Wolfgang Reinpold

Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia.

PurposeChronic inguinodynia is one of the most frequent complications after groin herniorrhaphy. We investigated the retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve to prevent direct nerve injury during hernia repairs and to find the most advantageous approach for posterior triple neurectomy.MethodsWe dissected the inguinal nerves in 30 human anatomic specimens bilaterally. The distances from each nerve and their entry points in the abdominal wall were measured in relation to the posterior superior iliac spine, anterior superior iliac spine, and the midpoint between the two iliac spines on the iliac crest. We evaluated our findings by creating high-resolution summation images.ResultsThe courses of the iliohypogastric and ilioinguinal nerve are most consistent on the anterior surface of the quadratus lumborum muscle. The genitofemoral nerve always runs on the psoas muscle. The entry points of the nerves in the abdominal wall are located as follows: the iliohypogastric nerve is above the iliac crest and lateral from the anterior superior iliac spine, the ilioinguinal nerve is with great variability, either above or below the iliac crest and lateral from the anterior superior iliac spine, the genital branch is around the internal inguinal ring, the femoral branch is either cranial or caudal to the iliopubic tract, and the lateral femoral cutaneous nerve is either medial or lateral to the anterior superior iliac spine.ConclusionNerve injury during inguinal hernia repairs can be avoided by taking the topographic anatomy of the inguinal nerves into consideration. The most advantageous plane to look for the iliohypogastric and ilioinguinal nerve during posterior neurectomy is on the anterior surface of the quadratus lumborum muscle. For the surgical treatment of severe chronic inguinodynia, especially after posterior open or endoscopic mesh repair (TAPP/TEP), the retroperitoneoscopic or open retroperitoneal approach for posterior triple neurectomy can be considered.

Laparoscopic transperitoneal sublay mesh repair: a new technique for the cure of ventral and incisional hernias

BackgroundIncisional hernia is a frequent complication after abdominal surgery. Today open sublay mesh repair and the laparoscopic intraperitoneal onlay mesh repair are the most widely used techniques for its cure. We developed a laparoscopic transperitoneal sublay mesh repair for the treatment of small- and medium-size ventral and incisional hernias. Outcomes of the new technique and the Rives–Stoppa repair were compared.MethodsThis prospective cohort study with a control group involved 93 patients. Between 2008 and 2010, 43 patients underwent the laparoscopic transperitoneal sublay mesh repair. During the same period of time, a control group of 50 patients underwent an open sublay repair after Rives and Stoppa. In 2011, all patients were invited for follow-up. This included pain assessments and physical examinations with use of ultrasound.ResultsThe two groups were comparable in terms of patient characteristics and hernia data. The operating time was slightly longer for the laparoscopic technique. The hospital stay was shorter in the laparoscopy group. There was less chronic pain in the laparoscopy group, but this difference was not statistically significant. There was no significant difference in postoperative complications, use of analgetics, foreign body sensation, and paresthesia between the two groups. We found one long-term hematoma in the laparoscopy group and one seroma in the open group. In this series, there were no recurrences and no wound infections.ConclusionsOur initial results indicate that the new laparoscopic transperitoneal sublay mesh repair is a safe and effective method for the treatment of small- and medium-size ventral and incisional hernias.

The Importance of Registries in the Postmarketing Surveillance of Surgical Meshes

Objective: To assess the role of registries in the postmarketing surveillance of surgical meshes. Background: To date, surgical meshes are classified as group II medical devices. Class II devices do not require premarket clearance by clinical studies. Ethicon initiated a voluntary market withdrawal of Physiomesh for laparoscopic use after an analysis of unpublished data from the 2 large independent hernia registries—Herniamed German Registry and Danish Hernia Database. This paper now presents the relevant data from the Herniamed Registry. Methods: The present analysis compares the prospective perioperative and 1-year follow-up data collected for all patients with incisional hernia who had undergone elective laparoscopic intraperitoneal onlay mesh repair either with Physiomesh (n = 1380) or with other meshes recommended in the guidelines (n = 3834). Results: Patients with Physiomesh repair had a markedly higher recurrence rate compared with the other recommended meshes (12.0% vs 5.0%; P < 0.001). In the multivariable analysis, the recurrence rate was highly significantly influenced by the mesh type used (P < 0.001). If Physiomesh was used, that led to a highly significant increase in the recurrence rate on 1-year follow-up (odds ratio 2.570, 95% CI 2.057, 3.210). The mesh type used also had a significant influence on chronic pain rates. Conclusions: The importance of real-world data for postmarketing surveillance of surgical meshes has been demonstrated in this registry-based study. Randomized controlled trials are needed for premarket approval of new devices. The role of sponsorship of device studies by the manufacturing company must be taken into account.

Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School

IntroductionThe increasingly more complex nature of hernia surgery means that training programs for young surgeons must now meet ever more stringent requirements. There is a growing demand for improved structuring and standardization of education and training in hernia surgery.Materials and methodsIn 2011, the concept of a Hernia School was developed in Germany and has been gradually implemented ever since. That concept comprises the following series of interrelated, tiered course elements: Hernie kompakt (Hernia compact), Hernie konkret (Hernia concrete), and Hernie complex (Hernia complex). All three course elements make provision for structured clinical training based on guest visits to approved hernia centers. The Hernia compact basic course imparts knowledge of anatomy working with fresh cadavers. Hernia surgery procedures can also be conducted using unfixed specimens. Knowledge of abdominal wall ultrasound diagnostics is also imparted and hernia surgery procedures simulated on pelvic trainers. In all three course elements, lectures are delivered by experts across the entire field of hernia surgery using evidence-based practices from the literature.ResultsTo date, eight Hernie kompakt (Hernia compact) courses have been conducted, in each case with up to 55 participants, and with a total of 390 participants. On evaluating the course, over 95% of participants expressed the view that the Hernia compact course content improved hernia surgery training. Following that positive feedback, the more advanced Hernie konkret (Hernia concrete) and Hernie complex (Hernia complex) course elements were introduced in 2016.ConclusionThe experiences gained to date since the introduction of a Hernia School—a standardized curriculum concept for continuing training in hernia surgery—has been evaluated by participants as an improvement on hitherto hernia surgery training.

Minimally invasive sublay mesh repair of incisional and primary abdominal wall hernias using the MILOS technique

SummaryIntroductionPrimary ventral and incisional hernia repair is a routine operation in general surgery. The most widely used techniques, however, have some disadvantages and risks. In order to minimize complications and postoperative pain, we developed the endoscopically assisted mini and less open sublay (MILOS) operation.MethodsThe surgical steps of this novel technique are described here. The operation is performed via a small incision transhernially with light-armed laparoscopic instruments either under direct visualization or endoscopic view. After creating an extraperitoneal space of at least 8 cm and CO2 insufflation, total extraperitoneal preperitoneal mesh repair (TEP) of ventral and incisional hernias can be performed.ResultsThe results and complication rates of 715 MILOS operations for incisional hernias are presented. The data of all MILOS operations were prospectively documented in the German hernia database “Herniamed.”ConclusionThe MILOS technique facilitates minimally invasive transhernial repair of primary ventral and incisional hernias using large retromuscular/preperitoneal meshes; the technique is associated with a very low morbidity rate and with less chronic pain.

Erratum to: Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia (International Endohernia Society)

The online version of the original article can be found under doi:10.1007/s00464-014-3917-8.

Groin hernia diagnostics: dynamic inguinal ultrasound (DIUS)

PurposeAlthough clinical examination is the gold standard for the diagnosis of groin hernia, imaging procedures can improve the detection of femoral hernias, incipient hernias, and less-common types of hernias (e.g., an obturator hernia). The aim of this study is to evaluate the sensitivity and specificity of dynamic inguinal ultrasound (DIUS).Materials and methodsBetween July 2010 and June 2015, 4951 clinical and ultrasound examinations of the groin area were conducted at the Hanse-Hernienzentrum in Hamburg, Germany. The ultrasonographic findings were prospectively evaluated to determine the number of inguinal and femoral hernia diagnoses that were ultrasonically confirmed and also to consider cases in which clinical examination overlooked these diagnoses. The results were compared with the intraoperative findings.ResultsThe results show that standardized ultrasound examination of the groin area with high-frequency, small-part linear transducers also serves to accurately display femoral and small or occult groin hernias. The high-level specificity (0.9980) and sensitivity (0.9758) are proof of the procedure’s quality.ConclusionsTo ensure high-quality hernia treatment, regular use of standardized ultrasound examinations is recommended.

Global Outreach Using a Systematic, Competency-Based Training Paradigm for Inguinal Hernioplasty

Importance Sustainable, capacity-building educational collaborations are essential to address the global burden of surgical disease. Objective To assess an international, competency-based training paradigm for hernia surgery in underserved countries. Design, Setting, and Participants In this prospective, observational study performed from November 1, 2013, through October 31, 2015, at 16 hospitals in Brazil, Ecuador, Haiti, Paraguay, and the Dominican Republic, surgeons completed initial training programs in hernia repair, underwent interval proficiency assessments, and were appointed regional trainers. Competency-based evaluations of technical proficiency were performed using the Operative Performance Rating Scale (OPRS). Maintenance of proficiency was evaluated by video assessments 6 months after training. Certified trainees received incentives to document independent surgical outcomes after training. Main Outcomes and Measures An OPRS score of 3.0 (scale of 1 [poor] to 5 [excellent]) indicated proficiency. Secondary outcomes included initial vs final scores by country, scores among surgeons trained by the regional trainers (second-order trainees), interval scores 6 months after training, and postoperative complications. Results A total of 20 surgeon trainers, 81 local surgeons, and 364 patients (343 adult, 21 pediatric) participated in the study (mean [SD] age, 47.5 [16.3] years; age range, 16-83 years). All 81 surgeons successfully completed the program, and all 364 patients received successful operations. Mean (SD) OPRS scores improved from 4.06 (0.87) before the initial training program to 4.52 (0.57) after training (P < .001). No significant variation was found by country in final scores. On trainee certification, 20 became regional trainers. The mean (SD) OPRS score among 53 second-order trainees was 4.34 (0.68). After 6-month intervals, the mean (SD) OPRS score among participating surgeons was 4.34 (0.55). The overall operative complication rate during training series was 1.1%. Conclusions and Relevance Competency-based training helps address the global burden of surgical disease. The OPRS establishes an international standard of technical assessment. Additional studies of long-term surgeon trainer proficiency, community-specific quality initiatives, and expansion to other operations are warranted.

Chronic Postoperative Inguinal Pain (CPIP)

It is well established that almost every surgical intervention may lead to chronic pain. According to published trials with systematic data collection, the highest chronic pain rates are reported after leg amputation, thoracotomy, and breast surgery with 60%, 50%, and 30%, respectively [1].

Incisional and Abdominal Wall Hernia Repair with Minimally Invasive Extraperitoneal Synthetic Mesh Implantation Using MILOS Technique (Mini and Less Open Sublay Surgery)

Incisional hernia is the most common complication after abdominal surgeries at 10–30% worldwide. Abdominal wall hernias never heal spontaneously. The risk of incarceration and strangulation is 1–2% per year. The main cause seems to be genetically determined insufficient cross-links between the collagen molecules.