Abstract Book. 16th ANNUAL HERNIA REPAIR. The World Journal of Hernia and Abdominal Wall Surgery. Invited Papers. Free Papers.

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123

The World Journal of Hernia

and Abdominal Wall Surgery

Official Organ of the European Hernia Society (EHS-GREPA)

Official Organ of the American Hernia Society (AHS)

Now indexed and included in✽ ♦ Science Citation Index ExpandedJournal Citation Reports/Science EditionCurrent Contents®/Clinical Medicine

See complete list below the table of contents

Abstract Book

16th ANNUAL

HERNIA REPAIR

LAS VEGAS, USA

March 12-15, 2014

Invited Papers

Free Papers

Posters

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4HEÈ7ORLDÈ*OURNALÈOFÈ(ERNIAÈANDÈ!BDOMINALÈ7ALLÈ3URGERY

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HERNIA

The World Journal of Hernia and

Abdominal Wall Surgery

1 Aims and Scope

“Hernia”was founded in 1997 with the purpose of promoting clinical studies and basic research as they apply to groin hernias, internal hernias, the abdominal wall (anterior and postero-lateral aspects), the diaphragm and the perineum. “Hernia” is the official organ of the European Hernia Society (GREPA), established in 1979, and of the American Hernia Society (AHS) established in 1997. These associations have common objectives:

the advancement of abdominal wall and hernia surgery in all aspects,

the study of anatomical, physiological, pathological and therapeutic issues concerning the abdominal wall and hernias,the creation of associated groups which will promote research and teaching in this field,

the development of interdisciplinary relations.

“Hernia”is a journal written by surgeons who have made abdominal wall surgery their special field of interest.

2 Copyright Information

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© Springer-Verlag 2014

16th Annual Hernia Repair

March 12-15, 2014

Las Vegas, USA

Wednesday, March 12, 2014

8:00-8:15 am Brent Matthews, MD & Michael Rosen, MD Welcome

Session 1 Abdominal wall reconstruction S8

Moderators: J. Scott Roth, MD & Yuri Novitsky, MD 8:15-8:35 am Robert Martindale, MD

USA

IP-12560: Risk reduction: preoperative patient optimization

8:35-8:55 am Michael Rosen, MD USA

IP-139: Rives-Stoppa, Ramirez, TAR or endoscopic CST: decision analysis

8:55-9:15 am Alfredo Carbonell, DO USA

IP-156: Preoperative pneumoperitoneum, botox injection, tissue expanders

9:15-9:35 am Parog Bhanot, MD USA

IP-12548: AWR and mesh infection

9:35-9:55 am Pranay Parikh, MD USA

IP-12583: AWR requiring muscle flaps and/or panniculectomy

9:55-10:15 am B. Todd Heniford, MD USA

IP-140: The consequence of complications in AWR: healthcare cost, reintervention, hernia recurrence

10:15-10:45 am Panel discussion 10:45-11:15 am Break & exhibits

11:15 am-12:00 pm Bruce Ramshaw, MD Presidential Address 12:00-12:15 am Jaime Cavallo, MD

USA

FP-12596: 2013 Resident Research Grant – A risk prediction model for ventral hernia recurrence and surgical site occurrences requiring procedural intervention following ventral hernia repair in clean-contaminated and contaminated surgical sites

12:30-1:30 pm Lunch & learn

Session 2A Scientific session I S11

Moderators: Gina Adrales, MD & Ricardo Abdalla, MD 1:45-2:00 pm Alexander Morrell, MD

Brazil

FP-12504: Obturator hernia treated by Tapp approach

2:00-2:15 pm Giel G Koning, MD, Ph.D USA

FP-126: TIPP versus Lichtenstein: a randomized controlled clinical trial

2:15-2:30 pm Clayton Petro, MD USA

FP-131: Predicting 90-day wound morbidity following incisional hernia repair with retrorectus mesh reinforcement

2:30-2:45 pm Christopher Rettenmaier, BS USA

FP-116: Component separation index (CSI) and width of diastasis predict complications after open component separation for abdominal hernias

SCIENTIFIC SESSIONS

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S2 Hernia (2014) 18 (Suppl 1): S1-S6 2:45-3:00 pm Lucas Timmermans, MD

USA

FP-207: Short term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation as a means to reduce incisional hernia

3:00-3:15 pm Jason Souza, MD USA

FP-109: In vivo evaluation of a novel suture design for abdominal wall closure

3:15-3:30 pm Bindhu Oommen, MD, MPH USA

FP-209: Predictors of 30-day readmission after ventral hernia repair

3:30-3:45 pm Joseph Fernandez-Moure, MD USA

FP-12574: 2012 Resident research grant – Synthetic hernia mesh with nitric oxide induced bacteriacidal properties – A paradigm shift

Session 2B Chronic inguinodynia S15

Moderators: Parviz Amid, MD & David Chen, MD

1:45-2:00 pm Melissa Phillips, MD USA

IP-12562: Assessment, evaluation and nonoperative treatment of patients with inguinodynia after inguinal hernia repair

2:00-2:15 pm Jacob Greenberg, MD USA

IP-160: Prophylactic neurectomy during inguinal hernia repair to prevent chronic inguinodynia: does it work?

2:15-2:30 pm William Hope, MD USA

IP-12545: Impact of novel mesh technology and fixation methods in the incidence of chronic inguinodynia

2:30-2:45 pm Parviz Amid, MD USA

IP-12557: Anterior approach with triple neurectomy for chronic inguinodynia

2:45-3:00 pm David Chen, MD USA

IP-165: Posterior laparoscopic approach with triple neurectomy for chronic inguinodynia

3:00-3:15 pm Sergio Roll, MD Brazil

IP-12556: International guidelines for prevention and management of postoperative chronic pain after inguinal hernia repair

3:15-3:45 pm Panel discussion 3:45-4:15 pm Break & exhibits

Session 3 Americas Hernia Society Quality S18 Collaborative

4:15-6:15 pm Moderators: Benjamin Poulose, MD, MPH & Michael Rosen, MD

IP-12582: Americas Hernia Society Quality Collaborative

Thursday, March 13, 2014

8:00-8:15 am Brent Matthews, MD & Michael Rosen, MD Welcome

Session 4 Controversies in open and laparoscopic S19 inguinal hernia repair

Moderators: Bruce Ramshaw, MD & David Earle, MD

8:15-8:30 am Matthew Goldblatt, MD USA

IP-162: Concomitant laparoscopic inguinal hernia repair during minimally invasive retropubic prostatectomy: do or don’t?

8:30-8:45 am Carl Boyd, MD USA

IP-12597: Is watchful waiting appropriate for asymptomatic or minimally symptomatic inguinal hernia?

8:45-9:00 am Kristi Harold, MD USA

IP-12550: Inguinal hernia repair in woman: laparoscopic or open repair?

9:00-9:15 am Leandro Cavazzola, MD Brazil

IP-12572: Over 45 prospective, randomized trials comparing laparoscopic and open inguinal hernia repair: what do I offer the patient?

9:15-9:30 am Guy Voeller, MD USA

IP-12558: Is there a role for tissue-based inguinal hernia repair in adults?

9:30-9:45 am James Bittner, MD USA

IP-12598: Is laparoscopic inguinal hernia repair an advanced minimally invasive technique?

Credentialing, training and quality assessment

9:45-10:15 am Panel discussion 10:15-10:45 am Break & exhibits 10:45-11:15 am B. Todd Heniford, MD

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Moderators: Harry Van Goor, MD & Sergio Roll, MD

11:15-11:20 am Harry Van Goor, MD & Sergio Roll, MD Introduction

11:20-11:30 am Guy Voeller, MD USA

IP-12559: Onlay repair after primary fascial closure

11:30-11:40 am Benjamin Poulose, MD, MPH USA

IP-12571: Underlay retrorectus or preperitoneal repair

11:40-11:50 am Kent Kercher, MD USA

IP-12553: Sublay intraperitoneal repair with barrier coated mesh

11:50 am-12:10 pm Faculty debate 12:10-12:15 pm Panel discussion

Session 5B International Hernia Collaboration: S22 Hernia consultation through social

media

Moderator: Brian Jacob, MD

IP-12595: International Hernia Collaboration: Hernia consultation through social media

11:15-11:30 am Brian Jacob, MD

Introduction: Facebook for international hernia collaboration

11:30 am-12:15 pm Panel: Shirin Towfigh, MD & Matthew Goldblatt, MD Cases

12:30-1:30 pm Lunch & learn

Session 6A Scientific session II S23

Moderators: William Cobb, MD & Yuri Novitsky, MD 1:45-2:00 pm Vít Novacek, PhD

France

FP-186: A new methodology for abdominal wall biomechanical strain analysis

2:00-2:15 pm Wolfgang Reinpold, MD Germany

FP-12505: Endoscopic assisted mini open transhernial sublay repair of ventral and incisional hernias – Matched pair analysis of 300 cases of the German hernia registry

2:15-2:30 pm Michael Rosen, MD USA

FP-182: One-year outcomes in a prospective, multicenter study of contaminated ventral hernia repairs using a biosynthetic material

for large open ventral hernia repair (OVHR) on post-operative physical activity

2:45-3:00 pm Samuel Wade Ross, MD, MPH USA

FP-12520: Long-term quality of life (QOL) between TEP, TAPP and modified Lichtenstein inguinal hernia repair (IHR): A two-year follow-up

3:00-3:15 pm Baukje Heuvel, MD The Netherlands

FP-11345: A new method of follow-up after inguinal hernia repair; validation of the Pinq-Phone

3:15-3:30 pm HT Brandsma, MD The Netherlands

FP-178: One-year results of prophylactic mesh placement during formation of an end-colostomy for prevention of parastomal hernia; the dutch Prevent-trial

3:30-3:45 pm Alex Cuenca, MD, PhD USA

FP-12213: Laparoscopic repair of a paraduodenal hernia

Session 6B Biomaterial science session I S27 Evidence based literature

Moderator: Bruce Ramshaw, MD 1:45-2:05 pm Corey Deeken, MD

USA

IP-12549: Preclinical evaluation of biomaterials: material characterization and predictability of clinical performance

2:05-2:25 pm David Earle, MD USA

IP-12547: Barrier coated mesh for laparoscopic ventral hernia repair

2:25-2:45 pm James Bittner, MD USA

IP-12564: Biologic, absorbable synthetic or permanent mesh for laparoscopic paraesophageal and hiatal hernia repair

2:45-3:05 pm Klaus-Joachim Conze, MD Germany

IP-12566: Lightweight mesh for open inguinal hernia repair: effect on recurrence, patient-centered outcomes

3:05-3:25 pm Harry Van Goor, MD The Netherlands

IP-12551: Biologic mesh for abdominal wall reconstruction

3:25-3:45 pm Panel discussion 3:45-4:15 pm Break & exhibits

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S4 Hernia (2014) 18 (Suppl 1): S1-S6

Session 7 AHS Journal Club: S29 Articles all hernia surgeons should know

Moderators: Leandro Cavazzola, MD & James Bittner, MD

4:15-4:30 pm Johannas Jeekel, MD The Netherlands

Paper #1: Long term follow up of a randomized controlled trial of suture vs mesh repair of incisional hernia (Ann Surg 2004)

4:30-4:45 pm Alfredo Carbonell, DO USA

Paper #2: Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial (Arch Surg 2009)

4:45-5:00 pm Giampero Campanelli, MD Italy

Paper #3: Randomized, controlled, blinded trial of tisseel/tissucol for mesh fixation in patients undergoing lichtenstein technique for primary inguinal hernia repair: results of the Timeli trial (Ann Surg 2012)

5:00-5:15 pm Brent Matthews, MD USA

Paper #4: Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial (Arch Surg 2010)

5:15-5:30 pm Richard Pierce, MD USA

Paper #5: Randomized clinical trial comparing suture and mesh repair of umbilical hernia in adults (Br J Surg 2001)

5:30-5:45 pm Gina Adrales, MD USA

Paper #6: A randomized, double-blind, placebo-controlled trial to determine effectiveness of antibiotic prophylaxis for tension-free mesh herniorrhaphy (J Am Coll Surg 2005)

5:45-6:00 pm Panel discussion

Session 8 Humanitarianism: S30 Honoring those who serve others

Moderators: Brent Matthews, MD & Charles Filipi, MD

6:00-6:10 pm Andrew Kingsnorth, MD United Kingdom

IP-12599: Operation hernia

6:10-6:20 pm Panel Discussion

Friday, March 14, 2014

8:00-8:15 am Brent Matthews, MD & Michael Rosen, MD Welcome

Session 9 Instruction through video: S31 Laparoscopic and open hernia repair

Moderators: Ricardo Abdalla, MD & William Cobb, MD

8:15-8:30 am Melissa Phillips, MD USA

IP-12563: Myofascial release: Rives-Stoppa and posterior component separation/TAR

8:30-8:45 am Yuri Novitsky, MD USA

IP-137: Laparoscpoic ventral hernia repair: defect closure, positioning systems, myofascial release

8:45-9:00 am J. Scott Roth, MD USA

IP-166: Anterior component separation release: open ramirez and endoscopic techniques

9:00-9:15 am Nathaniel Stoikes, MD USA

IP-161: Laparoscopic paraesophageal and type I hiatal hernia repair

9:15-9:30 am Karl LeBlanc, MD USA

IP-159: Laparoscopic parastomal hernia repair

9:30-9:45 am Ricardo Abdalla, MD Brazil

IP-12591: Laparoscopic TAPP and TEP inguinal hernia repair

9:45-10:15 am Panel discussion 10:15-10:45 am Break & exhibits

Session 10A Scientific session III S33

Moderators: Harry Van Goor, MD & Richard Pierce, MD

10:45-11:00 am Clayton C Petro, MD USA

FP-214: Suprapubic hernia repair with a rectus femoris flap

11:00-11:15 am Sean Orenstein, MD USA

FP-200: Outcomes of transversus abdominis muscle release (TAR) with synthetic mesh sublay for abdominal wall reconstruction

11:15-11:30 am Phillip Rowse, MD USA

FP-133: TEP and Lichtenstein anatomy – Does simulation accelerate acquisition among interns?

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evaluating the effect of small stitches on the long-term incidence of incisional hernia after midline laparotomy (Stitch-trial)

11:45 am-12:00 pm Jerrold Young, MD USA

FP-113: Long acting local anesthesia for groin hernia repair with a new product: liposomal bupivacaine. a preliminary study of efficacy for reduction of post-operative pain

12:00-12:15 pm Blair Wormer, MD USA

FP-220: A novel intervention for augmenting postoperative urination in patients undergoing laparoscopic inguinal hernia repair

Session 10B Athletic pubalgia S36

Moderator: L. Michael Brunt, MD 10:45-11:00 am Garth Jacobson, MD

USA

IP-154: Epidemiology and pathoanatomy of athletic pubalgia

11:00-11:15 am Brent Matthews, MD USA

IP-12573: Examination and imaging characteristics in a patient with athletic pubalgia

11:15-11:45 am L. Michael Brunt, MD USA

IP-12552: Nonoperative and operative treatment strategies in a patient with athletic pubalgia

11:45 am-12:15 pm Panel discussion 12:15-1:45 pm Lunch & learn

Session 11 Complication management: S37 Morbidity conference

at the Americas Hernia Society

Moderator: Kristi Harold, MD

IP-12594: Complication management: Morbidity conference at the Americas Hernia Society

1:45-3:45 pm Panel:

Marc Miserez, MD, Belgium Brent Matthews, MD, USA Eduardo Parra-Davila, MD, USA Salvador Morales-Conde, MD, Spain Garth Jacobson, MD, USA 3:45-4:15 pm Break & exhibits

Session 12A Hernia emergencies for the S38 on call general surgeon

Moderators: Maurice Arregui, MD & Jerrold Young, MD

morbidly obese 56 year old male

4:25-4:35 pm Alan Schuricht, MD USA

IP-135: Strangulated femoral hernia in a 82 year old female resident of a nursing home

4:35-4:45 pm Jacob Greenberg, MD USA

IP-12580: Incarcerated recurrent ventral incisional hernia in a 55 year old diabetic female with possible mesenteric ischemia

4:45-4:55 pm Deron Tessier, MD USA

IP-138: Incarcerated inguinal hernia in a 62 year old male with a small bowel obstruction

4:55-5:05 pm J. Scott Roth, MD USA

IP-12589: Umbilical hernia with epidermal erosion and ascites leak in a 44 year old male with cirrhosis

5:05-5:15 pm Matthew Goldblatt, MD USA

IP-163: Internal hernia in a 26 year old female 6 months after laparoscopic gastric bypass

5:15-5:30 pm Panel discussion

Session 12B Expert debates: S40 Fixation for laparoscopic inguinal

hernia repair

Moderators: Reinhard Bittner, MD & Guy Voeller, MD

4:15-4:25 pm Introduction 4:25-4:35 pm William Cobb, MD

USA

IP-164: Mechanical nonabsorbable fixation

4:35-4:45 pm Marc Miserez, MD Belgium

IP-12565: Mechanical absorbable fixation

4:45-4:55 pm Giampero Campinelli, MD Italy

IP-12555: Fibrin sealants

4:55-5:05 pm Brian Jacob, MD USA

IP-141: Self adherent mesh

5:05-5:15 pm Edward Felix, MD USA

IP-153: No fixation is required

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S6 Hernia (2014) 18 (Suppl 1): S1-S6

Saturday, March 15, 2014

8:00-8:15 am Brent Matthews, MD & Michael Rosen, MD Welcome

Session 13 The future of hernia surgery S42

Moderators: Marc Miserez, MD & Bruce Ramshaw, MD 8:15-8:30 am Johannas Jeekel, MD

The Netherlands

IP-12570: Prophylactic mesh placement after laparotomy: primary mesh augmentation to prevent ventral hernia

8:30-8:45 am J. Scott Roth, MD USA

IP-167: Quality of life metrics for hernia repair: functionality of abdominal wall reconstruction

8:45-9:00 am Michael Franz, MD USA

IP-12546: Biomimetic materials for ventral hernia repair: eliciting specific cellular responses

9:00-9:15 am Alfredo Carbonell, DO USA

IP-158: Routine use of synthetic mesh in clean-contaminated and clean-contaminated ventral hernia repairs

9:15-9:30 am Ricardo Abdalla, MD Brazil

IP-118: Robotic abdominal wall reconstruction

9:30-9:45 am Benjamin Poulose, MD, MPH USA

IP-152: Public disclosure of outcomes and cost after hernia repair: surgeon-centered metrics

9:45-10:15 am Panel discussion 10:15-10:30 am Break

Session 14A Biomaterial science session II S45

Moderators: Salvador Morales-Conde, MD & Dwijen Misra, MD

10:30-10:50 am John Murphy, MD USA

IP-12590: Inguinodynia – Causes and prevention

10:50-11:10 am Garth Jacobson, MD USA

IP-155: Absorbable synthetic mesh for abdominal wall reconstruction: clinical value or an inexpensive alternative to biologic mesh

11:10-11:30 am Igor Belyansky, MD USA

IP-136: Antimicrobial mesh as prophylaxis for mesh infection: preclinical and clinical support for technology

11:30-11:50 am Sharon Bachman, MD USA

IP-12600: Mesh selection will be determined by genetic profiling: hernia repair 2030

11:50 am-12:15 pm Panel discussion

Session 14B Posters of distinction S47

Moderators: David Earle, MD & Andrew Kingsnorth, MD 10:30-10:36 am Rebeccah Baucom, MD

USA

FP-10933: Does normothermia reduce the risk of surgical site infection in ventral hernia patients?

10:36-10:42 am Siavash Raigani, MD USA

FP-130: Single-center experience with parastomal hernia repair using sublay mesh placement

10:42-10:48 am Carl Tadaki, MD USA

FP-172: Comparing perioperative outcomes of laparoscopic vs open inguinal hernia repair using two national large data bases

10:48-10:54 am Clayton Petro, MD USA

FP-144: Apples to apples: a validated staging system (I-IV) for incisional hernias

10:54-11:00 am Jacob Greenberg, MD USA

FP115: A summative assessment of laparoscopic ventral hernia repair for general surgery residents: perception does not equal reality

11:00-11:06 am Yuhsin Wu, MD USA

FP-132: Efficacy of antibiotic pulse lavage irrigation for contaminated retro-rectus abdominal wall reconstructions

11:06-11:12 am Bindhu Oommen, MD, MPH USA

FP-12503: Do patients follow-up with their original surgeon when ventral hernia repairs (VHR) fail?

11:12-11:18 am Siavash Raigani, MD USA

FP-121: The impact of developing a comprehensive hernia center on referral patterns and cost of hernia care

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Hernia (2013) 17 (Suppl 1): S8-S10

ABSTRACTS

Wednesday, March 12, 2014

Session 1: Abdominal wall reconstruction

© Springer-Verlag 2014

IP-12560

Risk reduction: preoperative patient optimization

Martindale R

Oregon Health and Science University

The success of hernia repair is measured by absence of recurrence, appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound ischemia, and dehiscence, increases the risk of recur-rent hernia by at least 3-5 fold. The surgeon should optimize all measures that promote healing, reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate perioperative period is surgical site infection. Several factors such as smoking, obesity, poor glycemic control, malnutrition, and surgical site contamination are all detrimental to wound healing and should be optimized before sur-gery. Wound healing or a propensity for postoperative infections is the primary target, both of which increase the incidence of hernia recurrence, and there are some management options that improve wound healing. Obesity and smoking have been shown to be inde-pendent risk factors associated with increased recurrence of abdom-inal hernia and SSO. Poor glycemic control in the remote preoper-ative period (30-60 days), immediate perioperpreoper-ative and intraoperpreoper-ative period, and postoperative periods has been repeatedly shown to lead to an increase in superficial and deep tissue infections. Malnourished patients have significant alterations in wound healing and immune function and consequently have an increased incidence of postoper-ative hernia recurrence and SSI. In select populations recent studies now support the use of preoperative metabolic modulating formula-tions to minimize the catabolic effect of surgical intervention. Many of the things that surgeons do routinely that have been said to decrease infections and wound complications are steeped in tra-dition, have few if any randomized prospective trials, and are not evidence based. Examples including using shoe covers, scrubs not leaving the operating theater, and even wearing surgical masks have limited or no significant data to support them; one large prospective randomized clinical trial of performing surgery with and without sur-gical masks showed that it made no difference.

IP-139

Rives-Stoppa, Ramirez, TAR or endoscopic CST:

decision analysis

Rosen M

University Hospitals Case Medical Center

The field of abdominal wall reconstruction has seen tremendous growth in the last decade. Several innovative technical advancements have now allowed reconstruction of some of the most complex defect imaginable. This lecture will detail the technical aspects of many of these novel approaches. In addition, a careful assessment of indica-tions, contraindicaindica-tions, and reasonable expected outcomes of each of these approaches will be provided. It is likely that no one approach will address all types of ventral hernia repairs. Ultimately, the com-prehensive reconstructive surgeon will require a full complement of procedures to approach all ventral hernia repairs.

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Carbonell A

Greenville Health System

Patients with loss of domain have chronically herniated abdominal contents residing outside the abdominal cavity, in a secondary abdomen. Hernia repair in these patients is dangerous due to respi-ratory compromise and the risk of abdominal compartment syndrome when an attempt is made to relocate the herniated contents back into the abdominal cavity.

Numerous techniques abound for abdominal wall repair in these patients such as progressive preoperative pneumoperitoneum (PPP), botulinum toxin injection of the abdominal wall, tissue expanders, and sequential abdominal wall closure utilizing the artificial burr technique. The technique of PPP employs the gradual insufflation of the abdominal cavity with ambient air which acts as a pneumatic tis-sue expander, stretching the abdominal wall musculature, dissecting adhesions, and pressurizing the abdomen. This allows for a safer her-nia repair since the herher-niated contents can be relocated to the abdom-inal cavity without respiratory embarrassment due to elevated intra-abdominal pressures. Botulinum toxin paralysis of the intra-abdominal wall allows for oblique muscle lengthening preoperatively, in an effort to increase the elasticity of the abdominal wall and allow for complete abdominal wall reconstruction. Tissue expanders are saline-filled devices which act to slowly lengthen abdominal wall muscles is a similar fashion to botulinum toxin injection. The use of an arti-ficial burr device helps to exert constant medial traction on the mid-line abdominal wall muscles and slowly lengthens the oblique mus-cles via isotonic contraction. Each of these techniques are adjunctive maneuvers utilized preoperatively to prepare patients with large her-nias and loss of domain for definitive reconstruction

The purpose of this talk is to review these innovative preparatory techniques and review their outcomes.

IP-12548

AWR and mesh infection

Bhanot P

Georgetown University Hospital

Background: Infection of synthetic mesh following abdominal wall hernia repair is a complex problem. The purpose of this study is to determine whether a staged approach to abdominal wall reconstruc-tion using a porcine acellular dermal matrix is beneficial in the setting of infected synthetic mesh.

Methods: The authors performed a retrospective review of 27 patients who underwent immediate, staged complex AWR using porcine acellular dermal matrix (PADM) from 2007-2012.

Results: Primary fascial closure was achieved with component sep-aration in 21/27 (78%) patients while 6/22 (22%) received a bridged hernia repair with PADM. Wound related complications developed in 7/27 patients (26%) including wound dehiscence 6/27 (22%), sur-gical site infection 5/27 (18.5%), and hematomas 1/27 (4%). The hernia recurrence rate observed by 19 months was 18.5%. A bridged hernia repair and the development of a post-operative infection were associated with hernia recurrence, p<0.05.

Conclusion: A 2-stage approach to abdominal wall reconstruction with PADM can provide a safe and effective solution for patients with infected synthetic mesh.

Baystate

IP-140

The consequence of complications in AWR:

healthcare cost, reintervention, hernia recurrence

Heniford B, Augenstein V, Colivita P

Carolinas Medical Center

Objectives: To measure the expense of wound complications.

Background: Wound and mesh complications following ventral her-nia repair (VHR) are costly, but the price is more than just money.

Methods: Prospective, consecutive, open VHRs from 2008-2011 were analyzed. Wound infection, wound complications (breakdown, seroma requiring intervention, abscess), and mesh infection were examined. Charges incorporated all hernia-related visits, interven-tions, and re-admissions within one year. Wilcoxon-Mann-Whitney tests were used to compare charges. Quality of life (QOL) was meas-ured using Carolinas Comfort Scale.

Results: Five hundred consecutive open VHRs were analyzed. Patients were 57.2% female, mean age of 56.4 years, BMI of 33.1, and 60.6% had recurrent hernias. Average defect and mesh sizes were 198.3 cm2and 784 cm2. Panniculectomy and component separation

were performed in 31.8% and 25.4% of cases, respectively. Mean hospital changes included - mesh infections [11 patients (2.2%)]: $82,779; wound infections [## patients (XX%)]: $65,240; wound complications [## patients (XX%)]: $59,118; no wound complica-tions: $38,677 (p<0.001). Mean follow-up charges were: mesh infections $63,389, wound infecinfections $20,232, wound complications -$15,144 and no complications - $1,393 (p<0.001). Complications sig-nificantly impacted office efficiency. Patients without complications had 2.4 average post-operative visits, wound infections yielded 6.7, and mesh infections averaged 9.2. 51.7% and 90.9% of wound and mesh infection patients required readmission. At 2 week and 1 month follow-up, there were no differences in QOL in patients with and without infection or complications. At 6-month follow-up, 57.6% of patients with complications or infection had symptomatic discomfort versus 35.4% without complications (p=0.01), 58.6% versus 29.9% (p<0.001) had activity limitation, and 52.5% versus 34.2% reported mesh sensation (p=0.031).

Conclusion: VHR wound-related complications are responsible for significant cost on many levels: the financial impact during hospi-talization and after discharge, the increased patient and physician time investment, and the reduction in patient QOL. Efforts to reduce VHR wound-related complications should be strongly pursued.

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S10 Hernia (2014) 18 (Suppl 1): S8-S10

FP-12596

A risk prediction model for ventral hernia recurrence

and surgical site occurrences requiring procedural

intervention following ventral hernia repair in

clean-contaminated and clean-contaminated surgical sites

Cavallo J

Washington University School of Medicine

Introduction: The study purpose is to create multivariable risk pre-diction models that use patient characteristics, surgical site classifi-cations, and planned mesh type to pre-operatively calculate the risk of hernia recurrence (HR) and the risk of surgical site occurrences requiring procedural intervention (SSOPI) for patients undergoing clean-contaminated and contaminated ventral hernia repair (VHR). We hypothesize that mesh type will remain in the multivariable risk prediction models for both the risk of HR and the risk of SSOPI, and that permanent synthetic mesh reinforcement would incur reduced risk for both outcomes compared to biologic mesh reinforcement.

Methods: Leveraging existing resources of the MESH Consortium, the presence and frequencies of HR and SSOPI will be assessed from a prospectively maintained multi-institutional database for clean-con-taminated and conclean-con-taminated VHR. Univariate analyses between pre-operative patient characteristics, surgical site classifications, or mesh type (independent variables) and HR or SSOPI (dependent variables) will be conducted. Statistically-significant univariate associations (p<0.2) will be entered into the multivariable risk prediction models for HR and SSOPI, and evaluated via logistic or linear regression models. Multivariable models will be reduced via backward elimi-nation using a p<O.OS, and all possible combielimi-nations of models will be evaluated for best fit.

Potential: These pre-operative risk prediction tools will calculate risk values that aid appropriate patient selection for elective VHR in clean-contaminated and contaminated surgical sites, assist patient counseling about modifiable risk factors for HR or SSOPI, enable patient participation in decision making about the planned VHR, and inform surgeon selection of mesh type for VHR

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Wednesday, March 12, 2014

Session 2A: Scientific session I

© Springer-Verlag 2014

FP-12504

Obturator hernia treated by TAPP approach

Morrell A, Ribeiro D, Riberio G, Furtado M, Pareja T, Cavazzola L, Malcher F, Farah F, Meyer A, Costas M

Brazil

Obturator hernia is a rare but important cause of intestinal obstruc-tion.

Because it’s an unusual pathology, the diagnoses is usually delayed and is done during surgery or by the CT Scan in the pre operative evaluation of an acute abdomen.

The Obturator hernia represents 0.1 to 1.0% of all hernias and it is 6 times more frequent in woman in the 5th to 6th decade. In the etiology, we have factors as multiparity with format and pro-gressive relaxation and tilt of the female pelvis and slimming sharp. The video show a TAPP approach for an Obturator Hernia in a 55 years old woman presented at emergency room.

The video shows the CT Scan, a brief case description and the trans abdominal pre peritoneal (TAPP) procedure done in this case. At the end it’s enhanced some aspects in the diagnoses and pathology of the Obturator hernia.

FP-126

TIPP versus Lichtenstein: a randomized controlled

clinical trial

Koning G, Keus F, Koeslag L, Cheung C, Avci M, van Laarhoven C, Vriens P

Radboud University Nijmegen Medical Centre

Background: Preliminary experience has suggested that preperi-toneal mesh positioning causes less chronic pain than Lichtenstein’s technique for inguinal hernia repair. Therefore, a randomised con-trolled trial was conducted with the aim of evaluating the incidence of postoperative chronic pain after transinguinal preperitoneal (TIPP) mesh repair versus Lichtenstein’s technique.

Methods: Patients with a primary unilateral inguinal hernia were randomised to either TIPP or Lichtenstein’s repair in two teaching hospitals. The primary outcome was the number of patients with chronic pain after surgery. Secondary outcomes were adverse events. Follow-up was scheduled after 14 days, 3 months and 1 year. Patients and outcome assessors were blinded.

Results: A total of 302 patients were randomised to TIPP (143) or Lichtenstein (159) repair. Baseline characteristics were comparable in the two groups. Some 98.0 per cent of the patients were included in the analysis (141 in the TIPP group and 155 in the Lichtenstein group). Significantly fewer patients in the TIPP group had continuous chronic pain 1 year after surgery: five patients (3.5%) versus 20 patients (12.9%) in the Lichtenstein group (p=0.004). An additional 12 patients (8.5%) in the TIPP group and 60 (38.7%) in the Lichtenstein group experienced pain during activity (p=0.001). There were two patients with recurrence in the TIPP group and four in the Lichtenstein group, but no significant differences were found in other severe adverse events between the groups.

Conclusion: Fewer patients had continuous chronic pain or pain dur-ing activity at 1 year after the TIPP mesh dur-inguinal hernia repair com-pared with Lichtenstein’s repair.

Registration number: ISRCTN93798494 (http://www.controlled-tri-als.com).

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S12 Hernia (2014) 18 (Suppl 1): S11-S14

FP-131

Predicting 90-day wound morbidity following incisional

hernia repair with retrorectus mesh reinforcement

Petro C, Posielski N, Raigani S, Wang J, Criss C, Orenstein S, Rosen M, Novitsky Y

University Hospitals Case Medical Center

Background: Predicting wound morbidity after complex abdominal wall reconstructions (AWR) remains a challenge. While retrorectus repairs are gaining in popularity, specific risk factors for wound com-plications for this approach remain unclear. We aimed to identify the incidence and predictors of 90-day wound morbidity for patients undergoing complex AWR with retrorectus mesh placement.

Methods: Consecutive retrorectus hernia repairs performed at Case Medical Center were identified in our prospective database and ana-lyzed. Primary outcome measure was the incidence of surgical site occurrence (SSO) requiring an intervention. Statistical analysis was performed utilizing univariate analysis using Chi-squared and logistic regression as well as multivariate regression; p<0.05 was considered significant.

Results: From 2006-2013, 307 patients met inclusion criteria with at least 90-day follow-up. Eighty-nine SSOs were identified. Seven seromas required drainage, 3 at the bedside and 4 by interventional radiology (IR). There were 65 (21.2%) surgical site infections (SSI) with the majority being superficial. SSIs were treated with antibiotics alone in 27/34 superficial and 3/29 deep infections. Bedside drainage was necessary for 7 superficial and 4 deep SSIs, while IR drainage was necessary for 13/28 deep SSIs. Operative debridement was per-formed in the remaining 9 deep and 1 organ space SSIs (necessitating the only instance of mesh excision in the setting of perforated bowel/ileostomy creation). Obesity, diabetes, smoking, ASA, hernia width >20 cm and biologic mesh were independent predictors of SSO. SSO/SSI rates were 6%/6% for Grade 1, 16%/12% for Grade 2, and 39%/18% for Grade 3 hernias.

Conclusion: Mesh positioning during complex AWR has significant impact on wound complications. For the first time, based on a large cohort of patients, we identified specific patient and wound factors contributing to SSOs for hernia repairs with retromuscular mesh pal-cement. Our findings represent an important addition to AWR out-comes data to facilitate patient counseling as well as technique and mesh selections.

FP-116

Component separation index (CSI) and width of

diastasis predict complications after open components

separation for abdominal hernias

Goldblatt M, Rettenmaier C, Abston E, Frelich M, Wallace J, Gould J

Medical College of Wisconsin

Background: Components separation is a method of hernia repair utilized for complex hernias. This technique may have short term morbidity due to the extensive dissection required. The Component Separation Index (CSI) is a metric that objectively defines hernia morphology in relation to body habitus. We hypothesized that a larger CSI and longer Width of Diastasis (WD) were predictive of short-term (30-day) postoperative complications.

Methods: This is a retrospective review of patients who underwent components separation at the Medical College of Wisconsin from August 2009 to January 2013. Clinical and perioperative information was collected up to 30 days after surgery. The CSI was calculated from CT scans by dividing the angle of diastasis, measured from the aorta to the medial edges of the rectus abdominis muscles, by 360°.

Results: Thirty-nine patients underwent open components separation during the study period (35 bilateral, 4 unilateral). The majority of repairs were recurrent (31, 79.5%). A total of 9 patients (23.1%) experienced complications before discharge. Fourteen patients (35.9%) experienced complications within 30 days of discharge, of which 11 (78.6%) were wound complications. According to the ACS-NSQIP wound classification system our series presented 23 (59.0%) clean, 5 (12.8%) clean-contaminated, 9 (23.1%) contaminated, and 2 (5.1%) dirty wounds. No reoperations occurred. The mean follow-up interval was 17.8 months. There were three hernia recurrences (7.7%) with a mean interval to known recurrence of 7.0 months. A smaller CSI correlated with a greater incidence of total complications (p=0.05), post-discharge complications (p<0.01), and post-discharge wound complications (p=0.02). A larger CSI predicted hernia recur-rence (p=0.05). A larger WD predicted pre-discharge complications (p=0.04).

Conclusions: CSI is a valid predictor of 30-day complications, but unexpectedly, patients with lower CSI have more complications. These findings are not reproduced with WD. Larger CSI does cor-relate with greater recurrence rate in our cohort.

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augmentation as a means to reduce incisional hernia

Timmermans L, Jeekel J, Lange J

Erasmus MC

Background: Incisional hernia (IH) is one of the most frequent post-operative complications after abdominal surgery. Patients with an abdominal aortic aneurysm (AAA) or patients with a BMI of 27 or higher have a risk of developing an IH of more than 30%. Primary mesh augmentation (PMA) is a method in which the abdominal wall is strengthened to reduce IH incidence. This paper focuses on the short-term results of the PRIMA trial, a multicentre double blind ran-domized controlled trial (RCT) which compared onlay glued mesh augmentation (OMA) and sublay glued mesh augmentation (SMA) to primary suture (PS)

Methods: The RCT was performed in 11 hospitals in the Netherlands, Germany and Austria. Between 2009 and 2012, patients were included if they were either operated via midline laparotomy for an AAA or if they had a BMI of 27 or higher. Patients were ran-domly assigned to either receive PS, OMA or SMA.

Results: A total of 498 patients were selected of which 18 patients were excluded preoperatively, leaving 480 randomized patients. During analysis statistically significant (p=0.002) more seromas were detected after OMA (n=34, 18.1%) compared to PS (n=5, 4.7%) and SMA (n=13,7%). No other differences were discovered in any of the other outcomes. During multivariable analysis, seroma formation after OMA had an odds ratio (OR) of 4.5 (p=0.003) compared to PS and an OR of 2.9 (p=0.003) compared to SMA.

Conclusion: Based on the short-term results, PMA is a save proce-dure with only an elevation in seroma formation after OMA, but without an increased risk of surgical site infection (SSI). The long-term effects of PMA shall be evaluated after conclusion of the fol-low-up period of this RCT.

Souza J, Dumanian G

Northwestern University, Feinberg School of Medicine

Purpose:We present a novel suture design aimed at minimizing the early laparotomy dehiscence that drives ventral hernia formation.

Methods:Incisional hernias were produced in 30 rats according to an established hernia model. The rat hernias were randomized to repair with either two 5-0 polypropylene sutures (Group 1) or two mid-weight polypropylene mesh sutures (Group 2) placed in similar fashion. Standardized photographs were taken prior to repair and 1 month after repair, with an intra-abdominal sheet of 2 mm grid graph paper serving as a calibration reference for all photographs. Edge-detection software was used to define the border of the hernia defect and calculate the defect area. Histology was performed on all mesh suture specimens, with in-growth graded according to the ASTM 4-point scale.

Results:Seventeen hernias were repaired with mesh sutures; 13 her-nias were repaired with conventional sutures. Despite randomization, the defects repaired with mesh suture were significantly larger than those undergoing conventional suture repair (391.9±33.4 mm2 vs

255.4±23.3 mm2; p<0.0025). The mean area of the recurrent defects

following repair with mesh suture was 177.8±27.1 mm2, compared

to 267.3±34.1 mm2following conventional suture repair. This

corre-lated to a 57.4% reduction in defect area after mesh suture repair, compared to a 10.1% increase in defect area following conventional suture repair (p<0.0007). None (0/34) of the mesh sutures pulled-through the surrounding tissue, while 65% (17/26) of the conven-tional sutures demonstrated complete pull-through. Excellent (ASTM3) in-growth was observed in 13/17 mesh suture specimens; 4 specimens demonstrated Good (ASTM2) in-growth.

Conclusions: The mesh sutures better resisted suture pull-through than conventional polypropylene sutures. By more evenly distributing distracting forces and permitting tissue integration into the substance of the suture, a suture incorporating these design elements may pre-vent the early laparotomy dehiscence that leads to incisional hernia formation.

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S14 Hernia (2014) 18 (Suppl 1): S11-S14

FP-209

Predictors of 30-day readmission after ventral hernia

repair

Oommen B, Kim M, Ross S, Bradley J, Williams K, Walters A, Lincourt A, Heniford B, Augenstein V

Carolinas Medical Center, Department of Surgery, Division of Gastrointestinal & Minimally Invasive Surgery

Introduction: Hospital readmission within 30 days of surgery is associated with negative patient outcomes and increased healthcare costs. Current data regarding risk factors for readmission after ventral hernia repair (VHR) are limited. We analyzed basis for readmission after VHR.

Methods and procedures: The ACS-NSQIP database was queried for all inpatient VHRs. Inclusion criteria were elective VHR with 30-day readmission data recorded (available since 2011). Bivariate analysis was performed to determine variables that were potentially associated with readmission. Multivariate regression, incorporating significant factors identified on the bivariate analysis, was then per-formed.

Results: Out of 10,529 elective VHRs (7,987 open; 2,402 laparo-scopic), 9,495 met inclusion criteria. The overall 30-day readmission rate was 9.9%. Mean age was 57.8±13.5 years; 572% were female. Patients readmitted were more likely to have the following preoper-ative conditions (p≤0.05): higher mean BMI (34.0±9.1 vs 33.2±8.6 kg/m2), diabetes (12.7% vs 9.2%), smoking (12.5% vs 9.3%),

dysp-nea (14.5% vs 9.4%), dependent functional status (21.5% vs 9.7%), COPD (15.9% vs 9.5%), ascites (18.4% vs 9.8%), CHF (31.7% vs 9.8%), hypertension (10.7% vs 8.9%), dialysis (16.8% vs 9.8%), bleeding disorder (13.0% vs 9.8%), wound class II-IV (12.4% vs 8.5%), ASA class IV/V (17.5% vs 9.6%). Postoperative complica-tions were also associated with readmission (p<0.001): superficial SSI (36.1% vs 8.8%), deep SSI (62.2% vs 8.8%), organ space SSI (53.5% vs 9.2%), pneumonia (31.3% vs 9.5%), unplanned intubation (20.4% vs 9.7%), pulmonary embolism (45.9% vs 9.7%), ventilator >48 hours (20.2% vs 9.8%), progressive renal insufficiency (38.0% vs 9.8%), UTI (22.8% vs 9.7%), stroke (53.9% vs 9.8%), MI (43.2% vs 9.8%), perioperative transfusions (20.0% vs 9.4%), graft/prosthe-sis failure (66.7% vs 9.9%), DVT (46.9% vs 9.7%), sepgraft/prosthe-sis (50.4% vs 8.9%), septic shock (36.1% vs 9.7%), reoperation (57.5% vs 7.7%). Readmission was associated with longer mean operative time (181±111 vs 148±98 min), mean LOS (5.9±12.8 vs 4.4±7.8 days), and open repair (11.0% vs 6.2%); p<0.001 for all. Multivariate regression found diabetes, smoking, dyspnea, dependent functional status, CHF, wound classification, ASA class, open approach, and operative time to be independent factors associated with readmission after VHR.

Conclusions: Readmission after ventral hernia surgery is a more common occurrence that might before have been suspected and cor-relates with specific preoperative patient factors, operative character-istics, and postoperative complications. By targeting these risk factors for quality improvement and decreasing operative time, readmission rates and healthcare costs may be significantly improved. While laparoscopic VHR has lower readmission rates overall, other factors, including case complexity, may impact these findings.

FP-12574

2012 Resident research grant – Synthetic hernia mesh

with nitric oxide induced bacteriacidal properties –

A paradigm shift

Fernandez-Moure J, Van Eps J, Bryan N, Weiner B, Olsen R, Dunkin B, Tasciotti E

Houston Methodist Hospital

Background: Mesh infection after ventral hernia repair results in significant morbidity. Management includes re-operation with mesh excision and antibiotic therapy. Impregnating mesh with antibiotics may decrease infection but is prone to resistance. Nitric Oxide (NO), a diatomic free radical with no known resistance mechanism, plays a key role in the natural immune response to fighting infection and may overcome these limitations. We sought to create a NO-releasing mesh and study its antibacterial efficacy in vitro and in vivo, hypoth-esizing that a NO-releasing polyester mesh would prevent MRSA colonization and growth.

Methods: NO-Silica (NO-Si) nanoparticles were synthesized via a co-condensation of tetraethoxysilane with aminoalkoxysilane with methanol and ammonia under high pressure nitrous oxide. NO release was measured and confirmed using a chemiluminescence NO ana-lyzer. MRSA bactericidal efficacy of these nanoparticles was quan-tified in vitro through tryptic soy broth assay. The NO-Si nanopar-ticles were then bound to a commercially available polyester mesh and implanted in a rat model of ventral hernia repair and inoculated with MRSA. Bacterial growth was quantified using colony forming unit assay.

Results: NO-Si, synthesized at 500nm, was capable of NO release for up to 12 hours. NO release from the NO-silica polyester mesh was equivalent to NO-Si alone. MRSA CFUs recovered relative to treatment demonstrated a dose dependent response to NO-Si with 100% bactericidal effect at 66mg NO-Si in vitro. The in vivo bac-tericidal effects of the NO-releasing mesh correlated with in vitro results with 100% bacterial clearance at 66mg NO-Si.

Conclusion: This study created a NO-releasing synthetic mesh and demonstrated its MRSA bactericidal efficacy both in vitro and in vivo. Creation of a novel polyester mesh with enhanced non-antibi-otic antibacterial activity using nanoparticles may lead to a paradigm shift in treating not only abdominal wall defects in a contaminated environment, but perhaps all surgeries that require use of a synthetic mesh.

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Wednesday, March 12, 2014

Session 2B: Chronic inguinodynia

© Springer-Verlag 2014

IP-12562

Assessment, evaluation and nonoperative treatment of

patients with inguinodynia after inguinal hernia repair

Phillips M

University of Tennessee Health Science Center

Chronic groin pain has been estimated to occur in 15-25% of patients undergoing inguinal hernia repair. Surgical technique is an important aspect of prevention of this pain with identification and care to pre-serve the nerves of the groin playing an essential role. Assessment of these patients involves detailing the onset and quality of pain as well as the patterns of radiation and the nature of pain. Initial man-agement entails excluding non-neuropathic pain etiologies such as recurrent hernia or mesh infection. Imaging studies may be indicated to further investigate these sources. Pain management in the early postoperative period will include opioids and NSAIDs, where per-sistent pain may require the addition of nerve blocks or nerve abla-tion. Others will address the surgical techniques for management of chronic inguinodynia including groin exploration, mesh removal, and neurectomy.

IP-160

Prophylactic neurectomy during inguinal hernia repair

to prevent chronic inguinodynia: does it work?

Greenberg J

University of Wisconsin

The incidence of inguinodynia following inguinal hernia repair ranges from 0-63% in the literature. While neurectomy is frequently involved in the treatment of chronic groin pain, the role of prophy-lactic neurectomy during inguinal hernia repair remains unclear. Of the three nerves commonly responsible for postoperative inguin-odynia, prophylactic ilioinguinal neurectomy has been the most widely studied. Five separate randomized controlled trials (RCT) have evaluated the effect of prophylactic ilioinguinal neurectomy on the incidence of postoperative inguinodynia. A meta-analysis

incorporating four of these trials showed a small but significant decrease in the degree of pain at 6 months favoring neurectomy (-0.29 on a 10-point scale) [1]. The fifth and most recent study showed

no significant reduction in the rate of moderate or severe pain inten-sity beyond the first month of follow-up [2]. One RCT has looked at

ilioinguinal neurectomy in conjunction with subcutaneous transposi-tion of the spermatic cord and found no change in chronic pain at 6 months while at rest. However, neurectomy was associated with decreased rates of chronic pain while walking (0% vs 41.7%, p=0.001) and ascending stairs (0% vs 37.5%, p=0.02) [3].

An alternative approach to prophylactic neurectomy is identification and preservation of all nerves during herniorraphy. One multicenter prospective study of 973 patients undergoing open mesh inguinal hernia repair, found that the lack of identification of nerves as well as the division of nerves were both significantly correlated with the presence of chronic pain [4]. Another study of 525 patients undergoing

Lichtenstein hernioplasty assessed the value of nerve identification and resection of nerves “at risk” again found the non-identification of nerves correlated to the highest level of inguinodynia at 3 months[5].

While prophylactic neurectomy may have some benefit with respect to inguinodynia, a focus on intraoperative nerve identification and preservation is likely more beneficial.

References:

1. Johner, A., J. Faulds, and S.M. Wiseman, Planned ilioinguinal nerve exci-sion for prevention of chronic pain after inguinal hernia repair: a meta-analysis. Surgery, 2011. 150 (3): p. 534-41.

2. Crea, N. and G. Pata, Effects of prophylactic ilioinguinal nerve excision in mesh groin hernia repair: short- and long-term follow-up of a random-ized clinical trial. Am Surg, 2010. 76 (11): p. 1275-81.

3. Caliskan, K., et al., A method for the reduction of chronic pain after ten-sion-free repair of inguinal hernia: iliohypogastric neurectomy and subcu-taneous transposition of the spermatic cord. Hernia, 2010. 14 (1): p. 51-5. 4. Alfieri, S., et al., Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain. Ann Surg, 2006. 243 (4): p. 553-8.

5. Smeds, S., L. Lofstrom, and O. Eriksson, Influence of nerve identification and the resection of nerves “at risk” on postoperative pain in open inguinal hernia repair. Hernia, 2010. 14 (3): p. 265-70.

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