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Aim to point out the critical issues of the management of a challenging case of complex ventral hernia (CVH) in high risk patient Material and methods A 58-year-old female was referred to our Institution with a history of alcohol and smoking abuse, COPD and class I obesity. Four years before she underwent liver transplantation. In the next two years she had 2 VH repairs with polypropilene (PP) meshes. The postoperative course was complicated by a deep surgical site infection (SSI) and dehiscence. The wound resulted in a large R2 M3-L2 CWH with distorted anatomy. The patient experienced VH incarcerations and bowel obstructions. Clinical examination revealed no signs of infection and the CT scan showed partial loss of substance of the abdominal wall. Results The patient underwent posterior component separation with transversus abdominis release (PCS-TAR) and large PVDF mesh on top of a biosynthetic mesh implantation. The postoperative course was complicated after 14 days by a SSI causing a large wound dehiscence with underlying mesh exposure. The patient was readmitted and negative pressure wound therapy (NPWT) with topical wound solution instillation was initiated. After 1 month was followed up as an out-patient to continue traditional NPWT and removal of former PP remnants. NPWT was interrupted after 6 months and no signs of infection nor VH recurrence were recorded at 1 year. Conclusions the indication to PCS-TAR for such comorbid patient should be carefully evaluated. The use of a biosyntetic mesh could be debatable. The conservative management of a chronic infection could be the first-line option in case of macroporous mesh implantations.

Aim To assess the short- and long-term outcomes of posterior component separation with transversus abdominis release (PCS-TAR) at our Centre. Material and methods From 2016, our abdominal wall unit started with PCS-TAR for the treatment of patients with complex abdominal wall hernias. We report our prospectively collected preliminary results. Results Sixty-six patients underwent PCS-TAR. Twenty patients had already received at least one previous hernia repair, 16 with mesh implantation. The median width of the defect was 12 cm (range 3 - 35), the median length 15 (range 4 - 40). Defects were multiple in 13 cases, swiss cheese in 2 cases. Eleven defects had both a midline and a lateral component, 3 had a concomitant parastomal hernia. Thirty-eight cases were located near the abdominal wall borders. The median duration of surgery was 255 minutes (range 84 - 740). TAR was partial in 24 cases and monolateral in 24. Twelve cases involved previous mesh removal. Fifty patients received implantation of more than one mesh: the most common combination was a PVDF mesh on top of a biosynthetic mesh. The mesh seldom needed to be fixed. The median length of stay was 6 days (range 3 - 61). Postoperative complications occurred in 22 patients (3 were major). Surgical site occurrences happened in 7 cases. After at least 12 months of follow up per patient, there was 1 recurrence, 1 case of chronic pain and no chronic seromas. Conclusions Posterior component separation with transversus abdominis release offers a versatile solution for a variety of complex ventral hernias, with good short- and long-term results.

Aim Posterior component separation with transversus abdominis release (PCS-TAR) represents a good option for challenging complex ventral hernia repairs. We present a case of PCS-TAR for a giant lumbar hernia in a patient with a transplanted kidney. Material and Methods The patient is a 46 years old man with a Charlson Comorbidity Index of 2 and a BMI of 27.5 kg/m2 who underwent a kidney transplant in 2005 and a subsequent open repair with mesh implantation for an incisional hernia in 2007. Two years later, he experienced a hernia recurrence, but chose conservative management. In 2019, the patient complained of progressively worsening pain and bulky sensation. Due to the size and location of the defect and the massive relaxation of the muscle fibers, open repair with PCS-TAR was indicated. Results In 2019, the patient underwent right-sided PCS-TAR with retromuscular placement of one polyvinylidene fluoride (PVDF) mesh and one biosynthetic mesh. Duration of the procedure was 295 minutes. Two drains were placed, respectively in the subfascial and in the subcutaneous plane. Postoperative course required non-invasive ventilation for respiratory distress, but was otherwise uneventful and he was discharged on postoperative day 8. After 12 months, the patient showed no signs of recurrence. Conclusions PCS-TAR is a versatile technique for the repair of complex ventral hernias, with an acceptable rate of postoperative complications and good long-term outcomes.

Aim To assess the long-term outcomes after laparoscopic repair (LR) of ventral hernias located on the abdominal borders. Material and methods Out of our prospectively collected LR database, all cases of ventral hernias were reviewed. Defects located near the abdominal borders were identified (M1, M5, L1 and L4 according to the EHS classification). All patients received intraperitoneal implantation of an e-PTFE mesh. The primary aim of this study was to assess long-term outcomes. Results Out of 175 LR, 105 (60%) had a M1 component, 61 (35%) an M5, 24 (14%) an L1 and 5 (3%) an L4. The median defect width was 9 cm (range 2.5 - 30), the median length 13 (range 2 - 30), with a median defect area of 92 cm2 (range 5 - 471). Two (1%) cases required conversion to open approach. After a median follow up of 55 months, there were 7 recurrences: 4/105 in M1 patients, 1/61 M5 patients, 1/24 L1 patients and 1/4 L4 patients. 41 patients (23%) experienced chronic seroma, while 24 (14%) had chronic pain. 6 patients (3%) required a reoperation with mesh removal. At univariate analysis, only previous hernia repair was associated with recurrence; COPD, hypertension and M5 defect were associated with seroma development; seroma development and chronic pain were mutually associated. Conclusions Laparoscopic repair for ventral hernias is safe and feasible, with good long term outcomes.

Background Obesity is a risk factor for ventral hernia development and affects up to 60% of patients undergoing ventral hernia repair. It is also associated with a higher rate of surgical site occurrences and an increased risk of recurrence after ventral hernia repair, but data is lacking on the differences between obesity classes. Methods Between 2008 and 2018, 322 patients with obesity underwent laparoscopic ventral hernia repair in our department: class I n = 231 (72%), II n = 55 (17%), III n = 36 (11%). We compared short and long-term outcomes between the three classes. Results Patients with class III obesity had a longer median length of hospital stay compared to I and II (5 days versus 4 days in the other groups, p = 0.0006), but without differences in postoperative complications or surgical site occurrences. After a median follow up of 49 months, there were no significant differences in the incidence of seroma, recurrence, chronic pain, pseudorecurrence and port-site hernia. At multivariate analysis, risk factors for recurrence were presence of a lateral defect and previous hernia repair; risk factors for seroma were immunosuppression, defect > 15 cm and more than one previous hernia repair; the only risk factor for postoperative complications was chronic obstructive pulmonary disease. Conclusion Class III obesity is associated with longer length of hospital stay after laparoscopic ventral hernia repair, but without differences in postoperative complications and long-term outcomes compared with class I and class II obesity.

Prophylactic mesh placement has been proposed to reduce the high occurrence of parastomal hernia (PSH) after stoma formation. This is an observational study comparing two cohorts of patients: a mesh prophylaxis group (who received mesh prevention since introduction at our Institution) and a no mesh prophylaxis group (retrospectively selected from our historical series). Same exclusion criteria were applied for both groups. The study was conducted at a tertiary referral center for colorectal surgery. 43 patients were operated with mesh prophylaxis between May 2015 and may 2019. 45 patients underwent end-colostomy formation without prophylaxis between April 2011 and April 2015. The primary outcome measure was PSH development at 12-month follow up. Demographic variables and risk factors for PSH were comparable between the two groups. There was no difference between the two cohorts in terms of operative time and main early postoperative outcomes. 37 patients completed the 12-month follow up in each group. PSH occurrence after 12-months was 11% in the mesh prophylaxis group and 54% in the no mesh prophylaxis group (p

Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic “modified Sugarbaker” (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.‘‘Sandwich Repair’’ (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR. We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications. 13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13–78) for the SR group and 47 months (12–105) for the KH group. SR is safe and effective in expert hands and provides promising preliminary results.

Objective: Older patients with cancer value functional outcomes as much as survival, but surgical studies lack functional recovery (FR) data. The value of a standardized frailty assessment has been confirmed, yet it's infrequently utilized due to time restrictions into everyday practice. The multicenter GOSAFE study was designed to (1) evaluate the trajectory of patients' quality of life (QoL) after cancer surgery (2) assess baseline frailty indicators in unselected patients (3) clarify the most relevant tools in predicting FR and clinical outcomes. This is a report of the study design and baseline patient evaluations. Materials & Methods: GOSAFE prospectively collected a baseline multidimensional evaluation before major elective surgery in patients (≥70 years) from 26 international units. Short−/mid−/long-term surgical outcomes were recorded with QoL and FR data. Results: 1003 patients were enrolled in a 26-month span. Complete baseline data were available for 977(97.4%). Median age was 78 years (range 70–94); 52.8% males. 968(99%) lived at home, 51.6% without caregiver. 54.4% had ≥ 3 medications, 5.9% none. Patients were dependent (ADL < 5) in 7.9% of the cases. Frailty was either detected by G8 ≤ 14(68.4%), fTRST ≥ 2(37.4%), TUG > 20 s (5.2%) or ASAIII-IV (48.8%). Major comorbidities (CACI > 6) were detected in 36%; 20.9% of patients had cognitive impairment according to Mini-Cog. Conclusion: The GOSAFE showed that frailty is frequent in older patients undergoing cancer surgery. QoL and FR, for the first time, are going to be primary outcomes of a real-life observational study. The crucial role of frailty assessment is going to be addressed in the ability to predict postoperative outcomes and to correlate with QoL and FR.