Factors Predicting Increased Length of Stay in Abdominal Wall Reconstruction

Background Enhanced recovery after surgery (ERAS) programs have become increasingly popular in general surgery, yet no guidelines exist for an abdominal wall reconstruction (AWR)–specific program. We aimed to evaluate predictors of increased length of stay (LOS) in the AWR population to aid in creating an AWR-specific ERAS protocol. Methods A prospective, single institution hernia center database was queried for all patients undergoing open AWR (1999-2019). Standard statistical methods and linear and logistic regression were used to evaluate for predictors of increased LOS. Groups were compared based on LOS below or above the median LOS of 6 days (IQR = 4-8). Results Inclusion criteria were met by 2,505 patients. On average, the high LOS group was older, with higher rates of CAD, COPD, diabetes, obesity, and pre-operative narcotic use (all P < .05). Longer LOS patients had more complex hernias with larger defects, higher rates of mesh infection/fistula, and more often required a component separation (all P < .05). Multivariate analysis identified age (β0.04,SE0.02), BMI (β0.06,SE0.03), hernia defect size (β0.003,SE0.001), active mesh infection or mesh fistula (β1.8,SE0.72), operative time (β0.02,SE0.002), and ASA score >4 (β3.6,SE1.7) as independently associated factors for increased LOS (all P < .05). Logistic regression showed that an increased length of stay trended toward an increased risk of hernia recurrence ( P = .06). Conclusions Multiple patient and hernia characteristics are shown to significantly affect LOS, which, in turn, increases the odds of AWR failure. Weight loss, peri-operative geriatric optimization, prehabilitation of comorbidities, and operating room efficiency can enhance recovery and shorten LOS following AWR.

OV02 COMPLEX PARASTOMAL HERNIA REPAIR WITH MESH FISTULA AND MESH INFECTION

Aim Parastomal hernias of any size can be difficult to manage and greatly affect a patient’s quality of life, however, they can be even more problematic when associated with loss of domain and infection. The aim of our video was to demonstrate open repair of a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection. Material and Methods Images and footage from clinic and the operative procedure were included. Results A 51-year-old female with a history of prior APR followed by failed ventral and parastomal hernia repairs presented with a massive parastomal hernia that was significantly impacting her and her family’s quality of life. Due to her hernia, she had become immobile and was bed bound. Furthermore, the hernia had caused significant chronic constipation secondary to colonic dysmotility. The patient also had loss of domain, and her hernia appeared to be complicated by a chronic mesh infection with a draining sinus. She underwent pre-operative bilateral botulinum toxin A injection in the oblique abdominal musculature. She then underwent open preperitoneal parastomal hernia repair with biologic mesh, excision of prior mesh, primary fistula repair, total abdominal colectomy, and end ileostomy. The patient tolerated the procedure well without complications and has continued to do well in follow-up. She has had great improvement in her quality of life. Conclusions In this patient with a massive parastomal hernia complicated by loss of domain, mesh fistula, and mesh infection, we demonstrate a successful open preperitoneal repair following pre-operative BTA injection.

P159 PARTIAL VS COMPLETE MESH REMOVAL AFTER CROHNIC MESH INFECTION: COMPARISON OF OUTCOMES

Aim “The purpose of this study is to compare the postoperative outcomes between partial mesh removal (PM) and complete mesh removal (CM) due to chronic mesh infection.” Material and Methods “Patients with mesh removal due to chronic mesh infection were included from February 2010 to May 2020. The patients were consequently assigned depending on the surgical technique to either partial or complete mesh removal. The demographic, operative and follow-up data of the two groups were analyzed and compared in terms of surgical site occurrence (SSO), surgical site infection (SSI), overall complications following Clavien-Dindo classification and relapse of mesh infection at 1 year follow-up.” Results “The study included 65 patients (44.61% males) intervened of mesh explantation. MThe patients were assigned to PM 56.92% (n = 37) and CM 43.08% (n = 28). 27% of the patient in the CM group needed a new mesh vs. 7.1 % of PM p = 0,039 (4.38 OR 1.02-24.1). There were no statistically significant differences with respect to length of hospital stay CM 5.46 (DS 6.1) vs 5.82 (DS 10.09) days, p = 0.409. SSO were 84.4%, p = 0.631, while SSI was 61.2%. There were no differences in terms of Clavien-Dindo (p = 0.617). The appearance of new chronic mesh infection after surgery were: CM 29.7% vs PM 39.3%, p = 0.420.” Conclusions “Postoperative morbidity after mesh explants is comparable between partial and total explants. Those cases in which a total explant is performed are more likely to require the placement of a new mesh, while in partial explant there is a higher percentage of recurrence of chronic infection.”

P006 MICROBIOLOGY OF CHRONIC MESH INFECTION

Aim Mesh infection represents a significant concern due to its terrible consequences. Mesh sinus, infected seromas, mesh extrusion, and mesh-related enteric fistulas are common complications associated with synthetic mesh. This study aimed to review the microbiota of mesh infection in a series of 100 patients submitted to mesh explantation. Material and Methods We reviewed the charts of patients presenting with a history of mesh infection lasting six months or more after mesh placement. All patients submitted to further abdominal wall repair with complete removal of the infected mesh and presenting a positive culture were included. The microbiota analysis was based on positive cultures obtained from the fluids and tissues surrounding the mesh or a positive culture of the mesh itself. Microorganisms were divided into gram-positive or gram-negative, aerobic or anaerobic, and fungi. Results Pure aerobic gram-positive cultures were encountered in 50% of the patients, followed by a combination of aerobic gram-positive/gram-negative (9%) and pure gram-negative cultures (6%). Anaerobes were recovered from 31% of patients. Fungi were recovered from 6%. Staphylococcus aureus was identified in 64% of cultures, with methicillin-resistant Staphylococcus aureus present in 42% and methicillin-sensitive Staphylococcus aureus in 22%. Among aerobic gram-negative infections, six (17%) were caused by multi-resistant bacteria, including Pseudomonas aeruginosa, Proteus mirabilis, Acinetobacter baumanii, Klebsiella pneumoniae complex, and Enterobacter cloacae complex. Conclusions Pure Staphylococcus aureus infections, occurring in 29%, accounted for most single bacterial infections. Gram-negative infections and anaerobes were commonly encountered in polymicrobial infections. Most fungi cultures occurred in patients with enteric fistulas.

Enterocutaneous Fistula and Abscess Diagnosed with Point-of-care Ultrasound

Case Presentation: A 64-year-old female with history of umbilical hernia repair with mesh 18 years prior, cystocele, and diabetes mellitus presented with 10 days of abdominal and flank pain. The patient was tachycardic, normotensive, afebrile, and had an erythematous, tender, protuberant abdominal wall mass. Point-of-care ultrasound (POCUS) revealed an irregular, heterogeneous extraperitoneal fluid collection with intraperitoneal communication; these findings were consistent with an abscess and infected mesh with evidence for intraperitoneal extension. The diagnosis of enterocutaneous fistula (ECF) with infected mesh and abdominal wall abscess was confirmed with computed tomography and the patient was admitted for antibiotics and source control. Discussion: A rare complication of hernia repair with mesh, ECF typically occurs later than more common complications including cellulitis, hernia recurrence, and bowel obstruction. In the emergency department, POCUS is commonly used to evaluate for abscess; in other settings, comprehensive ultrasound is used to evaluate for complications after hernia repair with mesh. However, to date there is no literature reporting POCUS diagnosis of ECF or mesh infection. This case suggests that distant surgery should not preclude consideration of mesh infection and ECF, and that POCUS may be useful in evaluating for these complications.

TP9.2.13Outcomes of Emergency Groin hernia repair: 30-months experience of a tertiary care hospital

Aims Repair of Emergency groin hernia is variable across different regions and even within same units. Mesh is increasingly used these days. We aim to evaluate peri-operative and long-term outcomes over last 30-months. Methods Retrospective analysis of all emergency groin hernia repairs from January 2018- July 2020 in a tertiary Centre. Case notes and electronic patient records (clinical portal, PACS system etc.) used for data collection. Results Of 89 emergency groin hernia repairs 62(69.7%) males, 32/89 (35.9%) indirect inguinal hernia and 29 (32.5%) femoral hernia. Median age 72 years (range 20-95), 74(83.1%) primary hernia and 15(16.9%) recurrent hernias. Femoral hernia was most common in females 25/27 (92.5%) in contrast 58/62 males (93.5%) had inguinal hernia. All patients, except 1(1.1%) laparoscopic, had open repair, 11/89 cases (12.3%) required bowel resection, of those 10 (90.9%) had suture repair. Additionally, 6/89 cases (6.7%) needed laparotomy. Of 68/89 (76.4%) cases who had mesh repair, 52(76.4%) were inguinal and 23.5% (16/68) femoral hernia. Only 55% femoral hernias repaired with mesh. Median LOS was 3 days (range 0-54), 6/89 cases (6.74%) had wound complications (3 wound infections, 2 haematoma and 1 fluid collection). With median 19 months (range 6-36 months) follow-up, 1(1.1%) recurrence each in both mesh and suture repair groups, no mesh infection and 2/89 (2.2%) 30-day mortality recorded. Conclusion Mesh repair is increasingly used in emergency groin hernia repair without increased risk of mesh infection, although suture repair is still preferred in groin hernias requiring bowel resection.