Severe rectus diastasis with midline hernia associated in males: high recurrence in mid-term follow-up of minimally invasive surgical technique.

PROPOSE: The present study aimed to assess clinical results, in terms of postoperative pain, functional recovery and recurrence rates of FESSA (Full Endoscopic Suprapubic Subcutaneous Access) technique compared to endoscopic anterior rectus sheaths plication and mesh, in male patients with midline ventral or incisional hernias and severe rectus diastasis (SRD) associated. Secondary aims were to identify intra- and postoperative complications associated with each technique. METHODS: Male patients with midline ventral or incisional hernia and severe rectus diastasis were included in a prospectively maintained databased and retrospectively analyzed from January 2017 to December 2020. From January 2017 to January 2019, male patients underwent to anterior rectus sheaths plication (ARSP) (Control group). From January 2019 to December 2020, male patients underwent to FESSA technique (FT) (Case group). RESULTS: 53 patients were finally included. 28 patients (52%) underwent to FT and 25 patients (48%) to ARSP. Regarding intraoperative complications, no significant differences were identified between the groups. Hospital stay was significantly improved in FT group when compared to ARSP group. No significant differences in terms of postoperative seroma or hematomas, were shown. FT group showed significantly less pain on 1st, 7th and 30th postoperative days than ARSP group. Functional recovery was significantly improved in FT group compared to ARSP group on the 30th day and no differences were observed on the 180th day after surgery. The mean follow-up was 17.3 ± 2.6 months in FT group and 24 ± 3 months in ARSP group. During the follow-up, 1(3%) and 9 (36%) diastasis recurrences were identified respectively, with significant differences in favor of FT group. CONCLUSION: In males with SRD and symptomatic midlines hernias, ARSP with onlay mesh placement shows high diastasis recurrence rate in mid-term follow-up. We propose FESSA technique in those patients, which decreases the excessive midline tension, improving the postoperative pain, functional recovery and recurrence rate, without increasing postoperative complications.

Initial experience with intraoperative testing and repair of colorectal anastomosis using a TAMIS approach after a positive leak test.

Anastomotic leak is one of the most feared complications of colorectal anastomosis. Different techniques have been described for intraoperative testing of anastomotic integrity. These include air insufflation, methylene blue and endoscopic visualisation. If an anastomotic leak is identified intraoperatively, there are various management options. Redo anastomosis is a possibility, but may be difficult in some cases. Defunctioning is another option, but there is an associated morbidity and signficant detrimental effect on quality of life. Direct transanal repair is only possible when a low anastomosis has been performed. When the anastomotic leak occurs high in the rectum or a partial mesorectal excision is performed a transanal approach is technically very challenging. We present our experience with transanal minimally invasive surgery (TAMIS) approach for anastomotic assessment and repair in four patients. In all cases, a colorectal anastomosis was performed and the air insufflation test was positive. We assessed the anastomosis with TAMIS. In three cases, a defect was found and subsequently sutured. In one case, a scar in the rectal mucosa was found and reinforced with a suture. A protective ileostomy was performed in two cases, while in the other two cases, no stoma was added. All four patients were discharged with no further complications. Both protective ileostomies were taken down after radiological and endoscopic confirmation of anastomotic integrity and all 4 anastomoses remain intact after follow-up. TAMIS intraoperative assessment and repair of anastomotic leak is a safe and feasible technique whcih may avoid the need for a defunctioning stoma.

Endoscopic retromuscular technique (eTEP) vs conventional laparoscopic ventral or incisional hernia repair with defect closure (IPOM +) for midline hernias. A case-control study.

PURPOSE: This study aimed at clinical results in terms of postoperative pain and functional recovery of new technique (eTEP) compared to IPOM + for ventral/incisional midline hernias. Recurrence rate, intra/postoperative complications and aesthetic results are secondary aims. METHODS: Data from consecutive patients requiring minimally invasive hernia repair were collected. From January 2015 to September 2018, patients with midline ventral/incisional hernias underwent IPOM + were compared to patients underwent eTEP procedure from October 2018 to December 2019 in a case/control study. RESULTS: Thirty-nine patients in IPOM + group and 40 in eTEP group were included. No significant differences were identified when hernias types, mean defect area, mean mesh area and intraoperative/postoperative complications (except seroma rate in favor of eTEP group) were compared. Operative time and hospital stay were significantly higher in eTEP group and IPOM + group, respectively. eTEP group showed significantly less pain on 1st, 7th and 30th postoperative days than IPOM + group. Restriction of activities was significantly decreased in eTEP group on the 30th and 180th day after surgery. Significant differences were observed in terms of cosmetic results 30th and 180th days after surgery in favor of eTEP group. Average follow-up was 15 months in eTEP group and 28 months in IPOM + group. No recurrences were identified in eTEP group and one recurrence in IPOM + group with no significant differences. CONCLUSION: Endoscopic retromuscular technique shows significant lower postoperative pain, better functional recovery and cosmesis than IPOM + without differences in intra/postoperative complications (except seroma rate) or recurrences during the follow-up. eTEP requires longer operative time.