BackgroundBotulinum toxin type A (BTA) is a valuable adjunct in abdominal wall reconstruction (AWR). Chemical component relaxation (CCR) involves injecting BTA into the lateral abdominal wall, leading to muscle paralysis and elongation which facilitates primary fascial closure during surgery without the need for extensive dissection. There are currently no standardised protocols for BTA administration in the perioperative period for AWR. We present a standardised protocol for CCR from our tertiary hernia unit and report our outcomes following surgery.MethodsA retrospective analysis of a prospective dataset of all patients undergoing standardised pre-operative CCR between 1st May 2021 and 30th April 2024 for AWR were included in this study. Analysis of pre-operative multi-disciplinary team (MDT) planning, BTA administration, surgical procedure and outcomes were performed.ResultsDuring the 3-year-period, 35 patients underwent CCR with subsequent AWR. The median age was 58 and median BMI was 32. Median hernia defect width was 8 cm. Anterior and posterior sheath closure was achieved in 91% of cases. In total, 39% with defect size >8 cm did not require component separation and were considered “downstaged”. There were no complications following CCR, and the surgical site occurrence rate following AWR was 26%. Hernia recurrence occurred in 1 patient.ConclusionThe presented protocol of pre-operative BTA appears to be a safe method of CCR. We demonstrate that its use may reduce the need for component separation and is associated with good post-operative outcomes.

Reinforced tissue matrix (OviTex®, TELA Bio, USA) is a novel surgical mesh comprised of biological ovine rumen scaffold reinforced with polymer. It aims to deliver synthetic mesh strength whilst minimising foreign body reaction. We present our early experience of OviTex® mesh for abdominal wall reconstruction (AWR) in a district general complex hernia referral centre. A single-centre retrospective case-series of adult patients undergoing AWR with OviTex® mesh between February 2023 and October 2024 was conducted at Croydon University Hospital (London, UK). Data on primary outcomes was collected retrospectively and included rates of hernia recurrence and surgical site occurrences (SSOs). Forty two patients were included (19 male, mean age 56.8 years). All cases were elective ventral hernia repairs performed by four consultant surgeons independently, or as joint cases. Thus far 64.3

INTRODUCTION:Abdominal wall surgery is emerging as a new subspecialty with reconstructive operations becoming increasingly complex. Central to any surgical subspecialty is comprehensive anatomical knowledge, which can be enhanced by cadaver dissection. An expert panel convened to develop a consensus framework highlighting key anatomical concepts and operative steps for teaching posterior component separation. METHODS:The panel consisted of opinion leading abdominal wall surgeons from the UK and Europe. Intellectual content derived from anatomy lectures, training videos, and cadaver dissection instructions formed the basis of the consensus framework. This framework was subsequently implemented during a pilot cadaveric workshop. Afterward, content from the workshop was further refined, resulting in this educational article, endorsed by all authors. This article comprises two sections, (1) theoretical aspects of abdominal wall anatomy; (2) stepwise technical guidance for cadaver dissection. RESULTS:In the first section, "Essential Anatomy," we discuss: Anterior abdominal wall musculature, posterior abdominal wall, the semilunar line, preperitoneal space, subxiphoid anatomy and pelvic anatomy. In the second section, "Practical Anatomy taught via Cadaver Dissection," we discuss: Rives-Stoppa dissection, caudal extension, cranial extension, classic top-down transversus abdominis release and posterior component separation with Madrid modification (bottom-up or "Madrid PCS"). CONCLUSIONS:Using content delivered by senior members of the abdominal wall reconstruction community, this article provides a structured educational framework for teaching posterior component separation. This is intended as a reference guide for surgical training and details the essential anatomical and operative concepts every abdominal wall surgeon should know.

Background:Mesh suture, or Duramesh™, has recently gained attention because of potential advantages over conventional techniques for abdominal wall closure. However, the evidence base for any advantage has not been assessed formally. Via systematic review we evaluated clinical outcomes for mesh suture and its precursor, mesh strip, in clinical trials of abdominal wall closure or ventral hernia repair. Methods:A systematic search of MEDLINE, CENTRAL, Embase, Cochrane, WHO International Clinical Trials Registry, and ClinicalTrials.gov was conducted to identify studies using mesh suture and/or mesh strip. Primary outcome was incisional hernia occurrence after primary closure or recurrence following ventral hernia repair, summarised with median percentage rates. Secondary outcomes included surgical site occurrences and reoperations. Risk of bias was assessed using adapted forms of ROBINS-I and Cochrane RoB2 tools. Results:Five single-arm case series and one interim report from a randomised controlled trial were eligible for inclusion, reporting 585 patients. Median follow-up was 11.9 months (range 2.7-35.3 months). Median incisional hernia occurrence was 3.4% (range 0%-50%). Median surgical site occurrence was 17.4% (range 0%-50%) and surgical site infection 5.4% (range 0%-19%). Overall, 6.0% patients (33 of 553) returned to theatre to manage complications. Overall risk of bias for included studies was critical. Conclusion:This systematic review highlights a need for high-quality randomised controlled trials with long-term follow-up to evaluate the clinical benefits of Duramesh™ for abdominal wall closure and ventral hernia repair. Better evidence is required to determine its safety and clinical efficacy.

Abstract Background Botulinum toxin type A (BTA) is a valuable adjunct in abdominal wall reconstruction (AWR). Chemical component separation (CCS) involves injecting BTA into the lateral abdominal wall, leading to muscle relaxation and elongation. The aim is to achieve primary fascial closure of both anterior and posterior sheaths without the need for extensive dissection, associated with greater morbidity. Aim To present a standardised protocol for CCS in a tertiary hernia unit and to demonstrate the clinical benefit of BTA in AWR. Methods A retrospective analysis of a prospective dataset of all patients undergoing standardised pre-operative CCS between May 2021 and May 2024 for AWR were included in this study. Analysis of pre-operative multi-disciplinary team (MDT) planning, BTA administration, surgical procedure and outcomes was performed. Results During the 3-year-period, 45 patients underwent CCS in a standardised protocol with subsequent AWR, 4 were out of area referrals. The median age was 60, with a male:female of 2:3, median BMI was 32.1. Average hernia defect width was 8.7 cm. 23 patients underwent synthetic mesh repair and 20 had biosynthetic mesh repair. Anterior and posterior sheath closure was achieved in 84% of cases, with 36% avoiding the need for component separation. There were no complications following CCS, and the complication rate following AWR was 38%, including seroma (16%). Parastomal recurrence occurred in 2 patients. Conclusions The presented protocol of pre-operative BTA is a safe method of CCS. We demonstrate that its use reduces the need for extensive component dissection and is associated with good post-operative outcomes.

INTRODUCTION:Abdominal wall reconstruction (AWR) is an emerging specialty, involving complex multi-stage operations in patients with high medical and surgical risk. At our hospital, we have developed a growing interest in AWR, with a commitment to improving outcomes through a regular complex hernia MDT. An MDT approach to these patients is increasingly recognized as the path forward in management to optimize patients and improve outcomes.METHODS:We conducted a literature review and combined this with our experiential knowledge of managing these cases to create a pathway for the management of our abdominal wall patients. This was done under the auspices of GIRFT (Getting It Right First Time) as a quality improvement project at our hospital.RESULTS:We describe, in detail, our current AWR pathway, including the checklists and information documents we use with a stepwise evidence and experience-based approach to identifying the multiple factors associated with good outcomes. We explore the current literature and discuss our best practice pathway.CONCLUSION:In this emerging specialty, there is limited guidance on the management of these patients. Our pathway, the "Complex Hernia Bundle," currently provides guidance for our abdominal wall team and may well be one that could be adopted/adapted by other centers where challenging hernia cases are undertaken.

Abstract Background The target day case rate of laparoscopic cholecystectomies at a busy district general hospital is 75%, as per Model Hospital Guidelines. The current rate at which day cases are achieved is 55%. This audit aims to identify factors relating to the DGH not reaching their day case target and explore potential solutions for these, with the intention to reduce patient’s hospital stay and, therefore, overall costs. Method 119 patients had undergone a laparoscopic cholecystectomy in the first five months of 2024. Exclusion criteria included hot cholecystectomies, common bile duct explorations and planned admissions. The remaining 85 patients were included in this audit. The data proforma included age, ASA, BMI, co-morbidities, Nassar grade, scheduled and actual time of operation and any reasons for delay. Results Of the 85 patients included in this audit, 34% (29) were not daycases. 11 remained an inpatient due to post-operative nausea or pain, 3 due to requiring an MRCP, 9 were kept in for monitoring, 2 had intraoperative bleeding, 3 had social issues and 1 required IV antibiotics. 58% of the 29 had afternoon operations. 48% of the 29 had a Nassar grade of greater than 1. 38% of the 29 had a BMI greater than 30. Conclusion Various reasons for a case to not achieve daycase status were found, with the most common being post-operative pain or nausea. It would prove beneficial to educate patients on common post-operative symptoms and focus on managing these symptoms effectively. Pre-operative appointments should aim to explore a patients home setting at the time of the operation and ensure to book inpatient stays for those who require it, in advance. Theatre lists should be optimised by giving high-risk patients morning slots.

Purpose: To determine normal anatomical variation of abdominal wall musculature.Methods: A retrospective analysis of CT scans was performed on adults (>18 years) with normal abdominal wall muscles. Two radiologists analysed the images independently. Distances from three fixed points in the midline were measured. The fixed points were; P1, mid-way between xiphoid and umbilicus, P2, at the umbilicus, and P3, mid-way between umbilicus and pubic symphysis. From these three fixed points the following measurements were recorded; midline to lateral innermost border of the abdominal wall musculature, midline to lateral edge of rectus abdominis muscle, and midline to medial edges of all three lateral abdominal wall muscles. To obtain aponeurotic width, rectus abdominis width was subtracted from the distance to medial edge of lateral abdominal wall muscle.Results: Fifty normal CT scan were evaluated from between March 2023 to August 2023. Mean width of external oblique aponeurosis at P1 was 16.2 mm (IQR 9.2 mm to 20.7 mm), at P2 was 23.5 mm (IQR 14 mm to 33 mm), and at P3 no external oblique muscle was visible. Mean width of the internal oblique aponeurosis at P1 was 32.1 mm (IQR 17.5 mm to 45 mm), at P2 was 10.13 (IQR 1 mm to 17.5 mm), and at P3 was 9.2 mm (IQR 3.0 mm to 13.7 mm). Mean width of the transversus abdominis aponeurosis at P1 was −25.1 mm (IQR 37.8 mm to −15.0 mm), at P2 was 29.4 mm (IQR 20 mm to 39.8 mm), and at P3 was 20.3 mm (IQR 12 mm to 29 mm).Conclusion: In this study we describe normal anatomical variation of the abdominal wall muscles. Assessing this variability on the pre-operative CT scans of ventral hernia patients allows for detailed operative planning and decision making.

Abstract Background Gastro-oesophageal Reflux Disease (GORD) affects a substantial proportion of adults in the UK, with surgery offering superior short-to-medium term benefits compared to medical management alone. However, there is significant variation in surgical practice nationwide. This study aimed to assess the feasibility and safety of laparoscopic anti-reflux surgery (LARS) at a District General Hospital (DGH) by aligning outcomes with the national standards set by AUGIS (Association of Upper Gastrointestinal Surgeons). Methods Prospective data from patients who underwent LARS between May 2022 and May 2023 were collected and recorded locally as well as on the National Hiatal Surgery Register (NHSR). Pre-operative symptoms and investigations, intraoperative findings, post-operative short and medium-term outcomes, and patient-reported outcome measures (PROMs) were analyzed. Quality of life (QoL) questionnaires, administered by the NHSR, were collected at 6 months to 1 year post-surgery. AUGIS standards, including a minimum of 5 procedures per year by 2 surgeons, conversion rate below 5%, 30-day return to theatre below 5%, and 30-day readmission rate below 10%, were utilized for comparison. Results In one year, two surgeons performed 41 LARS procedures: 31 Nissen, 4 Toupet, and 2 Dor wraps, with 2 redo surgeries. Minor complications occurred in 3 patients, requiring no intervention. One surgery was converted to open due to bleeding, and hiatal repair performed. Wrap migration led to re-do after 10 months. The 30-day return to theatre rate was 0%, readmission rate 2% (n=1, unremarkable CT scan). One patient discharged as a day case, average stay 4 days. Out of 23 eligible patients, 15 completed post-op questionnaires, showing significant QoL improvement. Additionally, 55% no longer needed anti-reflux meds at 6-month follow-up. Conclusions We significantly increased the number of LARS procedures performed while meeting the national standards set by AUGIS and we observed a significant improvement in our patients' quality of life following surgery. Experienced laparoscopic Upper GI surgeons can safely and effectively offer anti-reflux surgery in a DGH setting. Our commitment to prospective data collection for audit and research purposes has been a major strength. Future objectives include further consolidation of our work and expanding the range of procedures, such as magnetic sphincter augmentation (LINX), to improve day-case rates.

Abstract Aim Up to 20% of adults in UK suffer from Gastro-oesophageal Reflux Disease (GORD). Surgery offers better short-to-medium term benefit compared to sole medical management. However, practice varies significantly nationwide. The volume of cases performed in our district general hospital (DGH) has increased from one in 2015, to 24 in 2022. We aimed to establish feasibility and safety of laparoscopic anti-reflux surgery (LARS) at a DGH, by matching our outcomes with the AUGIS national standards. Method Data from patients undergoing LARS between January - December 2022 have been collected prospectively and recorded both locally and on National Hiatal Surgery Register (NHSR). Pre-operative symptoms and investigations, intraoperative findings and post-operative short and medium-term outcomes were analysed. Average follow up was 6 weeks. Results 24 laparoscopic anti-reflux procedures were performed (21 Nissen and 3 Toupet), including 6 paraoesophageal hernia repairs. All patients underwent primary repair and fundoplication. Average length of hiatus hernia preoperatively was 4.1cm for sliding, and 7.6cm for para oesophageal. 23/24 patients were inpatients, 1 was a day case. Mean length of stay was 4 days. Conversion to open rate was 0%. 22 patients had no complications. One patient experienced a mediastinal collection, another patient had post-operative hypotension, both not requiring intervention (Clavien-Dindo 2). 30-day return to theatre rate was 0%, as was 30-day readmission rate. Conclusions At our DGH, we significantly increased the volume of LARS performed whilst achieving AUGIS national standards. Anti-reflux surgery can be offered safely and effectively by experienced laparoscopic Upper GI surgeons in a DGH.

Abstract Background Deliberate foreign body ingestion (DFBI) presents unique medical, surgical, and ethical challenges. Often, patients with psychiatric conditions repeatedly ingest foreign bodies, leading to frequent emergency department visits. Standardised management guidelines are lacking, resulting in high hospitalisation rates, interventions, and complications. This study focuses on recent DFBI cases at our institution, providing insights into this complex condition and holistic management. Methods Patients admitted by the surgical team at Croydon University Hospital between 2017 and 2023 with DFBI were included. Data on demographics, clinical presentation, investigations, and management were collected. Complications, hospitalisations, interventions, and cost analysis were recorded. Results Eight patients presented a total of 52 times. The incidence of DFBI increased over time. Swallowed objects included knives, needles, magnets, glass, batteries, pencils, gloves, lighters, and screws. Each patient underwent an average of 21 X-rays, 2 CT scans, and 3 OGDs. Eleven laparotomies and 1 laparoscopy were performed. The average length of stay was 44.5 days. Complications included pulmonary embolism, pneumonia, enterotomy, hernia, and infection. The average cost per patient was £30,866.25. Conclusions DFBI poses a significant burden on healthcare systems. Patients face radiation exposure and repeated invasive interventions, necessitating a comprehensive approach. Understanding DFBI from a biopsychosocial and ethical perspective is crucial. A multidisciplinary team should be involved early, with clear goals. Further research is needed for optimal management pathways.

Abstract Aims Management of perianal abscesses continues to revolve around prompt surgical drainage. The Association of Coloproctology of Great Britain and Ireland (ACPGBI) guidelines state that all patients should have incision and drainage within 24 hours and antibiotics are not indicated in routine uncomplicated perianal abscesses. We aimed to study the antibiotics prescription after surgical drainage in a London university teaching hospital against the national standard. Methods A single-centred retrospective analysis of all emergency surgical admissions for incision and drainage of perianal abscess was carried out for a 6 month period. Patients’ demographics, Co-morbidities, local and systemic complications and readmissions were studied. Results A total of 36 patients, (mean age 43, 64% males) were included in this study, 21 received incision and drainage without antibiotics prescription, while 15 received empirical post-operative antibiotics. Indications for antibiotic therapy in this group included diabetes, immunocompromise, local complications (necrosis, cellulitis) and recurrence. There was no clear indication for antibiotics in 60% of patients who received them. 86% of patients had surgical drainage within 24 hours of presentation. One patient was readmitted for a second drainage 3 months later. Most common empirical agent used was co-amoxiclav (53%), followed by (33%) combination of co-amoxiclav and metronidazole. Conclusion Although surgical drainage was generally carried out in timely manner according to guidance, there was excessive post-operative antibiotic prescriptions. Increase awareness of guidelines is required to improve antibiotic stewardship in these surgical patients in order to avoid unnecessary drugs’ prescription.

Abstract Aims Acute cutaneous abscess is a common surgical condition which mostly require incision and drainage. Despite this, there is no standardised national or international guidance on the post-operative antibiotics prescription. Traditionally, antibiotics are not indicated unless complications and/or risk factors such as immunocompromisation, diabetes or cellulitis exist. We aimed to study the local practice of the post-operative antibiotics prescription for cutaneous abscesses in a University teaching hospital in London. Methods A retrospective data collection of emergency general surgical admissions for a period of six months from July to December 2020 was carried out. All patients with superficial skin abscess were included in this analysis. Scrotal, breast and limb abscesses were excluded. Patients’ demographics, Co-morbidities, local and systemic complications were studied. Results A total of 149 patients presented during this period. Mean age was 40 (54% were male). Most common site of abscess was perianal (24%), followed by pilonidal, axilla, back, gluteal, neck, abdominal wall and groin. At total of 108 (72.5%) were managed surgically with incision and drainage, 70 (65%) got antibiotics and only 23 (33%) had indications for it (i.e. diabetic, immunocompromised, sepsis, cellulitis, MRSA carriage) = (χ2[1] =22.03, p<.0001). Co-amoxiclav was the most common post-operative empirical antibiotic prescribed in 61% of the patients. Conclusions This study has identified significant variation in clinical practice regarding post-operative antibiotic usage in superficial abscesses. Further research is required in cooperation with microbiologists to develop standardised evidence-based treatment protocol for management of such common surgical condition.

Acute gastric necrosis is a very rare but potentially fatal condition which has been reported in patients with abnormal eating behaviours.We describe the case of a 24-year-old female with a background of Asperger's syndrome, who presented with abdominal pain and gross distension. She underwent an emergency exploratory laparotomy and was found to have a massively distended, necrotic stomach. A total gastrectomy was performed with interval reconstruction planned. This case reports the surgical management of a rarely seen condition and highlights the importance of recognising gastric necrosis and its causes, which include patients with abnormal eating behaviours, the majority of whom are young females. This is the first report highlighting gastric necrosis in a patient with Asperger's syndrome and coincides with a growing recognition of the association between eating disorders and the autistic spectrum. It is also a rare example of patient survival following total gastric necrosis with perforation.

AIMTo investigate the role of music in reducing anxiety and discomfort during flexible sigmoidoscopy.METHODSA systematic review of all comparative studies up to November 2016, without language restriction that were identified from MEDLINE and the Cochrane Controlled Trials Register (1960-2016), and EMBASE (1991-2016). Further searches were performed using the bibliographies of articles and abstracts from major conferences such as the ESCP, NCRI, ASGBI and ASCRS. MeSH and text word terms used included "sigmoidoscopy", "music" and "endoscopy" and "anxiety". All comparative studies reporting on the effect of music on anxiety or pain during flexible sigmoidoscopy, in adults, were included. Outcome data was extracted by 2 authors independently using outcome measures defined a priori. Quality assessment was performed.RESULTSA total of 4 articles published between 1994 and 2010, fulfilled the selection criteria. Data were extracted and analysed using OpenMetaAnalyst. Patients who listened to music during their flexible sigmoidoscopy had less anxiety compared to control groups [Random effects; SMD: 0.851 (0.467, 1.235), S.E = 0.196, P < 0.001]. There was no statistically significant heterogeneity (Q = 0.085, df = 1, P = 0.77, I-2 = 0). Patients who listened to music during their flexible sigmoidoscopy had less pain compared to those who did not, but this difference did not reach statistical significance [Random effects; SMD: 0.345 (-0.014, 0.705), S.E = 0.183, P = 0.06]. Patients who listened to music during their flexible sigmoidoscopy felt it was a useful intervention, compared to those who did not (P < 0.001). There was no statistically significant heterogeneity (P = 0.528, I-2 = 0).CONCLUSIONMusic appeared to benefit patients undergoing flexible sigmoidoscopies in relation to anxiety and was deemed a helpful intervention. Pain may also be reduced however further investigation is required to ascertain this.

Ambulatory care is an underdeveloped concept in the setting of emergency surgery, however it is recognised that many institutions will need to develop this service to cope with increased time and financial pressures.[1] There is increased emphasis on ambulatory care pathways for a variety of medical conditions.[2] Risk management is important in managing patients with acute abdominal pain in an outpatient setting and senior doctor support is essential. While the patient remains in the community, effective communication with the patient's primary care provider improves patient safety and satisfaction.[3] This quality improvement project identified current service provision of ambulatory care for surgical patients in the hot clinic at Croydon University Hospital with subsequent consultation with the surgical department to identify problems arising from the throughput of patients. Guidelines were then updated incorporating solutions to the identified issues which were then validated by the department of general surgery. Post intervention measurement identified a decrease in patients whose principal assessment and management was made by a senior house officer level doctor through the hot clinic patient journey from 26% to 9% (64% decrease), indicating an increase in registrar and/or consultant involvement in managing the hot clinic. The number of patients attending hot clinic that had effective discharge liaison (in the form of a formal letter) to the GP increased from 18% to 68% (250% increase). In conclusion, the introduction of updated guidelines effected a safer and more effective ambulatory hot clinic to perform closer to full capacity, providing improved patient care for the local population.