Abstract Introduction Over the last decade we have made progress in laparoscopic mesh fixation, mainly to avoid post-operative pain. Post-operative pain can be significant, causing discomfort and delaying discharge. One of these advances has been the use of adhesives as a fixation system, there is currently a wide range available, from biological adhesives to cyanoacrylate derivatives. In our case, we present the absence of traumatic fixation systems in a LIRA type repair with glue. Case We present the case of a 49-year-old female patient who underwent laparoscopic appendectomy and presented with an incisional hernia over the umbilical trocar of 10 mm, with a defect of 4 cm in diameter in the transverse axis, multisacular, with associated diastasis. We used three trocars arranged in a fan between the left hypochondrium, left flank and left iliac fossa. After releasing the preperitoneal fat, the aponeurotic flap of the posterior aponeurosis of the rectum was prepared, turned and sutured in the midline. We placed the mesh and fixed it completely with adhesive (n-butyl-2-cyanoacrylate). The patient was discharged the day after surgery, and at 15 months follow up, there were no recurrence or complications. Discussion The evolution of fixation systems has brought us the existence of cyanoacrylates that allow precise fixation without leakage at the point of application, combined with an adequate mesh that allows a low postoperative pain. There are still gaps in the long-term results, it is therefore necessary to conduct studies on a larger number of patients to assess the long-term results.

Abstract Introduction Chronic pain in patients after inguinal hernia repair can be a serious problem that affects patients' lives. It is therefore important to prevent, as far as possible, the situations that can cause it, one of which is excess mesh and its placement in an inappropriate area. Case We present a very thin male patient who underwent surgery for a right inguinal hernia using a mesh plug technique three months post-operatively and began to experience persistent groin pain that worsened with exertion and left him incapacitated throughout the day. This pain was not consistent with a dermatoma. Examination revealed induration in the area, with no clinical recurrence. The patient was referred for surgery due to pain and the previous mesh explant. A laparoscopic approach was performed with a transabdominal laparoscopic approach (TAPP), where no recurrence was observed but a folded mesh plug was found. Explant and repair with flat mesh without traumatic fixation were performed. The patient reported an improvement in pain, although it did not disappear completely. No recurrence at follow-up 12 months. Discussion The use of mesh plugs has been questioned on many occasions, not only because of problems related to chronic postoperative pain but also because of the migration of the plug into the cavity. The excessive folding of the mesh favours the formation of meshomas which are difficult to explant due to their proximity to blood vessels and nerve structures, which can be injured by compression or irritation.

Abstract Aim To study complications in our e-TEP series in ventral and incisional hernias. Methods We reviewed all patients undergoing e-TEP for ventral or incisional hernias. We included 33 patients (14 M2 or M3W2 incisional hernias and 11 medium ventral hernias with rectus diastasis), in whom polypropylene mesh was used. Follow-up at least 6 months. Results We found 2 patients with interstitial hernia below the mesh, one of them in the acute postoperative period with intestinal obstruction. One patient with recurrence of incisional hernia in the subxiphoid area, one patient with asymmetry of the right hypochondrium, and one patient with a seroma requiring drainage and a hematoma in another (using drainage). Intensive postoperative pain in 6 patients with delayed discharge. Conclusion In our series, E-TEP is safe but not free of complications.We started the procedure very ambitiously with M3W2 incisional hernias, but we soon realized that this technique did not allow us to revise the cavity and perform adhesiolysis, so we changed the way we managed these patients, and became more selective, only indicating E-TEP in medium-sized primary hernias associated with rectus diastasis. We managed to improve surgical skill with the cases, reducing postoperative pain, surgical time and hospital stay.

Abstract Aim To show the effect on postoperative pain of direct instillation of ropivacaine into the retromuscular space. Method During the E-TEP Rives procedure, after mesh placement, we instilled ropivacaine into the retromuscular space via a working port. In our initial experience we compared only five patients from each group. We measured the decrease in postoperative pain with the visual analog pain scale 24 hours postoperatively. Results We achieved a decrease in postoperative pain, which we measured using the visual analog pain scale, with a reduction of 3 vs 5 in the control group, and which translates into a decrease in opioid consumption in the immediate postoperative period. Conclusion To decrease postoperative pain we implemented several actions, among the most important for us, was the technique of nerve block of the anterior abdominal wall with ropivacaine. This technique is easier and faster than ultrasound nerve localization and allows selectively blocking the nerve bundles of the rectus, having the same efficacy in our experience.

Abstract Aim In our series we analyze our experience in the subsequent separation of components with release of the transverse (TAR). Material & Methods Study of our series of retrospective cases since 2016 to the present. We analyzed 59 patients with large hernias (midline and sides) all with defects greater than 10 cm. We perform the technique accessing the Rossen space through down to up. We used two meshes as prostheses, one biodegradable and the other made of polypropylene low density. Results We present 59 patients (38 men/21woman), of mean age of 61 years old and average BMI 32.05 Kg/m2. The mean postoperative stay was 7 days. The technique was carried out bilateral in 39 patients, and 20 it was applied unilaterally. Mesh implant to retromuscular level in 56 of the cases and 4 preperitoneal. Reinterventions in 4 (6.78%) patients. As minor complications, 8 (13.56%) wound infections, 9 (15.25%) wound seromas, 7 (11.86%) patients with pain chronic with preserved management, 1 (1.69%) edge ischemia and 1 (1.69%) wound sinus. Readmissions 4 patients (6.78%). Average follow-up of 24 months, no recurrence has been detected in any of the patients. Conclusions TAR is a complex technique that requires a learning curve, and that, even in equipment experienced, is not exent from serious complications. Therefore, the indication must be individualized and in order for it to be definitive, because once the wall is remodeled with this technique, the surgical options that remain are few.

Abstract Aim We present our clinical experience in the urgent repair of traumatic hernias through two clinical cases. Material and Methods Case 1: A 45-year-old man suffering thoraco-abdominal trauma due to running over. Thoracoabdominal CT scan and surgical examination shows a meso tear of terminal ileum and traumatic section of the right lateral musculature. Case 2: A 19-year-old man suffering abdominal trauma due to a traffic accident. CT abdomen is performed which reports large traumatic hernia of the left anterior abdominal wall including intestinal loops, with pneumo and retroneumoperitoneum. Results Case 1: We close the mesenteric gap and repair musculature by associating a polypropylene mesh in the preperitoneal space. The patient is discharged after 13 days. During the two-year follow-up, no hernia recurrence was detected. Case 2: A reconstruction of the wall is performed associating posterior separation of left components, in addition to ileocecal and sigma resection with anastomosis. As a complication presents seroma and chronic sinus, without hernia recurrence during follow-up for 5 years. Conclusions The tendency in traumatic hernias is their repair in a second time attending first to injuries that compromise the survival of the patient, but larger defect can lead to irreversible sequelae since enlargement of hernia, atrophy and muscle retraction, resulting in a more complex repair. If the patient requires urgent surgical intervention for visceral injury, some authors defend the simultaneous repair of the hernia in stable patients. Our group thinks that patients requires individualized management and its urgent repair will depend on the clinical situation.

Abstract Aim We present our experience in the repair of strangled inguinal hernias using Nyhus technique. Material and methods Retrospective review from 2019 to 2021 of 39 patients operated on for strangulated inguinal hernia who underwent a subsequent repair with cavity exploration using Nyhus technique, with a minimum follow-up of 12 months. There were 39 patients (77% men/23% women) with a mean age of 67 years (range 45–87 years), of which 41% were smokers, 22% obese, 10% cardiopaths and 22% COPD. 28% of hernias were recurrent. Results Of the 39 patients operated, intestinal resection and anastomosis were necessary in two patients; seroma was observed in 3 patients (10%), SSI in 2 patients (6%), hematoma in 4 patients (12%). During follow-up, recurrence has only been recorded in 2 patients(6%). Conclusions Anterior repair is the most widely used technique today for the repair of strangled inguinal hernia due to its simplicity and reproducibility. In many centers, a laparoscopic approach is being imposed, which allows, in addition to the repair of the hernia, a correct revision of the intestinal package in cases of doubtful viability. However, few surgeons today master the open preperitoneal technique, so useful in cases of recurrences, complex hernias and especially in emergencies. The Nyhus technique is a very useful technical option in the repair of strangled inguinal hernias, allowing access with wide visibility and possibility of safe intestinal resection without the need for general anesthesia.

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