Anastomotic leakage remains a major complication in colorectal surgery. Indocyanine green (ICG) fluorescence and flexible endoscopy (FE) are used to assess perfusion and anastomotic integrity. We aimed to evaluate global practice patterns and intersurgeon variability to inform structured recommendations. This international survey was conducted between April and November 2024 within the EAES Rising Stars Academy 2023–2024. In a Delphi-like process, 53 questions addressing surgeon characteristics, institutional practice, and the use of ICG and FE were developed and distributed worldwide. A total of 1367 respondents from 80 countries participated (mean age 64 ± 10 years). ICG was available at 76

IntroductionThe management of giant diaphragmatic paralysis remains a significant surgical challenge, frequently associated with high rates of recurrence and the risk of developing abdominal compartment syndrome. While the use of Botulinum Toxin Type A (BTX- A) as an adjuvant therapy has been established in complex ventral hernia repair, its application in diaphragmatic paralysis is novel and sparsely documented. This study aims to present our institutional experience with BTX-A as a prehabilitation strategy in patients with complex diaphragmatic paralysis and to evaluate short- and long-term outcomes.Materials and MethodsThree patients with complex diaphragmatic paralysis underwent preoperative administration as part of a prehabilitation protocol prior to surgical repair. Loss of domain (LD) was calculated using the Sabbagh formula. According to Sabbagh, LD is defined as the ratio of herniated volume to total peritoneal volume (LD = HV/TPV), with a loss >20% being considered significant. All patients received a standardized BTX-A administration protocol consisting of ultrasound-guided injection of 500 units of botulinum toxin type A, administered at six sites following the technique described by Smoot, with three injection points on each side targeting the internal oblique muscle 4 weeks before surgery.ResultsPreoperative administration of Botulinum Toxin Type A (BTX-A) was safe in all three patients, with no postoperative complications or development of abdominal compartment syndrome, which was monitored through continuous intra-abdominal pressure measurements during the hospital stay (short-term outcomes). Six months postoperatively, all patients demonstrated significant improvement in respiratory function, assessed by standard pulmonary function tests, and reported improved quality of life, including relief from dyspnoea and enhanced daily functioning. At twelve months, two patients remained asymptomatic, with no clinical or radiological evidence of recurrence (long-term outcomes). Overall, preoperative BTX-A was associated with both short-term safety and sustained long-term functional benefits in this series.ConclusionPreoperative BTX-A appears to be safe and well-tolerated in complex diaphragmatic paralysis. The results suggest that BTX-A may reduce complications, improve functional outcomes, enhance respiratory function, and increase quality of life, with effects maintained for at least 1 year in most patients.

Indocyanine green fluorescence angiography (ICG-FA) in colorectal surgery allows changing the section line (CSL) based on objective evaluation of the vascular supply. The aim of this prospective study is to report our experience with CSL based on ICG-FA during colorectal surgery and to report risk factors influencing it. From 2014 to 2023, all patients who underwent any colorectal surgical procedure with anastomosis and ICG-FA were enrolled. Patients for whom changing the section line based on ICG-FA was not necessary were included in group A, and patients for whom ICG-FA determined a CSL were included in group B. Four hundred consecutive patients underwent laparoscopic surgery, except for two. In 334 patients (group A, 83.5

Abstract Video abstract A 63-year-old male with a history of abdominoperineal resection due to rectal adenocarcinoma presenting discomfort in a reducible 6 cm parastomal hernia (PSH) & M3W1 incisional hernia (Type IV PSH). We propose a full endoscopic minimally invasive extraperitoneal modified Sugarbaker approach (e-TEP Pauli). A 2 cm incision on the right subcostal region is made, opening the anterior rectal sheath, medializing the right rectus muscle. A dissection balloon was introduced to release the retromuscular space on the right side. Two more trocars were inserted in the right hypocondrium and right iliac fossa (10 mm, 5 mm respectively). The medial aspect of the right posterior rectus sheath (PRS) was incised, and the preperitoneal dissection was performed superficial to the Falciform ligament, doing the crossover above the umbilicus. The hernia was reduced, connecting both right and left retrorectus spaces. A modified posterior components separation (TAR) is performed, sectioning the aponeurosis of the transverse muscle (TM), accessing the preperitoneal space laterally without sectioning the TM. The colonic stump is released and reintroduced. The anterior defect is closed maintaining adequate passage of the colonic stump, and is fixated with sutures to the lateral abdominal wall. The peritoneal orifice is sectioned to lateralize the stump. The peritoneum and PRS are closed around the colonic stump. A PVDF-mesh covering both retrorectus and preperitoneal spaces is placed. A drainage is place and removed 24 h after. He was discharged 24 h after. In the CT 6 months after surgery, no abdominal wall defect was observed and pain and esthetic results where satisfactory.

Abstract Background Complex abdominal hernias present challenges in surgical practice, necessitating innovative strategies for successful reconstruction of the abdominal wall. We aim to elucidate the intricacies of reconstructing the abdominal wall in a complex hernia case, addressing preoperative considerations, intraoperative techniques, and postoperative outcomes. Method Presentation of a case of complex abdominal hernia through the case description, presentation of complementary diagnostic exams, and photographic documentation of the surgical steps. Results We present the case of a 49-year-old male patient with a history of obesity and multiple surgical interventions due to anorectal agenesis, including a previously closed colostomy. He was referred to our center due to a complex incisional hernia. Clinical examination and CT imaging revealed an umbilical hernia (M3W1, European Hernia Society Classification (EHSc)), and a left paramedian hernia (M3M4W3, EHSc), along with multiple retracted scars. The patient underwent a preoperative preparation program for obesity and abdominal wall prehabilitation with Botulinum Toxin. Four weeks after, he underwent abdominal wall reconstruction via laparotomy. The reconstruction involved posterior wall repair using the "small bites" technique, placement of a self-gripping mesh in a sublay position, and closure of the anterior aponeurosis using the same technique. The recovery proceeded without complications, and the patient was discharged on the 3th postoperative day. Conclusion This case highlights the importance of a thorough diagnostic and surgical approach in managing complex abdominal hernias. It also emphasizes the need for individualized preoperative strategies and advanced surgical approaches to ensure favourable outcomes for patients with complex abdominal hernias.

Abstract Video abstract A 58-year-old woman with a history of right nephrectomy and open appendectomy, with a past medical history of chronic abdominal pain and bulging at the level of the nephrectomy scar. A partially reducible 9 cm lateral hernia L3W3 (EHS) was diagnosed. The patient underwent an extended totally extraperitoneal hernia repair on the right side. A 2 cm incision on the epigastrium was made medially to the rectus muscle in order to enter the right homolateral retrorectus space. A dissection balloon was introduced to release this space. A 10 mm and 5 mm were inserted in the right hypocondrium and right iliac fossa respectively. A posterior component separation (TAR) was performed, caudal to cranial. We sectioned the aponeurosis of the transverse muscle (TM), accessing the defect and the preperitoneal space laterally. After the hernia content was introduced to the abdominal cavity, the defect was closed. Finally, a wide pore polypropylene mesh was placed, covering the right retrorectus space with the preperitoneal Bogros/Retzius spaces. Atraumatic fixation with cyanoacrylate was used. An aspiration drainage was placed and removed 24 h after surgery. The patient was discharged the day after, and no complications were reported. In the CT scan 6 months after surgery, the correction of the defect was confirmed and pain and esthetic results were satisfactory.

Abstract Background TAPE is suitable for laparoscopic repair of Suprapubic hernias where lower margin is within 5 cm from pubic arch. These hernias are known to occur after transverse or low vertical incisions in gynecological, urological or bowel related surgery. The repair of suprapubic hernias is as such difficult due to absent posterior rectus sheath, proximity to urinary bladder and essential neurovascular structures. Method After creation of pneumoperitoneum, the position of the ports is decided on the basis of the location of the suprapubic defect. 12 mm and Two additional ports of 5 mm are made on the lateral abdominal wall, mainly on the left flank to assess the hernial defect, previous scar and perform adhesiolysis. This allows space for adequate prosthetic overlap. The hernial content is completely reduced to expose the fascial borders of the defect. A peritoneal flap is dissected starting close to one anterior superior iliac spine (ASIS) and extended to the contralateral ASIS. The flap is inferiorly dissected till space of Retzius so that pubic arch and Cooper’s ligaments on either side are completely exposed. Medially, dissection is meticulous and carefully done avoiding any sort of iatrogenic injury to the urinary bladder. Close the defect with continuous suture with barbed suture of 1. A composite mesh (GORE® SYNECOR) of the appropriate size is chosen so that an overlap of at least 5 cm is achieved around the defect. The lower margin of the mesh must extend below the pubic arch by 1–2 cm to a low firm fixation to Cooper’s ligaments bilaterally with tackers CapSure™Permanent fixation. The rolled mesh is passed through a 12 mm port is spread inside the abdomen in a manner so that the surface with adhesion barrier faces the abdominal viscera. Spiral tacks are used to fix the mesh at two points on the Cooper’s ligaments on both sides. Circumferential fixation is also done at the mesh margins and around the margins of the hernial defect in the manner of double crowning. The peritoneal flap raised initially is made to reperitonealize the maximum possible part of the mesh. Results The main advantage of TAPE technique is suitable mesh overlap of more than 5 cm from the distal margin of the hernial defect. The fixation of the lower mesh margin to the Cooper’s ligaments on either side increases the strength of repair. The procedure does allow part of the mesh to remain in the extraperitoneal space. Since polypropylene meshes can be safely used, it allows to minimize the cost of procedure. Conclusion Laparoscopic repair of suprapubic incisional hernias is a safe and effective treatment option that offers several advantages over traditional open surgery. With careful patient selection and appropriate surgical technique, most patients can expect a successful outcome with low rates of recurrence and minimal complications.

Abstract Aims One of the main mid- and long-term complications after abdominal surgery is the occurrence of an eventration. The minimally invasive approach (MIS) to midline hernias currently one of the least used techniques in the emergency department. One of the great advantages of the laparoscopic approach to a strangulated ventral hernia (VH) is to be able to adequately assess the viability of the intestinal loops. The use of ICG can help to objectively assess adequate intestinal blood supply. Methods A 72-year-old woman with previous umbilical hernia operation, BMI: 44. Came to the ER with abdominal pain related to umbilical prolapse. CT-showed a diastasis of the rectum and a VH of approximately 4 cm containing a distal ileum loop with signs of distress in the hernial sac and the loops with liquid at that level. Results We observe a VH with dilated bowel loops and distressing fluid inside which is reduced with atraumatic maneuvers and graspers. A midline V-H is identified with a 4 × 5 cm defect (M3W1). Direct closure of the defect was performed with a non-absorbable barbed suture. Adhesiolysis and then a PVDF mesh is placed and fixed with absorbable tacker and cyanoacrylate glue. Affected intestinal loop is identified and fluorescence angiography with ICG is performed to confirm the adequate viability of the intestinal loops. Conclusions We believe that MIS to abdominal wall complications in the emergency setting is feasible and provides the advantages of laparoscopy in addition to being able to explore the abdominal cavity with support of ICG.

Abstract A 59-year-old female who underwent hysterectomy and exploratory laparotomy secondary to seromucinous ovarian carcinoma presents with discomfort in a partially reducible M5W3 incisional hernia. The patient is operated using a full endoscopic minimally invasive extraperitoneal approach (e-TEP + TAR). A 2 cm incision on the right subcostal region is made, exposing and opening the anterior rectal sheath (ARS), medializing the right rectus muscle. A dissection balloon is introduced to release the retromuscular space on the right side. A 10 mm trocar is placed in the right flank and a 5 mm trocar in the right iliac fossa. First, we access the medial posterior rectus sheath (PRS) of the right side, which is then incised, and the preperitoneal dissection is performed doing the crossover above the umbilicus. Once the hernia is completely reduced we connect both the retrorectus space with the preperitoneal spaces on both sides of the hernia. A modified posterior components separation (TAR) is performed on the left side, sectioning the aponeurosis of the transverse muscle (TM) and accessing the preperitoneal space laterally without sectioning the TM. The posterior and anterior defects are then closed separately using a barbed suture. A wide pore mesh, covering both retrorectus and preperitoneal spaces is placed and fixated using glue. An aspiration drainage was placed and removed 24 h after surgery. The patient was discharged the day after and no complications, where reported. In the CT scan 6 months after surgery the correction of the defects where confirmed.

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 Aim Urgent esophagogastric procedures are a complex field even in expert hands; even more so is the second procedure in cases of reinterventions. For this reason, it is important to apply safe techniques to minimize the clinical risk of unwanted events. Image-guided surgery based on indocyanine green fluorescence (ICG) has gained strength in recent years thanks to its widespread use. The combination of a white light probe along with the ICG mode of the tower facilitates the identification and safe dissection of structures during revisional surgery. Methods We present a case report. Results 58-year-old man with a history of total Roux-Y gastrectomy for distal esophageal adenocarcinoma, with anastomotic leak and need for endoscopic stent, uncomplicated posterior hernia and adequate follow-up at home. Consultation 5 months later due to chest pain and dyspnea for 48 hours. CT scan showed a giant paraesophageal hernia with signs of strangulation. An urgent laparoscopic surgical intervention was decided upon with the discovery of a large volume of herniated jejunal loops that could be reduced after chelotomy. The use of the device allows us to safely visualize the path of the esophagus and the anastomosis, for correct and safe adhesion and reduction. Finally, a raffia of the pillars and a pexy of the jejunum loop of the anastomosis to the crura are performed. After 6 days of hospitalization, he was discharged without complications. Conclusion The use of the white light probe with the intraoperative ICG mode, provides greater safety during the procedure, thus being a surgical technical resource.

Abstract Aim There has been a rapid growth in the robotic approach to inguinal hernia. This is because it has demonstrated similar results to the laparoscopic approach but with a significant increase in associated costs. Our objective is to conduct a cost analysis in Spanish National Health System. Materials and Methods A retrospective single-center comparative study of cost on inguinal hernia repair using a robotic approach versus laparoscopic approach. Results 98 patients who underwent inguinal hernia repair were analyzed between October 2021 and July 2023. Out of these 98 patients, 20 (20.4%) were treated with the robotic approach, while 78 (79.6%) underwent the laparoscopic approach. When comparing both approaches, no significant differences were found in terms of complications, recurrences, or readmissions. However, the robotic group exhibited a longer surgical time (86 ± 33.07 min vs. 40 ± 14.46 min, p <0.001), an extended hospital stay (1.6 ± 0.503 days vs. 1.13 ± 0.727 days, p <0.007), as well as higher procedural costs (2810.15€ ± 218.10€ vs. 725.81€ ± 158.91€, p <0.001) and total hospitalitation costs (3792.49€ ± 326.06€ vs. 1497.20€ ± 375.68 €, p <0.001). These results were consistent when performing subgroup analysis for unilateral and bilateral hernias. Conclusions The benefits observed in terms of recurrence rates and post-surgical complications do not justify the additional costs incurred by the robotic approach to inguinal hernia within the national public healthcare system. Nevertheless, it represents a simpler way to initiate the robotic learning curve, justifying its use in a training context.

Abstract Aims Lumbar hernias are defects occurring in the posterolateral wall of the abdomen, at the level of the upper Grynfelt’s triangle and a lower triangle (Petit triangle). The minimally invasive approach provides advantages in comparison to the conventional approach and the possibility of placing a preperitoneal mesh, avoiding contact with bowel. Methods We present the case of a 28-year-old man with a history of urological intervention in childhood for congenital defects in both kidneys through bilateral lumbotomy. The patient complained of discomfort at the site of the lumbar hernia for a year. On examination, a soft, reducible lump was palpated in the left posterolateral region of the abdominal wall. Computed tomography scan confirmed the lumbar hernia through the upper Grynfelt’s triangle of 35 mm (hernia type L4, EHS). Results Patient underwent surgery by transabdominal laparoscopic approach, placing three trocars in left clavicular midline. Right parietocolic groove is opened and a peritoneum is dissected to access Grynfelt’s triangle. After the reduction of the hernial content (fatty tissue), direct closure of the hernial defect is performed with non-absorbable barbed suture and a tailored PVDF mesh is placed intraperitoneally. Then peritoneal flap is closed with absorbable barbed suture. Patient was discharged on first postoperative day. At one-year follow-up complications or recurrence did not occur. Conclusions Laparoscopic approach to lumbar hernias is feasible providing the advantages of minimally invasive surgery, and in addition the possibility to explore the entire abdominal cavity. More studies with larger numbers of patients are needed to draw definitive conclusions.

Abstract Aims Laparoscopic approach to inguinal hernia has a great future as a gold standard' procedure given its advantages over the open approach. Regarding the TEP approach, one of the biggest 'fears' is repairing an accidental opening of the peritoneum in the surgery. An Endoloop can be used for closure, however, if the defect is too large it forces us to suture it. We present an alternative for closure of such holes. Methods A male patient with diagnosis of bilateral inguinal hernia who underwent repair by TEP approach. In the first surgical technique introducing the balloon to dissect the pre-peritoneal space in order to be able to approach the inguinal spaces, a very firm adherence of the peritoneum to the area of the vas deferens is observed, which when the balloon dissection is performed produces a laceration of the peritoneum and an important defect that must be repaired. Results Continued by dissecting and identifying the anatomical landmarks to determine the area of dissection and their location with respect to the hernial defect. The anatomical spaces are dissected and the hernial sac is freed from the rest of the structures and placed the mesh. Before going to the contralateral side, the orifice is closed with cyanoacrylate glue. It is not necessary to use sutures for this closure, checking its tightness and security in order to continue. Conclusions We believe that the use of cyanoacrylates for the closure of holes in the peritoneum during the TEP-approach can be a useful and efficient resource.

Abstract A 73-year-old female with history of diabetes mellitus and hepatic transplant presents with discomfort in a reducible 10 cm M1M2W3 incisional hernia. Botulinum Toxin was injected 4 weeks prior to the surgery in order to achieve the medialization of both rectus muscles without tension avoiding the need to do a posterior component separation. The patient is operated using a full endoscopic minimally invasive extraperitoneal approach (e-TEP). A 2 cm incision on the left subcostal region is made, exposing and opening the anterior rectal sheath (ARS), medializing the left rectus muscle. A dissection balloon is introduced to release the retromuscular space. Two more trocars are inserted in the left hypochondrium and left iliac fossa (10 mm, 5 mm respectively). We then proceed to incise the medial aspect of the left posterior rectus sheath (PRS) and start the preperitoneal dissection doing the crossover above the umbilicus. Cranially, we carefully section the adhesions of the old laparotomy to connect the preperitoneal space with the retrodiaphragm space bilaterally to not only correct the defect but to also enforce the laparotomy scar. The hernia is then reduced and the defect is closed with a barbed suture. A wide pore PPL mesh is inserted, covering both retrodiaphragm and preperitoneal spaces. The mesh is fixated. A drainage is placed and removed 24 h after surgery. The patient is discharged 24 h after without complications. In the CT scan 6 months after surgery the correction of the defect was confirmed and pain and aesthetic results where satisfactory.

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 Background Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) was first described in 2018. Since then, its application has grown, particularly in challenging scenarios, such as cases following Cytoreductive Surgery with Peritonectomy and Hyperthermic Intraperitoneal Chemotherapy (CRS + HIPEC). This video aims to demonstrate the application of Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) technique in a complex midline ventral hernia case. Patient and Methods Video presentation demonstrating the step-by-step execution of LIRA technique. The video showcases the feasibility, safety, and potential advantages of this method in improving surgical outcomes. Results We present the case of a 66-year-old female patient with a history of multiple surgeries for ovarian cancer. In 2016, she underwent CRS + HIPEC. In 2017, she was reoperated through bilateral subcostal laparotomy due to tumor recurrence in the celiac trunk. Because of several supra and infraumbilical hernial defects, she underwent minimally invasive abdominal wall reconstruction using LIRA technique. During the postoperative period, the patient developed a septic condition and on the tenth postoperative day a exploratory laparotomy was performed, but no signs of infection were found. Conclusion This case not only highlights the advancements achieved in minimally invasive techniques but also demonstrates that LIRA enables tension-free midline restoration, providing a promising alternative to conventional component separation or endoscopic procedures.

There has been a rapid proliferation of the robotic approach to inguinal hernia, mainly in the United States, as it has shown similar outcomes to the laparoscopic approach but with a significant increase in associated costs. Our objective is to conduct a cost analysis in our setting (Spanish National Health System). A retrospective single-center comparative study on inguinal hernia repair using a robotic approach versus laparoscopic approach. A total of 98 patients who underwent either robotic or laparoscopic TAPP inguinal hernia repair between October 2021 and July 2023 were analyzed. Out of these 98 patients, 20 (20.4

Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias. We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: More than 70