OC-010 RESULTS OF PREHABILITATION IN PATIENTS WITH COMPLEX ABDOMINAL WALL DEFECTS

Aim

Complex abdominal wall reconstruction (CAWR) remains challenging, even in expert centers. Complication rates are still high, especially in patients with modifiable risk factors (MRF) like obesity, smoking, or diabetes. For several surgical trajectories, prehabilitation of MRF has shown to reduce complication rate. The purpose of this study was to determine the effect of prehabilitation in high risk MRF patients undergoing CAWR on convalescence.

Materials and Methods

A retrospective cohort study was performed in an expert hernia center. All patients undergoing complex abdominal wall defect reconstruction (hernia width beyond 10 cm, contaminated surgical field or relevant comorbidities) between 2015 and 2019 were included. Each patient was discussed in a multidisciplinary meeting, after which those referred for prehabilitation were compared to those with direct approval. Focus of a supervised preconditioning program could be weight loss, smoking cessation, physical training or a combination.

Results

From 418 patients discussed, 259 patients underwent CAWR and were included for analysis, of which 126 (49%) underwent prehabilitation. Hernia and intra-operative characteristics were comparable. BMI (28vs30, p<0.001), HbA1c (41vs48, p=0.014), active smokers (4%vs25%, p<0.001) and risk factors (14%vs48%, p<0.001) were higher in the latter group. After prehabilitation, characteristics were comparable. There were no significant differences in postoperative outcome measures (hospital stay 6[5–8]vs6[5–8] days, p=0.908, complication rate 39%vs33%, p=0.190).

Conclusions

Prehabilitation of modifiable risk factors is profitable in patients planned for CAWR. Subsequent postoperative results were comparable to those without or with less risk factors: prehabilitation downgrades high risk patients to low risk patients. Prospective research is advised.

European Hernia Society guidelines on management of rectus diastasis

BACKGROUND

The definition, classification and management of rectus diastasis (RD) are controversial in the literature and a variety of different surgical treatments have been described. This article reports on the European Hernia Society (EHS) Clinical Practice Guideline for RD.

METHOD

The Guideline group consisted of eight surgeons. The Grading of Recommendation, Assessment, Development and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument were used. A systematic literature search was done in November 2018 and updated in November 2019 and October 2020. Nine Key Questions (KQs) were formulated.

RESULTS

Literature reporting on the definition, classification, symptoms, outcomes and treatments was limited in quality, leading to weak recommendations for the majority of the KQs. The main recommendation is to define RD as a separation between rectus muscles wider than 2 cm. A new classification system is suggested based on the width of muscle separation, postpregnancy status and whether or not there is a concomitant hernia. Impaired body image and core instability appear to be the most relevant symptoms. Physiotherapy may be considered before surgical management. It is suggested to use linea alba plication in patients without concomitant hernia and a mesh-based repair of RD with concomitant midline hernias.

CONCLUSION

RD should be defined as a separation of rectus muscles wider than 2 cm and a new classification system is suggested.

Open ventral hernia repair with a composite ventral patch - final results of a multicenter prospective study

Background

This study assessed clinical outcomes, including safety and recurrence, from the two-year follow-up of patients who underwent open ventral primary hernia repair with the use of the Parietex™ Composite Ventral Patch (PCO-VP).

Methods

A prospective single-arm, multicenter study of 126 patients undergoing open ventral hernia repair for umbilical and epigastric hernias with the PCO-VP was performed.

Results

One hundred twenty-six subjects (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 subjects completed the two-year study. Cumulative hernia recurrence was 3.0% (3/101; 95%CI: 0.0–6.3%) within 24 months. Median Numeric Rating Scale pain scores improved from 2 [0–10] at baseline to 0 [0–3] at 1 month (P < 0.001) and remained low at 24 months 0 [0–6] (P < 0.001). 99% (102/103) of the patients were satisfied with their repair at 24 months postoperative.

Conclusions

The use of PCO-VP to repair primary umbilical and epigastric defects yielded a low recurrence rate, low postoperative and chronic pain, and high satisfaction ratings, confirming that PCO-VP is effective for small ventral hernia repair in the two-year term after implantation.

Trial registration

The study was registered publically at clinicaltrials.gov (NCT01848184 registered May 7, 2013).

Randomized clinical trial comparing self-gripping mesh with suture fixation of lightweight polypropylene mesh in open inguinal hernia repair

BACKGROUND

Postoperative pain is an important adverse event following inguinal hernia repair. The aim of this trial was to compare postoperative pain within the first 3 months and 1 year after surgery in patients undergoing open mesh inguinal hernia repair using either a self-gripping lightweight polyester mesh or a polypropylene lightweight mesh fixed with sutures.

METHODS

Adult men undergoing Lichtenstein repair for primary inguinal hernia were randomized to ProGrip™ self-gripping mesh or standard sutured lightweight polypropylene mesh.

RESULTS

In total 557 men were included in the final analysis (self-gripping mesh 270, sutured mesh 287). Early postoperative pain scores were lower with self-gripping mesh than with sutured lightweight mesh: mean visual analogue pain score relative to baseline +1·3 and +8·6 respectively at discharge (P = 0·033), and mean surgical pain scale score relative to baseline +4·2 and +9·7 respectively on day 7 (P = 0·027). There was no significant difference in mid-term (1 month) and long-term (3 months and 1 year) pain scores between the groups. Surgery was significantly quicker with self-gripping mesh (mean difference 7·6 min; P < 0·001). There were no significant differences in reported mesh handling, analgesic consumption, other wound complications, patient satisfaction or hernia recurrence between the groups.

CONCLUSION

Self-gripping mesh for open inguinal hernia repair was well tolerated and reduced early postoperative pain (within the first week), without increasing the risk of early recurrence. It did not reduce chronic pain.

REGISTRATION NUMBER

NCT00827944 (http://www.clinicaltrials.gov).

Secondary healing versus midline closure and modified Bascom natal cleft lift for pilonidal sinus disease

BACKGROUND AND AIMS

Pilonidal sinus disease is a common disease in young employed male adults. Ongoing discomfort usually indicates an operative intervention. The main drawback is however the complication of wound healing. Numerous techniques for surgical treatment have been proposed, which underlies the lack of a superior technique.

MATERIAL AND METHODS

A retrospective study was performed on the medical notes of 62 patients operated for a pilonidal sinus between May 2005 and December 2006. Used techniques were: 'modified Bascom procedure', 'excision and primary closure' and 'excision with secondary wound healing'. Patients' characteristics, operative parameters and data on outcome were included. The primary endpoint was wound healing.

RESULTS

Twenty-five patients underwent the modified Bascom procedure, 19 underwent surgical excision with primary midline closure and 18 underwent surgical excision with secondary wound healing. There were no demographical differences between the groups of patients. The modified Bascom technique showed a significantly reduced wound healing time (29 days) compared to primary closure (52 days, p < 0.01) and secondary healing (62 days, p < 0.01). The duration of this modified procedure was significantly longer (49, 33 and 24 minutes respectively, p < 0.01).

CONCLUSIONS

Wound healing remains an important problem in the surgical treatment of pilonidal disease. Significant faster convalescence can be achieved using the modified Bascom procedure. Wide local excision as primary therapy should not be advocated.

Fluorodeoxyglucose-positron emission tomography and sentinel lymph node biopsy in staging primary cutaneous melanoma

AIM

We report the value of sentinel lymph node (SLN) biopsy and fluorodeoxyglucose-positron emission tomography (FDG-PET) in relation to SLN biopsy in staging primary cutaneous melanoma.

METHODS

Fifty-five patients with primary cutaneous melanoma >1.0 mm. Breslow thickness and no palpable regional lymph nodes underwent a FDG-PET scan before SLN biopsy.

RESULTS

SLN's were retrieved in 53 patients. Melanoma metastases were found in the SLN of 13 patients. FDG-PET detected the lymph node metastases in two of the 13 patients with SLN metastases. In five patients FDG accumulation was recorded in a regional lymph node basin, while no tumour positive SLN was found. In eight patients FDG-PET showed increased activity at a site of possible distant metastasis. Metastatic disease was confirmed in one patient. No explanation for the positive FDG-PET result could be found in five cases.

CONCLUSION

FDG-PET should not be considered in this group. SLN biopsy reveals regional metastases that are too small to be detected by FDG-PET. The prevalence of distant metastases is too small to justify routine use of FDG-PET.