Christine Schug-Pass

How Long Do We Need to Follow-Up Our Hernia Patients to Find the Real Recurrence Rate?

Introduction It is known that recurrences continue to occur after the follow-up period of 1–5 years usually used in most hernia studies. By reviewing the data in the Herniamed Hernia Registry documenting the time interval between the recurrent operation and previous inguinal hernia repair, the present study identifies the temporal course of onset of recurrence. Patients and Methods Prospective data were recorded in the Herniamed Registry between 1 September 2009 and 4 May 2015 on a total of 145,590 patients with 171,143 inguinal hernia operations. These included 18,774 operations due to an inguinal hernia recurrence (10.94%). During the same period, prospective data were collected on 24,385 incisional hernia operations. The latter cases included 5,328 patients with a recurrent incisional hernia (21.85%). Results Only 57.46% of all inguinal hernia recurrences occurred within 10 years of the previous inguinal hernia operation. Some of the remaining 42.54% of all recurrences occurred only much later, even after more than 50 years. The course of onset of recurrence is markedly different for incisional hernia. About 91.87% of such recurrences occur already within 10 years of the last operation. Conclusion Ascertainment of the actual recurrence rate after hernia repair calls for a follow-up of 10 years for incisional hernia and of 50 years for inguinal hernia. The data collected can be used to give an approximate estimate with a shorter follow-up.

Tailored Approach in Inguinal Hernia Repair – Decision Tree Based on the Guidelines

The endoscopic procedures TEP and TAPP and the open techniques Lichtenstein, Plug and Patch, and PHS currently represent the gold standard in inguinal hernia repair recommended in the guidelines of the European Hernia Society, the International Endohernia Society, and the European Association of Endoscopic Surgery. Eighty-two percent of experienced hernia surgeons use the “tailored approach,” the differentiated use of the several inguinal hernia repair techniques depending on the findings of the patient, trying to minimize the risks. The following differential therapeutic situations must be distinguished in inguinal hernia repair: unilateral in men, unilateral in women, bilateral, scrotal, after previous pelvic and lower abdominal surgery, no general anesthesia possible, recurrence, and emergency surgery. Evidence-based guidelines and consensus conferences of experts give recommendations for the best approach in the individual situation of a patient. This review tries to summarize the recommendations of the various guidelines and to transfer them into a practical decision tree for the daily work of surgeons performing inguinal hernia repair.

TEP or TAPP for recurrent inguinal hernia repair—register-based comparison of the outcome

AbstractIntroductionThe guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.Materials and Methods Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).Results Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.Conclusion TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.

The Intra- and Postoperative Complication Rate of TEP in Patients Undergoing Unilateral Endoscopic Inguinal Hernia Repair Is Not Higher Compared with TAPP

We read with much interest the article by Gass et al. [1], in which the results of endoscopic repair of unilateral inguinal hernias using either total extraperitoneal inguinal hernia repair (TEP) or transabdominal preperitoneal inguinal hernia repair (TAPP) were compared on the basis of prospective data from the Swiss Association of Laparoscopic and Thoracoscopic Surgery. The period of time covered was from 1995 to 2006 and involved 3,457 TEP operations and 1,095 TAPP operations. For TEP, the authors noted a significantly higher intraoperative complication rate (TEP 1.9 % versus TAPP 0.9 %; p = 0.029) and surgical postoperative complication rate (TEP 2.3 % versus TAPP 0.8 %; p = 0.003). They therefore concluded that, based on their prospectively collected data, the TAPP technique was superior to the TEP technique. That finding is surprising because all systematic reviews, meta-analyses, and guidelines published to date have concluded that these two methods are equivalent, and none of the reports showed any significant differences between them [2–4]. In the German-speaking countries it has been possible since January 2010 to participate in the Herniamed Register, into which data on all hernia surgical operations can be entered in a standardized manner [5]. Among the more than 50,000 cases recorded in that register up until September 2012 there are 4,583 TEP operations and 8,220 TAPP operations for unilateral inguinal hernias. The intraoperative complications for TEP are 1.5 % (hemorrhage, 40; injuries to internal organs/blood vessels, 29); for TAPP, the corresponding numbers are 1.65 % (hemorrhage, 85; injuries to internal organs/blood vessels, 51). The postoperative complication rate for TEP is 1.8 % (82/4,587), and that for TAPP it is significantly higher at 4.35 % (358/8,220; p \ 0.0001). This difference is primarily due to a significantly higher seroma rate for TAPP (278/8,220; 3.38 %). For TEP, the seroma rate is only 0.52 % (24/4,583; p \ 0.0001). In the Herniamed Register the reoperation rate for TEP after unilateral inguinal hernia operation is 0.81 % (37/4,583), and that for TAPP it is 0.98 % (81/8,220). From the Herniamed data it can be concluded that the intraoperative and postoperative surgical complications for TEP are not higher than for TAPP. That TAPP is associated with a significantly higher seroma rate compared with TEP suggests that not enough attention is being paid to a reduction of the hernia cavity in TAPP operations for medial inguinal hernia repair [2]. There can be no other explanation for the higher incidence of postoperative seromas following TAPP compared with TEP. In any case, based on the data recorded in the Herniamed Hernia Register, it can be reliably stated that the intraoperative and postoperative complication rates with TEP for unilateral inguinal hernia repair are not higher than the rates with TAPP. In fact, the Herniamed Register data show a significantly higher seroma rate for TAPP compared with TEP, and it is precisely that problem that can be overcome by observing the guidelines [2]. F. Köckerling C. Schug-Pass D. A. Jacob (&) Department of Surgery and Center of Minimally Invasive Surgery, Vivantes Hospital, Neue Bergstr. 6, 13585 Berlin, Germany e-mail: dietmar.jacob@vivantes.de

Seroma following transabdominal preperitoneal patch plasty (TAPP): incidence, risk factors, and preventive measures

BackgroundThe reported range of seroma formation in the literature after TEP repair is between 0.5 and 12.2% and for TAPP between 3.0 and 8.0%. Significant clinical factors associated with seroma formation include old age, a large hernia defect, an extension of the hernia sac into the scrotum, as well as the presence of a residual indirect sac. Seroma formation is a frequent complication of laparoendoscopic mesh repair of moderate to large-size direct (medial) inguinal hernia defects. This present analysis of data from the Herniamed Hernia Registry now explores the influencing factors for seroma formation in male patients after TAPP repair of primary unilateral inguinal hernia.MethodsIn total, 20,004 male patients with TAPP repair of primary unilateral inguinal hernia were included in uni- and multivariable analysis.ResultsUnivariable analysis revealed the highly significant impact of the fixation technique on the seroma rate (non-fixation 0.7% vs. tacks 2.1% vs. glue 3.9%; p < 0.001). Multivariable analysis showed that glue compared to tacks (OR 2.077 [1.650; 2.613]; p < 0.001) and non-fixation (OR 5.448 [4.056; 7.317]; p < 0.001) led to an increased seroma rate. A large hernia defect (III vs. I: OR 2.868 [1.815; 4.531]; p < 0.001; II vs. I: OR 2.157 [1.410; 3.300]; p < 0.001) presented a significantly higher risk of seroma formation. Likewise, medial compared to lateral inguinal hernias had a higher seroma rate (OR 1.272 [1.020; 1.585]; p = 0.032).ConclusionsMesh fixation with tacks or glue, a larger hernia defect, and medial defect localization present a higher risk for seroma development in TAPP inguinal hernia repair.

A word of caution: never use tacks for mesh fixation to the diaphragm!

BackgroundThe mesh fixation technique used in repair of hiatal hernias and subxiphoid ventral and incisional hernias must meet strenuous requirements. In the literature, there are reports of life-threatening complications with cardiac tamponade and a high mortality rate on using tacks. The continuing practice of tack deployment for mesh fixation to the diaphragm and esophageal hiatus should be critically reviewed.MethodsIn a systematic search of the available literature in May 2017, 23 cases of severe penetrating cardiac complications were identified. The authors became aware of two other cases in which they acted as medical experts. Furthermore, the instructions for use issued by the manufacturers of the tacks were reviewed with regard to their deployment in the diaphragm.ResultsTwenty-three of 25 cases (92%) with severe cardiac injuries and subsequent cardiac tamponade were triggered by the use of tacks in the diaphragm. In six cases (24%), these related to ventral and incisional hernias with extension to the subxiphoid area, and in 19 cases (76%) to mesh-augmented hiatoplasty. Twelve of 25 (48%) patients died as a result of pericardial and/or heart muscle injury with cardiac tamponade despite heart surgery intervention. In the tack manufacturers’ instructions for use, their deployment in the diaphragm, in particular in the vicinity of the heart, is contraindicated. Likewise, the existing guidelines urgently advise against the use of tacks in the diaphragm, recommending instead alternative fixation techniques.ConclusionsTacks should not be used for mesh fixation in the diaphragm above the costal arch.

What Is the Current Knowledge About Sublay/Retro-Rectus Repair of Incisional Hernias?

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

Laparoskopische Resektion beim kolorektalen Karzinom – aktueller Stand und Perspektiven

Die laparoskopische Resektion des kolorektalen Karzinoms in kurativer Absicht hat bis heute im chirurgischen Alltag einen nur begrenzten Stellenwert. Dies zeigt die «Qualitätssicherungsstudie Kolorektales Karzinom». Dennoch gibt es inzwischen einige prospektiv randomisierte Vergleichsstudien, deren Auswertungen für die offene und die laparoskopische Resektion vergleichbare onkologischen Ergebnisse nachweisen konnten. Das rezidivfreie Überleben hängt dabei neben dem Tumorstadium von der operativen Erfahrung und Sorgfalt des Einzelnen ab und ist unabhängig von der Art des operativen Zugangs, wenn vorgegebene Standards eingehalten werden. Die Patienten profitieren von den allgemeinen Vorteilen des laparoskopischen Eingriffs im unmittelbar postoperativen Verlauf.

What are the influencing factors for chronic pain following TAPP inguinal hernia repair: an analysis of 20,004 patients from the Herniamed Registry

BackgroundIn inguinal hernia repair, chronic pain must be expected in 10–12% of cases. Around one-quarter of patients (2–4%) experience severe pain requiring treatment. The risk factors for chronic pain reported in the literature include young age, female gender, perioperative pain, postoperative pain, recurrent hernia, open hernia repair, perioperative complications, and penetrating mesh fixation. This present analysis of data from the Herniamed Hernia Registry now investigates the influencing factors for chronic pain in male patients after primary, unilateral inguinal hernia repair in TAPP technique.MethodsIn total, 20,004 patients from the Herniamed Hernia Registry were included in uni- and multivariable analyses. For all patients, 1-year follow-up data were available.ResultsMultivariable analysis revealed that onset of pain at rest, on exertion, and requiring treatment was highly significantly influenced, in each case, by younger age (p < 0.001), preoperative pain (p < 0.001), smaller hernia defect (p < 0.001), and higher BMI (p < 0.001). Other influencing factors were postoperative complications (pain at rest p = 0.004 and pain on exertion p = 0.023) and penetrating compared with glue mesh fixation techniques (pain on exertion p = 0.037).ConclusionsThe indication for inguinal hernia surgery should be very carefully considered in a young patient with a small hernia and preoperative pain.

What Do We Know About Component Separation Techniques for Abdominal Wall Hernia Repair

Introduction The component separation technique (CST) was introduced to abdominal wall reconstruction to treat large, complex hernias. It is very difficult to compare the published findings because of the vast number of technical modifications to CST as well as the heterogeneity of the patient population operated on with this technique. Material and Methods The main focus of the literature search conducted up to August 2017 in Medline and PubMed was on publications reporting comparative findings as well as on systematic reviews in order to formulate statements regarding the various CSTs. Results CST without mesh should no longer be performed because of too high recurrence rates. Open anterior CST has too high a surgical site occurrence rate and henceforth should only be conducted as endoscopic and perforator sparing anterior CST. Open posterior CST and posterior CST with transversus abdominis release (TAR) produce better results than open anterior CST. To date, no significant differences have been found between endoscopic anterior, perforator sparing anterior CST and posterior CST with transversus abdominis release. Robot-assisted posterior CST with TAR is the latest, very promising alternative. The systematic use of biologic meshes cannot be recommended for CST. Conclusion CST should always be performed with mesh as endoscopic or perforator sparing anterior or posterior CST. Robot-assisted posterior CST with TAR is the latest development.