Jochen Schwarz

Predictive Risk Factors for Persistent Postherniotomy Pain

Background:Persistent postherniotomy pain (PPP) affects everyday activities in 5–10% of patients. Identification of predisposing factors may help to identify the risk groups and guide anesthetic or surgical procedures in reducing risk for PPP. Methods:A prospective study was conducted in 464 patients undergoing open or laparoscopic transabdominal preperitoneal elective groin hernia repair. Primary outcome was identification of risk factors for substantial pain-related functional impairment at 6 months postoperatively assessed by the validated Activity Assessment Scale (AAS). Data on potential risk factors for PPP were collected preoperatively (pain from the groin hernia, preoperative AAS score, pain from other body regions, and psychometric assessment). Pain scores were collected on days 7 and 30 postoperatively. Sensory functions including pain response to tonic heat stimulation were assessed by quantitative sensory testing preoperatively and 6 months postoperatively to assess nerve damage. Results:Four hundred sixty-four patients were included, whereof 442 were examined at 6 months (95.3% follow-up). Fifty-five patients (12.4%) had “moderate/severe” PPP at 6 months. Logistic regression analysis identified four risk factors for PPP: preoperative AAS score, preoperative pain to tonic heat stimulation, 30-day postoperative pain intensity, and sensory dysfunction in the groin at 6 months (nerve damage) (all P < 0.03). A risk prediction model of only preoperative factors and choice of surgical technique revealed increased preoperative AAS score, increased preoperative pain to heat stimulation, and open surgery to increase the risk for PPP (all P < 0.02). Conclusion:PPP is related to both patient and surgical factors. Patients with a high preoperative AAS score and high pain response to a standardized heat stimulus may preferably be treated using an operative technique with lowest risk for nerve damage.

A Single Institution’s Experience with Transperitoneal Laparoscopic Hernia Repair

BACKGROUND Previous evaluations of endoscopic hernia surgery mostly are based on small prospectively documented series or on a few randomized comparative studies. In the following, results of a large single-institution experience concerning the transabdominal preperitoneal patch (TAPP) technique with regard to the development of methods and the routine use are described. METHODS From April 1993 to March 1997, 2,700 TAPP procedures were performed at the Department of General and Visceral Surgery, Marien-hospital, Stuttgart, Germany. The follow-up was documented prospectively in all cases by use of computed data base. RESULTS The majority of patients (83.8%) were operated because of primary hernias. In 17.2% a first or multiple recurrence of an inguinal hernia was indicated. At a median postoperative observation period of presently 20 months and a follow-up rate of 86.5%, 28 recurrences have been determined so far (total recurrence rate 1.03%), 6 of which occurred after a recurrent hernia reparation (1.33%) and 22 after primary hernia repair (0.97%). The most common cause for recurrence was in 39.3% a mesh (12 x 8 cm) being too small. The total complication rate was 4.6%; as an expression of the learning curve it was reduced from 7.8% (operations 1 to 500) to 2.8% (operations 2,200 to 2,700). CONCLUSIONS According to our experience, the TAPP technique is sufficiently applicable as a standard method for an unselected group of patients in a routine setting. It is especially suited to the repair of recurrent and bilateral hernias as well as for patients with a high risk for recurrence that can profit from a tension-free endoscopic procedure, particularly in case of obesity.

Endoscopic Mini/Less Open Sublay (EMILOS) Technique: A Variation of the MILOS Operation in the Therapeutic Spectrum of Primary and Secondary Ventral Hernias

The optimal operative treatment of primary and secondary hernias of the abdominal wall is still debatable. Traditional open techniques are burdened with a high rate of infection [1], whereas the laparoscopic intraperitoneal onlay mesh (IPOM) repair carries an increased risk for intraoperative lesions to the bowel, adhesions, and bowel obstructions [2–4]. Despite great progress in mesh technology and development of expensive meshes promising less formation of adhesions between the mesh and the intestine, the potential risk of an intraperitoneal foreign body has not yet been solved [5]. Furthermore, the IPOM technique typically requires expensive fixation devices and, more important, fixation with tacks or sutures causes severe acute and chronic pain. In order to avoid these disadvantages of current open and laparoscopic techniques, the MILOS (mini/less open sublay) concept was developed by W. Reinpold (► Chap. 33). The aim of this novel technique is to keep the mesh out of the abdominal cavity. Following the MILOS concept, the surgeon is able to place a large mesh into the retromuscular plane through a small skin incision (2–6 cm = mini open; 6–12 cm = less open). The MILOS operation is an open procedure, using endoscopic dissection instruments and a novel specifically designed light tube which facilitates exposure, visualization, and retraction (Endotorch, Wolf TM). Despite this new innovative device, the technique which is extensively described in ► Chap. 33 may be technically challenging especially not at least because the assisting surgeon’s view is limited. Therefore, in order to increase utilization of the “MILOS concept,” we developed the endoscopic mini/less open sublay (EMILOS) operation which is essentially a reversed total extraperitoneal(TEP) procedure [6]. This variation of the original MILOS operation is a true hybrid technique which consists of two parts, the first steps (step 1–4) are identical to the MILOS operation, then immediately after opening of the rectus sheath, the operation continues with endoscopic dissection “reversed TEP” of the total retromuscular space.

EMILOS-Technik – endoskopische Variante der MILOS-Operation bei primären und sekundären ventralen Hernien

Die EMILOS-Operation ist eine Hybridtechnik, d. h. sie setzt sich aus einem offenen Teil (5 cm Hautinzision) und einem endoskopischen (Dissektion des gesamten retromuskularen Raums) zusammen. Der offene Teil entspricht der MILOS-Operation, wobei allerdings der Hautschnitt immer unterhalb von 5 cm liegen sollte. Es wird in der Regel ein groses Netz (40/30×15–20 cm) zur Stabilisierung der gesamten vorderen Bauchwand in den retromuskularen Raum ohne Eroffnung des Bauchraums eingesetzt. Die idealen Indikationen sind primare und sekundare ventrale Hernien in Kombination mit einer Schwache der vorderen Bauchwand (Rektusdiastase). Das Kapitel beschreibt detailliert in einzelnen Schritten die neue innovative Technik.