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Introduction: On the basis of six meta-analyses, the guidelines of the European Hernia Society (EHS) recommend laparo-endoscopic recurrent repair following previous open inguinal hernia operation and, likewise, open repair following previous laparo-endoscopic operation. So far no data are available on implementation of the guidelines or for comparison of outcomes. Besides, there are no studies for comparison of outcomes for compliance versus non-compliance with the guidelines., Patients and Methods: In total, 4812 patients with elective unilateral recurrent inguinal hernia repair in men were enrolled between September 1, 2009, and September 17, 2014, in the Herniamed Registry. Only patients with 1-year follow-up were included., Results: Out of the 2482 laparo-endoscopic recurrent repair operations 90.5% of patients, and out of the 2330 open recurrent repair procedures only 38.5% of patients, were operated on in accordance with the guidelines of the EHS. Besides, on compliance with the guidelines multivariable analysis demonstrated for laparo-endoscopic recurrent repair a significantly lower risk of pain at rest (OR 0.643 [0.476; 0.868]; p = 0.004) and pain on exertion (OR 0.679 [0.537; 0.857]; p = 0.001). Comparison of laparo-endoscopic and open recurrent repair in settings of compliance versus non-compliance with the guidelines showed a higher incidence of perioperative complications and re-recurrences for recurrent repairs that did not comply with the guidelines., Conclusion: The EHS guidelines for recurrent inguinal hernia repair are not yet being observed to the extent required. Non-compliance with the guidelines is associated with higher perioperative complication rates and higher risk of re-recurrence. Even on compliance with the guidelines, the risk of pain at rest and pain on exertion is higher after open recurrent repair than after laparo-endoscopic repair.

Despite all the progress made in inguinal hernia surgery driven by the development of meshes and laparoendoscopic operative techniques, the proportion of recurrent inguinal hernias is still from 12% to 13%. Recurrences can present very soon after primary inguinal hernia repair generally because of technical failure. However, they can also develop much later after the primary operation probably due to patient-specific factors. Supported by evidence-based data, this review presents the surgical risk factors for recurrent inguinal hernia after the primary operation. The following factors are implicated here: choice of operative technique and mesh, mesh fixation technique, mesh size, management of medial and lateral hernia sac, sliding hernia, lipoma in the inguinal canal, operating time, type of anesthesia, participation in a register database, femoral hernia, postoperative complications, as well as the center and surgeon volume. If these surgical risk factors are taken into account when performing primary inguinal hernia repair, a good outcome can be expected for the patient. Therefore, they should definitely be observed., (©2017 Niebuhr H., Köckerling F., published by De Gruyter, Berlin/Boston.)

The new worldwide guidelines of all international hernia societies only recommend the mesh-based methods TEP, TAPP and Lichtenstein. The best mesh-free technique, the Shouldice operation, should only be used if the patient has declined the use of a mesh or no mesh is available. The systematic use of the Shouldice technique for smaller inguinal hernias and younger men should be confined to study settings. A tailored approach should be taken for mesh-based procedures to minimize the risk to patients. Due to lower pain rates the laparoendoscopic techniques TEP and TAPP are the methods of choice for primary male unilateral inguinal hernia. They are also preferred for female patients as they improve the diagnostics of femoral hernias as well as for bilateral inguinal hernias in female and male patients. The Lichtenstein operation tends to be recommended for scrotal hernia, following previous pelvic surgery, vascular surgery, liver cirrhosis, radiotherapy and intolerance of general anesthesia. This also applies for recurrent hernia following a previous laparoendoscopic primary operation. Similarly, recurrent hernia after a primary suture or mesh procedure should be repaired using the TEP or TAPP technique. In emergency procedures for incarceration the diagnostic superiority of laparoscopy and the ability to reposition the incarcerated organs should be utilized. The inguinal hernia can then be repaired at the same time or later depending on whether there is any local infection.

Whereas for TEP the guidelines do not recommend mesh fixation on the basis of meta-analyses regardless of the defect size, for TAPP mesh fixation can be omitted only up to a defect size of 3 cm because of the paucity of studies on this topic. Hence, this study now seeks to explore this subject on the basis of prospective data from the Herniamed Hernia Registry. In the period September 01, 2009, to January 31, 2014, 11,228 male patients were operated on with the TAPP technique for a primary unilateral inguinal hernia and were followed up for 1 year. Mesh fixation was used for 7422 (66.1 %) of these patients and no mesh fixation for 3806 patients (33.9 %). Unadjusted analysis did not find any significant difference in the recurrence rate (0.88 % with fixation vs. 1.1 % without fixation; p = 0.259). Multivariable analysis of all potential influence factors (age, ASA, BMI, risk factors, defect size, mesh fixation, localization of defect, mesh size) did not identify any factor that impacted recurrence on 1-year follow-up. Only for medial and combined defect localization versus lateral localization was a highly significant effect identified (p < 0.001). With mesh fixation and larger mesh size, it was possible to significantly reduce the recurrence rate for larger medial hernias in this series (p = 0.046). For TAPP repair of an inguinal hernia, mesh fixation is not necessary in a significant number of patients. Patients with a medial and combined hernia are at higher risk of recurrence. In the patient series analyzed, it was possible to significantly reduce the recurrence rate with mesh fixation and larger mesh size for medial defects.

The potential for improvement of the results of laparoscopic operations as well as necessity of enhanced efficiency in the health-care systems are the main reasons for development and practical use of robotic systems in the field of laparoscopic surgery. While robotic systems imitate the human camera-holder the Image Tracking System (ImagTrac, Olympus, Tokio) is based on another principle: A voice-activated zoom function allows change between overview and detailed view. In the zoom-in position it is possible to select four different fields of view. The results of a clinical trial with control group show that the system: 1. Makes it possible to dispense with the human camera-holder without compromising patient safety, sometimes at greater convenience to the surgeon. 2. Makes it possible for routine laparoscopic operations such as laparoscopic cholecystectomy and laparoscopic hernia repair to be performed (as solo surgery) by a team of a surgeon and a nurse only. 3. Is more cost-effective than robotic systems with a similar range of features.

A prospective trial reveals that routine ultrasound in suspected appendicitis in the hands of experts can lead to a specificity of 94% and a sensitivity of 90% in opposite to 82% and 78% for clinical findings alone. The rate of "negative laparotomies" has decreased from 22% to 11%.

Although the required pneumoperitoneum for laparoscopic cholecystectomy and laparoscopic hernial repair means stress for the elderly, it does not affect them negatively from a clinical point of view. On the contrary, the patient profits by a low complication rate, a quick recovery and a shorter stay in hospital.

Over the last few years, laparoscopic surgery has gained widespread acceptance in surgical practice. The indications range has expanded extraordinarily in that time. Some of the practiced procedures are already considered the gold standard, while others are still on the way there. The fascinating technique and results notwithstanding, a number of risks, mistakes, and complications are possible in both the initial and the advanced states. We present our experience from 2118 laparoscopic operations performed between February 1991 to March 1995, focusing on the intraoperative complications (Tables 1, 2).

Laparoscopic cholecystectomy and appendectomy are widely accepted in clinical practice. In the initial stage, when the method is introduced, there are a number of mistakes, risks, and complications possible. The surgeons, the staff, the instruments, the anesthetist, and, last but not least, the patient, are among the possible contributing causes. We try to analyze the reasons and conditions leading to possible complications. Complications we have experienced are reported. In our conclusions we try to show how it is possible to avoid severe problems.

Based on the results of a prospective trial to establish the value of routine ultrasound examination in cases of polytrauma or blunt abdominal trauma, we report on our standard ultrasound examination and computer assisted documentation of the findings. Between May 1988 and December 1990 we examined 233 patients with polytrauma or blunt abdominal trauma. The results were compared with those of abdominal lavage (n = 47) performed during the same period. We found a sensitivity of 100% and a specificity of 99.5% for the ultrasound findings and a sensitivity of 80% and a specificity of 100% for the abdominal lavage. We conclude that ultrasonography should be the first diagnostic procedure used in the emergency room in cases of polytrauma and blunt abdominal trauma.

Between 4/90 and 2/91 we repaired 105 inguinal hernias according to Shouldice's technique. Instead of an absorbable suture (PDS no.0) we used a PTFE suture no.0. By this study we tried to assure that it is allowed to use as well the non resorbable PTFE suture no.0. in hernia repair as the slowly resorbable PDS suture no.0. We compared the rate of postoperative hematomas, seromas and pus collections and the rate of early recurrences in both groups. The results of the PTFE group were compared with those of a prospective study (n = 100) between 6.88 and 4.89 when we used PDS suture no 0. In the PTFE group we saw 9.5% hematomas, 1.9% seromas and 0.9% pus collections. In the PDS group 4% of the patients developed a hematoma, 4% a seroma and 2% a pus collection. We saw 1.9% early recurrences after 8 months (PTFE: 7-11; median: 9 months) and 3.2% after 9 months (PDS: 8-13; median: 10 months) medium follow-up time. The results did not significantly differ between both groups. (Chi-square test: p = 1.0). By these results we can draw the following conclusions: 1. The use of a non absorbable PTFE suture no 0 in hernia repair is of no disadvantage. 2. The principle of hernia repair is the induction of scar tissue in the site of hernioplasty; the use of slowly resorbable suture material is allowed as well.

Unlabelled: During 1978 to 1987 361 patients (312 female, 49 male) were treated with Variokopf-prosthesis (a bipolar hip prosthesis with a variable head) after femoral neck fracture, per- or subtrochanteric fracture. The mean age was 83 years. During postoperative treatment 73 patients (20.2%) died. 288 could be discharged. 98 of these died before the follow-up examination. The follow-up was possible in 103 cases. A good to satisfactory result was found in 91 cases (88%). A poor result in twelve cases (12%) (Score by Merle d'Aubigne et al.)., Conclusions: 1. The Variokopf-prosthesis is a favourable alternative to a normal hip prosthesis (e.g. Moore), 2. The implantation of a Variokopf-prosthesis was found to be indicated as well in the treatment of medial femoral neck fractures as in special cases in the treatment of per- or subtrochanteric fractures. 3. The operation should be performed soon after the trauma--after a two to three days treatment. 4. The dorsal approach is superior to the lateral in the treatment of hip fractures because of short operating time and the possible early mobilisation of the patients.

We report two cases of rare tumours of the pancreas: one case of a cystadenoma and one case of a PP-oma with no hormonal activity. Both cases were discovered accidentally while screening examination of other reasons. Guided by these cases we draw the following conclusions: 1. Ultrasound is the outstanding screening in diagnosis of rare pancreas tumours. 2. Surgery is the treatment of choice. 3. Final diagnosis can only be made by histology. 4. Immunohistochemistry is the best method in differentiation of endocrine tumours.

Forty five years after being injured by a grenade splinter a now 74-year old man suddenly developed colicky pain in the right upper abdomen, accompanied by colourless stools, jaundice and fever. The white cell count was 21,000/microliters, bilirubin was raised to 10.9 mg/dl, and ultrasound examination revealed a sharply circumscribed echo in the distal choledochal duct. Retrograde endoscopic cholangiography revealed a metal-dense concrement, presumably the nidus of gallstone formation. After endoscopic emptying of the bile duct the patient quickly improved so that cholecystectomy could be performed. The long symptom-free interval was most likely due to an at first peripheral position of the splinter in liver tissue. The secretory pressure of the liver cells then probably caused a slow migration into the choledochal duct.