ABSTRACTS

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1. PREPERITONEAL eTEP
   Author(s): Hector Valenzuela
   Hospital Angeles del Carmen, Guadalajara, México

Background: The eTEP Rives-Stoppa and TAPP techniques are proven minimally invasive resources for the treatment of ventral midline and off-midline hernias that have shown to be solid, durable, and reproducible repairs. The Preperitoneal eTEP repair is a surgical technique that combines the extraperitoneal access of eTEP Rives-Stoppa with a preperitoneal repair of TAPP, avoiding posterior rectus sheath division and use of the retrorectus space for primary small midline hernias while staying extraperitoneal. This article aims to share the initial experience using the Preperitoneal eTEP approach. Material and Methods: The analysis included 16 patients operated with the eTEPP approach from September 2022 to February 2023 in patients with primary small (< 4 cm) midline hernias, single or multiple defects with or without rectus muscle diastasis.

Age, gender, hernia characteristics, operative time, and surgical site occurrences will be discussed, as well as fine details and landmarks in the operative technique. Results: 16 consecutive patients were operated on, nine female (57%) y males 7 (43%) between 32 and 63 years of age, the most common comorbidity found was obesity (BMI>30). In 70% of the cases, operative time was 90 min +/- 25 min. The average hospital stay was one day, while some went home the same day, and so far, no reoccurrences have been reported. Conclusions: We believe the Preperitoneal eTEP approach for small primary midline hernias is an effective and solid repair that combines excellent features of proven surgical techniques and eliminates the need for posterior rectus sheath division while saving the retrorectus space, amongst other benefits that will be discussed. The reproducibility of the technique remains to be proven.

 

2. URETER IMPLICATION IN INGUINAL HERNIAS: A TRICK FEATURE ABOUT TWO CASES.
   Authors: Pablo C Arteaga Asensio, Jenny Guevara Martinez, Eduardo Gutierrez Iscar, Camilo Zapata Syro, Fuad Samir Lopez, Constantino Fondevila Campo, Sergio Salido Fernandez
   Hospital Universitario La Paz, Madrid, Spain

INTRODUCTION:

Inguinal hernias are one of the most frequent surgical procedures performed by general surgeons. Given its incidence, it becomes crucial to be familiar with unusual anomalies, such as ureteral involvement. Within existing literature, ureter engagement is a cause of urological symptoms, such as hematuria, dysuria, and potentially even pyelonephritis. Risk factors linked to these specific hernias include obesity, male gender, history of kidney transplants, and collagen-related disorders.

RESULTS:

We present two cases managed at La Paz University Hospital Abdominal Wall unit. These cases involve two male individuals aged 77 and 82 years, who presented with symptoms suggestive of inguinal hernia. Both cases were diagnosed with inguinoescrotal hernias and denied any urological symptoms. In both scenarios, abdominal computed tomography (CT) scans were conducted. For the 77-year-old patient, the CT imaging revealed a right-sided inguinoscrotal hernia with inclusion of the ureter within the hernia sac. The CT scan performed on the 82-year-old patient showed a left-sided inguinoscrotal hernia, accompanied ureterohydronephrosis, possible due to the presence of the ureter within the hernia sac.

After the preoperative studies and anesthetic evaluation, elective surgery was appointed. In consideration of the hernia dimensions observed in both cases, an open Lichtenstein repair was performed. During the surgery, when the ureter was identified a careful proximal and distal dissection was performed to identify the structure; with this two setons were placed around the ureter to keep identified during the surgery, when we finished the liberation of the sac, we reintroduced the hernia content to the abdomen and prior remove of the seton the ureter was reintroduced to his previous position. No preoperative specific treatment was necessary and no complications were experienced during the postoperative period.

CONCLUSIONS:

Although uncommon but probably under-described, we must know the possibility of ureter implication in inguinoscrotal hernias; because hernias with ureter in the hernial sac are very rare but can lead to an increase in surgical complexity and morbidity. A thorough preoperative study is essential, as well as the participation of surgeons specialized in the abdominal wall.

 

3. A COMPLEX LATERAL INCISIONAL HERNIA REPAIR BY TOTALLY EXTRAPERITONEAL APPROACH. CASE REPORT.
   Authors: Fuad Samir L.; María del Mar O.; Celia C.; Ana Belén S.; Jenny Rosario G.; Eduardo G.; Camilo Z.; Sergio S.; Constantino F.
   Hospital Universitario La Paz, Madrid, Spain

Introduction: Treatment of large lateral incisional hernias remains a surgical challenge. The totally extraperitoneal (eTEP) approach is a technique that could be used to treat this type of hernias with minimally invasive procedure.

Objective: Present a case report of a lateral complex incisional hernia repaired by totally extraperitoneal (eTEP).

Patient and methods: A 64-years-old female had a previous right kidney open surgery in 2021. A few weeks later developed a painful lateral incisional hernia that worsened with coughing and movement. Physical examination revealed a large incisional hernia L2W3. CT showed a large lateral hernia (18 cm wide x 11 cm high) that involved transverse abdominis and internal oblique muscles.

RESULTS: A totally extraperitoneal (eTEP) approach was done. The patient was discharged at day one. The follow-up was uneventful.

Conclusions: This eTEP technique can be used safely and effectively to treat lateral incisional hernias with advantages such less postoperative pain, esthetic results, better and early recovery and discharged.

 

 

4. eTEP REPAIR FOR BILATERAL LATERAL INCISIONAL HERNIA WITH A SINGLE DOCKING AND AVOIDING TAR.
   Authors: Celia C.; Sergio S.; Belén S.; Fuad Samir L.; Manuel Fernando P.; Álvaro G.; Jenny Rosario G.; Eduardo G.; Constantino F.
   Hospital Universitario La Paz, Madrid, Spain

OBJECTIVE: Incisional hernia repair ranks among the most frequent procedures undertaken by general surgeons. Lateral incisional hernias (subcostal, lumbar, iliac, pararectal, or flank) occur less frequently than their ventral counterparts. A distinctive feature of the lateral abdominal wall is its proximity to bony structures, complicating the establishment of adequate mesh overlap. This challenge is amplified when there are two lateral defects on both sides of the abdominal wall. The eTEP approach could serve as a method to circumvent bilateral open surgery, which requires two sizeable incisions, leading to elevated postoperative morbidity and pain. This study aims to present a case where two simultaneous lateral hernias were mended using a single eTEP port.

MATERIALS AND METHODS: We detail the case of a 69-year-old male who previously underwent a left partial nephrectomy via lumbotomy. A subsequent CT scan disclosed a 53x43 mm L4W2 incisional hernia, an inherent umbilical hernia, and a right Spiegel hernia measuring 87x55 mm. Given these observations, an eTEP procedure was chosen to rectify all defects. The left retromuscular space was developed using a PDB spacer balloon. Dissection carried on caudally, leading to the discovery of the Retzius and Bogros spaces. Three supplementary ports were positioned in the Retzius space. The need for a Left transversus abdominis release (TAR) was circumvented by employing a PDB balloon lateral to the linea semilunaris and formulating the pretransversalis space, where the incisional hernia was both reduced and the defect sealed. Crossover proved unnecessary as the Retzius space facilitated the identification and reduction of the Spiegel hernia. Both hernia defects were successfully sealed with Stratatix. Two polypropylene meshes, measuring 20x15 and 25x25, were affixed.

RESULTS: A follow-up CT scan at 2 months post-surgery showed that the left muscular defect wasn't entirely sealed, but the mesh coverage persisted without evident signs of a recurrence.

CONCLUSIONS: The eTEP technique provides surgeons with the latitude to traverse every region of the abdominal wall. This is especially advantageous when addressing defects considerably distanced from each other, as it minimizes pain and postoperative complications.

 

5. EXCISION OF INTERMUSCULAR LIPOMA FROM THE ABDOMINAL WALL USING MINIMALLY INVASIVE SURGERY
   Authors: Ana Belén Suárez, Sergio Salido, Camilo Zapata, Jenny Guevara, Eduardo Gutiérrez, Constantino Fondevila
   Hospital Universitario La Paz, Madrid, Spain

Objetive: Lipoma is the most common bening soft tissue tumor. It has variable locations, with intramuscular (1,8%) or intermuscular (0,3%) occurrences being uncommon. Intramuscular lipomas are most frecuently found in the lower limbs, while intermuscular lipomas are mainly localized in the anterior abdominal wall.

The appearance of symtoms depends on the size of the lesion, requiring differential diagnosis with conditions such as hernias or malignant tumors. Complementary test used in this lesions include ultrasound (US), CT scan or MRI. Surgical treatment will be used if symtoms are present or malignancy is suspected. The technique will be determined based on the patient´s characteristics and the tumor´s location.

Materials and methods: We present a 52-year-old woman who consulted General Surgery due to a mass in the anterior abdominal wall causing discomfort.

Ultrasound described a 85 x75x5mm lipomatous lesion within the internal oblique muscle. CT scan defines a homogenous structure of possible adipose origin within the abdominal wall musculature, possibly consistent with a lipoma.

After evaluating the patient, surgical excision is decided using eTEP, allowing access to the space between the transverse and internal oblique muscles through a minimally invasive posterior approach, reducing muscle and vasculonervous agression and minimizing the risk os incisional hernia.

Results: For this purpose, the transverse aponeurosis was opened from the Bogros space and dissection of the lipoma located between the internal oblique and transvese muscle was performed. Finally, closure of the muscular opening with 2/0 absorbable barbed sutures was done. The result of the pathological study concluded: adipone tissue compatible with lipoma. No malignant tissue found. Neither complications or recurrence were registered during 6 month of follow up.

Conclusion: Intermuscular lipomas are rare tumors. In the case presented, the location complicates the approach due to the presence of vasculonervous bundles and the need to section multiple muscular planes. Therefore, the chosen technique was eTEP, initially aimed at repairing abdominal wall defects, but currently allowing its use for managing other pathologies, providing the benefits of a minimally invasive approach.

 

6. REVERSE TRANSVERSUS ABDOMINIS RELEASE - AS THE FIRST CASE OF POSTERIOR COMPONENT SEPARATION IN THE CAREER OF A YOUNG SURGEON
   Authors: Benedek Z., Kantor T., Élthes E.
   Municipal Hospital, Odorheiu Secuiesc, Romania

Objective: We present the case of an obese and diabetic patient with a giant EHS-L3-L4W3 incisional hernia.

Materials and methods: After the assessment of the cardio-respiratory system, based on clinical and radiological findings, we evaluated the reductibility of the hernia contents. As surgical treatment, using a right side approach, as first step of the reconstruction we performed a right posterior component separation (reverse transversus abdominis release) followed by dissection of the right lateral and right inguinal preperitoneal space. In the dissected space (from the right psoas muscle to the midline and from the right costal arch to the Cooper ligament) we performed an abdominal wall reconstruction using a 35x30 cm polypropylene mesh.

Results: By using an extra large mesh, we achieved a 10 cm overlap. The postoperative evolution was uncomplicated, the patient was discharged on the 10th POD. The 1 year follow up evaluation was assessed by CT scan without any sign of recurrence.

Conclusions: The posterior component separation (in our case the reverse TAR) is a feasible technique to ensure an easily dissectible retrorectus space to achieve a proper mesh overlap.

 

7. BIOSYNTHETIC MESH USE IN COMPLEX ABDOMINAL HERNIA
   Authors: C.Dutu*, Ioana Florea*, Iulia Vintila*, Ema Sbârnea*, Madalina Dumitru* , Bianca Chiru*, Oana Baston**, O.Albita*
   * 2nd Surgical Department, Central Military Emergency University Hospital "Dr. Carol Davila", Bucharest, Romania
   ** Department of Radiology, Medical Imaging and Interventional Radiology I UMF "Carol Davila" Bucharest, Romania

A rapidly developing surgical subspecialty nowadays is abdominal wall reconstruction (AWR). The number of patients who develop an incisional hernia is increasing, despite the development of laparoscopy and robotics (the incidence of incisional hernia after major abdominal surgery via midline laparotomy is 20-41% after 2-4 years). Complex abdominal wall reconstruction (CAWR) with biosynthetic mesh reinforcement has significantly improved outcomes.

The present paper aims to review the experience of two surgical teams using both polypropylene (PP) mesh and biosynthetic mesh over 12 months. According to the European Hernia Society (EHS), risk factors for CAWR include patient comorbidities, location, size and number of defects, loss of domain, wound contamination, extraction of intraperitoneal mesh, component separation technique or emergency enterectomies. A total of 30 patients with CAWR were examined (14 with biosynthetic mesh and 16 with PP mesh) and age, sex, BMI (body mass index), comorbidities, mVHWG class (modified Ventral Hernia Working Group), previous recurrence, mesh location, presence of component separation, postoperative complications were analyzed.

A significant reduction of SSO ( surgical site occurrence) was shown by the short-term results. Also, a shorter hospitalization was observed when biosynthetic meshes were used. The recurrence at 6 months was not influenced by the type of the mesh.

Future observations of these patients will show the comparative risk of long-term recurrence after CAWR.

 

 

8. A RARE CASE OF SPIGELIAN HERNIA INCARCERATED WITH OVARY
   Authors: Ioana Florea*, Mădălina Dumitru*, Bianca Chiru*, Oana Baston**, C. Duțu*
   * 2nd Surgical Department, Central Military Emergency University Hospital "Dr. Carol Davila", Bucharest, Romania
   ** Department of Radiology, Medical Imaging and Interventional Radiology I UMF "Carol Davila" Bucharest, Romania

Spigelian hernia, a very rare form of anterior parietal defect (incidence reaching maximum 0.12- 2% of abdominal wall hernias), occurs at the semilunar line or Spigelian line. Frequently ambiguous and difficult, symptoms of Spigelian hernia are non-specific and consist more usual in intermittent pain and swelling sensation in the lower abdomen, 2/3 of the patients describing symptoms without any clinical findings. In the most cases, it is a small hernia defect, usually <2 cm in diameter and it has a high incarceration risk – 17-27 %. This is why no "watchful waiting" approach is recommended and it should be operated upon even if the patient is asymptomatic.

We present a case of a 32-year-old female patient with incarcerated Spigelian hernia, who presented with pain in the left iliac fossa. The clinical examination revealed a small, irreducible swelling at the level of the left semilunar line. CT examination described a 5 mm parietal defect – compatible with a left infraumbilical Spigelian hernia, in which the left adnexa was incarcerated.

A laparoscopic TAPP approach was chosen, practicing the reduction of the herniated content (left adnexa of normal macroscopic appearance) and the placement of an 11/8 cm synthetic mesh at the preperitoneal level.

After surgery, the patient was discharged safety on the second postoperative day, with favorable evolution, quick post-operative recovery, no surgical site infection, no postoperative complications and a good aesthetic outcome.

In conclusion, we want to highlight the importance of knowing rare pathologies such as Spigelian hernia and their high complication rate, as well as the benefits of minimally invasive treatment.

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