EAES Academy

Introduction

An inter-rectus distance (IRD) more than 5 cm is labelled as severe diastasis.
Endoscopic plication could develop excessive midline tension that could increase recurrence rate in patients with severe rectus diastasis (SRD) in midterm follow-up.
Previously published minimally invasive endoscopic repair (FESSA technique)(FT) was proposed in those patients to corrects both pathologies decreasing the excessive midline tension
The present study aimed to assess clinical results, in terms of postoperative pain, functional recovery and recurrence rates of FT compared to endoscopic anterior rectus sheaths plication and mesh (ARSP), for ventral or incisional hernias and SRD associated.
Secondary aims of the study were to identify intra- and postoperative complications associated with each technique.

PATIENTS AND METHODS
Study design and population
All male patients with midline ventral or incisional hernia and SRD were included in a prospectively maintained databased and retrospectively analyzed from January 2017 to December 2020. Patients were collected from Quiron Sagrado Corazón Hospital in Seville, Spain.
The distribution of FT of ST approaches were studied and grouped according to different time. From January 2017 to January 2019, patients with SRD and midline ventral or incisional hernias underwent to ARSP (Control group). From January 2019 to December 2020 patients with SRD and midline ventral or incisional hernias underwent to FT (Case group). The outcomes of patients who underwent ASRP were compared with those of patients who had SRD and midline hernias repairs using FT.
Inclusion criteria:
• Patients aged between 18 and 80 years old.
• Symptomatic midline ventral/incisional hernias with IRD > 5 cm.

For each patient, retrospectively, the following data were collected:
• Demographic: Age, Body mass index (BMI) risk factor for hernia recurrence and hernia type. Defect and diastasis width and length were measured using preoperative CT scan at rest.
• Surgical results:
o Operation time (minutes).
o Intraoperative complications.
o Hospital stay (days)
o Postoperative complications.
o Pain (VAS) preoperative and on 1th/7th/30th days using Eurahs Quality of life score for pain
o Functional recovery (Eurahs Quality of life score for restriction)
o Hernia recurrence: Clinical examination after 6 months and 1 year, as well as through an abdominal CT scan 6 month and 1 year after surgery.

Statistic
variables were compared using nonparametric tests. Chi-square test was used to evaluate categorical data. p values of < 0,05 were considered statistically significant. Data were expressed as mean +/- standard deviation (SD)


Results:

55 male patients were eligible. 2 patients were lost during the follow-up. 53 patients were finally included. 28 patients underwent FT and 25 to ARSP. Mean defect width and length were 4+/-1 cm and 3+/-1 cm in FT group and 3+/-1 and 3+/-1 cm respectively in ARSP group. Mean diastasis width was 6+/-1 in FT group and 5+/-1 in APRS group, without significant differences.
No intraoperative complications were identified.
Mean operative time was 70 +/-9 min in FT group and 55+/- 7 min in ARSP group with significant differences.(p:0.00002)
Hospital stay was 1.4+/- 0,5 days for FT and 2,08+/-0,5 days firo ARSP groups with significant differences in favor of FT group (p:0.00006)
Postoperative complications:
- one postoperative suprapubic subcutaneous hematoma, requiring surgical removal (2%) in ARSP group and none in FT group. .

Mean Pain at postoperative day 1 was 21+/2 in FT group and 25 +/-2 in ARSP group without significant differences. When postoperative pain after 7 and 30 days were compared, significant improvement were shown in favor of FT (p<0,05). Mean functional recovery at 1 postoperative month was 17,8 +/-2,4 in FT group and 27,8 +/-3,3 in ARSP group with significant improvement in favor of FT. After 6 months no differences were shown.
Overall recurrence after 24 months follow-up was 10 patient (28,9%).1 patient in FT group (3.6%) and 9 patient in ARSP group (36.0%) with significant differences in favor of FT (p=0.004), ODDS RATIO: 0.06 in favor of FT .

Conclusions:

Minimally invasive endoscopic Anterior rectus sheaths plication with mesh in severe rectus diastasis and midline hernias, shows higher recurrence rate, postoperative pain and worse functional recovery due to probably excessive midline tension. New endoscopic technique bringing together the medial aspects of both anterior rectus sheaths after those have been incised, solve the higher midline tension, minimizing the risk of recurrences and improving the postoperative pain and functional recovery.