Ferdinand Köckerling

Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia.

We thank Christophe Berney for his interesting and very important Letter to the Editor, in which he addresses a number of aspects of the evidence-based technique of total extraperitoneal patchplasty (TEP) discussed in the ‘‘Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia’’ [1]. The technique must once again be clarified in more precise terms. At issue is the role of fibrin sealant for mesh fixation in TEP and the implications of the role of fibrin sealant in seroma formation. Christophe Berney reports on his own experiences with fibrin sealant for mesh fixation in 650 TEP operations with low complication and recurrence rates [2]. In the subsection entitled ‘‘Should a drain be used after a TEP repair? Should seromas be aspirated?’’ [1, p. 2794], the study by Lau [3] is cited as a level 1B statement. In that prospective randomized comparative study of bilateral inguinal hernias, it was noted that the use of fibrin sealant compared to staples for mesh fixation in TEP led to a significant reduction in the need for analgesics, but it also led to a significant rise in the rate of postoperative seromas. Here it is important to focus on the definition used by Lau [3] for a postoperative seroma: ‘‘A seroma was defined as the clinical presence of a palpable fluid collection over the groin in the absence of bruising during follow-up.’’ Also noteworthy in the Lau study [3] is that the proportion of direct hernias was very high, amounting to 56.5% in the fibrin sealant group and 58.5% in the staple group. In the Lau study [3] a clinically palpable seroma with protrusion of the skin was noted in only 5.3% of cases in which staples were used and in 17.4% (p = 0.009) of cases in which fibrin sealant was used for mesh fixation. Therefore, by virtue of the Lau study [3], it must be borne in mind that mesh fixation to Cooper’s ligament with staples tends to be more suitable for prevention of a clinically palpable seroma with protrusion of the skin in the groin after a TEP operation for direct hernias. The classification system used in the Guidelines means that queries relating to both TEP and TAPP are dealt with in separate sections. Therefore, further statements and commentaries on the issues raised by Christophe Berney can be checked in Chapter 9, ‘‘Mesh fixation modalities: is there an association with acute or chronic pain?’’ and Chapter 10, ‘‘Risk factors and prevention of acute and chronic pain.’’ On p. 2822 there is a clear statement on the scientific level 1B whereby the risk of acute and chronic pain after staple mesh fixation is higher compared with fibrin fixation or nonfixation. On p. 2817 nonfixation of mesh in TEP is then elaborated on in greater detail: ‘‘In total, seven studies have compared fixation versus nonfixation in TEP, of which only two have 1 B evidence level. They did not discover any difference in the incidence of recurrence between fixated versus nonfixated mesh. In total, 12,114 hernia repairs F. Kockerling D. A. Jacob (&) Department of Surgery and Center for Minimally Invasive Surgery, Vivantes Hospital, Neue Bergstr. 6, 13585 Berlin, Germany e-mail: dietmar.jacob@vivantes.de

Herniamed: an Internet-based registry for outcome research in hernia surgery

PurposeDespite the high frequency of hernia surgery procedures and continuous improvements, thanks to new hernia meshes and fixation techniques, in Germany, for example, the recurrence rate and rate of chronic inguinal pain after inguinal surgery are more than 10% far too high. Introduction of a hernia register in Denmark led to a significant reduction in the recurrence rate.MethodsThe aim of a hernia registry as an application-oriented outcome research tool is to monitor and evaluate (concomitant research) how the knowledge gleaned from evidence-based science is implemented in the everyday clinical setting and, ultimately, investigate its effectiveness (outcome research).ResultsThe new Internet-based English- and German-language registry for the entire spectrum of inpatient and outpatient hernia surgery is designed to improve the quality of patient care and provide valid data on outcome research. Via the Internet, all relevant patient data (comorbidities, previous operations, staging, specific surgical technique, medical devices used, perioperative complications and follow-up data) can be entered into the registry database. The participating hospitals and surgeons can at any time view their own data by means of an evaluation statistics tool. The outcome research project Herniamed focuses on inguinal hernias, umbilical hernias, incisional hernias, epigastric hernias, parastomal hernias and hiatus hernias. The online-based outcome research registry meets the most stringent data protection criteria.ConclusionWith the Internet-based English- and German-language hernia register, a new instrument is now available for outcome research in hernia surgery.

Conversion in Laparoscopic Colorectal Cancer Surgery: Impact on Short- and Long-Term Outcome

INTRODUCTION Despite the well-documented safety and effectiveness of laparoscopic colorectal surgery in curative intention, the role of conversion and its impact on short- and long-term outcome after resection of a carcinoma are unclear and continue to give rise to controversial discussion. METHODS Within the framework of a prospective, multicenter observational study (Laparoscopic Colorectal Surgery Study Group), into which a total of 5,863 patients from 69 hospitals were recruited over a period of 10 years, a subgroup of all patients who had undergone curative resection was analyzed with regard to the effects of conversion. RESULTS Of the 1409 patients who had undergone curative resection for colorectal carcinoma, conversion had to be performed in 80 (5.7%) cases for the most diverse reasons. The duration of surgery (median: 183 vs. 241 minutes; P<.001) was significantly longer in the conversion group. Perioperatively, significant disadvantages were noted in converted patients in terms of intraoperative blood loss (median: 243 vs. 573 mL, P<.001), need for perioperative blood transfusion (10.8% vs. 33.8%; P<.001), and resumption of bowel movement (median: after 3 vs. 4 days; P<.001). With regard to postoperative morbidity, significant disadvantages were observed in converted patients, in particular in terms of specific surgical complications, including a higher rate of anastomotic insufficiency (5.0% vs. 13.8%; P=.003) and a higher reoperation rate (4.9% vs. 15.0%; P=.001). In the long term, conversion was associated with lower overall survival, but not with poorer disease-free survival. CONCLUSION Significantly higher postoperative morbidity was observed in patients after conversion, in particular in terms of specific surgical complications. In addition, conversion is associated with overall lower survival but not with poorer disease-free survival.

Laparoscopically assisted reversal of Hartmann procedure.

Introduction Restoration of intestinal continuity following Hartmann procedure is an operation associated with a lengthy stay in hospital, protracted convalescence, and a high morbidity rate. With the aim of using the advantages of minimally invasive surgery, such as rapid mobilization, less postoperative pain, early restoration of bowel function, and a rapid return to a normal diet, and reduced morbidity, the laparoscopic modality was employed. The objective of the present study was to investigate the usefulness of laparoscopic restoration of intestinal continuity following Hartmann procedure. Method A total of 71 patients who, in the period between 1995 and 2005 within the framework of the prospective multicenter study “Laparoscopic Colorectal Surgery Study Group,” underwent a laparoscopically assisted restoration of bowel continuity following Hartmann procedure, were investigated. Results In 62 patients (87%), the laparoscopic procedure was completed as planned, whereas 9 cases had to be converted to open surgery—mostly on account of massive intra-abdominal adhesions. The 39 male (55%) and 32 female (45%) patients had an average body mass index of 25 (range, 19 to 38), a height of 168 cm (range, 150 to 190 cm), and a weight of 72 kg (range, 49 to 103 kg). Mean operating time was 164 min (range, 60 to 410 min) and the intraoperative blood loss 196 mL (range, 10 to 1000 mL). Five patients (7%) received packed red cells. In all, 85.9% of the procedures (n=61) were free of complications. The most common intraoperative complications were injuries to the bowel and problems with the anastomosis (dehiscence, difficult stapling), each occurring in 5.6% of the cases (n=4). Intraoperative lesions to the ureters (0%), the bladder (n=1/1.4%), and blood vessels (n=1/1.4%) played a numerically subordinate role. Purely parenteral nutrition was applied up to the third postoperative day (range, 0 to seventh postoperative day). In those patients who were able to take a liquid meal on the third postoperative day (range, first to eighth postoperative day), enteral nutrition was initiated on the fifth postoperative day (range, second to tenth postoperative day). On average, bowel movements were restored on the fourth postoperative day (range, second to ninth postoperative day). Patients in whom a bladder catheter was placed for the operation had it removed on the third postoperative day (range, first to twelfth postoperative day) and had normal urination thereafter. In Hartmann procedure, patients without such a catheter, normal urination was possible from postoperative day 1 onward (range, 0 to second postoperative day). Postoperative complications included hematomas/abscesses (n=3/4.2%), transit disorders (n=2/2.8%), surgery-requiring ileus (n=2/2.8%), cardiopulmonary complications (n=1/1.4%), and surgery-requiring hemorrhage (n=1/1.4%), with other complications accounting for 4.2% (n=3). The median hospital stay was 11 days (range, 5 to 35 d); the mortality rate was 1.4% (n=1). Conclusions Reversal of Hartmann procedure employing the laparoscopic modality is compatible with acceptable morbidity and mortality rates. The elevated conversion rate is a reflection of the fact that the operation is technically demanding.

Is Pooled Data Analysis of Ventral and Incisional Hernia Repair Acceptable

Purpose In meta-analyses and systematic reviews comparing laparoscopic with open repair of ventral hernias, data on umbilical, epigastric, and incisional hernias are pooled. Based on data from the Herniamed Hernia Registry, we aimed to investigate whether the differences in the therapy and treatment results justified such an approach. Methods Between 1st September 2009 and 31st August 2013, 31,664 patients with a ventral hernia were enrolled in the Herniamed Hernia Registry. The implicated hernias included 16,206 umbilical hernias, 3,757 epigastric hernias, and 11,701 incisional hernias. Data on the surgical techniques, postoperative complication rates, and 1-year follow-up results were subjected to statistical analysis to identify any significant differences between the various hernia types. Results The laparoscopic IPOM technique was used significantly more often for incisional hernia than for epigastric hernia, 31.3 vs. 24.0%, respectively, and was used for 12.9% of umbilical hernias (p < 0.0001). Likewise, the open technique with suturing of defect was used significantly more often for umbilical hernia than for epigastric hernia, 56.1 vs. 35.4%, respectively, and was used for 12.5% of incisional hernias (p < 0.0001). The postoperative complication rates of 3.2% for umbilical hernia and 3.5% for epigastric hernia were significantly lower than for incisional hernia, at 9.2% (p < 0.0001). That was also true for the reoperation rates due to postoperative complications, of 1.0 vs. 1.2 vs. 4.2% (p < 0.0001). The 1-year follow-up revealed significantly higher recurrence rates as well as rates of chronic pain needing treatment of 6.3 and 7.9%, respectively, for incisional hernia, compared with 4.1 and 4.3%, respectively, for epigastric hernia, and 2 and 1.9%, respectively, for umbilical hernia (p < 0.0001). Conclusion Since significant differences were identified in the therapy and treatment results between umbilical hernia, epigastric hernia, and incisional hernia, scientific studies should be conducted comparing the various surgical techniques only for a single hernia type.

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.

What is a certified hernia center?The example of the German Hernia Society and German Society of General and Visceral Surgery

To date, the scientific definition “hernia center” does not exist and this term is being used by hospitals and private institutions as a marketing instrument. Hernia surgery has become increasingly more complex over the past 25 years. Differentiated use of the various techniques in hernia surgery has been adopted as a “tailored approach” program and requires intensive engagement with, and extensive experience of, the entire field of hernia surgery. Therefore, there is a need for hernia centers. A basic requirement for a credible certification process for hernia centers involves definition of requirements and its verification by hernia societies and/or non-profit organizations that are interested in assuring the best possible quality of hernia surgery. At present, there are two processes for certification of hernia centers by hernia societies or non-profit organizations.

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.

Endoscopic-Assisted Linea Alba Reconstruction plus Mesh Augmentation for Treatment of Umbilical and/or Epigastric Hernias and Rectus Abdominis Diastasis - Early Results.

Introduction Symptomatic umbilical and/or epigastric hernias are often seen concomitantly with rectus abdominis diastasis (RAD), and suture repair of such defects has a high recurrence rate. In the literature, there are reports of both endoscopic and open techniques for repair of symptomatic umbilical and/or epigastric hernias in association with RAD. This paper now reports on the early results of a hybrid technique used for reconstruction of the linea alba and mesh augmentation [endoscopic-assisted linea alba reconstruction plus mesh augmentation (ELAR plus)]. Materials and methods Between 15 June 2015 and 31 January 2016, 40 patients with symptomatic umbilical and/or epigastric hernia and concomitant RAD underwent reconstruction of the linea alba using a hybrid technique involving a small umbilical incision and the use of video-endoscopic equipment. The patients comprised 29 men and 11 women with a mean age of 53.6 years and mean BMI of 32.6. The mean operating time was 120 min. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm. Results Thirty-day follow-up results are available for all patients. Thirty-seven out of 40 patients (92.5%) experienced no postoperative complication. Two cases of discrete impaired umbilical wound healing and one seroma were successfully managed with conservative treatment. On 30-day follow-up, 3 out of 40 patients (7.5%) complained of intermittent pain on exertion, and 2 out of 40 patients (5%) still took painkillers when required. Conclusion ELAR plus is a novel minimally invasive procedure for repair of symptomatic umbilical and/or epigastric hernias with concomitant RAD. Reconstruction of the linea alba via a minimally invasive access route is able to restore the normal anatomy of the abdominal wall.

evidence for Replacement of an infected Synthetic by a Biological Mesh in Abdominal wall Hernia Repair

Introduction The incidence of deep infection using a synthetic mesh in inguinal hernia repair is low and reported to be well below 1%. This is in contrast to incisional hernia surgery where the reported incidence is 3% respective 13% comparing laparoscopic to open mesh repair reported in a Cochrane review. Main risk factors were long operation time, surgical site contamination, and early wound complications. An infected mesh can be preserved using conservative treatment were negative pressure wound therapy (VAC®) could play an important role. If strategy fails, the mesh needs to be removed. This review aims to look at evidence for situations were a biological mesh would work as a replacement of a removed infected synthetic mesh. Materials and methods A literature search of the Medline database was performed using the PubMed search engine. Twenty publications were found relevant for this review. Results For studies reviewed three options are presented: removal of the infected synthetic mesh alone, replacement with either a new synthetic or a new biological mesh. Operations were all performed at specialist centers. Removal of the mesh alone was an option limited to inguinal hernias. In ventral/incisional hernias, the use of a biological mesh for replacement resulted in a very high recurrence rate, if bridging was required. Either a synthetic or a biological mesh seems to work as a replacement when fascial closure can be achieved. Evidence is though very low. Conclusion When required, either a synthetic or a biological mesh seems to work as a replacement for an infected synthetic mesh if the defect can be closed. It is, however, not recommended to use a biological mesh for bridging. Mesh replacement surgery is demanding and is recommended to be performed in a specialist center.