key: cord-0072670-q5d6l8bv
authors: Lederhuber, Hans; Croix, Hanna de la; Dahlstrand, Ursula
title: O33 TREATMENT OF INCARCERATED GROIN HERNIA - EMERGING EVIDENCE BASED ON THE SWEDISH HERNIA REGISTER
date: 2021-11-25
journal: Br J Surg
DOI: 10.1093/bjs/znab396.032
sha: 5c284417308f50c030fda5e0041bccb31b3ac07b
doc_id: 72670
cord_uid: q5d6l8bv

AIM: The evidence base for statements about risk factors, morbidity and mortality for emergency hernia repair is mostly low quality. The aim of this study is to elucidate risk factors for the development of incarcerated hernia and outcome after adult emergency hernia repair using data from the Swedish Hernia Register (SHR). MATERIAL AND METHODS: Data in this observational study were extracted from the SHR. It included registered cases between January 1, 2009 and December 31, 2019. Maximal follow-up was until December 31, 2020. Demographic data were analysed descriptively, risk analyses were performed using multivariate- and Cox-regression models. RESULTS: A total of 164.844 cases could be included after application of the in- and exclusion criteria. Women [odds ratio (OR) 1.42 99%CI 1.32–1.51], patients with lateral hernia [OR 1.54, 99%CI 1.47–1.61], femoral hernia [OR 14.63, 99%CI 13.32–16.06] and hernia recurrence [OR 2.46, 99%CI 2.33–2.60] were at higher risk of developing an incarcerated hernia. The highest strangulation risk was seen among women [OR 2.36, 99%CI 1.91–2.90], femoral hernia [OR 7.00, 99%CI 5.40–9.11] and recurrent hernia [1.90, 99%CI 1.54–2.33]. Patients with hernia incarceration or strangulation suffer significantly more frequent from postoperative complications [16.7% and 40.9% respectively, both p < 0.001]. CONCLUSIONS: The data demonstrate that certain risks groups exist, which are prone to suffer from hernia incarceration and strangulation. These at risk patients should be prioritized, especially during the reorganisation of services to cope with the massive surgical backlog in the aftermath of the COVID-19 pandemic.

Aim: High level evidence recommends the use of mesh for umbilical hernias with defects >1 cm to reduce recurrence rates without increasing the risk of postoperative complications. For umbilical hernias with defect width 1 cm, the literature is sparse. The aim of the study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width <1 cm on a nationwide basis, and to evaluate outcomes after onlay mesh repair specifically. Material and Methods: By merging data from the Danish Hernia Database and the National Patients Registry from January 2007 until December 2018, patients receiving elective repair of an umbilical hernia with defect width 1 cm were identified. Available data included details about comorbidity, surgical technique, 90-days readmission, 90days reoperation and reoperation for recurrence. Results: A total of 7,849 patients were included, of whom 25.7% (2,013/ 7,849) underwent mesh repair. The cumulative 5-year incidence of reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1-4.1) compared with suture repair 6.7% (95% C.I. 6.0-7.4), P < 0.001. Onlay mesh repairs had the lowest cumulative risk of recurrence at 5 years 2.0% (95% C.I. 0.6-3.5). For onlay mesh repairs, readmission 7.9%, (65/826)) and reoperation (3.9% (32/826)) rates within 90-days were comparable to suture repairs (6.5% (381/5,836) and 3.3% (192/5,836) , P ¼ 0.149 and P ¼ 0.382, respectively. Conclusions: Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with the lowest risk of recurrence without increasing early complications.

Patrik Kjä rsgå rd Pettersson 1 , Ulf Petersson 2 1 Lund University, Department of Surgery, Skå ne University Hospital, Rå å , Sweden, 2 Lund University, Department of Surgery, Skå ne University Hospital, Malmö, Sö dra Sandby, Sweden Aim: In 2014 fascial dehiscence (FD) was treated with re-suturing the fascia as the only measure in half of the cases at our institution, with discouraging re-rupture and incisional hernia (IH) rates. A changing path away from fascia closure (FC) by re-suturing solely towards reinforcement of the closed fascia is now evaluated. Material and Methods: Retrospective chart review of consecutive patients operated for FD 2016-2020. Available CT scans were scrutinized for IH. Results: 58 patients (14 women) with a mean age of 71 years and a mean BMI of 27.3 were treated with: FC by re-suturing as the only measure (n ¼ 1, 1.7%); FC preceded by a reinforced tension line (RTL) suture (n ¼ 9, 15.5%); FC and on-lay mesh reinforcement (n ¼ 23, 39.7%); retromuscular mesh closure (n ¼ 10, 17.2%); open abdomen treatment with retromuscular mesh reconstruction (n ¼ 1, 1.7%); and, open abdomen treatment with vacuum assisted wound closure and permanent on-lay mesh-mediated fascial traction (VAWCPOM) (n ¼ 14, 24.1%). One patient in the RTL-group suffered a re-rupture (1.7%). The in-hospital mortality was 5%. Wound healing problems were seen in 29 (51.9%) patients. IH was evaluable in 49 patients with a total incidence of 22.4% at mean follow-up of 21 months. The hernia incidence for mesh reinforced or reconstructed patients was 17.5% compared to 44.4% in resutured or RTL patients. Conclusions: FD treatment with mesh reinforced FC prevented rerupture and resulted in a lower rate of IH. Additional standardization and refining the mesh techniques may further improve results. Conclusions: The data demonstrate that certain risks groups exist, which are prone to suffer from hernia incarceration and strangulation. These at risk patients should be prioritized, especially during the reorganisation of services to cope with the massive surgical backlog in the aftermath of the COVID-19 pandemic. Aim: Traditional approaches to ventral hernia repair involve implantation of synthetic mesh (SM), primary suture (PS) repair, and the use of biologic prostheses (BP). A body mass index (BMI) > 30 increases recurrence rates and complications for such repairs. We have begun to use Autologous Fenestrated Cutis Grafts (CG) as an alternative hernia repair. We investigated the impact of obesity on the recurrence and complication rates of CG compared to traditional repairs. Material and Methods: A five-surgeon, retrospective study included all ventral/incisional, epigastric and umbilical hernia repairs (SM, PS, and BP from 2015-2020; CG repairs from 2018-2020). Patients with a BMI 30 were stratified according to surgical approach. Outcomes included recurrence and complication rates. Descriptive statistics for demographics and outcomes were compared and logistic regression performed with p < 0.05 considered significant. Results: A total of 301 hernia repairs were performed (173 CGs, 54 SM, 59 PS, 15 BS). The groups had similar recurrence rates. A significant difference in complications rates did exist (37% CGs, 48.1% SMs, 15.3% PS, 66.7% BP, p < 0.001). Logistic regression revealed PS had fewer total complications than all other repairs. Compared to SM, CG had fewer seromas. Compared to BP, CG had fewer wound infections, systemic infections, renal complications, and additional procedures. Conclusions: CG for abdominal wall hernia repair in patients with BMI 30 is an acceptable hernia repair in obese patients with similar recurrence rates and an acceptable complication profile compared to traditional repairs. Aim: Acutely symptomatic abdominal wall and groin hernias (ASH) are a common reason for acute surgical admissions in the UK. There is limited data to guide the treatment of such presentations. This study aimed to assess outcomes of emergency hernia surgery, and identify common management strategies, to improve care for these high-risk patients. Material and Methods: A 12 week, UK-based, multi-centre, collaborative, prospective cohort study (NCT04197271) recruited adults with ASH. Data on patient characteristics, inpatient management, quality of life, complications and wound healing was collected. 30 and 90-day follow-up phone calls assessed complications and quality of life. Descriptive analyses were performed to describe population and outcomes. Results: Twenty-three acute Trusts recruited 268 patients. Inguinal (37.7%) and umbilical (37.7%) were the most common hernia locations. 13.4% were awaiting elective surgery and 13.1% had been previously declined intervention. CT was performed in 48%. 82% underwent surgical management with open repair (94%) under general anaesthesia (93%) being most common. 4/11 laparoscopic procedures were converted to open. 55% of repairs used mesh, typically synthetic nonabsorbable (87%). Complications were infrequent with surgical site infection (9.4%), delirium (3.2%) and pneumonia (2.3%) being most common. Mortality was 1.5%. Immediate surgical management was associated with significant improvement in quality of life at 30 days. Conclusions: There is variation in the investigation, management and surgical strategy to treat acutely symptomatic abdominal wall and groin hernias in the UK. Further large-scale work is needed to establish the optimal management strategy for specific acute presentations given the wide variation at present.

LOD (LOSS-OF-DOMAIN) HERNIA TREATMENT WITH INTRAOPERATIVE FASCIA TRACTION. DOES THIS TECHNIQUE MAKE RELEASE OPERATIONS SUPERFLUOUS?

Germany, 4 Clinic for General, Visceral and Thoracic Surgery, Protestant Hospital, Hamm, Germany, 5 Clinic for General, Visceral, Vascular and Endocrine Surgery

10 Department of Surgery, Division of General Surgery

Aim: Measurable and controlled stretching of the fascia for 30 minutes during surgery to achieve primary tension-free abdominal wall closure in LOD hernias. This prospective observational study aimed to clarify the extent to which this traction method can function as an alternative to component separation methods. Material and Methods: We have already applied this technique in > 50 procedures of LOD hernias. We published the data of first 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. The average patient age was 58 years with a gender ratio of 2.5 males: 1 female. ASA scores were III in 66.7% and II in 33.3%. The body mass index (BMI) averaged 32.5 kg/m2. Thirteen patients were treated with BTA 4 weeks before surgery. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect (r ¼ 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusions: This method allows primary closure of complex LOD hernias and is potentially less prone to complications than component separation methods.