Introduction LIRA (Laparoscopic Intracorporeal Rectus Aponeuroplasty) described in 2018 by our group showed advantages in preliminary results in terms of recurrence and bulging because a reduced tension in the midline in W2 defects following the EHS Classification. Otherwise permanent fixation in inlay meshes is related with and increase of pain and adhesions. We present LIRA-LESS step to step as an evolution in LIRA technique. Material and methods A 58 years old male affected by a M3W2 hernia. A LIRA procedure is proposed. Step 1: adhesions release and sac content reduced. Step 2: defect measurement and flap designed following the LIRA Technique principles with the neumoperitoneum deflated and flap mobilized and suture in the midline. Step 3 An in lay mesh of PVDF is positioned reducing permanent fixation in cardinal points combined with Cianocrilate in a 3:1 way. Step 4 A TAP-block anesthesia is performed in this case with Ropivacaine 2%. Results Operative time was 95 min. VAS 1 day was 3 and was discharge without complications. VAS 7 day in clinical office was 0. There were not recurrence or Bulkging in CT -Scan 1 month after the surgery. Discussion LIRA technique is a safe procedure with a low tension in the midline with good reults in terms of recurrence and bulging. LIRA-LESS concept allows a reduction in traumatic permanent fixation with good results in terms of pain and recurrence.

Background LIRA technique (Laparoscopic Intracorporeal Rectus Aponeuroplasty) was described in 2018 in order to reduce the tension in the midline as an alternative to defect closure (CD) in Laparoscopic Ventral Hernia Repair. We present our results in LIRA series in patients with a medium follow up Methods A prospective controlled study from January 2015 to December 2020 to evaluate (LIRA) performed on patients with midline w2 hernias (EHS Classification). Data analyzed included patient demographics, operative parameters and complications. Tomography was performed preoperatively and postoperatively (1 month and 1 year) to evaluate recurrence, distance between rectus and seroma. Clinical examination were performed yearly. Results 49 patients. Mean Age was 58± 10.59 years old and BMI 33.11± 6.61 kg/m2. Mean width of the defect was 6.19± 1.49 cm. Average VAS (24 h) was 5.09 ± 5, 0.38(1 month) and 0 (1 year). Mean preoperative distance between rectus was 5.55± 1.61 cm; postoperative was 2.15 ± 0.79 cm (1 month) and 2.20±0.68 cm (1 year). Radiological seroma at first month was detected in 40%. Seroma after 1 year was 4,08% Mean follow-up was 24 months. Bulging detected only in 1 case (2.04%) after 1 year follow up. No recurrence is data. Conclusion LIRA technique could be considered as an alternative to CD for w2 defects with a low rate of complication, and could be related to a low rate of postoperative pain with no recurrence and a low rate of bulging compared to CD, being a safe, feasible and reproducible technique.

Aim We present the experience in the transversus abdominis release (TAR) technique using a minimally invasive approach in our center. Methods We expose those W3 defects intervened by laparoscopic TAR(n=6). Step 1: Releasing adhesions from previous surgeries. Step 2: Bilateral Rives space dissection, as well as the Rossen's space, this one using “down to up” technique. Step 3: Closure of the gap with barbed suture. In all cases, a PVDF mesh has been associated with atraumatic fixation, and 2 drains were placed. Results The mean age was 62, 100% men, and their BMI was greater than 25Kg/m2. All underwent scheduled surgery, using a minimally invasive approach, placing the mesh at the retromuscular level. Postoperative stay was 7.6 days. We did not obtain major complications (perforation, bleeding), but a drainage hole wound infection was registered. We had no readmissions or any medical complications. Follow-up of 12 months, without signs of recurrence or chronic pain. Conclusions Although Robotic surgery and Botulinum toxin in surgery seems to be the future, in our experience TAR technique performed by laparoscopy is useful for large midline incisional hernias treatment as well as those associated with a lateral component in a terciary Hospital. We obtain good results in terms of recurrence and restoration of the abdominal wall dynamics. However, further studies are necessary to be carried out by experienced teams to reach conclusions.

Background The primary aim of this prospective study is to compare the postoperative outcomes between LIRA technique and IPOM plus, in terms of recurrence and bulging rates at one-year follow-up; the secondary aim is to compare the postoperative complications, seroma and pain at 30 days and one-year after surgery. Methods Patients with midline ventral hernia of 4–10 cm in width were included. Seromaand recurrence was evaluated by Computed tomography scan 1 month and 1 year after surgery. Pain was evaluated using the visual analogue scale score. Results Forty-five and forty-seven patients underwent LIRA and IPOM plus, respectively. Preoperatively, smoke habitus rate was statistically significantly higher in LIRA group (20 patients, 44.4%) in comparison to IPOM group (5 patients, 10.6%) (p=0.0001). Statistically significant differences were not considering the intraoperative variables. Two bulgings (4.4%) occurred in the LIRA group, while in the IPOM group occurred 10 bulgings (21.3%) and three recurrences (6.4%) (p=0.017 and p=0.085, respectively). Postoperatively, seven (15.6%, Clavien-Dindo I) and four complications (8.5%, two Clavien-Dindo I and two Clavien-Dindo III-b) occurred in the LIRA and in the IPOM group, respectively (p=0.298). One month after surgery, clinical seroma, occurred in five (11.1%) and eight patients (17%) in the LIRA and in the IPOM group, respectively (p=0.416). During follow-up, pain reduction occurred, without statistically significant differences. Conclusions LIRA showed lower bulging and recurrence rates in comparison to IPOM plus at one-year follow-up. Further prospective studies, with a large sample of patients and longer follow-up are required to draw definitive conclusions.