevent seroma and recurrence. Therefore the transversalis fascia lining this region should be inverted and either sutured to Cooper‘s ligament or ligated with a Roeder loop. Lipoma in the inguinal canal: Lipomas in the inguinal canal can be easily overlooked. Awareness and appropriate management of the sliding lipoma will help to reduce the risk of recurrence after TEP. Mesh fixation: In direct/medial defects larger than 3 cm, especially in bilateral cases, mesh fixation should be considered. If the evidence-based influencing surgical risk factors for inguinal hernia recurrence are taken into account, the surgeon can assure a good outcome for patients with regard to the recurrence rate.

O9.3 TAPP: Recurrence prevention: 5 crucial procedural steps R. Bittner Hernia Center Rottenburg, Rottenburg, Germany The first aim in inguinal hernia surgery is to avoid a recurrence. The following steps are crucial: 1. Deep knowledge of anatomy and understanding of hernia pathology. 2. Complete dissection of the pelvic floor with vast parietalization of the peritoneal sac. 3. Mesh size at least 10 9 15 cm. 4. Precise measurement of the size of the hernia defect: In patients with a hernia defect [3 and \4 cm, fixation is recommended: laterally with glue, medially with tacks. 5. In patients with a hernia defect [5 cm, implantation of a larger mesh (12 9 17 cm) is recommended.

Hernia (2017) 21 (Suppl 2):S139–S207 Understanding a disturbed collagen metabolism as one of the main etiologic factors for incisional hernia formation, it is therefore necessary to repair the complete fascia scar to avoid ‘‘pseudorecurrences’’ (1). The mesh size needs to follow the defect size with an overlap of 5 cm in all directions (2). This is difficult where the linea alba prevents a mesh placement. To achieve a sufficient mesh layer in this area it is necessary to incise the posterior rectus sheath on both sides beside the linea alba, reaching the preperitoneal space, the so called fatty triangle (3). The same problem occurs when the defect borders osseous or cartilage structures, such as the pubic bone or the xyphoid. In these cases the retropubic or the retroxyphoid space needs to be dissected (4). To eliminate the need of mesh fixation, the anterior fascia needs to be closed in front of the mesh (5). Therefore the knowledge of anterior or posterior component separation techniques is essential, not to forget a plan B, C and D.

O9.5 Laparoscopic IPOM S. Morales Conde University Hospital ‘‘Virgen del Rocı´o’’, Sevilla, Spain Abdominal wall hernia repairs are the most frequently performed operations in general surgery. They can be carried out using either open surgery or minimal access laparoscopy. In this setting, laparoscopic approach has revolutionized the management of ventral hernia and it has been shown to be an effective way of treating these diseases. Regarding its advantages, laparoscopic techniques offer better visualization of the entire defect, ensuring fixation to healthy tissue and complete coverage of the hernia. Moreover, review of large series of laparoscopic hernia repairs found a recurrence rate of less than 5% (1). Proper technique, mesh material, fixation and ovelap are basic steps to prevent recurrences. Among the benefits of the laparoscopic approach when compared to open repair are the reduced of local morbidity (2). Due to these advantages, laparoscopic hernia repair has been demonstrated to be an acceptable and successful technique.

10 Social Media in hernia sugery

Conflict of interests: The author has nothing to declare.

O10.1 Social media for herniologists O9.4 Sublay mesh repair J. Conze Herniacenter Dr. Muschaweck-Dr. Joachim Conze, Munich, Germany Where is the sublay-mesh position? It is necessary to be more precise: the original ‘‘sublay’’ is retromuscular, placing the mesh on the posterior layer of the rectus sheath. A standardised performed retromuscular mesh augmentation should provide a long-term stability. But the literature reveals a different truth. What are the reasons for this discrepancy? Main principle of this technique is a reinforcement of the abdominal wall with synthetic mesh, providing a sufficient contact area between mesh and host tissue.

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R. R. W. Brady Newcastle Upon Tyne University Hospitals, Newcastle, UK Social media engagement in healthcare continues to expand. For members of the hernia surgery community, social media is already making a significant impact on practice, medical education and patient care. The applications are unique such that they provide a platform for instant communication and information sharing with other users worldwide. The purpose of this talk is to provide an overview of how social media has the potential to change clinical practice, training, research and patient care in hernia surgery. A number of notes of caution in the use of this new technology are also mentioned.

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O10.3 The risks and pitfalls of social media in medicine J. Kukleta NetworkHernia, Klinik Im Park, Hirslanden Group, Zurich, Switzerland We live in accelerated times. In the era of alternative truths, fake news and a crisis of facts. The expression ‘‘Postfactual’’ was voted for the Word of 2016. The ‘‘traditional’’ spread of news, information in encyclopedic style, sharing of knowledge or exchange of opinions has dramatically changed since the introduction of internet to public. Social media are Internet-based tools that allow individuals and communities to gather and communicate. While patients are using social media to obtain health information, providers are using it to fill open positions. ‘‘Social media’’ is a collective term that covers a wide range of electronic communication tools, such as email, Wikis, Facebook, LinkedIn, Twitter, YouTube, social networking websites, blogs and many others. Social media (SM) became within the last decade an indispensable tool in communication and information. SM advances to a powerful tool in public and professional education. But the tremendous data flow, the speed of change and the high accessibility of this platform bear potential risks for health care professionals and the patients. The main limitation of health information in SM is the lack of quality and reliability. Unprofessional contents, breaching patient’s privacy, discriminatory language, violation of personal-professional boundaries, negative comments about patients or colleagues or damage to professional image may become very disadvantageous or even legal issues. Despite some regulative recommendations of various institutions about what not to do a systematic schooling of public and professionals in how to use is still inexistent. Conclusion: In order to appreciate the advantages of SM we have to learn how to use it and what to avoid appropriately.

O10.5 Social media sharing of speakers congress presentation slides: intellectual property violation or basic human right? M. Pawlak Clinic of Vascular Surgery, Institute of Hematology and Transfusion Medicine, Warsaw, Poland The use of social media is becoming more and more popular in dissemination of medical knowledge. Platforms including Twitter, Facebook and Researchgate, are becoming essential tools in both communication and sharing opinions among surgeons around the world. With reference to the recently introduced survey about the audience posting speakers slides, videos and other material, it has been highlighted by the respondents that individual conferences should be explicit on the rules for sharing speakers congress presentation slides. Opinions differed the most between the respondents who have taken up social media in their professional practice compared to the less frequent social media users. The aim of this presentation is to introduce the basic knowledge about the sharing of speakers slides on social media, how this can be used correctly from a legal stand point and what we shouldn’t do! Is such a practice our basic human right and should be encouraged for the educational benefit it affords, or is it a violation of intellectual property and should be stopped immediately?

S155 The simple algorithm will be outlined and the questions for the future of congresses as we know them presented. With new technologies of communication developing so fast, the translation of legal language to surgical societies needs is extremely necessary. We need to verify our knowledge about new platforms for the dissemination of knowledge and demonstrate that the path that is presently adopted meets good practice standards.

O10.6 Social media will soon replace journals and medical congresses as we know them K. K. Jensen Copenhagen, Denmark Background: The evolution of social media has begun to impact on traditional scientific journals and congresses, and will keep on doing so in the future. The fast and simple way to share articles, data, and opinions that social media represent has prompted traditional journals to adapt to the new reality where social media to a higher degree dictates the relevance of journals. #Visualabstracts, the use of altmetrics, planned online discussions and active social media strategies have been introduced by different journals underlining the changed environment journals must navigate in due to the rise of social media. Failure to adapt to this new way of communicating will lead to reduced attention and thus decrease the impact of some journals and perhaps even eliminate others. Methods: Review of the current status of medical journals in the above-mentioned context. Results: Currently, at least seven well-established surgical journals have implented #visualabstracts and actively embraced social media. But why do we even need high-impact journals, if the true value of publishing lies within the attention of fellow researchers, colleagues and layman press? Conclusion: The future outlook of journals and congresses in the above-mentioned context will be addressed and subject to discussion.

11 Video session: New techniques in inguinal, perineal and parastomal hernia repair V11.2 Management of the indirect hernia sac in laparoscopic inguinal hernia repair (TAPP) avoiding intra and postoperative complications N. Ueno1, T. Wakahara1, K. Kanemitsu1, T. Yoshikawa1, S. Tsuchida1, A. Toyokawa1, A. Arimoto2, M. Hosono2 1 Department of General Surgery, Yodogawa Christian Hospital, Osaka, Japan, 2Department of Gastrointestinal Surgery, Kobe University Hospital, Kobe, Japan Background: We will report our surgical technique with safe and rapid dissection to the total excision of indirect hernia sac in TAPP. Methods: We start the peritoneal incision at the level of the lateral to the medial umbilical fold in order to expose the prevesical space of Retzius and dissect the bladder off the pubis and the rectus muscle against the bladder injury.Then the dissection of the peritoneum (hernia sac) is continued in the caudal direction of sac along avascular plane, peeling off the peritoneum and leaving spermatic cord and vas deferens, as wrapped in the spermatic sheath, resting against the abdominal wall. (Parietalization) The sac dissection is more involved

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S156 as it requires identification and preservation of the spermatic cord and vas deferens. When fused portion of the processus vaginalis is finally exposed and dissected and hernia sac does not retract toward the inguinal canal on releasing traction, we define the hernia sac as completely reduced. In the case with a long sac, it can be wise to circumcise the sac in the inguinal canal and to leave the distal end open. Once the sac is reduced, preperitoneal dissection is made extending onto the anterior abdominal wall to create sufficient preperitoneal flaps which provides for a large peritoneal pocket for mesh placement. Results: This maneuver resulted in postoperative seroma in 8.3% but in no ischemic orchitis or testicular atrophy, and no recurrence among 162 cases (214 hernias) in 2016. Conclusion: We report the total excision of indirect hernia sac in TAPP.

V11.3 Management of large complete inguinal hernias: our experience with ‘Hybrid TEP’ P. Chelawat, A. Sharma, R. Khullar, V. Soni, M. Baijal, P. Chowbey Max Superspeciality Hospital, Delhi, India Background: Laparoendoscopic repair of inguinal hernias is indicated for the repair of primary bilateral inguinal hernias provided surgical expertise cognisant of patient/surgeon/local resource suitability to the surgical approach is available. TAPP and TEP have comparable outcomes hence it is recommended that the choice of technique should be based on the surgeon’s skills education and expertise. TEP is usually considered as a favoured approach in case of bilateral small, reducible groin hernias, however, with certain modifications, we demonstrate that TEP is a safe and versatile procedure even for the management of complex groin hernias. Methods: We performed a reterospective study at our tertiary care level institute. 1675 inguinal hernias were operated from 2011 to 2016. Our electronic data base was searched and after excluding TAPP, recurrent, irreducible and large scrotal hernias, 122 patients were included in the study. The procedures were performed using some modifications of the standard TEP approach (Hybrid TEP) described in the videos. Results: Mean operative time for hybrid endoscopic hernia surgery was 113(±22) min. The mean length of hospital study was 54 (±7) h. Intraoperative complications encountered were bleeding (n = 3), bladder injury (n = 1). Pain assessment using visual analogue scale was 6.6 (mean) and urinary retention in 7 patients. Seromas were seen in 18 patients. On a follow up of 1 year no recurrences were reported. Conclusion: TEP can successfully be modified to treat irreducible and large complete hernias. These hybrid TEPs are safe and feasible and are associated with good outcomes in experienced hands.

V11.4 Laparoscopic totally extraperitoneal hernia repair for inguinal bladder hernia P. Jitpratoom, W. Wandee, K. Ketwong, A. Anuwong, S. Vijitpornkul Police General Hospital, Bangkok, Thailand Background: Inguinal bladder hernias account for 1–4% of all inguinal hernias. Most of the hernias are asymptomatic and usually discovered incidentally during surgery or imaging studies performed

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Hernia (2017) 21 (Suppl 2):S139–S207 for other purposes. While most of the bladder hernias are repaired by open technique, laparoscopic surgery is chosen in some cases. This study reported a case that was managed with laparoscopic totally extraperitoneal repair (TEP). Methods: The surgical risk, complication, and procedure were explained and informed consent was obtained. The technique of laparoscopic totally extraperitoneal hernia repair was clinically applied in one male patient with palpable 7 cm diameter left groin mass. The data was documented. Laparoscopic TEP repair access was obtained by three abdominal skin incisions. One 30° endoscope was introduced into the preperitoneal cavity. Dissection was accomplished with available laparoscopic instruments. Mesh was placed over the abdominal wall defect and attached using endoscopic tackers. Results: This is a case report of bladder hernia which the diagnostic circumstance was by CT imaging for enlarging irreducible mass at left inguinal area in a 72-year-old male. The patient had no otherwise complaint such as urinary tract symptom or abdominal pain. The hernia was managed successfully by laparoscopic totally extraperitoneal hernia repair. The operative time was 65 min with estimated blood loss of 10 ml. The patient was discharged 2 days after the surgery without immediate complication. The overall clinical improved with no recurrent hernia examined at follow-up. Conclusion: Laparoscopic totally extraperitoneal hernia repair is safe and feasible in patient with inguinal bladder hernia.

V11.5 Successful treatment of refractory chronic neuropathic pain after inguinal hernia repair by means of laparoscopic retroperitoneal triple neurectomy M. Narita, S. Jikihara, R. Matsusue, H. Hata, T. Yamaguchi, T. Otani, I. Ikai Kyoto Medical Center, Kyoto, Japan Background: Most of patients having neuropathic pain following inguinal repair obtain pain relief by means of medical treatments, while it would evolve into a chronic refractory case and become a disabling disease. Herein, we report a successful case of surgical treatment by laparoscopic retroperitoneal triple neurectomy for chronic refractory neuropathic pain after inguinal hernia repair. Methods: A seventy-year-old male who underwent right-side inguinal hernia repair using Lichtenstein method revisited to our hospital with an exacerbate pain on 16 months after surgery. On physical examination, the area of tenderness was distributed over inside of right anterior superior iliac spine to superior margin of pubis along surgical wound, and the point of maximum tenderness is the upperlateral side of the surgical wound. He walked with a limp due to the pain. The patient was diagnosed with neuropathic pain because pain had been evoked by specific movement and no evidence of recurrence and meshoma were seen on MRI. Conservative therapies were not totally effective. Surgical treatment by means of retroperitoneal laparoscopic triple neurectomy was performed at 4 months after initiation of treatment. Under general anesthesia, in the left lateral recumbent position, three ports were inserted into retroperitoneal cavity. Ilioinguinal, iliohypogastric, genital branch of genitofemoral nerve were identified and resected respectively. Results: Pain relief was achieved immediately after surgery, and this patient has spent his life without pain. Conclusion: Laparoscopic retroperitoneal triple neurectomy is technically challenging but may be a useful option for chronic refractory neuropathic pain without nociceptive pain after inguinal hernia repair.

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V11.6 Modified laparoscopic sandwich technique: change in the surgical management of parastomal Hernias (PSH) over 15 years C. Bertoglio, B. Alampi, L. Morini, M. Origi, C. Magistro, S. Di Lernia, G. Ferrari ASST Grande Ospedale Niguarda, Milan, Italy Background: The results achieved over the years by both open and laparoscopic procedures for repair of PSH were poor. The Sugarbaker and the Keyhole techniques (KH) are currently performed and the combination of both has been recently described as ‘‘sandwich repair’’ (SR). Unfortunately the use of a mesh with a slit proved to relate with unacceptably high recurrence rates (RR) while SR showed better outcomes. We describe our experience in the treatment of PSH over a period of 15 years. Methods: From January 2002 to January 2017 we performed 755 laparoscopic ventral hernia repairs. Among them we assessed all cases of PSH repair and the results were collected and evaluated with regard to complications (PC) and RR. Results: 27 patients (3.6%) were operated with three different surgical techniques: KH (33%), modified KH (37%) and modified SR (30%). Changes of the original procedures consisted in the addition of direct suture and new fixation devices. Overall RR and PC were 22 and 18% respectively along a median follow-up of 36 months (range 6–96). Perioperative course after SR was uneventful and no early recurrence was recorded in the short term period. Conclusion: Inadequate results following KH elicited changes of our surgical approach in favour of SR. In fact data from the available meta-analysis and systematic review showed promising lower RR and less incidence of postoperative mesh-related infections after this procedure. Our early experience with this technique confirm these results though a rigorous long-term evaluation is expected to validate its use.

V11.7 Down to up TAR for the treatment of a stoma site hernia L. Bla´zquez Hernando1, M. Garcı´a Uren˜a1, A. Robı´n1, J. Lo´pez Monclu´s2, D. Melero1, C. San Miguel1, A. Cruz Cidoncha1 1 Hospital Universitario del Henares, Coslada, Spain, 2Hospital Puerta de Hierro, Majadahonda, Spain Background: Transversus abdominis release (TAR) is a surgical technique described recently but is increasingly used in complex abdominal wall hernias. One of the indications of TAR is the surgery for non midline hernias like the stoma site hernia. We present a video of a TAR procedure in a stoma site hernia. Methods: A 61 years old man with hypertension and diabetes, underwent a laparoscopic low anterior resection and a loop ileostomy in March 2012 for a rectal cancer. The reconstruction of the intestinaI continuity was performed in January 2013. Fifteen months after last surgery he develop an stoma site hernia who has grown progressively. The preoperative CT shows a defect with more than 8 cm in diameter. We approach this patients through a median incision and we perform a bilateral Rives procedure and a right TAR. The TAR was performed with some modifications of the technique originally described: we employ a down to up release of the transverse muscle and do not fix the mesh laterally. Results: The postoperatory course was uneventful and eighteen moths after surgery the patients present a very good aesthetic and functional results without relapse.

S157 Conclusion: As we shown in the video, TAR is an ideal technique to treat ostomy site hernias. This is a complex surgery in which knowledge of anatomy is essential but our modifications in surgical technique (down to up release of the transverse muscle and avoid lateral fixation) may help to perform it.

V11.8 Laparoscopic repair of a perineal hernia after abdominoperineal resection V. Dhooghe, A. Beunis, S. Van den Broeck, M. Ruppert, G. Hubens, N. Komen University Hospital Antwerp, Edegem, Belgium Background: Perineal hernias are difficult to repair as there is no clear evidence as to what is the best method. We report a case of a 78-year-old man with a history of a radical prostatectomy who underwent a laparoscopic abdominoperineal resection for an ultralow T3N0M0 rectum carcinoma after chemoradiation. Eighteen months postoperatively, he presented with a symptomatic perineal hernia. He developed difficulty sitting and had multiple episodes of lower abdominal pain. Methods: Clinical examination revealed a reducible, painless incisional perineal hernia. Computed tomography of the pelvis confirmed the hernia without evidence of recurrent malignancy. The patient consented to surgical intervention. Results: The defect was laparoscopically repaired using a nonabsorbable mesh (DynameshÒ-IPOM 15 9 15 cm) which was fixated to the coccyx and a rim of the levator ani muscle using a permanent fixation device (CapSureTM Fixation System) and tissue adhesive (IFABond Laparoscopic Hernia Glue). The remaining mesh was sutured to the surrounding muscle rim, lateral abdominal wall and bladder peritoneum using interrupted Ethibond 2/0 sutures. Placement of a drain transabdominally in the perineal hernia sac to prevent seroma formation. Removal of the drain at postoperative day 9, despite its production, due to the risk of mesh infection. Conclusion: We preferred a transabdominal repair because the high risk of wound complications of a transperineal repair considering the previous radiotherapy. We report a feasible technique with a composite mesh with an open pore mesh construction which facilitates the breakdown of seroma and the association of tissue adhesive as a fixation method.

12 New techniques in ventral & incisional hernias O12.2 Robotic assisted midline reconstruction: overview and description T. Costa, R. Abdalla, C. Gontijo University of Sao Paulo, Medical school, sao paulo, Brazil Background: Many studies have proven the benefits of abdominal wall restoration and the optimal position of the mesh. Rives and Stoppa, the sublay mesh repair technique has proven to be very effective, with minimal complications and low recurrence rates. Herein, we designed a technique to reconstruct the midline from the peritoneal cavity, approximating the rectus abdominis muscles and sublay mesh allocation, using robotic assisted surgery to avoid greater tissue detachments and suture efforts by the surgeon.

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S158 Methods: By using the DaVinci system four trocars were used (3 of 8 mm and 1 of 12 mm). After the complete liberation of the adhesions the posterior sheath of the rectus abdominis is opened. All the midline is reconstructed using anterior running suture. A mesh is placed retromuscular and fixated with stitches. The posterior sheath is then closed entirely with running suture as well. Results: Ten patients [age ranged from 35 to 63 years; mean body mass index, 22 ± 5 kg/m(2)] underwent robotic assisted midline reconstruction (RAMR) for ventral hernia repair. The median defect size was 8 cm (range 5–11). Operative time ranged from 120 to 180 min. There were no complications. All the patients were submitted to CT scan. They also had a close follow up with no recurrence, good acceptance and satisfaction. Conclusion: Although it is just the beginning of a technique, the RAMR is a feasible approach with interesting results and the possibility to approximate to open standards techniques along with the benefits of MIS in ventral hernia repair.

O12.3 Milos hernia repair. A new technique not only for the simple ventral hernia R. M. Wilke Hospital Calw-Nagold, Nagold, Germany Background: The Milos surgery is a new sublay technique with minimal operative trauma. With a minimal open access, a mesh is placed into a retromuscular position. That also allows supplying all major hernias. Methods: From 01/2015 to 01/2017, 34 large ventral abdominal hernias were operated. The approach was a 5 cm transverse supraumbilical incision. The rectus sheath was closed in all patients without fascia closure and was mesh augmented. The selection of the meshes (Dynamesh/Cicat/Visibile and GORE/BIO/A) was based on the size of hernia and the degree of comorbidity of the patients. Results: 16/34 operations were performed in posterior component separation technique. Operationslength was Ø 106 min, without component separation Ø 81 min. Hospitalstay was 4.5 days for all patients. Wound complication 2/34, Seromas 3/34, postoperative Hematomas 3/34, no recurrences. Patients with visible MRI meshes 21/34 were controlled with an MRI-Scan. 11/21 shown a beginning new inguinal hernia appeared at the border to the implanted mesh. 13/34 have received a BIO A-Mesh in order to their comorbidity. This showed a good ingrowth behavior. Conclusion: The MILOS technique is a safe method for the retromuscular mesh reinforcement of all ventral hernias. Low complication rate, minimal operative trauma, short hospital stay and functional result were excellent. Especially comorbid patients benefit from the procedure. A closure of the fascia is not necessary when the rectus sheath is closed and reinforced with a large overlapping mesh. Newly occurring inguinal hernias after surgery was noticeable. However, the inguinal canal should always be covered by the mesh.

O12.4 The peritoneal flap hernioplasty for repair of large ventral hernia D. Light, A. De Beaux, B. Tulloh Royal Infirmary of Edinburgh, Edinburgh, UK Background: A number of techniques have been described in the repair of large ventral hernia when primary fascial closure is not

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Hernia (2017) 21 (Suppl 2):S139–S207 possible. We report our recent experience of peritoneal flap hernioplasty as an alternative to component separation in ventral hernia. Methods: Mesh is positioned between transposed flaps of preserved hernial sac and rectus sheath. Patients undergoing this repair from 1 January 2012 to 31 December 2015 were identified and clinical outcome was assessed by a combination of case-note review, outpatient consultation and telephone interview. Results: 116 cases of primary and recurrent ventral hernia were identified over the study period. Defects ranged from 30 to 450 cm2. Mesh sizes ranged from 400 to 900 cm2. The median post op stay was 7 days (range 3–61 days). 11 cases developed superficial skin necrosis, 18 developed superficial wound infection and 15 developed seroma requiring clinical assessment. All were managed conservatively. 5 Patients developed a recurrence over the period. 3 were managed conservatively and 2 underwent a reoperation. Conclusion: This is a useful method for repairing large ventral and incisional hernias when primary fascial closure is not achievable, combining a sublay mesh repair with autologous tissue transposition across the fascial gap.

O12.5 Randomized clinical trial: comparison between robotic assisted and laparoscopic incisional hernia repair T. N. Costa, R. Z. Abdalla, I. Cecconello, U. Ribeiro Jr University of Sao Paulo, Medical School, Sao Paulo, Brazil Background: Minimally invasive surgery has modified dissection and anatomy preparation of surgical diseases. However, the benefit of this method has been delayed due to the lack of development and articulated movements. Robotic technology can overcome these problems, but there is no randomized trial comparing robotic and laparoscopic hernia repair. Methods: Between may 2015 and September 2015, 37 patients with incisional hernia were randomized in 2 groups: Robotic and Laparoscopic repair. All the patients had a pre and post-operative Qol-questionnaire as well as abdominal function evaluation. All of them were also submitted to Computed Tomography. Results: From the 37 patients, 18 patients were submitted to the robotic procedure and 19 to the laparoscopic. In terms of demography both groups were comparable. QOL-questionnaire showed improvement in the two groups, however without a statistically significant difference between them. CT scan showed good results in both groups. Abdominal function evaluation showed a better improvement in the robotic group. Overall surgical time and morbidities were similar. The cost analysis showed less costs per surgery in the laparoscopic group but total costs were similar. 4 Patients from the laparoscopic group and 2 from the robotic group had recurrence. Follow up was 15 months. There was one death in the laparoscopic group due to enteral fistulae. Conclusion: This is the first randomized prospective trial comparing laparoscopic and robotic hernia repair. It shows similar outcomes in terms of total costs, morbidities and QOL. However in terms of abdominal function and recurrence it favored the robotic group.

O12.6 Robotic hernia repair: Indian experience A. Prasad Apollo Hospital, New Delhi, India Background: Laparoscopic hernia repair has been widely accepted as a good procedure. However in some patients undergoing robotic

Hernia (2017) 21 (Suppl 2):S139–S207 abdominal surgery, we see a concomitant ventral or inguinal hernia. Robotic inguinal and ventral hernia repair is a relatively new concept and has been offered to patients. Methods: Between July 2012 and Jan 2017, we have had 31 patients who had abdominal wall hernia in addition to the primary problem for which they were undergoing robotic surgery. Patients included those with ventral and inguinal hernias. These patients were those undergoing fundoplication, achalasia surgery, rectopexy, radical prostatectomy and bariatric surgery. For inguinal hernias, robotic TAPP was done with mesh placement and suturing. For ventral hernias, IPOM or extra peritoneal mesh placement was done with suturing. Results: All patients did well. There were no intraoperative or post operative complications seen. No recurrence has been reported so far. Conclusion: Patients undergoing robotic abdominal surgery can have robotic mesh repair of a concomitant ventral or inguinal hernia. In inguinal hernias and some ventral hernias staplers are not needed for fixation. Results are comparable to the laparoscopic and open hernia mesh repairs.

O12.7 Transabdominal midline reconstruction: a stapled technique based on the Rives-Stoppa principles T. Costa, M. A. Santo, R. Z. Abdalla, C. Gontijo University of Sao Paulo, Medical School, Sao Paulo, Brazil Background: The introduction of the minimally invasive approach changed the way abdominal surgery was carried out. Although the laparoscopic approach, with defect bridging and mesh fixation, has been described since 1993, the procedure remains largely unchanged. Evidence shows that defect closure and retro-muscular mesh positioning have the best outcomes. We therefore aimed to develop and demonstrate a procedure, which combined the good results of open surgery using the Rives-Stoppa principles, with all the benefits of minimally invasive surgery. Methods: Indications: midline hernias (M2–M4), recti diastasis, functional patients, without contraindications. Technique: The peritoneal cavity is accessed through a five/eleven millimeter optical view cannula at the superior left quadrant. A suprapubic and two right and left lower quadrants cannulas are inserted for inferior access and dissection. The defect adhesions are released. The whole midline wall is closed with an endoscopic linear stapler, including the defect, from the lower abdomen, 4 cm below the umbilicus, until the epigastric region, including posterior sheath mechanical suturing and cutting in the same movement. A retro rectus space is created in which a retro-muscular mesh was deployed, from de xyfoid to the pubis. Fixation is done using a hernia stapler. The defect created in the posterior sheath is closed using running suture. Results: CT-Scans showed total closure of the defect. QOL questionnaire showed satisfaction, acceptance and no complaints. Conclusion: We demonstrated a feasible technique combining the benefits of laparoscopic and open surgery. The results, shown by CTscan, peri-operative and QOL findings, were good.

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O12.8 Evaluation of the operative time for robotic assisted laparoscopic groin hernia repair during the learning curve F. Muysoms1, C. Ballacer2, A. Ramaswamy3, S. Van Cleven1, I. Kyle-Leinhase1 1 Maria Middelares, Gent, Belgium, 2Center for Minimally Invasive and Robotic Surgery, Phoenix, AZ, USA, 3University of Minnesota, Minneapolis VA Medical Center, Minneapolis, MN, USA Background: Robotic assisted transabdominal preperitoneal inguinal hernia repair (rTAPP) is demonstrating rapid adoption in the United States. One of the barriers to adopting rTAPP in Europe is the perception of longer operative time. Methods: Patients undergoing rTAPP in our start-up period were entered in the prospective EuraHS database. Operations were performed with the DaVinci Xi by the same surgeon. Operative time is recorded as the time from incision to complete closure of skin. Results: Following proctoring on the use of the robotic system for this procedure in September 2016 by US surgeons, 50 rTAPP procedures have been performed up to January 2017. Of these, 34 were unilateral and 16 were bilateral repairs. Mean operative time for unilateral hernias was 54 min (32–89). For the first 17 unilateral hernias mean operative time was 61 min (43–89), compared with 47 min (32–77) for the second 16 patients. Mean operative time for bilateral hernias was 82 min (53–118). For the first 8 bilateral hernias mean operative time was 95 min (73–118), compared with 69 min (66–83) for the next 8 patients. During 2016, the same surgeon performed 116 conventional TAPP operations prospectively recorded in the EuraHS database. Mean operative times were 44 min (24–94) and 63 min (40–136) for 65 unilateral hernias and 51 bilateral hernias, respectively. Conclusion: Robotic TAPP was associated with a rapid reduction in operative time during our learning curve. The perception of a significantly prolonged operative time for robotic assisted laparoscopic inguinal hernia repair compared to conventional laparoscopy was not noted in our experience.

O12.9 A simple and foolproof technique for closing port sites in laparoscopic surgery A. Vindal, P. Lal Maulana Azad Medical College, New Delhi, India Background: Port site hernia is a complication unique to laparoscopic surgery with reported incidence between 1 and 39%. More and more complex procedures are now being done by the laparoscopic route necessitating an increase in number and size of ports, and thus increasing the chances of this complication. Although the standard recommendation is to close fascial defect for all ports C10 mm, it is often not easy or practical either due to patient’s body habitus (obesity) or due to difficult location of the port site (lateral abdominal wall). Methods: We describe an indigenously developed technique of port closure using a large bore i.v. cannula and a suture passer needle. Over a period of 6 years, this technique was used to close [700 port

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S160 sites (12–15 mm size) in 204 patients undergoing surgery for ventral hernia repair (98) or obesity (106). Results: All the patients receiving port closure with this technique were followed up for port site complications (follow up between 4 and 70 months). Six patients were lost to follow up after varying intervals. Two patients developed port site pain lasting [3 months. No patient developed any port site hernia in this series. Conclusion: Meticulous closure of port sites after laparoscopic surgery especially in patients with obesity or preexisting abdominal wall weakness (ventral hernia) is essential to minimize the risk of port site hernia formation. Our technique for port site closure is easy, fast, reliable and reproducible and uses inexpensive equipment that is commonly available.

13 Prophylaxis: hernia, infection O13.1 Midline closure: how to perform E. B. Deerenberg, H. Jeekel, J. F. Lange ErasmusMC, Rotterdam, The Netherlands Background: Incisional hernia is the most frequent complication following abdominal surgery and has a great impact on patients’ lives, as well as being a burden in terms of Healthcare costs. The radical cure of hernia is best presented by it’s prevention. Since the publication of the European Hernia Society guidelines on the closure of abdominal wall incisions in 2015, important research on the subject of abdomimal wall closure has been published. Methods: A literature search starting from the publication of the EHS guidelines was performed and relevant articles regarding closure of the abdominal wall and prevention of incisional hernia were selected. Results: 3 Large randomized controlled trials, a prospective study and a meta-analysis were found and the results will be presented during this presentation. The STITCH trial showed the superiority of a small bitessmall steps technique in midline closure and de PRIMA and PRIMAAT trials showed a decreased rate of incisional hernia when profylactic mesh augmentation was performed in high-risk patients. Conclusion: When closing abdominal wall incisions, patients characteristics and risk factors should be taken into account. Primary suture closure should be performed with a smal bites—small steps technique and in high-risk patients implantation of a profylactic mesh should be considered.

O13.3 Prophylactic meshimplantation in stoma creation G. Ko¨hler1, A. Hofmann2, M. Lechner3, F. Mayer3, H. Wundsam1, K. Emmanuel3, R. Fortelny2 1 Ordensklinikum Linz, Linz, Austria, 2Wilhelminenspital Wien, Wien, Austria, 3PMU Salzburg, Salzburg, Austria Background: In patients with terminal ostomies, parastomal hernias (PSHs) occur on a frequent basis. They are commonly associated with various degrees of complaints and occasionally lead to life-threatening complications. Various strategies and measures have been tested and evaluated, but to date there is a lack of published evidence with regard to the best surgical technique for the prevention of PSH development. Methods: We conducted a retrospective analysis of prospectively collected data of eighty patients, who underwent elective permanent ostomy formation between 2009 and 2014 by means of prophylactic

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Hernia (2017) 21 (Suppl 2):S139–S207 implantation of at hree-dimensional (3D) funnel mesh in intraperitoneal onlay (IPOM) position. Results: PSH developed in three patients (3.75%). No mesh-related complications were encountered and none of the implants had to be removed. Ostomy-related complications had to be noted in seven (8.75%) cases. No manifestation of ostomy prolapse occurred. Follow-up time was a median 21 (range 3–47) months. Conclusion: The prophylactical implantation of a specially shaped, 3D mesh implant in IPOM technique during initial formation of a terminal enterostomy is safe, highly efficient and comparatively easy to perform. As opposed to what can be achieved with flat or keyhole meshes, the inner boundary areas of the ostomy itself can be well covered and protected from the surging viscera with the 3D implants. At the same time, the vertical, tunnel-shaped part of the mesh provides sufficient protection from an ostomy prolapse. Further studies will be needed to compare the efficacy of various known approaches to PSH prevention.

O13.5 Strategies to prevent infection at mesh implantation in contaminated fields A. Montgomery1,2 1 Malmo¨, Sweden, 2Department of Surgery, Ska˚ne Universitey Hospital, Malmo¨, Sweden The use of meshes in contaminated fields have been questioned. The degree of wound contamination is usually given using the Centre of Disease Control (CDC) classification using four groups. The Ventral Hernia Working Group (VHWG) lounged a new classification specially designed to also include patients global and hernia specific risk factors. The latter classification system has been criticised since it attaches different domains in the same classification and also take into account historical backgrounds of the patient. Both the patients’ global risk factors like obesity, steroid treatment, immunosuppression as well as local factors like skin contamination, fistulas and stomas play a role in the decision-making when surgery is discussed, especially for incisional hernias, were the use of a mesh for reinforcement is needed. A synthetic mesh can safely be used in contaminated situations when precautions are taken to minimize the risk of mesh contamination during surgery. This is achieved by treating skin infections and optimizing the patient preoperatively by quit smoking, reducing overweigh, quit alcohol use and initiate physical training. At operation the use of skin protection, stoma protection, antibiotic prophylaxis, careful and clean dissection, avoid large mobilisation of skin from fascia saving the circulation, put the mesh in the retromuscular position, fascial protection of mesh subcutaneously and a liberate use of vacuum wound treatment. There are different options for vacuum treatment available that could be used depending degree of contamination.

14 EHS: historical view, status quo and vision for the future O14.5 The role of the national chapters of EHS revisited S. Morales Conde University Hospital ‘‘Virgen del Rocı´o’’, Sevilla, Spain The role of a society is to analyze the needs of its members. In Europe, there are more than 50 different countries with more than 200

Hernia (2017) 21 (Suppl 2):S139–S207 languages, with a great diversity of cultures and religions, where the local egos of the surgeons also have a great impact. The best way to meet these needs and adapt training and research is to identify local leaders who convey the needs of their members. The European society has created an organizational network to achieve these objectives. The national chapters represent a way to reach places where the voice of the members can be silent without a response by this European organization. The main goal of this network is to create a direct contact with the leaders of the national chapters to achieve these objectives, stimulating the communication in order to respond to the needs of our members.

S161 Methods: Hernia registers with high case load have existed in Sweden since 1992, in Denmark since 1998, and in Germany/Austria/ Switzerland since 2009. We have analyzed the register data and try to compare them. Results: The quality of all this Register-Studies seems to be very different. The Data which are implemented in the Database are mostly not comparable. For female groin hernias we could find some controversial details regarding the recurrence and reoperation rates and the part of femoral hernias. Additional observational studies out of the Hernia databases have shown the complexity and also difficulties of any Evaluation. Conclusion: It can therefore be stated with certainty that, for scientific evaluation of inguinal hernia surgery, RCTs and register-based observational studies are partners in the evolution of medical evidence.

15 Boston Consensus vs. World Guidelines: Is there a place for Pure Tissue Repairs O15.1 Guidelines and evidence: a second sober thought? F. Ko¨ckerling Vivantes Hospital Berlin Department of Surgery and Centre of Minimally Invasive Surgery, Berlin, Germany On the basis of the Cochrane systematic review of 2012 the HerniaSurge-Group states in the new ‘‘World Guidelines for Groin Hernia Management’’, that the Shouldice technique has lower recurrence rates than other suture repairs and strongly recommends the Shouldice technique in non-mesh inguinal hernia repair, if a patient refuses a mesh or a mesh is not available in low resource settings. But the HerniaSurge-Group also strongly recommends a mesh-based repair, because the use of open non-mesh repair in specific patients or types (e.g. young males with lateral hernias L1, L2) of inguinal hernia as an acceptable alternative to a mesh technique has not been adequately investigated so far. To date, more than 380,000 operations have been performed at the Shouldice Hospital in Toronto. On average each surgeon at the Shouldice Hospital operates on 700 patients per year. In a publication without any involvement of the Shouldice Hospital by Urbach et al. (2016) using population-based, administrative health data of Ontario residents found that inguinal hernia repair at the Shouldice Hospital was associated with a significantly lower risk of subsequent surgery for recurrence than repair at a general hospital. These data clearly show the influence of surgeon‘s experience and volume on the outcome in inguinal hernia repair independent from the technique used. Future comparative studies in inguinal hernia repair need to respect more the role of the surgeon and his experience as influencing factor on the outcome. Surgical skills might be more important for the outcome than technique.

O15.2 Registries: nothing but the truth and hard nosed statistics? R. Lorenz Berlin, Germany Background: RCTs and Meta-analysis are the gold standard in evidence-based medicine. Several key questions in hernia surgery have not been answered so far by RCTs and will probably not be in the future either. Besides, data are needed to confirm that the findings from RCTs and Meta-analyses can also be implemented in routine practice.

O15.5 Inguinal hernia repair in women: one cannot argue with statistics, experience and volume J. Morrison Chatham Kent Health Alliance, Chatham, ON, Canada Background: The proposed World Guidelines recommend that ‘‘In female patients, for all groin hernias, laparoscopic repair is the recommended method’’. This study brings into question this recommendation. Methods: From January 2008–December 2012 a total of 32 361 groin hernia operations were carried out in male and female patients. Of this, a total of 1343 operations were carried out in females. Follow up consisted of a mailed out questionnaire to all patients. There were a total of 829 responses received (62.5%). A total of 894 operations were carried out in the responding 829 patients. Results: In the female cohort, pure femoral hernias accounted for 16.9%, Indirect hernias 64.7%, direct inguinal hernias 6.2%, combined hernias 12.4%. Mesh repairs were carried out in 9.6% of patients. Recurrence rates: Pure tissue femoral hernia repair 84/151, recurrence = 8 (9.5%), Mesh femoral hernia 67/151, recurrence 2 (2.9%). Pure tissue direct hernia repair 53/55, recurrence = 5 (9.4%). Mesh direct hernia repair 2/55, recurrence 0. Pure tissue repair of indirect hernias 578/578, recurrence = 11 (1.9%). Pure tissue repair of direct + indirect hernias 37/37, recurrence = 2 (5.4%). Pure tissue repair of direct + femoral hernias 5/8, recurrence = 3 (60%), mesh repair 3/8, recurrence = 0. Pure tissue repair of Indirect + femoral hernias 24/35, recurrence = 1 (4.3%), mesh repair 11/35, recurrence = 1 (4.3%). Pure tissue repair of direct + indirect hernias 3/4 recurrence = 1 (33%), mesh repair 1/1, recurrence = 1 (100%). Inguino-femoral 1/1, pure tissue repair = 0, mesh repair = 1, recurrence = 0. Miscellaneous hernias 25/894, pure tissue repair 24, mesh 1. Conclusion: The use of mesh is indicated when there is a femoral hernia or a femoral component of a combined hernia.

O15.6 Pure tissue repairs: who erred, where, when? Time for ‘‘revisionism’’? R. Bendavid University of Toronto and Shouldice Hospital, Toronto, ON, Canada Background: While it’s frequently claimed in countless publications that inguinal hernias are the most common of surgical conditions, hernias still remain the most elusive and least understood of surgical challenges.

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S162 Following the seminal contribution of Bassini in 1884, there have been more than 80 procedures emulating Bassini’s repair. Only the Shouldice repair respected the Bassini principles adding a reconstruction of the deep inguinal ring and four layers of continuous steel sutures. Methods: The common error of the more than 80 imitators was the failure to divide the posterior inguinal wall. When you do divide the wall, a matter of 15–20 min, you display all possible hernias! It is this omission which led to such high recurrence rates in pseudoBassini and pseudo-Shouldice repairs, to the levels of 20–30%. Results: ‘‘Revisionism’’ started with the publication of the landmark article by David Urbach who analyzed 235 192 patients over a period of 14 years in the province of Ontario/Canada. Of these cases, 65 127 patients (27.7%) had surgery at the Shouldice Hospital where the recurrence rates was 1.1% while in the rest of the province, the recurrence rate ranged from 4.50 to 5.44% depending on the volume of surgery carried out in each hospital. Conclusion: While mesh has become well established as a standard in hernia surgery, this means that all patients operated outside the Shouldice hospital will have received mesh. At the Shouldice Hospital, mesh was used in 1.1% of men, 4.5% of women and in 1.36% of all patients combined!

16 Prevention of complications in laparoscopic groin hernia repair O16.1 Lower recurrence rate with heavyweight mesh compared to lightweight mesh in laparoscopic total extra-peritoneal (TEP) inguinal hernia repair. A nationwide population-based register study M. Melkemichel1, S. Bringman2, B. Widhe1 1 Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden. Department of Surgery, So¨derta¨lje Hospital, Stockholm, Sweden, 2CLINTEC, Karolinska Institutet, Stockholm, Sweden. Department of Surgery, So¨derta¨lje Hospital, Stockholm, Sweden Background: Lightweight meshes (LWM) have shown benefits compared to heavyweight meshes (HWM) in terms of less postoperative pain and stiffness in open inguinal hernia repair. It appears to have similar advantages in laparoscopic total extra-peritoneal repair (TEP), but concerns exist if it may be associated with higher recurrence rates. The aim of this study was to compare the outcome of LWM to HWM in TEP. Methods: Between 1 January 2005 and 31 December 2013 patients C15 years operated with TEP at surgical units participating in The Swedish Hernia Register were eligible. Data collected included clinically imported hernia variables. Primary endpoint was reoperation for recurrence. Overall follow-up was 11.5 years with a minimum of 2.5 years postoperatively. Mean follow-up was 5.9 years. Results: Totally 17.348 groin hernia repairs where registered for TEP during the study period. After exclusion 16.060 repairs were included and 572 were re-operated for recurrence. Multivariate analysis demonstrated significant increased risk of reoperation for recurrence in LWM 4.0% (HR 1.54, 95% CI 1.29–1.87, p \ 0.001) and Preformed mesh 3.6% (HR 1.67, 95% CI 1.28–2.17, p \ 0.001)

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Hernia (2017) 21 (Suppl 2):S139–S207 compared to HWM 3.2%. Age over median[59 years (HR 1.34, 95% CI 1.13–1.59, p \ 0.001) and hernia repairs with defect [3 cm (HR 1.43, 95% CI 1.10–1.85, p \ 0.01) was a risk factor for reoperation for recurrence. Conclusion: In this study LWM showed an increased risk of reoperation for recurrence compared to HWM in TEP. However, other aspects, like chronic pain, needs to be considered when choosing type of mesh.

O16.2 Five-year recurrence rate after endoscopic TEP hernia repair with lightweight versus heavyweight mesh: results of a randomized controlled trial M. Roos, W. J. Bakker, G. Clevers, E. M. M. Verleisdonk, P. H. Davids, I. P. J. Burgmans Diakonessenhuis, Utrecht, The Netherlands Background: Recurrence is one of the most important long-term complications following inguinal hernia surgery. Lightweight meshes suggest a higher incidence of recurrence compared to heavyweight meshes, yet data regarding prolonged follow-up are limited. We compared the recurrence rate of lightweight and heavyweight mesh 5 years after endoscopic total extraperitoneal (TEP) inguinal hernia repair. Methods: From 2010 to 2012, 950 male patients with a primary unilateral hernia were randomized to TEP hernia repair with heavyweight (Prolene) or lightweight (Ultrapro) mesh. Five years after surgery, the validated PINQ-PHONE telephone questionnaire for detection of symptomatic and asymptomatic recurrences was carried out. Participants that replied positively to one or more of the four elements of the questionnaire were scheduled for a clinical visit. Patients who had already developed a recurrence within 5 years after surgery were not contacted. A recurrence was defined as a clinically detectable bulge in the operated groin. Results: Until now, we contacted 683 patients. Thirty patients (4.4%) who replied positively [median age 61 (IQR 51–68), 63% lightweight versus 37% heavyweight] were seen at the outpatient clinic and in 2 patients, both treated with lightweight mesh, a recurrence was detected. The total recurrence rate after 5 years of follow-up was 1.1% in the heavyweight group, and 3.8% in the lightweight group (p = 0007). Conclusion: The recurrence rate 5 years after TEP inguinal hernia correction is low. Lightweight meshes show higher recurrence rates and are not recommended for endoscopic TEP hernia repair.

O16.3 Management of complex inguinal hernias J. A. Wegdam1, J. Gjaltema1, E. H. H. Mommers2, S. W. Nienhuijs3, T. S. de Vries Reilingh1 1 Elkerliek Hospital, Helmond, The Netherlands, 2Maastricht University Medical Centre, Maastricht, The Netherlands, 3Catharina Hospital, Eindhoven, The Netherlands Background: Posterior inguinal hernia repair leads to less pain than the anterior approach. It is unclear if this also applies for inguinal hernias in which posterior repair is complex. Inguinal hernias after previous open lower abdominal surgery, prostatectomy or ipsilateral posterior mesh-based repair are considered complex when using the

Hernia (2017) 21 (Suppl 2):S139–S207 posterior approach. This study evaluated pain following posterior repair of these complex hernias. Methods: All patients planned for a totally extraperitoneal (TEP) repair of their complex inguinal hernia between 2009 and 2016 were included and analyzed. Pain and quality of life was measured at follow up using the EuraHS and PINQ-PHONE questionnaires. Results: Sixty-three patients were included of which 22 (35%) had a recurrent inguinal hernia. Previously, 33/63 (52%) had lower abdominal surgery, 19/63 (30%) preperitoneal mesh placement, and 11/63 (17%) prostatectomy. Conversion rate to transabdominal preperitoneal (TAPP) approach was 38%. Median operative time was 56 min (17–130). Surgical Site Occurrences (SSOs) were observed in 20 patients (32%). Follow-up in 87% was median 27 months (1–96). Patients satisfaction was high (80% satisfied). Ten patients (18%) reported any groin pain in rest; 7 had had a previous posterior mesh placement. Recurrence rate was 3%. Operative time, conversions and pain were significantly higher when previous intervention was meshbased versus lower abdomen surgery or prostatectomy. Hospital stay, SSO’s, recurrences and satisfaction were not different between groups. Conclusion: Posterior inguinal hernia repair has good results after previous lower abdominal surgery or prostatectomy. However, it is related to postoperative inguinal pain after previous posterior mesh placement.

O16.4 Telescopic dissection versus balloon dissection in total extraperitoneal (TEP) inguinal hernia repair: a randomized clinical trial N. Sharma1, A. Inbasekaran1, T. S. Mishra2 1 University College of Medical Sciences, Delhi, India, 2All India Institute of Medical Sciences, Bubhneswar, India Background: The two common methods of initial dissection of extraperitoneal space in TEP is either using a balloon or directly using a telescope. Very few studies have compared the two techniques in a randomized manner. This study aimed to find whether one technique was better than the other. Methods: Sixty patients aged between 18 and 70 years undergoing surgery for unilateral inguinal hernia were randomized into two groups: telescopic dissection (30) and balloon dissection (30).The primary outcome measure was the time difference from making the first skin incision to the time of insertion of all three midline ports. Results: Out of 60 patients, 30 patients underwent telescopic dissection and 30 patients had balloon dissection after randomization. Creation of initial working preperitoneal space was satisfactory in all patients. Mean time for initial space creation was 19.17 ± 9.19 min in telescopic dissection and 16.47 ± 5.72 min in balloon dissection, respectively (p = 0.177). No statistically significant differences were observed between the two groups for intra-operative and post-operative complications, and pain scores (visual analog scale) at regular intervals post surgery. There was no recurrence reported at 3 months follow-up. Conclusion: There was no difference in the creation of initial space with a balloon or using a telescope. The use of telescope saves on the cost of the commercially available balloon and potential complications related to balloon rupture and consequent visceral injuries can be avoided.

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O16.5 TAPP versus TEP: post-operative complications and their recurrence prevention R. Villa, G. Cesana, F. Ciccarese, G. Castello, G. Legnani, F. Caruso, M. Uccelli, R. Giorgi, B. Scotto, S. Olmi Policlinico San Marco, Zingonia, Osio Sotto, Italy Background: total extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) hernia repair are the standard endoscopic techniques to manage inguinal hernia. The objective of this study is to compare post-operative complications, surgery outcomes and recurrence rate between the two techniques. Methods: our analysis is based on a single centre experience retrospective database of 1976 patients undergoing TEP and 1524 undergoing TAPP for inguinal hernia repair between 1999 and 2015. In TAPP group 392 patients had a recurrent defect versus 149 patients of TEP group. We compared outcomes for postoperative complications such as wound infection, haematoma, seroma, inguinodynia and recurrence. Results: according to our study, patients undergoing TEP hernia repair experienced more intra-operative complications, although not statistically significant, and a recurrence rate of 3.95%. Patients undergoing TAPP hernia repair had less intra-operative complications and a recurrence rate of 0.98%. Post-operative complications, on the other hand, were higher in TAPP group rather than TEP, with statistical significance for seroma (p = 0.0000) and pain (p = 0.0026). Recurrence was associated to larger hernial defects and direct inguinal hernias in both groups, particularly the TEP one. Conclusion: to prevent inguinodynia, using TAPP approach, is advisable to apply fibrin glue instead of tacker to fix the mesh, even if it is associated to a superior risk of hernia recurrence. The risk of inguinodynia is trascurable with TEP approach, even with the use of tacker. TEP carries a higher recurrence probability in large defects and direct hernias; for those patients TAPP should be preferred.

O16.6 Safety and efficacy of laparoscopic transabdominal preperitoneal herniorrhaphy using a partially absorbable polypropylene mesh for recurrent femoral hernias Y. Shen, S. Yang Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: Femoral hernias are relatively scarce in clinic, but the patients frequently present as emergency or recurrent cases. 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 in our institution from 2013 to 2015. Data was collected regarding patients’ demographics, prior surgery, recurrence rate, duration of hospital stay, and complications.

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S164 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 12 months followup, there were no recurrences or infections. Three cases (16.7%) of seroma occurred. No postoperative pain (visual analogue score [4, lasted 3 months) was observed. Conclusion: 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.

O16.7 Laparoscopic surgery for the treatment of pediatric incarcerated inguinal hernia: 10 years experience in a single institution B. Li, D. Gong, X. Nie, Y. Mo Hexian Memorial Affiliated Hospital of Southern Medical University, Guangzhou, China Background: Many children with inguinal hernia would experience the scenarios of incarceration. Fatal consequences will arise if it was not handled properly and timely. In the last decade. We utilized laparoscopic surgery to reduced and repaired incarcerated inguinal hernia (IIH) for children. We report the experience of a large series in our institution. Methods: In the last decade more than 4000 children with inguinal hernia were treated by laparoscopic surgery in our institution. There were 521 children needed emergent admittance due to hernia incarceration. Manual reduction was performed on 314 patients and they were rendered to selective operation subsequently, while 207 cases needed urgent laparoscopic operation. we focus on this 207 emergency surgical cases. Results: All surgery was successful without serious complications. Two cases needed open conversion because hernia was irreducible under laparoscopy. The mean operative time was (27 ± 11) min. The mean of postoperative hospital stay was (49 ± 20) h. During the operations, contralateral patent processus vaginalis was found and subsequently repaired in 63 cases (30.4%). Mild complications occurred in 5 cases, no major impact on final outcome. There were 6 recurrent cases (2.90%) in these patients who had been followed-up for 3–143 months. Conclusion: Laparoscopic surgery is a safe and reliable alterative for the treatment of pediatric IIH. It has the advantages of minimally invasive and highly efficient that enable attain a satisfactory outcome. Vitality of the incarcerated organ can be inspected while strangulation was rare in pediatric IIH.

O16.8 Missed hernias causing failure of primary open mesh inguinal repair C. Ng1, M. Moat1, H. Eltyeb1, S. Ng2, N. Kansal1, A. Mudawi1 1 Queen Elizabeth Hospital, Gateshead, UK, 2Wrexham Maelor Hospital, Wrexham, UK Background: Early recurrence within first 5 years following mesh repair of inguinal hernia has been attributed to technical factors. We

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Hernia (2017) 21 (Suppl 2):S139–S207 attempt to identify the proportion of patients with likely missed hernia sac on primary open repair. Methods: Patients who underwent recurrent inguinal hernia repairs between 1/9/2011 and 31/8/2016 with previous primary mesh repairs in the preceding 5 years were identified. Operation notes were reviewed to identify anatomical location of the hernias and were grouped into direct, indirect or pantaloon hernias. Results: 106 Patient were found to have recurrent inguinal hernia but due to lack of documentation 47 were analysed. 24 had open primary repair with a median time between primary and recurrent repair at 3 years 7 months (IQR: 3 years 1 month). During the recurrent repair 19 had repeat open and 5 had laparoscopic repair. 25% had different hernia location on recurrent surgery. 20% of cases with direct hernias had recurrence in a different position; 62.5% in indirect hernias. Fishers test showed this to be not significant (p [ 0.05). Relative risk ratio for primary repair (open vs laparoscopic) for differing hernia position is 0.97 (95% CI 0.39–2.40). Conclusion: In our population, 20% had differing recurrent hernia position. We infer this as likely hernia sacs missed during primary surgery. In laparoscopic repairs, the posterior inguinal view allows clearer inspection and better possibility of not missing a sac. However, our analysis fails to support this. We recommend that meticulous dissection during primary repair is vital for ensuring hernia sacs are not missed.

O16.9 Trends of recurrent inguinal hernia repairs in the United States B. L. Murphy1, J. Zhang2, D. S. Ubl1, E. B. Habermann1, D. R. Farley1, K. Paley1 1 Mayo Clinic, Rochester, MN, USA, 2Medtronic, Mansfield, MA, USA Background: While recurrence following inguinal hernia repair (IHR) is an important clinical outcome, its rate has not been reliably established in the United States. We sought to determine the proportion of IHRs performed for recurrence in the United States over time. Methods: A retrospective study of patients (C18 years) undergoing IHR 1/2010–9/2015 was performed using the Premier database, which provides data from over 700 USA hospitals. Patients were stratified both by primary versus recurrent IHRs and by gender. One-tailed Cochran-Armitage tests evaluated trends over time and multivariable logistic regression identified factors associated with recurrent IHR. Results: 317,636 patients (91.2% male) underwent an IHR. The proportion of IHRs for recurrence decreased from 11.4% in 2010 to 10.4% in 2015 (p \ 0.01) in males but remained constant in females [6.5%—2010 to 6.7%—2015 (p = 0.46)]. Females were about half as likely as males to undergo recurrent hernia repair (p \ 0.01). Older patients were more likely to undergo recurrent hernia repair. Compared to patients aged 18–24, those between 25–34, 35–44, 44–54, 55–64, 65–74 and over age 74 were 1.5, 1.9, 2.4, 2.6, 2.9 and 3.3 times more likely to undergo a recurrent hernia repair, respectively (all p \ 0.01). Patients who were overweight, had COPD, or had an emergency repair were 1.09, 1.14, and 1.08 times more likely to undergo a recurrent hernia repair (all p \ 0.01). Conclusion: The proportion of IHRs performed for recurrence in the United States between 2010 and 2015 decreased slightly in males but remained stable in females.

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17 Hernia prevention of the midline laparotomy & stoma creation O17.1 Hernia prevention: short stitch trial 6:1: preliminary results 2017 M. Golling1, S. Felbinger1, Z. Zielska1, K. Maurer2, P. Baumann3 1 Das DIAK, Diakonieklinikum, Schwa¨bisch Hall, Germany, 2 Aesculap-BBraun, Tuttlingen, Germany, 3Aesculap-BBraun, Tuttlingen, Germany Background: Aim of our prospective, non-randomized, monocentric study is a comparative analysis of the perioperative stitch Ratio Performance and complication rates following midline and transverse incisions in elective and emergency laparotomies. Methods: The trial is ongoing since 1/2013 with 284 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. Relevant patient specific data were entered into the registry database (supplied by BBraun). Satistics involved the Chi2-/ANOVA and Mann–Whitney Test. Results: Overall 88% were operated electively, while 14% had an emergency laparotomy, 68% had a midline, 17% a transverse and 15% a combined, inverted L-shaped laparotomy. Stitch interval and no. of stitches were adequately done from the start, a learning curve with respect to the bite width was encountered. SL/WL ratio in midline/transverse laparotomies were similar, bite width varied but improved with time. SSI was higher in transverse vs. median laparotomies and in emergency operations. Comparing the trial results to our historic control group until 2013, the rate of burst abdomen/2° wound dehiscence decreased. 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. Median and transverse (2 layered) laparotomies can be closed safely by a 6:1 SL/WL ratio. Wound infection could be reduced to our historic patient cohort but was independent of stich ratio. Emergency laparotomies can also be safely performed with the short stitch technique.

O17.2 Long-term outcomes after prophylactic use of onlay mesh in midline laparotomy C. San Miguel1, J. Lo´pez2, E. Jime´nez1, P. Lo´pez1, L. Bla´zquez1, ´ . Robin1, N. Palencia1, A. Cruz1, A. Moreno1, E. Gonza´lez1, A A. Galva´n1, A. Aguilera1, D. Melero1, R. Becerra1, C. Jime´nez1, M. Garcı´a Uren˜a1 1 Hospital Universitario del Henares, Coslada (Madrid), Spain, 2 Hospital Universitario Puerta de Hierro, Majadahonda (Madrid), Spain Background: The prevalence of incisional hernias (IH) is still high after midline laparotomy. Up to date, there are two main contributions for improving these results: implementing ‘‘small bytes’’ technique and the use of prophylactic meshes. This study aims to describe our long-term experience in the use of polypropylene prophylactic meshes.

S165 Methods: Observational and prospective study including all patients undergoing the use of prophylactic onlay polypropylene mesh for the closure of midline laparotomy since 2008–2014. Results: 172 patients were analyzed in an intention to treat: 74% elective surgery, 26% emergency cases. Mean age was 68 ± 12 years (men, 56%). Mean BMI was 29.2 ± 5.6 kg/m2. Wound classification: clean (2%), clean-contaminated (82%), contaminated (10%) and dirty (6%). Follow-up of patients was up to 8 years (mean: 5 ± 1.6 years). Two meshes were removed (one partially and one completely) due to chronic infection in first six postoperative months. None of them have developed IH to date. No other chronic complications were registered; such as chronic pain, seroma or meshoma. 8 Patients developed IH (4.6%), in whom 3 of them have been reoperated for IH repair with retromuscular or component separation technique without any trouble related to previous mesh. The other 5 patients remain asymptomatic and have not accepted reoperation. During follow-up, 4 patients have been reoperated for other surgical reasons and the integrity of abdominal wall was also checked. Conclusion: In our setting, the use of polypropylene prophylactic meshes in midline abdominal incisions is safe, efficient and durable.

O17.3 Cyanoacrylate (HistoacrylÒ) as alternative to fix a prophylactic mesh in laparoscopic colonic surgery C. Hoyuela, F. Carvajal, M. Juvany, J. Ardid, A. Martrat, M. Trias Hospital Plato´, Barcelona, Spain Background: Incisional hernia will appear in high-risk patients (obesity, cancer, etc.) after a laparotomy, even after laparoscopic surgery. Objective: To evaluate the safety of cyanoacrylate to fix a prophylactic mesh in the sublay position to reinforce the assistance incision in colonic laparoscopic surgery. Methods: Between 2015 and April 2016, the assistance incision in those obese patients (BMI [ 25 kg/m2) who underwent a laparoscopic colonic resection due to cancer was reinforced using a prophylactic mesh. The mesh was always positioned in the premuscular (over the rectum muscles), retrofascial space (sublay) with at least 3 cm overlapping. The mesh was always fixed using a crown of drops of HistoacrylÒ in order to avoid additional postoperative pain. In addition, HistoacrylÒ made the procedure easier and faster than suturing the mesh. The fascia was then closed with a running suture of MonomaxÒ 2/0 (minimum of ratio 4:1). Standard intravenous antibiotics, a plastic wound protector and mechanical lavage of the wound with serum were used as a prophylaxis of infection. Any drain was used. Results: The mesh was implanted in 15 patients. The mesh placement needed less than 5 min in all of them. There were only one case of wound infection (6.6%) but the mesh did not need to be explanted. All patients completed one year follow-up. No incisional hernias were observed in this series. Conclusion: The placement of a prophylactic mesh in colonic laparoscopic surgery is safe. To fix the mesh with HistoacrylÒ makes easier and faster the procedure without additional complications.

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O17.4 Triclosan-coated sutures and surgical site infection in abdominal surgery. A meta-analysis

late postoperative complications and reduce the incidence of parastomal hernias, which means that this technique must be considered as a first choice treatment.

N. Henriksen1, E. Deerenberg2, L. Venclauskas3, R. Fortelny4, M. Miserez5, F. Muysoms6 1 Zealand University Hospital, Koege, Denmark, 2Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands, 3 Lithuanian University of Health Sciences, Kaunas, Lithuania, 4 Hernia Center, Wilhelminenspital, Vienna, Switzerland, 5University Hospitals, KU Leuven, Leuven, Belgium, 6AZ Maria Middelares, Ghent, Belgium

O17.6 Prophylactic parastomal mesh, a randomised controlled study

Background: Surgical site infection (SSI) is a frequent complication to laparotomy contributing to incisional hernia formation. Triclosancoated sutures are recommended to reduce SSI. The aim of this systematic review and meta-analysis was to evaluate the evidence from randomized controlled trials (RCT) comparing the rate of SSI in abdominal surgery when using triclosan-coated or uncoated sutures. Methods: A systematic computerized literature search was conducted using Medline, EMBASE, the Cochrane library, CINAHL, Scopus and Web-of Science including publications until December 2016. The quality of the RCTs was evaluated using critical appraisal checklists from SIGN. Meta-analyses and trial sequential analysis were performed with Review Manager v5.3. Results: Eight RCTs on abdominal wall closure were included in the meta-analysis. In an overall comparison including both triclosan-coated Vicryl and PDS sutures for fascial closure, triclosan-coated sutures were superior in reducing the rate of SSI. When evaluating PDS sutures separately, there was no effect of triclosan-coating on the rate of SSI. Trial sequential analysis estimated that the required information size has not been reached for triclosan-coated PDS sutures. Conclusion: Triclosan-coated Vicryl sutures for abdominal fascial closure decreases the risk of SSI significantly, however it is not recommended to use fast-absorbable sutures for fascial closure due to risk of incisional hernias. There was no effect on SSI rate with the use of triclosan-coated PDS sutures, but further RCTs are required to conclude if triclosan-coated PDS sutures decrease SSI.

O17.5 The prophylactic mesh placement during the initial stoma formation: a safe & effective procedure? A. Fortunova, Berger Klinikum Mittelbaden Baden-Baden, Baden-Baden, Germany Background: Parastomal hernia is frequent complication in patients with an ostomy which considerably impairs quality of life. Despite the evidence of clinical studies showing decreased incidence of parastomal hernia and no additional complications after mesh augmentation, this technique is still rarely used. Methods: The perioperative course of 165 patients who received permanent enterostomy with additional mesh augmentation between March 206 and July 2015 was prospectively studied. This intervention group was compared with a group of 110 patients with a traditional stoma. The Follow-up time was a median 23 months. Results: The mesh augmentation is not associated with an increased rate of infective complications (4.2%). None of the implants had to be removed because of infection. Late postoperative complications such as adhesions and ileus was equally distributed over both groups. Parastomal hernia was observed in 4.2% of intervention patients and in 32.8% in the control group. Conclusion: Intraperitoneal mesh augmentation during initial formation of permanent enterostomy with a three-dimensional nonresorbable implant is not associated with an increased rate of peri- and

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P. Na¨svall1, J. Rutega˚rd2, M. Dahlberg3, C. Odensten1, U. Gunnarsson2, K. Strigard2 1 Dep of Surgery and Perioperative Sciences, Umea˚ University and Dep of Surgery Sunderby Hospi, Lulea˚, Sweden, 2Department of Surgery and Perioperative Sciences, Umea˚ University, Umea˚, Sweden, 3Department of Surgery Sunderby Hospital, Lulea˚, Sweden Background: Parastomal hernia is a challenge and there is still no treatment considered as gold standard. Mesh to prevent parastomal hernia has been proposed and favored in three small RCT: s, contrary, other studies have shown no effect. STOMAMESH is a randomised controlled double-blinded multicenter study comparing the formation of colostomy with and without a prophylactic mesh. The incidence of parastomal hernia is the main endpoint. Methods: Patients planned for permanent colostomy were randomised to prophylactic polypropylene light weight mesh or no mesh. Operations were performed at eight hospitals by experienced colorectal surgeons. The mesh was placed in sub-lay position by open technique. Early postoperative complications were assessed at one month. One-year follow-up included clinical examination and CTscan to assess complications and the possible existence of parastomal hernia. Assuming a parastomal hernia incidence of 20% without and 5% with mesh, 5-year survival rate just above 50 and 80% power, 220 patients were planned for inclusion. Results: 230 patients were randomised (115 in each group). Basic characteristics showed no difference between groups. Early complications occurred in 74 patients (36 without and 38 with mesh). In the mesh group, 102 patients and in the non-mesh group 104 were followed up at one year. Parastomal hernia rate was equal in the two groups after one year (31 without mesh and 30 with mesh, p value 0.950). Conclusion: Polypropylene-mesh in sub-lay position did not prevent parastomal hernia in routine surgical care at one-year follow-up. Early complication rate was equal in the two groups.

O17.7 Development of a screening measure for symptomatic parastomal hernia: assessing clinically relevant endpoints in the CIPHER study C. Murkin1, K. N. L. Avery1, D. Elliott1, S. Cousins1, L. Rooshenas1, N. Blencowe1, N. J. Smart2, J. M. Blazeby1, On behalf of the CIPHER Study Group 1 School of Social and Community Medicine, University of Bristol, Bristol, UK, 2Exeter Surgical Health Sciences Research Unit (HESRU), Royal Devon and Exeter Hospital, Exeter, UK, Exeter, UK Background: A distinctive feature of pragmatic study design is the selection of clinically relevant outcomes that are meaningful to patients. As such, more informative studies may focus on measuring the severity of symptoms of a condition rather than their absence/ presence alone. This work develops a questionnaire to identify and measure the severity of symptomatic Parastomal Hernia (PSH) for use as part of the definition of the primary outcome; presence of a symptomatic PSH, in the The UK Cohort Study to Investigate the Prevention of parastomal HERnia (CIPHER).

Hernia (2017) 21 (Suppl 2):S139–S207 Methods: This work has three components: (1) Literature review and qualitative interviews with patients, surgeons and stoma nurses to identify relevant healthcare domains, (2) operationalisation of healthcare domains into questions, (3) pre-testing and refinement of the questionnaire and development of symptomatic thresholds (green, amber and red). Results: 169 descriptions of PSH symptoms were identified from the literature. These were grouped into 19 health domains, including pain and body-image. 17 patients (9 with PSH and 8 without) were interviewed as well as 10 surgeons and stoma nurses from two centres. Transcripts were coded and categorised into 127 themes. These were grouped into 16 additional domains. The combined domains have been developed into items for the questionnaire. Work is ongoing to pre-test the tool and establish thresholds to trigger CT investigation. Conclusion: This mixed methods feasibility work is developing a patient-centred outcome measure that can be used to inform decisionmaking around investigation and treatment of symptomatic parastomal hernia. Validation will occur in the main study.

O17.8 Parastomal hernias after colorectal cancer surgery: a national population-based cohort study M. Tivenius1, G. Sandblom2 1 Karolinska University Hospital, Huddinge, Sweden, 2Karolinska Institutet, Solna, Sweden Background: Parastomal hernia is a complication that often implies suffering and reduced quality of life. The risk of developing a parastomal hernia has been found to be high, but the rate varies considerably in previous studies. The aim of this study was to assess the incidence of parastomal hernia in patients who have undergone colorectal cancer surgery and to identify potential risk factors that could predispose for development of this type of hernia in a large population-base cohort subjected to a long-term follow-up. Methods: All procedures for colorectal cancer registered in the Swedish Colorectal Cancer Registry (SCRCR) 2007–2013 were identified. Patients for which procedures with permanent stoma was performed were included in the study group. Concomitant diseases and potential risk factors were obtained from the National Patient Registry. The linking between the two registries was performed using the Swedish Personal Registration Numbers. Analysis was performed to identify the impact of each risk factor and to estimate the incidence of parastomal hernias. Results: During the study period 39 984 patients were registered in SCRCR and 7 649 received a permanent stoma. The cumulative incidence of patients diagnosed or surgically treated for parastomal hernias after a follow-up period of five years was 7.7%, CI 95% 6.1–9.2%. The only independent risk factor for developing a parastomal hernia was obesity with BMI C 30. Conclusion: The cumulative incidence for parastomal hernias after five years is at least 7.7%. The risk of developing parastomal hernias increases over time with BMI.

O17.9 ‘‘Top hat’’ repair of parastomal hernia, a promising approach to a difficult problem M. J. Fitzgerald, S. Ulrich, K. Singh, O. Misholy, P. Kingham, M. S. Brady Memorial Sloan Kettering Cancer Center, New York, NY, USA Background: Successful parastomal hernia repair remains a challenge. Recurrence after conventional repair is common. We report our experience with 30 patients using a novel technique.

S167 Methods: A ‘‘top hat’’ construct was created using a cylinder of xenograft attached to 10–15 cm piece of xenograft or composite mesh (underlay, or ‘‘brim’’). The top hat was then inverted and secured around the conduit and sutured to the undersurface of the abdominal wall after hernia reduction. Clinical and radiologic follow up was reviewed to assess for recurrence. Results: 30 patients underwent 31 consecutive top hat procedures. Most patients had an ileal conduit (n = 22), while eight had colostomies. The median age was 71 and the median BMI was 30. There were 17 males and 13 females. 15 patients had simultaneous incisional hernia repair. Complications occurred in 60% of patients, the most common were wound infection (23%) and seroma (23%). Of 31 procedures, six (19%) resulted in a parastomal hernia recurrence at a median follow-up of 25 months (range 0.5–68). Four recurrences occurred after the initial experience, when we used xenograft for the ‘‘brim’’ and cylinder. We subsequently modified the technique and used a composite mesh for the ‘‘brim’’. Only two subsequent recurrences occurred in 18 patients (11%) at a median follow-up of 14 months (range 0.5–61). Conclusion: The top hat repair appears to provide a more successful approach to parastomal hernia than conventional techniques, most likely due to occlusion of the vulnerable stoma/fascial angle by the construct.

18 Mesh related complications & new mesh technologies O18.1 Lessons learned from 221 biological meshes used for surgical treatment of ventral abdominal defects G. Munegato1, R. Ferrara2, G. De Manzoni3, G. Baldazzi4, A. Brolese5, D. Snidero6, M. Rebonato7, F. Ricci8, S. Merigliano9, A. Basso10, M. Antoniutti11, E. Molinari12, R. Merenda13, P. Sorrentino14, N. De Manzini15, B. Zani16, M. Sorrentino17, M. Frego18, F. De Marchi19, R. Gianesini20, E. Morpurgo21, S. Ramuscello22, V. Fiscon23, N. Baldan9 1 Ospedale ‘‘S. Maria dei Battuti’’, Conegliano (TV), Italy, 2Ospedale di Bolzano, Bolzano, Italy, 3Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy, 4Policlinico, Abano Terme (PD), Italy, 5Chirurgia 2, Ospedale ‘‘Santa Chiara’’, Trento, Trento, Italy, 6 Ospedale di S. Antonio, San Daniele del Friuli (UD), Italy, 7 Ospedale Alto Vicentino, Sant’Orso (VI), Italy, 8Ospedale di Rovereto, Rovereto (TN), Italy, 9Clinica Chirurgica 3-Azienda Ospedale-Universita` di Padova, Padova, Italy, 10Ospedale di Arzignano, Arzignano (VI), Italy, 11Ospedale ‘‘San Bassiano’’, Bassano del Grappa (VI), Italy, 12Ospedale di Legnago, Legnago (VR), Italy, 13Ospedale ‘‘SS. Giovanni e Paolo’’, Venezia, Italy, 14 Ospedale di San Dona` di Piave, San Dona` di Piave (VE), Italy, 15 Azienda Sanitaria Universitaria Integrata, Trieste, Italy, 16 Ospedale di Bussolengo, Bussolengo (VR), Italy, 17Ospedale di Palmanova-Latisana, Latisana (UD), Italy, 18Ospedali Riuniti Padova Sud ‘‘Madre Teresa di Calcutta’’, Schiavonia (PD), Italy, 19 Ospedale ‘‘San Bortolo’’, Vicenza, Italy, 20Ospedale di Valdagno, Valdagno (VI), Italy, 21Ospedale di Camposampiero, Camposampiero (PD), Italy, 22Ospedale ‘‘Madonna della Navicella’’, Chioggia (VE), Italy, 23Ospedale di Cittadella, Cittadella (PD), Italy Background: Considering the high costs of biological meshes (BM), some surgeons, operating in the North-East of Italy, shared their experiences in order to limit implantation to cases which might take more advantage of them.

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S168 Methods: A retrospective database was instituted to register all the cases presenting abdominal wall defect treated with BM from 1/2010 to 3/2016. Results: A total of 221 patients (mean age: 64 years) who underwent reconstruction of ventral abdominal defects with a BM were included in the study. The type of BM used for reconstruction was porcine cross-linked and non-cross-linked in 60 and 35% of cases, respectively. Patients were divided according the 2010 four-level surgical-site occurrence (SSO) risk grading system proposed by the Ventral Hernia Working Group: grade 1 (G1, 3.7%), grade 2 (G2, 21.2%), grade 3 (G3, 51.6%) and grade 4 (G4, 23.5%). SSOs (mainly seroma and infection) were observed more in G4 (53%) than in other 3 groups (33%) and their incidence was higher (69%) in patients with 3 or more risk factors (i.e. diabetes, smoke, obesity, steroid, immunosuppression, coronary disease, COPD). Recurrence was more frequent in G4 (35%) and in case of inlay positioning of the mesh (43%). Conclusion: Due to their high costs, BM should not be used in G1. In infected fields (G4), particularly in case of patients with 3 or more risk factors, because of their bad results in term of postoperative complications and recurrence, BM should be used only in case of no other surgical solution.

O18.2 The influence of mesh selection on surgical site infection following mesh repair for abdominal wall hernia: a complete audit cycle J. Ngai, H. Sarwary Dr Gray’s Hospital, Elgin, UK Background: Surgical site infections (SSIs) following mesh repair for abdominal wall hernia are associated with significant morbidity and healthcare cost for an usually economically-active population. We wanted to determine the actual incidence of SSIs and any associated peri-operative factors at our institution, in order to identify any areas of improvement to our current practice. Methods: The initial audit was carried out between September 2013 and May 2014. Data was gathered from electronic patient record and operating theatre mesh prosthesis record. A diagnosis of SSI was noted when a patient presented with symptoms and signs of infection around the site of hernia repair within 60 days of surgery, noted in discharge letters, clinic letters and/or microbiology requests. Following presentation at our departmental meeting, a decision was made to change from using a heavy-weight (SurgiPro) to a light-weight (Optilene) mesh. The re-audit was carried out between April 2015 and December 2015. Results: The initial audit did not find any difference between the rate of SSIs and operating theatre staff, surgical site preparation or duration of procedure. SSI rate fell from 9.7 to 4.3% between the two cycles. 50% SSIs in both cycles required surgical treatment, and the remainder were treated with antibiotics. However, the rate of mesh removal fell from 28.6 to 0% during the second cycle. Conclusion: Our experience confirms the existing knowledge on lower rate of SSIs with light-weight mesh. Patients from the second audit cycle also experienced lower morbidity as less invasive interventions were required to manage the SSIs.

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O18.3 Multicenter experience with absorbable and permanent mesh in complex abdominal wall M. Garcia-Urena1, J. Lo´pez-Monclu´s2, D. Cuccurullo3, L. Bla´zquez1, E. Jime´nez1, A. Robı´n1, A. Cruz1, D. Melero1, P. Lo´pez1, N. Palencia1, C. San Miguel1, N. Palencia1, A. Moreno1, J. Lucena2, R. Becerra1, E. Gonza´lez1, C. Jime´nez1 1 Henares University Hospital, Coslada, Spain, 2Puerta de Hierro University Hospital, Madrid, Spain, 3A.O. del Colli Monaldi Hospital, Naples, Italy Background: Retromuscular mesh reinforcement are increasingly being used in complex incisional hernias Methods: Patients undergoing open retromuscular or posterior component separation technique with a double mesh reinforcement, in 3 European referral centers. The absorbable mesh is made of polyglycolic acid and carbonate trimethylene (BioAR). This mesh was used to reinforce posterior layer and separate the peritoneum from a large piece of polypropylene (PP) that was only fixed cranially and caudally. The initial rigidity of aborbable mesh helped to extend and mantained the PP mesh in place. Results: 132 patients were operated with a mean 52 years (32–86) and BMI 31.6 (21–46). 34% were diabetic and 32% smokers. Hernias included: 57 midline hernias, 39 lateral, 18 midline + lateral, 7 medial + parastomal and 11 parastomal. Mean hospital stay: 10 days. Mean hernia defect was 10.5 cm. Complete closure of anterior layer was achieved in 57%. 6 cases were operated in emergency situation and another 25 had simultaneous dermolipectomy. The VHWG classification was: 30 type I, 69 type II, 25 type III and 8 type IV. There were 2 postoperative deaths. Wound morbidity was: 17% seromas, 9.8% hematomas, 12% superficial SSI, 9% partial skin necrosis. With a mean follow-up of 18 months there were 8 recurrences (8.5%) and 6 buldging (4.5%). The recurrences occurred in 8: 5 parastomal, 2 lateral, 1 midline. Conclusion: The introduction of a bioabsorbable mesh in combination with a permanent mesh is a good option to solve complex cases.

O18.4 Non-cross-linked biological mesh in complex abdominal wall hernia: German cohort study R. Kaufmann1, F. E. Isemer2,3, J. Jeekel1, J. F. Lange1, G. Woeste4 1 Erasmus University Medical Center, Rotterdam, The Netherlands, 2 St Josefs-Hospital Wiesbaden, Wiesbaden, Germany, 3 Hernienzentrum DKD HELIOS-Klinik Wiesbaden, Wiesbaden, Germany, 4Uniklinikum Frankfurt, Frankfurt, Germany Background: Complex abdominal wall hernia repair (CAWHR) is a surgically challenging procedure. The use of biologic meshes in these cases is contrioversial. The aim of our study was to evaluate longterm results of CAWHR with biologic mesh. Methods: In this cohort study, we included all patients operated for CAWHR with StratticeTM mesh in six German hospitals. Patients underwent abdominal examination and ultrasound to assess hernia recurrence, and completed Quality of Life questionnaires. Results: Thirty patients met the inclusion criteria, and 15 have so far been seen for long-term follow-up (7 male, mean age 67.3 years, median follow-up 34.8 months). With regard to the surgical intervention, the most frequent postoperative complication was wound

Hernia (2017) 21 (Suppl 2):S139–S207 infection (33%), no StratticeTM had to be removed. By the time of outpatient clinic visit, 2/15 patients (13.3%) had a recurrent hernia, none had undergone reoperation. N = 1 patient (6.7%) had bulging of the abdominal wall. Quality of Life questionnaires revealed that patients judged their scar with a median 3 out of 10 points (0 is best) and judged their restrictions during daily activities with a median of 0 out of 10.0 (0 means no restriction). Conclusion: These preliminary results show that despite a high rate of postoperative wound infection no biologic mesh had to be removed. The recurrence rate after long-term follow-up is acceptable and the quality of life is good in these complex hernias. StratticeTM seems therefore to be an appropriate option for CAWHR. Data are still acquired; results and analysis will be completed in March 2017.

O18.5 Single stage open ventral hernia repair (OVHR) in high risk patients with acellular porcine dermal biologic mesh (APDM) K. Coakley, P. D. Colavita, C. R. Huntington, D. White, T. Prasad, A. E. Lincourt, T. Heniford, V. A. Augenstein Carolinas Healthcase System, Charlotte, NC, USA Background: Mesh choice for OVHR is debatable in high risk patients. Options in these high risk patients include use of biologic mesh, such as APDM. The present study examines a large series of OVHR with APDM at a single institution. Methods: An analysis of all OVHR with APDM was performed from 2008 to 2016, including elective and emergent or traumatic presentations. Patient demographics, operative factors, and outcomes were reviewed. Results: Of 136 patients undergoing OVHR with APDM, the average age was 60.3 years with 55.2% female patients. Average BMI 37.1, with 38.5% having diabetes and 19.3% a history of MRSA. Number of previously failed OVHR was 2.6, with mean defect size 281.8 cm2. 67.4% of cases were clean contaminated, 14.1% contaminated, and 18.5% dirty. 72.9% of cases were performed with component separation, 29.8% a panniculectomy, 13.2% an enterotomy, and 5.4% had a fistula present. Average mesh size was 560.9 cm2. Mesh placement was preperitoneal (84.7%), intraperitoneal (6.5%), retro-rectus (5.6%), and onlay (3.2%). Mean follow-up was 16.1 months. 30.2% of patients underwent delayed primary closure. Complications included wound infection in 22.1%, and recurrence in 9.5%. Median length of stay was 8.0 days. Advancement flaps were associated with higher rates of wound complications (WC) (44.4 vs 26.9%, p = 0.0418) and were an independent risk factor for WC (OR 2.49; 95% CI 1.02–6.06). Patients with WC had a 14.0% recurrence rate, compared to 6.9% for others (p = 0.1792). Conclusion: OVHR with APDM in high risk patients appears safe and has low recurrence rates with long term follow up.

O18.6 Macroporous silk-lectin mesh as a new biomaterial for hernia repair: in vitro and in vivo evaluation O. Guillaume1,2, J. Park2, A. Petter-Puchner2, S. Gruber-Blum2, H. Redl2, A. Teuschl3 1 AO Foundation, Davos, Switzerland, 2Ludwig Boltzmann Institute for Experimental and Clinical Traumatology/AUVA Research Center, Vienna, Austria, 3University of Applied Sciences Technikum Wien, Department of Biochemical Engineering, Vienna, Austria Background: Covering mesh with autologous cells isolated from patients has shown great potential in research and clinics. In the

S169 presented work, we investigated if the immobilization of lectin (proadhesive glycoprotein) by covalent grafting onto silk mesh can accelerate cells adhesion, which is essential for the development of an intra-operative seeding procedure. Then, we evaluated the biocompatibility and the tissue integration of meshes made of silk-lectin on rats, compared to commercially available materials (OptileneÒ and TigrMeshÒ). Methods: Silk mesh was fabricated from fibres and modified using lectin. First, we investigated in vitro how fibroblasts attached and proliferated on silk-lectin compared to OptileneÒ. For the in vivo experiment, bilateral implantation of meshes over the abdominal wall was performed on 14 male Sprague–Dawley Rats. After 7 days, we evaluated the mesh integration, dislocation, seroma formation, inflammation, vascularization and shrinkage. Results: In vitro investigation demonstrated that grafting lectin to the surface of silk accelerated cell attachment, whereas the controls (OptileneÒ and native silk) did not promote similar features. Further in vivo experiments demonstrated that the presence of lectin did not negatively impact the healing process. Silk-lectin meshes were well integrated in the muscle and the grafts were vascularized within 7 days of implantation with no sign of exaggerated inflammatory reaction. Conclusion: Developing new material suitable for one-step intraoperative seeding implant with autologous cells would bring benefice in soft tissue repair. In this study, we showed that silk-lectin mesh is a suitable candidate as it allows for quick cell adhesion and exhibits satisfying biocompatibility.

O18.7 The polypropylene-nanofibre composite mesh: a biocompatible alternative? B. East1, M. Plencner2, M. Rampichova´3, M. Ota´hal4, J. Lorenzova´5, E. Amler3, J. Hoch6 1 Motol Faculty Hospital, Praha 5, Czech Republic, 2Cademy of Science, Czech Republic, Praha 4, Czech Republic, 3Academy of Science Czech Republic, Praha, Czech Republic, 4Department of Biomechanics and Anathomy, Faculty of physical education, Charles University; Department of Natural Sciences Faculty of biomedical Engineering, Czech Technical university, Praha, Czech Republic, 5Veretrinary and Farmacological University, Brno, Czech Republic, 6Motol Faculty Hospital, Praha, Czech Republic Background: The recurrence and complications rate of an incisional hernia repair using a standard mesh is even in the century of a technical revolution unacceptably high. Nanofibers of various polymers are used in tissue engineering to grow cell cultures and tissues, are biocompatible and biodegradable. Electrospun polycaprolactone has been tested in this application before with promising results. Its combination with a polypropylene mesh was the subject of this study. Methods: A standard large-pore mesh with adhered nanofibers was used as a hernia mesh in a porcine model. The mesh was placed in the onlay position in total of 14 defects in the midline. The experimental animals were sacrificed 6 weeks after the surgery, their abdominal walls harvested and submitted to a biomechanical (tensile strength test, Young’s modulus) and histological (inflammatory infiltrate, collagen I content, density of myofibroblasts and microvessels) examination. Results: Macroscopic evaluation revealed a surprising fact—all the composite meshes were overgrown by a dense fibrous tissue forming a thick rigid plate. Both the biomechanical and histopathological examinations have confirmed these results. The scar formed around the composite mesh had a lower tensile strength and significantly higher concentration of myofibroblasts. However, the composite mesh

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S170 induced less inflammatory reaction, scar contained less fat and the collagen type I fibrils we more organised. Conclusion: In contrast with our previous experiments the composite mesh led to formation of a rigid plate with a lower tensile strength. Our hypothesis was not confirmed.

O18.8 Comparison of mesh fixation devices for ventral hernia repair D. Lukic1, C. Hollinsky1, Z. Sow1, M. Monschein1, E. Calek2, Y. Chan3 1 SMZ Floridsdorf, Vienna, Austria, 2Medical University of Vienna, Vienna, Austria, 3General Hospital Steyr, Steyr, Austria Background: Mesh fixation plays a fundamental role in laparoscopic ventral hernia repair (LVHR). A wide variety of fixation devices have been developed using absorbable and non-absorbable materials. Recently, articulating fixation devices have been introduced which allow better angulation. A very important characteristic is the level of tensile stress these fixation materials can withstand. Methods: In this biomechanical study, tensile tests were performed to determine the ultimate tensile strength of eight different fixation techniques for LVHR, including six fixation devices, glue fixation and transfascial sutures. To determine the fixation strength in Newton (N), small meshes were fixed onto the peritoneum of fresh-frozen human cadavers after median laparotomy using one of the aforementioned approaches. Results: Overall, tensile strength was significantly higher with transfascial sutures than in the fixation device group (30.18 ± 3.44 vs. 17.41 ± 3.94 N). Glue fixation was shown to have the lowest fixation strength (3.45 ± 2.45 N). Within the fixation device group, non-articulated application provided significantly higher resistance to tensile stress compared to articulated fixation (20.32 ± 9.51 vs. 14.57 ± 7.43 N, p = 0.004). Devices with greater penetration depths had markedly higher fixation strength than fasteners with shorter depths (18.29 ± 3.81 vs. 16.52 ± 4.43 N). Conclusion: As far as maximum tensile strength is concerned, transfascial sutures show the best results. The sole use of glue fixation does not seem to be feasible in LVHR. While articulating devices improve practicability, the use of angled instruments limits the force that can be applied and therefore diminishes fixation strength. Our results demonstrate that devices with sufficient penetration depth are crucial in LVHR.

O18.9 The use of the new target mesh in the preperitoneal space, for the treatment of the small ombilical hernias, with an open minimal invasive surgery

Hernia (2017) 21 (Suppl 2):S139–S207 months. 79 men, 33 women primary 108, secondary 4 day surgery, n = 106 (88%) complications; seroma, n = 2; ombilical necrosis, n = 1; recurrence, n = 1 with a good result after reoperation Postoperative pain at one month: Visual Analogic scale (VAS) VAS = 0: 96 (86%) VAS (1–3): 11 (10%) VAS (4–7): 4 (3.5%) VAS 8: 1 (0.90%) Post-operative pain between 3 and 6 month (only the patients with pain at one month are reviewed) VAS = 1–3: 5, VAS = 4–7: 1 VAS = 8:1 for all these patients the post-operative pain is less important than the preoperative one Post-operative pain between 12 and 51 months (all the patients are reviewed at one year) VAS = 4–7: 4 patients. Conclusion: The use of the extra peritoneal mesh is a safe technique. The use of the target mesh make easier to unroll the prosthesis in the Preperitoneal space. The post operative pain rate is very low.

19 National Education Programs: survey O19.1 India: Anil Sharma A. Sharma New Delhi, India National Education Program in India—Laparoscopic hernia repair. India is a country of great diversity, multiethnicity with wide variation of socioeconomic parameters within the country. A large majority of University academic programs now include hernia repair with minimal access techniques. Several surgical units in university affiliated and other government recognised teaching hospitals offer hernia repair with minimal access techniques. Surgical postgraduates are therefore exposed to these hernia repair techniques in their academic curriculum and practical training in hernia repair is available in select surgical units in teaching hospitals. Single themed, focussed training programs on hernia are conducted regularly by three laparoscopy national associations and teaching hospitals, often supported by industry. These may include hands on training in animal tissue as well as simulated training on endotrainers. Industry contributes to hernia training by organizing 2–3 days of live surgery and didactics at Hernia centers of excellence in the country. Surgeons trained in these programs initially learn and observe the nuances of laparoscopic hernia repair at centers of excellence. Subsequently, these surgeons are mentored at their own workplaces by hernia experts to take them thorough their initial cases. Hernia Essentials is an Asia Pacific Hernia Society (APHS) accredited hernia training course based on current international guidelines on hernia management. This training course is being offered in India as well as the Asia Pacific continent to advance the art and science of safe hernia practice.

M. Soler Clinique Saint Jean, Cagnes Sur Mer, France Background: Our preference to treat an ombilical hernia is to put a mesh in the preperitoneal space. The main difficulty of the technique was to unroll the prosthesis through the small incision. Methods: So we created a new semi rigid and self-expandable mesh. It is the target mesh: a twelve cm rounded polypropylene mesh with three not knitted and not woven concentric rings. The mesh can be cut. The main step of the procedure is the preperitoneal space dissection. Results: A personal prospective study (n = 112) is under way, under the control of the French ‘‘club hernie’’ data base. Follow up: (15–63)

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O19.3 Indonesia: Barlian Sutedja B. Sutedja Jakarta, Indonesia Background: Indonesia has a population of nearly 260 million people and the incidence of inguinal hernia is approximately 290 thousand cases each year. This has a tremendous impact on the cost of health care and become an important socio-economic problem not worldwide, but also in our country.

Hernia (2017) 21 (Suppl 2):S139–S207 Methods: All data of the academic activity of the Indonesian Hernia Society since it was founded in 2008, including our international congress, symposia and hands-on workshops, were retrieved and evaluated to assess the impact on the development of hernia surgery in Indonesia. Results: The Basini procedure, for decades had been chosen as the treatment of choice for inguinal hernias in adults. Now it has been gradually replaced in almost 70% of cases by the mesh repair technique, mostly the tension free hernia repair technique introduced by Lichtenstein. The newly developed meshes have now become more accepted and used by the surgeons. However, the use of the laparoscopic hernia repair techniques, despite already being introduced since 1992, is still very limited. This procedure has only been performed in less than 3% of all hernia repair. Conclusion: The Indonesian Hernia Society, since it inception in 2008 has contributed towards the shift to modern hernia surgery in Indonesia and accelerated it’s popularity. More effort needs to be done to popularize the laparoscopic hernia repair techniques.

O19.8 Thailand: Suthep Udomsawaengsup S. Udomsawaengsup1,2 1 Chulalongkorn Minimally Invasive Surgery Center, Chulalongkorn University, Bangkok, Thailand, 2Thai Hernia Society, Bangkok, Thailand Background: National Education Systems are different country by country, we are reviewing hernia education in Thailand. Methods: The Royal College of Surgeons of Thailand guideline for surgical training program in essential operative procedures was reviewed. Resident program directors were interviewed. Survey was done by surgeons and residents. Results: Hernia surgery is a mandatory procedure that Thai surgical residents have to have efficient skill to take care of hernia patients. All graduate surgeons will be able to perform open inguinal hernia repairs. For laparoscopic surgery, it has been required for all resident to be able to do safely laparoscopic cholecystectomy. In this laparoscopic era, with several proves that minimally invasive procedures are at least or even better than open techniques in several surgeries, all training programs have incorporated laparoscopic hernia repair in their curriculums. The Laparoscopic and Endoscopic Society of Thailand (LEST) has been initiating the compulsory basic laparoscopic courses that all residents have to participated. The Thai Hernia Society (THS) is taking the continued education in advanced hernia as well as laparoscopic hernia repairs. Several workshops have been scheduled year round that junior surgeons or practicing surgeons may take their opportunity to attend and update their knowledge as well as their skills. Thai Hernia Society is responsible for preparing and promoting the regional training facilities to be able to run their own workshops in advanced hernia repairs. Thai hernia society is providing proctors and mentors. Conclusion: Regarding hernia training, we are keeping our best practice as well as following the evidence based medicine.

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20 Prevention of complications in open groin hernia repair O20.1 Bilateral endoscopic totally extraperitoneal (TEP) hernia repair does not impair male fertility M. M. Roos, G. Clevers, C. van de Water, R. J. Spermon, L. Sibinga Mulder, I. P. J. Burgmans Diakonessenhuis, Utrecht, The Netherlands Background: Endoscopic totally extraperitoneal (TEP) hernia repair with polypropylene mesh has become a well-established technique. However, since the mesh is placed in close contact with the spermatic cord, mesh-induced inflammation might affect its structures, possibly resulting in impaired fertility. The aim of this observational prospective cohort study was to assess fertility after bilateral endoscopic TEP inguinal hernia repair in male patients. Methods: Fifty-six male patients (18–60 years) with primary, reducible, bilateral inguinal hernias underwent elective bilateral endoscopic TEP hernia repair with use of polypropylene mesh.The primary outcome was testicular perfusion; secondary outcomes were testicular volume, endocrinological status and semen quality. All parameters were assessed preoperatively and 6 months after surgery. Results: Follow-up was completed in 44 patients. No statistically significant differences in measurements of testicular blood flow parameters and testicular volume were found. Postoperative LH levels were significantly higher [preoperative median 4.3 IU/L (IQR 3.4–5.3) versus postoperative median 5.0 IU/L (IQR 3.6–6.5), p = 0.03]. Levels of inhibin B were significantly lower postoperatively [preoperative median 139.0 pg/ml (IQR 106.5–183.0) versus postoperative median 127.0 pg/ml (IQR 88.3–170.9), p = 0.01]. No significant changes in FSH or testosterone levels were observed. There were no differences in semen quality. Conclusion: Our data suggest that bilateral endoscopic TEP hernia repair with polypropylene mesh does not impair male fertility; no differences in testicular blood flow, testicular volume or semen quality were found. Postoperative levels of LH and inhibin B differed significantly from preoperative measurements, yet no clinical relevance could be attached to these findings.

O20.2 Male fertility after inguinal hernia mesh repair: a national register study A. Kohl, K. Andresen, J. Rosenberg Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark Background: The effect of inguinal hernia repair on male fertility has previously been investigated through indirect measures such as testicular blood flow and sperm concentrations. No previous studies have evaluated the final measure of male fertility, which is the number of children fathered by patients. This study aimed to investigate the effect of inguinal hernia repair on male fertility. Methods: Prospectively collected data on 32,621 male patients between the ages of 18 and 55 years who received one or more inguinal hernia repairs during the years 1998–2012 were found in five

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S172 comprehensive Danish linked registers. Patients were matched with 97,805 controls, and number of fathered children was recorded as the primary outcome. Results: Patients who were operated unilaterally fathered more children than the controls (156 vs. 147 children per 1000 patients, P = 0.02), while patients who were operated bilaterally fathered the same number of children as controls. Unilateral Lichtenstein operation was associated with a marginal increase in number of children fathered by patients compared with controls (P = 0.009). No difference in number of children fathered was found for any year following operation. Meanwhile, time between operation and first child was longer among controls than patients (log-rank P = 0.003). The youngest (18–30 years of age) bilaterally operated patients fathered the same number of children as controls. Conclusion: Inguinal hernia repair with mesh did not impair male fertility. Rather, unilateral inguinal hernia repair may in fact increase male fertility.

O20.3 Chronic post-operative pain strongly correlates with patch fixation method used in tension-free inguinal hernias repair under local anesthesia C. Qin, Y. Shen Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: To identify factors associated with post-operative chronic pain in tension-free inguinal hernia repair under local anesthesia. Methods: The data of 2875 cases of tension-free inguinal hernia repair under local anesthesia, performed from January 2013 to May 2015, were retrospectively analyzed. Results: A month later, among the 2875 cases, a total of 83 (2.89%) patients reported post-operative pain; Three months later, only 2 cases sill have pains, and the occurrence rate is 0.69%. All the patients with pains have not last over 6 months. Age, gender, type of hernia, occurrence of complications and pre-existing underlying diseases showed no correlation with chronic post-operative pain, while the patch suture fixation method showed significant correlation (P \ 0.001). Four fixation methods were used: 7-stitch, 5-stitch, 3-stitch and 0-stitch patch fixation. Significant differences in postoperative pain incidence were found among the groups. The stitchfree method did not increase postoperative complications. Conclusion: Multiple factorial analyses demonstrated that patch fixation method is an independent risk factor for chronic pains after tension-free inguinal hernia repair under local anesthesia.

O20.4 Open inguinal hernia repair using a self-gripping mesh: report of a two surgeons experience on 1568 patients M. Gallinella Muzi1, A. Sorge2, A. Cianfarani1, M. Colella1, P. Mascagni1, C. Mosconi1, G. Muto2, O. Buonomo1, G. Petrella1 1 General Surgery, Policlinico Universitario Tor Vergata, Rome, Italy, 2 General Surgery, San Giovanni Bosco Hospital, Naple, Italy Background: ProGripÒ is a self-gripping partially absorbable mesh. Tension-free open inguinal hernia repair using this devicehas proven not to be inferior to the gold standard Lichtenstein technique. Here we present a 10 year experience on 1568 patients treated in 2 Italian centers from 2006 to present.

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Hernia (2017) 21 (Suppl 2):S139–S207 Methods: Muzi’s team treated 903 patients presenting with inguinal hernias in Rome, while Sorge’s team treated 665 patients in Naples. Both the Roman and the Neapolitan teams performed tension-free open anterior hernioplasty using ProGripÒ, with the following differences: local vs. general anesthesia, nerve identification and resection vs. no resection, internal inguinal ring plasty vs. no plasty, Trabucco vs. Lichtenstein positioning of the mesh, absorbable vs. non-absorbable fixation stich. All patients were contacted by phone call and evaluated with theVAS scale; when recurrence was suspected, the patients where assessed in outpatient setting. Results: According to the EHS classification, the 1568 patients treated hadthe following inguinal hernias: 140 M1, 58 M2, 68 M3, 604 L1, 463 L2, 235 L3.The mean operating time was 46.38 min. Following surgery, 4.71% patients experienced acute pain, 8.61% had fever and 6.31% developed a seroma. We managed to follow up by telephone 96.36% of the patients and only registered 4 (0.26%) recurrences and no one sufferedfrom chronic inguinal pain. Conclusion: This is the biggest experience ever presented on the use of self-gripping mesh to treat primary inguinal hernias. Both surgical teams showed outcomes comparable with the highest standard reported on the specialized literature.

O20.5 A simplified surgical technique for recurrent inguinal hernia repair following total extraperitoneal patch plastic P. Kniazeva, P. F. Alesina, M. Anaya-Cortez, P. Stadelmeier, M. K. Walz Kliniken Essen-Mitte, Essen, Germany Background: To present a new and alternative method for surgical treatment of recurrent inguinal hernia after total extraperitoneal patch plastic (TEP). Methods: From January 2005 to September 2015 fifty-four patients (52 male, 2 female; mean age 65 ± 13.3 years) with recurrent inguinal hernia following TEP were operated either by Lichtenstein procedure (LP; n = 19) or the Simplified Essen Method (SEM; n = 35). In SEM, the hernioplastic was performed by refixation of the primary mesh to the inguinal ligament by an anterior approach. Results: Operating time was significantly shorter in SEM (47 ± 22 min vs. 77 ± 37 min, p = 0.0021). All complications were minor and rare in both groups (10% in LP vs. 6% in SEM, p = ns). Postoperative hospital stay was shorter in SEM (2 ± 0.2 days vs. 2.7 ± 1.6 days; p = 0.027). After a mean follow-up of 54 months one re-recurrence was observed in each group (p = ns). Conclusion: The Simplified Essen Method (SEM) for recurrent inguinal hernias after TEP is as safe as the Lichtenstein procedure but avoids additional foreign body implantation and offers faster surgery. Therefore, SEM is our method of choice.

O20.6 Pathogens and drug resistance of surgical site infection after tension-free inguinal hernia repair in adults: a case series Y. Zhu, M. Wang, J. Chen, Y. Liu, J. Cao Beijing Chao-Yang Hospital, Beijing, China Background: Surgical site infection after tension-free hernia repair is crucial because once it happens, it is likely to develop into delayed and unhealed incision, leading to surgical failure, or

Hernia (2017) 21 (Suppl 2):S139–S207 even re-operation. To investigate the pathogens and the drug resistance of surgical site infection after tension-free inguinal hernia repair. Methods: This was a retrospective analysis of 80 patients who underwent debridement surgery due to infection after inguinal hernia repair from January 2010 to December 2015 at the Beijing Chaoyang Hospital. Purulent secretions were collected to conduct bacterial culture and drug resistance analysis before and during debridement surgery. Results: Preoperative bacterial culture results were positive in 62 patients (78%), which were mainly Gram-positive bacteria (42 patients, 68%). Intraoperative bacterial culture showed positive results in 52 patients (65%), which were mainly Gram-positive bacteria (31 patients, 59.6%). Gram-positive bacteria, mainly represented by Staphylococcus aureus, showed strong resistance to penicillin and sulfamethoxazole/trimethoprim, and low resistance to quinolone drugs, both pre- and intraoperatively. Gram-negative bacteria, mainly represented by Escherichia coli, showed strong resistance to ampicillin, and low resistance to quinolone drugs, both pre- and intraoperatively. Conclusion: Various pathogens were responsible for surgical site infection after tension-free inguinal hernia repair. Gram-positive bacteria were the main pathogens. Pathogens showed different resistance rates to various antibiotics. Antibiotic combinations could be considered at the early stage of infection and should be adjusted according to the results of drug sensitivity tests during the course of treatment.

O20.7 External hernia of the supravesical fossa. A misidentified protrusion with high risk of incarceration G. Amato1, G. Romano2, E. Erdas1, F. Medas1, L. Gordini1, P. Calo`1 1 University of Cagliari, Cagliari, Italy, 2University of Palermo, Palermo, Italy Background: Protrusions of the supravesical fossa is a rather neglected but not uncommon anatomical condition. Probably, being misidentified with direct hernias, are not listed in existing classifications. Underlining its characteristics helps early diagnosis, thus reducing risks of complications. Methods: 249 consecutive open anterior inguinal hernia repairs consecutively carried out were analyzed. The Nyhus classification was used to categorize the protrusions detected in the cohort of patients. True hernias of the supravesicalis fossa were considered as a subgroup of direct hernias. Combined protrusions (direct + fossa supravesicalis hernia) were also taken into account. Results: Among the 249 patients were identified 13 true hernias of the supravesicalis fossa and 16 bi-component combined hernias composed by direct hernia together with a hernia of the supravesical fossa. All protrusions of the supravesicalis fossa presented diverticular outline with tightened basis. In 4 individuals of the uncombined and in 3 of the combined group, the stricture was so tight as to provoke incarceration. Conclusion: External hernias of the supravesical fossa seem to be more frequent than imagined. Indeed the incidence of these hernia types, both in the uncombined and combined version, is above 10%. The diverticular shape of these protrusions together with the stricture at its base, seems to explain the high trend to incarceration affecting this hernia type. Consequently, if a mid-sized protrusion with pain and/or irreducibility is present, the occurrence of a hernia of the supravesicalis fossa should be taken into account. In these

S173 cases, the indication for an urgent surgical treatment is recommended.

O20.8 Incidence and complications of intestinal resection in routine hernia P. Adelsgruber, C. S. Ro¨sch, M. Sengstbratl, R. Fu¨gger Ordensklinikum Linz Elisabethinen, Linz, Austria Background: Morbidity and mortality are elevated in acute hernia surgery. We performed a postoperative survey investigating complication rates after ventral—and groin hernia operations with need for intestinal resection. Methods: From 2011 to 2015 we performed n = 1377 operations for hernias (inguinal—and femoral hernia n = 885, ventral hernia n = 492). Patient charts were analyzed for the incidence of emergency surgery with need for synchronous intestinal resection, morbidity and mortality. Results: In 16 (1.2%) patients bowel resection and herniotomy was performed as an emergency procedure. Indication for bowel resection was incarcerated hernia with segmental necrosis. The incidence for acute hernia surgery was distributed equally with respect to groin—and femoral hernia 10/885 (1.2%) and ventral hernia 6/492 (1.2%). All operations were performed via laparotomy. Intestinal resections comprised small bowel (n = 13), colon (n = 2) and ileocoecum (n = 1). Primary anastomosis and hernia repair by suture were performed in all patients. The use of mesh was avoided. Major complication rate was 7/16 (43.8%), there were 6 (37.5%) unplanned reoperations (anastomotic leakage n = 2; burst abdomen, hematoma, abscess, adhesion ileus, all n = 1). One Patient (6.3%) died from multi organ failure. Preoperative therapeutic anticoagulation was a striking risk factor. Overall 5/16 (31.1%) were anticoagulated, three of them developed major complications. Otherwise 3/7 (43%) major complications were observed in anticoagulated patients. Conclusion: Not surprisingly, complications rates are increased in emergency hernia surgery with synchronous intestinal resection. Preoperative therapeutic anticoagulation plays a crucial role in developing complications.

O20.9 Inconsistency in consent for open inguinal hernia B. Amr, H. Dunkerley, D. L. Sanders North Devon NHS Trust, Barnstaple, UK Background: Inguinal hernia operation is one of the most common procedures performed by surgical trainees and consultants. Consenting patients is an essential part of the procedure to ensure that patients are fully aware of the benefits of the procedure as well as its possible associated morbidity. This is a fundamental step assisting patients making their informed decision. Furthermore, it has legal, professional and educational requirements that need to be met. Methods: A prospective study was conducted examining consents for elective open inguinal hernia repair. The important points of interest were the documented complications and the seniority of the surgeon completing the consent. Results: 30 consents were examined. We have identified inconsistency in consenting practice regarding documented complications of the procedure. We also identified a discrepancy among surgeons as well as between surgical consultants and surgical trainees.

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S174 Conclusion: Inconsistency in consenting patients for elective inguinal hernia repair affects patients’ right in making an informed consent that might lead to raising legal claims afterwards. A pre-prepared consent form is an ideal adjunct that facilitates the consenting process and ultimately benefits the patients as well as surgeons.

21 Meshes in hiatal & groin hernia repair O21.1 Tissue reinforcement with Gore BioA Matrix in large hiatal hernias. ‘‘State of the Art’’ in hiatal augmentation? D. Birk Department of General and Visceral Surgery, Ludwigsburg/ Bietigheim Hospitals, Bietigheim, Germany Background: The use of meshes after repair of a crural defect is still under debate. In the light of a recurrence rate up to 40% in larger defects the augmentation of the hiatal closure with a mesh prosthesis seems to be advisable. However severe complications due to mesh migration and erosion have been reported, The Gore BioA tissue reinforcement is a three dimensional resorbable mesh which has demonstrated to be a ideal ‘‘scaffold’’ facilitating tissue generation and healing without the risk of a non-resorbable implant. Methods: In this prospective single centre study, and in addition in a multi-center prospective trial 134 patients with a hiatal defect of more than 4 cm were enrolled. The types of hiatal hernia were: 90 large axial hernias, 17 paraesophgeal hernias and 27 ‘‘upside down’’ stomach situations. 34patients had a recurrence of the hernia, two patient a second recurrence. None had previously received any type of mesh implant at hiatus. All operations were performed laparoscopically. After closure of the hiatus with sutures a u-shaped Gore BioA tissue reinforcement was placed and secured across the sutured hiatus. Results: Median OR time was 81 min, no serious perioperative SAE were observed. 12 Patient suffered from prolonged dysphagia over a three week time period. Median follow-up is 23 month with 91% included patients. Clinical recurrence rate is 11%, an additional 4% of patients demonstrated small recurrences during gastroscopy without clinical relevance. No complications connected to the mesh implantation occurred. Conclusion: The Gore BioA tissue reinforcement has so far led to a very favourable clinical outcome. To my knowledge this is the lowest reported recurrence rate after 23 month as compared to similar patient cohorts. This implant may become ‘‘state of the art’’ in hiatal augmentation.

O21.2 Experience with MRI visible meshs for a better treatment of inguinal hernias R. M. Wilke Hospital Calw-Nagold, Nagold, Germany Background: The use of MRI visible meshs in laparoscopic Repair (TAPP/TEPP) enables an objective follow-up. The visualization of meshs under clinical application allowed a new understanding of implants in patients and explains postoperative pain. Methods: From 03/2015 to 01/2017, an MRI-visible-mesh (Dahlhausen Endolap visible) has been routinely implanted with TAPP/ TEPP Repair. A full postoperative physical load from the first day

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Hernia (2017) 21 (Suppl 2):S139–S207 was allowed. If there were complaints during postoperative follow-up, ultrasound and MRI was performed. MRI-Mesh position was analyzed in relation to complaints and ultrasound findings. Results: 131/643 patients (25–74 years, 48 years) had postoperative mild complications. MRI was performed within 3 weeks to 5 months after surgery. 36/131 seromas, 21/131 hematomas and 2/131 mesh dislocation was detected. 1/131, a operation was indicated with mesh repositioning. Mesh-shrinkage in the area of the inner groin-canal be showed in correlation to the physical load. Particularly athletes had a crinkle formation of the implant on the inguinal canal. The meshshrinkage in this group was Ø 15%. In 6/131 cases a scarring around the mesh was found. Extraperitoneal seroma in 11/36 and preperitoneal seroma in 25/36 cases. All extraperitoneal seromas were punctured. Conclusion: The correct mesh integration is able to see by MRI. A clear relation between mesh and postoperative pain was documented. The correct positioning of the mesh is important for understanding postoperative pain. Physically activity show more mesh-shrinkage. However, for this special group of active patients, we need a especially mesh. The distinction between pre- and extra-peritoneal seromas is necessary for the therapy.

O21.3 Hiatal hernia recurrence rate and durability after magnetic sphincter augmentation in patients with large hiatal hernias and gastroesophageal reflux disease J. Zehetner1, K. A. Rona2, A. Yu2, N. Bildzukewicz2, C. Houghton2, J. C. Lipham2 1 Klinik Beau-Site Berne, Berne, Switzerland, 2USC, Los Angeles, CA, USA Background: We have previously demonstrated excellent short-term outcomes following concomitant hiatal-hernia repair (HHR) and magnetic-sphincter-augmentation (MSA) in patients with GERD and large hiatal hernias. The objective of our study was to report the durability of this approach. Methods: This is a retrospective review of prospectively gathered data in all patients who underwent MSA and formal HHR at our institution between 2009 and 2015. Large hiatal hernias were measured intra-operatively and defined as those hernias measuring C3 cm. All patients underwent formal hiatal dissection with posterior cruroplasty. Patients were followed for hiatal hernia recurrence with postoperative videoesophagram (VEG) and/or esophagogastroduodenoscopy (EGD) at 6 months and yearly thereafter. Primary endpoints included hiatal hernia recurrence, proton-pump inhibitor (PPI) elimination rate, and GERD Health-Related Quality-of-Life (HRQL) scores. Results: 41 patients were identified who underwent HHR of a large hiatal hernia with concomitant MSA. Mean pre-op DeMeester score was 52.4 (±5.5) and mean hiatal hernia size was 4.0 cm (range 3–7 cm). Twelve patients (29.3%) were diagnosed with Barrett’s esophagus preoperatively. There was a significant decrease in GERDHRQL score (19.6 vs. 2.8, p = 0.036) with a PPI elimination rate of 92.7%. All patients underwent VEG (43.9%) and/or EGD (56.1%) to evaluate for hernia recurrence over a mean follow-up time of 15.1 months. One asymptomatic recurrence (2.4%) was diagnosed with VEG at 11 months post-op. Conclusion: Magnetic sphincter augmentation with a full hiatal dissection and posterior cruroplasty appears to be a durable and effective approach with a low hernia recurrence rate in patients with gastroesophageal reflux and a large hiatal hernia.

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O21.4 A novel technique of abdominal wall hernia repair using mesh decreasing recurrence and chronic pain M. Salih, F. Kakamad, M. Aziz, I. Jalal University Of Sulimani, Goran Street, Iraq Background: The use of meshes has become standard procedure in abdominal hernia repair. The aim of the trial is to evaluate a novel technique in mesh placement for the repair of abdominal wall hernias (AWH). Methods: A clinical trial was performed on 225 patients presenting with AWH. Comparing standard mesh placement in 98 patients (Group A) with a novel technique of mesh placement in 127 patients (group B). The novel technique included three steps; First. The edges of the defect were closed. Second. The mesh was put over the midline longitudinally. Third. The mesh was covered by a 2 folds of the abdominal wall from each side of the hernia so that the defect is augmented by 2 full thickness abdominal walls with mesh in between and the stoma of the defect inverted internally. The median duration of follow up was 5 years. Results: There was no significant anesthetic complication or death. The mean duration of surgery was shorter for standard technique than for the novel one (45 versus 50 and 90 versus 100 min when associated with abdominoplasty). Rates of early complications such as seroma, hematoma and infection were similar in the two groups. Long term pain and discomfort were more common among the group A (20 patients) than group B (5 patients) (P-value less than 0.0001). The hernia recurrence were higher in group A (3 patients) than group B (no recurrence) (Pvalue 0.047). Conclusion: This novel technique could replace the standard technique in AWH repair.

O21.5 Initial evaluation of using 2P-UCMC mesh in hernia surgery in two spanish university hospitals C. San Miguel1, C. Leo´n2, E. Jime´nez1, P. Lo´pez1, J. Lo´pez2, L. Bla´zquez1, N. Palencia1, A. Cruz1, A. Moreno1, E. Gonza´lez1, ´ . Robin1, A. Galva´n1, A. Aguilera1, D. Melero1, R. Becerra1, A C. Jime´nez1, M. Garcı´a Uren˜a1 1 Hospital Universitario del Henares, Coslada (Madrid), Spain, 2 Hospital Universitario Puerta de Hierro, Majadahonda (Madrid), Spain Background: 2P-UCMC mesh (DIPROMEDÒ) is a nonabsorbable surgical prothesis composed by an ultra-fine transparent macroporous mesh of polypropylene, a monofilament and a transparent polypropylene film which minimizes the formation of adhesions, allowing its placement both preperitoneal and intraperitoneally. It is indicated in treatment of abdominal defects, such as umbilical and epigastric hernias and incisional hernias. This study aims to describe our first results in its use for hernia surgery. Methods: Observational, multicenter and prospective study including all patients undergoing the use of DIPROMEDÒ mesh for surgical repair of hernias (umbilical hernia and eventration) in Puerta de Hierro and Henares University Hospitals (Madrid) from January 2015 to August 2016. Results: 111 patients were analyzed: 88% elective surgery, 12% emergency cases. Mean age was 56 years (44–67). Men, 58%. Mean BMI was 28.7 kg/m2 (26.2–32.6). 83% of umbilical hernioplasty. European Hernia Society classification: M3 (87.4%, 97 patients) versus M2 (12.6%, 14 patients). Related to prothesis placement, in almost 70%

S175 of cases was preperitoneal. 86 patients (77.5%) had an early discharge (less than or equal to 24 h). Our distribution of complications was: 4.5% (5 patients) of chronic pain, 7.2% (8) of seroma, 5.4% (6) of haematoma, 11.7% (13) of wound infection, 2 cases of recurrence (less than 2%). There were not any case of obstruction or exitus registered. Conclusion: In our experience, the use of DIPROMEDÒ mesh presents safe results in the performance of umbilical hernioplasty, and to a lesser degree of eventroplasty, given the small number of complications presented in all cases.

O21.6 Absorbable meshes in inguinal hernia surgery: a systematic review and meta-analysis ¨ berg, K. Andresen, J. Rosenberg S. O Center for perioperative optimization, Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark Background: Absorbable meshes used in inguinal hernia surgery are believed to result in less chronic pain than permanent meshes, but concerns remain whether absorbable meshes result in an increased risk of recurrence. The aim of this study was to present an overview of the advantages and limitations of fully absorbable meshes for the repair of inguinal hernias, focusing mainly on postoperative pain and recurrence. Methods: This systematic review with meta-analyses is based on searches in PubMed, Embase, Cochrane, and Psychinfo. Included study designs were case series, cohort studies, randomized controlled trials (RCTs), and non-RCTs. Studies had to include adult patients undergoing an inguinal hernia repair with a fully absorbable mesh. Results: The meta-analyses showed no difference in recurrence rates (median 18 months follow-up) and chronic pain rate (one year followup) between absorbable- and permanent meshes. Crude chronic pain rate was 2.1% for the absorbable meshes and 7.6% for the permanent meshes. For the absorbable meshes, medial hernias were more susceptible for recurrence compared with lateral hernias (p \ 0.0005). None of the studies reported any allergic reactions or other serious adverse events related to the absorbable mesh. Conclusion: Patients with an absorbable mesh seem to have less chronic pain following inguinal hernia surgery compared with permanent meshes, without increased risk of recurrence.

O21.7 TEP procedure with long-term resorbable mesh in patients with lateral inguinal hernia F. Ruiz Jasbon1,2, K. Ticehurts1, J. Ahonen1, J. Norrby1, M. Ivarsson1,2 1 Department of surgery, Halland‘s Hospital, Kungsbacka, Sweden, 2 Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Background: A previous study using a synthetic long-term resorbable mesh in Lichtenstein repair showed good results regarding pain/ discomfort and no recurrences were detected at three years follow up in patients with lateral inguinal hernia (LIH). Total extraperitoneal (TEP) operation of inguinal hernia has showed in several studies lower risk of chronic post-operative pain compared with Lichtenstein. Therefore the aim of this study was to assess the incidence of recurrence and chronic postoperative pain in patients with lateral inguinal hernia operated with TEP technique, using a long-term resorbable implant. This is the first study in human using a long-term degradable mesh with TEP approach.

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S176 Methods: Prospective study including 35 primary inguinal lateral hernias operated with TEP repair using TIGRÒ Matrix Surgical Mesh at a hernia specialized clinic in Sweden. At one year follow up recurrence was assessed by clinical examination and the incidence of pain or discomfort was assessed pre- and post-operatively by Visual Analogue Scale (VAS) and Inguinal Pain Questionnaire (IPQ). Results: All patients followed a normal early postoperative course. Preliminary results of adverse events included recurrence and chronic post-operative pain up until 1-year follow up will be presented at 39th International Congress of the European Hernia Society. Conclusion: It will be presented during the congress.

O21.8 Minimal open pre peritoneal, MOPP, approach, a new minimal invasive technique for groin hernia repair. With a new mesh and a new and specific ancillar. First presentation with a long term results

Hernia (2017) 21 (Suppl 2):S139–S207 show our recent surgical strategies and clinical outcomes of the tension-free repair using self-fixating mesh for inguinal hernia. Methods: From January 2012 to December 2015, a total of 465 consecutive patients underwent inguinal hernia repair in our hospital. Basically, Lichtenstein repair was used for unilateral and TEP for bilateral cases. All the patients were treated under local anesthesia. Results: TEP was used in 134 patients (29%). Significantly more female patients were treated with TEP (4.5 vs 16.4%, P = 0.00004). Operating time (min) was 109 and 176, respectively. Post-operative median hospital stay was 1 day in both group. No severe complications (CD 3 or more) nor chronic pain after surgery were observed in this case series. Minor complications including hematomas (0.8 vs 1.0%), seromas (3.4 vs 3.9%) were treated conservatively. During medial follow-up of 36 months, we had 2 cases of recurrence (1 for each group). Conclusion: Tension-free repair using self-fixating mesh for inguinal hernia had good clinical results. The cost for mesh fixation and general anesthesia is not required in both methods. Our strategy using self-fixating mesh may provide further minimally invasive surgical care for the patients with inguinal hernia.

M. Soler Clinique Saint Jean, Cagnes sur Mer, France Background: For the treatment of groin hernias we prefer to put a large prosthesis in the pre peritoneal space. With a small incision. Methods: We changed the classic mesh design, giving an asymmetrical ovoid shape, to fully adapt to the wide coverage of the musculo pectineal hole. Two sizes were provided to accommodate the importance of the parietal defect. After the introduction, the prosthesis is not fixed. Strips are set up on the skin and will be removed during the first postoperative consultation. Results: Personal data under the control of the French hernia club data base: 850 hernias have been operated between September 2011 and October 2015. Mean follow up: 860 days day surgery: (92.8%), one night staying: (4.64%) Complications: bladder retention: 2; phlebitis: 1; superficial infection 2; deep infection: 1, recurrence: 1 reoperation: 2 with a good result. Post-operative pain: Visual Analogic Scale (VAS) day 8: VAS: 0 = 54%, VAS (1–3) = 36.05%, VAS (4–6) = 9.13%, VAS (7–8) = 1.28%. Day 30; VAS: 0 = 81.73%, VAS (1–3) = 13.92%, VAS (4–6) = 3.43%, VAS (7–8) = 0.9%. Chronic pain 97 patients with pain at one month was rewiened between 3 and 6 months. At 3–6 months: VAS: 0 = 79.38%, VAS (1–3) = 9.27%, VAS (4–6) = 10.30%, VAS (7–8) = 11.03%. At two years; no discomfort = 97.27, discomfort = 2.27%; moderate pain = 0.45% patient opinion: excellent 99.5%, medium 0.5%. Conclusion: MOPP technique give an excellent result, with a very low chronic pain, recurrence and complication rates.

O21.9 Clinical outcomes of tension-free repair under local anesthesia using self-fixating mesh for inguinal hernia N. Wada, T. Furukawa, Y. Kitagawa Keio University School of Medicine, Tokyo, Japan Background: Tension-free repair using synthetic meshes have been reported to have better results in terms of recurrence rates and patient QOL compared with conventional tissue repair and become common and considered the standard procedure. However, little is known about what types and fixation methods of mesh are optimal. Here, we

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22 Sportman’s Groin: still a challenge O22.1 Inguinal ligament releaseand TAPP repair for the treatment of Sportsman’s Groin D. M. Lloyd University Hospitals Leicester, Leicester, UK Background: The management of groin pain in athletes and nonathletes remains controversial. It is often referred to as a sport’s hernia despite the fact that no hernia exists. Numerous open and laparoscopic surgical approaches exist to treat this condition but none address any single pathological entity. The general over-riding terminology of inguinal disruption has been accepted and encompasses hypotheses such as posterior wall weakness and adductor longus enthesopathy yet reproducible pathological evidence to explain the symptoms is lacking. Evidence that this condition is caused by inguinal ligament disruption has been published suggesting that releasing the tension in the inguinal ligament may offer a logical approach to treat this enigmatic condition. Methods: Athletes and non-athletes were assessed for inguinal ligament disruption when most of the symptoms were localised around the pubic tubercle and inguinal ligament insertion. Hip pathology was excluded in the majority of patients with plain X-ray and MRI. These patients underwent a laparoscopic release of their inguinal ligament together with a trans-abdominal pre-peritoneal (TAPP) inguinal hernia repair. Results: More than 90% of athletes and non-athletes had significant improvement of their groin pain with a laparoscopic release of the inguinal ligament and TAPP repair. Most athletes and non-athletes are able to resume normal physical activities within a few weeks and most return to their professional sport between 4 and 6 weeks after surgery. Conclusion: A TAPP inguinal hernia repair with release of the inguinal ligament is a unique and innovative procedure specifically developed to address the pathology of sportsman’s groin.

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O22.2 OMR: open minimal repair

O22.5 TEP reinforce

U. Muschaweck Herniacenter Dr. Muschaweck-Dr. Conze, Munich, Germany

H. Paajanen1, A. Sheen2, T. Simon3, A. Montgomery4 1 Kuopio University Hospital, Kuopio, Finland, 2Manchester University Hospital, Manchester, UK, 3Heidelberg University Hospital, Heidelberg, Germany, 4Malmo¨ University Hospital, Malmo¨, Sweden

In 2002 the open minimal repair, the Muschaweck technique, was introduced. It is based on the pathophysiological understanding that the reason for the Sportsmen’s groin origins from of a local weakness with protrusion of the posterior wall of the inguinal canal, leading to transmission of the intraabdominal pressure onto the inguinal canal content, the spermatic cord with its nerves. This is often combined with a cranial and medial dislocation of the rectus abdominis muscle, leading to the typical symptoms of a pubalgia/osteitis pubis due to an increased tension at the pubic bone. The pain character is typically more sharp, very often with a burning sensation, often combined with radiation to the inner upper thigh or the scrotum/labia, that occur after extensive physical stress. Primary diagnostic tool is the ultrasound. The therapeutic approach, when conservative treatment fails, is a surgical reinforcement of the posterior wall of the inguinal canal. The OMR is an open mesh-free technique that avoids mesh-related risks, reducing the repair to the local weakness of the posterior wall. This technique facilitates an exploration of inguinal nerves, especially the genital branch as the main pain cause, with a simultaneous resection if affected. Also a relocation of the rectus abdominis muscle can be achieved. The procedure can be performed under local anesthesia in an outpatient setting. With the right diagnostic tool and indication the OMR is an excellent procedure for the surgical therapy of a Sportsmen’s groin leading to fast return to full activity with a long lasting effect.

O22.3 TEP release and reinforce

Background: No single operative technique (either open or laparoscopic) has been proven to be the preferred method for longstanding groin pain in athletes. Our aim is to compare whether there are any differences in the return to full sporting activity following laparoscopic repair compared to open minimal repair technique (OMR). Methods: The minimal access approaches include laparoscopic transabdominal pre-peritoneal (TAPP) or endoscopic total extraperitoneal (TEP) techniques. Firstly, a systematic literature search was performed to report outcomes of laparoscopic repair (TAPP/TEP). The primary outcome was return to full sporting activity. Secondly, we present our initial results of randomized controlled trial comparing TEP vs. OMR in 60 athletes with groin pain (Clinical Trial NCT01876342). Results: Only 18 studies fulfilled the search criteria with both laparoscopic and sports hernia repairs. The studies were mainly observational, but no large randomised controlled trials were detected. The median return to sporting activity of 4 weeks (28 days) was the same for the TAPP as well as TEP techniques. More reported cases to date in the literature used the TAPP technique compared with TEP repair (n = 605 vs n = 266). In our RCT study, TEP technique appears to give slightly improved recovery to sport activities than OMR technique. Conclusion: No particular laparoscopic technique appears to offer any advantage over the other. Both TEP and OMR techniques are comparable, choice of technique depends on surgeon’s expertise. ref. Paajanen H, Montgomery A, Simon T, Sheen AJ. Systematic review: laparoscopic treatment of long-standing groin pain in athletes. Br J Sports Med. 2015;49:814–8.

M. Dudai TelAviv, Israel

23 How to manage atypical hernias. Background: At 1987 we upgraded our technique for Sportsman Hernia (SH) to TEP with releasing of the inguinal ligament (IL). At 1998 independently David Lloyd add the IL release to his technique. We will describe our release reinforce technique (RRT). Methods: The pathologies of SH are in the posterior wall (PW), resulting in high pressure in the inguinal canal (IC) and on the nerves (entrapment) during sport activities (SA). The aim of the surgical repair is to avoid those consequences and reinforcing the PW. TEP. Results: In RRT we combining pressure releasing with PW reinforcing. doing a vast release, you should reinforce the Groin. Reinforcing the Groin without releasing the pressure creators, the patient can remain with the pain. The strained and inflamed IL creates pressure in the IC and on the nerves behind it (entrapment); genital and femoral. Pressure can be created by herniation of lipomas into injured opened anatomical Orifices. PW deficiency leading to bulging during SA and increasing pressure in the IC. We use TEP, SH is always bilateral. Steps of PPT: adhesiolysis, extraction of any herniated lipoma, dividing the IL at the lateral aspect of the IR, reinforcing the PW with wide light PPP mesh, PO rehabilitation program. Conclusion: The injured IL is a major factor of pressure creating in the IC and entrapping the genital and femoral nerves. Dividing the IL add a great advantage for reliving pain during SA. RRT procedure leads to very good results of less than 0.5% persistent pain after returning to SA.

O23.1 The general surgeon’s perspective of rectus diastasis. A systematic review of treatment options E. H. H. Mommers1, J. E. H. Ponten2, A. K. Al Omar1, T. S. de Vries Reilingh3, N. D. Bouvy1, S. W. Nienhuijs2 1 Maastricht University Medical Center, Maastricht, The Netherlands, 2 Catharina Hospital, Eindhoven, The Netherlands, 3Elkerliek Hospital, Helmond, The Netherlands Background: Diastasis of the rectus abdominis muscles (DRAM) is characterized by thinning and widening of the linea alba, combined with laxity of the ventral abdominal musculature, causing the midline to ‘‘bulge’’ under increased intra-abdominal pressure. The efficacy of surgical treatments and physiotherapy remain elusive. The primary aim is to evaluate complication and recurrence rates after surgical DRAM repair. The secondary aim is to evaluate if physiotherapy is an alternative to surgical treatment in terms of patient reported outcomes (PROs), inter-rectus distance (IRD), and recurrence rate. Methods: MEDLINEÒ, Embase, PubMed (CentralÒ), Cochrane Central Registry of Controlled Trials (CENTRAL), Google Scholar, and Physiotherapy Evidence Database (PEDro) were searched using the following terms: ‘rectus diastasis’, ‘diastasis recti’, ‘midline’, and

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S178 ‘abdominal wall’. All clinical studies concerning surgical or physiotherapeutic treatment of DRAM were eligible for inclusion. Results: Twenty articles (1691 patients) were included. Overall methodological quality was low. Open plication techniques with mesh reinforcement were applied most frequently. There was no difference in postoperative complications or recurrence rate after laparoscopic or open procedures, nor between plication versus modified hernia repair techniques. Physiotherapy programs could reduce IRD. Conclusion: Both plication based methods and hernia repair methods are used for DRAM repair. No distinction in recurrence rate, postoperative complications, or patient reported outcomes can be made. Complete resolution of DRAM, measured in a relaxed state, following physiotherapy is not described in current literature. Physiotherapy can achieve a limited reduction in IRD during muscle contraction, though it’s impact on PROs is unclear.

O23.2 Laparoscopic versus open repair of subxiphoid incisional hernias J. Raakow, A. Plath, Y. M. Callister, J. Pratschke, M. Kilian Charite´-Universita¨tsmedizin Berlin, Berlin, Germany Background: The repair of subxiphoid inscional hernias is a difficult procedure because it is a complex region beside boney and cartilaginous structures, the confluence of abdominal fascia and the diaphram. Only few reports, mainly after median sternotomy focused on subxiphoid hernia formation and the treatment. We therefore reviewed our experience with the treatment of subxiphoid hernias especially regarding the differences of laparoscopic and open technique. Methods: A prospectively maintained database was analyzed identifying patients undergoing hernia repair for subxipoid ventral incisional hernia (EHS classification M1) between January 2010 and November 2016. The incidence of subxiphoid hernias was 3.8% (32 of 843 patients). Patients were categorized into two groups: laparoscopic and open repair. Statistical evaluation included the description and comparison of demographic factors and perioperative outcome. Results: A total of 32 patients were grouped. Eight cases (25%) underwent laparoscopic repair. Demographic factors, site of primary incision (sternotomy vs. laparotomy) and hernia size did not differ significantly between the two groups. The laparoscopic operations lasted significantly shorter than the open repair (96 vs. 171 min; p = 0.006). There was no significant difference in postoperative complications with a tendency to more severe complications (Calvien-Dindo [3a) following open repair. A reoperation was necessary in four patients (16.7%) after open repair and none after laparoscopic repair (p = 0.550). Conclusion: Laparoscopic repair of subxiphoid hernias offers a feasible alternative to open repair with shorter operative times and a low rate of minor complications.

O23.3 Treatment of bilateral subcostal incisional hernias with posterior component separation technique: multicentric prospective descriptive study J. Lopez-Monclus, M. A. Garcia-Uren˜a, L. A. Blazquez, J. L. Lucena1, M. D. Chaparro1, M. Artes, A. Pueyo, D. A. Melero2, A. Robin2, V. Sanchez-Turrion1 1 Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain, 2 Henares University Hospital, Madrid, Spain Background: Bilateral subcostal incisional hernias are a surgical challenge for general surgeons. Posterior component separation (PCS)

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Hernia (2017) 21 (Suppl 2):S139–S207 techniques, initially described for midline incisional hernias, could be an ideal treatment option. Methods: Prospective descriptive multicentric study, including patients of two Spanish hospitals undergoing bilateral subcostal incisional hernia repair by means of a PCS technique (Carbonell or Transversus abdominis release [TAR] techniques) from may 2010 to December 2016. Descriptive patient data, surgical details (maximum hernia defect, type of PCS, surgical time), systemic and local complications, outpatient clinic follow up and hernia recurrence were recorded in a specific data chart. Results: 41 patients were included in the study, 30 males (73.2%) and 11 females (26.2%) with a mean age of 61 years (range 35–89 years). Our population included 28 patients (67.3%) with hernias type II or III according to the ventral hernia working group classification. Mean maximum defect size was 12.4 cm (range 4–30 cm). Considering the surgical technique, 8 patients underwent Carbonells PCS (19.5%), and 33 patients PCS-TAR (80.5%), with a mean surgical time of 214 min (range 100–375 min). As local complications we had 8 subcutaneous seromas (19.5%), 2 deep haematomas (4.8%) and 2 surgical site infections (4.8%). After a mean follow up of 21 moths (range1–79 months), we had 1 hernia recurrence (2.4%) and 5 asymptomatic buldging (13.9%). Conclusion: Posterior components separation is an ideal treatment option for complex bilateral subcostal incisional hernias, with a reasonable incidence of local and systemic complications, and an extremely low rate of hernia recurrence.

O23.4 Incisional hernia after iliac crest graft harvesting for reconstructive maxilla-facial-procedures. Is there an indication for prophylactic mesh implantation during initial surgery? F. Mayer1, E. Ahmic1, S. Enzinger2, A. Gaggl2, R. Bittner1, M. Speiser1, S. Gruber-Blum3, K. Emmanuel1, M. Lechner1 1 University Hospital Salzburg, Department of Surgery, Salzburg, Austria, 2University Hospital Salzburg, Department of Oral and Maxillofacial Surgery, Salzburg, Austria, 3Wilhelminenspital, Department of General und Visceral Surgery, Vienna, Austria Background: Resections of the mandible or maxilla are commonly reconstructed with iliac crest transplants. Functional results are good but incisional hernias at the harvesting site are common. We aim to evaluate the incidence of this herniatype. Methods: 83 patients underwent partial resection of the mandible or maxilla and reconstruction by bone graft with a vascular pedicle from the iliac crest between 10/2010 and 11/2016.During follow-up (median 12 months) 56 of these patients had CT-, PET-CT- or MRIscans. Attention was paid to oncological aftercare and presence of hernias at the donor sites. Incidence and defectsize were evaluated in relation to demographic parameters and typical hernia-specific riskfactors. Results: 56/83 patients underwent sectional imaging and were included in further analysis: 29 (51.78%) showed incisional hernias at the donor site. 15 (51.7%) were moderately obese (BMI 25–30), 11 (37.9%) had normal BMIs (18.5–25), two patients were obese, two underweight, 6 had previous abdominal operations, 20 were smokers. 8 reported intake of platelet inhibitors or oral anticoagulants. Conclusion: Iliac crest resection for maxillo-facial reconstruction leads to incisional hernias in more than 50% of patients at the donor site within only 12 months. Their surgical repair puts these oncological patients at additional risk of complications. In view of these results it is our understanding that prophylactic preperitoneal mesh implantation at the donor site after harvesting of the graft is feasible and indicated to reduce the incidence of this hernia type. Additional studies will lead to an improved understanding of this particular issue.

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O23.5 Long term study of using biologic mesh in bridging the perineal gap after ELAPE D. Vijayan, J. Richardson, C. Forde, K. Futaba, T. Ismail Queen Elizabeth Hospital, Birmingham, UK Background: Extra-levator abdomino-perineal excision (ELAPE) for low rectal cancer is advocated to reduce rates of local recurrence compared with conventional abdomino-perineal resection. The more radical surgical resection results in a larger defect in the pelvic floor which necessitates perineal reconstruction. Methods: This is a retrospective study of patients undergoing ELAPE and perineal reconstruction using a non-dermis, non-cross-linked biologic mesh between December 2008 and September 2013. Patient records were reviewed with specific regard to perineal wound complications including perineal hernia. CT scans were reviewed independently by two radiologists to assess for radiological evidence of perineal hernia. Results: ELAPE with biological mesh reconstruction of the perineum was performed in 23 patients. 20 patients (87%) had a complete surgical resection, 3 patients (13%) had a positive resection margin. 11/23 (48%) had acute perineal wound infection during the initial admission. 8 patients (35%) had chronic perineal wound complications, 2/23 (8%) necessitated operative repair. No clinical perineal herniae were identified for a median follow-up of 35 months (2–81). 3/23 (13%) had radiological perineal herniae, but were clinically undetectable and asymptomatic. Conclusion: Reconstruction of the perineal defect following ELAPE with a non-dermis, non-cross-linked biological mesh appears to be safe and efficacious. The technique utilised in this cohort study is reproducible and easily implemented to standard surgical practice and there is no apparent compromise to patient safety and oncological outcomes. Radiological perineal hernia has been defined and classified using the novel Birmingham Perineal Hernia Classification which may enable accurate assessment of patients following ELAPE.

O23.6 Laparoscopic transabdominal preperitoneal approach in Spiguelian Hernias with self-fixation mesh. Mid-term results J. Bellido Luque1, J. Gomez Menchero1, J. Suarez Gra´u1, A. Tejada Gomez2, A. Bellido Luque2, J. Garcı´a Moreno3, I. Duran Ferreras1, J. Guadalajara Jurado3 1 Riotinto Hospital, Quiro´n Sagrado Corazo´n Hospital, Sevilla, Spain, 2 Quiro´n Sagrado Corazo´n Hospital, Sevilla, Spain, 3Riotinto Hospital, Minas de Riotinto, Huelva, Spain Background: 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 (helicoidal or transfascial sutures)that increase acute, chronic pain and adhesions. Aim: Prospectively check the effectiveness of laparoscopic approach in Spiguelian Hernias, using self-adhesive mesh in the preperitoneal space without traumatic fixation. Methods: Patients aged between 18 and 80 years old with primary lateral hernias (Spiguelian Hernias) are included in this prospective Cohort study. 12 patients were included from January 2013 to January 2017.

S179 Results: Average length of surgery: 43.2 ± 7.1 min (DS). Average hospital stay: 1.1 ± 0.4 days. Average time for back to work: 9 ± 2.44 days. The most common postoperative complication was seroma, in 2 patients (16%), all type 1 in the Morales et al. classification. Other complications (Clavidien-Dindo grade 1): 1 abdominal wall Haematoma. Average follow-up: 24.1 ± 14.3 months (48–3 months range). No lost during this period. No hernia recurrence during examination nor in CT scan, in the follow-up period. Average visual analogical scale before surgery: 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 and 0 after the first month. No patient showed chronic pain. Conclusion: The use of self-adhesive meshes during laparoscopic transabdominal preperitoneal approach in Spiguelian hernias is safe and effective, with low postoperative pain and quick functional recovery without increasing recurrences in mid-term.

O23.7 Laparoscopy in spighelian hernia repair F. X. Felberbauer, L. Unger Department of General Surgery, Vienna Medical University, Vienna, Austria Background: One of the main problems in Spighelian hernias remains their diagnosis. We describe three cases of Spigelian hernias. In two cases, diagnostic laparoscopy proved the only means of confirming their presence. Methods: One male (53 years.) and two female patients (23 and 31 years) underwent closure of Spighelian hernias. All the hernias had been symptomatic for many months. In the male patient sonographic identification was achieved during a Valsalva maneuvre. The two females presented with symptoms highly suspective of Spigelian hernias, but ultrasound failed to show the hernias and CT scans were avoided because of the age of the patients. Instead, they agreed to undergo diagnostic laparoscopy followed by open repair in the case of a positive diagnosis. Results: In the male patient primary suture repair was done in local anesthesia. The hernial sac was resected and the muscular defect closed with non-absorbable sutures. In both women right-sided hernias with incarcerated preperitoneal fat buds were identified and the hernias were repaired in the same manner. The symptoms resolved promptly after surgery in all three patients. Conclusion: In a Spigelian hernia, palpation of the hernial bulge is usually not possible as the hernia is an intraparietal hernia covered by the strong aponeurosis of the external oblique abdominal muscle. Furthermore, the hernia is very often reduced during US or CT scan when the patient is supine, therefore even modern imaging techniques may fail to show the hernia. Diagnostic laparoscopy is a valuable tool in identifying these rare hernias.

O23.8 Obstruction secondary to transmesosigmoid hernia: a rare case of congenital internal hernia in an adult N. Ahmad, R. Melvin, M. McKirdy Royal Alexandra Hospital, Paisley, UK Background: Internal hernia involve protrusion of an organ through a defect within the mesentery or peritoneal cavity, resulting in 0.2–0.9% of small bowel obstruction (SBO). Congenital internal

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S180 hernia (CIH) is mainly detected in childhood. In adults, mesenteric degfects are often acquired (secondary to surgery or trauma). Methods: We discuss the case of an adult with a congenital transmesosigmoid hernia, of which less than 30 similar cases were found in the literature. Results: A 53 year-old male presented with six days lower abdominal pain, vomiting and no flatus nor stool for over one week; no past medical history. His abdomen was soft but distended, with tenderness in the left lower quadrant. Observations and blood tests were unremarkable. Abdominal x-ray demonstrated small bowel dilatation; CTscan reported mechanical SBO with transition point in the left side of the pelvis, likely adhesional. He proceeded to laparotomy where a transmesosigmoid hernia was identified—a small bowel loop herniated through a defect in sigmoid mesentery (no adhesions observed). This was reduced without compromise and defect sutured shut. The patient made a good recovery and was discharged three days later. Conclusion: Such findings are incredibly rare and neither clinical nor radiological assessment identified the pathology. Fortunately, early surgery preempted strangulation. This highlights the importance of considering CIH in patients with obstructive symptoms where there is no history of surgery, trauma nor presence of external hernia. This further supports a decision for early surgery when faced with equivocal radiological findings, preventing ischaemia and injury to the bowel.

O23.9 Our experience of treatment of postoperative lumbar hernia T. Gvenetadze1, Z. Chkhaidze2 1 Acad. O. Gudushauri National Medical Centre, Tbilisi, Georgia, 2 Ivane Javakhishvili Tbilisi State University, Medical Department, Tbilisi, Georgia Background: Current open repair methods of lumbar hernia characterized by frequent recurrent and relaxation hernia.Objective; Analysis of efficiency of our (BY GVENETADZE) modified open repair method with polypropylene large size mesh fixation on the bone-fascial structures. Methods: 123 patients were operated from 2010 till 2015 for lumbar hernia.They were divided into two group. First Group including 50 (40.65%) patients with lumbar hernia, which was repaired with polypropylene mesh by standard ‘‘Onlay’’ technique. Second group including 73 (59.35%) patients with lumbar hernia, which was open repaired with large size polypropylene mesh with fixation on bones (costal margin and iliac bone) and fascial structures. Results: In first group wound infiltration—7pts (14%), seroma-4pts (8%). Suppuration of wound—3(6%). No pain in incisional wound. In second group 9 (12.3%) patients first 2–3 days complain for a pain, according to us, associated with sutured on periostial structures. Infiltration of incisional wound-11pts (8.9%). Seroma—15 (12.2%). Suppuration of incisional wound—4(3.25%) Long-term results were—study during 2–5 years. In first group 39 (78%) patients, second group 68 (93.1%) patients. In I-st group 2 (5.1%)-recurrent, 5 (12.7%)—relaxation hernia. In II-nd group—no recurrent and ralaxation hernia. Conclusion: GVENETADZE’ S modified method open repair of lumbar hernia with fixation of large sized polypropylene mesh on

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Hernia (2017) 21 (Suppl 2):S139–S207 costal margin and iliac bone is effective method which reduces the risk of the postoperative recurrent and relaxation hernia.

24 Education in hernia surgery: Europe and US O24.1 EHS-survey: benchmarks and indicators of quality ` more3, A. DeBeaux4 R. Lorenz1, A. Montgomery2, L. DA 1 2 Berlin, Germany, University, Malmo¨, Sweden, 3University, Rome, Italy, 4University, Edinburgh, UK Background: Training young surgeons in hernia surgery is a major challenge today. All countries in Europe have national differences regarding used techniques, used materials, access to meshes, part of day case surgery and training methodology. The development of a needs-based continuing European education program as a European Hernia School calls for careful analysis. Methods: The Training and Education Committee of the EHS has defined his role to facilitate Communication, to offer Support and to develop best practice in Training and Education relating to Hernia Surgery across Europe. They develop a questionnaire as a first step for all National Chapters of the European Hernia Society to analyze the already existing national education program. This survey is needed to promote an efficient and ideal way of teaching abdominal wall surgery, in a similar way in all places and trying to reach as many surgeons as possible all over Europe. Results: We got the answers from almost all national Societies in Europe (19 from 20 countries). In 15/19 countries exists already a kind of training and education. In 13/19 there are already existing hands-on training courses in any form. A web-based video library exists in 10 of 19 countries. All countries have a high interest to create an European Hernia School. Conclusion: This survey is needed to promote an efficient and ideal way of teaching abdominal wall surgery, in a similar way in all places and trying to reach as many surgeons as possible all over Europe.

O24.3 Country-specific: Sweden A. Montgomery Malmo¨, Sweden The official educational program in hernia surgery in Sweden is based on a national course that is included in the curriculum of the teaching program for surgical residents during the second year of training. It is an obligatory courses that has been built by a national faculty. The course is given in six different locations spread around in the country. The faculty have built the lectures including power point lectures on different hernia topics including videos. The residents brings either a case to present or they are assigned a recent publication on a hernia topic to be presented and critically reviewed to the audience. A group of teachers are assigned for each course. One extra day for teacher guided surgical practice in preforming the Lichtenstein procedure is optional.

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O24.4 Country-specific: Spain

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26 Prevention of complications in ventral and incisional hernia repair 2

S. Morales-Conde University Hospital ‘‘Virgen del Rocı´o’’, Sevilla, Spain Training and education is an important part of the surgery. Surgery of the abdominal wall involves a specific training that must be carried out by scientific societies and by centers specialized in hernia surgery. In Spain, an important line of training has been carried out for years with a specific course for first and second year residents. This course is composed of a 3-day day that combines theoretical training, live surgery with all different surgical techniques and interactive sessions. During these courses have been trained between 150 and 200 surgeons annually who have considered the course of much importance for their daily clinical practice. On the other hand, a course on the prevention of ventral hernia has been carried out in the last to year to teach residents the proper technique to close the abdominal wall.

O24.8 Hernia education in the US W. Hope New Hanover Regional Medical Center, Wilmington, NC, United States Disclosures: CR bard (honorarium: consulting-research-speaker), WL Gore (honorarium:research), Lifecell (honorarium:Consulting). There has been an increased emphasis on hernia education in the United States (US) and parallels the growing complexity associated with modern day hernia repair and the appreciation that hernia disease is no longer a simple disease. In the US, hernia education is delivered in multiple methods depending on the learner however is somewhat disjointed with no nationwide coordinated effort. Hernia education in the US starts in surgical residency training and varies depending on the program. There is some effort to standardize the curriculum with the SCORE program but has not been universally accepted. Education after residency also varies and in the US is mostly delivered through didactic courses or labs (cadaver/animal) that for the most part are industry funded or sponsored by specialty societies. One of the newest methods for hernia education in the US has been the introduction of social media with online forums. Although there are many opportunities for hernia education in the US, the efforts have not been coordinated and are quite variable. Many new novel ways of delivering education are ongoing and allow for easy and quick dissemination of information and opportunity for collaboration globally. Further coordinated efforts are warranted but will require a major effort likely requiring major societal support. Keywords: Hernia, Education, Repair

O26.2 Influence of specialisation in the results of incisional hernia operations J. Pereira, B. Montcusı´, S. Pe´rez-Farre´, L. Fresno de Prado1, N. Argudo, J. Sancho, L. Grande-Posa Hospital del Mar, Barcelona, Spain Background: Our objetive is to analyse the influence of abdominal wall surgery expertise in the results of the operations for incisional hernia. Methods: We compare the data of patients operated for an incisional hernia in the period between July 2012 and December 2014 in an University Hospital. Data were collected prospectively and registered in the Spanish Register of Incisional Hernia (EVEREG). We compare the postoperative and late complications between the group of patients operated by the abdominal wall unit (AWS Group) and the rest of units (NAWS Group). Results: During the study period a total of 236 patients were operated; 213 (93 AWS Group; 120 NAWS Group) completed a median follow-up of 21 months (SD = 6). Groups were comparable in terms of: age, sex, BMI, comorbidities and complexity of hernia. Patients operated by an specialised surgeon presented less postoperative complications (22.8 vs. 36.4%; P = 0.034) ans less recurrences (9.8 vs. 27.3%; P = 0.001). In the multivariant analysis, surgery performed by an expert (P = 0.003; CI 0.130–0.651) and trocar hernias (P = 0.037; CI 0.125–0.937) were the final variables associated to a decrease in recurrences. Conclusion: In any type of incisional hernia, when the operation is performed by an specialized abdominal wall surgeon, better results in terms of postoperative complications and late recurrences are associated.

O26.3 Intra-operative adjuncts used during open incisional hernia repair to reduce seroma formation: a systematic review L. H. Massey1, S. Pathak2, A. Bhargava3, N. J. Smart1, I. R. Daniels1 1 Royal Devon and Exeter Hospital, Exeter, UK, 2Bristol Royal Infirmary, Bristol, UK, 3Institute of Health Sciences, Queen Mary University of London, Romford, UK Background: Seroma remains a common complication of incisional hernia repair. The use of surgical drains is widespread but evidence for the use of these and other adjuncts is limited. The aim was to perform a systematic review of the available literature on techniques used to reduce the incidence of post-operative seroma formation. Methods: A systematic search of Pubmed and Embase databases was conducted using the terms ‘‘incisional hernia’’ and ‘‘seroma’’. All studies on adults undergoing open incisional hernia repair with at

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S182 least one intervention designed to reduce seroma formation were included. Results: Of 542 studies identified, 6 met the inclusion criteria. Medical talc: one cohort study of 74 patients undergoing talc application following pre-peritoneal mesh placement found a significantly decreased rate of seroma formation of 20.8 versus 2.7% p \ 0.001 but another retrospective study including 21 patients with an onlay mesh found an increased rate of 76% seroma formation from 9.5% (p = 0.001). Fibrin glue: One comparative study including 60 patients found a reduction in seroma formation from 53 to 10% (p = 0.003) whereas another retrospective study of 250 patients found no difference (11 vs 4.9% p = 0.07). Negative pressure dressing: Four retrospective studies including a total of 358 patients found no difference in seroma outcome. Others: One randomised study of 42 patients undergoing either suction drainage or ‘‘quilting’’ sutures found no difference in seroma formation. Conclusion: There is currently insufficient quality evidence to recommend any of the investigated methods, some of which incur significant additional cost.

O26.4 Final two year results of the PANACEA study: A prospective multinational trial of an innovative composite patch for repair of open primary ventral hernia F. Berrevoet1, C. Doerhoff2, F. Muysoms3, S. Hopson4, M. Muzi5, S. Nienhuijs6, E. Kullman7, T. Tollens8, M. Schwartz9, K. Leblanc10, V. Velanovich11, L. Jørgensen12 1 Ghent University Hospital, Ghent, Belgium, 2Surgicare of Missouri, Jefferson City, MO, USA, 3AZ Maria Middelares Ghent, Ghent, Belgium, 4Mary Immaculate Hospital, Newport News, VA, USA, 5 University Hospital Tor Vergata, Rome, Italy, 6Catharina Hospital, Eindhoven, The Netherlands, 7Medicinskt Centrum Linko¨ping, Linko¨ping, Sweden, 8Imelda Hospital, Bonheiden, Belgium, 9 Monmouth Medical Center, Long Branch, NJ, USA, 10Our Lady of Lakes Regional Medical Center, Baton Rouge, LA, USA, 11Tampa General Hospital, Tampa, FL, USA, 12Bispebjerg Hospital, Copenhagen, Denmark Background: The ParietexTM Composite Ventral Patch (PCO-VP) is a monofilament polyester mesh with four fixation points and absorbable expanders to support mesh placement. PCO-VP is for treatment of ventral defects. The PANACEA study assessed clinical outcomes following open intraperitoneal implantation of PCO-VP for primary hernia repair. Methods: Primary ventral hernias were repaired by open repair with PCO-VP, and patients were assessed at 1, 6, 12, and 24 months for adverse events, pain, and quality of life (QOL). The primary endpoint was recurrence rate evaluated by ultrasound at 24 months per protocol. Results: 126 patients (110 with umbilical hernia and 16 with epigastric hernia) with a mean hernia diameter of 1.8 cm (0.4–4.0) were treated with PCO-VP. One hundred patients completed the two year study. Cumulative hernia recurrence was 3.0% (3/101; 95% CI: 0.0–6.3%) within 24 months. Numeric Rating Scale pain scores improved from 2.1 ± 2.0 at baseline to 0.5 ± 0.7 at 1 month (P \ 0.001); pain levels remained low at 24 months (0.1 ± 0.63). Mean global Carolina’sTM Comfort Scale score was 3.8 ± 6.2 at 1 month, compared to 1.4 ± 4.3 (P \ 0.001) at 12 months and 1.3 ± 4.8 (P \ 0.001) at 24 months post-surgery. 99% (102/103) of patients were satisfied with their repair at 24 months postoperative.

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Hernia (2017) 21 (Suppl 2):S139–S207 Conclusion: Outcomes with PCO-VP revealed a low rate of recurrence, minimal postoperative pain, and good patient comfort and satisfaction ratings at 24 months, suggesting long-term efficacy of PCO-VP in primary open ventral hernia repair.

O26.5 Resorbable synthetic mesh for non-complex abdominal wall hernias: a review of literature A. Jairam1, S. Boersema1, E. Peeters2, Y. Bayon3, J. Jeekel1, J. Lange1, M. Miserez2 1 Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands, 2University Hospitals Leuven, Leuven, Belgium, 3 Covidien Surgical Solutions, Research and Development, Trevoux, France Background: A new approach for repair of abdominal wall defects is the use of a synthetic absorbable mesh, which combines advantages of both synthetic and biological meshes. The objective of this review was to give an overview of the chemical characteristics and biomechanical, histological and preclinical outcome of the use of resorbable synthetic meshes, for treatment and prevention of abdominal wall hernias. Methods: A systematic review was conducted according to the PRISMA guidelines. Only experimental studies were included. Outcome parameters were resorption, degradation, organization of connective tissue, inflammatory response, tensile strength and adhesion formation. Results: GOREÒ BIO-AÒ mesh, TIGRÒ mesh and PhasixTM mesh are currently available on the market. In GOREÒ BIO-AÒ mesh, a minimal inflammatory response was present. Optimal tissue remodeling was seen after a follow up of one year. TIGRÒ mesh showed an intense inflammatory response, with significantly more macrophages than GOREÒ BIO-AÒ mesh. Optimal tissue remodeling was seen after a follow-up of three years. A mild inflammatory response was seen in PhasixTM mesh. No information on remodeling was available. No recurrences were seen for one of the resorbable synthetic meshes. Conclusion: The use of resorbable synthetic meshes seems safe. Most studies showed the formation of new collagen. However, there is still no clear experimental evidence available that can support the advantages of resorbable synthetic meshes over the use of synthetic or biological meshes. More experimental studies are needed, using common models and parameters, in order to reveal the advantages.

O26.6 The SymCHro registry study: one year results of incisional and primary ventral hernia repair with a novel three-dimensional textile composite mesh M. Lepere1, C. Zaranis2, H. Khalil3, F. Jurczak4, G. Fromont5, A. Dabrowski6, C. Barrat7, O. Cas8, A. Bonan9, J. Gillion10 1 Clinique St Charles, La Roche sur Yon, France, 2Clinique du Mail, ˆ pital Charles Nicolle, Rouen, France, La Rochelle, France, 3Ho 4 ˆ pital Clinique Mutualiste de l’estuaire, Saint Nazaire, France, 5Ho Prive´ Bois, Rouvroy, France, 6Clinique de Saint Omer, Saint Omer, ˆ pital Jean Verdier, Bondy, France, 8Cabinet de chirurgie, France, 7Ho ˆ pital Prive´ d’Antony, Antony, France, 10Ho ˆ pital Ares, France, 9Ho Prive´ d’Antony, Antony, France Background: The SymCHro study aims to assess patient outcomes and surgeon satisfaction following ventral hernia repair with a threedimensional monofilament polyester mesh (SymbotexTM composite

Hernia (2017) 21 (Suppl 2):S139–S207 mesh) that contains an absorbable collagen barrier on one side to minimize tissue attachment. Methods: SymCHro is a multicentric observational registry study of 100 consecutive patients in the Club Hernie database who underwent ventral hernia repair with SymbotexTM composite mesh. The primary objective is to assess recurrence and complications within 2 years of surgery. One year follow-up was completed at this analysis. Results: One hundred consecutive patients from the Club Hernie database were treated for a total of 105 hernias (37.1% primary, 62.9% incisional; 79.2% repaired laparoscopically). Patient followup after one year was 94% (94/100). Six (6.0%) low-grade seromas (unrelated to the mesh) and 3 (3.0%) cases of low-grade transitory ileus (mesh relationship unknown) occurred perioperatively or within one month follow-up. One (1.0%) recurrence, which was asymptomatic, not requiring surgery, occurred within one year. No other adverse events occurred within 12 months follow-up and no serious adverse events were reported. All surgeons reported good mesh flexibility and ease of insertion. Patient pain, assessed by a Visual Analog Scale, reduced significantly at day 1 through month 3 postoperatively compared to baseline. Conclusion: These promising one year registry results show minimal pain and low complication rates with SymbotexTM composite mesh in ventral hernia repair.

O26.7 Polyglactin Mesh inlay for combined gastrointestinal reconstruction and and abdominal wall repair (AWR). A safe, effective and inexpensive alternative to biologics R. R. W. Brady, H. Clouston, A. Howe, I. Peristerakis, G. L. Carlson, D. Slade Salford Royal Foundation Trust, Manchester, UK Background: The optimum method of reconstruction for large contaminated abdominal wall defects remains unclear. We present outcomes within a series of patients with massive contaminated abdominal wall defects requiring combined gut and/or abdominal wall reconstruction (AWR) in which Polyglactin mesh inlay was used alone or in combination with component separation (CS). Methods: Consecutive patients from 5th May 2006 to 24th April 2014 from a single specialist national centre, with intestinal fistulation and/or requirements for re-establishment of intestinal continuity associated with large associated abdominal wall defects, underwent combined gastrointestinal and AWR surgery. Results: 75 patients (47 male, mean 48.75 years) underwent AWR. 65 (86%) patients had enterocutaneous fistulae. 75% patients were dependent on artificial nutrition prior to surgery. All patients had polyglactin mesh positioned as; inlay 31 (41.3%), bridge 30 (40%) and inlay/bridge 14 (18.7%). 61 patients had at least 1 anastomosis, 24 gastrostomy, 46 stoma and 54 CS. Morbidity was 34.1% (Clavien-Dindo 18 grade 1, 6 grade 2, 1 grade 3 and 3 grade 4). 25 (33.3%) patients developed postoperative incisional hernias; 6 (8%) required subsequent operative repair, 13 (17.3%) were asymptomatic. Incisional hernia was not associated with age, gender, BMI [ 30 or smoking (p [ 0.05). 6 (8%) patients developed recurrent fistulas. There was no post-operative 30-day mortality. Conclusion: Polyglactin mesh inlay repair is a simple, inexpensive and safe method for AWR in a contaminated field and has a postoperative complication rate, with levels of fistulation and requirements for future incisional hernia repair better than series reporting utilisation of more expensive biological implants.

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O26.8 Polylactide-caprolactone composite mesh used for ventral hernia repair: a prospective, randomized, single-blind controlled trial Y. Shen, C. Qin Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: Composite surgical mesh is widely used in laparoscopic repair of ventral hernia but may carry the risk of postoperative adhesion and more serious complications. The present study was undertaken to demonstrate the effectiveness and safety of a new composite polypropylene mesh coated with poly L-lactide-co-ecaprolactone (EasyProsthesTM). Methods: This randomized, controlled trial was designed to compare EasyProsthes composite mesh (EPM) with ParietexTM Composite (PCO) in patients undergoing laparoscopic ventral hernia repair (with or without the hybrid technique). Hernia recurrence, chronic pain, seroma formation, intestinal fistula and obstruction, wound or abdominal infection, and ultrasound evidence of viscera adhesion were evaluated. Results: Forty patients were randomly assigned to each of the EPM and PCO groups. All patients completed 24 months of follow-up. One patient in EPM group (2.5%) and two patients in PCO group (5%) developed mesh-viscera adhesions after surgery (p = 1.000). No patients developed intestinal fistulas or obstructions. Seventeen patients in EPM group (42.5%) and 21 in PCO group (52.2%) developed post-surgical seromas in the operative area (p = 0.370). One patient from each group developed postoperative wound infection. There were no cases of abdominal infection and no reports of chronic pain or hernia recurrence. Conclusion: The incidence of postoperative complications in EPM group was similar to that seen with PCO. EPM is safe and effective when used in ventral hernia repair.

O26.9 Ventral hernia repair using a longterm resorbable synthetic mesh versus a large pore synthetic mesh: an international multicenter RCT L. Benmaridja1, M. Miserez2, M. Smietanski3, L. Jorgensen4, F. Berrevoet1 1 Ghent University Hospital, Gent, Belgium, 2Digestive and Pediatric surgery, UZ Gasthuisberg, Leuven, Belgium, 3Ceynowa Hospital, Wejherowo, Poland, 4Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark Background: Mesh complications are increasingly reported using synthetic meshes. TIGRÒ Matrix Surgical mesh is a synthetic mesh with longterm strength retention that might adress some issues. Although some data exist using this type of mesh in inguinal hernia, data on ventral hernias is scarce. Methods: This prospective randomized controlled trial compares the use of TIGRTM mesh with a large pore mesh, located in a retromuscular fashion. All patients with ventral hernias less than 20 cm in length and less than 6 cm in width were eligible. Double-blind assessments of peri-operative morbidity, postoperative pain, discomfort and numbness, and recurrence rate were obtained. The primary outcome of the study is the recurrence rate at 3-year followup. Follow-up is done after 4–6 weeks, 1, 2 and 3 years. Results: This interim analysis included 85 patients, 7 primary hernias were treated with TIGRÒ mesh versus 12 in the control group and 29 versus 37 patients were treated for incisional hernias. At 4–6 weeks

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S184 FU no significant difference in perioperative morbidity (seroma and hematoma) between the two groups was observed. Postoperative pain, discomfort and numbness were similar at 1 year follow-up, while no recurrences were observed. Only 60% of patients reached 2 year FU with no recurrence in the TIGRÒ mesh and 1 in the control group. Conclusion: Longterm resorbable TIGRÒ mesh shows acceptable results after 1–2 years of follow-up for small ventral hernias. Wound morbidity and recurrence are similar compared a large pore synthetic mesh. Longterm results have to awaited for more definite conclusions.

27 Management of complex and giant hernias. O27.1 Progressive preoperative pneumoperitoneum. Our criteria in giant abdominal hernias J. A. Gonzalez Sanchez, M. A. Heras Garceau, S. Valderrabano, A. I. Herrera Sampablo, P. Martinez, E. Alvarez Pen˜a Hospital Universitario La Paz, Madrid, Spain Background: Repair of hernias with loss of domain without the right preparation may cause serious complications, being the most relevant the abdominal compartment syndrome. To attenuate the adverse effects, Gon˜i Moreno described in 1940 the progressive preoperative pneumoperitoneum (PPP) technique. At the beginning, the need of PPP was determined by physical examination only. Recently, the use of radiological findings as CT calculation of the volume ratio of the hernia sac to the abdominal cavity, without considering the elasticity of the abdominal wall, has led to an excessive use of PPP. In our opinion, it’s essential to evaluate as well if the hernia content can be reduced below the fascia. Methods: 14 patients with giant hernias with loss of domain (11 incisional, 3 inguinal) were prepared for surgery with progressive pneumoperitoneum. Results: The mean insufflation period was about 18 days (16–21) and the mean volume of total instilled air was 14.700 ml (8400–21,000 cc). We also present a series of patients with giant hernias who didn’t require PPP, based on laxity of the abdominal wall. Single-stage repair was feasible, with similar results to PPP series, without major complications. Conclusion: Not only the volume of the hernia sac and abdominal cavity should be considered for preoperative planning. Physical examination, an attempt to reduce the herniated contents, and evaluation of elasticity and compliance of the abdominal wall would determine the necessity of preoperative pneumoperitoneum.

O27.2 Progressive preoperative pneumoperitoneum preparation for surgery of complicated hernias Y. Li, S. Chen, Z. Jiang, T. Zhou The sixth affiliated hospital of Sun Yat-sen University, Guangzhou, China Background: Repairing complicated hernias with loss of domain is a challenge for the general surgeon. Even with a prosthetic aid, the forced repair of such huge defect without enough preparation leads to unsatisfactory results immediately materialized in an abdominal compartment

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Hernia (2017) 21 (Suppl 2):S139–S207 syndrome(ACS) and late, if the patient survives, in a high recurrence rate. A progressive preoperative pneumoperitoneum (PPP) was used to increase the volume of the abdominal cavity and abdominal wall compliance. The aim of the study is to evaluate the efficacy of PPP in management of complicated hernias with loss of domain. Methods: All patients were placed catheters under ultrasound guidance for PPP. All patients had pre- and postoperative progressive pneumoperitoneum computed tomography of the abdomen, and the volumes of the incisional hernia (VIH), the total peritoneal content (VP) and the VIH/VP ratio were measured, respectively. All patients were received laparoscopic hernia repair by complete closure of the defect and reinforcement with anti-adhesion mesh. The rate of overall postoperative morbidity and recurrence was evaluated. Results: Twenty-nine patients were included in a retrospective, observational study. Before and after PPP, the mean VIH was 2408 and 3155 ml, and the mean VP was 7525 ml. The VIH/VP ratio was decreased from 32 to 24%. The overall postoperative morbidity rate was 20.7%. At a mean follow-up of 13.2 months, the recurrence rate was 10.3%. Conclusion: The preoperative preparation method of PPP is safe and effective choice for surgery of complicated hernias with loss of domain.

O27.3 An early experience of using progressive preoperative pneumoperitoneum in patients with giant hernias of the abdominal wall in a district teaching hospital— 3 years follow-up P. M. Bojovic´, V. R. Cijan, M. Sˇcˇepanovic´, Z. Bokun, M. Brankovic´, E. Isakovic´ Clinical Hospital Center Zvezdara, Belgrade, Serbia Background: Since 1947., when preoperative progressive pneumoperitoneum was proposed by Goni-Moreno, which is mostly indicated in large incisional hernias with irreducible contents, It was widely accepted by herniologists that the surgeon should cooperate with the internist, physiotherapeutist and anesthetist.The aim of this study was to present the outcomes of the elective Rives–Stopa hernioplasty after Goni-Moreno procedure, performed in first four patients suffered of giant hernias with ‘‘loss of domain’’ in a district general hospital with 3-year follow-up. Methods: Prospective study of four patients undergoing elective Rives–Stopa hernioplasty after Goni-Moreno procedure in a district teaching hospital. Results: From 01.01. 2012 to 31.12.2015., four female patients who underwent elective Rives–Stopa hernioplasty after Goni-Moreno procedure were recorded. Same surgical team operated on all patients who underwent hernia repairs by using polypropylene heavyweight flat mesh size 30 9 30 cm, Hermesh 3 (Herniamesh, Italy). Data regarding demographics, co-morbidity, preoperative preparation, the average insufflation time, complications of insufflation, postoperative complications, return to normal daily activities and patient satisfaction were recorded in three-years follow up. Conclusion: The elective Rives–Stopa hernioplasty after Goni-Moreno procedure is a comfortable and effective method, with good recovery and low complications and can be done safely in general surgical unit. Cooperation with an internist, physiotherapeutist and anesthetist is important in obtaining satisfactory results in general surgical unit.

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O27.4 Long term results of open complex abdominal wall hernia repair with a self-gripping mesh, a retrospective cohort study L. F. Kroese1, L. H. A. van Eeghem2, J. Verhelst1, J. Jeekel1, G. Kleinrensink1, J. F. Lange1 1 Erasmus University Medical Center, Rotterdam, The Netherlands, 2 Havenziekenhuis, Rotterdam, The Netherlands Background: In case of complex ventral hernias, Rives-Stoppa and component separation technique are considered as favorable treatment techniques. However, mesh-related complications like recurrence, infection and chronic pain are still a common problem after mesh repair. Previous studies have reported promising results of the use of a self-gripping mesh (ProGripTM) in incisional hernia repair. This study aimed to evaluate the long term results of this mesh for complex ventral hernia treatment. Methods: Patients with complex ventral hernia undergoing repair between June 2012 and June 2015, using the ProGripTMmesh in retromuscular position, were included. All patients visited the outpatient clinic to evaluate short term complications and recurrence. After at least one year, telephone interviews were conducted to evaluate long term results. Results: A total of 46 patients (median age 59 years) were included. 40 patients (87.0%) were diagnosed with incisional hernia. Seven patients (17.5%) had incisional hernia combined with another hernia. Four patients (8.7%) had an umbilical hernia, one patient (2.2%) had an epigastric hernia and one patient (2.2%) had rectus diastasis. 39 patients completed follow-up. Median follow-up was 25 months (IQR: 19–35 months). 28 Patients (71.8%) did not report any complaints. Nine patients reported pain (average VAS of 1.7). Two patients developed a recurrence requiring reoperation. One patient developed mesh infection requiring reoperation. Conclusion: Long term results of the use of a self-gripping mesh for complex abdominal wall hernias show a low recurrence rate, even in complex hernia cases. This makes the mesh a good choice in this difficult patient group.

O27.5 Abdominoplasty approach for giant incisional hernia repair: a functionally and aesthetically abdominal wall reconstruction A. Abusalih, R. Dar Taha, E. Shusterman, Y. Ramon Rambam health care campus, Haifa, Israel Background: Giant incisional hernia is hard to repair and has high recurrence rate. Surgical approaches for repair includes the traditional previous incision approach, laparoscopic approach and low transverse abdominal wall incision as done for abdominoplasty. No single type of repair is reliable in all cases, and each has its own limitations and complications. Methods: 38 patients with giant hernia were reconstructed via abdominoplasty approach, which enabled the surgeons to view the entire abdominal wall, define the exact borders of the hernia and identify good quality fascia. The type of repair was chosen according to the findings after this wide dissection. Repair was done with or without mesh and/or component separation. Access skin and fat were removed at the end of the procedure. Results: 2 Patients had respiratory depression after the operation and required prolonged ventilation, 1 patient had wide flap necrosis, 1 patient had flap necrosis with exposed mesh, 1 patient had infection, 2 Patient had seroma and 4 patients had minor skin flap necrosis. 2

S185 Patient had recurrent hernia. All the minor complications were treated conservatively, while the patients with wide flap necrosis, exposed mesh and recurrent hernia had a second operation that solved the problem. All patients were satisfied with the end result. Conclusion: Abdominoplasty approach for hernia repair enables the surgeon to view the entire abdominal wall and thus choose the best way of repair. In addition access skin can be removed, and thus provide combined functionally and aesthetically abdominal wall reconstruction, with minimal recurrence rate.

O27.6 Botox supportedabdominal wall reconstruction in IPOM technique (B.U.B.I)-our solution fordifficult cases N. Bohnert1, E. Elieyioglu2, A. Ba¨r1, B. J. Lammers1 1 Lukaskrankenhaus Neuss, Clinic for General-, Visceral-, Thoracic and Vascular Surgery, Department for Hernia Surgery, Neuss, Germany, 2Lukaskrankenhaus Neuss, Institute for Radiology, Neuss, Germany Background: The biggest problem in hernia surgery is, to get proper results in cases of giant ventral hernias. To avoid dissection of healthy parts oft he abdominal wall like in the Ramirez operation, we developed our own method of Botox supported abdominal wall recontruction in IPOM technique, B.U.B.I Methods: In this method we combine the Botox induced relaxation of the abdominal wall with the IPOM technique to achieve a full reconstruction of the midline combined with a mesh. 2 Weeks prior to surgery patients were treated with sonography guided Botox injection in both sides of the lateral abdominal wall muscles.To verify the result of the injection a low dose CT scan is done on the day before the IPOM repair. Results: 12 Patients have been treated with Botox injection so far, 9 of them have already been operated. In 6 of 9 cases we could do a full reconstruction oft he midline. In 3 cases we could at least reduce the defect. Defect sizes have been between 6 9 6 cm up to 30 9 35 cm. 9 patients already went through follow up after 6 months and are without a hernia recurrence so far.We havent seen any Botox related problems so far. Conclusion: Our patients show, that it s even possible to do a midline recontruction in giant hernias without creating any pressure related problems. B.U.B.I. is a safe and efficient procedure to treat patients with a giant ventral hernia and is a good alternative for the Ramirez operation.

O27.7 How to manage the monster groin hernia M. Zuvela1, D. Galun1, I. Palibrk1, D. Basaric1, A. Bogdanovic2, N. Bidzic1 1 University Clinic for Digestive Surgery; Medical School, University of Belgrade, Belgrade, Serbia, 2University Clinic for Digestive Surgery, Belgrade, Serbia Background: A challenging task for any surgeon is the management of groin hernias with hernia defect larger than 10 cm, increased abdominal pressure and loss of domain. We present results of the modified Rives technique with or without the use of components separation technique (CST) for the management of monster groin hernias. Methods: Between January 2006 and January 2017 17 consecutive patients with monster groin hernias were operated on by the modified Rives technique performed through direct inguinal approach (in 4 pts Maas modification CST for enterostomies was performed to enlarge abdominal cavity and in 5 patients omentectomy was done in order to reduce the volume of reintegrated viscera). Three patients had

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S186 prolonged postoperative intubation and myofascial relaxation in the intensive care unit during 1 day (2 patients) and 5 days (1 patient) to adapt to the intra-abdominal pressure. Results: The mean hernia defect was 12 cm (10–18). The mean operation time was 125 min (70–350). The mean postoperative hospital stay was 4.5 days (2–42). There were two postoperative deaths 14 and 42 days after the surgery due to comorbidities. There was no hernia recurrence during a mean follow-up of 47 months (3–106). Conclusion: The modified Rives technique performed through direct inguinal approach with or without CST is feasible solution for management of the monster groin hernias.

O27.8 The role of hydrofiber dressing with silver, natrium ethylenediaminetetraacetic acid and benzethoniumchloride in the treatment of mesh infection M. Zuvela1, D. Galun1, I. Palibrk1, N. Bidzic2, S. Miric2, J. Gajic2 1 University Clinic for digestive surgery, Belgrade; Medical School, University of Belgrade, Serbia, Belgrade, Serbia, 2University Clinic for digestive surgery, Belgrade;, Belgrade, Serbia Background: The study aim was to present the role of hydrofiber dressing with silver, natrium ethylenediaminetetraacetic acid— NaEDTA and benzethoniumchloride—BeCl in the management of resistant mesh infection after abdominal wall hernioplasty. Methods: Between January 2015 and January 2017 21 patients with mesh infection were managed using hydrofiber dressing with silver, NaEDTA and BeCl. Fourteen patients had 30 9 30 cm sublay or onlay haevy-weight polypropylene mesh infection, 5 had 7 9 5 cm preperitoneal low-weight mesh infection, 1 had 30 9 30 cm intraperitoneal composite mesh infection and 1 patient had Lichtenstein 15 9 10 cm low-weight mesh infection. Staphilococcus aureus was isolated in 14 patients, Staphilococcus aureus and Acinetobacter in 1, Peptococcus in 1, Proteus mirabilis and Klebsiela/Enterobacter in 2, and Pseudomonas aeruginosa was isolated in 3 patients. The treatment included wound opening, mesh exposure and daily hydrofiber dressing with silver, NaEDTA and BeCl. Results: The presented treatment led to complete resolving of mesh infection and wound healing in all patients during the mean period of 75 (14–268) days and was achieved at average of 53 (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. In 6 patients mesh excision 1–2 cm in size was done to stimulate wound clousure. There was no mesh re-infection during the mean follow-up of 7.5 (1–22) months. Conclusion: Hydrofiber dressing with silver, NaEDTA and BeCl is a feasible therapeutic option for the management of mesh infection.

O27.9 Loss of entire abdominal wall in severe malnutrition patient: how I do it? K. Ketwong1, P. Jitpratoom1, P. Chonlathee2, A. Anuwong1 1 Police General Hospital, Bangkok, Thailand, 2Chiang Rai Regional Hospital, Chiang Rai, Thailand Background: Large ventral hernia from open abdomen is a complex abdominal wall problem. Many techniques such as component sepa-

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Hernia (2017) 21 (Suppl 2):S139–S207 ration, advancement flaps, skin grafts and staged repairs are used depending on each patient’s comorbid conditions, type of hernia, and the surgeon’s preference. This report discusses the management in open abdomen from necrotizing fasciitis in severe malnutrition patient. Methods: This was a case report of a 63-year-old female with ruptured appendicitis and necrotizing fasciitis of the entire anterior abdominal wall, who underwent right hemicolectomy and debridement of abdominal wall. Temporary abdominal closure with vacuum dressing was applied. Septic condition was improved and nutritional status was optimised. Large ventral hernia was repaired with composite mesh after the abdominal defect was well granulated. Regional flap advancement was done from both thighs to cover the defect. Clinical data was recorded. An informed consent was obtained. Results: Hernia was managed successfully with composite mesh and regional flap advancement. The operative time was 250 min with estimated blood loss of 100 ml. Flap necrosis developed on day 3 post-operation and serial debridement was done. Vacuum dressing was applied continuously until the necrotic area was well granulated. Finally, split thickness skin graft was performed. Total hospital stay was 4 months. The patient was discharged with rehabilitation program. Conclusion: Multidisciplinary approach with well planning is the key to success for large ventral hernia repair. Infection control and optimising nutritional status are also required. Complications should be managed and rehabilitation should be encouraged to improve quality of life.

28 Legendary Surgeons: Take home tips to improve your hernia practice O28.1 Andrew Kingsnorth A. Kingsnorth Plymouth, UK Background: For more than 25 centuries, anatomists, surgeons and pathologists have contributed to the total fund of medical knowledge concerning Hernia, providing a platform for successful surgical repair of hernias. Surgical technique was only matched by this knowledge in the mid-nineteenth century with the advent of general anaesthesia and antisepsis, and culminated in the classic operation of Bassini. However, this advance was squandered in the next century by empiricism, until Shouldice painstakingly revived Bassini’s operation and convinced surgeons of its value. Simultaneously, Usher was working on the new concept of prosthetic repairs and Ger introduced the intraabdominal use of the laparoscope to close the internal ring. Methods: The twenty-first century saw the rapid evolution of techniques utilising these two new modalities. Lichtenstein proved that in open groin hernia surgery, polypropylene meshes were safe and effective. Many surgeon contributed in the development of the laparoscopic TEP and TAPP operations, including Delucq, Arregui and Katkhouda. Devlin and Nilsson identified the need to audit and monitor the results, and this provided the impetus for specialization. Results: In turn, these surgeons began to tackle the huge problem of incisional hernia. Pioneers included Rives, Stoppa and Chevrel. Later plastic surgeons such as Ramirez brought forward innovative techniques to further improve results. Conclusion: The ideas of these and other legendary surgeons can be identified as a seminal advance, each of which can be recommended as a ‘‘Top Tip’’ to improve clinical practice.

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O28.3 Reinhard Bittner

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29 Biomeshes in Hernia Surgery: update and consensus

R. Bittner Hernia Center Rottenburg, Rottenburg, Germany Legendary surgeons – take home message to improve your hernia practice. In order to do your best for the patient you must be familiar with the traditional operation techniques. It is essential to record the results and provide a critical appraisal. Follow the respective literature. Discuss the value of the operation for the patient. Be open for new techniques. If you want to learn a new technique you should be convinced about the advantages in comparison to the traditional operation. Before starting with the new technique it is recommended to visit a surgeon who already is familiar with this procedure and watch the performance. If you want to start with the new procedure by your own talk with the patient about and discuss with him the advantages and possible disadvantages. Document your cases from the beginning. Include all patients in a follow-up program. In order to know how to proceed it is absolutely necessary to analyze the complications and the overall results at regular intervals. If you are satisfied you should discuss if the technique can be transformed in clinical routine and if this new operation can be learned by all surgeons or only a procedure which may be performed by specialists only. Finally the cost-effectiveness should be an issue of concern. Conflict of interests: The author has nothing to declare.

O28.4 Davide Lomanto D. Lomanto Minimally Invasive Surgical Centre, National University Health System, National University Singapore, Singapore, Singapore Background: Being for 2 decades a passionate about abdominal wall reconstruction and hernia surgery, make me understand the continuous challenges arising from its ethology and therapy. I was very fortunate to personally experience the changes and the evolution of hernia repair from the century old Bassini’s repair, that i was lucky to learn from an expert, to the today Robotic repair that i perform with an eye to the future. Methods: I wish to be able to transfer not only my knowledge but mainly my passion for this fascinating disease to the young surgical trainees and my surgeon fellows. Results: Learning continuously and teaching to tailor the different approaches to each single patients to made the best of each treatment is the path to become a good hernia surgeon. I always express my concern towards a single technique surgeon and push the junior to learn the different surgical options. Conclusion: Hernia in its complexity and with the different aspect cannot be enclosed in a lonely cage but requires an approach that implies knowledge of technique and biology of its multifactorial implications.

O29.1 Is there a place for replacement of an infected synthetic by a biological mesh in incisional hernia repair? A. Montgomery Malmo¨, Sweden Deep infection including the mesh is luckily not very common in ventral/incisional hernia surgery. The scenarios can vary widely. In many situations local wound care, including VAC treatment, can save the mesh. For mesh infection in inguinal hernia repair there is no report of a replacement of the explanted mesh. Reports on replacement of an infected mesh in ventral/incisional hernia repairs with a biologic mesh are few and of low quality. Only 90 patients were identified in either case series or reports. The overall wound infection rate was 39% and the recurrence rate 27% with a median follow up of around two years. The wound complication rate is very high, but will resolve on local treatment with no report on mesh removal during a median of two years follow up. The use of a biologic mesh as a replacement in either an onlay or retromuscular position seems to work in most situations, taken the complicated scenarios into account. Caution should be taken not to bridge a biological mesh due to a high risk of a later recurrence.

O29.3 Are biologic meshes useful in the prevention of incisional hernia? F. Muysoms1, A. Jairam2, M. Lo´pez-Cano3, M. S´mietan´ski4,5, G. Woeste6, I. Kyle-Leinhase1, S. A. Antoniou7,8, F. Ko¨ckerling9 1 Maria Middelares Gent, Gent, Belgium, 2Erasmus university Medical Center, Rotterdam, The Netherlands, 3Vall’d Hebron Hospital, Universidad Auto´noma de Barcelona, Barcelona, Spain, 4 Department of Surgery, District Hospital in Puck, Puck, Poland, 5 Department of Radiology, Medical University of Gdansk, Gdansk, Poland, 6Klinikum der Johann Wolfgang Goethe-Universita¨t, Frankfurt am Main, Germany, 7Center for Minimally Invasive Surgery, Hospital Neuwerk, Mo¨nchengladbach, Germany, 8 Department of General Surgery, University of Heraklion, Heraklion, Greece, 9Vivantes hospital, Berlin, Germany Background: Prophylactic mesh augmented reinforcement during closure of abdominal wall incisions has been proposed in patients with increased risk for incisional hernias (IH). As part of the BioMesh consensus project, a systematic literature review was performed to detect studies where MAR was performed with a non-permanent absorbable mesh (biological/biosynthetic). Methods: A computerized search was performed within 12 databases (Embase, Medline, Web-of-Science, Scopus, Cochrane, CINAHL, Pubmed publisher, Lilacs, Scielo, ScienceDirect, ProQuest, Google

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S188 scholar) with appropriate search terms. Qualitative evaluation was performed using MINORS score for cohort studies and 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 terms of mesh configuration (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 level of evidence on the efficacy and safety of biological meshes for prevention of incisional hernias is very low. No comparative studies were found comparing biological mesh with synthetic non-absorbable meshes for the prevention of incisional hernias. Conclusion: There is no evidence supporting the use of non-permanent absorbable mesh (biological or biosynthetic) for prevention of incisional hernias when closing a laparotomy in high-risk patients or in stoma reversal wounds. There is no evidence that a non-permanent absorbable mesh should be preferred to synthetic non-absorbable mesh both in clean or clean-contaminated surgery.

O29.5 Biological vs biosynthetic meshes: similar or different? S. Morales Conde University Hospital ‘‘Virgen del Rocı´o’’, Sevilla, Spain New meshes are being introduced in the market looking for solutions to the problems that surgeons find. The initial boom of biological meshes has declined because they have not fulfilled the expectations that they originally created. Biological meshes are very expensive, presenting a high rate of recurrence accompanied by an uncertain role on infected fields and the behaviour of some of them as permanent meshes, creating an encapsulation. Even that there is a role for them and alternative has raised to solved the problems of this meshes with better cost-efectiveness. For that reason, biosynthetic meshes has come to improve the results of abdominall wall repair in contaminated and infected fields, although short and long term results are needed to establish the exact role of this new materials.

30 Video-session: New techniques in midline hernia repair V30.2 The use of the new target mesh for the treatment of the small ombilical hernias, with an open minimal invasive surgery. Video M. Soler Clinique Saint Jean, Cagnes Sur Mer, France Background: Our preference to treat an ombilical hernia is to put a mesh in the preperitoneal space. The main difficulty of the technique was to unroll the prosthesis through the small incision.So we created a new semi rigid and self-expandable mesh. It is the target mesh: a

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Hernia (2017) 21 (Suppl 2):S139–S207 twelve cm rounded polypropylene mesh with three not knitted and not woven concentric rings. Methods: The movie shows the preperitoneal dissection of an umbilical hernia, with several small holes.The mesh can be cut. The main step of the procedure is the preperitoneal space dissection. Results: A personal prospective study (n = 112) is under way, under the control of the French ‘‘club hernie’’ data base. Follow up: (15–63) months. 79 men, 33 women primary 108, secondary 4 day surgery, n = 106 (88%) complications; seroma, n = 2; ombilical necrosis, n = 1; recurrence, n = 1 with a good result after reoperation postoperative pain at one month: Visual Analogic scale (VAS) VAS = 0: 96 (86%) VAS (1–3): 11 (10%), VAS (4–7): 4 (3.5%), VAS 8:1 (0.90%).Post-operative pain between 3 and 6 month (Only the patients with pain at one month are reviewed) VAS = 1–3: 5, VAS = 4–7: 1 VAS = 8:1 For all these patients the post-operative pain is less important than the preoperative one. Post-operative pain between 12 and 51 months (All the patients are reviewed at one year) VAS = 4–7: 4 patients. Conclusion: The use of the extra peritoneal mesh is a safe technique. The use of the target mesh make easier to unroll the prosthesis in the preperitoneal space.

V30.3 Totally endoscopic subcutaneous surgery in rectus diastasis with onlay mesh and umbilical hernia associated J. Bellido Luque1,2, J. Gomez Menchero2, J. Suarez Gra´u2, A. Bellido Luque1, J. Garcı´a Moreno2, I. Duran Ferreras2, J. Guadalajara Jurado2 1 Quiro´n Sagrado corazo´n Hospital, Sevilla, Spain, 2Riotinto Hospital, minas de riotinto, Huelva, Spain Background: Many patients present umbilical hernia and Rectus diastasis simultaneously. If only the hernia is corrected, we will repair the hernia on a anatomically weak tissue, so the rate of hernia recurrence may increase. It would be suitable to correct both conditions at once. We propose minimally invasive access using a subcutaneous approach. Methods: 45 years old with umbilical hernia 4 cm size and diastasis recti(subxiphoid 3 cm, 4 cm supraumbilical, 4 cm subumbilical size).3 trocars in suprapubic position are placed. Supraaponeurotic space is created until the umbilical region. Hernia sac is released and reintroduced into the abdominal cavity. Preperitoneal space is created subcutaneous dissection continues until subxiphoid region. A composite mesh is placed in preperitoneal position secured by two sutures at the umbilical defect. Rectus plication is achieved using nonabsorbable suture endostich V-loc no 0. A low weigth polipropilene mesh is placed in onlay position, fixed with Cianocrylate glue to reinforce the plication. The navel is fixed to the fascia and suction drain is placed. Results: The postoperative course was without complications. The drain is removed at 48 day. After 24 months the patiens is completely satisfied with the results. No hernia o diastasis rectus recurrence is seen during follow-up. Conclusion: Totally endoscopic subcutaneous approach is useful to solve both umbilical hernia and rectus diastasis. Mesh should be used in Rectus diastasis more than 4 cm size to avoid recurrences. This minimal invasive access provides high aesthetics results.

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V30.4 Laparoscopic Rives technique for diastasis recti and ventral hernias: feasibility of a fully minimally invasive abdominal wall reconstruction C. Stabilini, D. Soriero, E. Gianetta Department of Surgery, University of Genoa, Genoa, Italy Background: Despite their widespread adoption, standard techniques of laparoscopic midline abdominal hernia repair have their greatest weakness in not being able to reproduce Rives procedure, the gold standard technique for the repair of midline abdominal wall hernia. In the last year we developed a fully minimally invasive technique for VHR repair preserving the crucial steps of the French procedure (LapRives). Methods: Twelve patients (6 males, mean age 52 years) affected by abdominal wall defect with or without diastasi recti (5/7) were submitted to LapRives in two cases with transversus abdominnis release. The procedure consists in the dissection of the different layers of the abdominal wall trhough an intraperitoneal route, then a retromuscular mesh placement with progressive suturing of the aponeurosis from the intramuscular and subcutaneous sides of the abdomen. Results: Mean major defect diameter was 14 ± 2.7 cm, operative time ranged from 184 to 245 min. One patient required conversion to open surgery due to technical issues. All patients were free from painkillers within 3 days postoperatively. Mean hospital stay was 6 days. One seroma requiring bedside drainage was recorded. Within 3 months from surgery no late complications were recorded, no recurrences were encountered and patients were satisfied with the procedure. Conclusion: The present series, small in size, shows feasibility of a complete laparoscopic reconstruction of the linea alba. Despite its complexity, the procedure is safe, reproducible and effective in treatment of midline abdominal wall defects without the need for intraperitoneal material.

V30.5 Laparoscopic retromuscular mesh repair for umbilical and small ventral hernias: a report of two cases G. Akiyama, D. Uematsu, T. Sugihara, A. Magishi, K. Oono Saku Advanced Care Center, Saku, Japan Background: Intraperitoneal onlay mesh repair has been introduced for umbilical and ventral hernias. However, the use of fixation devices reportedly results in complications. We report two cases of laparoscopic retromuscular mesh repair, whereby intraperitoneal mesh fixation was avoided (one case each of umbilical hernia and ventral hernia). Methods: A 1-cm skin incision was made at the lateral border of the left rectus abdominis to identify the space between the rectus abdominis and posterior sheath. An operating cavity was made at the scope insertion port during air insufflation; a working port was placed on either side of the scope port. Ablation was performed at the posterior sheath, traversing caudally from the left to the right side of the arcuate line, to identify the right rectus abdominis muscle and the posterior sheath. The linea alba was incised while focusing on the right and left posterior sheaths, and ablation was performed cephalocaudally. After establishing a necessary and sufficient overlap cephalocaudally, bilaterally, a mesh was inserted and developed. Fixation was omitted since migration is unlikely. Results: The surgical time was 112 (case 1) and 134 min (case 2), with minimal bleeding in both. Pain was experienced only at the port

S189 insertion site, which resolved soon. No severe, persistent abdominal pain was reported; the hospitalization period was 3 days. No recurrence or infection occurred during the 12- (case 1) or 6-month (case 2) observation. Conclusion: As fixation was omitted, chronic pain and intestinal complications could be avoided and relief from acute pain was possible.

V30.6 Laparoscopic retromuscular sublay mesh repair ¨. O ¨ gredici, W. Brunner, S. Spampatti, L. Benigno, T. Kastiunig, O J. Janczak Kantonsspital St. Gallen/Rorschach, Rorschach, Switzerland Background: Sublay retromuscular mesh position is the favoured technique in open ventral and incisional hernia repair even so accepting large wound fields. Upcoming new less invasive methods as MILOS (Mini Less Open Sublay) and E-MILOS try to reduce the open approach. On the other hand, the laparoscopic technique avoids these wound regions but is performed by intraperitoneal mesh placement (IPOM). Recently, to avoid potential disadvantages and complications of intraperitoneal mesh position, first attempts for preperitoneal mesh positioning (PPOM) were undertaken. One step further, combining laparoscopic approach and sublay mesh position reduces or even avoids the potential disadvantages from IPOM and open approach. Methods: We present a video of a single port laparoscopic sublay retromuscular mesh repair for incisional umbilical hernia: A 56-yearold female patient presented with symptomatic umbilical hernia after laparoscopic mesh rectopexy 10 years ago. Results: Starting with a 2 cm open single incicion approach left lateral a single port system with four trocars was introduced. The video shows all steps of retromuscular laparoscopic mesh repair and glue fixation (Liquiband). Conclusion: L-Sublay is a new technique in ventral and incisional hernia repair combining laparoscopic approach and retromuscular mesh position. Potentially it avoids the disadvantages of open approach and intraperitoneal mesh positioning. Of course it is more time demanding than IPOM procedures and we have to be aware of the learning curve.

V30.7 Laparoscopic transversus abdominis release: a novel technique ¨ zveri2, E. Hatipog˘lu1 M. Ertem1, H. Go¨k2, E. O 1 Istanbul Uni. Cerrahpasa School of Medicine, ˙Istanbul, Turkey, 2 Acibadem Kozyatagi Hospital, ˙Istanbul, Turkey Background: In the repair of complex abdominal wall hernias, posterior component seperation via transversus abdominis release (TAR) provides ability to close the large defects, less surgical site complications and high success rates. Doing TAR by laparoscopic approach, makes the repair less invasive. Methods: In this video, laparoscopic TAR hernia repair of 32 years old female patient are presented. The steps of technic has been well demonstrated. Results: The patient was discharged uneventfully on postoperative day 4. There has seen no complication at the early and late follow-up period.

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S190 Conclusion: Laparoscopic abdominal wall hernia repair with transversus abdominis release is a versatile and feasible approach to complex abdominal wall defects. Advanced anatomy knowledge and surgical skills are necessary for succesful results.

V30.8 PPOM: preperitoneal onlay mesh repair: a novel technique ¨. O ¨ gredici, J. Janczak, S. Spampatti, L. Benigno, T. Kastiunig, O W. Brunner Kantonsspital St. Gallen/Rorschach, Rorschach, Switzerland Background: IPOM is the current technique for laparoscopic repair of ventral and incisional hernias. However, placement of synthetic mesh intraperitoneally may potentially lead to mesh related complications as adhesions with intestinal obstruction, enterocutaneous fistula or even mesh erosion into organs. Methods: We present a video of a single port laparoscopic preperitoneal onlay mesh repair in a primary umbilical hernia. Results: A 2 cm open single incicion approach was performed left lateral and a single port system with four trocars introduced. After intraabdominal overview adhesiolysis was carried out and the greater omentum reduced out of the hernia sac. To create a peritoneal flap peritoneal incision was startet close to the port system. Peritoneum was taken down both by blunt and sharp dissection surrounding the hernia gap. After freeing strong fibrotic adhesions to the hernia defect, sac and umbilical skin the preperitoneal layer was followed towrds the patients right side. The hernia defect was closed with unreseorbable sutures. A 15 cm Symbotex Mesh was placed and glued with Liquiband. No tacks or sutures were used. Peritoneal flap closure was partially glued resp. sutured with V-Loc, even complete covering of the mesh was not possible. Conclusion: PPOM is a new minimal invasive technique in ventral hernia repair trying to avoid intraperitoneal mesh position and hopefully its potential complications due to the position. It is more time demanding than IPOM procedures, but gap-free dissection and complete covering of the mesh is not easy to achieve in the learning curve.

V30.9 Transabdominal preperitoneal approach to incisional border hernia repair S. Reggio, D. Cuccurullo, L. Guerriero AORN dei Colli-Ospedale Monaldi, Napoli, Italy Background: An incisional border hernia on previous Mc Burney for appendectomy is a quite uncommon finding. The fixation of the mesh in these types of hernia is the more challenging problem. Laparoscopy offers a surgical benefit, because of reduced abdominal wall trauma added to all the advantages of minimally invasive surgery. Methods: The authors report a case of a 43-year-old man who presented with a symptomatic incisional border hernia in right iliac fossa. Laparoscopic 3D surgery was performed approaching the defect with a transabdominal pre-peritoneal TAPP procedure. Results: All trocars were placed in an upper position than in standard TAPP technique for inguinal hernia repair: a 10-mm blunt torcar is placed 1 cm above the umbilicus then two 5 mm trocars are placed under direct visualization in right and left flank at the same level. The

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Hernia (2017) 21 (Suppl 2):S139–S207 Flap was raised and the contents of the incisional hernia and properitoneal fat were reduced with the hernial sac. A properitoneal pouch was created exposing the Cooper ligament and the hernia sac was separated from the cord structures. A ULTRAPRO ADVANCE mesh was spread out to cover the Fruchaud’s orifice and the parietal defect (5 cm overlap on each side). The mesh was fixed with a tension free method using fibrin glue. The peritoneal flap was closed with a running autolocking suture. Conclusion: Among the laparoscopic procedures, in this case, TAPP was preferred to IPOM in order to prevent adhesion formation, allowing a better positioning and fixation of the mesh.

31 Treatment of chronic pain and sportsman’s groin O31.1 Pulsed radiofrequency (PRF) and conventional radiofrequency (RF) as minimally invasive treatment options in ACNES: a retrospective analysis of 45 patients R. C. Maatman1,2, M. A. H. Steegers3, J. Kallewaard4, T. M. Heeren-Coumans5, M. R. M. Scheltinga1,2, R. M. H. Roumen1,2 1 Department of Surgery, Ma´xima Medical Center, Veldhoven, The Netherlands, 2SolviMa´x, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Ma´xima Medical Center, Eindhoven, The Netherlands, 3Department of Anaesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands, 4Department of Anaesthesiology, Rijnstate Hospital, Velp, The Netherlands, 5Department of Anaesthesiology, Slingeland Hospital, Doetinchem, The Netherlands Background: Chronic abdominal pain is occasionally due to entrapped intercostal nerves (ACNES, abdominal cutaneous nerve entrapment syndrome). Pulsed Radiofrequency (PRF) and conventional Radiofrequency (RF) are relatively new treatment options for chronic pain syndromes. Evidence regarding their effect in ACNES is lacking. Methods: A cohort of ACNES patients undergoing PRF or RF treatment between January 2014 and December 2015 was retrospectively evaluated. Pain was recorded using a numerical rating scale (NRS, 0 (no pain) to 10 (worst possible)) prior treatment and after 6 weeks. Successful treatment was defined as [50% NRS pain reduction. Patient satisfaction was scored by patient global impression of change (PGIC, 1 very much worse to 7 very much improved). Results: 45 patients were treated (PRF 27, RF 18, 30 women, median age 46 years, range 18–69 years). After 6 weeks, median NRS in the PRF group decreased from 7.0 (range 6.0–7.5) to 4.0 (range 2.0–6.0, p \ 0.001), and in the RF group from 8.0 (range 7.0–9.0) to 4.0 (range 2.0–6.0, p = 0.001). The PGIC score was 4.9 ± 1.8 in PRF group vs. 5.5 ± 1.0 in the RF group. Treatment was successful in 56% (n = 15) of the PRF group and 50% (n = 9) of the RF group. Median effect duration was 4 months (range 2–26) after PRF vs. 5 months (range 2–18) after RF. Conclusion: Both treatment options may be effective for ACNES. PRF remains favorable as it offers pain relief without the nerve tissue destruction associated with RF. A prospective study is currently conducted to confirm the value of PRF in ACNES.

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O31.2 Pulsed radiofrequency (PRF) or anterior neurectomy for anterior cutaneous nerve entrapment syndrome (ACNES): Initial results of a randomized controlled trial R. C. Maatman1,2, M. A. H. Steegers3, P. V. van Eerten1,2, T. C. Lim4, H. J. van den Berg4, S. A. S. van den Heuvel3, O. B. A. Boelens5, M. R. M. Scheltinga1,2, R. M. H. Roumen1,2 1 Department of Surgery, Ma´xima Medical Center, Veldhoven, The Netherlands, 2SolviMa´x, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Ma´xima Medical Center, Eindhoven, The Netherlands, 3Department of Anaesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands, 4Department of Anaesthesiology, Ma´xima Medical Center, Veldhoven, The Netherlands, 5Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands Background: Chronic abdominal pain is occasionally due to entrapped intercostal nerves (anterior cutaneous nerve entrapment syndrome, ACNES). If abdominal wall infiltration using an anesthetic agent is unsuccesful, a neurectomy may be considered. Pulsed Radiofrequency (PRF) applies an electromagnetic field around a nerve possibly leading to pain relief. Limited retrospective evidence suggests that PRF is effective in ACNES. Aim was to determine whether PRF may be used as a minimally invasive alternative treatment in ACNES. Methods: Patients diagnosed with ACNES who temporarily respond to abdominal wall injections are randomized to PRF or neurectomy. Pain was recorded using a numerical rating scale (NRS, 0 (no pain) to 10 (worst possible)) prior treatment and 8 weeks after intervention. Successful treatment was defined as [50% NRS pain reduction. Secondary outcomes are quality of life, satisfaction and analgesics use. If PRF is unsuccessful, ‘‘crossover’’ to neurectomy is allowed. Results: By October 2016, data of 42 randomized patients (dropout, n = 3) were available (21 PRF, 18 neurectomy, 30 women, median age 43 years, range 18–69 years). Median NRS score in the PRF group dropped from 6.0 (range 2.0–8.0) to 4.5 (range 0–8.0, p \ 0.05) and in the neurectomy group from 6.3 (range 3.3–8.0) to 3.3 (range 0–9.0, p = 0.003). Treatment was successful in 35% (7/20) of the PRF group and 53% (10/19) of the neurectomy group. Conclusion: The initial results of this first randomized trial point towards a potential role of PRF in ACNES. The trial will be closed (n = 66 patients) towards the end of 2017.

O31.3 Survey for postoperative pain after inguinal hernia repair in Japanese patients: a questionnaire study at a single institution K. Okura, M. Narita, H. Okada, K. Goto, S. Jikihara, M. Saji, R. Matsusue, H. Hata, T. Yamaguchi, T. Otani, I. Ikai Department of Surgery, Kyoto Medical Center, Kyoto, Japan Background: Postoperative chronic pain is one of the major concerns after inguinal hernia repair, but its rate in Japanese population remains unclear. The aim of this study was to evaluate postoperative chronic pain after inguinal hernia repair using questionnaire and to recommend how we address it.

S191 Methods: The study population comprised 592 adult patients (617 lesions) older than age 18 years who underwent inguinal hernia repair between April 2010 and May 2016. Self-administered questionnaires were mailed to these patients at 3 months or later after surgery to ask whether they had postoperative pain at 3 months after surgery. Results: The response rate to the first questionnaire was 72.8% (n = 449 lesions: 426 patients). Pain in the inguinal area at 3 months after surgery was reported by 31.0% (n = 139 lesions: 132 patients). Patients younger than 75 years and patients who had severe pain at the early postoperative period had significantly higher incidence of pain. There were no differences in the incidence of pain among surgical procedures or among anesthetic methods. In 111 patients (118 lesions), severe pain at the early postoperative continued at 3 months after surgery. Eight (8 lesions: 6.8%) of 111 patients required medical or surgical treatment due to persistent severe pain. Conclusion: Chronic pain is not rare complication. Most patients get relief from pain spontaneously within a few months, while some patients would require further treatment. Patients with severe pain at the early postoperative period should be monitored at least for 3 months after surgery.

O31.4 Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain R. C. Maatman1,2, N. E. Papen-Botterhuis1, M. R. M. Scheltinga1,2, R. M. H. Roumen1,2 1 Department of Surgery, Ma´xima Medical Center, Veldhoven, The Netherlands, 2SolviMa´x, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Ma´xima Medical Center, Eindhoven, The Netherlands Background: Chronic abdominal pain is occasionally due to entrapped terminal endings of intercostal nerves (ACNES, abdominal cutaneous nerve entrapment syndrome). Spontaneous neuropathic flank pain is possibly also caused by involvement of intercostal nerves. Aim is to describe a series of patients with flank pain due to nerve entrapment and to increase awareness for an unknown condition coined Lateral Cutaneous Nerve Entrapment Syndrome (LACNES). Methods: Patients possibly having LACNES (constant area of flank tenderness, small point of maximal pain, locoregional altered skin sensation) presenting between January 2007 and May 2016 received a diagnostic 5–10 mL 1% lidocaine injection. Pain levels were recorded using a numerical rating scale (0, no pain to 10, worst possible). A [50% pain reduction was defined as success. Long term effect of injections and alternative therapies was determined using a satisfaction scale (1, very satisfied, no pain—5, pain worse). Results: 30 patients (21 women, median age 53, range 18–73) were diagnosed with LACNES. Pain following one injection dropped from 6.9 ± 1.5 to 2.4 ± 1.9 (mean, n = 22, P \ 0.001) leading to an 81% immediate success rate. Injection therapy was successful in 16 (pain free n = 7, pain acceptable, n = 9; median 47 months follow-up). The remaining 14 patients received (minimally invasive) visceral surgery (n = 5) or other treatments (medication or manual therapy or PRF, n = 9). Overall satisfaction with treatment (scale 1 or 2) was attained in 79%.

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S192 Conclusion: LACNES should be considered for chronic flank pain. Injection therapy is long term effective in more than half of the patients.

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O31.7 Justification of neurectomy as routine procedure in sports inguinal hernia D. Dabic, V. Perunicic Surgery department,General Hospital Cacak, Cacak, Serbia

O31.5 Algorithm of diagnosis of sportsmen’s groin R. Lorenz1, J. Kru¨ger2, J. Schro¨der3 1 Berlin, Germany, 2Sportchirurgische Praxis, Berlin, Germany, 3 Charite Mitte/Rudolf Virchow Kliniken, Berlin, Germany Background: Sportsmens Hernia was one of the most missunderstood diagnosis. In the last decade took place some consensus meetings regarding this diagnosis and controversial therapies. They gave an more detailed insight. Methods: A group of 5 dedicated hip orthopedic surgeons and 6 hernia surgeons have met in Hamburg on February 9th in Hamburg do develop an algorithm for the diagnosis of the sportsmens groin and the femoro-acetabular impingement. Results: A huge impact for the right diagnosis has already a detailed medical history and the examination not only of groin and hip of the patient. Additional apparative examinations are needed in case of not cleear diagnosis. We could get an agreement, when and why an indication for an operation of the hip or groin was given. Conclusion:

O31.6 Laparoscopic incisional and ventral hernia repair with TAP block M. Nardi, P. Millo, R. Brachet Contul, R. Lorusso, A. Usai, M. Grivon, F. Persico, S. Razzi USL Valle D’aosta-Regional Hospital, Aosta, Italy Background: The first aim of this study is to describe our experience in order to establish the safety and efficacy of LIVHR using composite mesh and to identifie the factors related to the surgical technique that influence the risk of recurrence. The second aim is to analyse the effectiveness of Transversus Abdominis Plane Block (T.A.P. Block) in term to reduction of postoperative abdominal pain. Methods: Between Jan 2007 and Jan 2016, 227 patients were subjected to repair the hernia by laparoscopy using a composite mesh. In 88 patient (32%) we performed a T.A.P. block. The type and size of surgical defects, mean operative time, length of hospital stay, morbidity, mortality, rate of recurrence at 5 years follow-up were analysed. Results: We performed 132 (58%) intervention for incisional hernias and 95 (42%) for primary wall hernias. Mean age was 62.5 years. The mean size of defect was 3.5 cm, mean BMI was 30 kg/m2. The mean operative time was 48 min., conversion rate was 2.7%. The mean length of hospital stay was 4 days (but 2 days in patient with T.A.P. block). Overall morbidity was 12.3%. At 5-year follow-up we observed 19 (9%) hernia recurrences. Conclusion: LIVHR is a safe procedure; the fixation of the mesh with a double crown of absorbable tacks and 4 transparietal points, with an overlap at least 5 cm, turns out to be very safe in terms of prevention of recurrence. The T.A.P. block can better control the post-operative pain and reduce the average hospital stay.

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Background: Introducing a diversity of tehnological achievements and application of new prosthetic materials opened a new chapter in hernia surgery. One of the biggest problem in hernia surgery is chronic pain. Methods: From January 2010 till March 2016, we performed 29 Lichtenstein hernioplasty in group of young sportsman. Most of them were football players. We used monofilament polypropylene lightweight mesh 8 9 15 cm (Hermesh 8Ò). Local anaesthesia was used in every single case. Results: 7 (24.114%) patients were operated without neurectomy, double neurectomy has been done on 14 (48.28%) and triple neurectomy on 8 (27.59%) patients.Average age of the patients was 27.7 years (19–33).Average duration of the operation was 54.6 min (38–65).Average hospitalisation was 2.2 h (2–3). In 36 month average follow up period 3 (10.34%) patients without neurectomy had a strong short term pain in a case of extreme effort. None of the patients with neurectomy had any kind of pain. 4 (13.79%) patients in neurectomy group had moderate feeling of paresthesia 6 month after operation. One (3.45%) patient had seroma. Conclusion: From my point of view,neurectomy in combination with light-weight mesh is a useful and justifiable procedure to avoid possibility of chronic pain in sports inguinal hernia surgery.

O31.8 Sport hernia. Which is the roll of ultrasound? O. Santilli, H. Santilli, N. Nardelli, H. Etchepare, J. Videla Centro de patologia herniaria, Buenos aires, Argentina Background: Athletic Pubalgia is a syndrome characterized by chronic groin pain during sports activities.There is consensus that imbalanced vector forces between abdominal and adductors muscles, produce micro myotendinous tears initiating the aductor tendinosis and the sports hernia, which is an inguinal posterior wall disruption. Ultrasound has helped to recognize these lesions, but it does not by itself make a correct diagnosis.The purpose of this study is to show the result of multidisciplinary evaluation and treatment done to patients that consulted for athletic pubalgia with ultrasounds signs of sports hernia. Methods: A group of patients with athletic pubalgia and ultrasound findings of sports hernia were included, during the period 2011–2016. Ultrasound imaging of inguinal soft tissues determined the presence of inguinal disruption or some sign of sport hernia. The patients were studied systematically by physical therapist, orthopedic surgeons, abdominal wall surgeons and ultrasound medical specialist. Results: 3863 athletes were assessed with athletic pubalgia and ultrasound sports hernia findings. After multidisciplinary evaluation, the final diagnoses were adductor tendinopathy in 2704 cases. Sports hernias were confirmed in 1004 patients. Femoroacetabular impingement was found in 155 patients. The tendinopaties, were treated with corrective exercises individualized for each patient. We use Microelectrolysis in 220 patients and we did 16 tenotomies. 1004 Tapp hernioplasties were done in order to treat their sports hernia followed by physical therapy rehabilitation.

Hernia (2017) 21 (Suppl 2):S139–S207 Conclusion: We believe that multidisciplinary intervention is to detect functional and organic causes responsible for Athletic Pubalgia. Isolated ultrasound finding does not lead to accurate diagnosis.

O31.9 When can I return to sport before Tapp hernioplasty? O. Santilli, H. Santilli, N. Nardelli, D. Tripoloni, A. Greco, M. Estevez Centro de patologia herniaria, Buenos aires, Argentina Background: Early rehabilitation managed by physical therapists is advantageous throughout postoperative period or during recovery for musculoskeletal injuries in athletes but its effects are unknown in postoperative period of inguinal hernia repair of individuals who do not play sports. The present study aims to analyze the results of a sports rehabilitation program applied to non-athlete patients underwent to TAPP hernioplasty. Methods: Patients underwent to TAPP hernioplasty were invited to perform the first phase of a sport rehabilitation program. Postsurgery complications, hernia recurrence, pain intensity, start time and duration for first phase of the rehabilitation plan and timing of return to work were evaluated. Patients underwent to TAPP hernioplasty. Results: We repaired 296 hernias, 213 indirect, 71 direct, 9 mixed and 3 femoral; 8 were inguinal recurrences of repairs performed by anterior approach. No complications occurred during or immediately after surgery so that all patients were discharged during the operative day. 4 onfalitis, 3 haematoma, 9 self-limiting seroma and one umbilical incisional hernia were recorded. One patient had recurrence 14 months after a direct hernia repair. They starting the exercises at 3 days after surgery and reached the goals at 7 days. Conclusion: Patients who joined the sports rehabilitation program did not suffer more severe pain and returned to their work sooner. Application of a sports rehabilitation program does not increase the rates of recurrences and complications and may speed up the return to full physical activity in non-athletes patients.

O31.10 Why failed surgery for sportsman’s groin prevents return to play J. F. W. Garvey Groin Pain Clinic, Sydney NSW 2000, Australia Background: The published success rate for groin reconstruction for Sportsman’s Groin Hernia is between 87 and 97%. However a significant number of players do not return to their pre-injury level of performance after groin surgery and present a continuing challenge. Methods: Players who failed to return to their pre-injury level of performance over a 20 year period between 1990 and 2009 were reviewed and/or re-imaged and yielded the following outcomes. Results: Incorrect pre-operative diagnosis and inadequate surgical reconstruction Unrecognised and uncorrected pelvic instability including pubic symphysis diastasis. Persisting conjoint insertion tendonitis and suture-induced tendonitis. Adductor muscle tear complicating tenotomy and recurrent Adductor tendinopathy. Persisting

S193 neuralgia including ilio-inguinal, obturator and lateral femoral cutaneous nerves. Hip joint: Femoro-acetabular impingement and labral tear. Pubic bone: Osteitis pubis and apophysitis in younger players. Surgical errors: Overtight superficial inguinal ring closure and suture impingement of nerve. Mesh inguinodynia. Lack of compliance with Specialist groin physiotherapy postoperatively. Conclusion: Meticulous pre-operative diagnosis with plain radiography, ultrasound and MRI scan together with a team approach including Physiotherapist, Podiatrist, Radiologist and Sports Physician is essential to achieve optimal outcome. All players should be reviewed 12 months post-operatively (or earlier if symptomatic after 3 months) and if less than 90% fit, re-studied by physical examination and diagnostic imaging

33 Experimental basics in hernia surgery O33.2 The presence of an aortic abdominal aneurysm is associated with an altered response of macrophages to meshes in vitro C. L. Sparreboom1, G. S. A. Boersema1, L. Utomo1, Y. Bayon2, N. Kops1, A. A. E. A. de Smet3, J. F. Lange1, Y. M. BastiaansenJenniskens1 1 Erasmus Medical University Rotterdam, Rotterdam, The Netherlands, 2Medtronic, Trevoux, France, 3Maasstad Ziekenhuis, Rotterdam, The Netherlands Background: Laparotomy for AAA (abdominal aortic aneurysm) is a risk factor for incisional hernia often treated with primary mesh augmentation. A well-balanced foreign body reaction driven by macrophages is required for integration of the mesh. The aim of this study was to examine whether macrophages of AAA patients have a different acute response to mesh materials in vitro and whether monocyte subsets as precursors of macrophages are different in AAA patients. Methods: Monocytes were isolated from peripheral blood of AAA patients and gender matched controls, and seeded onto polypropylene (PP), polyethylene terephthalate multifilament (mPET), polyethylene terephthalate monofilament (PET), and polylactic acid (PLA). The IL6, CCL18 and IL1RA production of macrophages was determined as a measure of the inflammatory response. Monocyte subsets were determined based on CD14 and CD16 cell surface expression. Results: AAA affected the acute response of macrophages on different materials; more IL6 production in response to PP and less IL1RA production in response to mPET in comparison with macrophages from control subjects. AAA also resulted in larger differences between the responses each material elicited. Intermediate CD14++ CD16+ monocytes were more present in peripheral blood of AAA patients than in controls. Percentages of the three monocyte subsets correlated with how the macrophages responded in culture. Conclusion: The presence of AAA is associated with an altered response of macrophages to meshes in vitro and this response is related to the phenotype of monocytes in the peripheral blood. Therefore, the clinical impact of AAA on the foreign body response needs further exploration.

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O33.3 Biomechanical parameters for abdominal wall closure: An experimental study R. Villalobos1, M. Mias1, M. Nogue´s2, J. Roca2, C. Gas1, M. Comelles2, A. Escartin1, J. J. Olsina1 1 Arnau de Vilanova University Hospital, Lleida, Spain, 2Lleida University, Lleida, Spain Background: Tensile forces when closing abdominal wall after midline laparotomy have a very important influence on the development of an incisional hernia. There’re not sufficient data about what are the suitable forces depending on wound edges biomechanical characteristics. Methods: 27 female pigs divided in 3 groups (20, 50, 100 kg) were included. Each group of 9 pigs were at the same time divided in 3 depending on the distance from the edge to the stitch (5, 10, 15 mm). 3 basic biomechanical parameters were analysed: tensile forces (Tf), fascia thickness (t) and wound amplitude between edges (A). Tf and A were measured with a digital dynamometer and t with a digital micrometre. A midline supra-infraumbilical laparotomy was made to each pig and a template was used for measure. Results: Tensile forces along midline laparotomy are quite variable and the highest ones were observed at the supraumbilical area. The maximum Tf at the supraumbilical area were about 60–100% higher than the minimum ones observed at the imfraumbilical area.Tf were greater in the subgroups of 5 mm stitch to fascia edge than the others. Fascia thickness increases progressively from infraumbilical to supraumbilical. Amplitude and Tf increase from infraumbilical to umbilical area. Conclusion: Tf increase along infraumbilical up to umbilical area showing a correlation with t and A while remain high toward to supraumbilical area probably due to largest fascia thickness and to ribs traction. Knowledge of tensile force characteristics can help to a better abdominal closure.

O33.5 Biomechanical analysis of intraperitoneal repair of incisional hernia with a surgical mesh N. Baldan1,2, S. Merigliano3,2, P. G. Pavan4,2, P. Pachera4,2, S. Todros4,2, A. N. Natali4,2 1 Padova General Hospital, Padova, Italy, 2Centre for Mechanics of Biological Materials, University of Padova, Padova, Italy, 3 Department of Oncologic and Gastroenterologic Surgical Sciences, University of Padova, Padova, Italy, 4Department of Industrial Engineering, University of Padova, Padova, Italy Background: Incisional hernia repair can lead to complications, as recurrence, pain and discomfort. The selection of a suitable surgical mesh is still a debated task and represents an important term for surgical practice reliability. This work aims at evaluating mechanical aspects of intraperitoneal repair through computational approach, comparing the response of the healthy and repaired abdominal wall. The analysis of mesh interaction with abdominal tissues can provide an insight on its biomechanical compatibility. Methods: A virtual solid model of abdominal wall is developed from computed tomography images. The mechanical behavior of muscular and fascial tissues is described by specific constitutive formulations and parameters, based on data from experimental tests on human tissues. A hernia defect, with size and position according to clinical evidence, is introduced in linea alba. The defect is virtually repaired with different prostheses, modelled according to their mechanical characteristics with an isotropic or anisotropic nonlinear formulation. Results: Numerical analyses are performed considering a uniform intraabdominal pressure corresponding to different daily tasks. The

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Hernia (2017) 21 (Suppl 2):S139–S207 comparison of numerical results in physiological conditions and after repair highlights a significant increase of overall stiffness after surgery as a direct consequence of mesh insertion. Conclusion: The mechanical behavior of the abdominal wall after hernia repair is analyzed through a computational biomechanics approach, in direct correlation with surgical practice. This method can be exploited to investigate operational aspects, as mesh mechanical characteristics and tackling devices, offering a support for a biomechanical evaluation of surgical procedures efficacy and reliability correlated with a patient-specific pre-surgery approach.

O33.6 Study of sutureless fixation techniques using lightweight surgical meshes of different polymers in experimental study G. Khachatrian, M. Anurov, S. Titkova, A. Oettinger, M. Polivoda RNRMU, Moscow, Russian Federation Background: In recent years increases the number of publications on postoperative pain after hernioplasty. Studies show correlation between fixation and postoperative pain. More surgeons prefer sutureless techniques. The purpose of study is to evaluate the sutureless techniques: glue, self-gripping meshes and no fixation on a rat model. Methods: In 36 male rats two symmetrical lateral musculo-fascial defects were made in the anterior abdominal wall under general anesthesia. There was two type of polymer used: polipropilene (PP) and polyester (PET). In the 1st group (n = 12) defects were covered by self-gripping meshes. 2nd—glue fixation (n-butyl-2-cyanoacrylate) was used. 3rd—no fixation. After 5 days, mesh dislocation was evaluated. The fixation strength was determined by a sliding rupture test. Histological evaluation has been done in 5, 30 and 180 days with haematoxylin-eosin staining. Results: Dislocations were detected in the 3rd group. The strength of fixation in 3rd group was 3.1 ± 1.2 N (PP) and 5.8 ± 2.6 N (PET), was significantly lower than the 1st group [13.98 ± 3.0 N(PP), 23.6 ± 5.8 N (PET)] (P \ 0.05) and 2nd—[17.2 ± 5.1 N (PP), 20.5 ± 7.04 N (PET)] (P \ 0.05). The strength of fixation in all groups was PET [ PP. Histological study show no significant differences on the 5th day. In 30, 180 days inflammation decreased in all groups, but was significant high in 2nd group, between 1st and 3rd group no difference. Conclusion: Sutureless methods show high strength of fixation. Better results in the PET group may be related to the surface properties of fibers. Self-gripping mesh have high strength of fixation and low inflammation reaction in the long term. Sutureless techniques are good alternative for postoperative pain prevention.

34 Novel approaches for abdominal wall reconstruction O34.3 Don’t have a robot? Do it lap! I. Belyansky, A. Weltz Anne Arundel Medical Center, Annapolis, MD, USA Background: Despite numerous advantages of the robotic platforms integration in complex abdominal wall reconstruction (AWR), high capital costs still limit its use in some centers. The aim of this study is

Hernia (2017) 21 (Suppl 2):S139–S207 to discuss an alternative approach to complex ventral and incisional hernias; the enhanced view totally extraperitoneal approach with laparoscopic transversus abdominis release (eTEP TAR). Methods: A retrospective review of prospectively maintained consecutive complex ventral and incisional hernia cases performed at Anne Arundel Medical Center utilizing eTEP TAR between August 2015 and February 2017 was conducted. Patient demographics, hernia characteristics, operative details and perioperative complications were recorded. Results: Forty-three patients with mean age, BMI and ASA of 57.7 years, 31.6 kg/m2 and 2.4 respectively were included. Twentysix percent of patients had a prior ventral or incisional hernia repair. An average mesh area of 634.4 cm2 was used for an average defect area of 132.1 cm2. Mean operative time, blood loss and length of hospital stay were 279.0 min, 63.6 mL and 1.6 days, respectively. There were no conversions to open procedure. There was one seroma that required IR drainage. There were no readmissions within 30 days and no hernia recurrences were noted at mean follow up of 107 ± 95.9 days. Conclusion: eTEP TAR procedure offers the benefits of open surgery where large mesh is placed in the retromuscular position, while harnessing the benefits of minimally invasive surgery associated with low wound morbidity, shorter length of stay and reduced costs compared to robotics.

35 Abdominal wall repair avoiding intraperitoneal mesh with a minimally invasive approach? O35.1 MILOS W. Reinpold1,2 1 Hamburg, Germany, 2Gross Sand Hospital Hamburg, Hamburg, Germany Background: In order to minimize complications of the existing open and laparoscopic techniques we developed the endoscopic assisted Mini- and Less Open Sublay (MILOS) technique. Methods: The operation is performed transhernially with light-armed laparoscopic instruments either under direct vision or endoscopic view, while the abdominal wall is circumferentially elevated with retractors. The light source is a specifically designed light tube (Endotorch, TM Wolf Company). Every MILOS operation can be converted to standard total extraperitoneal gas endoscopy (ventral hernia TEP) once an extraperitoneal space of at least 8 cm has been created (endoscopically assisted MILOS operation). Matched pair analysis of incisional hernia operations comparing the results of the novel MILOS operation with laparoscopic IPOM and open sublay repair of other institutions participating in the German Hernia registry was performed. Results: For the comparison of 615 MILOS operations with lap. IPOM operations and open sublay repair propensity score matching was possible with 541 (88.0%) and 576 (93.7%) pairs of patients, respectively. The one year follow-up rate in the MILOS cohort was 97%. The MILOS repair is associated with significantly fewer postoperative complications, reoperations, general complications, recurrences and chronic pain after one year at rest and during physical activities. There were significantly more infections after the open sublay operation. Conclusion: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular/ preperitoneal meshes with very low morbidity. The technique is

S195 reliable, reproducible, cost effective, easy to standardize and combines the advantages of the open sublay and lap. IPOM repair.

O35.2 eMILOS R. Bittner, J. Schwarz Hernia Center Rottenburg, Rottenburg, Germany Background: Primary and secondary ventral hernias of the abdominal wall are very common diseases, however the ideal operative treatment is not yet found. Methods: In order to avoid the disadvantages of open sublay repair and IPOM technique we developed an endoscopic technique (EMILOS) which allows a complete dissection of the retromuscular space for placement of a huge mesh to reinforce the whole anterior abdominal wall, but performing a 5 cm skin incision only. Results: From June 2015 to January 2017—a total of 50 patients were operated using the MILOS concept—9 patients underwent the original MILOS technique and 41 patients had the EMILOS operation. The operative steps of this novel endoscopic variation, the EMILOS procedure (Endoscopic Mini/Less Open Sublay)—are described in detail. The average skin incision was 5.1 cm (3–8)—mean operative time was 160 min (90–255). In 38 patients the size of the mesh was 30 9 20 cm, in two patients 30 9 16 cm, in one patient 15 9 15 cm. The average hospital stay was 3.2 days. The median pain score (VAS) under physical stress (e.g. climbing stairs) was 2.7. Conclusion: The first results of the EMILOS operation are promising. The technique is standardized, reproducible, cost-effective and allows to place a large mesh into the retromuscular position, but avoids a severe trauma to the abdominal wall and the transabdominal route as well.

O35.3 eTEP Rives J. Daes1, I. Belyasky2 1 Clinica Portoazul, Barranquilla, Colombia, 2Anne Arundel Medical Center, Annapolis, MD, USA The extended-view totally extraperitoneal (eTEP) technique was originally described for inguinal hernia repair to facilitate the extraperitoneal approach during surgical training. Soon it was evident that the eTEP approach could also be used to repair more complex inguinal hernias as well as ventral and lumbar hernias. The eTEP Rives/TAR techniques in theory represent the summit of all advances described for ventral hernia repair, such as the closing of defects and placing meshes retromuscularly with minimal fixation, with the additional advantage of being minimally invasive and totally extraperitoneal. The eTEP Rives technique is indicated for noncomplicated central ventral hernias with or without diastasis recti; experienced surgeons can also use it for more complex cases. The technique involves creating an extraperitoneal space in one or both rectus abdominis compartments, connecting both spaces by crossing the midline, suturing the posterior aponeurosis closed, primarily closing the anterior aponeurosis using barbed suture, and placing a mesh retromuscularly with minimal fixation. Sometimes lateral extension as a TAR is required to accommodate a larger mesh or to free tension from the defect closure. Our initial multi-center evaluation of the eTEP technique for ventral and incisional hernias included patients with a mean defect area of 132.1 cm2; 34% of patients had previous ventral or incisional hernia, and 50% required a TAR extension. Complications were

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S196 negligible, mean hospital stay was 1.8 days, and there were no readmissions within 30 days and no hernia recurrence at a mean follow-up of 107 days. The eTEP approach is feasible, safe and effective.

O35.5 Different indications: different techniques J. F. Kukleta NetworkHernia, Klinik Im Park, Hirslanden Group, Zurich, Switzerland Background: The introduction of prosthetic mesh in the repair of abdominal wall defects improved markedly recurrence rate. The open sublay repair became a standard. The extensive dissection necessary is associated with substantial number of soft-tissue complications with/without mesh removal. To avoid this fact the endoscopic IPOM (intraperitoneal onlay mesh) was proposed. The nature of IPOM is a bridging repair with its classical limitations: not repairing the functional deficit of displaced abdominal muscles, indispensable mesh fixation causes severe acute pain, elevated material cost of fixation devices and composite meshes and the intraperitoneal mesh (IM) position with known possible consequences. The closure of the hernia defect(s) and the augmentation IPOM improved functional aspect and solidity of repair (IPOM Plus). Nevertheless the IM remained. Methods: The consequence is to appreciate advantages of both approaches and place the mesh outside of abdominal cavity with minimal invasive techniques. The extraperitoneal mesh placement reduces the extent of fixation/pain and allows use of standard mesh. The cost saving of this new concept is not the primary goal, but a positive bonus. The price to be paid is longer operating time, advanced endoscopic techniques, higher requirement on technical skills and hidden risks as expected when introducing new techniques. Conclusion: Abdominal wall hernias represent various etiologic entities requiring different strategies to face them. The onlay-, retrorectus- or extraperitoneal mesh deployment is utilized for different hernia conditions with variable advantages and different limitations. Which technique is suitable for which pathology will be the important answer in the upcoming years.

36 Video session: Complex situations in hernia repair V36.1 Pneumoperitoneum, TAR and panniculectomy for abdominal wall reconstruction in a loss of domain incisional hernia M. Garcia-Urena, L. Bla´zquez, J. Lo´pez-Monclu´s, P. Lo´pez, A. Robı´n, E. Jime´nez, A. Cruz, C. San Miguel, E. Gonza´lez, D. Melero, R. Becerra, A. Aguilera, A. Moreno, A. Galva´n, N. Palencia, C. Jime´nez Henares University Hospital, Coslada, Spain Background: Loss of domain incisional hernias are a real challenge. The combination of a good preoperative strategy (preoperative

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Hernia (2017) 21 (Suppl 2):S139–S207 neumoperitoneum) and surgical technique (TAR and dermolipectomy) gives a great opportunity to solve very complex cases. Methods: We present a 72 years old obese frail woman who was previously operated of morbid obesity in 2003. Three years later was operated urgently for intestinal obstruction due to incarcerated incisional hernia. A recurrent incisional hernia developed and two episodes of intestinal obstruction were solved conservatively. A preoperative neumoperitoneum was scheduled 10 days before. The surgical approach was made through a bi-iliac incision in order to add a panniculectomy. An incisional hernia of almost the entire anterior abdomen was found under the previous onlay mesh. A bilateral TAR according was made. The abdominal viscera were reintroduced in the abdomen after the release of intense adhesions to the colon. Absorbable mesh was used as reinforcement of posterior layer and support the ‘‘taco’’ configuration of a big 50 9 50 cm polypropylene mesh fixed inferiorly to both Cooper ligaments and superiorly with transcostal stitches. No lateral fixation was made. A great bridge in the midline was left but covered with the previous onlay mesh. Results: The patient was discharged on the 14 postoperative day. A small anterior seroma was successfully treated with simple aspiration in an outpatient basis. Conclusion: In complex huge incisional hernias, a right preoperative strategy, posterior components separation and panniculectomy are appropriate methods to achieve a complete reconstruction of the abdominal wall.

V36.2 Progressive pneumoperitoneum and component separation for incisional hernia with loss of domain C. Hoyuela, M. Juvany, F. Carvajal, M. Trias Hospital Plato´, Barcelona, Spain Background: The objective is to describe the technical aspects of the sequential treatment of a huge incisional hernia with loss of domain using the preoperative progressive pneumoperitoneum (PPPn: Gon˜i-Moreno technique) following by an anterior component separation technique as a repair of the abdominal wall hernia. Methods: A 75-years-old woman presented with a 25-years evolution huge incisional hernia with loss of domain secondary to a midline laparotomy. The abdominal wall defect was 25 9 20 cm. A sequential treatment was planned. First step was to perform a PPPn during 4 weeks under clinical and radiological monitoring. The second step was the surgical repair performing a modified anterior component separation technique (level I and II) and a dermolipectomy. Results: The abdominal cavity was inflated with 14 L of air in total (500–1200 per day during 4 weeks) and the surgical procedure was scheduled 15 days after. Operating time: 180 min; hospital stay: 5 days. There were no postoperative complications. The patient remains asymptomatic and without recurrence 36 months after the operation. Conclusion: The PPPn allows the necessary preoperative physiological adaptation of the patient (abdominal capacity and pulmonary function) prior to the surgical repair of a giant incisional hernia with loss of domain, avoiding further complications secondary to an excessive abdominal pressure.

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V36.3 Management of a very complex eventration with loss of domain using BT-A and PPP and posterior components separation-tranverse abdomens release and bridging A. Torregrosa Gallud, P. Garcia Pastor, R. Jimenez Rosellon, C. Muniesa Gallardo, J. Bueno Lledo´, S. Bonafe Diana, J. Iserte Hernandez, E. Garcia Granero, E. Garcia Granero La Fe University and Politechnic Hospital, Valencia, Spain Background: We present this technique in video; to show the possibility of reconstruct a very complex case with more than 60% of the abdominal contents lying outside the cavity. Methods: We present this patient 63 years old, their morbidity: obesity with IMC more than 33, smoker, sleep apnea, Hypertension, alcohol consumer, hyperuricemia, epilepsy,. He was operated of Colon ca´ncer and has a colostomy, was operated of aortic stenosis. The preoperative techniques like CT scan, BTA and PPP. Also the operative technique. Results: We present the case, the preoperative techniques as BTA, CT Scan, PPP and operative technique were transverse abdomens release was possible and even to close the patient. Conclusion: This techniques provides the possibility of solve complex ventral hernia cases with loss of domain.

V36.4 Bone anchor mesh fixation for complex incisional hernia repair E. Delgado Oliver, J. Espert, M. Ribal, M. Ribal, G. Dı´az-DelGobbo, R. Corcelles, B. Martin, A. Lacy Hospital Clinic, Barcelona, Spain Background: Large suprapubic hernias are difficult to repair and are associated with high-recurrence rates owing to difficulty in obtaining substantive overlap and especially mesh fixation due to bone being a margin of the hernia. Corkscrew suture anchors have been used to attach prosthetic material to bony surfaces and can be used in the repair of these hernias where suture fixation was impossible. We report a case where in a large incisional hernia was repaired by bone anchor mesh fixation. Methods: We report the case of a 58-year-old men underwent Cystectomy + Neobladder for T3N0M0 invasive bladder tumor after initial treatment with neoadjuvant chemoradiotherapy, nine years ago. The patient developed incisional hernia, has relapsed three times. Subsequently present an important functional limitation in relation to extensive scrotal sac with half of intra-abdominal volume. The hernia was repaired by mesh fixated directly to the pubis with corkscrew suture anchors. Results: The surgery procedure was completed successfully. The mesh overlapped all hernial margins nicely and was anchored firmly. Postoperative course was uneventful, without any complications. During the follow-up period of 10 month, there is no recurrent evidence of the hernia. Conclusion: The placement of corkscrew suture anchors represents an effective approach for repair of large suprapubic hernias. The anchors facilitate the long-term fixation of mesh despite the lack of fascia in this area. This technique is a ideal approach for repair of these challenging hernias.

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V36.5 Complex incisional hernia repair J. Pinto, M. Delgado, C. Antunes, M. Sousa, S. Ribas Hospital de Braga, Braga, Portugal Background: The treatment of complex abdominal wall hernias is a surgical challenge and a tailored approach paradigm. The recurrence rate remains high and increases cumulatively with each failed correction attempt. There is no standard surgical treatment. Since 1990, a number of component separation techniques (TSC) have been described and more recently the posterior TSC with transverse abdominal (TAR) release. Our goal is to demonstrate the application of this technique in a complex and successfull case with a particularly personalized approach. Methods: Case-report with video and photographic records. Results: Our report concerns a 54-year-old male patient with history of Hartmann’s surgery for Hynchey IV diverticulitis in January 2012 and Intestinal transit reconstitutionof in March 2012. Subsequently, he developed a massive midline incisional hernia, with increased difficult correction by the manipulation of temporary colostomy area. The correction in May 2015 involved the separation of unilateral components with transverse abdominal release and, thus, it was possible to perform surgery, applying a self-adhesive prothesis, without any occurrences. The postoperative period was uneventful, and the patient was discharged on the fourth postoperative day, with no evidence of complications or relapse to date. Conclusion: The posterior TSC is a simultaneous anatomical and functional surgery. It increases the abdominal circumference by mobilizing the muscular layers of the abdominal wall which allows the reconstruction of large and often complex hernias. Its variant with TAR, adapted to the patient’s reality, allows minimizing possible complications of the traditional technique, combining optimal results, as documented in the case-report.

V36.6 Laparoscopic transabdominal repair ofincarcerated recurrent inguinal hernia T. Lubrano, M. E. Allaix, C. Giaccone, M. Morino Department of Surgical Sciences, University of Torino, Torino, Italy Background: Repair of a incarcerated inguinal hernia is a challenging procedure. The indications for a laparoscopic approach is under debate. Methods: A 77-year-old man presented with acute abdomen secondary to recurrent incarcerated right inguinal hernia. The patient underwent a laparoscopic transabdominal properitoneal inguinal hernia repair. Results: Three trocars were used. After insertion of the camera, the incarcerated ileal limb in the right inguinal canal was detected. No free liquid was found in the abdomen. Several ineffective attemps to reduce the small bowel into the abdominal cavity were performed. The operation started with the incision of the peritoneum laterally to the inferior epigastric vessels. The dissection proceeded between the peritoneum and the trasversalis fascia. The peritoneal flap was then mobilized extending laterally to the anterior superior iliac spine and medially to the ipsilateral medial umbilical fold. The properitoneal plane was dissected leaving the fatty tissue against the abdominal wall. After a prolonged dissection, the inguinal ring was incised to obtain reduction of the incarcerated

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S198 bowel. The bowel presented signs of ischemia with no evidence of perforation. After 20 min, the bowel ischemia significantly improved. A macroporous mesh was then placed with no fixation, the peritoneal flap was closed and the small bowel checked once more to rule out any sign of late perforation. The postoperative course was uneventful. Conclusion: The laparoscopic approach to incarcerated inguinal hernia allows to perform the reduction under direct visualization and to inspect the incarcerated bowel at the end of procedure, limiting the need for bowel resection.

V36.7 Laparoscopic retromuscular repair of a recurrent midline incisional hernia in a high risk patient J. Lopez-Monclus1, J. L. Lucena1, J. Serrano1, M. D. Chaparro1, A. Pueyo1, P. Calvo1, R. Bennazar1, J. Mun˜oz1, L. A. Blazquez2, M. A. Garcia-Uren˜a2 1 Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain, 2 Henares University Hospital, Madrid, Spain Background: Laparoscopic approach of medium size midline incisional hernias may offer a benefit compared with open approach in patients with high risk of local complications. We present a video showing de feasibility of a laparoscopic retromuscular repair with a dual-sided polypropylene mesh. Methods: 65-Years-old male with a recurrent M3 incisional hernia after a supraponeurotic repair 3 years before. The defect size measured in the CT scan was 30 9 60 mm. The patient had diabetes mellitus, was an active smoker and his BMI was 34.9. The calculated CeDAR score was 47% risk of complications. A laparoscopic retromuscular repair was proposed. Six trocars were placed. After reduction of the hernia sac content, full dissection of both retromuscular spaces was performed, reaching the semilunaris line limit in both sides and the xiphoid process and the retropubic space as the cranial and caudal limits. A 20 9 30 cm dual sided polypropylene mesh (reticulated and laminar polypropylene sides) was placed in the dissected space. The mesh was fixed with absorbable tackers in the cardinal points, and both posterior rectus sheets were fixed to the mesh in the medial border with absorbable tackers. The exposed intraperitoneal mesh gap was of 3 9 9 cm. Results: No complications took place in the postoperative period, and the patient was discharged in the second po day. Conclusion: Laparoscopic retromuscular repair of midline incisional hernias is feasible, with the theoretical adventage of a better mesh integration in this position and less intraperitoneal mesh exposition.

V36.8 Small bowel obstruction as a possible complication for endoscopic Rives-Stoppa procedure V. Radu, M. Lica Life Memorial Hospital, Bucuresti, Romania Background: Endoscopic repair for ventral hernia became more and more popular today. As any surgical procedure, the endoscopic Rives-Stoppa technique can followed by specific complications.

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Hernia (2017) 21 (Suppl 2):S139–S207 Methods: We present a video illustrative case of intestinal obstruction after endoscopic Rives-Stoppa surgery and its surgical solution. Results: MM, 63 yo male, diabetic with a history of peritonitis by perforated ulcer, developed epigastric incarcerated incisional hernia (M2W1). The patient was operated by endoscopic Rives-Stoppa technique: retromuscular space dissection, reducing of the hernia sac (incarcerated omentum), closure of the posterior sheath of the rectus abdominis using absorbable barbed suture, restoring the linea alba using unresorbable barbed suture and closing the defect (W 4 cm L 5 cm), sublay polypropylene mesh 30/18 cm fixed by cyanoacrylate. Patient was discharged next day.After 24 h, he was readmitted presenting abdominal pain, nausea, vomiting and no bowel movement. Diagnostic of small bowel obstruction was established and we decided to re-operate the patient. By laparoscopic approach we found a viable ileal loop herniated through 4 cm dehiscence of the posterior sheath. We reduced the internal hernia and sutured the dehiscence.Postoperative course was uneventful and patient was discharged 2 days later. Conclusion: The surgeons should be aware that this specific complication can occur if there is too much tension during posterior sheath suture.

V36.9 Multirecurrent lumbar and midline hernias solved by transversus abdominis release M. Garcia-Urena1, L. Bla´zquez1, J. Lo´pez-Monclu´s2, C. San Miguel1, D. Melero1, R. Becerra1, E. Jime´nez1, A. Robı´n1, A. Galva´n1, E. Gonza´lez1, P. Lo´pez1, N. Palencia1, A. Aguilera1, A. Moreno1, A. Cruz1, C. Jime´nez1 1 Henares University Hospital, Coslada, Spain, 2Puerta de Hierro University Hospital, Madrid, Spain Background: A thorough knowledge of the retroperitoneum and posterior muscles are essential to achieve a successful repair for lumbar incisional hernia. Methods: We present a challenging case of a 70 female operated for the first time of a retroperitoneal benign tumor by lumbar approach. She developed a very symptomatic incisional hernia that recurred after 5 attempts of repair: 4 open and 1 laparoscopic. In the CT, a 7 cm wide disruption on the posterior abdominal wall was observed and also en midline incisional hernia from the previous approaches. A combination of midline and lateral approach was made. The first step was to perform a right TAR in order to access to the subdiaphragmatic and retrocostal plane superiorly and psoas muscle inferiorly. An obliteration of quadratus lumborum was identified. The content was reduced and a retromuscular repair was made with the combination of absorbable (polyglycolic acid and carbonate trimethylene) and permanent mesh (polypropylene). The mesh was fixed to the iliac crest, lumbar vertebrae and transcostal fixation. Results: The patient was discharged on 7 postoperative day after an uneventful recovery with an acceptable control of pain. The CT control at 6 weeks showed a complete reconstruction of the posterior abdominal wall. After 4 months the patient is completely satisfied with the procedure and has improve her quality of life. Conclusion: Comprehesion of anatomy of posterior abdominal wall is essential to properly repair this complex mutirecurrent incisional lumbar hernias.

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37 Patients outcome and education in hernia surgery O37.1 Incisional hernias following gallstone surgery. A Swedish population-based study ¨ sterberg1, L. Enochsson2, G. Sandblom2 A. C. Wallin1, J. O 1 Mora lasarett, Mora, Sweden, 2Karolinska institutet, Stockholm, Sweden Background: The incidence of incisional hernias and the impact of individual risk factors for their development following gallbladder surgery is at present not sufficiently studied. Methods: All cholecystectomies registered in the Swedish register for cholecystectomy and ERCP (GallRiks) 2006–2014 where identified. Diagnoses from all hospital admissions and out-patient consultations relevant for determining the history of concomitant diseases as well as post procedural development of incisional hernia were obtained from the National Patient Register (NPR). The cohort was stratified according to surgical technique. Analyses were performed to determine the impact of each hypothesised risk factor on the development of incisional hernias. Results: A total of 83,938 patients were identified having undergone a cholecystectomy 2006–2014, where laparoscopic, open and minilaparotomic technique was used in 78,463, 13,238 and 1823, respectively. Five-year cumulative incidence of incisional hernia was 1.2% in the laparoscopic group, 4.0% in the open group, 2.4% in the minilaparotomy group. Risk factors obesity HR 4.15 (p \ 0.001), open surgical technique HR 2.95 (p \ 0.001), liver cirrhosis HR 2.73 (p = 0.002), chronic kidney disease HR 1.80 (p = 0.020), minilaparotomy HR 1.74 (p = 0.004), age [ median HR 1.44 (p \ 0.001) and chronic pulmonary disease HR 1.31 (p = 0.007) were found to significantly predict the development of incisional hernia. Conclusion: Laparoscopic surgical techniques lowers the risk of incisional hernias. Extra effort is required in the closure of the abdominal wall in patients with liver cirrhosis, obesity, chronic kidney disease and chronic pulmonary disease.

O37.2 Lessons learned from 239 mesh infection V. A. Augenstein, K. Coakley, T. Cox, C. Hlavaceck, A. Lincourt, T. Bradley, J. Horton, K. Kercher, P. D. Colavita, B. T. Heniford Carolinas Medical center, Charlotte, NC, USA Background: While mesh implantation significantly reduces hernia recurrence, mesh infection (MI) can lead to complex postoperative problems. We evaluated mesh infection treatment and identifying factors predicting resection. Methods: A prospective study was performed from 2004 to 2016 at a single, tertiary hospital. Mesh salvage (MS) was attempted in all patients. Statistics included Chi square, Fisher’s, and WilcoxonMann–Whitney tests. Results: 239 consecutive MI were treated in 225patients, 78.7% were referrals. Patient factors included: mean age—57.2 ± 12.2 years, BMI—35.5 ± 8.2 kg/m2, female—57%, diabetic—39.5%, smokers—26.5%, previous hernia repairs 1.8 ± 1.4 repairs (82.3% open). Follow-up was 37.5 ± 31.5 months (median—28.2 months). Mesh

S199 types included polytetrafluoroethylene (PTFE) in 36 patients (23.1%), polypropylene (PP) in 75 patients (48.1%), composite (PTFE/PP) in 31 patients (19.9%), and polyester in 14 patients (8.9%). Median time-to-infection was 5 months; average time-to-infection was 31.5 months (range: 6–9944 days). Unsuspected intestine-mesh fistulas were found in 52 cases (22.8%); all were excised. The most common bacteria was Staphylococcus aureus (89%) (MRSA, 50.4%). During long-term follow-up, MS failed in 207 (86.6%) and required mesh excision. Of the 32 MS, 50.0% remain on antibiotic suppression therapy. No smokers were infection free. Salvage rate of PP was higher (19.6%) than PTFE (4.5%); one polyester mesh was salvaged (p = 0.01). Lightweight PP was salvaged more frequently than midweight or heavyweight (39.5 vs. 12.5%, p \ 0.0001). MRSA was associated with a significantly higher rate of mesh resection (p \ 0.01). Conclusion: Long-term follow up indicates that most MIs require excision. Lightweight PP mesh in non-smokers with non-MRSA infections has the best success with mesh salvage.

O37.3 External validation of a clinical prediction tool for wound infection in open ventral hernia repair (OVHR) P. D. Colavita1, K. M. Coakley1, D. W. Heniford1, J. F. Bradley III2, T. Prasad1, A. E. Lincourt1, A. M. Carbonell3, W. S. Cobb3, V. A. Augenstein1, B. T. Heniford1 1 Carolinas Medical Center, Charlotte, NC, USA, 2Premier Surgical, Fort Sanders Regional Medical Center, Knoxville, TN, USA, 3 Division of Minimal Access and Bariatric Surgery, Greenville Health System, Greenville, SC, USA Background: Carolinas Equation for Determining Associated Risk (CeDAR) is a prediction tool estimating OVHR patients’ risk of postoperative wound complications based on preoperative risk factors. For risk-models to be utilized in clinical practice, external validation is necessary. This study evaluates the performance of the model in a validation cohort. Methods: The CeDAR equation was created from preoperative and operative data of 534 OVHR. 915 patients from a separate institution in a different state were analyzed with the CeDAR algorithm. Using Area under the Curve (AUC) and Somers’ D statistic as an indicator of overall model fit, the model’s prediction accuracy was determined in this validation cohort. Results: In the derivation cohort, mean age—55.9 ± 13.1 years, mean BMI—33.5 ± 8.5 kg/m2, 58.2% female, 84.8% Caucasian, 23.3% had diabetes, 19.0% smoked, 7.0% had an active infection at surgery, 68.5% had previous hernia repair, 7.0% concomitant stoma present, 45.7% advancement flaps and 64.5% had component separation. The model yielded an AUC of 0.78, 95% CI (0.74, 0.82) and Somers’ D statistic of 0.561. 915 patients from a separate hospital were used in the validation cohort. Patient factors were: average age—56.2 ± 13.7 years, mean BMI— 31.9 ± 8.1 kg/m2, 54% female, 25.4%—diabetic, 25.7%—smokers, 6.2% had active infection, 33.2%—previous hernia repair, 26.1%—concomitant stoma present, 21.7%—advancement flaps, 64.5%—component separation. The validation model yielded an AUC of 0.75, 95% CI (0.72, 0.78) and Somers’ D statistic of 0.499. Conclusion: In more than 1450 patients, CeDAR is a validated, effective wound complication prediction tool for OVHR.

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O37.4 An international appraisal of the Carolinas Comfort Scale (CCS) as a measure of quality of life (QOL) following hernia repair K. Coakley, A. Lincourt, A. Walters, P. D. Colavita, I. Belyansky, K. Kercher, R. Sing, V. A. Augenstein, B. Heniford Carolinas Healthcase System, Charlotte, NC, USA Background: The CCS is a hernia-specific, QOL questionnaire developed for patients undergoing hernia repair with mesh. Developed in 2004, the CCS has been validated in a single institution and has been adopted internationally. A revalidation of the CCS using international, multi-institutional data was performed to reaffirm the psychometric properties and validity of the scale. Methods: The data were extracted from the International Hernia Mesh Registry (IHMR), an international database designed to capture hernia patient demographics, surgical findings, and quality of life outcomes using the CCS at 1, 6, 12, and 24 months postoperatively. Results: 11,060 postoperative surveys were completed by 3788 patients. At 1-year post-hernia repair survey response rates exceeded 80%. Surveys with less than 2 missing items were included. The formal test of reliability revealed a global Cronbach’s alpha exceeding 0.95 for all hernia types. Test–retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance. Discriminant validity was assessed by correlating the symptom aggregates with indicators of disease severity, such as pain medication requirements and return to work. Symptomatic patients demonstrated higher odds of requiring pain medication in all activities, across all hernia types. Conclusion: The CCS questionnaire is a validated tool for assessing QOL after hernia repair, which has become the chief outcome measure in hernia surgery.

O37.5 HERQL, a mobile app to enhance long-term follow up of hernia patients

Hernia (2017) 21 (Suppl 2):S139–S207 Conclusion: The establishment of the mobile app could enhance the quality of care for hernia patients and facilitate outcomes research for this common disease with a more comprehensive and complete follow up. Our experiences from this project could propagate into other common surgical procedures as well.

O37.6 Secondary paraesophageal hernia after gastric fundoplication: causes and prevention R. Villa, R. Giorgi, G. Cesana, F. Ciccarese, G. Legnani, M. Uccelli, G. Castello, F. Caruso, B. Scotto, S. Olmi1 Policlinico San Marco, Zingonia, Osio Sotto, Italy Background: laparoscopic repair of large hiatal hernias is associated with high recurrence rates. We aim to estimate the risk of secondary paraesophageal hernia occurrence and possible tips to treat and prevent it, based on our centre experience. Methods: our analysis is based on a single centre experience retrospective database of 503 patients undergoing laparoscopic gastric fundoplication for a large hiatal hernia associated to GERD (gastroesophageal reflux disease), 21 of which reported secondary paraesophageal hernia (4.2%). At the annual follow-up 14% of patients showed symptoms of GERD; 12% had dysphagia, chest pain and tachycardia; the remaining presented aspecific symptoms. A followup of about 3 years from surgery showed secondary paraesophageal hernia at gastric emptying after oral contrast ingestion and EGDS (esophagogastroduodenoscopy). Results: according to our study none of the patients underwent a hiatoplasty associated to the fundoplication during first hernia repair. 28.5% of the patients after surgery had a significative average weight gain of 15–20 kg, suggesting that increased abdominal pressure caused by rapid weight gain could have an effect on esophageal hiatus continence and favor hernia recurrence. Hiatoplasty and mesh reinforcement showed no recurrence at a mean follow up of 1 year. Conclusion: many patients with secondary paraesophageal hernia are clinically pauci-symptomatic, surgical follow-up of a period of at least 3 years with gastric emptying after oral contrast ingestion and EGDS is important to detect and treat paraesophageal secondary recurrences. Hernia reappearance is treated with a redo fundoplication associated to hiatoplasty and mesh reinforcement.

C. Huang, C. Huang Cathay General Hospital, Taipei City, Taiwan Background: Hernia repair is one of the most common surgeries while the outcomes research of hernia suffers from high loss to follow up rate and poor compliance, resulting in a biased estimate of hernia recurrence, complication, and patients’ quality-of-life perception. We purpose a novel mobile app to enhance the follow up and outcomes assessment of hernia patients. Methods: The HERQL mobile app is supported by a cloud-based corroborative system. The questionnaire comprises a 4-item summative pain score measuring pain and discomfort resulting from various strenuous activities. Symptomatic burden, functional domains, postoperative satisfaction, and potential complications are evaluated as well. Results: A total of 1869 patients who had their hernias repaired at our institute were invited by postal mail. The response rate was 12.2% (228 patients). There were 48 ventral/incisional hernias and 180 groin hernias. The earliest hernia repair took place more than 13 years. The overall recurrence rate was 0.44%, and 89% of participants rated their last hernia repair as satisfactory or very satisfactory. 70% of patients reported no discomfort related with hernia repairs, and 64% never experience mesh foreign body sensation.

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O37.7 Impact of resident participation on postoperative complications in inguinal hernia repair—data from the Swedish hernia register H. Lederhuber1, B. Hanßke1, U. Dahlstrand2 1 Torsby hospital, Torsby, Sweden, 2Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, and Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden Background: Resident participation in inguinal hernia repair is a known risk factor for certain postoperative complications. The registration of resident participation however is very heterogeneous and no large-scale, long-term data exist on this issue. Methods: Data on all male, full-age patients who underwent open mesh repair for direct or indirect inguinal hernia between 1998 and 2014 were retrieved from the Swedish Hernia Register. Independent risk factors for hernia recurrence and 30-day complications were identified by multiple logistic regression. Resident participation was assessed in the following subgroups: resident(s) only; resident as

Hernia (2017) 21 (Suppl 2):S139–S207 primary surgeon with assisting attending; attending as primary surgeon with resident assisting; attending(s) only. Results: Data from 92,551 complete cases were analysed. Resident participation led to higher odds for hernia recurrence in the resident(s) only group (OR 1.20, 95% CI 1.07–1.34). Resident participation with an attending as either primary or assisting surgeon led to higher odds for 30-day complications (OR, 1.08, 95% CI, 1.01–1.16 resp. OR, 1.22, 95% CI, 1.13–1.31). Further independent risk factor for hernia recurrence or 30-day complications were hernia reducibility, hernia-type, surgical duration, surgical priority and body-mass-index. Conclusion: Senior residents should get collegial support to master the transit towards autonomous surgeons without impairing their operative outcomes. Higher odds for 30-day complications are a problem of junior residency but must not hinder early education in inguinal hernia repair.

O37.8 A novel training course in laparoscopic inguinal hernia repair: the LIGHT training course D. Light1, L. Horgan2, S. Bawa2 1 Royal Infirmary of Edinburgh, Edinburgh, UK, 2Northumbria NHS Trust, Newcastle, UK Background: The Ethicon LIGHT course is an educational course based on three days of didactic lectures, practical cadaveric procedures and a third day involving direct supervision by a consultant surgeon during laparoscopic hernia surgery on a real patient. We reviewed our outcomes for procedures performed on real patients on the final day of the course for early complications and outcomes. Methods: A retrospective study was undertaken of patients who had laparoscopic hernia surgery as part of the LIGHT course from 2013 to 2015. A matched control cohort of patients who had elective laparoscopic hernia surgery over the study period were identified. There were no exclusions. The outcome measures were peri-operative and post-operative complications, post operative stay, readmission and hernia recurrence (\6 months). Results: 60 patients had a laparoscopic inguinal hernia repair and 23 patients had a laparoscopic ventral hernia repair during the course. There was a significant increased operative time for laparoscopic inguinal hernia repair and ventral hernia repair during the course compared to consultant performed procedures (p \ 0.002). All the patients operated on during the course were performed as day case procedures. There were no significant peri-operative or post operative complications. One patient presented with an early recurrence in both groups (both had a large direct inguinal hernia). Conclusion: The outcomes of patients operated on during the LIGHT course are comparable to procedures performed by a consultant. Supervised operating by trainees is a safe and effective educational model in hernia surgery.

O37.9 Endoscopic skills for groin hernia repair can be learned and trained in the lab: presentation of a new TAPPteacher U. Dietz University of Wuerzburg, Wu¨rzburg, Germany

S201 Methods: The endoscopic view of the groin region shows direct parallelism to the human anatomy, including the shape of the lesser pelvis (important form mesh accommodation), the spermatic cord, the spermatic vessels, the epigastric vessels, the iliacal vessels, the nerves as well as the respective hernia orifices median, lateral and femoral. There is the possibility of ligation of the hernia sac (direct hernia) and of retrieval of preperitoneal fatty tissue from the inguinal canal (indirect hernia). The peritoneum-substitute used can be cutted, parietalized and sutured with commercially available suture materials and is easy to be replaced between two training units (about 1 min a` 20c/session). Results: We have tested the TAPP-teacher in a pilot study with trainees without any TAPP experience (4) and with experienced surgeons (6). Content validity (theoretic steps, anatomy, different hernia types, cutting of peritoneum, parietalization of the structures, insertion and positioning of the mesh. Mesh fixation as well as suture of the peritoneum) and construct validity (participants with previous experience had clearly more proficiency in solving the tasks than beginners) were demonstrated. Predictive validity has to be shown in future studies. Conclusion: A prerequisite for this will be the development of an evaluation system for real TAPP procedures in the OR and should be developed in cooperation with the ongoing education-module of the EHS.

O37.10 Hernia Social Media Study. The sharing of speakers presentation slides: intellectual property violation or basic right? D. Light, M. Pawlak, R. Brady, A. De Beaux Royal Infirmary of Edinburgh, Edinburgh, UK Background: The sharing of speaker’s slides from a conference is commonplace but raises a number of ethical questions. We investigated the views of the hernia surgery community on this topic. Methods: A survey was sent out by email to the membership of the British and European Hernia Societies. The survey was also promoted on Twitter. There were surveys for each group allowing subgroup analysis. Results: 165 responses were received (66 BHS, 60 EHS, 39 Twitter). 32% of society members used social media for professional communication against 95% of Twitter respondents. The commonest reasons for sharing speakers slides in both groups was dissemination of information, networking and personally having learnt in the past from posts by others who they followed on twitter. 60% of Twitter respondents have posted speakers slides versus 11% from society members. In terms of setting the rules for sharing content, Twitter respondents felt it was the role of the conference committee (45%) or that this should be implied as a given right (30%). Society respondents felt that either the conference committee (36%) or individuals (38%) should decide. 21% of Twitter respondents felt that sharing content was a violation of intellectual property compared to 62% of society members. Conclusion: Current opinion on sharing of speakers slides is that individual conferences should set rules explicitly. Respondents who use social media in their professional practice are more comfortable on sharing such content and do not see speakers slides as intellectual property when compared to less frequent social media users.

Background: A new training module for TAPP is presented. The module was developed to resemble realistic anatomical proportions and coordination of movements, mimicking a real TAPP procedure (face validity).

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38 Guidelines Update O38.2 Parastomal hernia guidelines S. Antoniou, The EHS Guidelines Development Group for Parastomal Hernias Heraklion, Greece Background: International guidelines on the prevention and treatment of parastomal hernias are lacking. The European Hernia Society therefore implemented a Clinical Practice Guideline development project. Methods: The guidelines development group consisted of general, hernia and colorectal surgeons, a biostatistician and a biologist, from 14 European countries. These guidelines conformed to the AGREE II standards and the GRADE methodology. Results: End colostomy is associated with a higher incidence of parastomal hernia, compared to other types of stomata. Clinical examination is necessary for the diagnosis of parastomal hernia, whereas computed tomography scan or ultrasonography may be performed in cases of diagnostic uncertainty. There is insufficient evidence on the policy of watchful waiting, the route and location of stoma construction, and the size of the aperture. The use of a prophylactic synthetic non-absorbable mesh upon construction of an end colostomy is strongly recommended. It is strongly recommended to avoid performing a suture repair for elective parastomal hernia. So far, there is no sufficient comparative evidence on specific techniques, open or laparoscopic surgery, and specific mesh types. However, a mesh without a hole is suggested in preference to a keyhole mesh when laparoscopic repair is performed. Conclusion: An evidence-based approach to the diagnosis and management of parastomal hernias reveals the lack of evidence on several topics, which need to be addressed by multicentre trials. Parastomal hernia prevention using a prophylactic mesh for end colostomies reduces parastomal herniation. Clinical outcomes should be audited and adverse events must be reported.

Hernia (2017) 21 (Suppl 2):S139–S207 East are involved in this huge project. Some of the most important results are presented. Conflict of interests: The author has nothing to declare.

O38.4 European Consensus on the World Guideline for GroinHernia Management N. Van Veenendaal1, M. P. Simons2, H. J. Bonjer1 1 VU University Medical Center, Amsterdam, The Netherlands, 2 OLVG Hospital, Amsterdam, The Netherlands Background: Groin hernia repair is one of the most common surgeries performed globally, with more than 20 million procedures per year. Since no global guidelines existed working group HerniaSurge developed the first world guideline for groin hernia management containing the best evidence and statements and recommendations. An unique method was used to reach consensus on the statements and recommendations. Methods: All statements and recommendations were formulated according to the GRADE-methodology. First consensus was sought within the Hernia Surge working group at an expert consensus meeting. Forty-six statements and recommendations were selected as key items. Secondly, consensus was sought among the surgical community. The 46 key items were presented at two European congresses and distributed by a web survey among EHS- and EAESmembers. Consensus was defined as more than 70% agreement. Results: In total 708 surgeons casted there votes on the key statements and recommendations. 399 delegates voted at two European congresses and 309 participants completed the online websurvey. Consensus was reached in 42 items: on six statements and 36 recommendations. No consensus was obtained on one statement and three recommendations. Conclusion: The World Guideline for Groin Hernia Management is developed to improve the results of groin hernia surgery around the world. An unique, new method was used to reach consensus on the key statements and recommendations in the guideline.

O38.3 HerniaSurge update

O38.5 Closure guidelines update

R. Bittner Hernia Center Rottenburg, Rottenburg, Germany

N. A. Henriksen Department of Surgery, Zealand University Hospital, Koge, Denmark

HerniaSurge update. The development and implementation of guidelines constitutes an important step towards the introduction of optimal diagnostic and therapeutic concepts with the aim to improve the quality of treatment. Guidelines should define standards to help the surgeon in his/her daily work finding the best surgical strategy for his patient. The Guidelines are essentially evidence based (Evidence-Based Medicine, EBM), but also allow to deal with ‘‘eminence’’-based statements in a critical way. Guidelines in inguinal hernia repair are developed and published by the European Hernia Society (EHS), the Internatinal Endohernia Society (IEHS), and the Europpean Association for Endoscopic Surgery (EAES). These three guidelines are in some way distracting although describing similar ‘‘statements’’ and ‘‘recommendations’’ regarding the most important questions. In order to summarize the current knowledge about herniology and to update the previous guidelines as well a real global project to develop ‘‘World Guidelines’’ was planned and realized during the past 4 years. 50 representatives of the hernia societies of Europe, America, Asia, Australia and Africa/Middle-

Background: In 2015, the European Hernia Society (EHS) Guidelines on the closure of abdominal wall incisions was published. Optimizing laparotomy closure will potentially decrease incisional hernia rate. In this update, relevant new studies will be discussed. Methods: The published EHS guidelines included studies published up to April 2014. An updated literature search including studies from April 2014 to April 2017 was performed. Results: New randomized controlled trials were published on the small bites suture technique, prophylactic mesh augmentation and the use of triclosan-coated sutures for laparotomy closure. Further, some new meta-analyses were published summarizing results on laparotomy closure. In order to change the recommendations of the guidelines, a consensus meeting in the guidelines group is necessary. Conclusion: New studies on laparotomy closure have been published since the publication of the guidelines in 2015. Possibly, the guidelines recommendations statements considering the small-bites suture technique, the use of prophylactic mesh augmentation and triclosancoated sutures may be changed after a consensus meeting in the guidelines group.

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39 Open abdomen: how to handle the abdominal wall. O39.1 Permanent meshes in the contaminated environment of open abdomen M. Jakob, T. Pinworasarn, D. Candinas, G. Beldi Department of Visceral Surgery and Medicine, Bern, Switzerland Background: Open abdomen may be due to a intraoperative necessity (laparostomy), or postoperative complication (fascial dehiscence or burst abdomen). Its clinical challenge is to regain the integrity of the abdominal wall and to prevent long-term morbidity. In our institution, permanent intraperitoneal meshes have been regularly used within the setting of contaminated open abdomen. Methods: In this retrospective case control study consecutive patients with open abdomen were analysed, starting in 2006. Groups with and without mesh implantation were compared. Primary outcome parameter was incisional hernia. Secondary outcome parameter was mesh-related morbidity. Results: A total of 202 patients were included in the study. 124 (61.4%) patients with mesh implantation in the contaminated abdominal cavity and 78 (38.6%) without mesh implantation. The rate of intestinal fistula did not differ between groups (15.3% with mesh vs. 16.7% without mesh, p = 0.799). There was no difference in mortality at 30 days (16.9% with mesh vs. 19.2% without mesh, p = 0.678). Patients with mesh implantation had a lower incidence of hernia or operation because of hernia during follow up (12.1% with mesh vs. 25.6% without mesh, p = 0.013). Conclusion: Implantation of permanent mesh in the contaminated environment is safe, increasing treatment options for the challenge of contaminated open abdomen.

O39.2 Technique and outcome of VAWCM U. Petersson1,2 1 Department of Surgery, Skane University Hospital, Malmo¨, Sweden, 2 Lund University, Lund, Sweden Background: Open abdomen (OA) therapy is widely used in situations where the abdominal cavity cannot or should not be closed. The vacuum-assisted wound closure technique fulfill many of the desired criteria for an optimal temporary abdominal closure technique with the exception of satisfactory fascial closure rates. The combination of vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) was developed in order to increase the fascial closure rates. Methods: The VAWCM-technique is described in detail and results from eleven studies are reported. Results: The number of patients included in six prospective and five retrospective studies varied from seven to 111. The primary fascial closure rate per protocol varied from 80 to 100%, and time to closure of the OA varied between 9 and 84 days. Entero-atmospheric fistula rates between 0 and 10.0%, and in-hospital survival rates between 57 and 100%, were reported. In the largest prospective study, the incisional hernia rate among survivors at 63 months of median follow-up was 54%, and one-third of incisional hernias were repaired. The study patients reported lower quality of life (SF-36) scores than the population mean, mainly dependent on prevalence of major co-morbidity. No difference in SF-36 scores or modified ventral hernia pain

S203 questionnaire (VHPQ) between those with versus without incisional hernias were found. Conclusion: The vacuum-assisted wound closure and mesh-mediated fascial traction technique results in high fascial closure rates, even after prolonged OA therapy. Incisional hernias are common but mostly associated with mild symptoms. Improvement of the technique is discussed.

O39.4 Open abdomen management in the UK A. de Beaux Royal Infirmary of Edinburgh, Edinburgh, UK Background: Individual surgeon experience of the open abdomen in the UK is in general, very low. The reasons for this are multifactorial, but include a very low incidence of gun crime, low incidence in general of penetrating abdominal trauma, quality surgery at the primary operation and senior input in the post-operative care, allowing early return to theatre for complications such as anastomotic leak. This makes learning expertise as to how to manage such patients with an open abdomen, and adopting techniques such as early graduated traction closure of the abdominal wall more difficult. Methods: Many patients still go down a period of lengthy hospital stay with a laparostomy wound, regular but multiple dressing changes, with slow granulation and healing over many months. This inevitably results in a large abdominal wall defect. Results: Getting patients out of hospital early is good for the patient and reduces medical costs. Thus techniques to get the abdominal wall closed or closed enough to allow safe discharge, and how to repair such defects when left to heal by secondary intention is the theme of this talk. The points will be illustrated around real cases and their management. Conclusion: Like most clinical cases, maybe you would have done something differently, so come along and add to the debate.

O39.5 Introducing the EHS open abdomen registry A. Willms1, R. Schwab2 1 Koblenz, Germany, 2Armed Forces Central Hospital, Koblenz, Germany Background: Open abdomen management has become a wellestablished strategy in the treatment of serious intra-abdominal pathologies. Key objectives are fistula prevention and high fascial closure rates. The current level of evidence is insufficient. Collecting data in a standardised, multicentre registry is necessary to draw up evidence-based guidelines. Methods: In order to improve the level of evidence on laparostomy, CAMIN, the surgical working group for military and emergency surgery of DGAV (German Society for General and Visceral Surgery), initiated the implementation of a laparostomy registry. This registry was established as the Open Abdomen Route by EuraHS (European Registry of Abdominal Wall Hernias) Since 1 May 2015, the registry is available as an online database. It includes eleven categories for data collection. Results: All entries of the first year were analysed, resulting in a review of 164 patients. Secondary peritonitis was the predominant indication (44%). The mortality rate was 25%. A comparison of methods with and without fascial traction reveals fascial closure rates of 70 and 45%, respectively (p = 0.03). Inert visceral protection was used in 52% of patients and achieved a significant lower small bowel

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S204 fistula incidence in comparison with the patients without a visceral protection (7.4 vs. 22%, p = 0.002). Conclusion: Optimising laparostomy management techniques in order to achieve the key objectives is possible. The method that ensures the best possible outcome would involve fascial traction, visceral protection and negative pressure. The laparostomy registry is a useful tool for quickly generating sufficient evidence for open abdomen treatment.

40 Hiatal mesh repair: when, why and how O40.1 Does the size of the hiatus influence recurrence? O. O. Koch Department of Surgery, Paracelsus Medical University, Salzburg, Austria Background: Hiatal hernia is an underlying factor contributing to gastroesophageal reflux disease (GERD). Laparoscopic antireflux surgery (LARS) has proven to be a successful treatment alternative to lifelong medical treatment of GERD. Crural closure during LARS is routine and generally accepted. Hiatal closure during LARS should prevent the migration of the wrap into the thorax. However, one of the most common complications after LARS is intrathoracic herniation of the wrap into the chest, which is caused by inadequate closure of the crura or disruption of the crural closure. Especially large hiatal hernias show a high tendency toward postoperative reherniation, which raises the questions whether the size of the esophageal hiatus has an influence on the rate of recurrence. Methods: The work is based on a selective Medline-research ( http://www.ncbi.nlm.nih.gov). Results: Recently there has been a scientific interest in accurate intraoperative and preoperative measurement of the esophageal hiatus, since its pathologic enlargement carries clinical implications. Studies could demonstrate that in patients with GERD undergoing fundoplication, a large hiatus area correlates with diminished lower esophageal sphincter pressure and increased acid reflux. Furthermore recent studies could show that a large hiatus is associated with an increased rate of surgical failure. Conclusion: The size of the hiatus has an influence on hiatal hernia recurrence. Therefore some authors recommend tailoring the technique of the hiatal closure according to the size of the hiatus.

O40.2 Mesh repair of paraesophageal hernias: risk/benefit analysis B. P. Mu¨ller-Stich Heidelberg University Hospital, Heidelberg, Germany Background: Mesh augmentation seems to reduce recurrences and reoperations needed following laparoscopic repair of large hiatal hernias. However, there is a risk of mesh-associated complications. The presented study was performed to evaluate whether the benefits of mesh augmentation outweigh the risks. Methods: A systematic review of randomized controlled trials (RCT) and observational comparative studies (OCS) comparing laparoscopic mesh-augmented hiatoplasty (LMAH) with laparoscopic mesh-free hiatoplasty (LH) was performed. Random effects meta-analyses and risk benefit analyses using a Markov Monte Carlo decision-analytic model were performed.

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Hernia (2017) 21 (Suppl 2):S139–S207 Results: 915 patients from 3 RCT and 9 OCS were included in the meta-analysis. A lower recurrence rate for LMAH was found (12.1 vs. 20.5%; p = 0.004). The reduction of recurrences was even more prominent in the sub-group analysis when only follow-up periodes of two years or longer were included (11.5 vs. 25.4%; p = 0.007) and when synthetic meshes were applied (9.9 vs. 19.0%; p = 0.005). For both procedures similar complications rates were found (15.3 vs. 14.2%; p = 0.94). The mesh-associated complication rate was low with 1.9%. Polypropylene was the most commonly used mesh, and it was associated with a lower complication rate (0.8%) than polytetrafluorethylene (2.5%) and biomeshes (1.3%). Risk–benefit analysis revealed a low life-long procedure-related mortality of 1.6% for LMAH compared to 1.8% for LH. Conclusion: In large hiatal hernias with paraesophageal involvement mesh should be used since a positive effect on the prevention of recurrences was found and the risk for complex reoperations can be reduced. Risk–benefit analysis seems to benefit mesh application since life-long procedure-related complications are not increased and mortality even reduced.

O40.3 Functional results after mesh repair F. Ko¨ckerling Vivantes Hospital Berlin Department of Surgery and Centre of Minimally Invasive Surgery, Berlin, Germany Mesh-reinforced hiatal hernia repair is associated with a decreased risk of recurrence in comparison with simple suture repair (Antoniou et al. 2012). Overall procedure-related complications and mortality seem not to be increased despite of potential mesh-associated complications (Mu¨ller-Stich et al. 2015).The main complications of mesh hiatoplasty include wrap migration or hernia recurrence, periesophageal mesh-induced fibrosis, and intraluminal mesh erosion. The common denominator of the above complications is a potential newonset dysphagia. In a review the dysphagia rate in mesh-reinforced hiatal hernia repair was between 0 and 21.7% with a median of 3.9% (Antoniou et al. 2012). Higher dysphagia rates after polytetrafluoroethylene (PTFE) and expanded PTFE (ePTFE) mesh hiatoplasty have been recorded (15.5–34.3%).The limited available information does not allow to make conclusions about the long-term efficacy of biologic meshes in this setting(Antoniou et al. 2015). In a series of 13 repairs of large hiatal hernias with biologic mesh dysphagia was the most common complaint (Antonakis et al. 2016). In a series of 170 patients with mesh hiatoplasty postoperative dysphagia was increased during the early period after surgery, but resolved without any further treatment within the first year after laparoscopic antireflux surgery(Granderath et al. 2002).In a comparative study Kepenekci et al. (2007) found no difference regarding the rate of postoperative dysphagia between mesh-and non-mesh-hiatoplasty. In conclusion there seems to be an increased risk for postoperative dysphagia in mesh hiatal hernia repair depending on the mesh type and design used in the procedure.

O40.4 Mesh-free augmentation techniques-feasible or not? G. Bischof1, F. Schneider2, W. Feil1 1 Evangelisches Krankenhaus, Vienna, Austria, 2St. Josef Krankenhaus, Vienna, Austria Background: Operative treatment of large and recurrent hiatal hernias remains challenging. Use of synthetic or (bio)absorbable meshes

Hernia (2017) 21 (Suppl 2):S139–S207 is increasing, but carries potential dangers such as mesh migration, infection, esophageal perforation and scarring. We report on our experience with the hepatic shoulder technique, introduced by Quilici et al. 2009. Methods: Between 2010 and 2016 35 patients (15 m, 20 f) were operated laparoscopically. Mean age was 68 years, 14 cases were reoperations. In 11 patients an upside-down stomach was present. After complete exposure of the hiatus, suture repair was performed. The left liver lobe was dissected off the left diaphragm using ultrasonic shears, interpositioned between hiatus and distal esophagus and sutured back to the left diaphragm. A floppy Nissen or Toupet fundoplication was carried out additionally. Results: All operations were completed by laparoscopy. Intraoperatively, 2 venous bleedings from diaphragmatic veins were managed. 1 patient with recurrent hernia developed gastric leakage and was reoperated on the 4th postop. day. During follow-up all patients had improved gastrointestinal symptoms. 1 radiologic recurrence was shown on a routine CT scan 1 year postop. Conclusion: In giant hiatal hernia repair this mesh-free technique proved to be feasible and safe.

41 Prevention of complications in ventral and incisional hernia repair 3 O41.1 Reduction of complications by risk stratified vacuum therapy in complex abdominal wall reconstructions: a unicentric study G. Baschleben St. Elisabeth-Hospital Leipzig, Leipzig, Germany Background: Complex incisional hernias and abdominal wall defects are still representing surgical challenges. Neverthless, through renaissance of the component separation and the establishment of transversus abdominis release, we are able to treat a large part of these difficult cases. However, present studies show high complication rates regarding wound infections, seromas and fascia or skin necrosis. Methods: From 1.1.14 to 31.10.2016 we treated 37 patients belonging to group 3 according to the Ventral Hernia Risk Score were treated with an additional vacuum dressing. Open IPOM (n = 12) as well as anterior component separation and transversus abdominis release (n = 25) were the chosen methods. The average defect size was 202.2 cm2. Both biosynthetic (n = 12) and synthetic meshes (n = 25) were used. Results: There was only one case in wich vacuum therapy had to be terminated because of a recurrent multi resistant infection (SSI rate 2.7%). The median follow-up of the other 36 patients was 10 months (2–32 months) and the median time to definite wound closure was 7 days (4–53). We registered postoperative complications (hematoma n = 1, cutaneous fistula n = 2, seroma n = 2) in 13.8% of the cases, no mesh explantation was necessary. To this date the recurrent rate is 2.8% (n = 1). In comparison 5 of 19 patients treated without vacuum therapy experienced complications such seroma and infection (26.3%). Conclusion: Compared to therelevant literature, our data exhibits a significant reduction of surgical site infection rate and thus an improvement of the surgical quality.

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O41.2 Implementation of an updated protocol in abdominal wall closure. Strategy and preliminary results S. Pe´rez Farre´1, B. Montcusı´ Ventura1, E. Alonso Simo´n1, M. Gimeno Lopez2, L. Ferna´ndez Yagu¨e1, A. Conesa Palma2, L. Grande Posa1, J. Pereira3 1 Parc de Salut Mar, Barcelona, Spain, 2Institut Hospital del Mar d’Investigacions Me`diques, Barcelona, Spain, 3Departament de Cie`ncies Experimentals i de la Salut. Universitat Pompeu Fabra, Barcelona, Spain Background: The aims of this study are (1) to implement in a University Hospital a series of measures to update the laparotomy closure technique by digestive, vascular, urological and gynecological surgery and (2) to monitor and audit the results after the implementation of the technique. Methods: Informing scientific sessions, training sessions as workshops, clinical interventions implementing the abdominal closure protocol by the EHS and an audited evaluation of the results were undertaken. During the prospective study of the results patients undergoing midline laparotomy, subcostal laparotomy and laparoscopy surgery converted to open, were being progressively included. Results: A total of 74 surgeons took part in the training sessions achieving a mean suture/wound length (SL:WL) ratio of 4.96 in 6.5 min after three attempts. The difficulty of the technique was rated as 1.92 and the global satisfaction with the activity was rated 8.69 out of 10. The preliminary analysis of the first 100 laparotomies conducted after the formative sessions and the implementations of the protocol compared to the 100 laparotomies conducted during the same period in the previous year, consisted in a bivariate analysis accepting a statistically significant p value < 0.05. Among the sample characteristics studied statistically significant differences were only found in the comorbidity between both groups (53.5 vs. 28.5%; p = 0.014). The frequency of postoperative complications was not statistically significant between groups. Conclusion: In this preliminary stage, the results of this study show that the short stitch technique is feasible and safe for patients.

O41.3 Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study M. Ahonen-Siirtola1, T. Nevala1, T. Pinta2, S. Niemela¨inen3, J. Vironen4, M. Streng4, J. Ward5, I. Ilves6, P. Vento7, V. Falenius8, M. Kokkonen9, J. Karvonen10, P. Ohtonen1, J. Ma¨kela¨1, T. Rautio1 1 Oulu University Hospital, Oulu, Finland, 2Seina¨joki Central Hospital, Seina¨joki, Finland, 3Valkeakoski Regional Hospital, Valkeakoski, Finland, 4Helsinki University Hospital, Helsinki, Finland, 5Pa¨ija¨t-Ha¨me Central Hospital, Lahti, Finland, 6Kuopio University Hospital, Kuopio, Finland, 7Kymenlaakso Central Hospital, Kotka, Finland, 8Loimaa Regional Hospital, Loimaa, Finland, 9Kokkola Central Hospital, Kokkola, Finland, 10Turku University Hospital, Turku, Finland Background: Seroma formation rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is also related to relatively rare but dangerous perioperative complication enterotomy especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sac reduce the

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S206 risk of seroma and adverse hernia-site events. The aim of this study was to evaluate whether hybrid operation with fascial defect closure has lower early complication rates compared to standard LIVHR. Methods: This is a multicentre randomized controlled clinical trial. From November2012 to May2015, 188 patients undergoing LIVHR for primary incisional hernia with fascial defect size 2–7 cm were recruited in eleven Finnish hospitals. Patients were randomized to either laparoscopic (LG) or to hybrid group (HG). The endpoints were (1)clinically and radiologically detected seromas and their extent one month after surgery, (2) peri/postoperative complications and 3)pain. Results: Bulging was observed by clinical inspection in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm3, p = 0.025)in LG than in HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019). Conclusion: Closure of the fascial defect reduces seroma formation. In hybrid method, the risk of enterotomy is lower and it should be considered during laparoscopic hernia repair in cases with large fascial defect and complex adhesions.

O41.4 Prospective study on mesh shrinkage with MRI visualization after laparoscopic ventral hernia repair with intra-peritoneal iron oxide loaded PVDF mesh

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O41.5 Ventral incisional hernia repair in immunosuppressed patients J. Raakow, A. Plath, Y. M. Callister, J. Pratschke, M. Kilian Charite´-Universita¨tsmedizin Berlin, Berlin, Germany Background: Immunosuppression is known to be a risk factor for surgical complications especially wound healing disorders. It is also known as a risk factor for the development of incisional hernias following solid organ transplantation. The purpose of this retrospective study was to review a large population of immunosuppressed patients undergoing hernia repair for ventral incisional hernias with special focus in the short-term postoperative outcome. Methods: A prospectively maintained database was analyzed identifying immunosuppressed patients undergoing ventral incisional hernia repair between January 2010 and November 2016. These patients were compared with a cohort of non-immunosuppressed patients undergoing ventral hernia repair during the same period. Statistical evaluation included the description and comparison of demographic factors and perioperative outcome. Results: A total of 799 patients were reviewed with 174 immunosuppressed patients (21.8%). Main reason for immunosuppression were liver and kidney transplantation (52.9, 25.2%). Immunosuppressed patients were significantly younger (55.2 vs. 59.5; p \ 0.001) and had a lower body-mass-index (25.9 vs. 27.8; p = 0.007). The width of the hernias and the size of the used meshes were not significantly different. Overall postoperative complications (28.2 vs. 24.6%; p = 0.375) and especially wound healing complications (6.9 vs. 8.2%; p = 0.637) were comparable in the two groups. Conclusion: Ventral hernia repair for incisional hernias is feasible and safe in immunosuppressed patients regarding the short-term outcome.

F. Muysoms, R. Beckers, E. Heindryckx, K. Carels, C. Schoofs, I. Kyle-Leinhase Maria Middelares, Gent, Belgium Background: Data on shrinkage of intra-peritoneal meshes come mainly from animal studies. Novel mesh that can be visualized with MRI allow the opportunity to prospectively evaluate mesh shrinkage after implantation. Methods: Intra-peritoneal PVDF mesh enhanced with iron particles (Dynamesh) was implanted during laparoscopic ventral hernia repair. Mesh was fixed with a double crown of absorbable tackers (Securestrap). MRIs were performed at 1 and 13 months postoperatively. The width and length of the mesh were measured by four blinded radiologists independently and were compared to the measurements by the surgeon at time of implantation. Results: Fifteen patients underwent laparoscopic ventral hernia repair and 13 received an MRI exam at both 1 and 13 months. The mean width was 198 mm at baseline, 190 mm at 1 month and 191 mm at 13 month. Mean difference in width compared to baseline was 3.8% at 1 month and 3.1% at 13 month. The mean length was 262 mm at baseline, 244 mm at 1 month and 242 mm at 13 month. Mean difference in length compared to baseline was 6.6% at 1 month and 7.2% at 13 month. The mean shrinkage of the width between 1 and 13 month was -0.7% (range: -6.0 and 4.2%) and the mean shrinkage of the length between 1 and 13 month was +0.7% (range: -6.1 and 6.4%). Conclusion: Although the measured width and length on postoperative MRI differs from the measurement at implantation, no significant shrinkage after implantation was observed in either dimension.

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O41.6 Incisional hernia and hyperthermic intraperitoneal chemothe´rapy M. Antor, M. Dazza, L. Schwarz, J. Coget, V. Bridoux, H. Khalil, J. Tuech Rouen University Hospital, Rouen, France Background: Cytoreductive surgery (CRS) and hyperthermic intra peritoneal chemotherapy (HIPEC) is an effective and agressive treatment for colorectal peritoneal metastases increases overall survival in selected patients. There are no datas in literature on incisional hernia after CRS and HIPEC. The aim of this study was to evaluated abdominal wall complications after CRS and HIPEC. Methods: From January 2008 to June 2016, 142 patients underwent CRS and HIPEC for colorectal metastases. All patients had physical examination 3 months after surgery and oncological follow up (clinical examination and CT scan). Results: The median age of patients was 53 years (range 21–77) with a median BMI of 25 (range 15–51). Postoperative mortality rate was 18% (n = 26). Twenty-four patients (17%) had abdominal wall complications. Ten patients (7%) presented evisceration (midline: n = 9, parastomal: n = 1) with a median occurrence to 28 days after CRS and HIPEC (range 10–40). Among these patients, seven patients needed surgical closure with suture repair. During follow up, 14 patients (10%) presented a incisional hernia (midline: n = 12, parastomal hernia: n = 1, iliac: n = 1). Among these patients, 6 had

Hernia (2017) 21 (Suppl 2):S139–S207 symptoms. Four patient had mesh repair (retro muscular mesh: 3, intra peritoneal mesh: n = 1) and two patients had suture repair. No post operative complications were observed (no abscess, no hematoma, no seroma). One patient developed a seroma at 3 months. No recurrence was identified during follow up. Conclusion: In this large study, complication rate of the abdominal wall after CRS and HIPEC is not superior to the data of literature after laparotomy.

O41.7 Goodbye IPOM? Early results after laparoscopic to endoscopic switch in ventral hernia approach V. Radu, M. Lica, A. Radu Life Memorial Hospital, Bucharest, Romania Background: Rives-Stoppa procedure is the gold-standard in ventral hernia repair by open approach.The aim of this paper is to present that Rives-Stoppa procedure could be performed by minimal invasive surgery summing it’s advantages and sublay positioning of the mesh. Methods: We study the prospective collected data of consecutive endoscopic Rives-Stoppa hernia repair cases operated by same surgical team. Results: We reviewed 23 patients with ventral hernias operated since June 2016 until January 2017: 7 patients with primary ventral hernia, 16 patients with incisional hernia. Mean age 55 yo, mean BMI 31, mean blood loss \50 ml. For primary ventral hernia mean OR time was 136 min, mean LOS 1 day, mesh/defect ratio vary between 9 and 112 (depending of presence of diastasis recti). Regarding incisional hernia mean OR time was 221 min, mean LOS 1.5 day, mesh/defect ratio 2.5–27, TAR performed in 6 cases. Meshes secured in position by cyanoacrylate in 16 cases, the others include a combination of tacks, sutures and cyanoacrylate; 1 case—self fixation mesh. Followup at 1 week, 1 month, 6 months.Regarding postoperative pain, the patients required mean 2.2 doses of analgesic/day. Complications: 1 case—limited muscular rupture during dissection with balloon. Conversions: 1 to IPOM, 2 to open (ventilation reasons).Postoperative complications: 2 cases early bowel obstruction, 1 chronic pain. No recurrence were note in 6 month. Conclusion: The Endoscopic Rives-Stoppa procedure is safe, feasible and it is a realistic solution to replace IPOM.

O41.8 Endstorch TM: a novel illumination device for miniopen Sublay (MILOS) repair of ventral and incisional hernias W. M. J. Reinpold, C. Berger, M. Schro¨der Gross Sand Hospital Hamburg, Hamburg, Germany Background: The MILOS operation allows the minimal invasive sublay implantation of large standard alloplastic meshes with anatomical reconstruction of the abdominal wall. While performing operations via mini incisions within the abdominal wall the light source is always a technical problem. Methods: For the optimal illumination the operative field distant to the mini incision we have developed together with Wolf company an

S207 endolight tube, Endotorch TM. The device is 20 cm long and has the shape of a laparoscopic 10 mm optic with a central canal of 5.5 mm which allows the insertion of any laparoscopic 5 mm Instrument. The front light is administered via glass fibres like in a laparoscope. The Endotorch gives maximum light at the tip of the inserted laparoscopic instrument, thus automatically pointing to the center of the surgeon’s dissection field. Results: We have performed 1.500 endoscopic assisted transhernial mini-open sublay (MILOS) operations of ventral and incisional hernias with very low complication rates and without any negative effects or complications which were related to our novel device. Via a 3 and 4 cm incision the Endotorch allows circumferential dissection of the preperitoneal and retromuscular plane with a radius of up to 15 and 20 cm, respectively. The dissection is either performed under direct vision or endoscopic view. Conclusion: The Endotorch is an efficient and efficacious device for the minimal invasive sublay repair of repair of ventral and incisional hernias. It is also very useful in many other mini open access procedures of general and abdominal surgery (Video available).

O41.9 The modified sublay technique for management of major subcostal incisinal hernia: Rives sublay technique with components separation techniqe M. Zuvela1, D. Galun1, I. Palibrk1, D. Basaric1, A. Bogdanovic2, N. Bidzic2, J. Gajic2 1 University Clinic for digestive surgery; Medical School, Univeristy of Belgrade, Belgrade, Serbia, 2University Clinic for digestive surgery, Belgrade, Serbia Background: The study objective is to present the concept of original technique in the management of major subcostal incision hernias bassed on sublay position of large haevy-weight polypropylene mesh between the two myofascial layers in the anterolateral abdominal wall. Methods: The operative technique: (a) hernia sac dissetion and reposition into the abdominal cavity; (b) rectus muscle dissection from posterior rectus sheath at the opposite side of the hernia defect, rectus muscle atachement dissection from thoracic wall and external oblique muscle dissection from internal oblique muscle in a circle around hernia defect at the side of the hernia defect; (c) posterior and anterior rectus sheaths are separately reconstructed at the midline; (d) complete reconstruction of the posterior miofascial layer is achieved by stitching internal oblique/transversal muscle and posterior rectus sheaths; (e) large haevy-weight polypropilene mesh placement in a sublay position between posterior miofascial layer consisting of internal oblique muscle and both posterior rectus shaeths; (f) reconstruction of the anterior miofascial layer. Results: Between January 2010 and June 2016 30 patients with major subcostal incision hernia with hernia defect equal or exceeding 10 cm were operated. The average subcostal hernia defect size was 183 (90–375) cm2. Except wound infection in two patients (6.7%), there were no other complications and recurrences during mean follow-up of 33 (9–76) months. Conclusion: The modified sublay technique using large haevy-weight polypropylene mesh provide good results in the management of major subcostal abdominal wall defects.

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Hernia (2017) 21 (Suppl 2):S208–S263

ABSTRACTS

Poster Presentations 1. Patients selection and tailored approach in hernia surgery P001 Physiopathology of inguinal region & hernia genesis. Highlighting the visceral impact theory G. Amato1, P. Calo`1, F. Medas1, E. Erdas1, F. Podda1, G. Romano2 1 University of Cagliari, Cagliari, Italy, 2University of Palermo, Palermo, Italy Background: Despite advances in materials and techniques, the dilemma of the genesis of inguinal hernia remains undisclosed. Being the etiology of the disease still unaddressed, a series of questions arise: n It’s possible to correctly manage a pathology without knowing the pathogenesis? n Can such defective knowledge of the pathogenesis lead to incongruent hernia repair concepts? n Are the typical complications of the actually performed hernia repair techniques, such as discomfort and chronic pain, related to this incongruence? Methods: Answering to these queries should be imperative for a correct management of a disease but, surprisingly, among herniologists the issue hernia genesis seems not to be significant. Results: Recent studies focused on the functional anatomy of the groin and supported by histological evidences, have shown an unexpected world that needs to be interpreted. Noteworthy damages to muscle (ranging from hyaline degeneration along with fibrosis to fatty dystrophy) were detected. These changes, associated to chronic inflammatory infiltrate, venous congestion, medial hyperplasia of the artery, nerve fibrosis/atrophy, demonstrated a common trait: that of tissue degeneration following chronic compressive damage. Conclusion: In the lower abdomen, no other source of chronic compression exists but visceral impact. Therefore, appears logical that the orthostatic vector forces produce a steady visceral compression against the lower abdominal wall. As a consequence, chronic visceral impact could be indicated as the culprit of the protrusion disease that, by considering the gender related differences of the pelvis outline, in women mainly produces visceral prolapse and, in men inguinal protrusions.

P002 Outcome measures between open Lichtenstein technique and laparoscopic TAPP repair of inguinal hernias L. J. Aragon, P. M. Rojas, S. E. Rivera, L. F. Tale, J. A. Altuve Instituto Guatemalteco de Seguridad Social, Guatemala, Guatemala Background: Hernioplasty is one of the most common surgical procedures around the world. In our institution hernioplasty is performed with Lichtenstein technique (open) and laparoscopic TAPP (transabdominal pre peritoneal) repair. The aim of the study is to compare clinical outcomes between both procedures. Methods: In this retrospective study, 45 patients were treated with one of the techniques to hernia repair, between June and November 2015 at the General Hospital Juan Jose Arevalo Bermejo at Guatemala City. The prevalence of chronic inguinodynia, inguinal hernia recurrence, complications and time to return to normal activities were compared.

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Results: There is no statistical difference between open technique compared with laparoscopic repair, in the prevalence of chronic inguinodynia (21.4 vs 17.7%, p: 0.75), nor in emergency room visits for pain (8.5 vs 13%, p: 0.55), nor in postoperative infections, seroma, rejection or hydrocele complications (p: 0.36). Inguinal hernia recurrence was more common in the laparoscopic group (17.3 vs 2.1%, p: 0.019). Mean time to return to work was 29 days in both groups (p: 1.0). Conclusion: In our institution both open and laparoscopic inguinal hernia repair have comparable outcomes and more experience is needed to decrease hernia recurrence.

P003 Total extraperitoneal groin hernia repair using 3Dlaparoscopy vs 2D-laparoscopy I. Avram, C. Lamberty, S. Ro¨hr, D. Borces CaritasKlinikum Saarbru¨cken, Saarbru¨cken, Germany Background: 3D-laparoscopy is proven to improve performance in dry laboratory settings, especially for novice laparoscopists, the benefits for experienced laparoscopic surgeons are still discussed. Methods: From a total of 332 hernia patients that were operated during 2016 in our clinic we selected all patients operated with the TEP technique using 3D Einstein Vision by the same team (35 PTS). As control group we randomly selected 35 patients who underwent TEP by the same team using a conventional HD laparoscope. All patients were retrospectively analyzed in terms of OR time, duration of operation, intra- and postoperative complications, length of hospitalization, pain score and necessity of analgesics, risk factors for complications and recurrence (BMI, smoker, diabetes, COPD, BPH). Results: Our study group underwent TEP hernia repair using 3Dvision for 48 inguinal hernias, mean age 47.3 years; 28 PTS were male and 7 female and the mean BMI was 28.7 kg/m2. We selected a control group of 35 patients who also underwent 48 inguinal hernia repairs. Mean operation time in the study group was 43.2 min in the study group, while mean OR time was 86.4 min. Mean operation time in the control group was 45.3 min, while mean OR time 71.4 min. One early recurrence was noted in the control group. Conclusion: There were no significant differences regarding the outcome of inguinal hernia repair; total OR time was significantly higher in the study group due to the time needed to set up the 3Dsystem; there was no difference in short-term complication rate.

P004 Laparoscopic double incisional ventral hernias repair G. Borroni1, V. Quintodei1, M. R. Moroni2, P. Veronesi2, D. Chiari2, M. Platto2, D. Tornese2, P. Militello2, W. Zuliani2 1 University of Insubria, Varese, Italy, 2Humanitas Mater Domini, Castellanza, Italy Background: This video shows the laparoscopic double incisional ventral hernia repair technique using intraperitoneal, double-layed e-PTFE/PP mesh RelimeshÒ (HerniameshÒ Srl, Italy) fixed with absorbable tacks in our high-volume center with over 100 procedures performed in 5 years. Methods: A 55 years old female patient with a past medical history of nephrolithiasis, hysterectomy and laparoscopic sigmoid resection for diverticulitis, with a current weight of 80 kg and a height of 160 cm (BMI = 31.25), comes to our department for after onset of onset of epigastric and right flank swelling, increasing in size. At the

Hernia (2017) 21 (Suppl 2):S208–S263 physical examination we notice a reducible right iliac fossa incisional hernia and a second, infraumbilical, not reducible incisional hernia. The patient underwent to pre-operative CT-scan that confirmed in right iliac fossa incisional hernia (5 cm wall defect) containing ascendant colon, cecum and last small bowel loop, and a second, epigastric incisional hernia (2 cm wall defect) containing omentum. Results: According to the EHS Classification for Primary Abdominal Wall Hernias (2009), we identified a medium (W2) iliac fossa (L3) incisional hernia and small (W1) epigastric (M2) incisional hernia. Conclusion: The patient underwent to laparoscopic double incisional ventral hernia repair technique using intraperitoneal mesh RelimeshÒ fixed with absorbable tacks with no complications. She was discharged in 3POD. The 3-months follow-up shows no recurrence nor chronic pain.

P005 Extraperitonealtreatment in local anesthesia through anterior way of a giant Spigelian herniawith the use of polypropylene mesh (Hermesh 5) G. Brancato1, M. Donati2, E. Deiana1, M. Ristagno1, F. Lentini1, M. Belfiore1, G. Basile1 1 U.O. di Chirurgia Addominale e d’Urgenza, Azienda Ospedaliero Universitaria Policlinico-OVE, Catania, Italy, 2U.O.C. di Chirurgia Generale e Oncologica, Azienda Ospedaliero Universitaria Policlinico-OVE, Catania, Italy Background: The purpose of this work is to demonstrate the validity of the pre-peritoneal repair technique in local anesthesia, with the use of soft mesh macroporous polypropylene (Hermesh 5), in the treatment of a voluminous Spigelian hernia and to describe the results in short and middle term. Methods: Female patient, age 70, suffering from a giant Spigelian hernia, as well as other multiple hernias of abdominal wall. Chronic epatitis and cirrhosis since 2014, diabetes type II, cystic adenoma of the left adrenal gland, gallbladder microlithiasis, chronic autoimmune thyroiditis. Preoperative CT scan showed a hernial defect of about 12 cm with a commitment of loops of the large intestine and adipose tissue, with sac occupied by abundant fluid. It was possible to easily isolate the peritoneal sac, which had the size like a melon, without opening it. Repair was completed using double polypropylene mesh, packaged intraoperatively. It was anchored in a circle to the healthy wall using U points. Results: Post-surgery time was regular and she was dismissed on the second postoperative day. Six months later, CT scan revealed a very well reinforced abdominal wall with no signs of recurrence. Conclusion: Thanks to our experience in treating abdominal wall defects, this approach was possible in local anesthesia also through the use of a macroporous and soft polypropylene mesh (Hermesh 5) which is a safe and dependable device, and which affords an early healing of abdominal wall due to its physical features, allowing a rapid and pain-free return to normal daily activities.

P006 Geography of groin hernia for Day Surgery in the IIIIV area of the Community of Cantabria-Spain J. Cagigas1, E.G. Cantero1, J. Ruı´z1, M. Bolado1, R. Gonzalo1, M. Ochoa1, J. Robledo1, C. Martı´nez1, P. Cagigas-Roecker2, M. Mozo1, A. Gutie´rrez1 1 Hospital Sierrallana, Torrelavega-Cantabria, Spain, 2Hospital Cruces, Baracaldo-Pais Vasco, Spain

S209 Methods: 414 patients treated by DS were analyzed (183/3290 in 2013, 231/3006 in 2014) within the III and IV areas of the Community of Cantabria-Spain. The coding was applied in GRDs and ICD-9. Results: There are 69 of 307 and 69 of 306 populations where groin hernia of the total DS were involved in 2013 and 2014, respectively. Only Polanco has more women operated in 2014. In high mountain areas with difficult access is zero (Potes). In high mountain areas with good access are [50% of DS and 3 ASA III patients, pre-anesthetic assessment, in Reinosa. In populations with higher ASA I–II–III increases in 2014, compared to 2013. The population of Torrelavega, which is the main one in area III–IV, has the highest number of ASA III. It is observed that in 2013 in the near populations, fewer moderate ASAs II and III were made than in 2014. In large populations, patients with ASA II and III increased and could be treated as DS. In the geography of the groin hernia, the population with more inhabitants of the area III-IV, (Torrelavega), presents a greater number of procedures (101) in DS. Conclusion: The relationship between number of inhabitants and SD per population is maintained, which helps to estimate costing and endowment.

P007 Costs of the surgical process of groin hernia in day surgery in Cantabria, Spain J. Cagigas1, E.G. Cantero1, J. Ruı´z1, M. Bolado1, R. Gonzalo1, S. Die´z-Aja1, J. Robledo1, M. Mozo1, C. Martı´nez1, P. Cagigas-Roecker2, A. Gutie´rrez1 1 Hospital Sierrallana, Torrelavega-Cantabria, Spain, 2Hospital Cruces, Baracaldo-Pais Vasco, Spain Background: A comparative study is carried out in the years 2012–2014, auditing the cost obtained by analytical accounting in the three hospitals of the Cantabria Health Service. The prices agreed with the hospitals and the prices published in the price order. Methods: The cost-per-process estimate is analyzed in Valdecillalevel III hospital, Sierrallana hospital, level II and Laredo hospital, level I. The mean cost of all patients discharged in the group related to the diagnosis is obtained (GRD) code 162 of groin hernia. Results: It is observed lower cost in Day Surgery(DS) than with income. The cost from 2012 to 2014 is progressive, both in the hospitalization and the DS. During the year 2014 HUM Valdecilla (III) continues to have more surgery costs in the groin hernia (1286.90) than the one predicted in The price order (932.65)€. The GRD 162 has a cost in 2012–2014 from 1158.62/1207.82/1286.90 (III), 728.78/472.91/680.90 (II) and 1120.36/1.007.29/1.018.09 (I), in DS, respectively. The GRD 162 presents a cost in the income from 2012 to 2013, from 2336.96/2734/(III), 1574.17/1881.78 (II) and 2251.35/1835.76 (I), respectively. Conclusion: Level I and II Hospitals are cheaper than the Level III hospital to perform DS for groin hernia. Only the county hospital level II is cheaper (€ 680.90), than the concerts and the price order making it the most suitable for the Community of Cantabria in costeffectiveness.

Background: The distribution and relation of the pathology of the Day Surgery (DS), and the health centers applying the geography of the health care.

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P008 Audit biannual in procedures for improvement of Day Surgery in the groin hernia of the Western Community of Cantabria, Spain J. Cagigas1, E.G. Cantero1, R. Gonzalo1, J. Ruı´z1, M. Bolado1, M. Ochoa1, P. Cagigas-Roecker2, C. Martı´nez1, J. Robledo1, A. Gutie´rrez1 1 Hospital Sierrallana, Torrelavega-Cantabria, Spain, 2Hospital Cruces, Baracaldo-Pais Vasco, Spain Background: We analyzed several surgical programming procedures to ensure the optimization of resources in Day Surgery (DS). Period of study biannual 2013 (a)–2014 (b). Methods: Improvement procedures audited for the type of anesthesia, the opportunity cost, the substitution index for DS, and reference times for surgical programming for groin hernia. Results: In year (a) of the 3290 DS interventions, 183 were groin hernia. In year (b), about 3006, they were 231 of DS, that is to say, 2.1% more. Women were 12.71/11.73% in (a)/(b) respectively. There are 57.22/46.52% (a)/(b) of anesthesia with laryngeal mask (ML) as the most frequent. According to the ASA anesthetic assessment, type I was 23.69% in (a) and 33.04% (b), with [9.4%. Spinal anesthesia was 17.91% in (a) and 20.43%, with[2.5%. And was performed from ASAII (10.40 (a) and [12.60% (b).The substitution index was 79.2 (a) and 84 (b), improving by 4.8%. The surgical time (TQ) with rank (80 –1h360 in (a), the rank in (b) was 80 –1h200 .The mean TQ was ´ SAIII 0.250 ASAI at 0.330 ASAIII in (a), and from 0.210 ASAI to 0.30A In (a), there are no females from 0.50’ of TQ in (a), and of 0.45 in (b), there are no females from 0.500 of TQ in (a) and (a) all of them are males from ASAIII. With this time, begin to be only men operated. Conclusion: To schedule groin hernia surgery, the cost-opportunity is valued. Surgery time, type of anesthesia and pre-anesthesia risk assessment are required.

P009 Comparative study of needle-type grasper assisted single-port laparoscopic repair and two-port laparoscopic repair for pediatric inguinal hernia F. Wang, F. Chen, S. Liu, Y. Shen, J. Chen Beijing Chao-yang Hospital, Beijing, China Background: Laparoscopic repair is more and more popular in the treatment of pediatric inguinal hernia. Many methods of laparoscopic techniques have been described. The basic principle is to close the hernia ring either by intracorporeal suture or by extracorporeal suture. This study was aim to observe the clinical effect of single-port laparoscopic extracorporeal suture repair using a needle-type grasper in children. Methods: A total of 1010 cases of pediatric indirect inguinal hernia in Beijing Chao-yang hospital from March 2011 to December 2014 were enrolled. 508 cases were treated by singleport laparoscopic repair with the assistant of a needle-type grasper, while the other 502 children underwent the traditional two-port laparoscopic repair. Results: The operating time, intraoperative bleeding loss, time return to physical activity and length of hospitalization stay in needle-type grasper group were significantly lower than those in traditional group. In addition, the incidence of complications and contralateral occult hernia occurrence rate were equivalent in the two groups. 2 cases of recurrence were found in traditional group after 2 years of follow-up. Conclusion: Needle-type grasper assisted single-port laparoscopic repair for pediatric inguinal hernia is safe and effective. It has the

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Hernia (2017) 21 (Suppl 2):S208–S263 advantages of being easy to handle, less trauma, rapid recovery and good cosmetic results, can be worthy of clinical promotion.

P010 Incisional ventral hernia: technique and outcome in 330 patients F. Zingales, S. Degasperi, G. Pozza, S. Rampado, V. Beltrame, C. Bernardi, C. Da Re, M. Gruppo, R. Bardini University Hospital of Padua, Padua, Italy Background: Incisional ventral hernia is reported with a prevalence of 8–19%. A standardized technical approach is still lacking. The aim of this study is to analyse our experience with particular attention to the postoperative complications and recurrence. Methods: A consecutive series of patients who underwent surgery for incisional hernia repairing were reviewed retrospectively. Large defect with degraded fascia were treated with biological meshes. Repairable fascia defects were treated with meshes chosen according to SSO risk (VHWG classification). Results: Between 2009 and 2016, 330 patients were enrolled; 57 patients (17.2%) were operated for incisional hernia recurrence; 18 patients (5.5%) underwent emergency surgery. According to VHWG classification: 148 patients (44.8%) were Grade1, 98 patients (29.7%) were Grade 2, 72 patients (21.8%) were Grade 3, 12 patients (3.6%) had infected wound (Grade 4). Direct suture repairing was performed in 58 cases. Prosthetic incisional hernia repairing were 272. Polypropylene mesh was used in 248 cases (90.8%) with different procedures: 211 cases (85%) using Rives technique, 7 (2.8%) with Rives-Ramirez, 30 (12.1%) with Chevrel technique. Biological mesh was used in 21 cases (7.7%), while ePTFE mesh in 3 cases (1.1%). Postoperative complications were 59 (17.8%), 21 (6.3%) required surgical treatment or ICU admission. Median follow-up interval was 22.2 months. Recurrence occurred in 47 (14.2%). Mortality rate was of 0%. Conclusion: In our series, complications and recurrence rates were similar to those found in literature. Our flow-chart could represent a standardized approach to incisional hernia surgical repairing.

P011 Laparoscopic total extraperitoneal repair under epidural anesthesia versus general anesthesia. Retrospective clinical study T. Donmez1, V. M. Erdem1, D. A. Erdem2, O. Sunamak3, D. Yildirim4, A. Hut1, E. Hatipoglu5, S. Ferahman5, S. Uzman6, S. Demiryas5 1 Lutfiye Nuri Burat State Hospital, Department of General Surgery, Istanbul, Turkey, 2Lutfiye Nuri Burat State Hospital,Department of Anesthesiology, Istanbul, Turkey, 3Haydarpasa Numune Training and Research Hospital,General Surgery, Istanbul, Turkey, 4Haseki Training and Research Hospital,Department of General Surgery, Istanbul, Turkey, 5Istanbul Universty Cerrahpasa Medicine Faculty,Department of General Surgery, Istanbul, Turkey, 6Haseki Training and Research Hospital,Department of Anesthesiology, Istanbul, Turkey Background: Laparoscopic total extraperitoneal (TEP) inguinal hernia repair is a well-known approach to inguinal hernia repair that is usually conducted under general anesthesia (GA). To date, any reports haven’t compared the efficacy of epidural anesthesia (EA) with that of GA for laparoscopic hernia repairs. The purpose of this study was to compare TEP inguinal hernia repair under EA to TEP under GA.

Hernia (2017) 21 (Suppl 2):S208–S263 Methods: Between July 2016 and October 2016, 62 patients of GA TEP group (Group I) and EA TEP group (Group II) were analyzed retrospectively. EA with a combination of 20% lidocaine, 0.5% bupivacaine and 50 lg fentanyl was administered through a lumbar epidural catheter, achieving a sensory blockade at the level of T6. Propofol, fentanyl, rocuronium, sevoflurane, and tracheal intubation were used for GA. Intraoperative events related to EA, operation and anesthesia durations, postoperative complications, patient satisfaction and pain scores were recorded. Results: Operations of thirty patients were started under EA, 5 of which (16.66%) were converted to GA; the other 25 (83.33%) were completed under EA. All cases were successfully completed laparoscopically, and there was no conversion nor intraoperative complications. Pain was significantly less at the 1st h (P \ 0.001) after the procedure for the EA and GA groups, respectively. There was no difference between the two groups regarding complications, hospital stay, recovery, or surgery durations. Generally, patients were more satisfied with EA than GA (P \ 0.024). Conclusion: Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative to TEP under general anesthesia.

P012 A comparative study of laparoscopic extraperitoneal inguinal hernia repair: slit mesh versus non-slit mesh placement T. Donmez1, D. Yildirim2, A. Hut2, M. C¸akir2, S. Ferahman3, S. Demiryas3, E. Hatipoglu4, O. Sunamak5 1 Lutfiye Nuri Burat State Hospital,Department of General Surgery, Istanbul, Turkey, 2Haseki Training and Research Hospital,Department of General Surgery, Istanbul, Turkey, 3Istanbul Universty Cerrahpasa Medicine Faculty,Department of General Surgery, Istanbul, Turkey, 4Lutfiye Nuri Burat State Hospital, Istanbul, Turkey, 5Haydarpasa Numune Training and Research Hospital,General Surgery, Istanbul, Turkey Background: Laparoscopic inguinal hernia repair; totally extraperitoneal(TEP) and transabdominal preperitoneal(TAPP) approach are widely accepted alternatives to open surgery. The TEP approach for surgical repair of inguinal hernias has emerged as a popular technique. Our aim was to analze patients who underwent laparoscopic total extraperitoneal repair using slit and non-slit mesh placement. Methods: This retrospective clinical study was conducted between January 2014 and December 2015 and included 62 patients suffering from uncomplicated primary groin hernia. Patients were in two groups: Group 1 was slit mesh TEP and group 2 was of non-slit mesh TEP. Hernia recurrence, postoperative pain, surgical outcome, hospital stay, postoperative complications, return period to normal physical activities, and patient satisfaction were compared. Results: During the study period 116 consecutive patients underwent laparoscopic groin hernia repair. Two of the TEP patients were converted to TAPP. Eighty-three patients in the TEP group had slit mesh placement and 33 had non-slit mesh placement. Mean follow-up was 25 months (range: 16–36 months). At follow-up, 116 patients responded to a request for interview and 112 were examined. The overall recurrence rate was 2.58%, the overall incidence of scrotal edema and seroma were 5.17 and 6.03%, respectively. The incidence of constant postoperative pain was 4.31% and patient satisfaction with the surgery was 94.5%. There was no difference between the groups in terms of return period to normal activities, recurrence, patient satisfaction, and postoperative pain. Conclusion: Laparoscopic inguinal hernia repair is a safe and effective way by both methods.

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P013 Coexistence of inguinal hernias with cholelithiasis. One year prospective evaluation of patients undergoing laparoscopic cholecystectomy E. Kalogridaki, L. Dritsoulas, A. Papadopoulou, C. Tzamourani, E. Mourikis, A. C. Dounavis Sismanogleio-Am.Fleming Hospital, Melissia Athens, Greece Background: During laparoscopic inspection of the inguinal region a lot of distortion was found in many patients. So, during a one year period, we decided to thoroughly examine both inguinal areas in a population of patients undergoing laparoscopic cholecystectomy for cholelithiasis. Methods: Seventy-three patients were operated laparoscopically for gallstones by a team leaded by an experienced surgeon during a period of one year. Thirty-three were male and fourty female. Two patients had known inguinal hernias. Results: In 33 occasions no hernia was detected, in 30 patients different hernias were observed and in 10 patients inspection of the inguinal areas was not possible. The anomaly was bilateral in 50% of patients inspected with hernia. In one occasion the operation was turned to open due to carcinoma of the gallbladder. Of the detected hernias some were incomplete but the distortion was present as was the potential for further worsening and hernia development. All the patients were informed about the findings and consultation was given about weight loss and body habits. Conclusion: In conclusion, it seems that patients operated on for cholelithiasis have a high incidence of inguinal hernias. Detection of these at an early stage during laparoscopy, may prevent full clinical manifestation with proper consultation.

P014 Modified mayo repairin local anesthesia: back to the roots F. X. Felberbauer Department of Surgery, Medical University of Vienna, Vienna, Austria Background: Small umbilical hernias are usually symptomatic and carry a high risk of incarceration. Therefore early surgery is mandatory. In high-risk patients general anesthesia and the use of prostheses may result in further morbidity. Methods: Between 2002 and 2016, 64 patients (33 male, 31 female) had surgery for umbilical hernias up to 3 cm. In all patients a modified MAYO repair was performed in local anesthesia. Twenty-two patients were considered as high-risk patients because of renal failure with continuous ambulatory peritoneal dialysis (CAPD, 9), chronic obstructive pulmonary disease (8), or congestive heart disease (5). Hernia orifices were closed transversally with a mattress suture covered by a simple continuous suture. Non-absorbable polyethylene monofilament sutures (ProleneÒ 3-0 or 2-0) were used. Results: Hernia repair was achieved in all patients. Oral anticoagulation had to be switched to low-molecular s.c. heparin injections. Platelet aggregation inhibitors were not discontinued, in these cases epinephrine was added to local anesthetic. CAPD patients continued their peritoneal dialyisis. Follow-up identified a single recurrence twelve years after primary closure (1.5% recurrence rate). This recurrence was successfully repaired again using the same technique. Conclusion: We ascribe our low recurrence rate to the adherence to the original MAYO description. The method was wrongly applied as longitudinal repair of incisional hernias, resulting in a high recurrence

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S212 rate. Instead, the original technique was devised as a single stitch transverse duplication repair of healthy fascial margins. We added monofilament suture material and used continuous sutures, resulting in a modern ‘‘small bites’’ closure technique.

P015 Total extraperitoneal laparoscopic inguinal hernia repair making exclusive use of the square lumbar muscle anestesia guided by ultrasound M. L. Favaro1,2, S. Gabor1,2, O. M. Rosa1, B. S. Arantes1, D. B. F. Souza1, A. L. Castro1, R. F. P. Pedroso2, T. B. Machado1, M. A. F. Ribeiro Jr1 1 Santo Amaro University-UNISA, Sa˜o Paulo, Brazil, 2Private Clinic, Sa˜o Paulo, Brazil Background: The inguinal hernia is the second most common surgical pathology. Many different techniques have been described for its treatment. Open technique is used oftenly however the laparoscopic correction has shown to be very effective in hernioplasty. There has been a current tendency of doing a day-hospital surgical procedures in order to reduce costs, either in public and private health. The locoregional anestesia guided by ultrasound has absolutely contributed in a positive way to control pain in abdominal surgery postop. Considering both tendencies our proposal consists in joining total extraperitoneal (TEP) day-hospital surgery and locoregional anestesia of the square lumbar in inguinal hernioplasty. Methods: The locoregional anestesia of the square lumbar for a TEP laparoscopic inguinal hernia repair has already been accomplished. The paciente has been discharged at the same day of surgery showing no pain. Analgesy and anti-inflammatories were prescripted for three days and it has been followed upo n days 7, 14 and 21. Results: The patient denied any paresthesia or pain, showing no phlogiston signs over the incision. There were no signs of early relapse or other early complications. Conclusion: The laparoscopic TEP inguinal hernia repair making use of square lumbar muscle anestesia guided by ultrasound is perfectly doable and can be accomplished with low rates of complications and cost reducing. News studies must be developed.

P016 Posterior Component Separation-TAR (PCS-TAR) in the management of complex abdominal wall defects. Our experience with 40 cases P. Garcı´a-Pastor, A. Torregrosa, M. Lopez, J. Sancho, R. Jimenez, C. Muniesa, S. Bonafe, J. Iserte, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain Background: Abdominal wall surgeon must know and master different options to offer the right solution for each patient. Recently, various surgical techniques developed on component-separation basis. We present our experience with the Posterior Component SeparationTransversus Abdominis Release (PSC-TAR) in the management of complex abdominal wall defects. Methods: Since its description by the Rosen-Novitsky team, we’ve progressively implemented this technique in our group. We present data from our series (40 patients until January 2017): demographics, hernia’s analysis (dynamic CT-scan with Valsalva maneuver), preoperative tricks (10 cases preconditioned with Botulinum Toxin-A and progressive pneumoperitoneum), technical details, immediate postoperative and medium-term evolution (up to 24 months follow-

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Hernia (2017) 21 (Suppl 2):S208–S263 up). CT and MRI images provide pre-and-postoperative control, especially if new materials visible by imaging techniques have been used: multidetector-CT for absorbable prostheses (BioA, GoreÒ) and MRI for those with iron-nanoparticles (IPOM-visible, FEG-Dynamesh Ò). Then, we’re able to control positioning, retraction, folding and complications associated with prostheses. Results: Especially useful in lateral incisional hernias (lumbotomy, pararrectal for kidney transplantation) and paraestomal hernias (sometimes associated with midline), with the advantage of low morbidity in terms of wound ischemia-necrosis and wound dehiscence. Although follow-up is still scarce (max 24 months), results are encouraging. We found a reproducible and versatile alternative, with no complications specifically associated and no medium-term relapses despite the complexity. Conclusion: Our experience with PSC-TAR technique, although still initial, is very positive. We need to extend the follow-up period for a better valuation over time.

P017 A rare hernia: prevascular hernia. TEP repair ¨ zveri1, E. Hatipog˘lu2 H. Go¨k1, M. Ertem2, E. O 1 Acibadem Kozyatagi Hospital, ˙Istanbul, Turkey, 2Istanbul Uni. Cerrahpasa School of Medicine, ˙Istanbul, Turkey Background: A prevascular femoral hernia is a rare type of femoral hernia in which the neck lies anterior to the femoral vessels. Femoral hernias have been treated successfully by laparoscopic techniques, prevascular hernias can also be treated in this way. The anatomical basis and management of prevascular hernia are discussed. Methods: In this video, Left TEP hernia repair of 35 years old female patient are presented. During the operation, the prevascular hernia was diagnosed. Herniated lipoma through the defect reduced and mesh implantation was performed in a standard manner. Results: The patient was discharged uneventfully on postoperative day 1. There has seen no complication at the early and late follow-up period. Conclusion: Prevascular herniation is rare and the diagnosis may be difficult. It’s mostly diagnosed during the surgical exploration. Their laparoscopic repair does not differ from the repair of an inguinal hernia.

P018 Commentary on the Amyand hernia ¨ zveri2 M. Ertem1, H. Go¨k2, E. O 1 Istanbul Uni. Cerrahpasa School of Medicine, ˙Istanbul, Turkey, 2 Acibadem Kozyatagi Hospital, ˙Istanbul, Turkey Background: Claudius Amyand, was a French surgeon who performed the first successful appendectomy in 1735, on an 11-year-old boy who presented with an inflamed, perforated appendicitis in his inguinal hernia sac. To encounter an innocent appendices vermiformis within a hernia sac is quite possible. The possibility of the misplacement of the appendices is probably higher in repairs where the hernia sac is not opened and our experience indicates that the possibility of true Amyand is low. Methods: We have encountered an Amyand hernia accompanied by mucocel and performed an appendectomy during the laparoscopic hernia repair, which led us to make a review of approach to Amyand hernia. Results: The patient discharged uneventfully in postop day 1. The histopathological exam of the appendices was normal.

Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: What qualifies or does not qualify as an Amyand hernia is the subject of discussion here. An easily reducible appendices found in a hernia sac should not be considered as an Amyand hernia. The presence of a pathological situation of the appendices as well as its misplacement in the inguinal hernia sac should define an Amyand hernia. In adults with Amyand hernia, simultaneous appendectomy is under debate. As laparoscopic hernia repair techniques become more widespread, available options for approach to Amyand hernia increase. We believe that laparoscopic repair techniques present an advantage in such hernias.

P019 An innovative ‘‘555 Technique’’ for Mini TEP repair of inguinal hernia by all 5 mm ports M. K. Gupta, S. Idrees, K. Muley, M. K. Bethanbhatla, J. D. Nanavati, R. Sarangi Sir Ganga Ram Hospital, New Delhi, India Background: Accessing the pre-peritoneal space (PPS) by Hasson trocar for totally extra-peritoneal (TEP) repair of inguinal hernia is the only technique known to Laparoscopic Surgeons till now. It leads to bigger defect in the rectus sheath and large wound which causes more pain and cosmetically less acceptable. We have innovated a ‘‘555 Technique’’ for MINI TEP repair of inguinal hernia by all 5 mm ports. Methods: Mini TEP repair was done in 66 consecutive cases since Oct’ 2014. Innovative, inexpensive ‘‘Manish Retractor’’ plays a key role in accessing PPS. A 5 mm infra-umbilical port is made to create PPS, and two other 5 mm working ports for dissection. There is no need of costly Hasson trocar. Innovative technique of mesh insertion through 5 mm port is devised. Results: 29 indirect, 35 direct inguinal, 1 femoral and 1 obturator hernias were operated. The average duration of 1st port placement to access PPS was 150 s. All cases except one were successfully operated by this technique. There was no complication on 6 months follow up. Conclusion: ‘‘555 Technique’’ is simple, less invasive, less morbid, time saving and cost effective without compromising the principles of current surgical practice. It also avoids the dependence over Hasson trocar for TEP repair.

S213 nerve block with local wound infiltration is the anaesthetic technique of choice. All patients receive intraoperative opioid-free pain relief according to their allergies and comorbidities. Nursing staff check for absence of nausea, vomiting, shivering, pain and fainting feeling when sitting upright in the ward before discharge. Potential administered rescue therapies are noted into a clinical registry. During the first 5 postoperative days, patients are contacted by phone or undergo medical examination. The antalgic team (nurse, surgeon and anaesthetist) follow-up with the patients who suffer from ongoing acute pain and invite selected unresponsive cases to refer to the department of antalgic science. Results: Our experience demonstrates chronic pain onset incidence of 5%, far less than 10% described in literature. Conclusion: The data are actually not complete and susceptible to criticisms but implementation of multidisciplinary approach in hernia surgery could determine a lower rate of complications, costs and unnecessary inpatient admissions.

P021 Simultaneous minimally invasive procedures in patients with groin hernia combined with spigelian hernia M. Halei1, I. Shavarov1, K. Halei2 1 Volyn Regional Clinical Hospital, Lutsk, Ukraine, 2Ternopil State Medical University, Ternopil, Ukraine Background: With the introduction of minimally invasive technologies in herniology, intraoperative diagnostics of bilateral groin hernia (GH) was significantly improved, accordingly, not frequent combination of GH and spigelian hernia (SH) is increasingly discovering. Methods: 43 minimally invasive simultaneously hernia repair were operated, within 38 (88.37%) with bilateral GH-TAPP was performed, and 5 (11.63%) with combination of GH and SH—also TAPP in both hernias was perfopmed. Results: The average postoperative hospital stay was 3.2 days. All patients were in the absence of postoperative pain discharged. There were no postoperative complications observed. Conclusion: The implementation of simultaneous minimally invasive operations allows: to decrease the period of postoperative hospital stay, to improve cosmetic effect, to discover not diagnosed hernias.

P020 Open mesh inguinal hernia repair in Day Surgery: our anesthesiological approach

P022 41 cases of round ligament varicosities that easily misdiagnosed as inguinal hernias

L. Guzzetti, L. Latham, F. Giuffrida, G. Stuppia, M. Binda, C. Lanza, C. Peverelli, I. Ceriani, D. Sambucci, S. Cuffari, E. Cocozza, A. Ambrosoli A.O. di Circolo Ospedale di Varese, Varese, Italy

Y. Huang, P. Wang, G. Gao, J. Ye, F. Zhang, H. Wu Hangzhou First People’s Hospital, Hangzhou, China

Background: Nowadays most recurrent inguinal hernia mesh repairs are performed in selected outpatient surgical units, many of which follow a specific clinical pathway characterized by preoperative optimization, tailored intraoperative patient management and postoperative clinical evaluation. Methods: In our Day Surgery Department we have a standardized anesthesiological approach for patients undergoing open mesh inguinal hernia repair. During preoperative assessment, great importance is given to daily use of antalgic drugs, to preoperative pain intensity, location and nature. A few patients are admitted to the inpatient surgical unit but the majority of procedures are performed within outpatient setting. Ultrasound guided ilioinguinal and iliohypogastric

Background: Round ligament varicosities(RLVs) in pregnancy, present swelling or soft masses in the inguinal area reducible after pressing, with or without swelling pain, which are similar to inguinal hernias. Differential diagnosis would be difficult if only according to medical history and physical examination. So RLVs are easily misdiagnosed as inguinal hernias, and it would do much harm to those patients if surgical procedures go with the misdiagnosis. Ultrasonography could differentiate RLVs from inguinal hernias precisely, and is the most important examination in differential diagnosis between these two diseases. Methods: Retrospectively analyzed clinical materials of 41 consecutive cases of RLVs diagnosed by ultrasound in single hospital from January 2011 to December 2015. Misdiagnosis rate, clinical and

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S214 sonographic features, management after diagnosis and prognosis were recorded. Results: All of the 41 cases were pregnant females in the second or third trimester. 28 cases were firstly misdiagnosed as inguinal hernias (68.3%). 30 cases complained of reducible masses in the inguinal area (73.2%), 25 cases swelling pain as well as mass (61.0%), and 4 cases swelling pain without mass (9.8%). 7 cases were diagnosed during routing pregnant examination of ultrasound without any complaints (17.1%). All cases were justified a wait-and-see policy. 37 cases were followed until total recovery after delivery (follow-up rate 90.2%). Mass or swelling pain disappeared spontaneously postpartum in all cases. Conclusion: RLVs are easily misdiagnosed as inguinal hernias. Ultrasonography of the inguinal area is the best examination to make a correct diagnosis. Conservative therapy is beneficial and safe when assured by ultrasonography.

P023 A study of short-term postoperative pain factor on inguinal hernia H. Imazu Imazu Surgical Clinic, Nagoya, Japan Background: Postoperative pain is the most important factor on day surgery for inguinal hernia. I was considering some factors affecting this pain. Methods: Subjects were 3892 lesions (3691cases). Pain grade was classified into 5 stages (0: none, 1: feeling pain only moving, 2: sometimes, 3: mild continuous, 4: severe pain). I compared several factors in the POD1 and POD21. I examined the following factors. The period of operation, Gender, Age, Skin cuts length and deference of mesh. Results: The POD1 was 0: 43.8%, 1: 32.7%, 2: 5.7%, 3: 17.8%, and only one case of uncontrollable pain was found. At the POD21 reexamination, 0: 86.6%, 1: 3.1%, 2: 9.3%, 3: 1%, all cases were within self-control. There were no differences in the pain on the POD1 and POD21 when the operation was divided into three stages. The ratio of male to female was 98: 11, male had superior postoperative painless cases and there were few cases of persistent pain, but there was same in the POD21. Compared to age group, the older the younger than 20 age group, the more the pain tended to be stronger immediately after surgery. There was no significant difference in size and pain of a wound on skin cut length and mesh type. Conclusion: The POD1 pain was strong tendency toward women, young people. No relationship between the size of the wound and pain intensity. Type of mesh and the pain had no correlation.

P024 Laparoscopic treatment of primary ventral and incisional hernias with Relimesh: our expirience S. Jovanovic Center for minimally invasive surgery, Nis, Serbia Background: Hernia is an opening or weakness in the muscular structure of the wall of the abdomen. This defect causes a bulging of the abdominal wall. This bulging is usually more noticeable when the

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Hernia (2017) 21 (Suppl 2):S208–S263 abdominal muscles are tightened, thereby increasing the pressure in the abdomen. Methods and materials: The mesh is placed from the internal side of the abdominal wall, with the use of a laparoscopic procedure that minimizes the operative trauma and enables fast recovering. According our experience with laparoscopic solving of ventral and incision hernias, we used Relimesh. Meshes (Herniamesh, Italy) made with polypropylene and ePTFE, used in open techniques and in laparoscopic procedures. They are available in different dimension. We fixed the mesh with non-absorbable suture (prolene 0) and tackers (Protack). Results: During the period from April, 2010 till January 2016 in Center for minimally invasive surgery Nis, were perfomed 165 operations of primary ventral (68) and incisional (88) hernias, using Relimesh by laparoscopic techniques.We used 121 mesh dimension 11 9 14 cm, 41 mesh 14 9 18 cm, and 3 mesh dimension 25 9 35 cm. There was two operative complication—intestine lesion, which caused to mesh infection and enterocutaneous fistula and one abscessus of abdominal wall. We had 5 relapses. The cases were solved with mesh extraction and Ramirez tension technique. We had 5 relapses. Conclusion: The Relimesh using in laparoscopic treatment of ventral hernias is technically easy, efficiently and brings a huge benefit for patient.

P025 Laparoscopic umbilical hernia repair with noncomposite mesh: how I do it? K. Ketwong, P. Jitpratoom, A. Anuwong Police General Hospital, Bangkok, Thailand Background: With advances of laparoscopic technology, umbilical hernia can be repaired with laparoscopic technique. But we have to repair with composite mesh which is quite expensive especially in our developing country. This study is conducted to use non-composite mesh (polypropylene mesh) instead of composite mesh to repair umbilical hernia with Transabdominal preperitoneal (TAPP) repair technique. Methods: The patient is 40-year-old male presented with reducible mass at umbilicus for 1 year without history of previous surgery. The abdominal ultrasound showed umbilical hernia with 5 cm of defect. He underwent laparoscopic umbilical hernia repair by polypropylene mesh with TAPP repair technique. The operation was started with creating peritoneal flap like TAPP repair, reducing hernia sac, anchoring the polypropylene mesh with spiral tacks, and closing peritoneal flap. Clinical data was recorded. An informed consent was obtained. Results: Umbilical hernia was managed successfully with laparoscopic polypropylene mesh by TAPP repair technique. The operative time was 90 min with estimated blood loss of 20 ml. There is no immediate postoperative complication such as bowel injury. The patient was discharged safely two days after the operation. We followed-up the patient at two weeks after the operation, there is no umbilical hernia recurrent. Conclusion: Laparoscopic umbilical hernia by polypropylene mesh with TAPP repair technique might be an alternative choice of umbilical hernia repair in restricted budget situation. However, longterm outcome should be observed.

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P026 A prospective study of 48 patients symptom load before and after repair of parastomal hernia M. Krogsgaard1,2, B. Pilsgaard2, T. B. Borglit2, J. Bentzen3, L. Balleby2, P. Krarup2 1 Abdominal Centre, Rigshospitalet, University of Copenhagen, Copenhagen Ø, Denmark, 2Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen, Copenhagen NV, Denmark, 3 Danish Mental Health Fund, Copenhagen NV, Denmark Background: There is no consensus on how to report symptoms in patients with parastomal hernia (PH), and very few studies have investigated symptoms before and after surgery. The aim of the study was to determine the symptom load before and after surgical repair of PH. Methods: Stoma-related symptoms were prospectively recorded before, 10 days and 6 months after PH repair with the Sugarbaker technique. Symptoms were registered using a standard form based on existing literature and included: Leakage, skin problems, difficulty with the appliance, limitation of activity, difficulty with clothing, cosmetic complaints, social restriction, erratic action of the stoma and a bearing-down sensation at the site of the stoma and pain. Results: Forty-eight of patients referred with PH to a specialized centre, were treated with a slightly modified Sugarbaker technique. Preoperatively a bearing down sensation (71%) and pain (64%) were the most prevalent symptoms. The number of symptoms decreased in more than 90% of patients. At six months, only the prevalence of skin problems and leakage were not significantly reduced compared with the preoperative level. The overall symptom load decreased significantly from median of 4 (IQR 2.5–6) preoperatively to 2 (IQR1–3) on postoperative day 10 and 1 (IQR 0–2) at six months, P \ 0.001. Conclusion: The preoperative symptom load was high and this underlines the importance of detailed knowledge regarding the symptomatology of PH when addressing patient’s problems and complaints. Symptom load was reduced after PH repair.

P027 Comparative analysis of the TAPP and TEP in the treatment of inguinal hernias: 1 year observation period S. Kuliev, V. Egiev SM-Clinlc, Moscow, Russian Federation Background: Currently, hernia repair is one of the most common operations in abdominal surgery. Their use allows to achieve a reliable closure of the hernia defect with few complications and a low frequency of disease recurrence. Search Results TAPP and TEP by using one kind of a mesh implant for the treatment of unilateral inguinal hernia, without fixing led us to carry out their own research. Methods: We included in the study 610 patients were operated from April 2014 to October 2015. Among them were 207 women-34% and 403 men-66%, aged 21–79 years. Results: During the study, 323 patients underwent Tapp and 287 patients underwent TEP using one type and one manufacturer of the mesh implant lightweight macroporous polypropylene prosthesis, without fixation of the mesh implant. The duration of hospital stay in TAPP group averaged 3.5 days, and in group TEP 2 days. In each group, one relapse observed. Duration TAPP operation group was 50 min on average, while in the group TEP 35 min. The analysis found that the differences in pain and quality of life are stored up to 3 months after surgery, and at 6 and 12 months after surgery, patient satisfaction after surgery TAPP or TEP did not differ.

S215 Conclusion: Thus, when TEP shorter hospitalization, less pain syndrome the first 90 days, which contributes to the early rehabilitation of patients and their return to a normal and everyday lifestyle.

P028 Single-port mini laparoscopic herniorrhaphy for pediatric inguinal hernias by hernia forceps and spinal needle: a simple method of hernia repair in children P. Li Yan’an Hospital of Kunming City, Kunming, China Background: The clinical effectiveness of laparoscopic high ligation in treatment of inguinal hernial sac in children has gradually been accepted and approved by surgeon, but various methods of repair have been described. Basic principle is to close the internal inguinal ring either by intracorporeal or by extracorporeal suturing. Methods: The objective of our study is to describe and evaluate the outcome of a simple technique of internal ring closure by a hernia forceps and a spinal needle. A total of 98 hernias in 70 patients were repaired. A 2-0 prolene thread was passed percutaneously around the internal inguinal ring by threading it though a hernia forceps and a spinal needle under mini laparoscopic control. The suture is then tied extracorporeally in the subcutaneous plane. The 70 patients included 49 boys and 21 girls operated on for inguinal hernia. The age was 1.2–10 years. Right-sided hernia was present in 28 cases and leftsided hernia in 24 cases, and 18 cases had bilateral hernia. Results: All surgery was successful without any intraoperative or postoperative complications. The mean operative time was 9 (range 7–12) min in 52 cases of unilateral repair and 19 (range 15–24) min in 18 cases of bilateral repair. Conclusion: This new technique has all the advantages of laparoscopic hernia repair in children (minimally invasive, less pain, less complication, and cosmesis). In addition, the method is simple, It is easy to perfect and to perform and therefore is a worthy choice for pediatric inguinal hernias.

P029 Single day surgery for inguinal hernia repair M. R. Maksimovic´, I. Zarev, Z. Veselinovic General Hospital Studenica, Kraljevo, Serbia Background: Inguinal hernia operation in surgery department, when the patient get released the same day or within 23 h after the intervention, is considered single day surgery or ambulatory surgery. Single day department of General Surgery Ward have been founded since 2010th. For last 6 years it has been operated over 1650 patients with inguinal hernia. All patients were operated under local anesthesia Novocaine chloride 2%, with medication. Patients were operated various operating techniques, tension and non–non tension. Methods: Retrospective control study. Results were collected using ‘‘Helliant’’ Medical Software. Results: Almost 95% patients were male. Most of the patient were NYHA 1 and 2 criteria. We have also operated patients from NYNA 3 & 4 criteria. At first we used heavy weight prosthesis, but from 2013th we implanted over 950 prosthesis H80611 Herniamesh S.r.lÒ. The most common used technique is Lichtenstein 84%, followed by Rives operating technique 3.5%. Relapses and late complications we have depressed from 5 to 1.71%. We had 2 cases of rejection and 5 cases of infection of prosthetic material. It is not conducted adequate

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S216 testing and monitoring recovery time measured the quality of life questionnaires or surveys about the end of sick leave. Conclusion: Single day surgery for inguinal hernia, under local anesthesia, demands adequately conducted selection of patients. It represents safe,less expensive, way of operative treatment of inguinal hernia, with no difference in the occurrence of infection or relapse, in relation to the conventional method of treatment. Prothesis H80611Ò is by our experience excellent choice.

P030 Laparoscopic inguinal repair with combined transabdominal approach and intrabdominal onlay PTFE Dualmesh Plus D. Del Castillo, P. Martinez, E. Raga, A. Mun˜oz, E. Homs, M. Vives, J. Domenech, E. Bartra, A. Sanchez, M. Paris, M. Pin˜ana, F. Sabench Hospital Universitari de Sant Joan, Faculty of Medicine, Reus, Spain Background: The Authors report their experience on laparoscopic hernia repair using the intraperitoneal onlay mesh repair combined with transabdominal aproach in 255 patients. Methods: Twenty patients had a monolateral hernia, 15 of which were recurrent and 235 had a bilateral hernia, 76 of which were recurrent. Overall, a total of 490 hernias were treated. The hernia repair was performed by using GORETEX Dual Mesh Plus biomaterial with a peritoneal flap is performed. The prostheses were fixed with titanium spiral tacks (Protack, Auto Suture, Tyco Healthcare). Results: No intraoperative complications occurred and no conversion was necessary. Five minor postoperative complications (1.9%), 1 seromas, 1 transient parestesias and 3 with urinary catheter. Only twenty patients (7%) needed analgesics after the first 24 h. Mean hospital stay was less 24 h for 235 patients, 24–48 h for 12 patients and 8 for 48–72 h. Mean resumption of normal activity was 8 days with return to work within two weeks. At an average 12 months follow-up, 5 recurrences were recorded (1.9%). Conclusion: The results of this study, indicate that the intraperitoneal onlay mesh combined with transperitoneal approach using PTFE Dualmesh may be a feasible, safe and effective procedure in the treatment of recurrent and bilateral hernias. No major complications happened and low recurrence rate.

P031 Inguinal hernia repair and self-adhering mesh A. Messina Campanella, J. Atzeni, A. Saba1, G. Poillucci, E. Pinna, P. Serra, S. Licheri, A. Pisanu Policlinico Universitario di Monserrato, Cagliari, Italy Background: This retrospective cohort study analyzes the postoperative outcomes of patients with primary inguinal hernia who underwent hernia repair by sutureless technique, with self adhering Polypropylene Prosthesis (AdhesixÒ). Our purpose is to evaluate recurrence, early post operative complications and chronic pain in hernia repair. Methods: From January to June 2015, we treated 40 consecutive patients with primary inguinal hernia, who underwent, sutureless Lichtenstein hernia repair using light self adhering Polypropylene mesh (AdhesixÒ) in Day surgery. Adhesix is light polypropylene mesh coated with polyethylene glycol (PEG) and polyvininylpirrolidone (PVP). We evaluated characteristics of the patients, early postoperative complications, recurrence and chronic pain, by clinical follow up (3 days, 10 days, 1 month, 12 months and 24 months) and using visual analogue scale (VAS).

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Hernia (2017) 21 (Suppl 2):S208–S263 Results: We treated 40 patients: 34 male (85%) and 6 female (15%). Mean age was 56 years (range 28–80 years). Mean follow-up was 21 months (range 18–24 months). 2 patients presented chronic seroma (5%). No cases of postoperative chronic pain and no recurrence were observed during follow up. Conclusion: The use of light weight self adhering mesh (AdhesixÒ), is a safe, easy and acceptable alternative approach to inguinal hernia. Our results showed a low incidence of early postoperative complications, no recurrence and no cases of post-operative chronic pain. Nevertheless we believe that a long follow up is necessary to evaluate the real post operative recurrence.

P032 Umbilical hernia with primary umbilical endometriosis, description of the ablation and reconstruction with the Celtic cross technique A. Messina Campanella, S. Licheri, M. Podda, G. Poillucci, A. Pisanu Policlinico Universitario di Monserrato, Cagliari, Italy Background: We present a case of primary umbilical hernia and endometriosis, with the aim to highlight the challenges encountered during the diagnostic and therapeutic workup. Methods: A nulliparous 39-year-old woman presented at our department with a 2 year history of a tender, painful, non-reducible, firm umbilical macroscopic mass that enlarged slowly reaching 0.6 cm in diameter. She had never been pregnant nor had any abdominal surgery. No sequential bleeding was reported in anamnesis. We reached the diagnosis by clinical examination, ultrasound scan and Fine-Needle Aspiration Citology (FNAC). No others localization for endometriosis at the Gynecology consulting were found. A direct wall reconstruction was performed (Vicryl 2/0) and the removal of the umbilical scar was carried out using the Celtic cross technique under local anesthesia. We performed a follow up of 12 months (1, 3, 10 days, 1, 3, 6, 9 and 12 months). Results: We evaluated the patient during 12 months of follow-up, and we find no recurrence (no hernia and no endometriosis), no early post operative complication and no chronic pain. Conclusion: This study describes an uncommon case of primary umbilical hernia and endometriosis. The patient underwent surgical ablation of the umbilicus, with direct wall suture and immediate reconstruction through Celtic cross technique. At the 12th month follow up appointment, the result was aesthetically acceptable, with the scar that mimed a new umbilicus.

P033 Efficacy of tumescent anaesthesia vs ilioinguinal field block in inguinal hernia repair: A randomized controlled trial T. S. Mishra, S. Meher, S. Mishra, P. K. Sasmal, R. Sharma, S. Rath, B. Rout AIIMS Bhubaneswar, Bhubaneswar, India Background: Local anaesthesia for performing Lichtenstein’s tension free hernioplasty is under-used despite proven benefits. An ideal technique of local anaesthesia could increase its acceptance. The tumescent anaesthesia technique of giving local anaesthesia is now being increasingly used for these surgeries instead of the traditional

Hernia (2017) 21 (Suppl 2):S208–S263 ilio-inguinal field block, although few studies have demonstrated the superiority of one over the other. Methods: A prospective, single blind, randomized control trial was undertaken to compare the efficacy both techniques using various parameters. Results: Ninety-four patients were included in the study, 47 patients being placed in each arm. There was no significant difference in intraoperative and post operative pain relief (p 0.59, p 0.63). The post operative pain relief was longer with tumescent anaesthesia (255.19 vs 218.97 min), although it was not statistically significant (p 0.56). Minor intra-operative complications were more in the tumescent anaesthesia group (27.6 vs 6.8%). There was no significant difference in number of top up used during operation in either arm (82.9 vs 70.2%). However total dosage of anaesthesia used in tumescent anaesthesia was significantly lower than ilio-inguinal block (95.9 vs 200.3 mg, p 0.00) and patient satisfaction was more in tumescent anaesthesia than ilio-inguinal block(p 0.03). Conclusion: The dose of local anaesthesia required in tumescent anaesthesia is significantly lower than that in ilio-inguinal field block method, despite having similar efficacy. This technique can be beneficial in bilateral inguinal hernia repair and in obese without the running the risk of overdosing.

P034 The inguinal measurements in African population to assess the standard mesh size for hernia repair in low-income countries K. Mitura1, S. Kozieł2 Siedlce Hospital, Department of General Surgery, Siedlce, Poland, 2 Department of General Surgery, Beskid Center of OncologyMunicipal Hospital in Bielsko Biała, Bielsko Biała, Poland

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Background: The Lichtenstein repair is a globally used and effective surgery using mesh to reinforce the floor of inguinal canal. Small mesh size is considered as one of the factors responsible for recurrence after Lichtenstein repair. Although there are available different sizes of commercial meshes, in low-income countries the access to multiple products isn’t supportable and it is necessary to use the only available mesh size or mesh has to be trimmed out of large sheet. There are no data available whether the standard size of the mesh used in routine clinical practice in European countries is compliant with the anatomy of native Africans in low-resource healthcare countries. Methods: During the humanitarian medical mission of Polish surgeons to Tanzania in 2016, 75 surgeries were performed, including 47 herniorrhaphies. During each hernia repair the detailed measurements of key dimensions were taken and compared to respective values assessed intraoperatively in elective hernia repairs in patients in Poland. Results: The diameter of inguinal internal ring was 1.6 ± 0.8 cm in African group and 2.3 ± 0.6 cm in European group. The length of inguinal ligament between pubic tubercle and medial margin of internal ring respectively—3.9 ± 0.6 vs. 4.9 ± 0.8 cm; length of transverse arch aponeurosis 4.1 ± 0.6 vs. 5.3 ± 0.7 cm; length between the midpoint of the inguinal ligament and the transverse arch aponeurosis 2.7 ± 0.8 vs. 4.1 ± 1.1 cm. Conclusion: The recommended mesh size should be revised in regard to anatomical characteristics of patients in low-income countries. It may determine smaller size of implanted mesh with no influence on increased risk of recurrence.

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P035 Tailor made repair of inguinal hernia after lower abdominal surgery T. Nagahama Department of Surgery, Kudanzaka Hospital, Tokyo, Japan Background: TEP hernia repair after lower abdominal surgery may have risk for conversion to open repair due to technical difficulties. We have evaluated our series of TEP repair for patients with previous lower abdominal surgery to propose strategy for tailor made hernia repair. Methods: 14 patients of inguinal hernia (unilateral: 7, gilateral: 7) with previous history of lower abdominal surgery received TEP hernia repair were reviewed. Breakdown of previous surgery was total hysterectomy: 5, low anterior resection: 3, sigmoid-colon resection: 2, prostatectomy for prostatic hypertrophy: 2, replacement of aortic aneurysm: 1, repair of open abdomen: 1. Results: Among 21 lesion, 6 lesions needed conversion to open repair due to difficulty in dissecting pre-peritoneal space. Breakdown of those patients were radical hysterectomy: 1, low anterior resection: 3, prostatectomy: 1, open abdomen: 1. On the other hand, for patients who received sigmoidectomy, simple hysterectomy, replacement of abdominal aorta, TEP could be successfully completed regardless of previous procedure. Our evaluation could demonstrate that previous lower abdominal surgery was not regarded to be contraindication for TEP. However, for patients with previous pelvic node resection, dissection or inflammation of pre-peritoneal space, we should recognize that there is risk for conversion to open repair due to preperitoneal scar formation. Conclusion: For designing tailor made hernia repair, previous pelvic node resection and dissection of pre-peritoneal space are key factor to decide approach between open and TEP. Open repair may be recommended for those patients.

P036 A single-center experience with laparoscopic intraperitoneal onlay mesh repair (IPOM) in 159 patients S. Ntaoulas, F. Solimene, P. Nussbaumer Lachen, Lachen, Switzerland Background: Abdominal wall hernias are very common and there are different techniques available for a repair. We report our results of 10 years’ experience with intraperitoneal onlay mesh repair (IPOM) regarding short and long-term outcome comparing different meshes. Methods: We included 159 IPOMs performed for primary or secondary abdominal wall hernias in our hospital between 6/2006 and 2/2015. Mean age of patients was 59 (31–89) years with 99 male and 60 female patients. Experienced surgeons principally performed the operations according to our institutes SOP. A first follow-up including clinical examination was planned 12 weeks after the operation. All patients were followed up 2016 with a questionnaire with particular reference to hernia recurrence, local complications and reinterventions. Results: The 159 hernias treated are allotted as follows: Primary 60; Incisional 78; Recurrent 13; Various 8. Early complications reported included 2 wound infections; of which 1 was treated with negativepressure wound therapy. Hematomas were found in 3 patients. Most

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S218 patients were satisfied with the result at 12 weeks follow-up. 26 patients (13.2%) had residual pain by movement and 6 patients (3.8%) described abdominal discomfort. 1 case of subileus und 1 chronic wound infection were reported. A seroma formed in 6 patients (3.8%). 72 patients could be analyzed after a mean follow-up of 68 (12–120) months. Conclusion: Laparoscopic intraperitoneal onlay mesh repair for abdominal wall hernias seems to be safe and efficient with good longterm results. We did not find any correlation between complications und the type of mesh or the fixation used.

P037 Mesh infection after open incisional hernia repair-our expirience V. Pejcic, S. Jovanovic Center for minimally invasive surgery, Nis, Serbia

Hernia (2017) 21 (Suppl 2):S208–S263 support and care, patient’s compliance. A telephonic interview is performed on the next day after surgery and in 2nd postoperative day monitoring is carried out in a dedicated ambulatory. Other follow up are carried out after 8 and 30 days. Results: From October 2016 we have performed 7 laparoscopic hernia repairs: n.3 inguinal hernias, n.3 incisional ventral hernias, and n.1 Spigelian hernia. Average age: 53.4 years; average BMI 24.8 Average duration of surgical procedure is 80 min. No prolonged hospitalization has been needed and we had no perioperative complications. All had early mobilization, spontaneous diuresis and early feeding. VAS average was 1.14 in the first P.O.D. VAS average was 1.57. Only one had nausea (14.2%). In second postoperative day, no case of nausea or vomiting, and VAS average was 1.43. Conclusion: Although our experience of laparoscopic hernia repairs in day surgery is limited, it seems to be feasable in carefully selected and educated patients, and it is a viable alternative to inpatient, with obvious advantages in terms of costs and comfort for the patient.

Background: Incisional hernia occurs after 3.8–11.5% of all abdominal operations. Due to high recurrence rate following conventional repairs like Mayo, direct suture repair, in 1999 we started to use polypropylene mesh in open repair of incisional hernias. The aim of this study is to show our experiences with mesh infection after incisional hernia repair. Methods: Since 1999 until present day we have operated 646 patients with incisional hernia, using prosthetic repair (Rives-Stoppa, Trabucco, Chevrel). Patients were hospitalized after previous examination of anesthesiologist. Median age of patients was 65 (28–74 years). There were 214 men (32.73%) and 432 women (67.27%). All were operated in general anesthesia. We have analyzed correlation between size of the hernial defect and infection. Results: Most of our patient received one-shot prophylaxis. Average hospitalization was 8.5 days (2–45). 64.55% (416 patient) had postoperative drainage with one or two Radon drains. Duration of drainage was 2–5 days. We had 8. 18% (53 patients) deep infections, which were caused by: Staphylococcus aureus, Proteus mirabilis, E. coli, Bacterioides fragilis. All infections occurred among patients with hernial defect wither then 10 cm. We treated them with antibiotics according to antibiogram, and local wound treatment. Five cases needed mesh extraction. Conclusion: Tissue trauma, operating time and mesh size increases the risk for infection. Infections were caused by nosocomial spices. Since these factors are crucial for infection probably laparoscopic approach is more useful and decreases morbidity of these patients. Laparoscopic repair is to become priority for incisional hernia repair.

P039 Individualized treatment of the elderly tension-free hernia repair

P038 Our early experience in laparoscopic hernia repair in day surgery

P040 Laparoscopic umbilical hernia repair

C. Peverelli, L. Latham, L. Livraghi, M. Berselli, L. Farassino, D. Sambucci, V. Marchionini, V. Raveglia, M. Ripamonti, V. De Berardinis, A. Ambrosoli, E. Cocozza A.O. di Circolo Ospedale di Varese, Varese, Italy Background: laparoscopic ventral or inguinal hernia repairs is performed in day surgery only in few centers in Italy. Minimally invasive technique ensures minimal postoperative pain and rapid recovery and this, combined with accurate patient selection, granted feasibility of these procedures. Methods: Appropriate selection criteria are needed in order to enlist the patient: age\70 years, absence of severe comorbidities (ASA I or II), BMI \ 30, hospital-home distance \30 min, adequacy of family

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C. Qin, J. Chen Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: To analyze tension-free hernia repair surgery carried in the elderly in terms of operation method, anesthesia method and therapeutic effect. Methods: A toal of 1652 cases of elderly patients with tension-free hernia repair performed in our hospital from September 2012 to September 2014 were retrospectively analyzed. We compared different operation schemes for operation time, postoperative pain, postoperative narcotic response, time to leave bed, time to active food intake, length of hospital stay, wound complications, recovery time, recurrence rate, and time to resuming routine daily life, etc. Results: All the elderly patients with inguinal hernia were cured, and the therapeutic effect was satisfactory. There has been no recurrence, and no wound infection. Compared with general anesthesia surgery, local anesthesia surgery has advantage in shortening the time to resuming daily life, time to leave bed, time to active food intake, and length of hospital stay. (P values \0.05). Conclusion: Individualized care plan is satisfactory in the surgical treatment of elderly inguinal hernia. Tension-free hernia repair in the elderly is safe, fast, and effective.

V. Quintodei1, G. Borroni1, M. R. Moroni2, P. Veronesi2, D. Chiari2, M. Platto2, D. Tornese2, P. Militello2, W. Zuliani2 1 University of Insubria, Varese, Italy, 2Humanitas Mater Domini, Castellanza, Italy Background: This video shows the laparoscopic umbilical hernia repair technique using intraperitoneal, double-layed e-PTFE/PP mesh RelimeshÒ (HerniameshÒ Srl, Italy) fixed with absorbable fixation device in our high-volume center with over 100 procedures performed in 5 years. Methods: a 78 years old female patient with a psst medical history of cataracts, mellitus diabetes and essential hypertension, with a current weight of 80 kg and a height of 165 cm (BMI = 29.4), comes to our department for an umbilical swelling increasing in size in the last

Hernia (2017) 21 (Suppl 2):S208–S263 15 years. At the physical examination we notice a not reducible umbilical hernia with a 25 mm abdominal wall defect. The patient underwent to pre-operative CT-scan that confirmed a 4 cm abdominal wall defect, with a 10.5 9 6.5 x 11 umbilical hernia with omentum and large bowel tract inside. Results: According to the European Hernia Society Classification for Primary Abdominal Wall Hernias (2009) we identified a medium umbilical Hernia (M3). Conclusion: The patient underwent to laparoscopic incisional hernias repair with intraperitoneal, double-layed e-PTFE/PP mesh RelimeshÒ (HerniameshÒ Srl, Italy) with no complications. She was discharged in 3POD. The 3-months follow-up shows no recurrence nor chronic pain.

P041 Dilemmas in dealing with incarcerated hernias: guidelines for the general surgeon on-call A. Rapoport1, S. Biswas1, A. Bukin1, D. Hazan1, I. Waksman2, E. Solomonov1 1 Ziv Medical Center, Galilee, Israel, 2Galilee Medical Center, Naharia, Israel Background: Dealing with patients with large abdominal wall defects, incarcerated umbilical or incisional hernias may challenge the expert hernia surgeon and general surgeon alike. We present our experience of emergency surgery in patients with incarcerated hernias as guidance for surgeons unaccustomed to specialist hernia surgery. We propose an optimal technique in dealing with these hernias and the common complications that arise, including infection and skin necrosis, so that further surgery and definitive repair, if necessary, is easy to perform. Methods: Since 2011, 20 patients with large incarcerated ventral incisional or umbilical hernias have been operated by non-specialist hernia surgeons during emergency on-calls. All patients underwent open surgery, 7 required resection of bowel or omentum, and all patients had onlay repairs using ULTRAPRO (partially absorbable lightweight) mesh. At follow up, no patient has suffered recurrence. Results: We propose the following guidance: take the patients to the operating theatre; proceed with repair (usually through an open approach) with minimal dissection in order to define the margins of the defect and resect non-viable tissue; repair the hernia defect via primary suture; place biological mesh (such as ULTRAPRO) using the onlay technique; and, close the wound in layers. If complications of infection or skin necrosis ensue, the wound may be managed with negative pressure wound therapy and antibiotics. ULTRAPRO mesh allows easy access to superficial planes and does not preclude future hernia repair should there be recurrence. Conclusion: This relatively simple technique is ideal for non-hernia specialist surgeons and provides good patient outcomes.

P042 Local anesthesia foropen inguinal hernia repair: standardisation is our way to success N. Ruyssers, M. Huyghe GZA St Augustinus Hospital, Antwerpen, Belgium

S219 high patient satisfaction. Despite this advantages, many surgeons prefer general or spinal anesthesia. Methods: Since 2009 we routinely propose local anesthesia to patients. Complete reducibility of the hernia and thorough informed consent are prior conditions. In all cases we performed a Lichtenstein hernioplasty. Bilaterals were operated with interval of at least one week. Local anesthesia is administrated in standard ‘‘step by step’’ procedure: (1) Lidocaine 1% adrenaline: slow cutaneous infiltration 10 cc into incision site. (2) Lidocaine 0.5%: 20–40 cc for all deeper layers. (3) Important: lateral dissection towards external oblique fascia, immediately infiltrate it underneath with 3–5 cc before opening and before dissection towards the external ring. (4) Adding small amounts into the fibers of Pouparts ligament near the pubic tubercle, in the cremaster layers around the internal ring and into the peritoneal sac. Results: More than 500 patients underwent inguinal hernia repair under local anesthesia, if desirable with light sedation. Patient satisfaction is high, not only concerning the experience of local anesthesia but also the fast and pain-free recovery. Conclusion: Local anesthesia is our first choice in patients with a completely reducible inguinal hernia. It can be proposed to the majority of patients and has the advantage avoiding side effects of general or spinal anesthesia. It makes this surgery more accessible to elderly patients with sometimes important comorbidities.

P044 Simultaneous laparoscopic procedures in patients with gallstone disease and hiatal hernia I. Shavarov1, M. Halei1, K. Halei2 1 Volyn Regional Clinical Hospital, Lutsk, Ukraine, 2Ternopil State Medical University, Ternopil, Ukraine Background: Gallstone disease (GD) is relevant pathology in surgery that deteriorates patients’ quality of life and decreases working capacity. Often this disease combines with hiatal hernia (HH). Methods: 1420 patients with chronic calculous cholecystitis were operated between 2011 and 2016, within 48 (3.38%) had the combination of GD and HH. Among this 48 persons with combined GD and HH pathology: male—10 (20.83%), female—39 (79.17%). The average age of patients approximately 53 years. As the first stage HH repair was performed by Toupet using 5 ports: (1) 10 mm (video) in the median line, 2–5 cm above the navel. (2) 5 mm right under xiphoid process. (3) 10 mm in the left mid-clavicular line below the rib. (4) 10 mm—in the right mid-clavicular line below the rib. (5) 10 mm in the middle of distance between 1 and 3 ports. As the second stage laparoscopic cholecystectomy was performed. Additional port in right front axillary line below the rip was inserted. Thus procedure duration decreased and surgeon’s easement was provided. Results: Postoperative hospital stay amounted 3.4 days, recovery period—the same as after only HH repair. Additional port didn’t cause more postoperative pain. Conclusion: Simultaneous surgery of combined pathology (GD and HH) minimizes the number of surgical interventions in patients of this category, which is reflected in hastening the recovery of working capacity and providing higher level of quality of life after surgery. This approach may be the method of choice for this combination of pathologies.

Background: Hernia repair under local anesthesia is safe, produces less pain and nausea postoperatively. It’s cost saving and results in

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P045 Laparoscopic transabdominal preperitoneal repair of inguinal hernias using acellular tissue matrix grafts Y. Shen, C. Qin, B. Wang Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: To explore the value and the clinical effect of laparoscopic transabdominal preperitoneal (TAPP) hernia repair with acellular tissue matrix grafts. Methods: Clinical data of 36 cases of inguinal hernia who underwent laparoscopic TAPP hernia repair with ACTM grafts from January 2014 to January 2016 in Beijing Chao-Yang Hospital, Capital Medical University, were retrospectively analyzed. Postoperative complications and recurrences were recorded. Results: Operations were completed successfully in all 36 cases and none was converted to open surgery. The mean operation time was (44.5 ± 7.8) min (range 33–62 min) and the mean hospital stay was (3.5 ± 1.5) days (range 2–7 days). The postoperative VAS pain score were (2.6 ± 0.9) (range 2–4); there were 3 patient suffered fever and 5 patients suffered scrotal seroma. There were no complications such as wound infection and intestinal obstruction after operation. All cases were followed-up for 6–30 months (mean of 19.3 ± 4.3 months) without obvious chronic pain, foreign body sensation and recurrence. Conclusion: Laparoscopic TAPP repair of inguinal hernias using acellular tissue matrix grafts is safe and feasible, and has the advantages of minimal invasion, few complications and good postoperative comfortable feeling, without increasing the risk of recurrence. This technique is especially suitable to young patients with inguinal hernia who have the requirement of fertility.

P046 Mesh containing biological material for the hernia repair: an ethical issue for a tailored made approach M. H. Shiwani Barnsley General Hospital NHS Foundation Trust and University of Sheffield, Barnsley, UK Background: The use of porcine derived mesh for the repair of abdominal wall hernia is increasing in surgical practice in recent years. Aim: To raise the awareness of new technology and changing medico-legal aspects of informed consent. Methods: The literature was searched for the current evidence and practice of use of biologic mesh for the repair of abdominal wall hernia. The medico-ethical deliberations of different religions and the components of an informed consent were reviewed in the light of a recent judgment by the Supreme Court of U.K. Results: There is a lack of high quality scientific research evidence justifying the use of abdominal wall implant containing porcine derivatives for the better quality of life for the abdominal wall reconstruction. The options of the use of a biological mesh given to a patient by a surgeon largely depends on the surgeon’s interpretation of the available data and personal experience. Majority of Muslims would only use forbidden material in life saving conditions, in dire need and in the absence of any other suitable alternative. Patients might have various views. In the light of a recent court decision, the popular ‘‘Bolam’’ test for the clinical negligence, can be challenged by an offended patient. Conclusion: Surgeons should keep themselves embrace with up to date knowledge in order to obtain a well informed consent to offer a

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Hernia (2017) 21 (Suppl 2):S208–S263 choice of implant to their patients. A separate consent form for the biological implant will bring the informed consent in line with the Good Medical Practice.

P047 The use of Onflex mesh on inguinal hernia Y. Suzuki, D. Tsukahara, H. Midorikawa, Y. Igarashi, N. Soeda, Y. Kumata, M. Horikawa, T. Kiyokawa, Y. Yaguchi, T. Inaba, R. Fukushima TeikyoUnivercityHospital, Tokyo, Japan Background: In Japan, a relatively high number of hernia specialists in particular utilize meshes that lie flat in the preperitoneal space. Here, we report on our experience using the new Onflex preperitoneal space flat mesh in 2 cases. Methods: Case 1 was a 78-year-old male with an indirect inguinal hernia.Case 2 was an 84-year-old male with an indirect inguinal hernia. Results: Case 1: Using the insertion method for the Polysoft Patch, which has the same shape, we grasped the area near the interior tip of an Onflex mesh with blunt towel forceps and inserted it interior side first. Although there were no problems with the expansion, the edge of the interior cranial side penetrated slightly too far into the preperitoneal space and the cranial side center was bent from being pushed from the cranial side. Case 2: An intestinal spatula was inserted into the medial pocket of an Onflex and it was inserted from the interior side. Although there were no problems with the procedure performed on the interior side, the center was liable to bending which made it slightly difficult to insert. Conclusion: Although the Onflex is shaped similarly to the Polysoft mesh, it has a pocket that is similar to a Kugel patch, which can be effectively utilized on insertion. But, since it cannot be used ‘‘insideout’’ unlike a Polysoft mesh can, excess folding occurs in the shapememory ring in the center of the cranial side, which requires manoeuvres for expanding g that were unnecessary in conventional devices.

P048 Retrospective analysis of various V-patch mesh repairs of umbilical hernia and its outcome and guidelines to choose the ideal mesh: Single Center Study S. Venkatraman Chennai Krishna Institute of Hernia, Chennai Krishna Hospital, Chennai, India Background: This paper analyzes retrospectively the various V-Patch Mesh repairs for Umbilical Hernia and to decide the ideal mesh with minimal incision and morbidity from a Single Centersingle Surgeon Experience. Methods: Surgery for umbilical hernia is always a challenge. Since the day of anatomical Repair by Double Breasting Technique of Mayo and Single sheet mesh open surgery repair and in some cases done by Lap. Hernia repair, the challenge continues. Latest V Patch Mesh Implants from various companies are available since 2011. We analyzed our 57 patients who underwent various V patch mesh repairs and how to choose the ideal. Results: Fifty-seven patients, predominantly of female gender who had Umbilical hernia and were operated by V Patch mesh. The majority of Patients are Young, the advantage of the V patch is that it can be operated by small incision so it is cosmetic and it has Adhesion Barrier in the Lower part so it can be placed direct into the

Hernia (2017) 21 (Suppl 2):S208–S263 peritoneum without extensive dissection and is absorbed mostly after a period of time and thus giving a good scar plate with minimal Foreign Body in it. The paper discusses the concept of this surgery and the variations devised in implanting the device and comparison between the available implants and the effects observed in detail. Conclusion: With properly chosen and well placed V patch mesh repairs gives a promising role to repair umbilical hernias with good surgical outcome.

P049 The application on self-made needle for using in laparoscopic pediatric inguinal herniorrhaphy X. Wang Chengdu Fifth People’s Hospital, Chengdu, China Background: To explore the clinical value on Self-made double-hole needle which use for laparoscopic pediatric inguinal herniorrhaphy. Methods: To analyzed the data of postoperative that 1532 cases were reviewed,who were divided into the single-hole needle group (652 cases)and the double-hole needle group (880 cases),All of they were treat by Laparoscopic from April, 2006 to April, 2016. Results: The average operation time of the group of single-hole needle was 17.7 min which 4.4 ml blood loss; 23 cases suffered small hematoma under the abdominal wall; and 3 patients recurred. The average operation time of the double-hole needle group was 7.4 min which 1.2 ml blood loss; 2 cases suffered small hematoma under the abdominal wall; and 1 patients recurred. Two groups of children staied in hospital with average of 2 days.The operation time, volume of bleeding,rate of complication in double-hole needle group were significantly less than those in the single-hole needle group (P \ 0.05).The hospital stay, recurrence rate was not statistically significant (P [ 0.05). Conclusion: Self-made double-hole needle in laparoscopic pediatric inguinal herniorrhaphy with short operation time, less trauma, simple operation, in the clinically more efficiently, and that was worth generalizing and applying.

P050 Lessons Learnt and New Concepts from a Retrospective Review of 107 Spigelian Hernias V. L. Webber, R. J. E. Skipworth, C. Low, A. de Beaux, S. Kumar, B. Tulloh Royal Infirmary of Edinburgh, Edinburgh, UK Background: SH is uncommon, accounting for approximately 2% of ventral hernias. The aim of this study was to update our knowledge of the anatomy, aetiology and treatment of SH. Methods: Patients undergoing SH repair from February 2006-February 2016 were identified. Data included patient demographics, clinical presentation, location and size of fascial defect and surgical treatment. The Mann–Whitney U and Chi squared tests were used (statistical significance p \ 0.05). Results: 107 SH were identified in 101 patients comprising 98 primary unilateral, 3 recurrent unilateral and 3 bilateral hernias. 63 female and 35 male. Age range 32–88 years. Defect size range 1 9 1 cm to 6 9 9 cm. 12 hernias arose above the arcuate line; 15 below the arcuate line and in 77 cases location of defect in relation to the arcuate line not recorded. 18 (17%) presented as an emergency. 65 cases were operated on with open surgery and 42 laparoscopically. 78 hernias had a peritoneal sac, in 29 cases the hernia comprised extraperitoneal fat only. In those with no peritoneal sac the median defect

S221 size was significantly smaller and patients were significantly younger than cases with peritoneal sac present. Conclusion: This is the largest series of SH reported in the literature. 10/107 (9%) of elective SH were found incidentally and another 18/107 (17%) presented for the first time as emergencies, suggesting that SH may be under-diagnosed. This series shows that SH is not a disease of the elderly, with 25/107 (23%) hernias diagnosed in patients \50 years and confirms that SH commonly arise above the arcuate line.

P051 Incisional hernia repair after abdominal solid organ transplantation G. Woeste, M. Knaak, A. Reinisch, W. O. Bechstein Uniklinikum Frankfurt, Frankfurt, Germany Background: Incisional hernia repair after abdominal solid organ transplantation is a challenging procedure due to the immunosuppressive therapy. This study analyses the outcome of hernia repair in these patients. Methods: We retrospectively reviewed our cohort of incisional hernia procedures. The postoperative complications were analyzed. Results: In 12 patients a hernia was treated after organ transplantation, 2 kidney transplantation, 1 simultaneous pancreas kidney transplantation, 9 liver transplantations. The mean age was 55.7 years, 9/12 patients were male. In 5/12 patients a component separation was performed. In 11/15 patients a synthetic mesh and one bioabsorbable mesh was used. The mean length of stay was 10.5 days. The postoperative course was uneventful in 10/12 patients. Two (16.7%) patients showed wound complications, 1 ascites fistula and 1 infected seroma. In no case the mesh had to be explanted. Conclusion: Incisional hernia repair after solid organ transplantation is safe using synthetic meshes without an increase of wound morbidity or mesh complications.

P052 The transabdominal preperitoneal (TAPP) repair in the inguinal hernia patient with hemophilia A L. Wu AnHui Provincial Hospital, HeFei, China Background: Laparoscopic hernia repair is recommended for inguinal hernias in patient because of most benefit such as less pain, excellent cosmesis, bilateral inguinal hernia, and so on. At the same time, Despite meticulous concentrated factor VIII and factor IX supply, Surgery in patients with inherited bleeding disorders is considered high risk and remains a challenge for surgeons. Laparoscopic hernia repair in patients with hemophilia is traditionally considered relative contraindication and report about that is very rare. Methods: We report a case with right inguinal hernia associated with hemophilia A. A 56-year-old married male suffered from hemophilia A for 30 years presented with a right inguinal hernia. This was repaired laparoscopically with a prothetic mesh (3D Max) using a transabdominal preperitoneal approach (TAPP). Results: The patients had a good surgical procedure and blood loss was similar to that with normal coagulation, despite the patient with hemophilia stayed in hospital a little bit longer and hospitalization cost increased a lot because of the need to give him factor 8 infusions. We obtained a successful outcome during a 19-month follow-up period.

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S222 Conclusion: Laparoscopic hernia repair in patients with hemophilia is safety and effciency.

P053 Inguinal Hernia Repair with Patch and Plug technique, in elderly patients with ASA score III-IV under local anesthesia

Hernia (2017) 21 (Suppl 2):S208–S263 Serom no recurrence during the two years post opeatoires, 3 patients had chronic post operative pain for a period of 15 days and 32 dayslimiting. Conclusion: Lapport of laparoscopy in the treatment of groin hernias can be an alternative to traitementd of inguinal hernias in young patients actif view the many benefits of this surgical approach.

S. Xenaki, M. Venianaki, A. Andreou, K. Lasithiotakis, G. Chalkiadakis, I. Petrakis Department of General Surgery-University Hospital of Heraklion Crete, Heraklion-Crete, Greece

P055 Low cost technique for the management of all types of ventral hernias in ambulatory settings: safe and reliable procedure

Background: While in the past, hernia surgery was carried out mainly under general and spinal anesthesia, in recent years there has been growing emphasis on the role of local anesthesia. Its advantages may be presented in elderly patients especially with major health problems that are unable to receive general or spinal anesthesia. Our aim is to assess the use of Trabucco technique for inguinal hernia repair in elderly patients with ASAscore III-IV under localanesthesia. Methods: From September 2012 till May 2016, one-hundred and forty-one (n = 141) consecutive operations of inguinal hernia repair have been performed in our department in elderly patients with ASAscore III-IV under local-anesthesia. The surgical technique used in all of the patients was with patch and plug. Patients’ follow up ranged between 2 and 50 months. The exclusion criteria where patients presented with incarcerated hernias with sepsis/necrosis. Results: Minor swelling of the scrotum was observed in thirty-two patients while twenty-six developed ecchymosis. All of the minor complications where limited and disappeared within a couple of days. None of the cases was presented with bleeding and there was no need for re-operation. None of the patients had recurrence. All patients reported a clear improvement of their quality of life. Conclusion: The inguinal hernia repair with tension free technique under local anesthesia is a safe, simple and perfect technique even for elderly patients after adequate preoperative assessment and appropriate management. It associated with quick hospital stay, low relapse rates and low morbidity and mortality, if performed at the right time.

M. Zuvela1, D. Galun1, R. Miletic2, I. Palibrk1, A. Bogdanovic3, N. Bidzic3 1 University Clinic for digestive surgery; Medical School, University of Belgrade, Belgrade, Serbia, 2University Hospital Foca, Bosnia and Hercegovina, Foca, Bosnia and Herzegovina, 3University Clinic for digestive surgery, Belgrade, Serbia

P054 Is that laparoscopy is the gold standard in the treatment of inguinal hernias in the active subject? About 128 cases S. Zatir, R. Koudjeti Militery Hospital University of Oran, Oran, Algeria Background: the army needs a young and active population, to the accentuation of the inguinal hernia pathology in the military we have adopted the treatment of inguinal hernias laparoscopic view the postoperative advantages of this surgical approach. Methods: We operated 128 patients for inguinal hernias on the age a period of 02 years, the age of our patients varies between 20 and 45 years, all of our patients are professional soldiers, 48% straight hernia, inguinal hernia 35% left, 13% inguinal hernias bilateral, 4% recurrent hernias. Results: our results was spectacular especially on the plan early resumption of activities in post-surgery all patients resumed their activities after 15 days of convalescence, our exit from hospital patients out one day postoperative.the post operative complications was 3 patients had a scrotal edema, a patient had a postoperative

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Background: Different devices for open ventral hernia repair and various composite meshes for laparoscopic ventral hernia repair are offered in the market. In contrast we present the results of the operative technique that uses simple polypropylene mesh for the management of all types of ventral hernias under local anesthesia in ambulatory settings. Methods: Between January 2004 and January 2017 472 patients with ventral (226 patients with umbilical, 109 with epigastric, 19 with spigelian, 73 with small and middle incision and 45 patients with 2 or more ventral hernias) were operated on by ‘‘the open preperitoneal flat mesh technique’’ using small piece of polypropylene mesh. All operations were performed under local anesthesia as a day-case procedure. The operative technique: a polypropylene flat mesh exceeding the size of the hernia defect for 2–3 cm in all directions is placed into a pre-peritoneal position above the intraabdominaly repositioned hernia sac (mesh is placed into hernia sac) and fixed by at least 8 transfascial ‘‘U’’ sutures. Results: The mean hernia defect was 2.2 cm (0.5–8). The mean operative time was 41 min (20–95). The mean duration in DSU was 3 h (2–8). During a mean follow-up of 27 months (1–152) the following complications occurred: infection in 8 pts, haematoma in 2 and recurrence in 6 patients. Conclusion: ‘‘The open preperitoneal flat mesh technique’’ is safe, low-cost and easy to learn and perform procedure for ventral hernia repair. It uses simple polypropylene mesh and the procedure is performed under local anesthesia in ambulatory settings.

2. Prevention and management of chronic pain P056 Mesh fixation in TAPP: introduction of a new method in a prospective non-randomized controlled trial Belousov1, Izrailov1, Sinyakin2 1 Moscow Clinical Scientific Center, Moscow, Russian Federation, 2 First Moscow State Medical University by I.M. Sechenov, 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

Hernia (2017) 21 (Suppl 2):S208–S263 significantly increased risk of developing a post-operative pain syndrome. Methods: A total of 156 patients underwent standard TAPP between September 2012 and September 2015. We compared four groups of patients: a group of 31 patients treated with sutures (I group), a group of 46 patients treated with non-absorbable tacks (II group), a group of 40 patients treated with absorbable tacks (III group), a group of 39 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, 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 postoperative 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.

P057 Postoperative pain after Lichtenstein inguinal herniorrhaphy under simplex lidocaine local anaesthesia V. Cijan1, M. Gencic1, J. Bojicic1, P. Bojovic1 1 Clinical Hospital Center ‘‘Zvezdara’’, Belgrade, Serbia Background: Lichtenstein inguinal herniorrhaphy can be successfully performed using local anaesthesia. Local anaesthesia has advantages over general and regional anaesthesia for this procedure in adults. Lidocaine-bupivacaine mixture is usually used, combining the faster sensory blockade with more profound and longer duration. At Belgrade Hernia Service, Lichtenstein procedure are performed under local infiltration anaesthesia with lidocaine alone. The aim was to assess the efficacy of simplex lidocaine local anaesthesia on postoperative pain and analgesic need. Methods: A database of male patients with primary inguinal hernia was maintained. Standardized Lichtenstein procedure under local lidocaine infiltration anaesthesia using polypropylene flat mesh, Hermesh 3 (HerniameshÒ S.r.l. Italy) were performed. Demography, operating time, hospitalization, return to normal activities were recorded. Postoperative pain were evaluated using the visual analogue pain scale (VAS) at 0, 6, 12 and 24 h, analgesic requirements were also noted. Results: During 2016 year, 142 patients of mean age 62.6 were evaluated with 57 min median operation time, 24-h hospitalization, returning to normal activities in 5.5 days. No pain was reported in the recovery room, the VAS values were 1.73; 2.8; 1.6; respectively, median 24-h VAS score was 2.1. 19% of patients denied pain postoperatively, pain was mild in 69% and moderate to severe in 12%. Postoperative analgesic requirements was low, the first analgesic dose was administered 8.2 h postoperatively. Conclusion: Lichtenstein inguinal hernioplasty under local anaesthesia is safe and effective procedure. Local anaesthesia with lidocaine alone significantly decreased postoperative pain and delayed analgesic requirements in the first 24 h postoperatively.

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P058 Chronic pain after Lichtenstein inguinal hernia repair Z. Demetrashvili1,2, I. Pipia2, G. Kenchadze2, D. Loladze2 1 Tbilisi State Medical University, Tbilisi, Georgia, 2Kipshidze central university hospital, Tbilisi, Georgia Background: The aim of our study was to determine the prevalence of chronic pain following Lichtenstein inguinal hernia repair and risk factors for pain development. Methods: 347 patients with primary unilateral inguinal hernia underwent Lichtenstein repair. Some preoperative, perioperative and postoperative data were studied. Patients were examined for inguinal pain after 1 week following hernia repair (early postoperative pain), they were as well examined 1 and 3 months, 1 and 2 years following the surgery. Inguinal pain scores were measured on a Visual Analogue Scale (VAS), ranging from 0 (no pain) to 10 (worst imaginable pain). Results: Information about 26 patients was lost during the observation. Subsequently 321 patients were examined during 2 years following the surgical intervention. One week later of the surgery 201 patients (62.6%) were experiencing inguinal pain of different intensity, one month later pain was experienced by 102 patients (31.8%), 3 months later—by 57 patients (17.8%), 1 year later by 34 patients (10.6%) and 2 years later by 27 patients (8.4%). Chronic postoperative inguinal pain (CPIP) development is correlated with following factors: pre-operative pain (P \ 0.001), young age (P = 0.04) and moderate and severe early postoperative pain (P \ 0.001). Development of CPIP was not related to the following factors: occupation status (P = 0.86), BMI (P = 0.59), tobacco use (P = 0.10), hernia side (P = 0.58), hernia type (P = 0.44), operation time (P = 0.86), anesthesia type (P = 0.21). Conclusion: Risk factors for chronic postoperative inguinal pain development following Lichtenstein inguinal hernia repair are: preoperative pain, young age and moderate and severe early postoperative pain.

P059 Open inguinal hernia repair with folded mesh M. Uccelli, G. Cesana, R. Villa, R. Giorgi, F. Ciccarese, G. Castello, B. Scotto, G. Legnani, S. Olmi San Marco Hospital, Zingonia (BG), Italy Background: The tension-free technique has become the standard in inguinal hernia correction using mesh over the past 30 years.. In contrast to recurrence, cronic pain has been reported in high rates with percentages ranging from 0 to 63% in some case series in the literature. The aim of this retrospective study was to compare the outcome after open inguinal sutureless hernia repair with a new type of mesh (AngiologicaÒ Folded Mesh) with respect to postoperative course, complications, and postoperative cronic pain. Methods: From 01/2002 to 01/2015 all patients scheduled for open monolateral inguinal hernia repair undergo to open groin hernia repair with AngiologicaÒ Folded Mesh. This mesh has a dual preformed reinforcement that allows easy use and easy positioning, with sutureless technique. We enrolled a total of 963 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 ± 23 min (range 15–60 min). Study population is predominantly male (96.44%); mean age: 68.50 ± 12.31 years. With a complete follow-up of 24 months, we recorded 19/963

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S224 recurrences (1.97%), 23/963 hematoma (2.39%), 26/963 seroma or scrotal ecchymosis (2.70%), 6/963 cronic inguinal pain (0.62%). Conclusion: Our results demonstrates the feasibility and effectiveness of sutureless inguinal hernia repair with this particular type of mesh, associated with an improvement in the incidence of chronic pain and a comparable recurrence rate compared to the case studies of literature.

P060 Comparative study of laparorrhaphies with Assut Europe sutures in eventrations prevention J. M. Goderich1, L. Luna Vazquez2, E. Molina3 1 Hospital General Santiago, Santiago de Cuba, Cuba, 2Hospital Ambrosio Grillo, Santiago de Cuba, Cuba, 3Hospital Comandante Fajardo, La Habana, Cuba Background: The technological development has brought the emergence of modern sutures that with synthetic materials which guarantee a quick tissue repair and produce an stable scar. Not everything can be seen in an isolated way; that is why, considering the present scientific problem, this study was carried out with the use of the sutures ASSUT EUROPE. Objective: To evaluate the use of two types of sutures in laparorrhaphies in groups of sick persons with similar characteristics. Methods: An observational clinical case control study of 300 patients. Patients with clean elective surgeries; 2. Patients with elective potentially polluted surgeries and 3. Patients with urgent surgeries and peritonitis with MEHECO sutures and the other with ASSUT EUROPE sutures. All the patients were followed during a year. Results: Just two eventrations emerged in group 1, and in them M sutures were used. There was no complication with the AE sutures in group 2, but with the M sutures, two eventrations and 2 eviscerations took place, always with infection of the surgery site; in group 3 there were 2 eviscerations and 2 eventrations with the Chinese M sutures, while in the other type of suture an eventration took place in a patient with severe peritonitis of gynecological cause and deep infection of the surgical site. Conclusion: Indpemdently from other causes; undoubtly the quality of the suture influences in a decisive way in the emergence of eventrationsand eviscerations, in this study the AE sutures demonstrate their quality.

P061 Nerves non-protected inguinal hernia Lichtenstein repair versus nerves protected: chronic pain analysis in personally operated patients A. Jezupovs Riga East University Hospital, Riga, Latvia Background: The aim of the study was to evaluate whether the protection of inguinal nerves during hernia repair decreases the frequency of chronic pain. Methods: A retrospective analysis of personally operated patients by Lichtenstein repair was done. The patients were divided into two groups.

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Hernia (2017) 21 (Suppl 2):S208–S263 Group 1—patients were operated until year 2007, without special attention to status of inguinal nerves. Group 2—patients were operated after year 2007, with careful attention to status of inguinal nerves during surgery. The anatomy of nerves was recorded in every operation. Patients with nerves injury during surgery were excluded from the analysis. In both groups heavyweight polypropylene meshes were implanted. Results: The data from 446 patients were obtained by phone interviewing and physical examination if chronic pain existed. 299 patients were enrolled in Group 1 and 147 patients in Group 2. The median follow-up was 26 months in Group 1 and 43 months in Group 2. Three nerves were protected in 56 (38.09%) patients, two nerves in 64 (43.54%) patients, one nerve in 27 (18.37%). The total chronic pain incidence was 16.36%, with no statistically significant difference between groups, respectively 54/299—18.86% in Group 1 versus 19/147—12.92% in Group 2. The pain intensity, regularity, provoking factors, influence on life quality and sensory loss also did not differ significantly between both groups. Conclusion: Results of this study don’t prove superiority of nerves protected Lichtenstein repair over nerves non-protected Lichtenstein repair, with regard to incidence of chronic pain.

P062 Inguinodynia after inguinal hernia repair with prosthesis (IHRP): prevention of the postoperative complications L. Latham, F. Arienti, G. Zorzetto, C. Peverelli, L. Guzzetti, C. Lanza, M. Binda, A. Ambrosoli, A. Romanzi, D. Sambucci, V. Marchionini, S. Cuffari, E. Cocozza A.O. di Circolo Ospedale di Varese, Varese, Italy Background: Inguinodynia after IHRP normally has an average incidence of 11%. It is connected with intraoperative risk factors, mainly failing to safeguard the Ilioinguinal and Iliohypogastric nerves and the lack of experience of the operator. In this study we have considered our clinical records from 2013 to today. Methods: We have analysed 830 patients who underwent IHRP and attention was paid to the important risk factors previously mentioned. Among these, the ones with Inguinodynia during the follow-up (programmed visits after 1-6-12 months from the operation) have been divided in two categories, on the basis of Pain Detect Score:\13 nociceptive pain (NOP), [13 neuropathic pain (NEP). The FlowChart established with anesthetists provides treatment with anti-inflammatory for NOP and Lidocaine Patch therapy for NEP. In case of failure of the pharmacological method we can resort to interventional procedures, such as nerves block and invasive treatment with pain therapists. Results: Out of 830 patients submitted to the operation, 47 have devoloped Inguinodynia (5.66%); of these, 27 have reported NOP (3.25%) and 18 NEP (2.17%); we lost 2 patients during the follow-up. Only 2 patients (0.24%) haven’t benefited from the pharmacology treatment, therefore they have been submitted to a nerve block, which brought to the disappearance of symptoms. Conclusion: More attention to the safeguard of the nerves during the operation and a greater experience of the operators greatly reduce the outbreak of Inguinodynia. Furthermore, the observation of the FlowChart allows the improvement or the complete remission of symptoms in almost all patients.

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P063 Abdominal transverse blocking for inguinal herniorrhaphy in an ambulatory surgery program V. Moreno1,2, C. Min˜ano3,2, M. Vives3,2, E. Raga3,2, M. Parı´s3,2, E. Homs3,2, F. Sabench3,2, J. Dome`nech3,2, A. Sa´nchez3,2, D. Del Castillo3,2 1 Hospital Universitari Sant Joan de Reus. Anesthesia, Reus, Spain, 2 Universitat Rovira i Virgili, Reus, Spain, 3Hospital Universitari Sant Joan de Reus. General and digestive surgery, Reus, Spain Background: To determine the results from blocking the transverse abdominal musculature in patients undergoing inguinal herniorrhaphy in our Major Ambulatory Surgery Unit. Methods: Blocking was performed after the intervention to 40 patients undergoing inguinal herniorrhaphy under our ambulatory surgery program. The pain in the recovery unit was monitored by visual analogue scale (VAS), and postoperative analgesia and global pain at discharge were recorded. Subsequently, at home, a telephone questionnaire was performed at 24 h from discharge, which included VAS, degree of satisfaction and adherence to analgesic regimen. Results: There was no need to administer opioids for pain control at any patient. At the moment of discharge, EVA less than 3 was observed in 100% of patients. 24 h after surgery, a 60% of the patients had an EVA less than 3, and a 35%referred to have no pain. Less than 5% had a moderate pain and no patient referreda severe pain. The degree of satisfaction reported was qualified as excellent or satisfactory in 65% of the patients, and considered the analgesic regimen at home sufficient. Conclusion: In our patient series, a treatment with analgesics classified according the WHO into the first step, has been adequate for controlling pain at home. It determines a good degree of satisfaction, recording an EVA pain score less than 3.

3. Prevention of recurrence and complications in ventral and incisional hernia repair P064 Paraostomal hernia: a more and more frequent surgical challenge M. Bustos-Jime´nez, A. Senent-Boza, J. A. Martı´n-Cartes, S. Dios-Barbeito, P. Garcı´a-Mun˜oz, M. Flores-Corte´s, J. L. GollonetCarnicero, F. J. Padillo-Ruiz Hospital Universitario Virgen del Rocı´o, Sevilla, Spain Background: Paraostomal hernias (PSH) are one of the most common complications following stoma creation. However, there is still little agreement about the most appropriate surgical technique to repair them despite of its prevalence. Over the past two decades there has been a great evolution with the introduction of new types of mesh and laparoscopic procedures. This review attempts to provide and overview of the management of PSH in our center. Methods: We reviewed the records of 60 patients who underwent an eventroplasty for PSH with a DynameshÒ-IPST from 2011 to 2015. Follow-up (median 37 months) was available for all of them with computerized tomography. 12 had an ileal conduit diversion, 6 an end ileostomy and 48 patients a terminal colostomy. Results: The mean age at diagnosis was 66.5 years. 11 patients had associated an incisional hernia. 66 patients (54.5%) with PSH were male. Mean body mass index was 35.5 kg/m2. Mean parostomal defect size was 9.88 (4–13 cm). In 55 patients (91.66%), PSH were clinically and radiologically evident. Five patients (8.33%) included in this series recurred with PSH; so

S225 far, we have succeeded in folding out and attaching again the mesh we had previously used in order to work those problems out. Those recurrences were diagnosed 12–24 months after the date of the operation. Conclusion: Mesh repair is the first choice for the repair of PSH. DynameshÒ-IPST provides a reliable alternative in repairing PSH with low incidence of recurrence and complications.

P065 Rives technique vs intrabdominal mesh in the treatment of abdominal incisional hernia C. Ba´ez, M. Bruna, A. de Andre´s, R. Nu´n˜ez, G. Valderas, R. Go´mez, M. Oviedo, P. Albors, A. Va´zquez, J. Puche General University Hospital of Valencia., Valencia, Spain Background: Until now there has not a consensus on the ideal mesh position in thetreatment of ventral hernia. The goal of this study is to compare the results of retromuscular versus intraperitoneal mesh position by analyzing a sample taken at our center. Methods: Between 2008 and 2016, we performed a surgical treatment of incisional hernia with mesh in 165 patients. They were divided in two different groups: Group A (retromuscular; Rives technique) and group B (intraperitoneal; open technique). Preoperative, intraoperative, postoperative and follow-up data were evaluated. Results: We placed a retromuscular mesh in 95 (57.8%) patients and an intraperitoneal mesh in 70 (42.4%). No significant differences were found in sex, age, BMI and comorbilities between groups. Incisional hernia type M2-3 was the most frequent in both groups. Intraoperative complications were higher in group B (7.1%) than group A (1%) (p = 0.018). The mean follow-up time was 472.7 days and there was a higher number of surgical wound complications in group A (52.6%) than group B (35.7%) (p = 0.043). Symptomatic seroma was the most common complication: 32.6% in group A and 17.1% in group B with significant statistical differences (p = 0.025). However, therewasn’t statistical difference in rate of infection (8.4% in group A and 12.8% in group B) (p = 0.354). Recurrence rate was higher in group B but there was no statistical difference between groups (12.6 vs 21.4%) (p = 0.131). Conclusion: Acording our results, retromuscular technique has less intraoperativecomplications and recurrence rate but has a higher rate of surgical wound complications only in relation to seroma.

P066 Prevention of recurrence, complicacions and management of chronic pain in ventral and incisional hernia repair S. M. Dencic General Hospital Pirot, Pirot, Serbia Background: Hernia surgery is a science is constantly changing and whose history is a constant struggle against pain, complications and recurrence. Methods: We analyzed the results of hernioplasty: 50—tension-free (TFH), 50—tension (TH). From TFH we did open repair polypropylene mesh—TFOH; laparoscopic repair of double-layer mesh, bi ePTFE (Bi-material RelimeshÒ)—TFLH. We sent a quesetionnaire to patients regarding postoperative outcomes, including: chronic pain, complications, recurrence.

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S226 Results: The intensity of chronic pain, VAS 2–4: (A) after 1 month: (1) TFH—20 (41.7%): TFOH—18 (46.2%), TFLH—2 (22.2%); (2) TH—27 (60%); (B) up to 3 months: (1) TFH—6 (12.5%): TFOH—6 (15.4%), TFLH—0; (2) TH—19 (42.2%); (C) up to 5 months: (1) TFH—2 (4.2%), TFOH—2 (5.1%), TFLH—0; 2) TH—7 (15.5%). Complications: (1) TFH—4 (8.3%), TFOH—4 (10.3%): major—1, minor—3; TFLH—0; (2) TH—6 (13.3%). Recurrences: (1) TFH—1 (2.08%), TFOH—1 (2.6%), TFLH—0; (2) TH—4 (8.9%). Conclusion: TFH are more successful in relation to the TH, promarily with abdominal wall defects larger than 4 cm, due to the lower value recurrence, chronic pain, complications. In TFLH with bi ePTFE, our results show the lowest level of complications, recurrence, chronic pain, and in terms of prevention, this technique can be considered the technique of choice.

P067 Easy bridging technique in ventral hernia repair M. Ertem, E. Hatipog˘lu Istanbul University, Cerrahpas¸ a Medical Faculty, Istanbul, Turkey Background: In ventral hernia repair, closure of the defect to create a functional abdominal wall has become the preferred method in last years. However, this goal may not always be accomplished.This is the case particularly in defects localized apart from the midline such as hernias occuring at subcostal or transverse incisions. When large defects are not closed prior to laparoscopic mesh insertion, bulging of the mesh into the defect is inevitable. The bridging and easy bridging technique showed in this video prevents this bulging. Methods: In this technique, the defect closed with darn method, using a running polypropilen suture. If any difficulty is encountered during suture placement, the use of SecurestapÒ (Ethicon, vs.) may be helpful. The abdominal pressure must be kept low throughout the suture application in order to assure the tightness of the suture which promotes the success of the procedure. Results: Our results show that using easy bridging technique prevents bulging of the mesh and increasing patient satisfaction in early postoperative period. Conclusion: Easy bridging technique might be useful when contesting against largely volumed incisionel hernias.

P068 IPOM combined with anterior component separation technique in giant incisional ventral hernia repairs Y. P. Feleshtynsky, V. V. Smishchuk, V. F. Vatamaniuk Shupyk National Medical Academy of Post-Graduate Education, Kyiv, Ukraine Background: Classical methods of allohernioplasty for giant incisional ventral hernia (IVH) often give rise to a reduction in volume of the abdomen and increased intra-abdominal pressure (IAP), which results in abdominal compartment syndrome (ACS) (2.4–6.4%) and mortality (0.9–1.2%). This requires a special technique for giant abdominal wall defect repair without increased intra-abdominal pressure. Methods: 164 patients aged 30–75 were operated for giant IVH. Depending on the way of alloplasty, IVH patients were divided into two groups. In Group I (82 patients), there was used ACST, the rectus abdominis muscles suturing combined with ‘‘onlay’’ technique. In Group II (82 patients), ACST was combined with IPOM, dosed

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Hernia (2017) 21 (Suppl 2):S208–S263 apposing of the rectus abdominis muscles was performed under IAP control. Polypropylene mesh implants were used in Group I. In patients from Group II there were used composite mesh implants (Proseed, Physiomesh, Parietex composite). Results: 24 h after the surgery the mean IAP was 15.1 ± 1.2 in 5 (6.1 ± 2.6)% patients from Group I and it was accompanied with ACS, Grade I. At the same time point, the mean IAP in Group II was 6.3 ± 1.2 with no ACS events observed. ACS and impaired intestinal motility in Group I patients were treated by use of conservative therapy. Conclusion: Owing to the use of intraperitoneal mesh and dosed apposing of the rectus abdominis muscles, intraperitoneal alloplasty combined with anterior component separation technique for giant incisional ventral hernia repairs contributes to a significant reduction in the incidence of abdominal compartment syndrome by ensuring optimal volume of the abdomen.

P069 Parastomal hernia repair with three-dimensional funnel meshes in intraperitoneal onlay position: results of 56 cases I. Fischer, H. Wundsam, G. Ko¨hler Sisters of Charity Hospital, Linz, Austria Background: Parastomal hernias (PSHs) are a common and challenging issue. In previous studies three-dimensional funnel mesh devices have be used successfully for prevention and repair of PSHs. Methods: We performed an analysis of prospectively collected data of patients who underwent a same-sided stoma relocation with 3D funnel shaped mesh augmentation in intraperitoneal onlay (IPOM) position at our department between the years of 2012 and 2016. Primary outcome parameters were intra- and postoperative surgical complications and recurrence rate during follow-up period. Results: Fifty-six patients could be included in this analysis. PSH repair was performed in 89.3% as elective surgery and in 73% in laparoscopic technique. A concomitant incisional hernia (EHS type 2 and 4) was found in 50% and repaired in a single step procedure with PSH. Major postoperative complications requiring redo surgery (Clavien-Dindo > 3b) were identified in 8.9% (5/56). Only one mesh had to be removed. Overall recurrence rate was 12.5% (7/56). Median follow-up time was 38 months and an adequate one year follow-up rate of 96.4% was reached. Conclusion: PSH repair with three-dimensional funnel mesh in IPOM technique is safe, efficient and easy to perform in laparoscopic and open surgical approach providing advantageous results compared to other techniques. Furthermore, simultaneous treatment of concomitant incisional hernias has shown favorable. The mesh funnel distends and become shortened encasing the bowel mesentery and shrinkage happens eccentric. Changing mesh construction according to lengthening the funnel could possibly lead to reduction of recurrence.

P070 Factors influencing recurrence in abdominal wall reconstruction (AWR) in biologic implants M. R. Grimaldi, F. Gossetti, P. Bruzzone, F. Ceci, P. Negro, L. D’Amore Sapienza, Rome, Italy Background: Interest about use of biologic implants (cross-linked or not) in complex abdominal wall reconstruction has grown up in the

Hernia (2017) 21 (Suppl 2):S208–S263 last years, supported by literature. From literature review, recurrence rate using non cross-linked biologics ranges from 14.7 to 59% and surgical site infection rate ranges from 28.6 to 31.9%. We present recurrence rate and surgical site infection in our experience with cross-linked implants (2005–2016). Methods: From 2005, we treated 49 patients (Grade 2 or 3, according to Ventral Hernia Working Group) with complex abdominal wall reconstruction by retro-muscolar repair, and posterior component separation when necessary, using a porcine cross-linked acellular dermal matrix. Implants were processed with 2 different cross-linking agents, hexamethylene diisocyanate (group A, n.36) or carbodiimide (group B, n.13). All patients underwent annual follow-up, including clinical evaluation and computed tomography/MRI scan with Valsalva maneuver. Results: The overall recurrence rate was 8.2% (at a mean follow-up of 59.3 months), with a significantly lower rate in group A (2.8%) vs group B (23%, p \ 0.05). No implant was removed. Surgical site infection was not significantly different in the 2 groups (19 vs 26%, p = 0.8). Conclusion: In our experience of complex abdominal wall reconstruction, overall rates of recurrence and surgical site infection using porcine cross-linked acellular dermal matrix are notably lower than those previously reported in literature using a non-cross linked biologic mesh. These results stress the role of proper indications (never in grade 4), mesh selection and site of the implant. These factors appear to play a key role in AWR using biologics.

P071 Comparative study of simple mesh versus tailored mesh in ventral abdominal wall hernia repairs J. Jorge Barreiro, I. Garcia Bear, R. Serra Lorenzo, J. Jara Quezada, N. Gutierrez Corral, M. Roldan Cuena, N. Aguado Suarez, R. Arias Pacheco, A. Rodriguez Infante Hospital Universitary San Agustin, Aviles, Spain Background: This study aims to compare the traditional (polypropylene) mesh versus a tailored (polypropylene) mesh with improved implantation procedures in ventral abdominal wall hernia repair in terms of duration of procedure and complications. Methods: 92 patients with ventral hernia ([4 cm) were taken for the study. Random allocation patients with 50 in Group A (traditional mesh) and 42 in Group B (tailored mesh) was done. In Group A, a sublay (Retrorectus) space was created and sublay simple mesh placed and fixed. In Group B, similar space was created and tailored mesh was placed with all its straps passed laterally through the transverse and oblique muscles with no suture fixation. Results: Duration of mesh placement (t1 = 24 min) and thus, duration of procedure (t2 = 37 min) in Group A were significantly higher than Group B (t1 = 6.5 min, t2 = 25 min). The mean hospital stay duration was 5.3 days for Group A patients, while 2.4 days for Group B patients. Group A patients were found to have greater degree of post-operative pain an VAS (visual analogue scale). Superficial wound infection was found in 8 patients (16%), flap necrosis in 5 patients (20%), seroma in 16 patients (32%) and recurrence in no patient, in Group A, while in Group B, superficial wound infection was found in 6 patients (12%), flat necrosis in 1 patient (4%), seroma and recurrence in no patient, Conclusion: Tailored mesh repair for ventral hernia repairs is more effective, with less complications and no recurrence than simple/traditional mesh repair.

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P072 Spigelia hernia J. Jorge Barreiro, I. Garcia Bear, V. Ramos Perez, N. Aguado Suarez, R. Serra Lorenzo, J. Jara Quezada, A. Rodriguez Infante, G. Minguez Ruiz Hospital Universitary San Agustin, Aviles, Spain Background: Spigelian hernia (SH) is a rare kind of abdominal wall defect. It is a spontaneous primary abdominal wall defects localized in the semilunar line. The purpose of this presentation is to describe our nineteen year experience with management of 50 SH. Methods: It was performed the SH technique. We made the skin incision in the lines Langer directly over the mass hernia. Incise the external oblique aponeurosis over the mass to expose the SH sac. The unopened sac is drop back through the ring into the abdominal cavity. We introduced mesh hernia plug, sutured fixation of the mesh. Results: All patients left the hospital the same day of surgery. With a follow up of 65% at 19 years we have not observed infections or recurrences. Conclusion: This technique simplifies the repair and the advantage of producing minimal postoperative pain and disability.

P073 Are drains necessary for all retrorectus ventral hernia repairs? J. Jorge Barreiro, I. Garcia Bear, A. Rodriguez Infante, G. Minguez Ruiz, N. Aguado Suarez, R. Serra Lorenzo, J. Jara Quezada Hospital Universitary San Agustin, Aviles, Spain Background: Drain usage is not without inherent risk including hematoma formation, drain site hernias, and a pathway for bacterial transit into the wound. While drain use is common practice following retrorectus hernia repair, there is a lack of objective data to guide their utilization. Methods: We conducted a retrospective review of consecutive patients undergoing retrorectus ventral hernia repair with or without unilateral posterior component without use of surgical drains between December 2008 and March 2015. Primary outcomes included incidence of SSO and SSI. Results: 22 patients (8 male, 14 female) were evaluated with a mean age of 62 years (range 27–80) and mean body mass index of 30 kg/m2 (range 28–39). All cases were performed in a clean operative field with synthetic mesh placed as a sublay. Average defect size was 31 cm2 (range 5–119). 15 patients (74%) had VHWG Grade 1 hernias, 5 (18%) had Grade 2 hernias, and 2 (9%) patients had a Grade 3 hernia. There were two (9%) surgical site occurrences including one case of superficial cellulitis and one patient with a superficial surgical site infection (SSI). The sole SSI was in a patient with history of wound infection and the Grade 3 hernia. Conclusion: With appropriate patient selection, namely in patients with few comorbidities and no history of wound infection (VHWG Grade 1 or 2),routine drain placement may not be necessary even with hernia repairs necessitating myofascial advancement. Further prospective evaluation is needed to determine which patients may benefit from avoidance of drains.

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P074 Mesh sutured repairs of abdominal wall defects J. Jorge Barreiro, I. Garcia Bear, J. Jara Quezada, N. Aguado Suarez, R. Serra Lorenzo, V. Ramos Perez, A. Rodriguez Infante, G. Minguez Ruiz Hospital Universitary San Agustin, Aviles, Spain Background: While biologics are touted in this context, recurrence rates are unacceptably high, as introduce a novel mesh sutured technique that avoids large sheets of mesh yet still limits suture pullthrough that leads to recurrences. Methods: 18 mm wide strips of mesh cut lengthwise from a sheet of midweight prolene mesh were passed through the abdominal wall on either side of the defect with a sharp clamp and simply tied as a suture. No other mesh was used for closure in these abdominal walls. Results: 90 patients underwent a mesh sutured repair. Mean age was 54.6 and mean BMI 29.8. Comorbidities included 12 diabetics, 8 smokers, and 15 immunosuppressed patients. Indicators for these mesh sutured repairs included a contamination (n = 38), defect too small to require mesh sheet (n = 10), non-midline defect (n = 15), and a medical or surgical reason precluding abdominal mesh placement (n = 32), 23 patients had more than 1 indication. Overall 30 day SSO rate was 22.9%: 5 SSI, 7 seromas, 5 hematomas, and 3 cases of delayed wound healing in 16 patients. 6 Patients required reoperation. One death occurred from amyloidosis included cardiac arrest. Conclusion: Mesh sutured repairs have been useful in many clinical indications where sheet meshes are either difficult or inadvisable to place. Early follow up is extremely promising for durability of repair and absence of hernia, and longitudinal patient analysis is ongoing for this novel technique.

P075 Immediate and long-term results of treatment of postoperative middle hernias S. Kuliev, V. Egiev, I. Evsucova SM-Clinlc, Moscow, Russian Federation Background: At present, the number of median postoperative hernia is not reduced, but rather increased. And no one has any doubt about the need for grid installation for the treatment of hernias, and many authors resort to the implantation of the mesh prosthesis for the purpose of prevention.In our study, we analyzed the immediate and long-term results of treatment of patients with hernias posleoperatsionnnymi. Methods: In our center hernia surgery from 2014 to 2016 91 patients were operated on, 40 of which made the anterior of the separation of plastic and 51 plastic posterior separation, follow-up was from one year to 2. Results: During the observation, we noted one recurrence, 2 suppuration of postoperative wounds, deaths were not. Duration of hospital stay by an average 6.5 day. Conclusion: The quality of life in these patients is almost the same, but the investigation must continue.

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P076 The closure of subcostal laparotomies in elderly patients suffering from concomitant diseases with high risk of incisional hernia incidence J. Mazur1, B. Dybas1, O. Mazur2 1 Danylo Halytsky Lviv National Medical University, Lviv, Ukraine, 2 Lviv Regional Pathology Bureau, Lviv, Ukraine Background: Incisional hernia can be inevitable consequence of the surgical intervention in elderly patients with concomitant diseases (diabetes, obesity). This complication arises in 5–14 to 30–54% patients. Methods: We investigated case histories of 56 patients (average age 75.2 ± 1.9 years) suffering from obesity (BMI over 30) undergoing the subcostal laparotomy with a incision length over 10 cm. The closure of the laparotomy wound was standard or using implantation of polypropylene mesh (PPM) under rectus abdominis muscle and external oblique muscle of the abdomen. During the anaesthetic induction third-generation cephalosporin was administered. The edges of the PPM extended from the line of the incision by 2 cm in all directions. Active subcutaneous aspirate drainage was used in all patients. Results: All the patients were divided: 28 were included in the group 1 with simple closure of the abdominal wall and the other 28 in the group 2 with closure of the abdominal wall using PPM. Differences in immediate postoperative complications between two groups were not statistically significant (p [ 0.05). Three years after surgery, in 3 patients (10.7%) from the group 1 incisional hernia was found, while none occurred in the patients from group 2. Conclusion: Retromuscular technology of cicatricial hernias prevention in elderly patients with concomitant diseases should be considered as the optimal one. Antibiotic prophylaxis significantly lowers the risk of wound infection in cases of PPM implantation in patients with diabetes and obesity. Considering the size of wound surface in patients with morbid obesity the active drainage is necessary.

P077 Sutureless incisional hernia repair with Oval PatchÒ A. Messina Campanella, S. Licheri, M. Podda, G. Poillucci, S. Aresu, A. Pisanu Policlinico Universitario di Monserrato, Cagliari, Italy Background: This retrospective cohort study analyzes outcomes of patients with incisional hernia who underwent abdominal wall reconstruction by sutureless Rives-Stoppa-technique, with stiffPolypropylene Prosthesis (Oval-PatchÒ). Methods: From 2010 to 2015, 44 patients underwent incisional hernia repair, using sutureless stiff Polypropylene mesh (Oval-Patch Ò ), whose fixing was guaranteed by fibrin-glue (2 or 4 ml TesseelÒ). Main inclusion criterion was a defect smaller than 12 cm. Surgery was tension free, sutureless closure, using a heavy-weight, stiff prosthetic in onlay position fixed with glue, with minimum 5 cm overlap. Drainage, always positioned above the prosthesis and the anterior fascia was closed with a 2/0 PDS running-suture. A second

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drainage in the subcutaneous plane. We evaluated operative time, length of hospital stay, complications and patient’s discomfort using Carolina-Comfort-Scale (CCS). Results: We treated 44 patients: 16 male (36.0%) and 28 female (64.0%). Mean age was 63 years (39–83 years), mean defect diameter was 9.0 cm (range 4–12). The mean operative time was 112 min (range 70–190), the mean postoperative hospital stay was 4 days (range 2–7), the mean CCS score was 0.8 (range 0–5). Follow-up was 25 months (range 6–60). Postoperative complication occurred in one patient, with chronic seroma and early recurrence (2.2%) at 30 days. No postoperative chronic pain was observed. Conclusion: Use of retromuscular, preperitoneal sutureless stiff mesh (Oval PatchÒ), is a safe, easy and acceptable alternative approach in selected patients. Our results showed a low incidence of postoperative complications and recurrence, short postoperative hospital stay and no chronic pain.

then 4 months later;the old mesh was extracted,a new mesh was placed,she has a purrulent drainage from the wound for 8 months the patient was in 2016 July,hospitalized,has minimal degree cardiac failure hypoproteinemia anemia. A culture was obtained from the wound and the bacterium was isolated from the culture. CT scan of the abdomen and ultrosonography showed a foreign body in abdominal wall some purullent material in lateral, inferior of the liver. Results: in laparoscopy a purullent material some brid and a foreign body was shown. A diagnostic laparoscopy was made; showed a urinary bag inside of right abdominal wall, the urinary bag was take out. The discharge was not continued from the wound after 15 days the patient has no complaint for 4 months. Conclusion: If a surgeon confronted a patient with nephrectomy, hernioraphy with mesh, discharged wound history.he/she should bring to his/her mind,a foreign body in the abdominal wall. This is a unique case who is not reported before in english literature.

P078 Open versus laparoscopic approach in ventral hernia repair with an intraperitoneal mesh

P080 Both colostomy retrival and incisional hernia repair could be made in the same hospital admission

R. Nu´n˜ez, C. Ba´ez, A. De Andre´s, M. Bruna, J. J. Puche, R. Go´mez, C. Navarro, M. Oviedo, P. Albors, A. Va´zquez Hospital General Universitario de Valencia, Valencia, Spain

N. Ozlem Ahi Evran University, Kirsehir, Turkey

Background: Intraperitoneal hernioplasty is an option to ventral hernia repair. Laparoscopic approach is an alternative to open technique due to it avoids large abdominal incisions and also many studies have reported less pain and hospital stay in selected patients. The aim of this study is to compare open versus laparoscopic approach in ventral hernia repair with an intraperitoneal mesh. Methods: 114 ventral hernia repairs were performed between January 2008 to September 2011 in our center, 44 (38.6%) laparoscopic and 70 (61.4%) open approach. A retrospective and descriptive study was performed comparing both groups, surgical time, complications, mortality and recurrence rate. Results: Patients in both groups attached to similar preoperative morbidity. The mean hospital stay was 3.7 days (S = 5.6). No statistically significant differences were found in surgical time (p = 0.4) with a mean of 90 min in laparoscopic surgery against 82 in open repair. Global morbidity rate was 40.3%. The most frequent complication was wound infection, 11 undergoing laparoscopic surgery (25%) versus 35 after open repair (49.3%), finding this difference statistically significant (p = 0009). Only one case of mortality was reported, due to torpid evolution after bowel injury. Global recurrence rate was 24.5%; 14 after laparoscopic procedure (31.8%) and 16 after open repair (21.3%), finding no statistically significant differences (p = 0.204). Conclusion: According to our experience, recurrence rate was higher after laparoscopic approach and there are more cases of intraoperative complications and wound infection by open surgery. It’s necessary to make a careful selection of technique related to individual characteristics.

P079 A urinary bag to close flank hernia N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: Many material has been used before to close the fascial defect except a urinary bag. This is a unique case in literature. Methods: 54, Y, F, who has renal cell ca,lap nephrectomy from iraq has incisional hernia repaired in 2 times with two meshes firstly 6,

Background: In the past when a hollow viscus was opened, a incisional hernia repair with mesh could not performed in the same admission, session. This is the first time released presentation in our knowledge in the World; a patient were operated for colostomy closure + incisional hernia repair with mesh in the same hospital admission without discharged. Methods: 43 year old woman was presented with septic shock.Upright abdominal X-ray showed free air below diaphrapm. Laparotomy showed advanced sigmoid colon tumor was perforated, hartmans procedure was apllied.Fascial dehiscence was occured. At 4 months later, firstly a retrival of colostomy was made, secondly one week later her incisional hernia repair with mesh was done. Results: The patient was discharged without problem. Conclusion: Geisler et al.; when a patient have a stoma or electively hernia repaired the hernias recurred at a rate of 23% and seroma occured at a range 13%, wound infection rate; 7%. Recurrence and wound infection were not associated with hernia type and mesh type or operative intervention. The author suggested after bowell preparation non absorbable mesh electively could be placed with acceptable recurrence rate with minimal infection risk and mino¨r morbidity raigani et l and kasperk et l their cases with both recurent parastomal, incisional herni cases were repaired and the rate of recurrence in incisional hernias were 30%. Raigani et l note their recurrence of patient were %17 macairas etl; bowel resection and polipropilen mesh repair of hernia in a patient could be made in the same operation.

P081 Managment of patients with mesh-site infection after ventral hernia repair D. Katsaounis, N. Rapti, E. Kefalou, C. Chouliaras, E. Manioti, A. Papadopoulos, P. Ioannidis 1st Department of Surgery, Nikea General Hospital, Nikaia, Pireus, Greece Background: The use of mesh to repair ventral hernias is well established in order to prevent recurrence, although it is prone to infection. The aim of this study is to review cases and management of

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S230 mesh-site infection after hernia repair that took place in General Hospital of Nikaia, Greece. Methods: We retrospectively examined the cases of patients who underwent a surgical repair of ventral hernias with mesh and some of them developed mesh-site infection, Results: Over a period of 24 months (2012–2014) 112 patients underwent hernia repair surgery. In 55 (49.1%) of the ventral hernia cases the mesh was placed underlay and in 57 (51.9%) sublay. Out of 112 patients, the 7 (6.25%) of them developed mesh-site infection and 3 (2.7%) seroma. Out of the 7 infected meshes, the 3 (43%) were placed sublay and the 4 (57%) were underlay. The 3 (43%) of the infected mesh incidents were treated with negative pressure wound therapy, 3 (43%) were treated conservatively with local woud care and antibiotics, and 1 (14%) operated for removal of the infected mesh. Enteroatmospheric fistula was developed in two cases: one patient from the negative wound pressure therapy and one of the conservatively group and they underwent surgery. Conclusion: The mesh-site infection after ventral hernia repair is not a very often complication. There is a big debate in the international literature about the management (surgical/conservative) and the time of surgical removal of the infected mesh.

P082 Biological mesh in abdominal incisional hernia:outcome from a retrospective case series F. Zingales, G. Pozza, S. Degasperi, G. Bordignon, S. Rampado, M. Gruppo, R. Bardini University Hospital of Padua, Padua, Italy Background: The use of biological meshes in management of potentially contaminated or incisional infected hernia and of giant wall defect is well established. The use of fascia lata and pericardium allografts as biological meshes is still under investigation. Methods: Patients undergoing incisional hernia repair with biological mesh (strattice xenograft; fascia lata and pericardium allograft) were reviewed. A retrospective evaluation of clinical data was performed paying specific attention to hernia recurrence and wound complication. Results: From December 2010 to December 2016, 22 patients were treated (11 F, 11 M), 60 years median age. In 14 patients there were a potentially contaminated wounds, in 5 patients there were an infected surgical site and in 3 patients had a giant wall defect. Five patients were treated with use of xenograft mesh, 15 patients with omologus allograft mesh and 2 patients with omologus allograft combined with polypropylene mesh. Median follow-up was 18 months (range 0–68). Recurrence was observed in 7 patients (32%). Recurrence occurred in 3 patients treated with Strattice mesh (60%); 4 patients treated with omologus allograft had recurrence (24%). Post-operative major complication who required surgical treatment or ICU admission were 3 (14%); post-operative minor complication who required ambulatory medications were 4 (18%). Conclusion: No comparative trials have been performed to date evaluating different biological materials in incisional hernia repair. According to our preliminary outcome, omologus allograft seem to be a safe and an effective method for the repair of infected or giant incisional hernia.

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P083 Combined surgical procedure for ventral abdominal hernias A. Radzikhovskiy1,2 1 AGAPLESION Diakonie Kliniken Kassel, Kassel, Germany, 2Red Cross Hospital, Kassel, Germany Background: Laparoscopic surgery of the ventral abdominal hernias has developed into an integral part of the repertoire of most visceral surgery departments worldwide. Despite sophisticated surgical Methods and substantial support from industry recurrence rates as well as amount of complications still have a relevant extent. From divers studies it has been known that alone the closure of the facia defect can significantly reduce complications such as recurrence, seroma formation and mesh eventration. Methods: A combined surgical method of ventral abdominal hernia repair has been applied at our department since 2014. The dissection and removal of the hernia sac as well as the primary closure of fascia defect is carried out via a usual open incisional, whereas the positioning and fixation of the mesh is performed laparoscopically. Results: We have examined the first consecutive 23 patients who have been operated on. The mesh sizes were between 6 9 7 and 15 9 20 cm. Discharge took place on the 2nd–3nd postoperative day. A postoperatively control was performed after 6 weeks in all patients. In 8 patients (35%) an additional follow up was perform 3 months postoperatively. In one patient further follow up in 15 months postoperatively. No complications requiring intervention and no recurrence were observed. Conclusion: The presented method of a combined approach of ventral abdominal hernia repair is a safe procedure. It connects the advantages of the conventional and laparoscopic technique. At the same time, it offers a tailored approach for the patient.

P084 Incarcerated Spiegel hernia containing ascending colon carcinoma A. Skarpas G.H Sismanolion, Vrillisia, Greece Background: Spigelian hernia is a relatively rare entity with a wide variation in clinical presentation. Complications of Spiegel Hernia, caused by delayed diagnosis and small size of the hernial neck, are very common, reaching up to 35% of all cases. The most common complications include, strangulation (6.7%), incarceration (10.4%), intestinal obstruction (12.9%) and the incomplete obstruction (5.5%). We present a rare case of incarcerated Spiegel hernia, containing carcinoma of the ascending colon. Methods: A female patient 88 years of age was admitted to the E.R. of our hospital in a bad general condition, with symptomatology of obstructive ileus and a painful mass on the right side of the abdomen. The patient had a known Spiegel hernia, confirmed from a previous CT. The patient was immediately taken into the O.R. Results: An incision over the mass of the abdominal wall was performed, and revealed an incarcerated Spiegel hernia containing part of the ascending colon that was obstructed from a neoplasm. Right hemicolectomy was then performed. For the Spiegel hernia, reconstruction of the anterior abdominal wall without the use of mesh was

Hernia (2017) 21 (Suppl 2):S208–S263 preferred. The postoperative period was uneventful. The patient was released on 11th postoperative day. Conclusion: The presence of a malignancy of the colon as a content of an incarcerated Spiegel hernia is an extremely rare case and should always be considered since the presence of a neoplasm changes completely the operative plan.

P085 Midline incisional hernia with open ventral hernia repair with mesh: OVHR S. Tahir, G. Stavridis, A. Nikolovski, T. Baldjiev, A. Devaja, D. Mladenovik University Surgical Clinic-St. Naum Ohridski, Skopje, Macedonia, The Former Yugoslav Republic of Background: The incidence of incisional hernias following midline abdominal incisions is difficult to estimate. Methods: From 2005 to 2015, 266 patients were operated with midline incisional hernia. 35% were previously operated at our clinic and 65% at various hospitals with standard absorbable suture closure. Open ventral hernia repair with mesh was used on all of the patients that were operated. Pre-surgical prophylactic dose of antibiotic was given to all patients, no antibiotics were used postoperatively except for patients with wound inflammation, analgesia were commonly used. Generally used materials were prolene mesh or dual mesh. Commonly used mesh size was: 20 9 30 cm with 157 patients (59%), 15 9 15 cm with 82 (31%), other sizes with 27 (10%). Chevrel technique of the premuscular placement of prolene mesh was used with 183 patients (69%), retromuscular preperitoneal mesh was placed in 64 patients (24%), and in 19 patients (7%) intraperitoneal dual mesh was placed. In 176 patients (66%) that were operated vacuum drainage was inserted. Results: In 23% operated patients seroma occurred and lasted for more than 10 days. In 4% patients inflammation of the incision site occurred and were treated with antibiotics for more than 7 days. Only 0.8% retromuscular mesh patients needed removal of the mesh. In intraperitoneal mesh patients longer usage of analgesia was recorded. Average time for hospitalization was 7.5 days. Recidivism occurred in 4% patients. Conclusion: Chevrel’s technique in midline incisional hernia repair and Retromuscular mesh repair technique with all the remaining incisional hernias demonstrate best results respectively.

S231 Results: We enrolled 18 patients (10M/8F; median age: 56.1 year; BMI 30.1 and ASA II). 2/18 patients developed seromas and 3/18 haematomas, they were treated conservatively without infective complications. A thrombophilic patient with a previous hepatic transplant had a wound dehiscence. Another patient went through the necrosis of the cutaneous flap and the mesh removal has been necessary. Conclusion: In our experience PrevenaTM, if applied in selected patients, may help to reduce superficial wound complications, while it seems to not play a role in deep wound complications; however larger samples and high-level studies are needed to validate these findings.

P087 A novel technique for applying trans fascial sutures for fixing mesh in laparoscopic ventral hernia repair A. Vindal, P. Lal Maulana Azad Medical College, New Delhi, India Background: Fixation of mesh remains the ‘Achilles’ Heal’ in laparoscopic ventral hernia repair (LVHR). There are several methods of mesh fixation available for use by the surgeon. Trans-fascial sutures have been shown to be one of the most reliable and pivotal mesh fixation mechanism that has stood the test of time. Methods: We present our experience with a simple and hitherto unreported technique of applying the trans-fascial sutures for fixing the mesh during LVHR using a large bore i.v. cannula. A total of 98 patients were operated using this technique over a period of 70 months. Results: Out of the 98 patients, there were 36 males and 62 females (age ranging from 18 to 66 years). The types of hernias operated included incisional (41), umbilical and paraumbilical (36) and epigastric (21). There were 73 midline and 25 lateral hernias. Different meshes were used according to the availability in our institution. The average time taken to apply four trans-fascial sutures was 4.5 ± 0.8 min. There were no intra operative complications attributable to the technique except for puncture related bleeding in 2 patients that settled on its own. None of the patients developed any recurrences in the follow up period (range 4–70 months). Conclusion: The present technique provides a fast, easy to learn and reproducible solution to an established and important step of fixing mesh during LVHR using trans fascial sutures, without the need for any special equipment.

P086 Wound management with negative pressure medication system after open retro-muscular mesh repair in incisional hernia: our experience

4. Prevention of recurrence and complications in groin hernia repair

F. Trombetta, R. Moscato, P. Chiaro, S. Sofia, M. Morino University of Turin-General Surgery Unit 1 U., Turin, Italy

P088 Groin hernia repair: open versus laparoscopic repair

Background: Incisional hernia mesh repair are associated with superficial and deep surgical site complications (infections, seromas, hematomas, wound dehiscence); these complications increase costs and worsen patients’ quality of life. An early adoption of negative pressure wound therapies (NPWT) may reduce these complications and therefore reduce overall costs. The aim of this study is to. Methods: All the patients with risk factors for delayed wound healing (diabetes, smoke and/or obesity) between August 2014 and October 2016, who underwent incisional hernia repair with Rives–Stoppa technique, were enrolled in the study. PrevenaTM, a NPWT system, was applied in surgical theatre on the closed laparotomy, with a negative pressure of 125 mmHg, and it was removed after seven days.

I. O. Avram, S. Ro¨hr, C. Lamberty, D. Borces, J. Gensberger, F. Schu¨tze, R. Metzger CaritasKlinikum Saarbru¨cken, Saarbru¨cken, Germany Background: The repair of inguinal hernia is the most common surgical procedures performed yearly. While there is a general consensus regarding the mesh repair, there is still an ongoing debate regarding the surgical technique of choice, open or laparoscopic.Aim of the study is to compare the outcome of conventional mesh repair 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 one year postoperatively. The risk factors, intra- and postoperative

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S232 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 897 hernia patients operated in our clinic in the last 3 years we selected the 559 patients operated for inguinal hernia. 184 patients were operated for bilateral inguinal hernia (32.91%), 171 for left side hernia and 204 for right side hernia. All bilateral inguinal hernias were operated endoscopically. Only 367 out of the 559 patients summoned for the 1-year follow-up were examined (56.0%). We recorded 5 recurrences (1.36%), 3 after TEP repair and 2 after Lichtenstein repair. All 3 recurrences after TEP occurred during the first 30 days. Conclusion: 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.

P089 Surgical treatment of a big-sized direct inguinal hernia I. Babii1, V. Vlasov1, O. Kharyshyn2 1 Regional Hospital, Khmelnitsky, Khmelnitsky, Ukraine, 2Slavuta Central District Hospital, Slavuta, Ukraine Background: Inguinal hernia (IH) comprises about 5% of all surgical diseases, plastic hernias are most common in the planned surgery (10–15%). Methods: We have analysed the treatment of 286 patients with IH. The majority of operated patients (from 18 to 87 years) were men— 266 (93%). According to the classification EHS PL1 type of IH was diagnosed in 13 cases (4.5%), PL2—54(18.9%), PL3—71(24.8%), Rm1—4(1.4%), RM2—63(22.0%), PM3—53(18.5%), rS1—1(0.4%), RS2—3(1.04%), rS3—5(1.8%), RL3—4(1.4%), RM2—8(2.8%), rm3—7(2.4%). Results: 60 (21.0%) patients underwent surgery on big-sized direct hernia. Lichtenstein surgery was performed in 12 (4.2%) patients, transinguinal preperitoneal plastic surgery (TIPPS) of hernia defect in the modification of the authors—in 48(16.8%). The transverse fascia was cut circularly at the base of the hernia sac. The transverse fascia was not separated from the hernia sac. The hernia sac was immersed into the abdominal cavity without checking its content. The defect in the transverse fascia was sewn line-on-line. This method reduces the time of operation and prevents bleeding from the hernia sac. The complications after TIPPS were: postoperative scar infiltrate (2), wound hematomas (1) that don’t require surgical correction. The Lichtenstein surgery complications were: hydrocele (1), postoperative scar infiltrate (1), wound hematoma (2). The patients were examined after 3 years—one patient had a relapse after the Lichtenstein surgery. Conclusion: TIPPS is better for the patients with a big-sized direct IH.

P090 Inguinal hernia repair in adolescents: a 15-year review S. Dios-Barbeito, M. Bustos-Jimenez, M. Flores-Corte´s, J. A. Martı´n-Cartes, P. Garcı´a-Mun˜oz, V. Camacho-Marente, J. L. Gollonet-Carnicero, J. Padillo-Ruiz University Hospital Virgen del Rocio, Seville, Spain Background: It is not clear the best surgical treatment in adolescents with inguinal hernia because of their growing and high prevalence of chronic pain. While high ligation of the sac is the gold standard

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Hernia (2017) 21 (Suppl 2):S208–S263 treatment in children, it is preferred a mesh repair in adults. Therefore, we have examined our long-term outcomes in this group. Methods: We have retrospectively studied all patients between 14 and 20 years old suffering from inguinal hernia treated between 1 January 2001 and 31 December 2015. We analysed age and sex, anaesthetic risk according to the ASA classification, characteristics, surgical technique, recurrence and postoperative chronic pain. Results: We included 88 patients with a mean age of 17.28 years (range: 14.0–20.0), 44 were treated by a Lichtenstein repair with a polypropylene mesh (49.9%), 39 with a PHS mesh (44.3%), 4 with a muscular repair (4.5%) and only one patient with a high ligation of the sac (1.1%). 76 patients were males (86.4%) and 66 were classified as ASA I (75%). 59 hernias were on the right side (67%), 62 lateral (70.5%) and 85 primary hernias (96.6%). The average follow-up time after hernia repair was 93.5 months (range: 12.0–188.0). After having performed radiologic images to patients with inguinal pain or bulge, we defined one patient with recurrence (1.1%) and 8 with chronic pain (9.1%). Conclusion: Mesh hernia repair appears to be effective in adolescents with low recurrence rate and less incidence of chronic pain than the reported in the literature.

P091 Long-term follow-up of a prospective randomized study comparing polypropylene mesh fixed with sutures vs. self-fixating polypropylene mesh in inguinal hernia repair G. Chatzimavroudis, B. Papaziogas, I. Koutelidakis, I. Galanis, P. Christopoulos, N. Voloudakis, G. Kotoreni, S. Laskou, E. Christoforidis 2nd Surgical Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece Background: Mesh repair is the gold standard treatment for inguinal hernia repair due to the significant decrease of recurrence rates in relation to the classic herniorrhaphies. Nowadays, chronic groin pain is considered the most significant postoperative complication of inguinal hernia repair. Self-gripping semi-resosbable meshes have been developed in order to reduce chronic postoperative pain. However there is a concern regarding the long-term effectiveness of these meshes. The aim of this study was to evaluate the effect of a self-fixating polypropylene mesh on long-term recurrence rate. Methods: Between June 2009 and June 2010, 50 patients with primary unilateral inguinal hernia were treated using the Lichtenstein technique. Patients were randomly assigned to receive either a polypropylene mesh, fixed with polypropylene sutures (n = 25; group A), or a self-fixating polypropylene mesh with resorbable polylactic acid microgrips (n = 25; group B). In June 2016 follow-up regarding recurrence (primary end-point) and chronic postoperative pain (secondary end-point) was updated. Results: Median follow-up was 75 months for classic polypropylene mesh group and 76 months for self-gripping polypropylene mesh group. Chronic pain was reported by one patient (4%) of group A and one patient (4%) of group B (p = 1). Both patients rated their pain as mild without affecting their daily activities. Regarding hernia recurrence, no case of recurrence was recorded during this long-term ([ 6 years) follow-up in either group. Conclusion: Self-fixating polypropylene mesh showed excellent long-term outcomes, comparable with classic polypropylene mesh and thus it can be can safely and effectively used in open inguinal hernia repair.

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P092 Fast and safe methods for local anaesthetics administration in ambulatory hernia surgery: district General Hospital experience D. Dabic, V. Perunicic General Hospital Cacak, Cacak, Serbia Background: Ambulance hernia surgery is unimaginable without local anaesthesia and a qualified and experienced surgeon who is capable of operating in these conditions without complications.These operations are no longer reserved for specialized hernia surgery centres only. Methods: From January 2006 till December 2016 using two procedures for giving local anaesthesia 1076 elective, 972 unilateral and 52 bilateral inguinal hernia operations have been done on 1024 patients.On 473 (46.19%) patients ‘‘one step procedure’’ was applied and when it comes to the other 551 (53.81%) ‘‘step by step procedure’’ were performed.Anaesthetics that were used are procain,lidocain,bupivacain and levobupivacain. Results: The average age of the patients was 66 years (20–87).All of them were in the group ASA I-III. We were performed Lichtenstein technique (Hermesh 5/8Ò), PHS/UHS/3DP Ò, Progrip Ò and Schouldiice technique.There were no any complications as neurovascular injury, bowel and bladder injury, haemathoma, bleeding and chronic pain. Conclusion: The amount of local anaesthetic necessary for achieving the optimal effect didn’t depend on applied operation technique.The applied administered procedure influenced on the total amount of the anaesthetic necessary for achieving the optimal effect of anaesthesia.Because of the specifity of ‘‘one step procedure’’,a significantly higher amount of anaesthetic is required. The amount directly depended on the experience and qualification of the surgeon and gently tissue dissection. Higher amount of anaesthetic was used for younger people (20–50 years).

P093 Experience of using n-butyl cyanoacrylate mesh fixation in laparoscopic groin hernia repair: influence on the recurrence

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P094 Evaluation of TAPP efficacy and combined fixation of mesh implants for inguinal hernia repairs Y. P. Feleshtynsky, A. V. Kokhanevych, V. F. Vatamaniuk Shupyk National Medical Academy of Post-Graduate Education, Kyiv, Ukraine Background: Implementation of TAPP for inguinal hernia repairs has improved the treatment outcomes. Meanwhile, the recurrence rate for inguinal hernia after TAPP repairs is still 3.5–10%. Usage of combined fixation of mesh in TAPP repair will contribute to a reduction in the recurrence rate. Methods: The efficacy of TAPP repair of inguinal hernias was evaluated in 128 patients aged 25–75. The patients were divided into two groups. In Group I (64 patients), there was performed classical TAPP. In Group II (64 patients) we used improved TAPP: Ultrapro mesh implant (10 9 15 cm) was fixed with Protack hernia stapler at typical points, but Sulfacrylate adhesive was used at the area of the iliopubic tract and iliac vessels. Results: The events seen in the early postoperative period included: seroma in 3 (4.68%) patients in Group I versus 2 (3.12%) patients in Group II, hematoscheocele in 2 (3.12%) and 3 (4.68%) patients in Group I and II, respectively. Long-term results of treatment were studied at 1–5 years after surgery. Among 45 patients examined in Group I, inguinal hernia recurrence was seen in 3 (6.66%) patients, among 46 patients examined in Group II, no hernia recurrence was observed. Conclusion: TAPP with combined fixation of mesh by use of Protack hernia stapler at typical points and Sulfacrylate adhesive at the area of the iliopubic tract and iliac vessels reduces the recurrence rate of inguinal hernias. It seems to be more effective in comparison with classical TAPP

P095 A combination of bromelain and boswellia serrata casperome: effects on post-operative course of inguinal hernioplasty with prosthesis at one year follow-up

M. Ehrenberger, P. Galvanek, P. Bartkova Surgery department, Hospital Uherske Hradiste, Uherske Hradiste, Czech Republic

M. Gallinella Muzi1, P. Maida2, C. Mosconi1, G. Muto3, P. Sileri1, A. Sorge3 1 General Surgery,Policlinico Universitario Tor Vergata, Rome, Italy, 2 Evangelical Hospital, Naple, Italy, 3General Surgery,San Giovanni Bosco Hospital, Naple, Italy

Background: Methods of mesh fixation in inguinal hernia repair are evaluated in many aspect. The most evaluating aspects are safety resp. adverse effect, time of fixation, strength of fixation, impact on reccurent hernia and price. Methods: For a 24-months we operated 420 patients with 462 inguinal hernia of TAPP method with N-butyl cyanoacrylate mesh fixation. The method introduction was quick and without complications. Results: In compare with the second group of 365 patients with 422 inguinal hernia was no significant different in time of fixation, impact on reccurence or strength of fixation. In tis method on the other hand was a lesser incidence of minor vascular injury and the price for using this method was lower. Conclusion: This fixation method is just for ‘‘lightweight’’ polypropylene meshes. Time of fixation is the same lenghth of time as fixation with titan or plastic tack. N-butyl cyanoacrylate is very good fixation product with minimal adverse effect on soft tissues (i.e. is used for varix sclerotization or haemostatic glue in cardiac or vascular surgery). The number of recurrences are the same as other fixation methods. Another significant advantage is price.

Background: This inguinal hernioplasty do not normally involves the subministration of antiinflammatory agents. Aim of this study is to investigate the potential benefits about post-operative outcomes of inguinal hernia repair with prosthesis, using a combination of bromelain (200 mg) and boswellia serrata casperome (200 mg), SibenÒ and compare responses with control patients (placebo). Methods: one hundred eighty patients (twenty-seven females, one hundred fifty-three males) underwent open tension-free hernioplasty with ProgripÒ and were divided into two homogeneous groups (mean age 57 years, BMI 27 kg/m2). Group A took one tablet of SibenÒ, Group B (control) took a placebo, every twelve hours for eleven days on an empty stomach, starting the first post-operative day. All patients fill a questionnaire on pain, based on VAS scale (from zero to ten). Results: The perception of pain, is similar in the two groups at baseline, while it is significantly reduced in SibenÒ group compared to the group B, both at seven (p \ 0.05) eleven post-operative day (p \ 0.05) and one post-operative year (p \ 0.05) All patients using SibenÒ, resume daily activities and return to work earlier than control group; no patients have paresthesia.

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S234 Conclusion: the results at one year show an important improvements about open inguinal hernioplasty post-operative outcomes in patients treated with SibenÒ, especially in return to daily and working activities.

Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: We reported on a relatively rare case caused by posthernioplasy complication with reference to relevant medical literature.

P096 Evaluation of cause of recurrence after laparoscopic groin hernia surgery: TAPP

P098 Analysis of the first hundred personally operated inguinal hernia with laparoscopic transabdominal preperitoneal repair

P. Galvanek, P. Bartkova, M. Ehrenberger Surgery department, Hospital Uherske Hradiste, Uherske Hradiste, Czech Republic

A. Jezupovs Riga East University Hospital, Riga, Latvia

Background: One of complication after laparoscopic groin hernia repair is recurrence. Existing guidelines will seek to minimize this risk. Despite the recurrence occurs remains almost in all of the publicating studies. Causes of recurrence is more, it is the experience of the surgeon, inadequate dissection, insufficient overlap, small mesh, bad/poor fixation and mesh rolling. Methods: In our report we have focused on evaluating the causes of recurrence after TAPP in our group where we observed recurrence in 1.1% of cases. In a short video presentations we are trying to verify the cause of recurrence, that we localized the defect and evaluate the disection and compared it with primary surgery. Results: As a fundamental perceive a lack of preparation in preperitonea in mediokauda´lnı´ part. Another crucial thing is to save the mesh without lifting at the bottom. Conclusion: The results of this is important for further self-evaluation and also in the education of younger colleagues.

P097 A case of mesh perforation into the bladder following inguinal hernia repair Y. Igarashi, M. Horikawa, H. Midorikawa, Y. Suzuki, D. Tsukahara, N. Soeda, Y. Kumata, T. Kiyokawa, Y. Yaguchi, T. Inaba, R. Fukushima Teikyo university hospital, Tokyo, Japan Background: Complications arising during inguinal hernia repair include injury to the nerves, blood vessels, intestinal tract, seminal duct, and bladder. We report our experience of a rare case in which the mesh plug migrated into the bladder. Methods: The patient was a 79-year-old male who underwent laparoscopic hernioplasty for bilateral inguinal hernia. We used Bard 3DMaxTM mesh (Bard) on both sides. As postoperative progress was satisfactory, the patient was discharged on day 8 post admission, but he subsequently experienced repeated edema in the right inguinal region for which he underwent outpatient follow-up care. However, the edema did not improve, and a detailed examination performed after a five-month period led to a diagnosis of recurrence of right inguinal hernia. We performed a right laparoscopic hernioplasty using the anterior approach with an UltraproÒ Plug (Ethicon Inc., Johnson and Johnson Company). Cystoscopic observation performed on day 7 post admission due to continuous hematuria since following surgery indicated that the mesh had become displaced. As a result, we planned a partial cystectomy and partial mesh resection. We performed a cystotomy and resected the anchor part of the Plug that had become displaced. As there were no complications postoperatively and progress was good, the patient was discharged on day 25 post admission. Results: The bladder complication was thought to have occurred during the second surgery.

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Background: The procedure of laparoscopic transabdominal preperitoneal repair (TAPP) was mastered in a self-taught manner. The aim of the study was to analyse the first hundred personally performed TAPP procedures. Methods: The frequency of intraoperative and early postoperative complications, imperfect surgical technique, chronic pain, rate of recurrences were analysed totally and separately between the first 10, the next 30, the following 30 and the last 30 procedures. Results: The intraoperative and early postoperative complications were in 11 patients, in 6 of them during the first 40 procedures. Imperfect surgical technique was recorded in 11 patients, with no difference between groups. Long-term results with average follow-up of 36 months were collected from 86 patients. The recurrence rate was 4. 65% (4/86). Three of recurrences were in the group of the first 40 procedures. The frequency of recurrences significantly (p \ 0.007) depends on imperfect surgical technique. Chronic pain was confirmed in 13.95% (12/86), with no influence of analysed factors and difference between groups. Conclusion: The frequency of recurrences depends on imperfect surgical technique. Increasing experience of a surgeon doesn’t decrease the frequency of chronic pain.

P099 A case of ileus complications soon after laparoscopic inguinal hernia repair Y. Kumata, Y. Suzuki, D. Tsukahara, H. Midorikawa, H. Igarashi, N. Soeda, M. Horikawa, T. Kiyokawa, Y. Yaguchi, T. Inaba, R. Fukushima Teikyo University Hospital, Tokyo, Japan Background: The case was a 72-year-old male who had undergone laparoscopic inguinal hernia repair (transabdominal preperitoneal; hereinafter TAPP) for bilateral inguinal hernias. From day 2 following surgery, the subject exhibited vomiting, with ileus clearly visible in abdominal X-ray imaging; therefore, an ileus tube was inserted. However, there was no improvement in the ileus, and thus we decided to perform surgery. Methods: Laparoscopic ileus removal was commenced. At the right medial umbilical fold mass formation of the small intestine was confirmed. In this area a band had formed, from inside of which the small intestine had embedded into the preperitoneal cavity. Although the band was dissected, and repair was attempted laparoscopically as much as possible, there was strong adhesion of the mesh and small intestine; therefore, the procedure was changed to open surgery. Upon detaching the embedded small intestinal adhesion, 40 cm of the small intestine was embedded in the preperitoneal cavity. This portion of the small intestine was partially perforated and thinned, and thus partial resection of the small intestine was performed. The peritoneum was ligated and closed again, thereby completing the surgery.

Hernia (2017) 21 (Suppl 2):S208–S263 Results: Progress following surgery was favorable, and there was no subsequent recurrence of ileus observed. Conclusion: In the present case, a band had formed soon after surgery, and this obstruction caused an increase in the internal pressure of the intestinal tract, which led to rupture of the peritoneum closed during TAPP repair, and through this rupture we believe the small intestine became embedded in the preperitoneal cavity.

P100 Novel use of botolinum A injection in optimisation of abdominal domain prior to repair of giant inguinoscrotal hernias C. Lau1, W. Tay1, W. Cheah1, A. Rauff2 1 Ng Teng Fong General Hospital, Singapore, Singapore, 2National University Hospital, Singapore, Singapore Background: The challenge in giant inguinoscrotal hernia surgery is the difficulty in reducing contents into the limited abdominal space and complications from postoperative intra-abdominal hypertension. Lack of abdominal domain also predisposes to early recurrence. We describe a novel technique using botulinum A (BTA) injection into the abdominal wall to achieve abdominal domain before repair of these hernias. Methods: 2 Patients each received 300 units of BTA injection in divided doses into the external oblique, internal oblique and transversus abdominis muscles at three sites on each side, each dose 50 units, 2 weeks before the planned surgery. The 6 injections were performed with ultrasound aid. Both hernias were later repaired in one stage. Results: Patient A presented with intestinal obstruction. Nasogastric tube decompression and parenteral nutrition were started; he was monitored inpatient prior to surgery. Patient B returned to outpatient activities between the injections and surgery date. BTA injections were tolerated by both. Patient A had a concurrent laparotomy to aid reduction of hernia contents. Patient B’s hernia was reduced with a groin incision alone. Mesh repair were performed for both. There were no postoperative complications and no post-operative recurrences at the 6 months review. Conclusion: Pre-operative BTA injection prior to elective giant inguinoscrotal hernia repairs is safe and feasible in a select group. The injections lead to progressive paralysis of the abdominal wall and increase in abdominal domain, which aid surgical reduction of inguinoscrotal contents. This also decreases abdominal pressure in the postoperative period and the risk of hernia recurrence.

P101 Effect of prevention procedure for the development of inguinal hernia after prostatectomy T. Nagahama Department of Surgery, Kudanzaka Hospital, Tokyo, Japan Background: It is well known that inguinal hernia after retro-pubic prostatectomy is common adverse event. We have evaluated our series of inguinal hernia after prostatectomy and assessed the effect of prevention for inguinal hernia. Methods: From 2003 to 2016, 78 patients of inguinal hernia after retro-pubic prostatectomy for prostate cancer were referred from

S235 single cancer center. At this cancer center dissection of peritoneum from vas deference and transection of processus vaginalis was carried out as preventive procedure for inguinal hernia from 2008. Incidence of inguinal hernia and association of prevention procedure were compared and the effect was evaluated. Results: Break down of the treated hernia was lateral hernia: 111, and medial hernia: 1. Patients were classified into two groups by the prevention procedure (Group-pre without prevention and Group-post with prevention). Incidence of inguinal hernia in the Group-pre was 7.0% (62/883) and that in the Group-post was 2.8% (21/737). Incidence of inguinal hernia in the Group-pre was statistically higher than that in the Group-past. (p \ 0.001 by Chi square) Mean interval of prostatectomy and onset of hernia was 29.5 months in the Group-pre and 18 months in the Group-post. The difference was not statistically different. (p = 0.73). Conclusion: Our result remonstrated that simple prevention procedure could satisfactory reduce the incidence of inguinal hernia by 60%.These results suggested possible role of processus vaginalis in development of inguinal hernia. Dissection of peritoneum and transection of processus vaginalis can be easy but effective prevention for inguinal hernia after prostatectomy.

P102 Analysis of emergency inguinal hernia repairs in elderly patients N. Ozlem Ahi Evran Univerity, Kirsehir, Turkey Background: The results of emergency inguinal hernia repair (IHR)in elderly patients will be shared. Methods: Between 2008 and 2012 in our hospital, patients evaluated retrospectively at age 65 and over, which made an emergency IHR, one-year process of wound complications and recurrences. Patients’ informations have gotten by calling. Results: %5 (91patients)of 1793 IHR, has been in emergency conditions. 62.6% (57 patients) of 91patients aged 65 and elderly.80.7% of patients are male (46 patients)and 19.3% of patients (11 patients) are female. Mean age of male patients: 76.6 (65–89), of female patients: 81.6 (68–92). 28of 57 patients get hernia repair with mesh and 29 patients get hernia repair without mesh.male/female rate at with mesh and without mesh group: 23/5–23/6 mean age at with mesh and without mesh group: 75.6–79.5 mean operation time(MOT) at hernia repair with mesh 70.4 min (25–120 min).MOT at hernia repair without mesh 91.2 min (25–150 min) mean length of stay(MLOS) of patients get hernia repair without mesh: 3.7 day (1–23) MLOS of patients get hernia repair with mesh: 2.7 day(1–11).Mean time of first assesment of patient in emergency room to surgery room: 7.3 h 39 patients (68.4%) have incarcerated hernia, 18 patients (31.5%) have strangulated hernia in hernia sacs.11 (61.1%) of 18 patients who have strangulated hernia,have intestinal resection + anastomosis.At 5 patients (8.7%) femoral hernia documented.Mortality rate in first 30 days is 8.7% (5 patients) (with/ without mesh: 1/4). 6 Patients (with/withoutmesh: 1/5) died in 1 year follw-up for various reasons.In hernia repair without mesh group;1 recurrence, 2wound infections, 1 hematoma documented.There was no recurrence in group of hernia repair with mesh.1 wound infection 1 seroma documented. Conclusion: IHR in elderly have to have surgery electively to avoid the operative risks.

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P103 The hernia repair techniques are still currently in use and have satisfactory results?

Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: The study shows that all 3 techniques are equally effective. TEP provides less postoperative pain, short-term hospitalization and faster return to work. Disadvantage is the higher cost.

N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: Inguinal herni repair (IHR) with mesh-plaque caused increased mesh complication. Methods: Randomised prospectively selected 100 patients with IH were operated by LR or Rutkow techniques (RT). Mean ages was 45. Female/male ratio was 8/92.41 and 59 of them respectively were operated by LR, RT. Mean follow up period was one year. Results: No significant differences were observed in the difficulty of the operation, postoperative complication, recurrence when LR or RT were compared. Conclusion: Kirsi et’l;Lichtenstein repair(LR) using glue or self-gripping mesh (SGM)was somewhat faster than suture fixation, with comparable hernia recurrence rates, long term recurrence of LR are below 1–2%, but patient discomfort and chronic pain are more common problems. Testini et’l concluded that both fibrin sealant and cyanoacrylate are better tolerated than sutures in tension-free (TFH) of IHs because the short-term morbidity was significantly higher in the suture group (27%) than in the glue groups (9%). They found no significant difference in morbidity between the fibrin glue and cyanoacrylate. Similarly, SGM can be safely and effectively used in I HR with the additional advantage of reducing the operative time compared with the classic LR technique. However its use does not seem to be accompanied by reduced rates in chronic postoperative pain (POP) reaction.In the recent well-conducted randomized study, SGM was well tolerated and reduced a little bit early POP within the first week,without increasing the risk of early recurrence. It did not reduce, however, chronic pain,and there were no significant differences in the rate of recurrence or SSIs between SG and suture fixation methods. LR or Rutkow TFH techniques are easy to be learned, simple, effective, safety, easy to be applied withLA. They have POP, short term convalesence, minimal recurrence.

P104 A comparative study in three techniques of inguinal hernia repair A. Skarpas G.H Sismanolion, Mellisia, Greece Background: The best method in inguinal hernia repair has not gained acceptance yet. We compare three techniques: Lichtenstein, Rutkow & Robbins and TEP. Methods: In 24 months, 333 inguinal hernia repairs were performed on 298 patients (273 men, 25 women) from 19 to 94 year.o. 35 patients were operated for bilateral inguinal hernia. Lichtenstein was performed on 155 repairs (Group A), Rutkow and Robbins on 136 (Group B), and TEP on 42 (Group C). In the Lichtenstein method, strengthening of the transverse fascia was applied. In Rutkow and Robbins the cone was sutured and the mesh with clips. Results: Duration of surgery was between 37 and 57 min for the Group A, 25–52 min for Group B, and 36–61 min for the C group. Postoperatively in 2 cases of Group A and in 2 of Group B there was accumulation of fluid collection and 3 cases of Group A and 4 cases of Group B one hematoma was observed. Both were treated successfully conservatively. Administration of analgesics was higher for groups A and B. Hospitalization ranged from 1 to 4 days (Group A); 1–3 days (Group B), while all patients of Group C left the first postoperative day. Return to manual labor was faster in patients of Group C. Operative costs were higher in patients who underwent TEP. No patient had recurrence in a period of 0.5–24 months.

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P105 Retrospective analysis of various mesh repairs for inguinal hernias over a decade and guidelines to choose the ideal mesh: Single Center Study S. Venkatraman Chennai Krishna Institute of Hernia, Chennai Krishna Hospital, Chennai, India Background: This paper analyzes retrospectively the various Mesh repairs for Inguinal Hernia performed over a decade and to decide the guidelines for choosing the ideal mesh for a patient to prevent recurrence and complications –from a Single Center-single Surgeon Experience. Methods: Surgery for Inguinal Hernia is diversified. Starting from anatomical Repair of Bassini to various new concepts meshes of today. We analyzed our patients who underwent various mesh repairs for Inguinal Hernia over a decade and formed a path—how to choose the ideal mesh to a patient by our prototype guidelines. Results: 250 patients, predominantly of male gender who had inguinal hernia’s of varied presentations and were operated by various Mesh Repairs. Over time as we used many mesh repairs and we tried to formulate a guidelines that fit in with our patients to choose the ideal mesh for that patient. The paper discusses the various meshes used with indications and comparison between the available implants and their clinical outcomes and the effects observed in detail with a prototype guidelines that can be adapted in choosing a mesh. Conclusion: With properly chosen and well placed mesh repairs gives a promising role to repair inguinal hernias with good surgical outcome.

P107 Clinical research of the prevention and treatment of seroma in bilateral inguinal hernias C. Yang, S. Deng School of Medicine, University of Electronic Science and Technology of China, Hospital of the Univers, Chengdu, China Background: To discuss the prevention and treatment of seroma in open preperitoneal approach repair of bilateral inguinal hernias and the effect on the patients. Methods: 90 patients with bilateral inguinal hernias, admitted in our Hospital from January 2014 to January 2016,were divided into observation group and control group randomly and treated with open preperitoneal approach repair. Results: The observation group preperitoneal drainage tube for the majority of light red serum like fluid drainage, postoperative drainage volume was 24 h on average (81.7 ± 16.4) ml, with significant postoperative 24–48 h mean flow difference (P \ 0.05).The observation group postoperative seroma, 5d after operation, hospitalization time and average temperature were lower than that of control group (P \ 0.05).The incidence of seroma type and treatment within 1 months after the operation: two group of type I and type II cases can be restored; the observation group of 1 cases of type III B, control group 5 cases, were treated with symptomatic treatment after the restoration; the observation group IV type a 1 cases, group IV type a 3 cases, were treated by local drainage and give pressure after 3 times of treatment, patients get better. Conclusion: In the open bilateral inguinal hernia repair surgery in the peritoneal space before placing drainage tube can reduce the

Hernia (2017) 21 (Suppl 2):S208–S263 incidence of complications in patients with serum, reduce the average temperature of 5 days and shorten the length of hospital stay. Accurate classification of serum, and the early implementation of symptomatic treatment can effectively control the serum.

5. Prevention of hernia occurrence after midline laparotomy and stoma creation (prophylactic mesh) P108 Prophylactic implant of 3-D shaped mesh around the stoma: early experience B. Alampi, C. Bertoglio, L. Morini, M. Origi, C. Magistro, S. Di Lernia, G. Ferrari ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy Background: Parastomal hernia (PSH) occur in up to 50% of cases and its treatment is still considered a real challenge for the surgeon. According to the recent literature, the use of prophylactic mesh at the time of primary stoma should decrease the odds of hernia formation. We report our early experience. Methods: From January 2015 we have been proceeding with a perspective evaluation of intraperitoneal stoma technique (IPST) with a preshaped 3-D dual-layer onlay mesh. IPST mesh provide a visceral side of polyvinylidene difluoride (88%) and a parietal side of polypropylene (12%). All gathered data were collected and evaluated with regard to operative technique, early postoperative course and recurrence rate. Results: 10 patients (5 male and 5 female) undergoing laparoscopic (6 cases) and robotic (4 cases) Miles procedures for neoplastic disease have been selected for mesh reinforcement around left colostomy. IPST has been fixed by means of tackers and tissue liquid adhesive in 6 and 4 cases respectively. Mean operative time for mesh positioning was 43 min (range: 37–65 min.). Postoperative course concerning mesh-related complications was uneventful. Mean time to stool passage was 3 days. Median follow up was 10 months. No early recurrence or stoma-site and overall complications were recorded. Conclusion: Placement of a prosthetic mesh reinforcement by the laparoscopic approach may be safe and effective to prevent PSH, without impairing postoperative course. Our initial experience with IPST seems to confirm these promising outcomes though a long-term follow up is expected for a better evaluation of relapse.

P109 Incisional hernias following gynecological surgery: a population-based study ¨ sterberg1,2, H. So¨derba¨ck3,4, M. Lo¨fgren5,6, K. Bewo¨1, J. O G. Sandblom2,7 1 Department of Surgery, Mora Hospital, Mora, Sweden, 2Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden, 3Department of Surgery, Capio S:t Go¨rans Hospital, Stockholm, Sweden, 4Karolinska Institutet, Stockholm, Sweden, 5Department of Obstetrics and Gynecology, University Hospital of Norrland, Umea˚, Sweden, 6 Institution of Clinical Sciences, Obstetrics and Gynecology, Umea˚ University, Umea˚, Sweden, 7Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden Background: Incisional hernia is a common (5–20%) and costly complication following abdominal surgery. The incidence of incisional hernia after gynecological surgery is not as well studied as that after general surgery.

S237 Methods: The Swedish National Quality Register for Gynecological Surgery (GynOp) collects preoperative, intraoperative and postoperative information on women undergoing gynecological surgery. Data were extracted from 2006 to 2014. The National Patient Register (NPR) contains physicians’ data from both public and private hospitals. Univariate and multivariate Cox proportional hazard analyses were performed on risk factors. Results: Between 2006 and 2014 39 312 patients were entered into GynOp. The NPR recorded a total of 526 patients who were diagnosed with or had undergone surgery for incisional hernia. The mean follow-up was 2.8 years. Five years after surgery the cumulative incidence of incisional hernias was 2.1% (95% confidence interval 1.9–2.3%). In multivariate Cox proportional hazard analysis obesity (BMI [ 30), midline incision, smoking, kidney, liver and pulmonary disease and age [60 years were found to predict increased risk for incisional hernias (all p \ 0.05). Conclusion: There is much to be won if the patient can cease smoking and lose weight before undergoing abdominal surgery. The Pfannenstiel incision results in fewer incisional hernias and should be considered whenever possible.

P110 Long-term (5-years) abdominal wall complications after single-port laparoscopic surgery (SILS) C. Hoyuela, J. Ardid, A. Martrat, M. Juvany, F. Carvajal, M. Trias Hospital Plato´, Barcelona, Spain Background: The objective of the present study is to determine if single port laparoscopic surgery with the SILS device is associated with a higher rate of long-term abdominal wall complications. Methods: A study of cases and controls was performed with patients who underwent laparoscopic cholecystectomy at our hospital between July 2009 and June 2011 and followed prospectively. In this period, 42 non-selected patients undergoing laparoscopic SILS surgery (SILS group) and were compared with a control group of 85 patients undergoing laparoscopic cholecystectomy using the conventional technique with three trocars operated on during the same period (LAP group). Both groups are comparable in age, sex, BMI and ASA classification. Results: The mean follow-up was 72 (65–84) months. There are no remarkable differences between groups in terms of hospital stay, severe complications, wound infection and patients cosmetic satisfaction. However, operating time (55 versus 32 min) and long-term incisional hernia rate (9.5 vs 4.7%) were significantly higher in SILS group. Conclusion: Laparoscopic SILS cholecystectomy requires longer operating time and is associated with a higher rate of long-term incisional hernias than conventional laparoscopic surgery. The use of prophylactic meshes could be considered when performing SILS surgery in high-risk patients.

P111 Opening the black box of surgical interventions: Understanding variations in stoma formation to inform uniform data collection in a multi-centre cohort study C. Murkin1, L. Rooshenas1, J. M. Blazeby1, C. Jones2, I. R. Daniels3, N. J. Smart3, N. Blencowe1, On behalf of the CIPHER Study Group 1 School of Social and Community Medicine, University of Bristol, Bristol, UK, 2Peninsula College of Medicine and Dentistry, Exeter, UK, Exeter, UK, 3Exeter Surgical Health Sciences Research Unit (HESRU), Royal Devon & Exeter Hospital, Exeter, UK, Exeter, UK Background: Recently, the NIHR-HTA funded a Cohort study to Investigate the Prevention of parastomal HERnias (CIPHER).

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S238 However, deciding which data items to collect is challenging because risk factors for parastomal hernia are uncertain and there are multiple possible ways to undertake stoma formation. This study used multimodal data collection to identify ‘known’ and ‘unknown’ variations in stoma formation, to inform the design of case report forms (CRFs) for CIPHER. Methods: Two phases of work were undertaken: (1) systematic literature reviews (to identify ‘known’ variations in technique) and (2) qualitative work (to identify ‘unknown’ variations). The qualitative work comprised of digital-video data capture and non-participant observation of stoma formation in theatre, and interviews with clinicians from two centres. A consensus meeting of senior surgeons from four different centres refined the final data items to be collected in CIPHER. Results: Literature work reviewed 488 papers, identifying 138 themes relating to technical variations and 50 non-technical factors including patient characteristics. Qualitative work identified 214 themes (150 = technical variations and 64 = non-technical factors). Using consensus methods the 265 unique themes (180 = technical and 85 = non-technical) were then rationalised to 97. Conclusion: This novel methodology employs multi-modal data collection to gain detailed insights into the ‘black box’ of stoma formation by documenting its key variations. It identified 126 variations that would have otherwise remained ‘unknown’ if a single method of data collection had been used. We recommend this approach to enable CRFs to be comprehensively designed for complex interventions such as stoma formation.

6. Prevention of mesh related adverse effects (complications, recurrence, new materials, biomeshes etc.) P112 Mechanical characterization of synthetic surgical meshes for hernia repair S. Todros1,2, P. Pachera1,2, P. G. Pavan1,2, N. Baldan3,2, S. Merigliano4,2, A. N. Natali1,2 1 Department of Industrial Engineering, University of Padova, Italy, Padova, Italy, 2Centre for Mechanics of Biological Materials, University of Padova, Padova, Italy, 3Padova General Hospital, Padova, Italy, 4Department of Oncologic and Gastroenterologic Surgical Science, University of Padova, Padova, Italy Background: Performances of synthetic surgical meshes for hernia repair, available in a variety of materials and structural conformations, are not easy to compare, considering patient-specific conditions. Mechanical properties of surgical meshes, as stiffness, time-dependent and anisotropic response, affect the interaction with surrounding tissues and play a crucial role in a successful surgical outcome. The aim of this study is to provide an integrated experimental and numerical approach to study mesh biomechanical characteristics. Methods: Mechanical tests are carried out through an ElectroforceÒ Planar Biaxial Test Bench Test Instrument (USA), under displacement control. Different protocols are adopted to evaluate stress–strain response replicating physiological loadings, time dependent mechanical behavior and anisotropy of the prostheses. This is achieved via uniaxial tensile tests along structure symmetry axes and biaxial tensile tests. Experiments are developed at different strain rates and with repetitive loading cycles. Results: Uniaxial and biaxial results reveal a wide range of different mechanical properties depending on mesh confromation, including a non-linear stress–strain behavior with a stiffening response. Meshes

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Hernia (2017) 21 (Suppl 2):S208–S263 show different anisotropic responses, which should be correlated with host-tissue anisotropy within surgery. No significant viscoelastic behavior is found at different strain rates for the investigated prostheses. Conclusion: The mechanical properties of different surgical meshes are evaluated. Acquired experimental data are the basis for the development of computational models to estimate mesh behavior in interaction with the abdominal wall.

P113 Short-term advantages of a new absorbable mesh in hiatal hernia recurrence J. Bellido Luque1, A. Bellido Luque2, J. Garcı´a Moreno3, J. Suarez Gra´u1, J. Gomez Menchero1, J. Guadalajara Jurado3 1 Riotinto hospital. Quiro´n Sagrado corazo´n Hospital, Sevilla, Spain, 2 Quiro´n Sagrado corazo´n Hospital, Sevilla, Spain, 3Riotinto Hospital, minas de riotinto, Huelva, Spain Background: The use of nonresorbable meshes has been generalized in hiatal hernia surgery, especially in large paraesophageal hernias. This technique could have complications, such as erosion and fibrosis, with the consequent risk of fistula or migration. In order to avoid these complications, fully resorbable meshes have appeared in the market. Poly-4-hydroxybutyrate (P4HB) mesh is a long-lasting absorbable material with full resorption within 2 years in preclinical studies. Fhasix TM ST Mesh combines two market-leading technologies: monofilament resorbable mesh and a hydrogel barrier. Methods: 75 year old woman is studied due to postpandrial vomiting and epigastric pain. She underwent open antireflux surgery in 2003. After endoscopy and CT scan, a hiatal hernia recurrence was confirmed. Manometry shows good peristaltics esophageal body movements. The patient underwent a laparoscopic approach. The right crura was identified. Adhesions were freed from de hiatus. Previous fundoplication was reduced to intraabdominal cavity. Retroesophageal tunnel was created, the previous fundoplication was released. A hernia defect of 5 9 5 cms was confirmed. The hiatus was closed with 5 non-absorbable sutures. In order to avoid a new recurrence, 6 9 6 cm size U-shaped phasix ST mesh was used, fixing it with 4 sutures to the crura and reinforcing the fixation with fibrin glue. A new 360° fundoplication was performed. Results: Postoperatory course was uneventful. The patients was discharged two days after surgery. 6 months after surgery, the patients remains asymptomatic. CT scan shows no recurrence. Conclusion: Fully absorbable mesh prostheses represent promising technology in the management of Hiatal hernia recurrences.

P114 Reperen Composite mesh vs. Physiomesh for laparoscopic incisional and ventral hernia repair: retrospective cohort study A. Belousov, Izrailov, Vasnev, Nigmatov Moscow Clinical Scientific Center, Moscow, Russian Federation Background: Aim of this study to compare postoperative outcomes with two different meshes used in LIVHR. Methods: 42 patients underwent LIVHR between August 2014 and September 2016. Among the 42 patients who underwent LIVHR, 21 patients (50%) presented with primary incisional hernia, 7 (16.7%) presented with a first recurrence, 14 (33.3%) presented with ventral hernia. There were two groups in study. ReperenTM Composite (Iconlab,RF) was used in first group (n = 19) and Physiomesh (Ethicon,USA) was used in

Hernia (2017) 21 (Suppl 2):S208–S263 second group (n = 23). The two groups were compared with respect to recurrence rates, incidence of seroma and chronic pain. Median followup was 23.4 months (range 4–30 months). Results: There was no significant difference in operating time in groups. 13% of patients had recurrence in the Physiomesh group in comparison to 5.2% in the Reperen mesh group. Reperen mesh was associated with a lower incidence of chronic pain (0 vs. 21.7%) and lower incidence of seroma and haematoma formation compared to Physiomesh group (10 vs. 17%). Of these, four patients of second group developed a hematoma in the early postoperative period, which was assessed clinically and with ultrasound, and two patients of first group were diagnosed with a seroma on ultrasound scan, 6 weeks postoperatively, which settled spontaneously in follow-up and required no further intervention. Conclusion: Reperen mesh is associated with a lower incidence of chronic pain, recurrence, seroma and hematoma formation compared with Physiomesh. However, there is a need for further well-designed, multicentre randomised controlled studies to investigate the use of these meshes.

P115 Trans abdominal pre-peritoneal (TAPP) approach for ventral hernia repair: An innovative, simple, cost effective laparoscopic technique P. Chelawat, A. Sharma, R. Khullar, V. Soni, M. Baijal, P. K. Chowbey Max Superspeciality Hospital, Delhi, India Background: Laparoscopic ventral hernia repair with IPOM is a well established procedure for the treatment of ventral hernias. However, it is not without its drawbacks. The intraperitoneal mesh placement has resulted in the use of expensive mesh technology, yet the problem of adhesion formation to the mesh persists. Complications of intestinal obstruction, mesh erosion, fistulization and mesh migration are being reported. The cost of barrier meshes is prohibitive especially in developing countries and is often the factor responsible for denial of benefits of laparoscopic surgery to the economically weaker sections of the society. Methods: We performed an observational study of 16 cases of primary abdominal wall hernias for a period of 6 months at our tertiary care level institute. Using a standard 3 port technique we performed TAPP for ventral hernia in these patients with technique described in the video. Results: Cost of the surgery was cut down up to 35% with our technique. The VAS score was 5.5 (mean) and lengh of hospital stay was 36 ± 10 h. Mean operative time was 88 ± 14 min. Peritoneal tears occured in 4 patients and 10–20% mesh exposure occured in 2 patients. No wound infections were observed. Conclusion: TAPP approach for management of ventral hernias is safe and feasible. Merits further multicentric studies before incusion in armamentarium of LVHR.

P116 Surgical outcomes of a novel omega-3 fatty acid coated polypropylene mesh in ventral hernia repairs D. E. Cheng1, L. J. Bonato2, C. Leinkram3 1 Royal Melbourne Hospital, Melbourne, Australia, 2Monash University, Melbourne, Australia, 3Melbourne Hernia Clinic, Melbourne, Australia

S239 treatment. Many of these new mesh designs have not been extensively tested and their complications rates are largely unknown. The C-QUR V PatchÒ combines a unique knit construction polypropylene mesh with an omega-3 fatty acid coating. The evidence surrounding this mesh design is limited and its rates of recurrence and infections have not yet been thoroughly investigated. Methods: A multicenter case series, with a single surgeon, of over 200 consecutive patients with ventral hernias underwent repair using a standardised open pre-peritoneal approach with the novel C-QUR V PatchÒ mesh design between January 2013 and June 2015. These patients were followed up after a year to assess for hernia infection and recurrence rates. Mesh infections were further classified into early and late infections for further subgroup analysis. Results: As of the date of submission, seventy patients have been followed up over 12 months. Infection and recurrence rates of the C-QUR V PatchÒ were compared with similar published results of alternate mesh designs. The results showed that the infection and recurrence rates were low and similar to those found with other types of meshes. Only one mesh needed to be removed due to mesh infection. Conclusion: This series finds that the infection and recurrence rates associated with the novel C-QUR V PatchÒ mesh is acceptably low and is a comparable product for use in ventral hernia repairs.

P117 Combined approach with NPWT (Negative Pressure Wound Therapy) and biological mesh for treatment of enterocutaneous fistula after synthetic mesh repair of incisional hernia M. Di Furia, A. Della Penna, D. Stifini, A. Salvatorelli, M. Clementi, S. Guadagni University of L’Aquila, L’Aquila, Italy Background: Mesh infection is the main complication of prosthetic repair of ventral incisional hernia, with an incidence up to 13%. Infection can occur immediately after operation or lately, months or even years, and in this case it can show as enterocutaneous fistula, a rare (0.5%) but severe complication. Surgical strategies to face mesh infection are not standardized. Some cases could be managed with conservative approach, aiming to preserve the mesh. However, this strategy often fails, and the mesh needs to be removed, as in case of enterocutaneous fistula. After mesh removal, the problem of abdominal wall reconstruction still exists, because of the infected surgical site, which leads to high rate of failure (recurrence, reinfections). We propose a combined approach using NPWT and biological mesh in a multiple-step strathegy. Methods: A 58-years male patient presented to our department one year after synthetic mesh repair of large incisional hernia with signs of mesh infection and enterocutaneous fistula, confirmed by CT scans. We decided for a multiple-step surgical approach, which consisted firstly in mesh removal and intestinal resection, followed by a treatment of one week with suprafascial NPWT, and subsequently definitive repair with biological mesh. Results: After a 6-months follow-up, the patient showed no signs of recurrence or reinfection. Conclusion: This combined 2-steps approach has revealed safe and effective for the treatment of such a difficult and rare situation.

Background: Ventral hernias are a common surgical issue and a myriad of surgical mesh designs have been developed for their

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P118 Use of absorbable biosynthetic polyglycolic acid with trimethylene carbonate prosthesis in the management of complex abdominal wall defects: experience in a reference unit P. Garcı´a-Pastor, A. Torregrosa, J. Sancho, M. Lopez, C. Muniesa, R. Jimenez, J. Iserte, S. Bonafe, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain

Hernia (2017) 21 (Suppl 2):S208–S263 and UHS) were observed in early postoperative period. No infectious complications and implant rejection of the implant were observed. In the long-term period (13 years), recurrence wasn’t observed and the patients were satisfied with the results. Conclusion: The method of hernioplasty using PHS and UHS prostheses is elegant, easy to perform, adaptable to the individual patient’s needs, provides excellent results. This method does not require restoration of abdominal wall layers by sewing weakened tissues.

Background: Abdominal wall repair requires handling multiple elements. Surgeon must know and master several techniques and materials to adapt to each case. We present our experience with absorbable biosynthetic polyglycolic-acid + trimethylene-carbonate prosthesis (Bio-A, GoreÒ) using modified-Anterior Component Separation (m-ACS, Carbonell-technique) and Posterior Component Separation-Transversus Abdominis Release (PSC-TAR) in the treatment of large and complex abdominal wall defects. Methods: Up to January 2017, we performed 40 PCS-TAR; in 29 complex cases rebsorbable prosthesis were implanted associated with a permanent PPL mesh. In 3 cases where m-ACS didn’t allow the midline closure, prosthesis were located in preperitoneal plane and between the two rectus muscles, completing surgery with large PPL onlay mesh. We present our data: demographics, type of hernia (dynamic study with Valsalva-CT, location and size of hernia’s ring, volume and sac’s content), preoperative management of complex cases (10 with botulinum toxin-A infiltration plus progressive pneumoperitoneum), procedure, postoperative and follow-up data (clinicCT control as a protocol). Results: Initial consistency attributable to prosthesis is highly valued by patients. There’s no complication related to its use; repair’s quality (maximum 24 months follow-up) is excellent, with no relapses so far. Likewise, possibility of CT-scan monitoring is very interesting, since it allowed to visualize prosthesis’s positioning and disclose complications when clinically suspected. Conclusion: Our experience, although still initial and reduced to 32 cases, has been positive and especially useful in management of lateral and peristomal hernias, allowing a firm preperitoneal plane where definitive mesh extends safely.

Background: Most of the meshes are radiologically invisible. MRI visible meshes has been produced over past years. If the hernia repair is complicated; such meshes may provide ease to the physician. Also chronic pain after inguinal herniorrhaphy is an important problem. Non-invasive fixation may help to reduce this. Methods: 110 laparoscopic inguinal hernia repairs in 89 patients (82 male, 7 female) were done by using MRI visible meshes. Mean age was 47.8 (range 21–83), BMI 25.5 (range 20–37). TEP repair was done to 64 patients unilaterally and to 18 bilaterally. TAPP repair was done to 4 patients unilaterally and 3 bilaterally. Three dimensional type of mesh (Dynamesh Endolap Visible 3DÒ) was used in 110 cases. Results: Invasive fixation was used in the 69 patients. Tissue adhesive (Liquiband Fix8Ò) was used solely in 20 patients. All patients except 4 ones were discharged first postoperative day. There were no recurrences or any other complications during follow-up period, mean 14 months (range 1–41). Conclusion: The incidence of implant-related complications such as shrinkage, deformation, migration with erosion of adjacent organs, and fistula formation has increased. In clinical practice, detection of possible mesh migration, mesh fractures, or deformation is facilitated with MRI visible mesh implants. Also non-invasive mesh fixation has promising results.

P119 Long-term results of ventral hernia treatment with prolene hernia system and ultrapro hernia system

P121 Development and evaluation of substitutes to repair abdominal wall defects by tissue engineering

B. Gogia, R. Alyautdinov A.V. Vishnevsky institute of Surgery, Moscow, Russian Federation

A. I. Gomez-Sotelo1, E. Garcia-Abril2, M. Lopez-Cantarero3, M. Martin-Piedra4, I. Garzon4 1 Department of Digestive Surgery, Valme Hospital, Sevilla, Spain, 2 Department of surgery, Rafael Mendez Hospital, Lorca, Spain, 3 Department of Digestive Surgery, University Hospital Complex of Granada, Granada, Spain, 4Tissue engineering group, Department of Histology, University of Granada, Granada, Spain

Background: In the last decade, the emergence of new implants made it possible to perform hernioplasty of the abdominal wall with preservation of normal anatomy without tension, which led to the reduction of hernia recurrence frequency. Aim of the study: estimation of the treatment results of abdominal wall hernias with Prolene Hernia System (PHS) and Ultrapro Hernia System (UHS). Methods: From 2001 to 2013, 199 patients were operated with PHS or UHS. 183 of them had inguinal hernia, 6—umbilical, 4—femoral, 4—small incisional, 1—spigelian, 1—epigastric hernia. Men were 178, women—21. Average age of patients 61.7 ± 2.1 years. PHS was used in 52 cases, UHS—in 147 cases. Surgery was performed under: local anesthesia—108 (54.3%) cases, spinal anesthesia—32 (16.0%), epidural anesthesia—24 (12.1%), general anesthesia—35 (17.6%) cases. Results: There were no intraoperative complications. Seroma (5 cases after UHS and 6—after PHS) and spermatic cord hematoma in patients with recurrent inguinal-scrotal hernia (2 cases—after PHS

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P120 MRI visible meshes and non-invasive fixation: case serie ¨ zveri2 M. Ertem1, H. Go¨k2, E. O 1 Istanbul Uni. Cerrahpasa School of Medicine, ˙Istanbul, Turkey, 2 Acibadem Kozyatagi Hospital, ˙Istanbul, Turkey

Background: In the present work, we combined the adequate mechanical properties of synthetic polymer meshes with tissue engineered matrices to generate a novel tissue-like artificial stroma (TLAS) for use in abdominal wall repair. Methods: Fourty Wistar rats were used at this work. Autologus fibroblasts were isolated and cultured from biopsies of dorsal skin. TLAS, consisting on fibrin-agarose hydrogels seeded with skin fibroblasts and reinforced with 2 types of commercial surgical meshes (SM) were evaluated in vitro and in vivo in animal models of abdominal wall defect. Inflammatory cells, collagen, extracellular matrix (ECM) components, peritoneal adhesions and other clinical complications were analyzed and compared with grafted SM.

Hernia (2017) 21 (Suppl 2):S208–S263 Results: No infections, necrosis or severe complications and no signs of digestive obstruction were detected. Use of TLAS resulted in less inflammation: SM group animals showed more than twofold inflammatory cells (45.13 ± 26.22 cells/ROI) than those whose abdominal defects were treated by TLAS implantation (19.5 ± 7.83 cells/ROI) (p \ 0.001); and less fibrosis than SM, with most ECM components being very similar to control abdominal wall tissues. Cell migration and ECM remodeling within TLAS was comparable to control tissues. Clinically, it was observed less peritoneal adhesions and less severity in TLAS group (p = ns). Conclusion: The use of TLAS could contribute to reduce the sideeffects associated to currently available SM and regenerated tissues are more similar to control abdominal wall tissues. Bioengineered TLAS could contribute to a safer treatment of abdominal wall defects with higher biocompatibility than currently available SM.

P122 Synthetic resorbable and non resorbable meshes in sift tissue reconstruction after mastectomy S. Gruber-Blum1, C. Scho¨nau1, M. Essenther1, A. Hocher1, K. Glaser1, A. H. Petter-Puchner2, B. Stocker1 1 Wilhelminenspital, Vienna, Austria, 2Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria Background: Different mesh materials are progressively used for primary breast reconstruction after skin sparing mastectomy. We performed a restrospective comparison of the synthetic non-resorbable Ti loop and the synthetic resorbable TigrÒ matrix in patients undergoing mastectomy with primary reconstruction at an academic teaching hospital. Methods: Between 2013 and 2016, 27 mastectomies with primary reconstruction were performed (nipple- and skin sparing). Cosmesis and adverse effects to the implants (n = 22 TIGR and n = 5 Tiloop) were assessed postoperatively at discharge and at 6 months (then including MRI). Seroma, inflammation and skin necrosis and dislocation of the submammary fold were documented as primary outcome parameters. Results: Four wound healing disorders occured, one in the TiLoop group and three in the TIGR group. Of those one implant in the TIGR group had to be removed due to a severe surgical site infection in a heavy smoking patient. One revision due to bleeding had tob e performed on the first postoperative day in one tigr augmented breast. The reoperation did not affect wound healing. Seroma formation was not a clinically relevant problem and did not require punction in any patient. Conclusion: TiLoop and TIGR are feasible options to reinforce and shape primary reconstruction after mastectomies. Handling of the implant is convenient, although there are differences in placement during surgery. Complication rates are low in admittedly small cohorts of patients.

P123 Long term safety and efficacy of mesh reinforced laparoscopic hiatus hernia repair S. Kanakaratne1, D. L. Chan1,2, S. Tran1, C. Thilakanathan1, N. Bull1, M. L. Talbot1,2 1 St George Hospital, Kogarah, Australia, 2University of New South Wales, Sydney, Australia Background: Mesh-reinforced laparoscopic hiatus hernia repair is an alternative to traditional primary suture repair and is promoted to

S241 reduce recurrence rates. However, although the role of mesh in abdominal hernias is well established, the role of mesh in hiatus hernias is less clearly defined. We present a single surgeon, single institution experience to examine the long-term safety and efficacy of this technique. Methods: A review was conducted of all patients undergoing meshreinforced laparoscopic hiatus hernia repair from 2005 to 2012. Data was retrieved from a prospective database and electronic clinical records. Patients were also contacted with telephone questionnaires to attain better than standard practice follow-up. Perioperative complications, mesh-type and long-term recurrence were analysed, with particular attention to mesh-related complications. Results: 224 laparoscopic hiatus hernia repairs were performed on 192 patients during this period. 119 patients were female and mean age was 59 years (range 22–88 years). The mean follow-up was 54.5 months. Primary repair was performed in 37 cases (19%), biologic mesh-reinforcement in 25 (13%), polpypropylene in 50 (26%) and ePTFE in 80 (42%). Four patients had mesh-related complications (dysphagia, infection and erosion). Overall recurrence rate was 22.9%. There was no mortality in this series. Conclusion: Mesh-reinforced laparoscopic hiatus hernia repair can be performed safely with low mesh-related morbidity with synthetic mesh. Late recurrence is not uncommon, particular in those with biologic mesh.

P124 A case of delayed perforation of bladder by mesh in inguinal hernia repair: rare occurence Y. Kumar Kasturba Medical College Manipal University, Mangalore, India Background: Mesh related complications are not uncommon after inguinal hernia surgery and may even necessitate removal of previously placed mesh. Methods: 48 year old gentleman with history of bilateral groin swelling for one month was diagnosed to have inguinal hernia and underwent Laparoscopic TEP repair. He presented two months later with a recurrence on the right side for which he underwent anPHS repair. He went home uneventfully and presented again three months later with severe inguinodynia on the right side. Due to failure of conservative management of inguinodynia, patient underwent open removal of the PHS mesh and hypertrophied scar tissue was excised. Patient had postoperative lymphorrhoea which was managed conservatively. Biopsy of the excised tissue showed giant cells and tuberculosis could not be definitely ruled out. Patient was started on empirical anti tubercular therapy. Lymphorrhoea stopped gradually. One month later patient presented with hematuria and painful micturition. Patient was suspected to have genitourinary tuberculosis and underwent cystoscopy, which showed perforation of bladder by mesh on right side. Patient underwent open removal of preperitoneal mesh and primary repair of bladder perforation was done. Postoperatively he had mild wound infection and ATT was discontinued after one month. Results: Patient has asymptomatic small hernia on the right side till date. Conclusion: Bladder perforation by mesh is not a documented complication after inguinal hernia repair. The cause why bladder perforation occurred in this caseis debatable. It may be due to mesh eroding into bladder from first surgery or due to subsequent exploration.

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P125 Biolap: Biological versus synthetic mesh in laparoscopic hernia repair: a randomized multicenter, prospective, self-controlled clinical trial J. Lange1, S. Seefeldt1, J. Meyer1, A. Rieger1, D. Seidel2, R. Lefering2, M. M. Heiss1 1 Kliniken der Stadt Ko¨ln, Ko¨ln, Germany, 2Universita¨t Witten/ Herdecke, Ko¨ln, Germany Background: Inguinal hernia repair is one of the most common surgical operations globally. Laparoscopic repairs provide very good results. Recurrence and chronic pain after inguinal hernia Operation are considerable clinical problems. There is raising evidence, that biological meshes could be of an advantage concerning occurrence of chronic pain due to a different postoperative remodelling without the disadvantages of a life-long implant. We hypothesize that the use of a biological mesh reduces postoperative pain without being inferior in terms of recurrence rate compared with a synthetic mesh. Methods: We will conduct a blinded trial, self-controlled design meaning every patient is his/her own control. Biological mesh is used in hernia repair for one of the bilateral hernias. The other side will be operated with a synthetic mesh. 451 patients will have to be analysed. Primary endpoints will be the incidence of postoperative local pain separately evaluated for each operated side per patient and the incidence of recurrent hernia within the first 2 years after Operation. Results: Results cannot be shown yet since the trial has not finished. A DFG-funding about 1.087.663€ has been granted. Conclusion: There is no trial that assesses the use of biological meshes in laparoscopic hernia repair. Our study design is really innovative as it allows a direct comparison of the two meshes with only very few confounding factors. We think that our trial can clarify one of the most discussed topics in hernia surgery, so we want to present it and maybe motivate further centers willing to participate.

P126 Bio-absorbable hernia plug in ventral herniorraphy L. Latham, L. Livraghi, M. Berselli, L. Farassino, S. Del Ferraro, C. Peverelli, V. Marchionini, I. Ceriani, N. Menegat, E. Cocozza A.O. di Circolo Ospedale di Varese, Varese, Italy Background: The purpose of our study is to evaluate the efficacy of the absorbable plug (providing low hernia recurrence) and the complication rate (seroma, hematoma, infection, short and long term postoperative pain) in ventral hernia repair. Methods: Between May and November 2016, 11 patients (8 women and 3 men, average age 59.8) affected by umbilical hernia (8 patients), epigastric hernia (1 patient), Spiegel hernia (1 patient), crural hernia (1 patient) underwent open repair using a Gore Bio-A hernia plug. The average BMI was 24.2 (range 19.5–28.4). Average defect sizes is 18.75 mm (range 10–30 mm). In 6 cases the prosthetic materials were inserted through the defect of anterior abdominal wall and held in place with some stitches of absorbable braided suture, in 2 of these the anterior fascia was sutured with non-absorbable stitches. In the others 5 cases, non-absorbable stitches were used. The patients were followed for 6 months. Results: No recurrence was noted. Complications occurred in 4.4% and consisted in minimal post-operatively pain. All patients had pain preoperatively, and 4 patients (4.4%) suffered from pain 1 month after surgical procedure. The average pre-operative VAS was 4.2 and the post-operative VAS was 2 at 1 month. Post-operative pain was unrelated to the type of fixation (50% absorbable, 50% nonabsorbable).

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Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: Even if our study group is little we can assure that Gore Bio-A Hernia Plug is associated with minimal short-term complication. In our cases no patients have hernia recurrence and the postoperatively pain is minimal, further studies are needed.

P127 Fixation free inguinal hernia repair with a new multilamellar implant D. S. Malik, N. Bhateja, B. S. Dhakad Eternal hospital, jaipur, India Background: Prosthetic reinforcement is the gold standard in inguinal hernia repair. Almost 20–30% patients complain of postoperative pain due to irritation and inflammation caused by the mesh and methods of fixation and about 4–10% of these, feel severe chronic postoperative pain. So a single arm study was conducted for the assessment of postoperative pain after inguinal hernia repair with a new dynamic, multilamellar self-fixating Proflor mesh. Methods: From Oct 2012 to December 2016, 180 consecutive patients of inguinal hernia were repaired with Proflor mesh (Insightra) where no suture fixation was done. All patients were assessed on visual analog scale (VAS) at 7 days, 3, 6 months and 1 year and examined for perioperative/postoperative complications. Results: According to VAS, pain was reported in a range from 1 to 3 during the first week. No perioperative complications occurred. 15 postoperative complications were reported. 5 seromas, 2 ecchymosis, 7 hypoaesthesia, 1 postoperative pain from 7th postoperative day onwards which was initially intolerable but reduced in intensity after 2 months and was minimal at the end of 6 months. No recurrence was found. Conclusion: Postoperative complication rates were comparable to the world literature. The use of this new mesh could be an alternative method to reduce chronic postoperative pain after inguinal hernia repair. It may become gold standard in future. Although further studies with long term results are still needed to establish it as a gold standar.

P128 The impact of three types of thermal sterilization on the structure and durability of mosquito net mesh for hernia repair in low-income countries K. Mitura1, S. Kozieł2 1 Siedlce Hospital, Department of General Surgery, Siedlce, Poland, 2 Department of General Surgery, Beskid Center of OncologyMunicipal Hospital in Bielsko Biała, Bielsko Biała, Poland Background: Although 35% of the global population live in the lowincome countries, surprisingly only 3.5% of operative procedures worldwide are conducted in those regions. The enormous cost of imported meshes makes it impossible to implement recommended mesh repair into surgical practice. As a result, surgeons are taking efforts to find inexpensive and globally available solution for commercial meshes. Recent experiments revealed that the use of a sterilized mosquito-net may be a solution. However, the influence of different sterilization methods on the mesh structure has not yet been analysed, to ensure both effectiveness and safety of the procedure. Methods: Different polymer mosquito-net meshes available on the local markets in low-income African countries were sterilized at different temperatures. The structure of meshes was analysed in microscopic measurement of filament diameter, pore size and mesh contraction. The tests were performed before/after the sterilization.

Hernia (2017) 21 (Suppl 2):S208–S263 The sterilized meshes were subjected to stress tests (elongation, tear/ burst force). Results: Polymer mosquito net mesh available in African countries can be safely sterilized at lower temperatures (below 122 °C) for 20 min or plasma low-temperature sterilization. Globally recommended sterilization under 134 °C for 3–4 min destroys the structure of the net and impairs durability. The polymer melting at higher temperatures causes pores to collapse and poses a risk of infection similar to heavy meshes. Conclusion: Hernia repair with mosquito net mesh may be a safe and cost-effective alternative in low-income countries but only when sterilization process is standardized and the sterilization temperature does not exceed melting point of the polymer used.

P129 Influence of polylacid acid microhooks on the biocompatibility of a polyester self-gripping mesh for hernia repair using an in vitro model M. Molegraaf, N. Grotenhuis, J. Lange Erasmus Medical Center, Rotterdam, The Netherlands Background: Chronic pain is the main complication in inguinal hernia surgery. Among the etiologic factors are mesh fixation and biocompatibility. To bypass mesh fixation, supplementary polylactic acid microhooks were added to a lightweight monofilament polyester (PE) mesh to provide for self-gripping properties in inguinal hernia repair. This study was designed to evaluate the influence of this additional polylactic acid on the mesh biocompatibility in a human macrophage in vitro model. Methods: The self-gripping polyester mesh (Parietex ProgripTM) was compared to apure polyester mesh (ParietexTM). To investigate the reaction of macrophages tothese meshes, macrophages were cultured in our in vitro model and pro- and antiinflammatorycytokines were measured in the culture medium. Results: There was no significant difference between the production of proinflammatoryand anti-inflammatory proteins by macrophages seeded on a selfgrippingpolyester mesh and a pure polyester mesh. The two meshes had almost thesame M1/M2 index. Conclusion: Polylactic micro-hooks does not seem to have a significant influence onthe inflammatory or fibrotic response. Compared to a pure polyester mesh, a polyesterpolylactidacid self-gripping mesh probably does not have negative effects onbiocompatibility.

S243 Demographics, co-morbidities, mesh characteristics and location, operative details and outcomes were recorded. Results: 59 patients (21 males) with the average age of 69 years were included. Chronic mesh infection and entero-cutaneous fistula were the main complications involved in 51 respective 8 patients. The mesh was completely removed in 57 patients. 49 polypropylene meshes were extruded. Various extended bowel resection were performed in 43 patients. The abdominal wall was closed primary with the Ramirez procedure in 39 patients, and with skin closure in 19. For the rest of the patients various techniques for open abdomen were used. 8 patients died. Conclusion: Our results suggest that re-operation for infectious complications of mesh repair is a difficult and challenging procedure. Mortality and morbidity are high. Caution and preventive measures are essential.

P131 Vacuum assisted closure therapy in a patient with infected dual mesh after graft excision N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: The use of mesh prosthesis to repair incisional hernias has superiority to suture repair in preventing recurrence. But the management of mesh infection after incisional hernia repair is a difficult clinical problem in surgical practice. Methods: We report the use of vacuum assisted closure (VAC) therapy in a patient with infected dual mesh after graft excision. Results: The patient presented with a discharge abdominal wall and wound without closure. The patient history has umblical herni, two times recurrent herni operation.the patient was hospitalized.a microbiologic examination show pseudomonas aurigonase grown in her wound;piperacillinplustazobactam started in the operation the wound was debrided vac is applied to the wound drainage volume is about 300 cc in a day then wound is became smaller than vicryl mesh was apllied to the wound the patient was discharged in po day 28. Conclusion: It is difficult to treat the mesh infection that arise after incisional herni repair with prostetic mesh. We think that vac is a treatment modality that an effective to use to treat a mesh.

P132 When a hernia operation should not be made? P130 Late severe complications of prosthetic repair of incisional hernias: outcomes of mesh removal V. C. Oprea, V. Oprea, F. Buia, D. Leuca Department of Surgery Emergency Military Hospital, Cluj-Napoca, Romania Background: The use of synthetic surgical meshes for incisional hernia repair has been shown to decrease the incidence of hernia recurrence but it can be associated undesirable effects such as infection, fistula, and visceral adhesions. The goal of our study is to asses the short-term results in patients who underwent removal of infected mesh. Methods: We retrospectively analyzed all medical records of the patients with complications of the prosthetic repair of incisional hernia admitted in the Surgical Department of the Military Hospital from Cluj-Napoca between January 2009 and December 2015.

N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: De garengeot hernia is generally an incidental finding in a hernia repair. Methods: 58 year old female patient presented both a femoral and a direct inguinal hernia. An ultrasonography showed some reactive lymph nodes,a femoral and inguinal hernia. Results: The patient electively was operated and observed the appendix is in femoral and inguinal hernia the hernias repaired and appendectomy was undertaken. Conclusion: ˙Inguinal hernia is a disease that it should be keep in mind in its differential diagnosis like the other entities;malignancy retroperitoneal sarcoma primer testicular pathology,femoral arter aneurysm/or pseudoanerysm,lymph node,sebaceous cyst,hidradenitis cyst of the canal of nuck,saphenous varix,psoas abcsess,hematoma ascites.As it is in our case,the patients had follow up for enlarged ingunial lypmh node.I˙f the patient had a

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S244 physical examination with ultrasonography the patient might be diagnosed correctly in the past.Omentum and instestinal incarceration are frequently seen,the incarcercation of the appendix in femoral hernia is observed 0.8–1% and called de’garengeot hernia.When the appendix is in inguinal herni sac,called de garengeot hernia present non specific findings like pain redness increased temperature.Lab tests maybenormal.ct finding can use to plan preop diagnosis and treatment.Ct is superior than usg in the light of the literature;the usg has an subjective evaluation disadvantage is cheaper than ct and mri.De garengeot herni should repair emergently if abscess or perforation of appendix did not occur synthetic mesh can be use to bridge the defect.When was encountered an inguinal lymphadenopathy,should also thought a inguinal, femoral hernia and also de garengeot hernia in differantial diagnosis.

P133 Mesh migration (MM) into the intestine is very rare after incisional hernia repair(IHR) N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: Mesh migration(MM) into the intestine is very rare after incisional hernia repair(IHR). Methods: 49YOM has an IHR, the case of transmural MM from the abdominal wall (AW) into the small bowel (SB) presenting as intestino-aeroic fistula (IAF) after sigmoid colon resection + loop ileostomi for sigmoid colon volvulus, ileostomy closure,IHR with mesh. Results: MM into the intestine is a possible, although very rare complication after IHR with nonabsorbable meshes (NAM).It tends to occur in postoperative period; in months with IAF, especially if the SB is involved. Conclusion: Although the use of multifilament polyester (MFP) may improve conformity with the AW it is also associated with a variety of disadvantages.higher incidences of infection entero-cutaneus fistula formation (ECF)andSBO have been reported with the use of MFP compared to other materials.Indeed the small intersctices of their MFP make it more susceptible to the occurence of infection and thus MFP is not commonly used within the US.Schneider et’l As a NA synthetic material,a mesh can produce microerosions in the adjacent tissues and subsequently migrate into the lumen of the intestine.The risk of migration is much higher if the mesh is placed intraperitoneal.Studies in animal models have shown that adhesions caused by such microerosions are reduced if the mesh is covered with a biological coating such as collagen. The new generation of prostheses with nonadherent coating may represent the future of the treatment of IH, avoiding MM and EKF.However,their advantages compared to a conventional mesh have been confirmed only in animal models.Avoiding the direct contact between the mesh and the intestinal wall may help to reduce this complication.

P134 Giant inguinoscrotal herni prepared to surgery with pneumoperitoneum N. Ozlem Ahi Evran University, Kirsehir, Turkey Background: Giant inguinal herni (GIH) are rare, defined to extend below the midpoint of the inner thigh in the standing position and are uncommonly encountered in modern surgical practice.However,they

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Hernia (2017) 21 (Suppl 2):S208–S263 may still occasionally present after years of neglect.We present a case of GIH extending to the midpoint of the inner thigh containing bowel in the hernial sac. Methods: A 75-year-old man presented with complaints of episodic abdominal pain and constipation accompanied by a huge right scrotal mass,it has been increasing in size since then.In fact, because during the previous 25 years he had been neglected by his family and had become socially isolated,this was the first time to visit hospital due to this problem.This development severely compromised his quality of life,prompting him to finally agree to visit hospital.Physical examination revealed a huge,irreducible,non-tender right inguinoscrotal hernia(ISH).The hernia mass was about 30 cm and extended to the midpoint of the inner thigh.There were no signs of cellulitis or ulceration of the scrotal skin.CTscan showed dislocation of the small bowel and ascending colon into the hernial sac. Results: The patient bring to operation room, in local anesthesia plus a sedation,his abdomen insuflate with co2 and create a pneumoperitoneum in 3 sessions.As we think to create a extra volume in abdominal cavity the patient are operated an inguinal herni repair. Conclusion: Several techniques such as distending the abdominal wall progressively or debulking the abdominal contents have been reported. However, no consensus has been reached on a standard surgical procedure for the management of giant inguinoscrotal hernias.

P135 Biodegradable silk fibroin meshes for complex abdominal wall reconstructions: in-vivo experiments J. Park1,2, O. Guillaume1, C. Keibl1, X. Monteforte1, A. Teuschl1, A. Petter-Puchner3,1, H. Redl1, S. Gruber-Blum3,1 1 Ludwig Boltzmann Institute for experimental and clinical Traumatology, Vienna, Austria, 2Medical University of Vienna, Vienna, Austria, 3Wilhelminenspital, Vienna, Austria Background: Application of surgical mesh for abdominal wall reinforcement is a common procedure performed in hernia repair. Research of silk protein is triggered for its unique mechanical properties and remarkable biocompatibility, as well as the long-term degradation. The aim of this study is to elucidate the potential of a self-manufactured silk mesh for soft tissue reconstruction in a rat model. Methods: Silk-fibroin meshes of 2.5 9 2.5 cm were manufactured and degummed. On 30 Sprague–Dawley rats, two soft-tissue defects of 1 cm were created per animal and consequently two meshes were implanted per animal. The abdominal wall defects were randomized to two different observation periods: 7 or 60 days and to 4 mesh groups: Single-stranded silk, Double-stranded silk, OptileneÒ (B. Braun, AG Melsungen, Germany), TigrÒ (Novus Scientific, Sweden). Samples were evaluated macroscopically, histologically and biomechanically. Results: In terms of macroscopical evaluation, the silk groups did not reveal more short-term or long-term complications compared to the synthetic mesh groups. Histologically a moderate foreign body reaction was observed in all groups. The outcome of the blunt-punch experiment in 60 days follow-up groups indicated that synthetic mesh groups (130 N) reached a higher force until rupture than silk mesh groups (90 N), which did not significantly differ from the abdominal native tissue (72 N). Conclusion: Silk-fibroin meshes revealed a good tissue ingrowth with a moderate foreign body reaction comparable to synthetic implant devices. The scar induced by fibroin showed biomechanical properties similar to native muscle tissue. In summary, long-term degradable silk meshes qualify for abdominal wall soft tissue repair.

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P136 Short-term recurrence and complication rates in patients with self-gripping mesh hernia repair G. Verdiyeva, M. Elnaggar, N. Rajesh Thamaran, O. Fafemi North Middlesex University Hospital, London, UK Background: Hernia represents one of the most common surgical problems of modern world with an estimated 20 million hernias requiring surgical repair around the world annually. Over the recent years, hernia management significantly improved with introduction of prosthetic mesh.Further improvements were made by utilisation of fibrin glue,absorbable sutures and self-adhesion.This study was focused on comparison of post-operative complication and recurrence rates of patients with self-gripping ProGripTM mesh and suture-fixed mesh. Methods: A total number of 84 patients over 18 years old with ProGripTM hernia repair within the six-month study period were included.Complications and recurrence rates within the six-month follow-up period were compared to national statistical numbers available for hernia repairs performed with other mesh types. Results: Mean age of patients was 54 ranging from 18 to 89. 28 patients were defined as having high-risk factors such as previous ipsilateral or contralateral hernia repairs,heavy smoking,asthma or COPD.79 patients had repair as an elective procedure as opposed to 5 emergency hernia repairs.The procedures lasted 53 min on average shortest performed in 23 min and longest in 110 min. In total 2.4% of patients with ProGripTM mesh had recurrence of hernia within the 6 months post-operative period which is similar to recurrence rates of patients who had suture-fixed mesh types according to literature.15.5% of patients had post-operative complications,the most common being surgical site wound infection. Conclusion: Self-gripping mesh has many advantages including better tissue integration and shorter procedural times.Our results demonstrate that it has similar recurrence and complication rates compared to other mesh types.

P137 Lichtenstein repair of indirect inguinal hernias with acellular tissue matrix grafts in adolescents and young adult patients (13–45 years old) Y. Shen, S. Yang, J. Chen Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: To evaluate the outcomes of Lichtenstein hernioplasty using acellular tissue matrix (ACTM) grafts in adolescents and young adult patients (13–45 years old). Methods: In this study, 317 patients, 13–45 years old, with primary unilateral indirect inguinal hernias, received Lichtenstein hernioplasty using ACTM mesh (ThormalGENÒ thoracic surgical graft produced by Grandhope Biotech Co., Ltd., bovine pericardium tissue graft, Guangzhou, China).The outcome measures were the length of the operation, postoperative visual analogue scale (VAS) pain score, length of hospitalization, postoperative complications and recurrence rate. Results: The operative time was (31.2 + 5.8) min and the length of hospitalization (1.4 + 0.7) days. The minimum follow-up was 24 months, there were 2 postoperative wound infections (0.6%) and fully recovered by change of dressing for 1 month; there were no chronic postoperative pain (visual analogue score [4, lasted 3 months) or local foreign body sensation occurred; 13 patients

S245 (4.1%) developed scrotal hydroceles and recovered by the scrotal puncturation. There were no recurrences and other complications. Conclusion: Lichtenstein hernioplasty using ACTM grafts is a safe and available treatment in adolescents and young adult patients (13–45 years old).

P138 Colostomy obstruction by mesh migration following paraostomal hernia repair A. Soares, M. Romano, S. Usurelu, L. Valencia, A. Gouveia ULS-Castelo Branco, Castelo Branco, Portugal Background: Complications directly associated with the use of prosthetic material are rarely mentioned in the literature. Results: Clinical Case: The authors describe a case of an 84-year-old patient with a surgical history of abdominoperineal amputation 8 years and hernioplasty for paraostomal hernia 4 years ago, presenting with intestinal occlusion due to a recurrent incarcerated paraostomal hernia. A hard formation was felt on touch through the colostomy. Colonoscopy revealed prosthetic material with transmural migration, causing luminal obstruction. The patient was submitted to a surgical intervention that showed an incarcerated paraostomal hernia with segmental ischemia of the ileum and colostomy obstruction by mesh migration. Segmental resection of the ileum and colon, including the mesh, and a terminal colostomy were performed as well as correction of the hernia with a biological mesh. Conclusion: In the consulted literature there are no reported cases of transmural mesh migration in paraostomal hernia repair. The pathophysiological mechanisms of this type of migration, although not fully known, can be attributed to the chronic inflammatory reaction by the prosthetic material creating adhesions between the mesh and the intestine and causing its erosion thus facilitating penetration of the foreign body into the intestinal lumen.

P139 The Minimal Open Pre Peritoneal, MOPP, approach to treat the groin hernias, with a new expandable, polypropylene mesh. A real minimal invasive surgery. Video M. Soler Clinique Saint Jean, Cagnes Sur Mer, France Background: The Minimal Open Pre Peritoneal approach (MOPP) represents after the grid iron technique (F. Ugahary), and the TIPP technique, the last evolution of the Minimal invasive approach for the treatment of groin hernias. This Minimal invasive approach, allows a minimal access, and a tension free, and sutureless procedure, with protection for the nerves. The main difficulty of the technique, was to unrolled the prosthesis through a 4 cm incision. Methods: The use of the new semi expandable prosthesis, makes easier the technique and secures the good position of the mesh, especially for the big medial hernia. The author has used a new selfexpandable prosthesis (polypropylene mesh with an additional not woven ring). The movie shows the MOPP technique, and specially, how to unroll, the prosthesis in the preperitoneal space. The semi rigid border of the prosthesis makes easier how to put the prosthesis in the right position. Results: After 1000 cases, a prospective study, is under way, with 2 recurrences, and a low rate of chronic pain. Conclusion:

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P140 Intraperitoneal only mesh: quality of life after abdominal wall hernias repair

Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: Negative pressure therapy is an efective and safe procedure for the treatment of chronic mesh infection although multicenter studies are needed to be widespread this affirmation.

F. Solimene, S. Ntaoulas, P. Nussbaumer Spital Lachen, Lachen, Switzerland Background: Abdominal wall hernia repair techniques are manifold. In the last decade minimal invasive methods have gained popularity and various new meshes are available. We report our results of 10 years’ experience with Intra Peritoneal Onlay Mesh repair (IPOM) in terms of Quality of Life (QoL) using the Carolinas Comfort Scale (CSS) and comparing different meshes. Methods: We included patients undergoing IPOM from 06/2006 to 02/2015, prospectively recorded data was evaluated retrospectively. We operated 159 patients, the mean age was 59 (31–89) years. 62% (n = 99) were male. An expert surgeon was present in the majority of procedures. A first follow-up was performed 12 weeks postoperatively including clinical examination. All patients were followed up 2016 with a questionnaire including the CSS with particular reference to QoL, hernia recurrence, local complications and reinterventions. We determined the following mean scores: Sensation (SS), Pain (PS), Movement (MS) and Total (TS). Results: The 159 hernias treated are allotted as follows: Primary 60; Incisional 78; Recurrent 13; Various 8. 3 months postop. Patients complained of the following: residual pain (18%), seroma (5%), recurrence (1%), infection (2%). Concerning QoL 72 patients could be analyzed after a mean follow-up of 68 (12–120) months. 22 patients had died of unrelated causes, 65 were non-responders. SS, PS, MS and TS were analyzed overall and according to the mesh used without differences. Conclusion: In our hands laparoscopic intraperitoneal onlay mesh repair for abdominal wall hernias has proved safe and efficient. Longterm QoL is very good, irrespective of the mesh implanted.

P141 Negative pressure therapy to save the mesh in chronic infection after incisional-ventral hernia repair

P142 The application of biological mesh in Transabdominal laparoscopic inguinal hernia repair for young male H. Yang Beijing United Family Hospital, Beijing, China Background: The issue of male infertility and mesh related complications raises more concern in hernia repair for young male. The adhesion caused by synthetic mesh to spermatic cord is the fear. Compare to synthetic mesh, biological mesh is considered to have better biocompatibility and better bacterial clearance. In this study, a series of patients who underwent laparoscopic transabdominal pre-peritoneal (TAPP) hernioplasty with biological mesh were evaluated respectively. Methods: From 2013 to 2016, 12 cases of TAPP with biological mesh (Surgisis, Cook) were performed. The mesh was fixed with interrupted PDS II Sutures at the following landmarks: Cooper’s ligament, posterior rectus sheath, and the transversalis fascia. Results: On average, the operation time was 80 (±10) min. The follow up time was 15.5 months. All patients were managed as day case. There was no mesh related complications, such as rejection or infection. There was no recurrence. Conclusion: Our initial experience showed that TAPP with biological mesh fixed with suture is feasible, effective and safe with good results. Even though the cost of the biological mesh is the consideration, it remains a good option for young patients due to the worry of side effect result from synthetic mesh. Of course, the longer follow up is needed to evaluate the long term result of biological mesh.

7. Interdisciplinary management of complicated and/or giant hernias

R. Villalobos, M. Mias, C. Gas, A. Escartin, J. J. Olsina Arnau de Vilanova University Hospital, Lleida, Spain

P143 Preoperative management of primary hernias with BTA and PPP: our results

Background: Negative pressure therapy (NPT) is a very ancient tool but was in 90s that state the bases for its scientific development. On the other hand, chronic mesh infection is an undesirable complication after incisional/ventral hernia repair since its hard management. NPT arise as an alternative treatment to avoid mesh removing. Methods: 15 patients with a chronic mesh infection were treated with NPT between January 2011 until December 2015. Demographic variables were analyzed, type of presentation (open wound or closed wound). A negative pressure of 80 mmHg were applied wether open or closed wound. Open wound was consider when a exposed mesh is present while closed wound when a cutaneous fistulae exists. Results: Median age was 59.3 (22–88) years, 9 (60%) male and 6 (40%) female, median BMI 31.2 (26–35). 7 (46.7%) were open wounds and 8 (53.3%) closed wounds. Any case of open wounds required surgery since a total granulation over the mesh was obtained. Only 1 case (12.5%) in closed wound required remove the mesh in a operating room. Median time of NPT was 18.7 (15–24) days in open wounds and 23.2 (19–27) in closed wounds. Replacement of the sponge of negative pressure was made every 3 days.

T. Antonio, P. Garcia Pastor, R. Jimenez Rosellon, C. Muniesa Gallardo, S. Bonafe Diana, J. Iserte Hernandez, J. Bueno lledo´, E. Garcia Granero La Fe University and Politechnic Hospital. Valencia, Spain., Valencia, Spain

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Background: When we have great hernias outside the abdominal cavity like large groin inguinoescrotal hernias, morgagni hernias,; the return to their home must be difficult appearing sometime compartment abdomen syndrom. Methods: In the last five years we have treated 10 cases of different primary hernias with botulinum toxin and PPP. In all cases we perform CT scan in valsalva and we measure the volumen of the hernias and the volumen of abdominal cavity and the ratio. Results: We could close all the defects and return the intestinal contents to their home in all cases. Conclusion: The use of both techniques together must be implemented routinely in this type of hernias.

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P144 Interdisciplinary ccoperation in operations of large rare hernias in regional/district type hospital: case report P. Bartkova, P. Galvanek, M. Ehrenberger Surgery department, Hospital Uherske Hradiste, Uherske Hradiste, Czech Republic Background: Surgical treatment of large hernias requires accurate indications besides choosing the right surgical technique and experienced surgeon also on the individual patient-tailored perioperative and postoperative care. In our case we presented full course of therapy in a patient with large scrotal hernia, where the whole process, including surgery and post-operative care is recorded and evaluated. Even after a careful selection of surgical methods and trying to minimize postoperative complications is the prediction of further development of postoperative sometimes uncertain and requires careful monitoring of intensive care and individual acces. Methods: The patient after preoperative evaluation was chosen technique open tension-free (Lichtenstein) with the aim not to lend a laparotomy in mid-line for minimizing restrictions of abdominal breathing. Results: Despite it in the postoperative duration arise respiratory insufficiency. Is necessary mechanical ventilation and monitoring in the ICU. These risks until resolution of abdominal compartment syndrome. The next course emphasizes the rehabilitation and subsequent surgical care, including additional correction. Conclusion: These rare large hernias can be treated in the district hospital type the condition well-functioning cooperation with other disciplines—anesthesiology, intensive care, urologist, pulmonary specialist. Equipped anesthesiology and resuscitation departments, including the possibility of postoperative mechanical ventilation is a necessity. So necessity is individual approach sometimes outside common practices.

P145 Giant left intercostal hernia-An interdisciplinary job T. Butro´n, J. A. Garcia-Salcedo, J. C. Meneses-Pardo, C. Rivas-Duarte, M. Manama´-Gama, J. Guadarrama, J. Martinez-Caballero, V. Vieiro, J. I. Martinez-Pueyo, A. Martinez-Pozuelo 12 de Octubre’’ University Hospital, Madrid, Spain Background: Acquired abdominal intercostal hernias AAIH with rupture of abdominal muscles are uncommon. Methods: We report a case where an interdisciplinary work was needed. Results: An 83-year old man reported bulging of the left inferolateral region of the chest. The patient associated the onset with a fall from his bed, and it was decided to wait. In the next visit a progressive bulging was found. Physical examination abdomen was globular, flaccid, and painless; there was reducible bulging of the left eighth intercostal space, more evident during a Valsalva maneuver. There was an abnormal distance between the ribs of the aforementioned intercostal space, 8–9 ribs. A CT scan revealed fractures of the anterior portion of the eighth rib, widening of the eighth intercostal space. Radiologist made a sagittal reconstruction which shows in the front transversus muscle rupture and in the back, diaphragma and spleen herniations. The patient was operated upon by a team of thoracic and general surgeons, via a left thoracotomy. The hernial sac was identified, disected, open, and resected and closed with running suture of reabsorbable material. Integrity of diaphragma and disruption of transversus muscle was shown. The hernial orifice was closed with two SternalZipFix w-NeedleÒ surrounding the lower and upper

S247 ribs, and the pleural cavity was drained. A polipropilene mesh was used in anterior position for reinforcement of the abdominal wall. He was discharged the third day, with no evidence of immediate complications. Conclusion: Giant intercostal hernia or AAIH require an interdisciplinary work for an appropriate treatment strategy.

P146 Management of massive inguinoscrotal hernia with loss of domain in an emergency setting M. A. Cesardo Navarrete, M. Lo´pez Cano Hospital Valle Hebron, Barcelona, Spain Background: Inguinoscrotal hernias with loss of domain are a challenge with high morbidity in the emergency. Particularly the reduction of the viscera without creating a compartimental syndrome. Methods: Case report. Results: A 72-year-old man with ASA-III presented with 10-year history of a right inguinoscrotal hernia with loss of domain, symptoms of incarceration with deterioration of quality of life, CT scan revealed dilated small bowel loops with some degree of suffering and a slight amount of free liquid. Managed as a suboclusive syndrome and prepped for surgery a prolonged oblique incision towards the scrotum, accessing the preperitoneal space at the scrotal level. Hernial content was distal jejunal and ileum handles with ascending and transverse colon, small bowel showed signs of suffering that reverted after liberation. Placement of polypropylene mesh in the preperitoneal position, fixing it to Cooper’s ligament, muscle-aponeurotic closure in 2 planes, points of order and 2 drains.In the ICU haemodynamic instability and intrabdominal pressure elevation presented, surgery had no abdominal findings so a negative pressure therapy was applied. After the third surgical revision a mesh was applied following wittman closure technique, two more surgeries for abdominal wall closure using chevrel techinque and onlay polipropilene mesh. Patient was discharged after a CT scan showed no intrabdominal complications on the 13th day. Conclusion: A non operative management should be an option with a consult to an abdominal wall surgeon for a tailored surgery for each case. Open abdomen is safe although a expensive way to manage complications.

P147 Laparoscopic treatment of a giant type IV hiatal hernia with intrathoracic gastric volvulus: a case report D. Chiari, P. Veronesi, M. Platto, D. Tornese1, G. Borroni, V. Quintodei, P. Militello, W. Zuliani Humanitas Mater Domini, Castellanza, Italy Background: We present a case of successful laparoscopic management of a giant para-oesophageal hernia composed of part of the transverse colon and part of the stomach with volvulus. Methods: A 66-years-old male had recurrent episodes of epigastric post-prandial spastic pain that were resolved with vomiting (weight loss of 20 kg). A gastroscopy showed a grade II esophagitis that was treated with proton pump inhibitors without resolution of symptoms. A barium swallow showed the herniation of the gastric fundus and of part of the transverse colon. A CT scan confirmed this finding and found the presence of an intrathoracic organoaxial volvulus of the stomach. The patient was referred to our centre and was submitted to surgery with a laparoscopic approach: reduction of the transverse

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S248 colon and of the stomach in abdomen with gastric volvulus resolution, posterior hernioplasty with interrupted sutures and Nissen fundoplication. Results: The post-operative course was uneventful. The patient started drinking and eating on first and second post-operative day respectively. The discharge occurred three days after surgery. A month after surgery, an oesophagography showed a rapid bolus transit from the oesophagus to the stomach and the patient was asymptomatic for reflux symptoms or dysphagia. Conclusion: Repair of type IV para-oesophageal hernia with intrathoracic gastric volvulus can be performed safely and successfully with laparoscopic approach by expert surgeons.

P148 Interdisciplinary treatment of recurrent midline incisional hernia plus recurrent hiatal hernia J. Comas, J. Robres, J. Barri, C. Buqueras, M. Vasco, J. Pe´rez, P. Barrios Consorci Sanitari Integral, Hospitalet de Llobregat, Spain Background: We present a 45 years old female. BMI 39.4. In 2005 was performed Nissen funduplicature by laparoscopic approach. In 2005 present recurrence of hiatal hernia and was performed prostetic reaparstion by laparotomy. In postoperative stay presented bilateral pulmonary thromboembolism. In 2010 presented incisional hernia that required elective surgical reparation with a polypropylene mesh. In 2010 presented recurrence of incisional hernia strangulated that required emergency surgery. No bowel resection was needed and was repaired with another polypropylene mesh. In 2010 presented acute appendicitis that required laparoscopic appendectomy. Posteriorly presented 2 intraabdominal abscesses treated by percutaneous drainage. In 2014 a new recurrence of incisional hernia was detected. Surgical elective treatment was required. It was performed reparation with double mesh technique (GoreBioAÒ sublay and polypropylene mesh onlay.) In 2016 presented new recurrence of incisional hernia and was referred to our team for evaluation. In physical exam we observed big midline ventral hernia affecting M1-3 territories with signs of chronic infection and an important dermolipoid tissue and skin excess. CT scan shows recurrence of hiatal hernia and incisional hernia containing transverse colon with 16 cm of transverse diameter. Methods: We performed interdisciplinary surgery. Reparation of hiatal hernia removing previous mesh by closing diaphragmatic abutments. Abdominal Wall was restored with double mesh technique, VentralightÒ 25 9 33 cm sublay fixed with transparietal stitches and polypropylene onlay mesh 45 9 45 cm. A dermolipectomy was also performed. Results: In postoperative course presented seroma that required drainage with no other adverse events. Conclusion:

P149 Complex incisional defects with PermacolTM Implant: an Italian multicenter retrospective study P. Conti1, S. Latteri2, V. Randazzo2, F. Scaravilli3, G. Trombatore1, F. Vasta4, G. La Greca1, D. Russello1 1 Ospedale Civile, Lentini, Italy, 2Ospedale Cannizzaro, Catania, Italy, 3Ospedale Policlinico-Vittorio Emanuele, Catania, Italy, 4 Ospedale San Vincenzo, Taormina, Italy Background: Repair of complex abdominal wall defects (CAWD) with synthetic mesh is often associated with a significant

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Hernia (2017) 21 (Suppl 2):S208–S263 complication rate. Recent studies reported good results with the use of collagen-based prosthesis for complicated or contaminated abdominal hernias. The aim of our study was to evaluate a multicenter experience using crosslinked acellular porcine dermal collagen matrix— PermacolTM, for complex incisional and parastomal hernia repair. Methods: Data were collected retrospectively on 60 patients, with CAWD, from January 2010 to May 2016 treated in 4 Italian public hospitals. Database including patient demographics, comorbidities, wound classification (Ventral hernia Working Group grading system), surgical technique, morbidity, hospital stay and recurrence rates was collected. Results: A total of 60 patients, median age 62 years (39 females, 21 males), 16 patients with BMI [ 35. Patients were classified using the VHWG grading system; 6.6% Grade 1, 35% Grade 2, 58.3% Grade 3. PermacolTM surgical implant was used as inlay 60.3%, bridge 24.1%, sublay 15.5%. Fascial closure was achieved in 51.6%. Primary endpoint was early complications seen in 33.3% (20) of patients with sieroma and wound infection as the most common. Hernia recurrence rates after 2 years follow up was 25%. Conclusion: According to our knowledge this is the first Italian multicenter study with the largest number of patients with CAWD undergoing hernia repair using PermacolTM implant. Our data strongly suggest that the use of PermacolTM for CAWD is safe and effective even if additional long-term follow-up is required to fully evaluate biological implants in repairing CAWD.

P150 Rives-Stoppa technique in ventral hernia repair: results in 100 consecutive patients A. de Andre´s Go´mez, M. Bruna Esteban, R. Nu´n˜ez Ronda, C. Ba´ez de Burgos, C. Navarro Moratalla, M. Oviedo Bravo, A. Va´zquez Prado, P. Albors Baga´, J. Puche Pla` Hospital General Universitario Valencia, Valencia, Spain Background: Incisional hernia is an important problem with an incidence rate between 12 and 15%. Different techniques are performed in order to reduce postoperative complications and recurrence rate. We report our results in 100 patients undergoing Rives-Stoppa technique. Methods: Four specialized surgeons performed Rives-Stoppa technique for ventral hernia repair in 100 patients from April 2009 to September 2016. Patients completed a satisfaction and pain questionnaire using a visual analogic scale (VAS). Patients were controlled at 1 month and 1 year after surgery. Results: 57 women and 43 men with a median age of 61 (IQR: 50–72) years were included. Forty patients had undergone previous hernia repair. According to the EHS classification the most frequent hernia’s locations were: 23% M3, 21% M4 and 11% M2 + M3. If we consider the width of the defect the distribution was: 11% W1, 49% W2 and 40% W3. A low-density polypropylene mesh was used in 91% of cases, fixed with transaponeurotic stiches and a median overlap of 5 (IQR: 4–6) cm. No intraoperative complications were reported. Median length hospital stay was 2 (IQR: 2–4) days. Median of VAS was 5 in the first postoperative day and comes down to 0 (IQR: 0–0.25) at 1 month after surgery. 73% of the patients were satisfied with surgical results. Median follow-up was 325 (IQR: 78–388) days, with 33% of clinical and symptomatic seromas, 8% of wound infection and recurrence rate was 10%. Conclusion: Rives-Stoppa technique performed by abdominal wall specialized surgeons obtains good results with low rate of recurrence and wound complication.

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P151 Treatment of a giant inguinoscrotal hernia: a large problem with a simple solution? V. Dhooghe, A. Beunis, G. Hubens University Hospital Antwerp, Edegem, Belgium Background: Giant inguinal hernias are uncommon in the Western world. We report a case of a 63-year-old morbid obese man with a BMI of 51.5 kg/m2 presented with a giant right-sided inguinoscrotal hernia which he has been neglecting for the last 20 years. He reported a large inguinoscrotal swelling that recently has enlarged and now has reached the level of his knees, making it difficult to be mobile. He developed pain and consulted our emergency room. Methods: Clinical examination revealed a very large irreducible hernia with important oedema of the scrotal region. During further diagnostic work up a computed tomography demonstrated a voluminous right-sided hernia sac containing small and large bowel loops with secondary a hydronefrotic right kidney caused by external obstruction of the weight of the mesentery and an accidental finding of an infrarenal abdominal aorta aneurysm (AAA) of 6 cm. Results: Together with our vascular surgeons, plastic surgeons, urologists and endocrinologists we set up a treatment plan for this uncommon multi pathology. Despite a significant weight loss after a strict protein sparing modified fasting (PSMF) diet he still lacked a safe groin access to perform an endovascular repair of his AAA. A hernia repair type Lichtenstein combined with a scrotoplasty was performed first. Five months later an endovascular repair of the AAA could be safely performed. The postoperative course was uneventful. Conclusion: This patient forms a therapeutic challenge where we must decide which comorbidity to treat first, before another becomes a larger problem.

P152 Biofilm removal usingnegative pressure therapy with instillation (NPT, VAC ULTA TM therapy, KCI) in an open, complex, infected abdominal wall and critical patient: aclinical case report J. Ferrando1, J. Ferrando1, G. Bellver2, R. Ca´novas1, P. Arago´3, S. Castan˜o4, S. Carceller1 1 Manises Hospital, Valencia, Spain, 2Gemma Bellver, Valencia, Spain, 3Pau Arago´, Valencia, Spain, 4Sergio Castan˜o, Valencia, Spain Background: It highlights our experience with a new generation of NPT-instillation handling an open abdomen in a critical clinical patient. We achieved an early Biofilm elimination which supported a corret wound closure preserving implanted prosthesis. According to the World Health Organization, Biofilms are a proliferating bacterial ecosystem and enzimatically active which is ever eradicated in the early stages of infection Key words: Instillation, infected wounds, biofilm. Methods: Patient: woman 49 operated in 2013 of obesity (open banded Gastroplasty); reoperated in April 2016 by persistence of morbid obesity and eventration (hernia sac size [30 cm): Sleeve Gastrectomy + Abdominoplasty with Anterior Anatomical Separation of components (SAAC); synthetic prosthesis on-lay 30 9 30 cm was implanted. Subsequent complication: necrotizing fasciitis and sepsis with multiorgan failure. Microbiology: Klebsiella pneumonie ssp. resistant to Carbapenems, Candida ssp, Staphylococcus coagulasa (-) and Enterococcus faecalis. Intensive Care Unit and Surgical desbridements were needed VAC UltaTM, Instillation using Colistin

S249 (Polymyxin E) 21,000.000 UI 9 500 ml of Saline every 6 h (retention time en the wound bed, fifteen minutes 6/h). Results: Biofilm elimination three weeks after treatment with consequent improvement of patient’s septic process and her hemodynamic stabilization. Granulation tissue optimization. No prosthesis removal. Easy subsequent handling by the Home Hospitalization Unit. Conclusion: The VAC UltaTM Instillation not only eradicated the presence of the biofilm but contributed to the resolution of the serious septic process underwent by the patient.

P153 Multidisciplinary complex abdominal wall reconstruction after resection of a tumor of the thoracoabdominal lateral area J. Lopez-Monclus, S. Crowley, J. R. Castello´, A. Pueyo-Rabanal, L. Hoyos, J. L. Lucena, M. D. Chaparro, C. L. Leon-Gamez, L. Roman-Garcia, V. Sanchez-Turrion Puerta de Hierro-Majadahonda University Hospital, Madrid, Spain Background: Resection of malignant tumors of the lateral thoracoabdominal region is a reconstructive challenge that involves thoracic, plastic and general surgeons for its management. Methods: 69 years old male with an isolated metastasis of a clear cell renal carcinoma in the 10th to 11th left ribs with extension to the lateral abdominal wall musculature. Under general anesthesia and in a right lateral decubitus a longitudinal incision was performed from the posterior axillary line to the iliac crest. A pediculated latissimus dorsi flap was dissected. Extrapleural resection of the 9th, 10th and the 11th ribs with diaphragm detachment was performed and the resection was extended to the cranial part of the transversus abdominis, internal and external oblique muscles. A semi rigid, absorbable, biosynthetic mesh was place in the preperitoneal lateral space to conform de convexity of the lateral abdominal wall. A 50 9 50 cm large pore polypropylene mesh was also placed in the preperitoneal from the midline to the back of the patient. The diaphragmatic border was reinserted in the polypropylene mesh. The bridging defect was covered with the latissimus dorsi flap. Results: No complications took place in the postoperative period. The patient was discharged in the 10th postoperative day, and he is asymptomatic 12 months after surgery. Conclusion: Tumors of the lower ribs with extension to the lateral abdominal wall are a surgical challenge. A multidisciplinary approach and the application of advanced abdominal wall surgery techniques can offer optimal results to the patient.

P154 Removal of infected prosthesis continued by repair of the abdominal wall with prosthesis absorbable in a single surgical time V. Martı´-Martı´, A. Martı´nez-Lloret, M. Torrico-Folgado, E. Martı´-Cun˜at Hospital Clı´nico Universitario de Valencia, Valencia, Spain Background: Our objective was to evaluate the efficacy of a method to repair abdominal wall with chronic suppuration due to infected prosthesis. We describe the technique and expose results. Methods: The SURGICAL TECHNIQUE consists on removing old scar; remove infected mesh completely; detaching it from intestinal loops, restoring integrity of bowels if is necessary. We closed the

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S250 aponeurotic borders of abdominal wall, practicing relaxation plastias if necessary. We implanted a mesh of polyglycolic acid in onlay situation. Above the prosthesis we place two wash drains for instill saline serum; and two capillarity drains, on the lower area; finally reconstruct subcutaneous and skin. The PATIENTS were 11(5 men, 7 women). With average age of 67.6 (84–47) years. Operated by our technique from February 2012 to October 2016, follow-upaverage of 31.1 (59–2) months. After complete healing we realize annual control until 5 years. All of them were diagnosed of abdominal wall abscess due to infected prosthesis, with chronic suppuration. Infection control was do by the Infectious Unit. Results: The stay average was 10 days, with only 1 readmission. The postoperative occurred without major problems in all; in 8 patients appeared seroma and residual secretion during a few weeks, stopping spontaneously. One patient developed abscess, and subsequently recurrence. None of the other patients presented recurrence. Conclusion: The technique described manage recostruction of infected abdominal wall in a single surgical time safely. The prosthesis we implant tolerates infected field. It can be incorporated into the therapeutic list to repair this hernias.

P155 Preoperatively botulinum toxin and progressive pneumoperitoneum in inguinoscrotal hernias with loss of intraabdominal domain P. Martı´nez Lo´pez1, M. Lo´pez Cano2, J. Domenech Calvet1, A. Mun˜oz Garcı´a1, E. Homs Farre´1, F. Buils Vilalta1, D. Del Castillo Dejardin1 1 Hospital Universitari Sant Joan de Reus, Reus, Spain, 2Hospital Vall d’Hebron, Barcelona, Spain Background: Inguinoscrotal hernias with loss of intraabdominal domain are a complex surgical problem associated with morbidity and mortality in the postoperative period and may lead to contraindicate the surgical repair. Botulinum toxin injections can be used preoperatively to produce a temporary reversible paralysis of the abdominal wall musculature and combined with progressive pneumoperitoneum (PP) it would be a good tool to prepare for the operation of this kind of patients. Methods: We report a 69 years old patient, with an inguinoscrotal hernia with loss of domain, right hydronephrosis secondary to inclusion in hernia contents of the right part of the urinary bladder with ureter insertion and a decubitus right scrotal ulcer. One month before the intervention, injections of 200 IU of botulinum toxin were done in the abdominal wall musculature under ultrasound guidance. Two weeks later, a pigtail for air instillation was placed under radiological control and PP was completed (17 L). Using a combined approach (anterior-posterior preperitoneal) the hernia contents were reduced, and a reconstruction of the abdominal wall was done with a preperitoneal polypropylene macroporus mesh. A reductive reconstruction of the scrotum with ulcer excision and right orchiectomy was associated. Results: The patient remained 36 h under sedation and mechanical ventilation in order to prevent the compartment syndrome. He had a good postoperative course and was discharged from the hospital 7 days later. Conclusion: Botulinum toxin combined with PP is a good approach to prepare these kind of patients for surgery otherwise probably with uncertain surgical solution.

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P156 Umbilical hernia repair in cirrhotic patients G. Anghelici, S. Pisarenco, T. Zugrav State University of Medicine and Pharmacy ‘‘Nicolae Testemitanu’’, Chisinev, Moldova, Republic of Background: The objective of this study is to provide management of pacients with cirrhosis ascites and hernia, and to distinguish the importance of laparoscopic drainage in this cases. Methods: Was performed an randomized study on 11 patients with umbilical hernia associated with liver cirrhosis and massive ascites, in the period between 2012 and 2016 year. To all pacinets was applied combined surgical treatment. I group of study heve been included 52 cirrhotic patients operated on high urgently, including 15 (28.8%) for strangulated hernias and 37 (71.2%)—for hernia sac erupts with ascites fluid averflow. Endoscopic hemostasis for variceal bleeding was performed in 9 (18.8%) patients at same time. II group have been evaluated 58 cirrhotic patients with massive ascites and spontaneous eruption risk of hernia, operated in postpones emergency way, after laparoscopic drainage of abdominal ascites and abdominal cavity lavage with antiseptics and antibacterials. Beside hernia repairs through method—’’tension-free no mesh’’ surgical treatment also consist of laparoscopic drainage of ascites. Sealing prophylactic endoscopic variceal was performed in 34 (58.6%) patients. Results: Mortality consists—8 (15.3%) patients in I group, all caused by hepatic failure. In II group were 2 (3.4%) death caused by hepatorenal failure. Postoperative eventration at 3–6 months: Igroup—11 (21.1%); II group—2 (3.4%). Suppuration of postoperative wound: I lot—8 (15.3%), II group without complications. Conclusion: Umbilical hernias in cirrhotic patients with ascites preferable operated planned. Laparoscopic abdominal drainage and lavage with antibacterials reduced the risk of ascites-peritonitis and improves wound healing. The preferably solutions is hernioplastia ‘‘tension-free no mesh’’.

P157 Hernia surgery in factor VII deficiency: a case report R. Premnath Ramakrishna Hospital, Bangalore, India Background: We present a 84 year old diabetic and hypertensive gentleman with a reducible right sided inguinal hernia. He gave no history of surgery or bleeding problems in the past. He gave no history of anticoagulation. Methods: Ultrasound revealed a right inguinal hernia with a 2.5 cms defect size and mild prostatomegaly (27 g) with no significant post void residue. Preoperative blood tests were within normal limits except elevated Prothrombin time. Three days of parenteral vitamin K was given with no improvement in Prothrombin time. A haemotologist opinion and blood investigation revealed Factor VII deficiency. Pre-operatively he received two units of fresh frozen plasma and intravenous 1 g of Transexamic acid. He underwent an uneventful inguinal hernioplasty with Ultrapro Mesh system (oval) under local anaesthesia (xylocaine with adrenaline and ropivacaine 0.75%) with sedation (Fentanyl). Results: The post operative period was uneventful with no bleeding. Conclusion: Congenital factor VII deficiency is an autosomal recessive disorder with an estimated prevalence of 1/500,000 individuals without ethnic or gender predilection. This rare bleeding

Hernia (2017) 21 (Suppl 2):S208–S263 disorder’s clinical severity ranges from life-threatening to asymptomatic. Surgery in patients with FVII deficiency has been reported to be endangered by intraoperative or postoperative bleeding, unless a replacement therapy is used. FFP and Tranexamic acid was used in this case. Tranexamic acid is an antifibrinolytic agent that competitively inhibits the activation of plasminogen to plasmin and promotes clot stability. We present this case because factor VII deficiency is a rare bleeding disorder and operating on such patients increases risk of bleeding.

P158 Abdominoplasty and complex hernia repair under epidural anesthesia: safer for the patient, easier for the surgeon Y. Ramon1,2, D. Yarhi2, A. Abusalih1 1 Rambam health care campus, Haifa, Israel, 2Elisha Medical Center, Haifa, Israel Background: A combined abdominoplasty and hernia repair is a challenging procedure. It is a major operation, commonly performed under general anesthesia, and is associated with a high rate of minor complications, such as seroma, wound dehiscence, infection, nerve damage and skin necrosis, and also some major life-threatening complication including myocardial infarction, cerebrovascular accident, deep vein thrombosis and pulmonary embolism. Methods: 16 abdominoplasties and hernia repair were performed under high (T12-L1) epidural anesthesia using 10 ml of 0.6% Ropivacaine (Naropin). This method provides sensory anesthesia without muscle paralysis. Length of operation, recovery and hospitalization were evaluated, as well as complications rates. Results: Complications were extremely rare: one patient had minor distal flap necrosis, one had seroma and one had partial umbilical necrosis. All patients were able to move during the operation according to the surgeon’s instructions. Patients expressed satisfaction with the operation and there were no complaints regarding the lack of general anesthesia. Conclusion: Abdominoplasty under epidural anesthesia has many practical advantages: the patient maintains the ability to cooperate with the surgeon throughout the operation, thus making the work of the surgeon easier and more efficient. The transfer to the recovery room is simple, as the patient is awake. This type of anesthesia seems to reduce the rate of major complications such as DVT, PE, MI and CVA. In addition, due to the continuing epidural analgesia, the recovery period is shorter, and associated with less pain, nausea and vomiting.

P159 Preoperative management of loss of domain eventrations with BT-A and PPP: Our results in last 6 years A. Torregrosa Gallud, P. Garcia Pastor, C. Muniesa Gallardo, R. Jimenez Rosellon, J. Iserte Hernandez, S. Bonafe Diana, J. Bueno Lledo´, E. Garcia Granero La Fe University and Politechnic Hospital, Valencia, Spain Background: In a loss of domain situation where the return one intestinal contents to the abdominal cavity could be troubled, its necessary to prepare the patients with different techniques to accurate the solution.

S251 Methods: Between January 2010 and January 2017 we perform both techniques in 60 cases. The volume of incisional hernia, of the abdominal cavity, the ratio between both, the transverse and longitudinal diameter of the defect and other parameters were measured. Results: We have significative differences between VIH, VACand the ratio before and after using BT + PPP; but we don’t have significance in the diameter of the size. Conclusion: The use of both techniques was sure, without important complications and must be implemented routinely in this type of eventrations.

P160 Practical solution for abdominal incisional hernia with abdominal wall lost and exposed small bowel loop: a case report M. Platto, S. Grappolini, M. Moroni, P. Veronesi, P. Militello, D. Chiari, D. Tornese, G. Borroni, V. Quintodei, W. Zuliani Humanitas Mater Domini, Castellanza, Italy Background: Incisional hernia with small bowel exposure after emergency surgery is an uncommon event. It decreases quality of life and it is technically difficult to repair especially in old patients. Here, we present a case report of an old woman with this type of hernia. Methods: Seventy-four-years old woman underwent urgent laparotomy due to small bowel volvulus following laparotomic cholecystectomy. She developed incisional hernia that was repaired by mesh. Post-operative course was complicated by entero-cutaneus leak. Patient had a new laparotomy with mesh removal, small bowel resection and biological mesh was implanted. She had wound dehiscence and small bowel loops exposure (15 cm diameter) that needed alternative days medication. Results: Due to reduced quality of life, previous operation, patient’s age and comorbidities it was decided to have a new surgical revision without abdominal wall repair. After negative cutaneous swabs, two skin and subcutaneous tissue flaps were created side to the wound and small bowel loops were covered. Patient was discharged on third postoperative day. The subsequent surgical follow-up was uneventful. Conclusion: Skin and subcutaneous flap is a solution for hernia with exposed small bowel loops and can increase quality of life in elderly patients that do not need a complete repair of abdominal wall.

8. Prevention and management of atypical hernias (flank, lumbar, non midline, subxiphoidal etc.) P161 Laparoscopic repair of parastomal hernia after radical cystectomy M. Antor, L. Schwarz, V. Bridoux, J. Tuech, L. Sibert, H. Khalil Rouen University Hospital, Rouen, France Background: Ileal conduit is the most prevalent type of urinary diversion performed after radical cystectomy. There are few studies on parastomal hernia in urological patients. The aim of this study was to evaluate the results of laparoscopic technique using intraperitoneal mesh for the repair of parastomal hernia in patients undergoing radical cystectomy.

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S252 Methods: From September 2006 to December 2015, 9 patients underwent laparoscopic surgery for symptomatic urostomy incisional hernia. All patients had physical examination 3 months after surgery and were contacted by phone for long term follow-up in July 2016. Results: The median age of patients was 63 years (range 59–83) with a median BMI of 29 (range 23–38). The mean operative time was 140 min (range 110–225). The mean hospital stay was 6 days (range 4–13). No post operative complication was observed during the study (no hematoma, no abscess, no seroma). After median follow up 27 months (range 7–106), two patients developed a seroma, and one patient developed a chronic abcess. Two recurrences was observed. Conclusion: Laparoscopic repair of parastomal hernia after radical cystectomy is a feasible technique with a low postoperative complication rate.

P162 Lateral incisional hernia: laparoscopic procedure is well: combined procedure is better M. Antor, V. Bridoux, L. Schwarz, J. Tuech, H. Khalil Rouen University Hospital, Rouen, France Background: Complex lateral incisional hernia are rares, and few datas are available in the litterature concerning the results of their surgical treatment. The aim of this prospective study was to analysed combined surgical technique using laparoscopy and laparotomy. Methods: From September 2014 to April 2016, 11 patients underwent surgery for complex lateral incisional hernia (lumbar: n = 5, iliac: n = 5, subcostal: n = 1) using combined surgical technique with mesh placed in intraperitoneal position. All patients had physical examination 3 months after surgery and were contacted by phone for long term follow-up in November 2016. Results: The median age of patients was 62 years (range 44–70) with a median BMI of 32 (range 25–46). The median parietal defect was 10 cm in diameter (range 7–30). The mean operative time was 120 min (range 90–140). The mean hospital stay was 6 days (range 4–9). No post operative complication was observed during the study (no hematoma, no abscess, no seroma). After median follow up 24 months (range 7–45), two patients developed seroma. No recurrence was observed. Conclusion: Combined surgical technique for the management of complex lateral incisional hernia appears safe surgical technique with low morbidity and no recurrence.

P163 incisional hernia repair in patient undergoing hemipelvectomy, case report M. A. Azevedo, C. S. S. Pacheco, P. A. Sanglard, D. C. Sucupira, C. M. Mercader Neto, C. P. Kotzias Complexo Hospitalar Mandaqui, Sa˜o Paulo, Brazil Background: Report the case in March 2014 in the department of general surgery Mandaqui Hospital Complex (CHM)—Sa˜o Paulo-SP, where we proceeded to correct incisional hernia in patient undergoing secondary hemipelvectomy a fibrosarcoma in childhood. We opted for the procedure by placement of proceed mesh, then correcting hernia ring and placement of polypropylene mesh in place, strengthening the pelvic floor. Thus, we discuss the use of mesh for correcting aponeurotic failure under plication of pelvic muscles correcting prior hernia ring. It is also highlighted in this case, the non-use of antibiotic therapy even after stent placement in the region prone to local infection and rejection of the screen.

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Hernia (2017) 21 (Suppl 2):S208–S263 Methods: Report the case in March 2014 in the abdominal wall department of general surgery Mandaqui Hospital Complex (CHM)— Sa˜o Paulo-SP, where we proceeded to correct incisional hernia in patient undergoing secondary hemipelvectomy a fibrosarcoma in childhood. Results: We opted for the procedure by correcting the hernia with two meshes, one intraperitoneal (proceed mesh), then one polipropilen onlay to reinforce the pelvic muscle, with a good stetitcs result. We had a follow-up of this patient for 3 years, without hernia recurrence. Conclusion: We discuss the use of mesh for correcting aponeurotic failure under plication of pelvic muscles, correcting prior hernia ring. It is also highlighted in this case, the non-use of antibiotic therapy even after stent placement in the region prone to local infection and rejection of the screen.

P164 Rectus diastasis plication with defect closure in Midlne suprapubic hernia after caesarean incision J. Bellido Luque1, J. Gomez Menchero1, J. Suarez Gra´u1, A. Bellido Luque2, J. Garcı´a Moreno3, J. Guadalajara Jurado3 1 Riotinto hospital; Quiro´n Sagrado corazo´n Hospital, Sevilla, Spain, 2 Quiro´n Sagrado corazo´n Hospital, Sevilla, Spain, 3Riotinto Hospital, minas de riotinto, Huelva, Spain Background: Defect closure presents certain advantages: It avoids ‘‘bulging’’, decreases seroma formation and improves abdominal wall functional dynamic. In case of coexistence of suprapubic incisional hernia and rectus diastasis, in cesarean scars, it‘d be recommended the correction of hernia, defect closure and the consequent rectus plication since it avoids bulging and approximates musculature to midline. It’d be able to diminish recurrence rate when it’s compared with no plication. Methods: 60-year-old patient, studied due to a hernia in midline of cesarean scar. In CT, a suprapubic incisional hernia M4W2 is identified. The patient underwent Laparoscopic approach. The defect is measured, (6 9 6 cm size) and the hernia content is reduced, Suprapubic parietal peritoneum was opened to identify pubis bone and both Cooper ligaments to fix the mesh in these structures. Both rectus muscles and defect margins are closed with continuous suture V-loc no 1. A 16 9 16 cm mesh is tackered with double crown of helicoidal sutures, fixing it to bony structures. Fibrin glue is used to cover the tackers and to improve the mesh fixation. The intervention ends with the peritoneal closure using tackers. Results: Hospital stay: 2 days. postperatory pain was high (VAS: 7 after first week). VAS decreased to 2 after second week. No complications were identified after 14 months of follow-up. Conclusion: In Laparoscopic approach of suprapubic incisional hernias with rectus diastasis associated, it is advisable to close the defect with rectus muscles plication, avoiding higher hernia recurrence rate and reducing prosthetic protrusion and seroma.

P165 Abdominal wall tumors: our case series A. Senent-Boza, M. Bustos-Jime´nez, V. Pino-Dı´az, V. Camacho-Marente, J. A. Martı´n-Cartes, M. Flores-Corte´s, M. J. Tamayo-Lo´pez, J. Gollonet-Carnicero, F. J. Padillo-Ruiz Hospital Universitario Virgen del Rocı´o, Sevilla, Spain Background: Abdominal wall tumors constitute a very rare entity that includes several histological types with similar clinical

Hernia (2017) 21 (Suppl 2):S208–S263 presentation but with different biological behaviour, in terms of both local and distant recurrence. We present the case series of our department, including malignant neoplasm or benign tumors with aggressive behaviour. Methods: Data from 15 patients affected by abdominal wall tumors between 2011 and 2016 in our Department of Abdominal Wall Surgery were recorded and analysed retrospectively. Results: A total of 15 patients were included. 6 presented desmoid tumors, 2 leiomiosarcomas, 1 dermatofibrosarcoma, 1 hemangiopericitoma, 1 schwannoma, 3 endometriomas and 1 metastasis of endometrioid adenocarcinoma. 11 patients (73.3%) needed prosthetic repair, in 6 cases with double mesh, and 4 patients (26.7%) did not, as their defects after resection were smaller than 5 cm and did not affect the full thickness of the abdominal wall. 2 of the patients (a leiomiosarcoma and a desmoid tumor) had positive microscopic margins when analysed. Both of them suffered form recurrence of the tumor later. Conclusion: Surgery is the elective treatment of abdominal wall tumors. Quality of resection, with enough margins, is the main risk factor of local recurrence. In those cases with size above 5 cm or full thickness affected it will be needed a prosthetic repair of the wall.

P166 Laparoscopic Spigelian Hernia repair: a 6-year review S. Dios-Barbeito, M. Bustos-Jime´nez, M. Flores-Corte´s, J. A. Martı´n-Cartes, V. Camacho-Marente, A. Senent-Boza, P. Garcı´a-Mun˜oz, L. Navarro-Morales, J. L. Gollonet-Carnicero, J. Padillo-Ruiz University Hospital Virgen del Rocio, Seville, Spain Background: Spigelian hernias (SH) are a rare abdominal wall hernia traditionally repaired with an open technique. Nowadays it appears to be preferred the laparoscopic approach. Therefore, we have examined our outcomes in this group. Methods: We have retrospectively studied all SH laparoscopic treated using an intraperitoneal repair with a PTFE mesh between 1 January 2011 and 31 December 2016. We analysed age and sex, BMI, anaesthetic risk according to the ASA classification, characteristics, conversion rate, hospitalization length, recurrence and postoperative chronic pain. Results: We included 21 patients with a mean age of 60.33 years (range: 44.0–75.0) and a mean BMI of 33.30 kg/m2 (range: 24.24–47.67), most of them females (18, 85.7%) and classified as ASA II (ASA II 16, 76.2%; ASA III 3, 14.3%; ASA IV 2, 9.5%). The mean hernia size was 5.07 cm (range: 1.9–20.0) and most of them were on the right side (11, 52.4%). In 20 patients we used three trocars (95.2%), one 10-mm and two 5-mm trocars; in one patient we added a 10-mm trocar. There were no conversions to an open repair. The mean hospitalization length was 2.14 days (range: 1.00–6.00), most of them with a favourable postoperative evolution, while three patients referred intense pain during the hospitalization (14.3%). There were no mortality cases. After an average follow-up time after repair of 34.9 months (range: 3.0–71.0), all patients were pain-free and 1 had recurrence (4.8%). Conclusion: Laparoscopic repair of SH appears to be effective with low hospitalization length, postoperative morbidities and recurrence rate.

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P167 Differential of inguinal hernia in a pre-menopausal woman: rare case of endometriosis in Canal of Nuck C. Chong, A. K. Eng Singapore General Hospital, Singapore, Singapore Background: The Canal of Nuck is formed from the failure of obliteration of processus vaginalis during fetal development. Endometriomas can deposit rarely within the Canal of Nuck with few cases reported in medical literature. This case report highlights the diagnostic dilemma in female inguinal hernias and possible imaging techniques to assist in the management of this rare case. Methods: We present an atypical and rare presentation of endometriosis in the Canal of Nuck hydrocele. A pre-menopausal 37 year-old lady presented with 6 month history of right groin lump, with increase in size and symptoms of intermittent pain over the lump. Clinically, lump was not reducible and cough impulse was equivocal. Results: She underwent an ultrasound examination which revealed a 5.6 9 4.1 9 1.6 cm hydrocele in the Canal of Nuck. During surgery—we noted a brown cystic structure within the Canal of Nuck hydrocele. The cystic structure was excised in entirety and mesh repair was performed. Final histology revealed an endometriotic cyst. Conclusion: Endometriomas can deposit in the Canal of Nuck in females and can masquerade as a symptomatic inguinal hernia. Ultrasound is a useful imaging modality to delineate anatomy for this case. Excision of endometriomas in the Canal of Nuck should be in complete and mesh repair can be performed to reduce symptoms.

P168 Recurrence of left lumbotomy incisional hernia. Posterior component separation technique J. Comas, J. Robres, J. Barri, M. Vasco, C. Buqueras, J. Pe´rez, P. Barrios Consorci Sanitari Integral, Hospitalet de Llobregat, Spain Background: We present a case of a 54 years old female, heavy weights charger. In 2011 suffered obstructive left pyelonephritis that required a left nephrectomy with an open approach with lumbotomy. On postoperative course presented surgical site infection. Posteriorly, presented an incisional hernia in lumbotomy zone. In 2012 underwent an elective repair. An open approach with an on lay polypropylene mesh implantation was the elected technique. That patient presented an important weakness of left abdominal wall. CT scan was performed that showed recurrence of incisional hernia. Then was referred to our abdominal wall unit. Methods: We performed an open approach trough previous lumbotomy. We removed the previous mesh. For abdominal wall repair we performed a posterior component separation technique dissecting preperitoneal space from diaphragm cranially to iliac crest caudally, and from lateral part of rectus abdominis laterally to quadratus lumborum medially. We create an important space that allowed implantation of a 20 9 25 cm composite mesh (VentralightÒ) fixed with transparietal stitches. Posteriorly an on lay 30 9 30 cm polypropylene mesh was implanted. 2 Drainage tube were inserted in subcutaneous tissue. On postoperative stay presented complication with left pneumothorax due to diaphragm manipulation, that required pleural tube insertion without complications.

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S254 Results: In our last follow up, the patient was in good performance status. No budging in left lateral wall was present, and no signs of recurrence were presents. Conclusion: Posterior component separation is a good and safe technique for lumbotomy incisional hernia.

P169 ‘‘Per astra ad aspera’’-unexpected complication after IPOM lumbar hernia repair D. Dabic, V. Perunicic Surgery Department, General Hospital Cacak, Cacak, Serbia Background: The management of incisional hernia outside the midline remains a challenging procedure. Incisional lumbar hernia is a rare hernia type. Methods: Our goal is to show uncommon complication in hand of 16 years experienced laparascopic surgeon after laparascopic lumbar hernia repair. Patient was 69 years old man who was previosly undergone right hemicolectomy, hepatic metastasectomy and midline supraumbilical incisional hernioplasty. Finally, 3 months ago he was undergone IPOM operation because of left lumbar incisional hernia. Results: We used 4 port, introduced by using Hasson technique. After removing the adhesion and hernia sack content we have inspected abdominal cavity and introduced composite mesh (Reli meshÒ). For mesh fixation we performed ‘‘double crown technique’’ with Absorbatack 30Ò. Operative time was 2.5 h. In first 5 day we didn’t have any significant clinical or labaratory signs of complication. Fifth postoperative day before release, at the site of subxiphoid port, we noticed a sign of the enteral fistula. We performed immidiate operation and we found a large bowel perforation with localised peritonitis. We removed the mesh and created unipolar ileostoma. The patient spent 8 days on artefitial ventilation, was given intensive antibiotic and rehidration terapy but the outcome was letal. Conclusion: IPOM technique is already an appreciated method. When it comes to possible complications, they can be related to various things, such as wrong way of fixing as well as the experience and the qualification of a surgeon. In this case I hadn’t yet understood the cause of bowel injury.

P170 Amyands’s hernia: a diagnostic challenge P. Del Pozo1, P. Pela´ez1, V. Gonza´lez Bu´rdalo1, M. Garcı´a Conde1, N. Taboada1, A. Garcı´a Ferna´ndez2, N. Yagu¨e1, T. Butro´n1 1 Hospital 12 de Octubre, Madrid, Spain, 2Hospital Clı´nico San Carlos, Madrid, Spain Background: Amyand’s hernia is a rare entity characterized by the presence of the appendix within the sac of an inguinal or femoral hernia. The incidence of a non-inflamed appendix within adult inguinal hernias ranges from 0.19 to 1.7%, but the incidence of a inflamed appendix is even lower (0.07–0.13%). Amyand’s hernia is almost always diagnosed intraoperatively during an usual hernia repair, due to the similar clinic it has compared with common inguinal hernia in the non-inflamed appendix.

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Hernia (2017) 21 (Suppl 2):S208–S263 Methods: The aim of the present study is to present a case of acute appendicitis within a right inguinoscrotal hernia and to perform a literature review. Results: A 63-year-old male patient, admitted to the hospital because of diverticular disease (Hinchey II), develops inguinal pain, as well as in the testicle and scrotal mass during the third day of evolution. Laboratory findings included elevated inflammation markers: 17,000 Leukocytes, CRP 24 mg/dl and Fibrinogen 1040 mg/dl. CT showed a 14 mm abscess in right iliac fossa, a right inguinoescrotal hernia with the appendix incarcerated with inflamatory changes and a 37 9 22 mm abscess next to the appendix tip. The patient was taken to the operating room. A gangrenous appendix was found inside the severely inflammed hernia sac (L3W3 EHS, Type II Losanoff y Basson). Appendectomy and hernioplasty with prosthetic low density mesh were performed. The post-operative period was uneventful and the patient was discharged home 2 days later. Conclusion: Due to the rarity of Amyand’s hernia, each case study is useful to light its treatment and diagnosis.

P171 Late evisceration of small bowel through postoperative perineal hernia after laparoscopic abdominoperineal resection. Repair with a composite mesh M. L. Florez Gamarra, M. J. Pen˜a Soria, J. L. Romera Martinez, M. J. Pe´rez Contin, A. Pe´rez Jime´nez, C. Fraile Olivera, A. J. Torres Garcı´a Hospital Clinico San Carlos, Madrid, Spain Background: Perineal hernia and late evisceration are uncommon complications after abdominoperineal resection. There is no general consensus about the best approach for repairing it. Methods: Case description: A 57-year-old woman underwent laparoscopic abdominoperineal resection for T3cN2 rectum adenocarcinoma, 2 years ago, after neoadjuvant chemoradiation. There wasn’t complications during early postoperative period. The patient underwent with planned adjuvant chemotherapy (Xelox and Bebacizumab). After eighteen months, during follow-up was diagnosed a perineal hernia. It was planned an elective surgery so the chemotherapy was interrupted. Computed tomography (CT) showed the small bowel protruding through the pelvic floor into the perineal a´rea. Suddenly she presented spontaneous drainage of serous material throught perineal scar. Physical examination showed a loop of small bowel protruding through a perineum ulcer of 2 cm without evidence of incarceration. We performed an urgent surgery with a combined abdominal and perineal approach and perineal repair using a VentralexÒ 8 9 8 cm mesh. Furthermore the postoperative course was uneventful. Results: Discussion: The incidence of symptomatic perineal hernia following abdominoperineal resection was estimated to be 0.62%. Several methods have been reported for perineal hernias treatment, including transabdominal, perineal and combined abdominoperineal approaches using various techniques including flaps or synthetic meshes. Conclusion: Many different approaches have been described for repairing perineal hernias or evisceration. However, the best approach must consider individual characteristics and risks. There is a consensus that the use of meshes for repairing these hernias is a good option.

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P172 Uncommon use of self-gripping mesh in open hernia repair: a description of 4 cases M. Gallinella Muzi1, A. Cianfarani1, M. Colella1, P. Mascagni1, F. Taliente1, G. Muto2, A. Sorge3, O. Buonomo1, G. Petrella1 1 General Surgery, Policlinico Universitario Tor Vergata, Rome, Italy, 2 General Surgery, San Giovanni Bosco Hospita, Naple, Italy, 3 General Surgery, San Giovanni Bosco Hospital, Naple, Italy Background: ProGripÒ is a self-gripping partially absorbable mesh developed for inguinal hernias. Thanks to a ten 10-year experience in the use of this device, we decided to report the surgical treatment of a Spigelian, a inguinoscrotal and two femoral hernias using self-gripping mesh. Methods: A 70 year old man presented with arecurrent right inguinal hernia and a Spigelian hernia on the ipsilateral flank. He was treated with a single incision on the inguinal scar; the recurrence was reduced using a ProGripÒ plug, the anterior inguinal wall reinforced positioning a second mesh, the Spigelian hernia was reduced with a TabotampÒand the abdominal wall strengthened with a third mesh. A 66 year old man presenting a growing lump on his right groin, was diagnosed with inguinoscrotal hernia. We performed a tension-free open anterior hernia repair; upon opening the hernia sac, we found alipoma-like lesion later described as MDM2 + sarcoma. Unshaped ProGripÒwas also used in an 80 year old woman and a 67 year old man presenting with femoral hernias: the mesh was placed below the inguinal ligament and a plug was stitched on both the Poupart and the Cooper ligaments. Results: The surgeries were uneventful and no patients showed complicationsupon follow-up. Conclusion: We present the first use of aProGripÒ mesh to treat femoral hernias and the firstSpigelian hernia treated with a single inguinal incision. The self-gripping property of this mesh makes it a feasible and safe option for difficult or uncommon hernias.

P173 Desmoids tumor of the lateral abdominal musculature. Excision and reconstruction by Posterior Component Separation (PCS-TRAM) P. Garcı´a-Pastor, A. Torregrosa, J. Sancho, M. Lopez, J. Iserte, S. Bonafe, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain Background: Desmoids tumour or aggressive fibromatosis is treated by extensive surgical excision to avoid local recurrence, and subsequent reconstruction of the abdominal wall that may be difficult and require the use of meshes. We present our experience with the Posterior Component Separation-Transversus Abdominis Release (PCSTAR) in the management of complex abdominal wall defect following desmoids tumour excision. Methods: Patient male 32 year, presenting a painless, firm, moving bump in de right flank. Diagnostic evaluation included imaging tests (ultrasound, CT scan and MRI) and thick needle biopsy; results showed a 10 9 7 cm well delimited tumour, affecting the oblique internal and transverse muscles, leaving the oblique external free. Patient was operated on, with extensive tumour resection and PCSTAR technique using an absorbable biosynthetic polyglycolic acid + trimethylene carbonatescaffold (BioA, GoreÒ) and a large PPL mesh to achieve complete abdominal wall reconstruction. Results: Surgery was performed without complications, with hospital discharge on the third postoperative day without associated early morbidity. In subsequent reviews, patient has evolved well. The

S255 pathology exam reports complete excision with disease-free borders. A CTscan control (9th postoperative month) shows not only that there’s no local recurrence but also the efficacy of abdominal wall reconstruction. Conclusion: Abdominal wall surgeon must know and master different options to offer the right solution for each patient. In this particular case, the lateral location of the tumor makes repair difficult; so, our experience with PCS-TAR facilitated the success with the patient we present.

P174 Incisional hernia after kidney transplantation. Management with Posterior Component SeparationTAR (PCS-TAR). Preliminary results P. Garcı´a-Pastor, A. Torregrosa, M. Lopez, J. Sancho, R. Jimenez, C. Muniesa, S. Bonafe, J. Iserte, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain Background: Incisional hernia in kidney-transplant recipients is a technical challenge: proximity to allograft and ureter could compromise the graft function, defect extension to nearby bony prominences complicates dissection and limits the mesh overlap, long-term immunosuppression impairs wound healing and increases hernia recurrences. The use of meshes is controversial, due to the risk of prosthetic infection and removal.We’ve implemented PCS-TAR technique in this scenario because enables fascial reconstruction and facilitates extensive preperitoneal dissection contiguous to the retroperitoneal fossa—where the graft was placed—allowing considerable mesh overlap and offering a safe, lasting repair. Methods: We evaluate safety and efficacy of PCS-TAR reconstruction in a cohort of 19 (from a total of 40 PCS-TAR until January 2017) renal-allograft recipients with complex lateral-flanks incisional hernia. We present our series: demographics, hernia analysis (dynamic abdominal wall CT-scan with Valsalva), preoperative management (9 cases pre-conditioned with botulinum toxin-A infiltration followed by progressive pneumoperitoneum), technical details and postoperative and medium-term evolution (up to 24 months). Results: 19 patients (mean age 59 years, BMI 32, mean hernia size 102 cm2). Without intraoperative incidents nor postoperative morbidity (no infection or mesh removal, no graft loss or dysfunction). Median follow-up 11 months (range 3–24), only 1 (5.2%) lateral recurrence was documented. We should extend the follow-up for a better valuation over time, but the initial experience is satisfactory. Conclusion: Although our series is still short, PCS-TAR seems a versatile, safe and efficient alternative without specific complications; a durable repair with acceptable morbidity.

P175 Incisional hernia after TRAM flap for breast reconstruction. Management with Posterior Component Separation-TAR (PCS-TAR): Preliminary results P. Garcı´a-Pastor, A. Torregrosa, J. Sancho, M. Lopez, C. Muniesa, R. Jimenez, J. Iserte, S. Bonafe, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain Background: The use of pedicled rectus muscle flaps (TRAM) for breast reconstruction is associated abdominal bulging and incisional hernias. Posterior Components Separation by transversus abdominis release (PCS-TAR) allows fascial reconstruction and dissection in

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S256 retromuscular plane where an overlapped mesh will be placed to provide competent and safe repair. Since its description by Rosen-Novitsky, we’ve implemented PCS-TAR technique in different scenarios. Methods: We evaluated safety and efficacy of PCS-TAR repair in a cohort of 4 patients (from a total of 40 PCS-TAR until January 2017) submitted to TRAM breast reconstruction that, despite an onlay mesh, developed incisional hernia in donor area. We present our series: demographics, hernia (dynamic CT-scan), technical details, postoperative and medium-term evolution (up to 20 months). Results: 4 women (mean age 56 years, BMI 26, mean hernia’s size 79 cm2). Without intraoperative incidents; postoperative morbidity in one case (wound ischemia treated as outpatient, smoker patient). No cases of wound infection, mesh infection or removal. Median followup 14 months (range 8–20), no clinical or CT-scan recurrence has been documented. Although sample size and follow-up are limited, we find that this is a safe and efficient technique, with no specific complications and little associated morbidity. Advantages are: provides well-vascularised plane for mesh location with wide overlap without wound devascularisation, preperitoneal mesh provides lower relapse rates, retromuscular mesh-position decreases infection or wound dehiscence risk and the TAR allows tensionless defect closure. Conclusion: We should extend the follow-up for valuation over time, but initial experience is very satisfactory.

P176 Atypical midline infraumbilical hernia with anterior aponeurosis preservation P. Guarner Piquet, J. Espert, G. Ca´rdenas, A. Torroella, A. Lacy Hospital Clinic Barcelona, Barcelona, Spain Background: Atypical hernias can be complicated cases to diagnose, due to their rarity and their clinical presentation. Non-specific symptomatology (chronic pain, slight lumps) can be found at clinical presentation instead of the classical signs of a hernia, which makes this diagnosis a challenge. In those cases, imaging techniques can become essential. Methods: We present the clinical case of a 40 year-old female patient with obesity grade II (BMI 37.5 kg/m2) and gestational diabetes that suffered from chronic lower abdominal pain since 2012. Clinical exploration did not reveal any lumps. Due to the patient’s condition of obese, we performed a pelvic ultrasonography, with no pathologic findings. Since the pain was increasing, an abdominalMRI was performed, revealing an epiploic infraumbilical midline hernia (6 9 9 cm), which protuded through linea alba placed bilaterally between the anterior aponeurosis and rectum abdominis plane. Results: We performed a small midline laparotomy confirming the diagnosis, so we sutured the abdominal weakness and placed a 15 9 20 cm TimeshR fixed with glue between layers. Correct postoperative evolution, with no pain or signs of recidive at 6 months follow-up. Conclusion: Atypical hernias present a difficult diagnosis and management for surgeons. The clinical case we presented is a midline infraumbilical hernia with preservation of anterior aponeurosis, an interesting case due to its spontaneity (no eventration and no hernialorifice) placed in an anatomic location with no typical weaknesses, and dissecting the rectum abdominis from anterior aponeurosis (which unlike the posterior one, is attached to the muscle), becoming an impossible clinic diagnosis.

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P177 Totally extraperitoneal (TEP) repair of Spigelian hernias B. Hanßke Sjukhuset i Torsby, Torsby, Sweden Background: Spigelian hernias, named after Adriaan van den Spieghel (1578–1625), are with 1–2% of all ventral hernias rather uncommon. The hernia defect is located at the lateral boarder of the rectus muscle, the semilunar or Spigelian line. Methods: We want to report the totally extraperitoneal (TEP) repair of a right-sided Spigelian hernia in a 74-year-old patient and the left sided repair of a combined inguinal and Spigelian hernia in a 83-yearold patient. Results: Both male patients were examined preoperatively with a CTscan. Three trocars were used for surgery. The preperitoneal space was initially created with a balloon dissector, both Spigelian hernia defects were about 2 cm in diameter. The hernia sacs and protruding preperitoneal fat were invaginated, standard polypropylene meshes were used. In the left-sided case, the inguinal hernia repair was done before the Spigelian hernia repair. The duration of both operations was 46, respectively 57 min. Both patients were discharged within 24 h. Conclusion: According to the literature surgical repair of Spigelian hernias is most commonly achieved by open or laparoscopic approach. While using the laparoscopic approach the usage of an intraperitoneal onlay mesh (IPOM) is mandatory. The totally extraperitoneal repair of Spigelian hernias allows synchronous repairs of inguinal hernias as demonstrated in one case as well as the usage of standard polypropylene meshes. Compared to the IPOM technique the costs are reduced tremendously without needing to compromise the safety of the repair. We think that the totally extraperitoneal repair of Spigelian hernias is patient friendly, safe and cost-efficient.

P178 8 year-experience on lateral incisional hernia. A prospective single center register study N. Meiers, J. Hellenkemper, C. Berger, M. Schro¨der, W. Stoltenberg, J. Nehls, W. Reinpold Wilhelmsburger Krankenhaus Groß-Sand, Hambourg, Germany Background: Lateral incisional hernia reflect only a small number of all incisional hernia (9%). Furthermore, it has a challenging approach due to its localization. The aim of this study was to evaluate the management used in our center. Methods: Between 01.01.2009 and 15.01.2017, 80 patients were examined in a prospective study using Herniamed dataanalysis and EHS classification. Combined hernia were excluded. 76 of 80 operations were performed in less open sublay technique: incision was maximum half of scar length and no longer than 12 cm. Recurrence and complications were evaluated considering the special management used in our center. Results: There were 16 (20%) W1, 37 (46%) W2 and 27 (34%) W3 hernia. Mesh size was between 50 and [200 cm2, of which 74% were larger than 200 cm2. Closure of the hernia defect was reached under minimal tension. Standardized management included preoperative MRSA screening, regular skin disinfection and change of surgical gloves during the operation, perioperative antibiosis, drainage and reduced load bearing after operation. There was only 1 case with intraoperative and 1

Hernia (2017) 21 (Suppl 2):S208–S263 case with postoperative bleeding complication. Average hospital stay was 3–8 days. No case of infection or recurrence occurred. Conclusion: The special management procedures are decisive to prevent infections. The mesh size is crucial to prevent recurrence. The enforcement of the whole scar and not only the fascia defect prevents occurrence of new hernia along the scar.

P179 Laparoscopic repair of large incisional flank hernia J. A. Gonzalez Sanchez, M. A. Heras Garceau, S. Valderrabano, A. I. Herrera Sampablo, P. Martinez, E. Alvarez Pen˜a Hospital Universitario La Paz, Madrid, Spain Background: Flank hernia repair may become a challenge. The anatomic proximity to bony structures, specially twelfth rib and iliac crest, limits the amount of tissue required for proper mesh-tissue overlap. The vicinity of major neurovascular structures requires a careful dissection. These defects can be approached open or laparoscopically. Methods: We present the case of a 72-year-old male. He underwent an open left nephrectomy and splenectomy in 2014. Physical examination revealed a reducible left flank hernia, that measures 10 9 8 cm. Results: We decided on a laparoscopic approach. Laparoscopic access is obtained using a Hasson trocar. Adhesiolysis and dissection of the hernia defect, clearing the abdominal wall, is performed. The iliohypogastric nerve is identified. An elliptical 25 9 20 cm mesh is used to cover the defect. The mesh is secured using two cardinal transfascial sutures and double circular tackers fixation, except near the iliohypogastric nerve, were we use surgical glue for fixation. The patient did well postoperatively and was discharged home. At postoperative follow-up 6 months later, the defect was clinically absent and the patient was pain free. Conclusion: Laparoscopic flank hernia repair is a safe procedure, provides an appropriate mesh overlap with minimum postoperative pain and fast recovery.

P180 A case of iatorogenic diaphragmatic hernia through the omentoplasty route M. Horikawa, Y. Suzuki, H. Midorikawa, D. Tsukahara, Y. Igarashi, N. Soeda, Y. Kumata, T. Kiyokawa, Y. Yaguchi, T. Inaba, R. Fukushima Teikyo University Hospital, Tokyo, Japan Background: Here we report this relatively rare condition. In Japan, there are only two previously reported cases of iatrogenic diaphragmatic hernia via the omentoplasty route after pedunculated omentoplasty. Methods: A 72-year-old man visited our clinic with the chief complaint of vomiting. One year prior to the consultation, artificial aortic replacement for infectious thoraco-abdominal aortic aneurysm and pedunculated omentoplasty had been performed. Nine months prior to the consultation, the patient had undergone open surgery for ascending colon cancer and rectal cancer. A left diaphragmatic hernia was observed on computed tomography, and the stomach was observed to be protruding through the thoracic cavity. Given the patient’s postoperative status, open surgery was performed because of the risk of conglutination. Results: Intraoperative observation indicated that the stomach protruded into the chest cavity through the omentoplasty route. The stomach was pulled out into the abdominal cavity, and the hernial

S257 orifice was closed by direct suture without excessive tightening of the omentum. Furthermore, a slit was made into the omental portion of a VentralightTM ST Mesh, and it was fixed onto the sutured part of the diaphragm. There were no major postoperative complications, and no recurrence has been observed to date. Conclusion: Recurrence was reported in a case in which only the hernial orifice was directly closed with sutures. It is also difficult to close the hernial orifice completely with sutures while preserving blood flow to the omentum. Therefore, mesh fixation, as used in the present case, appears to be highly useful.

P181 Sliding indirect hernia containing fallopian tube and ovary J. Kang1, Y. Fan1, X. Cai2 1 Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China, 2Gongli Hospital, Shanghai, People’s Republic of China, Shanghai, China Background: An inguinal hernia containing an ovary & fallopian tube is an extremely rare occurrence in an adult female. Methods: In this report, we introduced a case of a 23 year old female with a left sliding inguinal hernia. The left ovary and fallopian tube were in the hernial sac. Results: They were reduced to the pelvis successfully and the inguinal hernia was repaired with mesh.The patient was discharged without any surgical complication in 2 days after operation. Conclusion: Although this situation is very rare, we need to be very careful all the time, without unnecessary injury happened in the surgery.

P182 Role of laparoscopy in the management of cronic diaphragmatic hernias P. Marta, E. Homs, M. Vives, A. Mun˜oz, J. Dome`nech, E`. Bartra, E. Raga, P. Martinez, F. Sabench, A. Sa´nchez, D. Del Castillo HUSJR, Reus, Spain Background: Traumatic diaphragmatic hernias are rare, and most are after blunt trauma. Diagnosis is often difficult because symptoms are nonspecific. The use of laparoscopy is still debated, especially in acute trauma, but may be indicated in the chronic form. Methods: We report the case of a man (35 years old), that after an accident, suffered multiple trauma with rib fractures, hemothorax and abdominal contusion. A CT scan described the mentioned injuries and a subhepatic collection. He was treated with chest tube and, after a good evolution, was discharged asymptomatic. Within 8 months, he began with difficult and painful digestions. A new CT scan and a barium swallow showed a large diaphragmatic hernia. The defect was repaired laparoscopically, reducing herniation containing 70% of the stomach, omentum and upper splenic pole. A Parietene mesh composite fixed with absorbable tackers was placed and reinforced with fibrin sealant. A pleural drain was introduced to treat pneumothorax occurred during surgery. Results: Postoperatively, the patient recovered without complications. Pleural drainage was removed and he was discharged at home at 3rd day. In postoperative controls, remains asymptomatic. Conclusion: Early detection is essential for immediate treatment. The value of laparoscopy in these cases grows if the surgical team is expert, but its role in acute diaphragmatic hernias is far from being the standard for their added risks. However, those patients who have a

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S258 long-standing hernia are ideal candidates to undergo endoscopic treatment. In this case, laparoscopy has allowed satisfactorily the reduction of the content of the hernia.

P183 Repair of ventral hernia in the patient with ascites. Primary closure, double onlay prosthesis V. Martı´-Martı´, A. Martı´nez-Lloret, M. Torrico-Folgado, E. Martı´-Cun˜at Hospital Clı´nico Universitario de Valencia, Valencia, Spain Background: The patient with liver cirrhosis presents postoperative risks like ascitic decompensation which increases abdominal pressure and ascitic fluid leakage. Their haematological disorders force to minimal detachments. We expose a surgical technique to these patients that avoids risks. And analyze results. Methods: From May 2010 to July 2016 we operated 16 patients (11 men, 5 women) with average age 570 1 (39–70) years. All they suffer ventral hernia (9 umbilical, 4 epigastric, 3 infraumbilical); 12 primary, 4 incisional; the size of the hernial ring was 2–8 cm, with risk of strangulation. All hepatopathy with ascetic decompensation. The anesthetic risk was ASA III-IV. After complete healing, patient care reviewed annually to 5 years; the average follow-up 47.2 (79–6) months. SURGICAL TECHNIQUE: the sack is released, reintroducing its contents. We do primary closure. We detached subcutaneous; and implant biological laminar prosthesis over the defect. Over the first prosthesis implant reticular prosthesis of polypropylene with 5 mm of overlaping. Ending placing suction drainage. Results: The surgical-time average: 45 (30–75) minutes. The mean stay: 5.9 (1–15) days. Immediate local complications: 3 hemorrhagic subfusion, 1 trophic disorder, 1 paraesthesia. Hepatic decompensation with ascites: 4 patients. None seroma or collection of ascites. Now 3 patients died; with 2was lost contact; in the remaining 11, repair is strong. Have not detected recurrences. Conclusion: The technique is simple and fast. Avoids complications (seroma, infection or filtration of ascites). We consider it an adequate technique to repair the ventral hernia in patient with hepatopathy and ascites.

P184 Analysis of the occurrence of female pelvic floor hernia patients and the levels of menopause and estrogen C. Qin, Shen Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China Background: To study the relationship between the occurrence of female pelvic floor hernia patients and the levels of menopause and estrogen. Methods: The female patients with pelvic floor hernia admitted in out hospital were divided into two groups, according to whether they have the menopause or not. The levels of estrogen were detected respectively in the two groups, and the difference was compared and analyzed. Results: The estrogen levels of patients before and after menopause were significantly lower than normal control groups; (P \ 0.05).The difference is statistically significant.

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Hernia (2017) 21 (Suppl 2):S208–S263 Conclusion: Significant decrease of estrogen level is a high risk factor for women with pelvic floor hernia, and also is one of the important reason of higher incidence of pelvic floor hernia for women after menopause.

P185 eTEP-TAR for non-midline incisional hernia V. G. Radu, M. Lica Life Memorial Hospital, Bucuresti, Romania Background: Non-midline incisional hernia are challenging in abdominal wall reconstruction because of bone proximities, risk of injuries of neuro-vascular bundles and mesh-fixation difficulties. Methods: We describe an eTEP-TAR (endoscopic total extraperitoneal and transversus abdominis release) approach for repair of lateral (L3) incisional hernia.The procedure starts by cranio-caudal retrorectus dissection, then ipsilateral site hemi-TAR in order to develop a large space for closing the defect and accommodate a proper large mesh. 3 patients with L3W2 incisional hernia was operated in last 6 months. Defect range from 4/5 to 7/8 cm, mesh/ defect ratio 8, mesh fixation: cyanoacrylate 2 cases, self-fixating mesh—1 case, mean OR time 180 min, LOS: 1 day. Results: Patients was discharged without complications; low postoperative pain (2.3 analgesic dose/day), fast recovery. No recurrence at follow-up (1 month, 4 month, 6 month accordingly). Conclusion: The eTEP-TAR approach can be a feasible solution in repairing of this type of hernias.

P186 Management of traumatic lumbar hernia: a trauma surgeon’s challenge G. Shpoliansky, U. Kaplan, O. Abu-Hatoum, D. Kopelman Emek Medical Center, Afula, Israel Background: Traumatic lumbar hernia(TLH) is an uncommon entity which continue to be a major challenge for trauma surgeons. There is no consensus on the ideal timing and type of repair in this type of hernia. Methods: A 68 year old woman who was involved in MVA arrived to the ER hemodynamically unstable. Focus assessment sonography for trauma (FAST) was positive and the patient was taken to the operating room. Results: The patient underwent emergency laparotomy with bleeding control, bowel resections and repair of diaphragmatic injury. She was discharged home ten days post surgery. The patient was managed by watchful waiting and nine month post the initial surgery, she underwent elective repair, using nonabsorbable mesh by open approach. Conclusion: TLH should be considered in all cases of massive abdominal wall muscles disruption. The diagnosis of TLH, in the unstable patient, is based on radiology finding due to the difficulty of physical examination. TLH can be misdiagnosed during the explorative laparotomy and we believe that CT scan is mandatory in early postoperative period to rule out the diagnosis. When the lumbar defect is identified, the decision regarding the timing of repair should be made. The possibility of extensive abdominal wall tissue disruption and contaminated abdominal cavity, prohibit the use of prosthetic mesh for emergent repair of the defect. We reccomend, that the best strategy is watchful waiting with delayed repair in elective setting, to avoid unfavorable sequels.

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P187 Hernias here, hernias there: a test submission J. Smith1, B. Jones2 1 Harvard Medical School, Boston, MA, USA, 2Yale Medical School, New Haven, CT, USA Background: The beneficial effect of kidney transplantation in patients requiring continuous renal replacement therapy owing to chronic kidney disease is well known and accepted. Kidney transplantation protects the patient from complications that may develop during chronic dialysis. Unfortunately, there is also evidence that kidney transplant patients are more prone to developing cancer than healthy persons. The aim of this study was to evaluate the prevalence of gastrointestinal pathologies in patients after kidney transplantation. Methods: Adult patients after kidney transplantation, who are under the care of the Outpatient Department of Nephrology in Gdan´sk, received alarm symptom questionnaires and referral for testing for the presence of fecal occult blood. Then, in 45 selected patients (29 men and 16 women) endoscopic examination was performed. Mean age was 57.6 ± 10.1 (range, 35–83) years. Results: Out of *940 patients after kidney transplantation, resting under supervision of outpatient department, 181 patients completed the questionnaire and 100 gave a stool sample for testing: 32 results were positive. After analyzing the questionnaires and stool results, 88 patients were qualified for further investigation. The endoscopic examination had been performed so far in 45 patients and revealed gastritis and/or duodenitis in 33 patients, diverticular colon disease in 18, esophagitis in 8, colon polyps in 14, stomach polyps in 3, inflammatory bowel disease in 7, and cancers in 3. Conclusion: The preliminary results indicate that patients after kidney transplantation have significant risk of gastrointestinal pathologies and require detailed diagnostic endoscopy.

P188 Spontaneous diaphragmatic hernia: an entity to keep in mind A. Soares, S. Usurelu, J. Teixeira, A. Gouveia ULS-Castelo Branco, Castelo Branco, Portugal Background: Acquired diaphragmatic hernias are usually traumatic and most frequently due to blunt thoraco-abdominal trauma. ‘Spontaneous’ rupture, which implies absence of trauma, accounts for less than 1% of all diaphragm injuries. Although there is always the possibility that the diaphragmatic defect arose from a forgotten trauma in the past or structural in origin, spontaneous rupture can be induced by a number of factors such as heavy physical effort, violent emesis, labour, dancing, coughing and defecation. Methods: Results: Clinical case: we describe a case of an 82-year-old male with severe epigastric pain irradiating to the left thorax as well as respiratory distress, with no trauma history, presenting 2 days after an episode of intense vomiting. His left hemithorax was dull to percussion with reduced respiratory sounds at the left pulmonary bases. Upright chest X-ray arose the suspect of a diaphragmatic hernia that was not present 2 days before. Computed tomography showed a defect on the left side of the diaphragm and herniation of colon into the left hemithorax with compressive collapse of most of the left lower lobe and contralateral deviation of the mediastinum. The diaphragmatic defect was repaired surgically. The patient had a postoperative recovery complicated by an empiema with full response to antibiotherapy. Conclusion: Violent emesis can cause a spontaneous acquired diaphragmatic hernia. This condition is very rare and may be very

S259 difficult to diagnose unless a high index of suspicion is kept in mind. A good history taking is of extreme importance. Surgical repair is the definitive treatment.

P190 Successful repair of a bladder herniation after old traumatic pubic symphysis diastasis using polypropylene mesh with tissue growthing graft and hernia mesh L. Wu AnHui Provincial Hospital, HeFei, China Background: Bladder herniation associated with pubic symphysis diastasis is a very rare condition. Methods: We report a case with bladder herniation after traumatic pubic symphysis disruption.A 47-year-old man was admitted to our hospital complaining of under abdominal pain and reversible mass for 11 months in July of 2011.Eighteen months earlier the patient was treated with open Urethral reunion operation and jejunostomy procedure and definitive internal fixation of the pubis. Then, 2-month late, Open incisional hernia patch repair and jejunostomy closed surgery had been carried out. We used a polypropylene mesh with tissue growthing placed of previous surgery for closure of the diastasis and a prolene and a polytetrafluoroethylene mesh graft and for supporting the abdominal wall. Results: Our surgical procedure is different from others because of the use of polypropylene mesh with tissue growthing. Conclusion: We obtained a successful outcome during a 5-year follow-up period.

P191 Transabdominal laparoscopic hernia repair for inguinal hernia with sigmoid colon herniation H. Yang Beijing United Family Hospital, Beijing, China Background: The inguinal hernia repair is the common surgery for well trained general surgeons, and laparoscopic transabdominal preperitoneal (TAPP) hernioplasty is considered to be a popular technique for inguinal hernia repair. However, some unexpected hernia content, such as sigmoid colon, can cause dilemma even for experienced hernia surgeons. Methods: From 2012 to 2016, among elective TAPP hernia repair, 3 cases of inguinal hernia with sigmoid colon herniation without obstruction were encountered unexpectedly. Rather than making effort to reduce the hernia content directly with the risk of injuring the herniated organ, routine incising the peritoneum above the hernia defect to develop peritoneal flap as usual. With the hernia sac mobilized, the hernia content gradually reduced back safely without any injury. Mesh (Ultropro 15 9 10 cm, Johnsons&Johnson) was fixed with Securestrap (Johnson&Johnson). The peritoneum was closed with 3/0 v-loc suture. Results: TAPP hernia repair was successful without complications or conversion to open in all these three cases. On average, the operation time was 85 min. All the procedures were managed as day case. The follow up time was 18 months, and there was no recurrence. Conclusion: Even though sigmoid Colon herniation might complicate the laparoscopic hernia repair, TAPP remains to be a safe and an efficient method when performing at appropriate approach.

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9. Prevention of complications and recurrence: Education in hernia surgery P192 Education in hernia surgery in developing countries through ‘‘Hernia International’’ and ‘‘Surgeons in Action’’ Foundations T. Butro´n1,2, A. Martinez-Pozuelo2, A. Awojobi3, S. Barrio-Anaya4, G. Housari5, A. Kingsnorth6, J. A. Pascual7, S. Trabanco8, M. Lo´pez-Vizcayno9, S. Ferna´ndez-Arias10, B. Revuelta11, H. Llaquet12, A. M. Gay13, M. Fanjul14, M. C. Santiago15, M. Cires16, D. Ferna´ndez-Luengas17 1 Surgeons in Action Foundation, Madrid, Spain, 200 12 de Octubre’’ University Hospital, Madrid, Spain, 3Awojobi Clinic Eruwa, Eruwa, Nigeria, 4Hospital General, Segovia, Spain, 5University Hospital Getafe, Getafe, Spain, 6Hernia International Foundation, Plymouth, UK, 7Clinica Cemtro, Madrid, Spain, 8Valdecilla University Hospital, Santander, Spain, 9Hospital Clinico de San Carlos, Madrid, Spain, 10 Hospital Vital Alvarez Buylla, Mieres, Spain, 11Complejo asistencial Universitario, Leo´n, Spain, 12Hospital Vall d’Hebron, Barcelona, Spain, 13Hospital Alvaro Cunqueiro, Vigo, Spain, 14 Gregorio Maran˜o´n University Hospital, Madrid, Spain, 15Hospital Principe de Asturias, Alcala´ de Henares, Spain, 16Hospital de Estella, Navarra, Spain, 17University Hospital Quironsalud, Madrid, Spain Background: Inguinal hernia is a public health problem in Africa. Although inguinal hernia develops at all ages (mainly in men) and in all parts of the world with the same frequency, in Africa they are not treated due to lack of hospitals and surgeons. In rural Africa, it has been estimated that less than 1 in 5 inguinal hernias requiring surgery are actually operated. Methods: Hernia International and Surgeons in Action are two NGO that provide surgical care delivered by Teams of Volunteers who teach local doctors how to operate inguinal hernias using mosquito net meshes and, occasionally, commercial meshes. Results: From 2009 Hernia International in collaboration with Surgeons in Action has been operating in Nigeria, Senegal and Kenya with local doctors as assistants or first surgeons. Nigeria in 2009: 46 patients with 51 procedures, 31 Lichenstein, 2 local doctors helped in 50% cases; 2012: 38 patients, 44 procedures, 39 Lichenstein, 2 local doctors helped as assistants in 20 cases and as first surgeons in 2; 2016: 68 patients, 80 procedures, 72 Lichenstein, 7 local doctors helped as assistants in 38 cases and as first surgeons in 8. Kenya: 2015: 56 patients, 56 procedures, 35 Lichenstein, 3 local doctors helped as assistants in 14, and 4 as surgeons. Senegal: 2016, 140 patients, 167 procedures, 42 Lichenstein, 2 local doctors, 20 as assistants and 2 as surgeons. Conclusion: local doctors learned how to use mosquito nets as meshes for hernia repair and to compare them with commercial meshes, with Lichenstein technique.

P193 Usefulness of visible prostheses in the safety control for new mesh fixing systems P. Garcı´a-Pastor, A. Torregrosa, N. Carvajal, R. Garcı´a, S. Bonafe, J. Iserte, R. Blasco, J. Bueno, E. Garcı´a-Granero La Fe University Hospital, Valencia, Spain Background: In our team, Rives technique is of choice for smallmoderate midline hernia repair. We amended the standard technique

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Hernia (2017) 21 (Suppl 2):S208–S263 by using cyanoacrylate-glue for mesh fixation; we shortened surgery time and reduced local complications without impairing safety (relapse rate didn’t increase). We started four years ago, with good clinical results. With the appearance of meshes visible by imaging techniques, we proposed its use in non-stitches technique and later verification of the mesh fixation. Methods: Ten patients with incisional hernia (transverse diameter range 5–9 cm) were operated on with this technique: retromuscular PPL-PVDF prosthesis marked with iron-nanoparticles, visible by MRI images (IPOMvisible, DynameshÒ), fixed without stitches but using nebulized cyanoacrylate-glue (Glubran, GEMÒ). MRI is performed 6 weeks postoperatively as follow-up protocol, it allows visualizing positioning, retraction, folding and complications associated with prosthesis. Results: Technique was applied as usually, except for the use of visible mesh. There was no complications related to surgical procedure, immediate postoperative period was uneventful. MRI allowed, 6 weeks later, to control the mesh fixation system. A case of folding at the distal end of the mesh and the casual (not clinically suspected) finding of a seroma were the only discordant data. In all other patients, mesh were properly fixed, without displacements, wrinkles, folds or complications associated with their use or the fixation system used. Conclusion: The use of visible mesh allowed us to confirm that retromuscular prosthesis fixation exclusively with cyanocrylate-glue is safe and effective in the short term.

P194 Prevention of male infertility development after Lichtenstein method T. Gvenetadze Acad. O. Gudushauri National Medical Centre, Tbilisi, Georgia Background: The study and comparison of quantitative composition of spermatozoids prior and after Lichtenstein and Gvenetadze operations. Methods: For the recent 6 years 1500 patients have been operated on by the isolation method. 215 patients of the reproductive age (19–40 years.) with the bilateral inguinal hernias became the object of study. The patients were allocated into two groups. The first group contained those 66 patients (30.7%) who underwent bilateral Lichtenshtein hernia repair. The second group—149 patients (69.3%) on whom bilateral hernia repairs by Gvenetadze method have been utilized. Complete spermomorphocitological investigations have been performed in all groups 2 days prior to surgery, 30 days and six months after surgery. Results: Oligospermia, reduction of the quantitative sperm composition by 30–35% was revealed only in the first group (p \ 0.01). In the second group no significant differences was registered. 68 patients had children after surgery by Gvenetadze method. Conclusion: Hernioplasty by Gvenetadze prevents male infertility in all cases especially for bilateral inguinal hernia repair as well as in reproductive age. The given technique is more solid as the posterior wall of the inguinal canal presented by the transverse fascia, mesh and aponeurosis of the external oblique muscle therefore the recurrence rates of hernia is minimized and practically excluded. Based on the foregoing results this method is considered as an effective method of hernioplasty as for young as well for elderly patients.

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P195 Chen’s seven-step maneuver for laparoscopic transadominal preperitoneal inguinal hernia repair Y. Li, S. Chen The sixth affiliated hospital of Sun Yat-sen University, Guangzhou, China Background: The laparoscopic transabdominal preperitoneal (TAPP) technique was a leading mode of inguinal hernia repair, on the basis of lower incidence of postoperative pain and faster recovery compared with open technique. However, TAPP is still considered a more difficult surgical procedure. The aim of this study was to provide a step-by-step teaching module for hernia surgeons learning TAPP. Methods: One hundred and three patients who underwent laparoscopic inguinal hernia repair with Chen’s seven-step maneuver between May 2015 and April 2016 at our hospital were enrolled. The critical steps were presented in a standardized way. The difficult procedures’ key points (e.g. Anatomic landmarks recognition, preperitoneal space dissection, hernia sac dissection, mesh placement and peritoneal closure) are described and took photographs. Results: Laparoscopic repairs were successful in all patients, with a mean surgical time of 28 ± 16.7 min. Mean postoperative hospitalization duration was 3.2 ± 0.8 days. Four patients suffered from postoperative local hematomas. Six patients had short-term local pain. There were no cases of chronic pain. All patients were followed up at least 8 months, and no recurrence was observed. Conclusion: With this adequate program, the technique of Chen’s seven-step maneuver can be learn quickly, skillfully, and safely and easily perform by young trainees under the supervision of experienced laparoscopic surgeons.

P196 The knowledge and opinions on TAPP and TEP repairs in routine clinical practice of Polish surgeons K. Mitura1, S. Da˛browiecki2 1 Siedlce Hospital, Department of General Surgery, Siedlce, Poland, 2 Department of Nutrition and Dietetics, Nicolaus Copernicus University in Torun, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland Background: In 2012, a total of 56 647 inguinal hernia repairs were performed in Poland. However, the absence of a uniform hernia repair register obscures the current herniology status in Poland especially regarding laparoendoscopic procedures. The aim of the research was to determine the awareness of laparoendoscopic procedures among Polish surgeons and to ascertain their everyday clinical practice. Methods: The data was collected at the national hernia conference in 2016, during an interactive session for surgeons with special interest in herniology. They could respond to the survey items using the VoxVote application. All items and response options were displayed on participants’ smartphones. The questions were related to TAPP/ TEP hernia repair. The surgeons responded to 27 questions regarding routine inguinal hernia repair. 106 surgeons from all regions of Poland participated in the survey. Results: 19.2% respondents never inform patients about the possibility of performing laparoendoscopic repair. 45.2% admitted that they happened to have referred a patient with a difficult inguinal hernia to other hospital or surgeon. 75% stated they would be willing to perform TAPP/TEP if the reimbursement rates were more favourable. In bilateral hernias, 61.6% of the respondents perform a two-step open repair, only 25% perform a single-stage

S261 laparoendoscopic repair of bilateral hernia. In women, only 13.3% perform laparoendoscopic hernia repairs, and 19.0% don’t use mesh. Conclusion: The skill level to perform TAPP/TEP repair is still inadequate among Polish surgeons. The absence of accurate data makes it impossible to verify whether the treatment methods used in are compliant with the guidelines.

P197 Learning curve for minimally invasive openpreperitoneal herniorrhaphy (kugel) Y. Ohara, Nozomi Shinozuka, Hiroshi Asano, Hiroyuki Fukano, Yuusuke Fusejima, Yuuki Kanno, Makoto Takagi, Shingo Morioka, Tetsuyoshi Takayama, Saori Yajima, Ryousuke Uji1, Yoshie Hosoi Saitama Medical University, Iruma city, Japan Background: The Kugel repair, a minimally invasive technique, has become an alternative tolaparoscopic groin hernia repair. The advantages of a Kugel repair includes extensive dissection in the inguinal canal, avoidance of inguinal nerves, and minimal or no fixation as intra-abdominal pressure prevents migration of the mesh.Concerns have been raised about the extensive learning curve for both attending surgeons and residents to master this technique. Methods: Between April 2007 and December 2014, 1533 patients were included in this study that underwent a Kugel repair for inguinal hernia at the General Surgery of Saitama Medical University Hospital. We plotted the operation time against the number of operations performed by 4 residents (A,B,C,D) and attending surgeon. The number of operative cases needed by attending surgeons and residents to reach the appropriate operation time was analyzed. Results: In the 970 operations performed by residents, the mean operation time was 46 min and recurrence rate was 1.5%. The operation time of resident was stabilized after 50 cases. The mean operation time of attending surgeons was 34.6 min. The most recurrences occurred with the first 50 cases. Conclusion: The learning curve for the Kugel repair is about 50 cases. It is necessary to check the mesh position when instructing a resident. Recurrences occurred in the first 50 cases using the Kugel repair technique.

P198 Migrating a foreign body in subcutaneous tissue of mons pubis; a mesh plaque N. Ozlem Ahi Evran Univerity, Kirsehir, Turkey Background: The reasons for hernia repair using a mesh plug is more common in Japan are being a quick procedure, easy to learn, and also low at cost. recurrence (due to the shrink of the mesh) and prolonged pain have been reported as the main complications. However, some rare complications have emerged recently. There were five reported cases that indicated the complication being caused by mesh plug migration. Our case with mesh plaque migration will introduce cause it is rare occurence. Methods: 27 years female presented with pain and a mass in her subcutaneous tissue of mons pubis, was undergone a inguinal hernia repair with a mesh plaque 1 1/2 year before, her physical and lab examination results were normal except being an abnormal usg, ct, mri finding that showed a foreign body in her subcutaneous tissue. Results: Hermeshplaque was extirpatedandrepaired hernia withoutmesh.

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Conclusion: Recently, there are several reports concerning complications after hernia repair with a mesh plug. According to the reports, mesh migration was observed in the preperitoneal space, small intestine and colon, and scrotum, and fifth one is the case in whom mesh migrated to bladder is reported from japanese. The question is how mesh plug migration occurs. In a review article on mesh plug migration cases, the authors claim that surgical technique was poor in some cases, one case did not show true migration, another one was a case of the wrong operation being done, and one case due to the patient’s very poor health. They concluded that this kind of complication could be avoided by careful operation.

have femoral hernia. 71.6% of hernias were incarserated, 28.4% were strangulated. 57.5% of strangulated hernia have intestinal resection + anastmosis surgery. Conclusion: This study keynotes, patients who admit emergency department for inguinal hernia, likely to have  of patients a strangulation and ‘ of strangulated hernia have resection + anastmosis surgery.

P199 Bilateral inguinal hernias should be repaired in one or two session?

A. Soares, M. Romano, S. Usurelu, L. Valencia, A. Gouveia ULS-Castelo Branco, Castelo Branco, Portugal

N. Ozlem Ahi Evran Univerity, Kirsehir, Turkey Background: Recently there are many article released about inguinal hernia repair.but english literature has limited knowledge about bilateral inguinal hernias. 8–30% of inguinal hernias are bilateral. To repair to bilateral inguinal hernias in the same session is a debate for years. This study is conducted to add some knowledge to literature in this subject. Methods: Of 1594 patients who operated for inguinal hernia, 249 was en rolled in this study. Demographics, wheter the hernias are uni or bilateral, lengths of hospital stay of the patients if drain or not of the wound were all assesed. All patients have antibiotic profilaxy. Results: 113 patients have unilateral hernioraphy 136 have bilateral inguinal hernia repair. Lengths of hospital stay who are undergone bilateral hernioraphy is mean; 3166 (1–9)days. Mean hospital stay who operated for unilateral hernioraphy is 1.72 (1–7). When the patients who have any additonal operation are exclude, the LOS are 2.35 and 1.56 days respectively. Conclusion: Feliu et al. in their series mean ages were 54 ± 11, LOS were 1.3 ± 1.2 days, 4.7% of their patients discharged in the same day.no patient of our could not have day case surgery to repair a bilateral inguinal hernia in two session dont increase LOS more than in 2 times. LOS of bilateral hernia repair reduce in total. LOS of repairing of bilateral inguinal hernia are longer than los of unilateral hernia repair. Any additional operations increase LOS in both groups. The rate of drain the operation field decreased in later years than beginer ones.Peiper et’al; a redon drain is not requried.

P200 Emergency inguinal hernia repair and distribution of the content at samsun training and research hospital in 5 years N. Ozlem Ahi Evran Univerity, Kirsehir, Turkey Background: This study shares analyses of patients who have emergency surgery for inguinal hernia and distribution of the content and states of hernia sacs. Methods: 4.8% (113 patients) of 2341 patients who have inguinal hernia repair surgery, have surgery in emergency conditions at ahi evran university Training and Research Hospital between January 2008 and February 2013. Results: 79.6% of 113 patients were male, 20.4% were female. Mean age of males: 60 (23–89) females: 71.5 (31–92) Length of stay 3.09 days. Mean operation time 72.05 min. 8.84% of 113 patients

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P201 Colostomy obstruction by mesh migration following paraostomal hernia repair

Background: Complications directly associated with the use of prosthetic material are rarely mentioned in the literature. Methods: Results: Clinical Case: The authors describe a case of an 84-year-old patient with a surgical history of abdominoperineal amputation 8 years and hernioplasty for paraostomal hernia 4 years ago, presenting with intestinal occlusion due to a recurrent incarcerated paraostomal hernia. A hard formation was felt on touch through the colostomy. Colonoscopy revealed prosthetic material with transmural migration, causing luminal obstruction. The patient was submitted to a surgical intervention that showed an incarcerated paraostomal hernia with segmental ischemia of the ileum and colostomy obstruction by mesh migration. Segmental resection of the ileum and colon, including the mesh, and a terminal colostomy were performed as well as correction of the hernia with a biological mesh. Conclusion: In the consulted literature there are no reported cases of transmural mesh migration in paraostomal hernia repair. The pathophysiological mechanisms of this type of migration, although not fully known, can be attributed to the chronic inflammatory reaction by the prosthetic material creating adhesions between the mesh and the intestine and causing its erosion thus facilitating penetration of the foreign body into the intestinal lumen.

P202 The history of the preperitoneal approach from Annandale to the modern minimal invasive and minimal access approach, minimal open pre peritoneal, MOPP M. Soler Clinique saint jean, Cagnes sur Mer, France In 1817 Cloquet described the posterior inguinal wall. In 1876, Annandale reported for the first time the concept of the preperitoneal posterior approach. LAWSON Tait from Birmingham reported in 1883 the median abdominal section to treat groin hernia In 1920, Sir Lenthal CHEATLE from London had sutured hernias through a midline preperitoneal approach. But the surgeon who popularized this approach is LLyod Nyhus, 1960. One of the more important anatomist of the modern age is Henri R Fruchaud, one of the R Stoppa and Jean Rives mentor. He proposed in 1956: the deep reconstruction of the abdominal wall in the whole groin region Jean Rives, 1965 proposed the placement of the unilateral prosthesis by the midline pro peritoneal route. In 1967 Rene´ Stoppa proposed the first tension free and suture less hernia repair, after him G wantz for the unilateral hernias. The Laparoscopic pioneers used these principles, for the trans peritoneal approach, 1991: J. Leroy, G. Fromont, or pro peritoneal

Hernia (2017) 21 (Suppl 2):S208–S263 approach, G. Begin, Dulucq. In 1995 Franz Ugahary proposed the first pre peritoneal minimal invasive approach. More recently Gillion, Chollet, Berrevoet, De ghent propose the Trans Inguinal Pre Peritoneal approach TIPP. I modified recently the TIPP technique, using a new mesh, with the Ugahary pre peritoneal space dissection principle specific retractors. It’s now easier to put the big prosthesis through a 3, 5 cm incision. I propose to name this technique the Minimal Open Pre Peritoneal technique: The MOPP technique.

P203 Barrett’s esophagus: an algorithm for the treatment and correction of complications Barrett’s esophagus: an algorithm for the treatment and correction of complications A. Stasyshyn Lviv National Medical University, Lviv, Ukraine Background: Barrett’s esophagus is defined as a metaplastic change in which the squamous epithelium of the esophagus is replaced by a columnar epithelium containing goblet cells (intestinal metaplasia). Methods: Results of treatment of 195 patients with GERD during 2005–2016. Intestinal metaplasia of the epithelium in the lower third of the esophagus was performed using videoendoskopy, chromoskopy and biopsy. Results: In 176 (90.2%) patients completed Nissen fundoplication, in 14 (7.2%)—Toupe, 5 (2.6%)—Dor fundoplication. 7 patients with verified Barrett’s esophagus were held argon coagulation and applications for 8–12 weeks before surgery and PPI, 2—after. All patients with Barrett’s esophagus had epithelial regeneration in 3 months after the operation and there were no cases of adenocarcinoma in 36 months. 21 patients with acute bleeding from the upper gastrointestinal tract were performed combined hemostasis (injection + argon coagulation) in combination with infusional hemostatic, antiulcer therapy. 2 patients with Malory-Weiss syndrome with recurrent bleeding were successfully applied probe Blackmore. All patients with peptic ulcer of the esophagus were treated with proton pump inhibitors (PPIs) and prokinetic ans in 4–16 weeks after conservative treatment laparoscopic antireflux surgery was done. 4 patients with peptic stricture of the esophagus were performed balloon dilatation and conservative treatment duting 12 weeks, after which patients were operated. Conclusion: The developed diagnostic and therapeutic algorithm facilitates systematization and objectification of changes in complicated GERD, increases the timeliness of diagnosis and choice of differential treatment tactics and improve QOL of patients.

S263

P204 The clinical research of laparoscopic approach of recurrent inguinal hernia repair L. Wu AnHui Provincial Hospital, HeFei, China Background: Treatment for the recurrent inguinal hernia is difficult clinically. The purpose of this study was to examine clinical outcomes of laparoscopic treatment for recurrent inguinal hernia. Methods: A retrospective study reviewing the medical records of patients with recurrent inguinal hernia who underwent surgeries from October 2009 to June 2016 was done. Patients were divided into two groups according to surgical procedure (laparoscopic group n = 51 or conventional open group n = 45). Results: There were no statistical differences between the two groups relevant to age, time of hernia reoccurrence, or type of hernia reoccurrence. However, in the laparoscopic group the rate of recurrence, hospitalization time, and postoperative pain was more favorable relative to the conventional open group. But, the laparoscopic group required more time in the operating room. There were no statistical differences between the two groups relative to complications or bleeding volume. Conclusion: Surgical laparoscopic hernia repair for the treatment of recurrent inguinal hernia is preferable over the conventional open method because it has a low hernia recurrence rate, less postoperative pain, and effective.

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Hernia (2017) 21 (Suppl 2):S264–S273

ABSTRACTS

Author Index Ó Springer-Verlag France 2017 Aasvang E.K., O5.1, S146 Abbonante F., O3.8, S143, O8.7, S153 Abdalla R., O12.2, S157, O12.5, S158, O12.7, S159 Abu-Hatoum O., P186, S258 Abusalih A., P158, S251, O27.5, S185 Adelsgruber P., O20.8, S173 Aguado Suarez N., P071, S227, P072, S227, P073, S227, P074, S228 Aguilera A., O17.2, S165, O21.5, S175, V36.1, S196, V36.9, S198 Ahmad N., O23.8, S179 Ahmic E., O23.4, S178 Ahonen J., O21.7, S175 Ahonen-Siirtola M., O41.3, S205 Akiyama G., V30.5, S189 Al Omar A.K., O23.1, S177 Alampi B., P108, S237, V11.6, S157 Albors P., P065, S225, P078, S229 Albors Baga´ P., P150, S248 Alesina P.F., O20.5, S172 Allaix M.E., V36.6, S197 Alonso Simo´n E., O41.2, S205 Altuve J.A., P002, S208 Alvarez Pen˜a E., O27.1, S184, P179, S257 Alyautdinov R., P119, S240 Amato G., O20.7, S173, P001, S208 Ambrosoli A., P020, S213, P038, S218, P062, S224 Amler E., O18.7, S169 Amr B., O20.9, S173 Anaya-Cortez M., O20.5, S172 Andreou A., P053, S222 Andresen K., O20.2, S171, O21.6, S175, O3.1, S141, O7.2, S148 Anghelici G., P156, S250 Antonio T., P143, S246, V36.3 Antoniou S., O1.2, S139, O29.3, S187, O38.2, S202 Antoniutti M., O18.1, S167 Antor M., O41.6, S206, P161, S251, P162, S252 Antunes C., V36.5, S197 Anurov M., O33.6, S194 Anuwong A., O27.9, S186, P025, S214, V11.4, S156 Arago´ P., P152, S249 Aragon LJ., P002, S208 Arantes B.S., P015, S212 Ardid J., O17.3, S165, P110, S237 Aresu S., P077, S228 Argudo N., O26.2, S181 Arias Pacheco R., P071, S227 Arienti F., P062, S224 Arimoto A., V11.2, S155 Artes M., O23.3, S178 Atzeni J., P031, S216 Auer T., O4.2, S144, O8.4, S152 Augenstein VA., O8.1, S151, O8.6, S152 O18.5, S169, O37.2, S199, O37.3, S199, O37.4, S200 Avellana R., O3.5, S142 Avery K.N.L., O17.7, S166 Avram I., P003, S208, P088, S231

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Awojobi A., P192, S260 Azevedo M.A., P163, S252 Aziz M., O21.4, S175 Baastrup N.N., O8.3, S151, O8.5, S152 Babii I., P089, S232 Ba´ez C., P065, S225, P078, S229, P150, S248 Baijal M., P115, S239, V11.3, S156 Bakker W.J., O16.2, S162 Baldan N., O18.1, S167, O33.5, S194, P112, S238 Baldazzi G., O18.1, S167 Baldjiev T., P085, S231 Ballacer C., O12.8, S159 Balleby L., P026, S215 Ba¨r A., O27.6, S185 Bardini R., P010, S210, P082, S230 Barrat C., O26.6, S182 Barri J., P148, S248, P168, S253 Barrio-Anaya S., P192, S260 Barrios P., P148, S248, P168, S253 Bartkova P., P093, S233, P096, S234, P144, S247 Bartra E., P030, S216, P182, S257 Basaric D., O27.7, S185, O41.9, S207 Baschleben G., O41.1, S205 Basile G., P005, S209 Basso A., O18.1, S167 Bastiaansen-Jenniskens Y.M., O33.2, S193 Baumann P., O17.1, S165 Bawa S., O37.8, S201, O4.6, S145 Bayon Y., O26.5, S182, O33.2, S193 Becerra R., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Bechstein W.O., P051, S221 Beckers R., O41.4, S206 Beldi G., O39.1, S203 Belfiore M., P005, S209 Bellido Luque A., O23.6, S179, P113, S238, P164, S252, V30.3, S188 Bellido Luque J., O23.6, S179, P113, S238 P164, S252, V30.3, S188 Bellver G., P152, S249 Belousov: P056, S222 Belousov A., P114, S238 Beltrame V., P010, S210 Belyansky I., O34.3, S194, O35.3, S195, O37.4, S200 Bemelman WA., O4.8, S146 Bendavid R., O15.6, S161 Benigno L., V30.6, S189, V30.8, S190 Benmaridja L., O26.9, S183 Bennazar R., V36.7, S198 Bentzen J., P026, S215 Berger., O17.5, S166 Berger C., O41.8, S207, P178, S256 Berger D., O8.2, S151 Bernardi C., P010, S210 Berrevoet F., O1.3, S139, O26.4, S182, O26.9, S183 Berselli M., P038, S218, P126, S242 Bertoglio C., P108, S237, V11.6, S157

Hernia (2017) 21 (Suppl 2):S264–S273 Bethanbhatla M.K., P019, S213 Beunis A., P151, S249, V11.8, S157 Bewo¨ K., P109, S237 Bhargava A., O26.3, S181 Bhateja N., P127, S242 Bhutiani R., O7.5, S149 Bidzic N., O27.7, S185, O27.8, S186, O41.9, S207, P055, S222 Bildzukewicz N., O21.3, S174 Binda M., P020, S213, P062, S224 Birk D., O21.1, S174 Bischof G., O40.4, S204 Bisgaard T., O2.6 S141 Biswas S., P041 S219 Bittner R., O23.4, S178, O28.3, S187, O35.2, S195, O38.3, S202, O7.1, S148, O9.3, S154 Blasco R., P193, S260 Blazeby J.M., O17.7, S166, P111, S237 Bla´zquez L., O17.2, S165, O18.3, S168, O21.5, S175, O23.3, S178, V11.7, S157, V36.1, S196, V36.7, S198, V36.9, S198, Blencowe N., O17.7, S166, P111, S237 Boelens O.B.A., O31.2, S191 Boersema G.S.A., O33.2, S193 Boersema S., O26.5, S182 Bogdanovic A., O27.7, S185, O41.9, S207, P055, S222 Bohnert N., O27.6, S185 Bojicic J., P057, S223 Bojovic P., P057, S223 Bojovic´ P.M., O27.3, S184 Bokun Z., O27.3, S184 Bolado M., P006, S209, P007, S209, P008, S210 Bonafe S., P016, S212, P118, S240, P173, S255, P174, S255, P175, S255, P193, S260 Bonafe Diana S., P143, S246, P159, S251, V36.3, S197 Bonan, A., O26.6, S182 Bonato L.J., P116, S239 Bonjer H.J., O4.4, S145, O38.4, S202 Borces D., P003, S208, P088, S231 Bordignon G., P082, S230 Borglit T.B., P026, S215 Born D.E., O3.2, S141 Borroni G., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Bougard H., O3.7, S143 Bouvy N.D., O23.1, S177 Brachet Contul R., O31.6, S192 Bradley T., O37.2, S199 Bradley III JF., O37.3, S199 Brady M.S., O17.9, S167 Brady R.R.W., O10.1, S154, O26.7, S183, O37.10, S201 Brancato G., P005, S209 Brankovic´ M., O27.3, S184 Bridoux V., O41.6, S206, P161, S251, P162, S252 Bringman S., O16.1, S162, O3.7, S143 Brolese A., O18.1, S167 Bruna M., P065, S225, P078, S229 Bruna Esteban M., P150, S248 Brunner W., V30.6, S189, V30.8, S190 Bruzzone P., P070, S226 Bueno J., P016, S212, P118, S240, P173, S255, P174, S255, P175, S255, P193, S260 Bueno lledo´ J., P143, S246, P159, S251, V36.3, S197 Buia F., P130, S243 Buils Vilalta F., P155, S250 Bukin A., P041, S219 Bull N., P123, S241 Buonomo O., O20.4, S172, P172, S255 Buqueras C., P148, S248, P168, S253 Burgmans I.P.J., O16.2, S162, O20.1, S171

S265 Bustos-Jime´nez M., P064, S225, P090, S232, P165, S252, P166, S253 Butro´n T., P145, S247, P170, S254, P192, S260 Cabeza J., O3.5, S142 Cagigas J., P006, S209, P007, S209, P008, S210 Cagigas-Roecker P., P006, S209, P007, S209, P008, S210 Cai X., P181, S257 Cakir M., O7.6, S149, P012, S211 Calek E., O18.8, S170 Callari C., O4.7, S145 Callister Y.M., O23.2, S178, O41.5, S206 Calo` P., O20.7, S173, P001, S208 Calvo P., V36.7, S198 Camacho-Marente V., P090, S232, P165, S252, P166, S253 Candinas D., O39.1, S203 Ca´novas R., P152, S249 Cao J., O20.6, S172 Cantero EG., P006, S209, P007, S209, P008, S210 Carbonell A.M., O37.3, S199 Carceller S., P152, S249 Ca´rdenas G., P176, S256 Carels K., O41.4, S206 Carlson G.L., O26.7, S183 Caruso F., O16.5, S163, O37.6, S200 Carvajal F., O17.3, S165, P110, S237, V36.2, S196 Carvajal N., P193, S260 Cas O., O26.6, S182 Castan˜o S., P152, S249 Castello G., O16.5, S163, O37.6, S200, P059, S223 Castello´ J.R., P153, S249 Castro A.L., P015, S212 Cecconello I., O12.5, S158 Ceci F., P070, S226 Ceno M., O8.2, S151 Ceriani I., P020, S213, P126, S242 Cesana G., O16.5, S163, O37.6, S200, P059, S223 Cesardo Navarrete M.A., P146, S247 Chalkiadakis G., P053, S222 Chan D.L., P123, S241 Chan Y-W., O18.8, S170 Chaparro M.D., O23.3, S178, P153, S249, V36.7, S198 Chatzimavroudis G., P091, S232 Cheah W., P100, S235 Chelawat P., P115, S239, V11.3, S156 Chen D.C., O2.3, S140 Chen F., P009, S210 Chen J., O20.6, S172, O3.9, S143, O7.8, S150, P009, S210, P039, S218, P137, S245 Chen S., O27.2, S184, P195, S261 Cheng D.E., P116, S239 Chiari D., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Chiaro P., P086, S231 Chkhaidze Z., O23.9, S180 Chong C., P167, S253 Chonlathee P., O27.9, S186 Chouliaras C., P081, S229 Chowbey P., V11.3, S156 Chowbey P.K., P115, S239 Christoforidis E., P091, S232 Christopoulos P., P091, S232 Chudy M., O3.7, S143 Cianfarani A., O20.4, S172, P172, S255 Ciccarese,F., O16.5, S163, O37.6, S200, P059, S223 Cijan V., P057, S223 Cijan VR., O27.3, S184 Cires M., P192, S260

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S266 Clementi M., P117, S239 Clevers G.-J., O16.2, S162, O20.1, S171 Clouston H., O26.7, S183 Coakley K.M., O18.5, S169, O37.2, S199, O37.3, S199, O37.4, S200, O8.1, S151 Cobb WS., O37.3, S199 Cocozza E., P020, S213, P038, S218, P062, S224, P126, S242 Coget J., O41.6, S206 Colavita PD., O8.1, S151, O8.6, S152, O18.5, S169, O37.2, S199, O37.3, S199, O37.4, S200 Colella M., O20.4, S172, P172, S255 Comas J., P148, S248, P168, S253 Comelles M., O33.3, S194 Conesa Palma A., O41.2, S205 Conti P., P149, S248 Conze J., O9.4, S154 Corcelles R., O8.8, S153, V36.4, S197 Costa T., O12.2, S157, O12.5, S158, O12.7, S159 Cousins S., O17.7, S166 Cox T., O37.2, S199 Crowley S., P153, S249 Cruz A., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Cruz Cidoncha A., V11.7, S157 Cuccurullo D., O1.3, S139, O18.3, S168, O26.1, V30.9, S190 Cuffari S., P020, S213, P062, S224 Da Re C., P010, S210 Dabic D., O31.7, S192, P092, S233, P169, S254 Da˛browiecki S., P196, S261 Dabrowski A., O26.6, S182 Daes J., O35.3, S195 Dahlberg M., O17.6, S166 Dahlstrand U., O37.7, S200, O4.3, S144 ´ more L., O24.1, S180, O24.6, P070, S226 DA Daniels I.R., O26.3, S181, P111, S237 Dar Taha R., O27.5, S185 Davids P.H., O16.2, S162 Dazza M., O41.6, S206 de Andre´s A., P065, S225, P078, S229 de Andre´s Go´mez A., P150, S248 De Beaux A., O12.4, S158, O37.10, S201, O39.4, S203, P050, S221 De Berardinis V., P038, S218 De Manzini N., O18.1, S167 De Manzoni G., O18.1, S167 De Marchi F., O18.1, S167 de Smet A.A.E.A., O33.2, S193 de Vries Reilingh T.S., O16.3, S162, O23.1, S177, O8.9, S153 DeBeaux A., O24.1, S180 Deerenberg E., O13.1, S160, O17.4, S166 Degasperi S., P010, S210, P082, S230 Deiana E., P005, S209 Del Castillo D., P030, S216, P063, S225, P155, S250, P182, S257 Del Ferraro S., P126, S242 del Pozo P., O3.5, S142, P170, S254 Delgado M., V36.5, S197 Delgado Oliver E., O8.8, S153, V36.4, S197 Della Corte M., O8.7, S153 Della Penna A., P117, S239 Demetrashvili Z., P058, S223 Demiryas S., P011, S210, P012, S211 Dencic S.M., P066, S225 Deng S., P107, S236 Devaja A., P085, S231 Dhakad B.S., P127, S242 Dhooghe V., P151, S249, V11.8, S157

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Hernia (2017) 21 (Suppl 2):S264–S273 Di Furia M., P117, S239 Di Lernia S., P108, S237, V11.6, S157 Dıaz-DelGobbo G., O8.8, S153, V36.4, S197 Dietz U., O37.9, S201, O4.1, S144 Die´z-Aja S., P007, S209 Dios-Barbeito S., P064, S225, P090, S232, P166, S253 Dirschmid H., O6.1, S147 Doerhoff C., O26.4, S182, O3.7, S143 Domenech J., P030, S216, P063, S225, P155, S250, P182, S257 Donati M., P005, S209 Donmez T., O7.6, S149, P011, S210, P012, S211 Dounavis AC., P013, S211 Dritsoulas L., P013, S211 D’Souza N., O3.2, S141 Dudai M., O22.3, S177 Dunkerley H., O20.9, S173 Duran Ferreras I., O23.6, S179, V30.3, S188 Dwars B., O4.4, S145 Dybas B., P076, S228 East B., O18.7, S169 Egiev V., P027, S215, P075, S228 Ehrenberger M., P093, S233, P096, S234, P144, S247 Elieyioglu E., O27.6, S185 Elliott D., O17.7, S166 Elnaggar M., P136, S245 Eltyeb H., O16.8, S164 Emmanuel K., O13.3, S160, O23.4, S178, O7.1, S148 Eng A.K., P167, S253 Enochsson L., O37.1, S199 Enzinger S., O23.4, S178 Erdas E., O20.7, S173, P001, S208 Erdem, D.A., O7.6, S149, P011, S210 Erdem V.M., O7.6, S149, P011, S210 Ertem M., P017, S212, P018, S212, P067, S226, P120, S240, V30.7, S189 Escartin A., O33.3, S194, P141, S246 Espert J., O8.8, S153, P176, S256, V36.4, S197 Essenther M., P122, S241 Estela L., O3.5, S142 Estevez M., O31.9, S193 Etchepare H., O31.8, S192 Evsucova I., P075, S228 Fafemi O., P136, S245 Falenius, V., O41.3, S205 Fan Y., P181, S257 Fanjul M., P192, S260 Farassino L., P038, S218, P126, S242 Farley D.R., O16.9, S164 Favaro M.L., P015, S212 Feil W., O40.4, S204 Felberbauer F.X., O23.7, S179, P014, S211 Felbinger S., O17.1, S165 Feleshtynsky Y.P., P068, S226, P094, S233 Ferahman S., P011, S210, P012, S211 Ferna´ndez Yagu¨e L., O41.2, S205 Ferna´ndez-Arias S., P192, S260 Ferna´ndez-Luengas D., P192, S260 Ferrando J., P152, S249 Ferrara R., O18.1, S167 Ferrari G., P108, S237, V11.6, S157 Fischer I., P069, S226 Fiscon V., O18.1, S167 Fitzgerald M.J., O17.9, S167 Flores-Corte´s M., P064, S225, P090, S232, P165, S252, P166, S253 Florez Gamarra M., O3.5, S142, P171, S254 Forde C., O23.5, S179

Hernia (2017) 21 (Suppl 2):S264–S273 Fortelny R., O13.3, S160, O17.4, S166 Fortunova A., O17.5, S166 Fraile Olivera C., P171, S254 Frego M., O18.1, S167 French Club Hernie., O7.4, S149 Fresno de Prado L., O26.2, S181 Fromont G., O26.6, S182 Fu¨gger R., O20.8, S173 Fukushima R., P047, S220, P097, S234, P099, S234, P180, S257 Furukawa T., O21.9, S176 Futaba K., O23.5, S179

Gabor S., P015, S212 Gaggl A., O23.4, S178 Gajic J., O27.8, S186, O41.9, S207 Galanis I., P091, S232 Gallinella Muzi M., O20.4, S172, P095, S233, P172, S255 Galun D., O27.7, S185, O27.8, S186, O41.9, S207, P055, S222 Galva´n A., O17.2, S165, O21.5, S175, V36.1, S196, V36.9, S198 Galvanek P., P093, S233, P096, S234, P144, S247 Gao G., P022, S213 Garcıa R., P193, S260 Garcia Bear I., P071, S227, P072, S227, P073, S227, P074, S228 Garcı´a Conde M., P170, S254 Garcı´a Ferna´ndez A., O3.5, S142, P170, S254 Garcı´a Galocha J., O3.5, S142 Garcia Granero E., P143, S246, P159, S251, V36.3, S197 Garcı´a Moreno J., O23.6, S179, P113, S238, P164, S252, V30.3, S188 Garcia Pastor P., P143, S246, P159, S251, V36.3, S197 Garcı´a Uren˜a M., O17.2, S165, O18.3, S168, O21.5, S175, O23.3, S178, V11.7, S157, V36.1, S196, V36.7, S198, V36.9, S198 Garcia-Abril E., P121, S240 Garcı´a-Granero E., P016, S212, P118, S240, P173, S255, P174, S255, P175, S255, P193, S260 Garcı´a-Mun˜oz P., P064, S225, P090, S232, P166, S253 Garcı´a-Pastor P., P016, S212, P118, S240, P173, S255, P174, S255, P175, S255, P193, S260 Garcia-Salcedo J.A., P145, S247 Garvey J.F.W., O31.10, S193 Garzon I., P121, S240 Gas C., O33.3, S194, P141, S246 Gay A.M., P192, S260 Gencic M., P057, S223 Gensberger J., P088, S231 Getz S., O8.1, S151 Giaccone C., V36.6, S197 Gianesini R., O18.1, S167 Gianetta E., V30.4, S189 Gill R., O3.2, S141 Gillion J., O7.4, S149, O26.6, S182 Gimeno Lopez M., O41.2, S205 Giorgi R., O16.5, S163, O37.6, S200, P059, S223 Giuffrida F., P020, S213 Gjaltema J., O16.3, S162 Glaser K., P122, S241 Goderich J.M., P060, S224 Gogia, B., P119, S240 Go¨k H., P017, S212, P018, S212, P120, S240, V30.7, S189 Golling M., O17.1, S165 Gollonet-Carnicero J.L., P064, S225, P090, S232, P165, S252, P166, S253 Go´mez R., P065, S225, P078, S229 Gomez Menchero J., O23.6, S179, P113, S238, P164, S252, V30.3, S188

S267 Gomez-Sotelo A.I., P121, S240 Gong D., O16.7, S164 Gontijo C., O12.2, S157, O12.7, S159 Gonza´lez E., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Gonza´lez Bu´rdalo V., P170, S254 Gonzalez Sanchez J.A., O27.1, S184, P179, S257 Gonzalo R., P006, S209, P007, S209, P008, S210 Gordini L., O20.7, S173 Gossetti F., P070, S226 Goto K., O31.3, S191 Gouveia A., P138, S245, P188, S259, P201, S262 Grande Posa L., O26.2, S181, O41.2, S205 Grappolini S., P160, S251 Greco A., O31.9, S193 Grimaldi M.R., P070, S226 Grivon M., O31.6, S192 Groane S., O8.1, S151 Grotenhuis N., P129, S243 Gruber-Blum S., O18.6, S169, O23.4, S178, P122, S241, P135, S244 Gruppo M., P010, S210, P082, S230 Guadagni S., P117, S239 Guadalajara Jurado J., O23.6, S179, P113, S238, P164, S252, V30.3, S188 Guadarrama J., P145, S247 Guarner Piquet P., P176, S256 Guerriero L., V30.9, S190 Guillaume O., O18.6, S169, P135, S244 Gunnarsson U., O17.6, S166, O4.3, S144 Gupta M.K., P019, S213 Gutie´rrez A., P006, S209, P007, S209, P008, S210 Gutierrez Corral N., P071, S227 Guzzetti L., P020, S213, P062, S224 Gvenetadze T., O23.9, S180, P194, S260 Haastrup E., O7.2, S148 Habermann E.B., O16.9, S164 Halei K., P021, S213, P044, S219 Halei M., P021, S213, P044, S219 Hanßke B., O37.7, S200, P177, S256 Hartwig M.F.S., O8.3, S151 Hata H., O31.3, S191, V11.5, S156 Hatipoglu E., P011, S210, P012, S211, P017, S212, P067, S226, V30.7, S189 Hazan D., P041, S219 Heeren-Coumans T.M., O31.1, S190 Heindryckx, E., O41.4, S206 Heiss M.M., P125, S242 Hellenkemper J., P178, S256 Helm J., O8.1, S151, O8.6, S152 Heniford D.W., O37.3, S199 Heniford T., O1.4, S140, O8.1, S151, O8.6, S152, O18.5, S169, O37.2, S199, O37.3, S199, O37.4, S200 Henriksen N., O1.3, S139, O17.4, S166, O38.5, S202 Heras Garceau M.A., O27.1, S184, P179, S257 Herna´ndez Granados P., O2.5, S141 Herrera Sampablo A.I., O27.1, S184, P179, S257 Hiroshi Asano,: P197, S261 Hiroyuki Fukano,: P197, S261 Hlavaceck C., O37.2, S199 Hoch J., O18.7, S169 Hocher A., P122, S241 Hofmann A., O13.3, S160 Hollinsky C., O18.8, S170 Homfeld N., O8.4, S152 Homs E., P030, S216, P063, S225, P155, S250, P182, S257 Hope W., O2.3, S140, O24.8, S181 Hopson S., O26.4, S182 Horgan L., O37.8, S201, O4.6, S145

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S268 Horikawa M., P047, S220, P097, S234, P099, S234, P180, S257 Horton J., O37.2, S199 Hosono M., V11.2, S155 Houghton C., O21.3, S174 Housari G., P192, S260 Howe A., O26.7, S183 Hoyos L., P153, S249 Hoyuela C., O17.3, S165, P110, S237, V36.2, S196 Huang C.-C., O37.5, S200 Huang C.-S., O37.5, S200 Huang Y., P022, S213 Hubens G., P151, S249, V11.8, S157 Huntington CR., O18.5, S169 Hurd L., O3.2, S141 Hut A., O7.6, S149, P011, S210, P012, S211 Huyghe M., P042, S219 Idrees S., P019, S213 Igarashi H., P099, S234 Igarashi Y., P047, S220, P097, S234, P180, S257 Ikai I., O31.3, S191, V11.5, S156 Ilves I., O41.3, S205 Imazu H., P023, S214 Inaba T., P047, S220, P097, S234, P099, S234, P180, S257 Inbasekaran A., O16.4, S163 Ioannidis P., P081, S229 Isakovic´ E., O27.3, S184 Isemer FE., O18.4, S168 Iserte J., P016, S212, P118, 240, P173, S255, P174, S255, P175, S260, P193, S260 Iserte Hernandez J., P143, S197, P159, S251, V36.3, S246 Ismail T., O23.5, S179 Ivarsson M.-L., O21.7, S175 Izrailov., P056, S222, P114, S238 Jagoditsch M., O4.2, S144 Jahkola T., O4.5, S145 Jain B.K., O3.4, S142 Jain S., O3.3, S142 Jairam A., O26.5, S182, O29.3, S187 Jakob M., O39.1, S203 Jaksch W., O5.2, S147 Jalal I., O21.4, S175 Janczak J., V30.6, S189, V30.8, S190 Jara Quezada J., P071, S227, P072, S227, P073, S227, P074, S228 Jeekel J., O13.1, S160, O18.4, S168, O26.5, S182, O27.4, S185, O28.2, O4.8, S146 Jensen K.K., O10.6, S155, O8.3, S151, O8.5, S152 Jezupovs A., P061, S224, P098, S234 Jiang Z., O27.2, S184 Jikihara S., O31.3, S191, V11.5, S156 Jimenez R., P016, S212, P118, S240, P174, S255, P175, S255 Jime´nez C., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Jime´nez E., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Jimenez Rosellon R., P143, S246, P159, S251, V36.3, S197 Jime´nez-Valladolid D., O3.5, S142 Jitpratoom P., O27.9, S186, P025, S214, V11.4, S156 Jones B., P187, S259 Jones C., P111, S237 Jones P., O3.7, S143 Jorge Barreiro J., P071, S227, P072, S227, P073, S227, P074, S228 Jorgensen L.N., O4.9, S146, O8.3, S151, SO8.5, S152, O26.4, S182, O26.9, S183 Jovanovic S., P024, S214, P037, S218

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Hernia (2017) 21 (Suppl 2):S264–S273 Jurczak F., O26.6, S182 Juvany M., O17.3, S165, P110, S237, V36.2, S196 Kakamad F., O21.4, S175 Kallewaard J.-W., O31.1, S190 Kalogridaki E., P013, S211 Kanakaratne S., P123, S241 Kanemitsu K., V11.2, S155 Kang J., P181, S257 Kansal N., O16.8, S164 Kaplan U., P186, S258 Karvonen J., O41.3, S205 Kastiunig T., V30.6, S189, V30.8, S190 Katsaounis D., P081, S229 Kaufmann R., O18.4, S168 Kefalou E., P081, S229 Keibl C., P135, S244 Kenchadze G., P058, S223 Kercher K., O37.2, S199, O37.4, S200, O8.6, S152 Ketwong K., O27.9, S186, P025, S214, V11.4, S156 Khachatrian G., O33.6, S194 Khalil H., O26.6, S182, O41.6, S206, P161, S251, P162, S252 Kharyshyn O., P089, S232 Khullar R., P115, S239, V11.3, S156 Kilian M., O23.2, S178, O41.5, S206 Kingham P., O17.9, S167 Kingsnorth A., O28.1, S186, P192, S260 Kitagawa Y., O21.9, S176 Kiyokawa T., P047, S220, P097, S234, P099, S234, P180, S257 Klausen T.W., O3.1, S141 Kleinrensink G.-J., O27.4, S185, O4.8, S146 Knaak M., P051, S221 Kniazeva P., O20.5, S172 Kniepeiss D., O8.4, S152 Koch A., O7.3, S149 Koch O.O., O40.1, S204 Ko¨ckerling F., O2.2, S140, O7.1, S148, O7.3, S149, O9.2, S153, O15.1, S161, O29.3, S187, O40.3, S204 Kofler M., O7.1, S148 Kohl A., O20.2, S171 Ko¨hler G., O13.3, S160, P069, S226 Kokhanevych A.V., P094, S233 Kokkonen M., O41.3, S205 Komen N., V11.8, S157 Kopelman D., P186, S258 Kops N., O33.2, S193 Kotoreni G., P091, S232 Kottmann T., O8.2, S151 Kotzias C.P., P163, S252 Koudjeti R., P054, S222 Koutelidakis I., P091, S232 Kozieł S., P034, S217, P128, S242 Krarup P.-M., O8.3, S151, P026, S215 Kroese L.F., O27.4, S185, O4.8, S146 Krogsgaard M., P026, S215 Kru¨ger J., O31.5, S192 Kukleta J., O10.3, S155, O35.5, S196 Kuliev S., P027, S215, P075, S228 Kullman E., O26.4, S182 Kumar S., P050, S221 Kumar Y., P124, S241 Kumata Y., P047, S220, P097, S234, P099, S234, P180, S257 Kundu A.K., O3.4, S142 Kuthe A., O7.1, S148 Kyle-Leinhase I., O12.8, S159, O2.1, S140, O29.3, S187, O4.1, S144, O41.4, S206

Hernia (2017) 21 (Suppl 2):S264–S273 La Barbera C., O4.7, S145 La Greca G., P149, S248 Lacy A., O8.8, S153, P176, S256, V36.4, S197 Lal P., O12.9, S159, P087, S231 Lamberty C., P003, S208, P088, S231 Lambrichts D.P.V., O4.8, S146 Lammers B.J., O27.6, S185 Lange J.F., O4.8, S146, O13.1, S160, O18.4, S168, O26.5, S182, O27.4, S185, O33.2, S193, P125, S242, P129, S243 Lanza C., P020, S213, P062, S224 Lasithiotakis K., P053, S222 Laskou S., P091, S232 Latham L., P020, S213, P038, S218, P062, S224, P126, S242 Latteri S., P149, S248 Lau C., P100, S235 Leblanc K., O26.4, S182 Lechner M., O13.3, S160, O23.4, S178, O7.1, S148 Lederhuber H., O37.7, S200 Lefering R., P125, S242 Legnani G., O16.5, S163, O37.6, S200, P059, S223 Leinkram C., P116, S239 Lentini F., P005, S209 Leo´n C., O21.5, S175, P153, S249 Lepere M., O26.6, S182 Leuca D., P130, S243 Li B., O16.7, S164 Li P., P028, S215 Li Y., O27.2, S184, P195, S261 Lica M., O41.7, S207, P185, S258, V36.8, S198 Licheri S., P031, S216, P032, S216, P077, S228 Light D., O12.4, S158, O37.10, S201, O37.8, S201, O4.6, S145 Lim T.C., O31.2, S191 Lincourt A., O18.5, S169, O37.2, S199, O37.3, S199, O37.4, S200 Lindmark M.E., O4.3, S144 Lipham J.C., O21.3, S174 Liu S.-J., P009, S210 Liu Y., O20.6, S172 Livraghi L., P038, S218, P126, S242 Llaquet H., P192, S260 Lloyd D.M., O22.1, S176 Lo¨fgren M., P109, S237 Loladze D., P058, S223 Lomanto D., O28.4, S187 Loos M.J.A., O7.9, S150 Lopez M., P016, S212, P118, S240, P173, S255, P174, S255, P175, S255 Lopez R., O8.6, S152 Lo´pez J., O17.2, S165, O21.5, S175 Lo´pez P., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Lopez Cano M., O2.5, S141, O29.3, S187, P146, S247, P155, S250 Lopez-Cantarero M., P121, S240 Lopez-Monclus J., O18.3, S168, O23.3, S178, P153, S249, V11.7, S157, V36.1, S196, V36.7, S198, V36.9, S198 Lo´pez-Vizcayno M., P192, S260 Lorenz R., O15.2, S161, O24.1, S180, O31.5, S192, O7.3, S149 Lorenzova´ J., O18.7, S169 Lorusso R., O31.6, S192 Low C., P050, S221 Lo¨wenmark T., O4.3, S144 Lubrano T., V36.6, S197 Lucena J.L., O18.3, S168, O23.3, S178, P153, S249, V36.7, S198 Lukic D., O18.8, S170 Luna Vazquez L., P060, S224 Lupo M., O4.7, S145

S269 Maatman R.C., O31.1, S190, O31.2, S192, O31.4, S192 Machado T.B., P015, S212 Magishi A., V30.5, S189 Magistro C., P108, S237, V11.6, S157 Maida P., P095, S233 Ma¨kela¨ J., O41.3, S205 Maksimovic´ M.R., P029, S215 Malik DS., P127, S242 Manama´-Gama M., P145, S247 Mandala` S., O4.7, S145 Mandala` V., O4.7, S145 Manioti E., P081, S229 Marchionini V., P038, S218, P062, S224, P126, S242 Marta P., P182, S257 Martı´-Cun˜at E., P154, S249, P183, S258 Martı´-Martı´ V., P154, S249, P183, S258 Martin B., O8.8, S153, V36.4, S197 Martı´n-Cartes J.A., P064, S225, P090, S232, P165, S252, P166, S253 Martinez P., O27.1, S184, P030, S216, P179, S257, P182, S257 Martı´nez C., P006, S209, P007, S209, P008, S210 Martı´nez Lo´pez P., P155, S250 Martinez-Caballero J., P145, S247 Martı´nez-Lloret A., P154, S249, P183, S258 Martinez-Pozuelo A., P145, S247, P192, S260 Martinez-Pueyo J.I., P145, S247 Martin-Piedra M., P121, S240 Martrat A., O17.3, S165, P110, S237 Mascagni P., O20.4, S172, P172, S255 Massey L.H., O26.3, S181 Matsusue R., O31.3, S191, V11.5, S156 Maurer K., O17.1, S165 Mayer F., O13.3, S160, O23.4, S178, O7.1, S148 Mazur J., P076, S228 Mazur O., P076, S228 McKirdy M., O23.8, S179 Medas F., O20.7, S173, P001, S208 Meher S., P033, S216 Meiers N., P178, S256 Melero D., O17.2, S165, O18.3, S168, O21.5, S175, O23.3, S178, V11.7, S157, V36.1, S196, V36.9, S198 Melkemichel M., O16.1, S162 Melvin R., O23.8, S179 Menegat N., P126, S242 Meneses-Pardo J.C., P145, S247 Mercader Neto C.M., P163, S252 Merenda R., O18.1, S167 Merigliano S., O18.1, S167, O33.5, S194, P112, S238 Messina Campanella A., P031, S216, P032, S216, P077, S228 Metzger R., P088, S231 Meyer J., P125, S242 Mias M., O33.3, S194, P141, S246 Midorikawa H., P047, S220, P097, S234, P099, S234, P180, S257 Miletic R., P055, S222 Militello P., P004, S208, P040, S218, P147, S247, P160, S251 Millo P., O31.6, S192 Min˜ano C., P063, S225 Minguez Ruiz G., P072, S227, P073, S227, P074, S228 Miric S., O27.8, S186 Miserez M., O17.4, S166, O26.5, S182, O26.9, S183 Misholy O., O17.9, S167 Mishra S., P033, S216 Mishra T.S., O16.4, S163, P033, S216 Mitura K., P034, S217, P128, S242, P196, S261 Mladenovik D., P085, S231 Mo Y., O16.7, S164

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S270 Moat M., O16.8, S164 Mohta M., O3.4, S142 Molegraaf M., P129, S243 Molina E., P060, S224 Molinari E., O18.1, S167 Mommers E.H.H., O16.3, S162, O23.1, S177, O8.9, S153 Monschein M., O18.8, S170 Montcusı´ B., O26.2, S181 Montcusı´ Ventura B., O41.2, S205 Monteforte X., P135, S244 Montgomery A., O13.5, S160, O22.5, S177, O24.1, S180, O24.3, S180, O29.1, S187 Morales Conde S., O9.5, S154, O14.5, S160, O24.4, S181, O29.5, S188 Moreno A., O17.2, S165, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Moreno V., P063, S225 Morini L., P108, S237, V11.6, S157 Morino M., P086, S231, P160, S251, V36.6, S197 Moroni M.R., O3.6, S143, P004, S208, P040, S218 Morpurgo E., O18.1, S167 Morrison J., O15.5, S161 Moscato R., P086, S231 Mosconi C., O20.4, S172, P095, S233 Mourikis E., P013, S211 Mozo M., P006, S209, P007, S209 Mudawi A., O16.8, S164 Muley K., P019, S213 Mu¨ller-Stich B.P., O40.2, S204 Munegato G., O18.1, S167 Muniesa C., P016, S212, P118, S240, P174, S255, P175, S255 Muniesa Gallardo, C., P143, S246, P159, S251, V36.3, S197 Mun˜oz A., P030, S216, P182, S257 Mun˜oz, J., V36.7, S198 Mun˜oz Garcı´a, A., P155, S250 Murkin C., O17.7, S166, P111, S237 Murphy B.L., O16.9, S164 Muschaweck U., O22.2, S177 Muto G., O20.4, S172, P095, S233, P172, S255 Muysoms F., O1.2, S139, O1.3, S139, O12.8, S159, O17.4, S166, O2.1, S140, O26.4, S182, O29.3, S187, O4.1, S144, O41.4, S206 Muzi M., O26.4, S182 Nagahama T., P035, S217, P101, S235 Nanavati JD., P019, S213 Nardelli N., O31.8, S192, O31.9, S193 Nardi M., O31.6, S192 Narita M., O31.3, S191, V11.5, S156 Na¨svall P., O17.6, S166 Natali A.N., O33.5, S194, P112, S238 Navarro C., P078, S229 Navarro Moratalla C., P150, S248 Navarro-Morales L., P166, S253 Negro P., P070, S226 Nehls J., P178, S256 Nevala T., O41.3, S205 Ng C., O16.8, S164 Ng S., O16.8, S164 Ngai J., O18.2, S168 Nie X., O16.7, S164 Niemela¨inen S., O41.3, S205 Nienhuijs S.W., O8.9, S153, O16.3, S162, O23.1, S177, O26.4, S182 Nigmatov., P114, S238 Nikolovski A., P085, S231 Nogue´s M., O33.3, S194 Norrby J., O21.7, S175 Nozomi Shinozuka., P197, S261

123

Hernia (2017) 21 (Suppl 2):S264–S273 Ntaoulas S., P036, S217, P140, S246 Nu´n˜ez R., P065, S225, P078, S229 Nu´n˜ez Ronda R., P150, S248 Nussbaumer P., P036, S217, P140, S246 ¨ berg S., O21.6, S175, O3.1, S141 O Ochoa M., P006, S209, P008, S210 Odensten C., O17.6, S166 Oettinger A., O33.6, S194 Offner F., O6.1, S147 ¨ gredici O ¨ ., V30.6, S189, V30.8, S190 O Ohara Y., P197, S261 Ohtonen P., O41.3, S205 Okada H., O31.3, S191 Okura K., O31.3, S191 Olmi S., O16.5, S163, O37.6, S200, P059, S223 Olsina J.J., O33.3, S194, P141, S246 Oma E., O4.9, S146 Oono K., V30.5, S189 Oprea V.C., P130, S243 Origi M., O3.6, S143, P108, S237, V11.6, S157 ¨ sterberg J., O37.1, S199, P109, S237 O Ota´hal M., O18.7, S169 Otani T., O31.3, S191, V11.5, S156 Oviedo M., P065, S225, P078, S229, P150, S248 Ozata I.H., O7.6, S149 Ozlem N., P079, S229, P080, S229, P102, S235, P103, S236, P131, S243, P132, S243, P133, S244, P134, S244, P198, S261, P199, S262, P200, S262 ¨ zveri E., P017, S212, P018, S212, P120, S240, O V30.7, S189 Paajanen H., O22.5, S177 Pacheco C.S.S., P163, S252 Pachera P., O33.5, S194, P112, S238 Padillo-Ruiz F.J., P064, S225, P090, S232, P165, S252, P166, S253 Palencia N., O17.2, S165, O18.3, S168, O18.3, S168, O21.5, S175, V36.1, S196, V36.9, S198 Paley K., O16.9, S164 Palibrk I., O27.7, S185, O27.8, S186, O41.9, S207, P055, S222 Papadopoulos A., P013, S211, P081, S229 Papaziogas B., P091, S232 Papen-Botterhuis N.E., O31.4, S191 Paris M., P030, S216, P063, S225 Park J., O18.6, S169, P135, S244 Pascual J.A., P192, S260 Pathak S., O26.3, S181 Paul D., O8.2, S151 Pavan P.G., O33.5, S194, P112, S238 Pawlak M., O10.5, S155, O37.10, S201 Pedroso R.F.P., P015, S212 Peeters E., O26.5, S182 Pejcic V., P037, S218 Pela´ez P., P170, S254 Pen˜a Soria M.J., O3.5, S142, P171, S254 Pereira J., O26.2, S181, O41.2, S205 Pereira Rodriguez J., O2.5, S141 Pe´rez J., P148, S248, P168, S253 Pe´rez Contin M.J., P171, S254 Pe´rez Farre´ S., O41.2, S205 Pe´rez Jime´nez A., O3.5, S142, P171, S254 Pe´rez-Farre´ S., O26.2, S181 Peristerakis I., O26.7, S183 Persico F., O31.6, S192 Perunicic V., O31.7, S192, P092, S233, P169, S254 Petersson U., O39.2, S203 Petrakis I., P053, S222 Petrella G., O20.4, S172, P172, S255

Hernia (2017) 21 (Suppl 2):S264–S273 Petter-Puchner A., O6.5, S148, O18.6, S169, P122, S241, P135, S244 Peverelli C., P020, S213, P038, S218, P062, S224, P126, S242 Pilsgaard B., O4.9, S146, P026, S215 Pin˜ana M., P030, S216 Pinna E., P031, S216 Pino-Dı´az V., P165, S252 Pinta T., O41.3, S205 Pinto J., V36.5, S197 Pinworasarn T., O39.1, S203 Pipia I., P058, S223 Pisanu A., P031, S216, P032, S216, P077, S228 Pisarenco S., P156, S250 Plath A., O23.2, S178, O41.5, S206 Platto M., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Plencner M., O18.7, S169 Podda F., P001, S208 Podda M., P032, S216, P077, S228 Poelman M., O4.4, S145 Poillucci G., P031, S216, P032, S216, P077, S228 Polivoda M., O33.6, S194 Ponten J.E.H., O23.1, S177 Poulose B.K., O2.3, S140 Pozza G., P010, S210, P082, S230 Prasad A., O12.6, S158 Prasad T., O8.1, S151, O18.5, S169, O37.3, S199 Pratschke J., O23.2, S178, O41.5, S206 Premnath R., P157, S250 Puche J., P065, S225, P078, S229 Puche Pla‘ J., P150, S248 Pueyo A., O23.3, S178, V36.7, S198 Pueyo-Rabanal A., P153, S249 Qin C., O3.9, S143, O20.3, S172, O26.8, S183, P039, S218, P045, S220, P184, S258 Quintodei V., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Raakow J., O23.2, S178, O41.5, S206 Radu A., O41.7, S207 Radu V., O41.7, S207, P185, S258, V36.8, S198 Radzikhovskiy A., P083, S230 Raga E., P030, S216, P063, S225, P182, S257 Raible R., O8.6, S152 Rajaretnam N., O7.5, S149 Rajesh Thamaran N., P136, S245 Ramaswamy A., O12.8, S159 Ramon Y., O27.5, S185, P158, S251 Ramos Perez V., P072, S227, P074, S228 Rampado S., P010, S210, P082, S230 Rampichova´ M., O18.7, S169 Ramuscello S., O18.1, S167 Randazzo V., P149, S248 Rapoport A., P041, S219 Rapti N., P081, S229 Rath S., P033, S216 Rauff A., P100, S235 Rautio T., O41.3, S205 Raveglia V., P038, S218 Razzi S., O31.6, S192 Rebonato M., O18.1, S167 Redl H., O18.6, S169, P135, S244 Reggio S., V30.9, S190 Reinisch A., P051, S221 Reinpold W., O5.4, S147, O7.1, S148, O35.1, S195, O41.8, S207, P178, S256 Revuelta B., P192, S260 Ribal M., O8.8, S153, V36.4, S197

S271 Ribas S., V36.5, S197 Ribeiro Jr M.A.F., P015, S212 Ribeiro Jr U., O12.5, S158 Ricci F., O18.1, S167 Richardson J., O23.5, S179 Rieger A., P125, S242 Ripamonti M., P038, S218 Ristagno M., P005, S209 Rivas-Duarte C., P145, S247 Rivera S.E., P002, S208 ´ ., O17.2, S165, O18.3, S168, O21.5, S175, Robin A O23.3, S178, V11.7, S157, V36.1, S196, V36.9, S198 Robledo J., P006, S209, P007, S209, P008, S210 Robres J., P148, S248, P168, S253 Roca J., O33.3, S194 Rodriguez Infante A., P071, S227, P072, S227, P073, S227, P074, S228 Ro¨hr S., P003, S208, P088, S231 Rojas P.M., P002, S208 Rojo Abecia M., O3.5, S142 Roldan Cuena M., P071, S227 Roman-Garcia L., P153, S249 Romano G., O20.7, S173, P001, S208 Romano M., P138, S245, P201, S262 Romanowski C., O3.7, S143 Romanzi A., P062, S224 Romera Martinez J.L., O3.5, S142, P171, S254 Rona K.A., O21.3, S174 Roos M., O16.2, S162, O20.1, S171 Rooshenas L., O17.7, S166, P111, S237 Rosa O.M., P015, S212 Ro¨sch C.S., O20.8, S173 Rosen M.J., O2.3, S140 Rosenberg J., O20.2, S171, O21.6, S175, O3.1, S141, O7.2, S148 Roumen R.M.H., O7.9, S150, O31.1, S190, O31.2, S191, O31.4, S191 Rout B., P033, S216 Ruı´z J., P006, S209, P007, S209, P008, S210 Ruiz Jasbon F., O21.7, S175 Ruppert M., V11.8, S157 Russello D., P149, S248 Rutega°rd J., O17.6, S166 Ruyssers N., P042, S219 Ryousuke Uji., P197, S261 Saba A., P031, S216 Sabench F., P030, S216, P063, S225, P182, S257 Saji M., O31.3, S191 Salih M., O21.4, S175 Salvatorelli A., P117, S239 Sambucci D., P020, S212, P038, S218, P062, S224 San Miguel C., O17.2, S165, O18.3, S168, O21.5, S175, V11.7, S157, V36.1, S196, V36.9, S198 Sanchez A., P030, S216, P063, S225, P182, S257 Sanchez-Turrion V., O23.3, S178, P153, S249 Sancho J., O26.2, S181, P016, S212, P118, S240, P173, S255, P174, S255, P175, S255 Sandblom G., O17.8, S167, O37.1, S199, P109, S237 Sanders D.L., O6.4, S147, O20.9, S173 Sanglard P.A., P163, S252 Santiago M.C., P192, S260 Santilli H., O31.8, S192, O31.9, S193 Santilli O., O31.8, S192, O31.9, S193 Santo M.A., O12.7, S159 Saori Yajima., P197, S261 Sarangi R., P019, S213 Sarwary H., O18.2, S168 Sasmal P.K., P033, S216 Scaravilli F., P149, S248

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S272 Sˇcˇepanovic´ M., O27.3, S184 Scheltinga M.R.M., O7.9, S150, O31.1, S190, O31.2, S191, O31.4, S191 Schemmer P., O8.4, S152 Schneider F., O40.4, S204 Scho¨nau C., P122, S241 Schoofs C., O41.4, S206 Schreurs H., O4.4, S145 Schrittwieser R., O4.2, S144 Schro¨der J., O31.5, S192 Schro¨der M., O41.8, S207, P178, S256 Schu¨tze F., P088, S231 Schwab R., O39.5, S203 Schwartz M., O26.4, S182 Schwarz J., O35.2, S195 Schwarz L., O41.6, S206, P161, S251, P162, S252 Scotto B., O16.5, S163, O37.6, S200, P059, S223 Seefeldt S., P125, S242 Seidel D., P125, S242 Senent-Boza A., P064, S225, P165, S252, P166, S253 Sengstbratl M., O20.8, S173 Serra P., P031, S216 Serra Lorenzo R., P071, S227, P072, S227, P073, S227, P074, S228 Serrano J., V36.7, S198 Sharma A., O19.1, S170, P115, S239, V11.3, S156 Sharma N., O16.4, S163, O3.3, S142, O3.4, S142 Sharma R., P033, S216 Shavarov I., P021, S213, P044, S219 Sheen A., O22.5, S177 Shen., P184, S258 Shen Y.-M., P009, S210 Shen Y., O16.6, S163, O20.3, S172, O26.8, S183, O3.9, S143, O7.8, S150, P045, S220, P137, S245 Shingo Morioka., P197, S261 Shiwani M.H., P046, S220 Shpoliansky G., P186, S258 Shusterman E., O27.5, S185 Sibert L., P161, S251 Sibinga Mulder L., O20.1, S171 Sileri P., P095, S233 Simon T., O22.5, S177 Simons M.P., O38.4, S202 Sing R., O37.4, S200 Singh K., O17.9, S167 Sinyakin., P056, S222 Skarpas A., P084, S230, P104, S236 Skipworth R.J.E., P050, S221 Slade D., O26.7, S183 Smart N.J., O17.7, S166, O26.3, S181, P111, S237 Smietanski M., O26.9, S183, O29.3, S187 Smishchuk V.V., P068, S226 Smith J., P187, S259 Snidero D., O18.1, S167 Soares A., P138, S245, P188, S259, P201, S262 So¨derba¨ck H., P109, S237 Soeda N., P047, S220, P097, S234, P099, S234, P180, S257 Sofia S., P086, S231 Soler M., O7.4, S149, O7.7, S150, O18.9, S170, O21.8, S176, P139, S245, P202, S262, V30.2, S188 Solimene F., P036, S217, P140, S246 Solomonov E., P041, S219 Soni V., P115, S239, V11.3, S156 Sorge A., O20.4, S172, P095, S233, P172, S255 Soriero D., V30.4, S189 Sorrentino M., O18.1, S167 Sorrentino P., O18.1, S167 Sousa M., V36.5, S197 Souza D.B.F., P015, S212

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Hernia (2017) 21 (Suppl 2):S264–S273 Sow Z., O18.8, S170 Spampatti S., V30.6, S189, V30.8, S190 Sparreboom C.L., O33.2, S193 Speiser M., O23.4, S178 Spermon R.J., O20.1, S171 Stabilini C., V30.4, S189 Stadelmeier P., O20.5, S172 Stasyshyn A., P203, S263 Stavridis G., P085, S231 Stechemesser, B., O7.1, S148 Steegers M.A.H., O31.1, S190, O31.2, S191 Stifini D., P117, S239 Stocker B., P122, S241 Stockinger R., O6.1, S147 Stoltenberg W., P178, S256 Stoot J., O4.4, S145 Streng M., O41.3, S205 Strigard K., O17.6, S166, O4.3, S144 Stuppia G., P020, S213 Suarez Gra´u J., O23.6, S179, P113, S238, P164, S252, V30.3, S188 Sucupira D.C., P163, S252 Sugihara T., V30.5, S189 Sunamak O., O7.6, S149, P011, S210, P012, S211 Sutedja B., O19.3, S170 Suzuki Y., P047, S220, P097, S234, P099, S234, P180, S257 Taboada N., P170, S254 Tahir S., P085, S231 Talbot M.L., P123, S241 Tale L.F., P002, S208 Taliente F., P172, S255 Tamayo-Lo´pez M.J., P165, S252 Takagi M., P197, S261 Tay W., P100, S235 Teixeira J., P188, S259 Tejada Gomez A., O23.6, S179 Tetsuyoshi Takayama., P197, S261 Teuschl A., O18.6, S169, P135, S244 Thilakanathan C., P123, S241 Thoolen J.M.M., O8.9, S153 Ticehurts K., O21.7, S175 Titkova S., O33.6, S194 Tivenius M., O17.8, S167 Todros S., O33.5, S194, P112, S238 Tollens T., O26.4, S182 Tomaino G., O3.8, S143, O8.7, S153 Tornese D., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Torregrosa A., P016, S212, P118, S240, P159, S251, P173, S255, P174, S255, P175, S255, P193, S260, V36.3, S197 Torres Garcı´a A.J., O3.5, S142. P171, S254 Torrico-Folgado M., P154, S249, P183, S258 Torroella A., P176, S256 Toyokawa A., V11.2, S155 Trabanco S., P192, S260 Tran S., P123, S241 Trias M., O17.3, P110, S237, V36.2, S196 Tripoloni D., O31.9, S193 Trombatore G., P149, S248 Trombetta F., P086, S231 Tsuchida S., V11.2, S155 Tsukahara D., P047, S220, P097, S234, P099, S234, P180, S257 Tuech J.-J., O41.6, S206, P161, S251, P162, S252 Tulloh B., O12.4, S158, P050, S221 Tyagi A., O3.3, S142 Tzamourani C., P013, S211

Hernia (2017) 21 (Suppl 2):S264–S273 Ubl DS., O16.9, S164 Uccelli M., O16.5, S163, O37.6, S200, P059, S223 Udomsawaengsup S., O19.8, S171 Uematsu D., V30.5, S189 Ueno N., V11.2, S155 Ulrich S., O17.9, S167 Unger L., O23.7, S179 Usai A., O31.6, S192 Usurelu S., P138, S245, P188, S259, P201, S262 Utomo L., O33.2, S193 Uzman S., O7.6, S149, P011, S210 Valderas G., P065, S225 Valderrabano S., O27.1, S184, P179, S257 Valencia L., P138, S245, P201, S262 Van Cleven S., O12.8, S159 van de Water C., O20.1, S171 van den Berg H.J., O31.2, S191 Van den Broeck S., V11.8, S157 Van den Heuvel B., O4.4, S145 van den Heuvel S.A.S., O31.2, S191 van Eeghem L.H.A., O27.4, S185 van Eerten P.V., O31.2, S191 Van Veenendaal N., O38.4, S202, O4.4, S145 Vasco M., P148, S248, P168, S253 Vasnev., P114, S238 Vasta F., P149, S248 Vatamaniuk V.F., P068, S226, P094, S233 Va´zquez A., P065, S225, P078, S229, P150, S248 Velanovich V., O26.4, S182 Venclauskas L., O17.4, S166 Venianaki M., P053, S222 Venkatraman S., P048, S220, P105, S236 Vento P., O41.3, S205 Verdiyeva G., P136, S245 Verhagen T., O7.9, S150 Verhelst J., O27.4, S185 Verleisdonk E.-J.M.M., O16.2, S162 Veronesi P., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Veselinovic Z., P029, S215 Videla J., O31.8, S192 Vieiro V., P145, S247 Vijayan D., O23.5, S179 Vijitpornkul S., V11.4, S156 Villa R., O16.5, S163, O37.6, S 200, P059, S223 Villalobos R., O33.3, S194, P141, S246 Vindal A., O12.9, S159, P087, S231 Vironen J., O4.5, S145, O41.3, S205 Vives M., P030, S216, P063, S225, P182, S257 Vlasov V., P089, S232 Voloudakis N., P091, S232 Wada N., O21.9, S176 Waha J.E., O8.4, S152 Wakahara T., V11.2, S155 Waksman I., P041, S219 Wallin A.C., O37.1, S199 Walters A., O37.4, S200

S273 Walz M.K., O20.5, S172 Wandee W., V11.4, S156 Wang B., P045, S220 Wang F., P009, S210 Wang M., O20.6, S172 Wang P., P022, S213 Wang X., P049, S221 Ward J., O41.3, S205 Webber V.L., P050, S221 Wegdam J.A., O16.3, S162, O8.9, S153 Weltz A., O34.3, S194 White D., O18.5, S169 Widhe B., O16.1, S162 Wilke R.M., O12.3, S158, O21.2, S174 Willms A., O39.5, S203 Woeste G., O18.4, S168, O29.3, S187, P051, S221 Wouters L., O7.9, S160 Wright D., O3.2, S141 Wright R.C., O3.2, S141 Wu H., P022, S213 Wu L., P052, S221, P190, S259, P204, S263 Wundsam H., O13.3, S160, P069, S226 Xenaki S., P053, S222 Yaguchi Y., P047, S220, P097, S234, P099, S234, P180, S257 Yagu¨e N., P170, S254 Yamaguchi T., O31.3, S191, V11.5, S156 Yang C., P107, S236 Yang H., P142, S246, P191, S259 Yang S., O16.6, S163, O3.9, S143, O7.8, S150, P137, S245 Yarhi D., P158, S251 Ye J., P022, S213 Yildirim D., O7.6, S149, P011, S210, P012, S211 Yoshie Hosoi., P197, S261 Yoshikawa T., V11.2, S155 Yu A., O21.3, S174 Yuuki Kanno., P197, S261 Yuusuke Fusejima., P197, S261 Zani B., O18.1, S167 Zaranis C., O26.6, S182 Zarev I., P029, S215 Zatir S., P054, S222 Zehetner J., O21.3, S174 Zhang F., P022, S213 Zhang J., O16.9, S164 Zhou T., O27.2, S184 Zhu Y., O20.6, S172 Zielska Z., O17.1, S165 Zingales F., P010, S210, P082, S230 Zorzetto G., P062, S224 Zugrav T., P156, S250 Zuliani W., O3.6, S143, P004, S208, P040, S218, P147, S247, P160, S251 Zuvela M., O27.7, S185, O27.8, S186, O41.9, S207, P055, S222 Zwaans W.A.R., O7.9, S150

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