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Aim To evaluate the effectiveness, clinical practicability, and complication rate of the fascial traction procedure for the treatment of large ventral hernias. Method This observational study evaluated 90 patients from 1 specialised center with an intraoperatively measured fascial distance of more than 10 cm who were treated by Intraoperative Fascia Traction – IFT- (abdominal wall stretching) using the fasciotens® hernia traction procedure. Results Fascial gap measured pre-operatively ranged from 10 to 44 cm, with most patients (94%) having a fascial above 15 cm (W3 according to the European Hernia Society classification). The mean fascial distance was reduced from 16.1 ± 0.8 to 5.8 ± 0.7 cm (stretch gain 10.2 ± 0.7 cm, p < 0.0001, Wilcoxon matched-pairs signed-ranks test). A reduction in fascial distance of at minimum 50% was achieved in three quarters of the patients, and in half of the treated patients the reduction in fascial distance amounted to even more than 70% The closure rate achieved by fascial traction after a mean surgical duration of 207.3 ± 11.0 minutes was 90% (81/90). Postoperative complications occurred in 7 patients (8%). Re-operation was required in 4 patients (4.5%). Conclusion This described intraoperative fascia traction (IFT) method is a new, promising procedure for abdominal wall closure in large ventral hernias. The presented results demonstrate a high effectiveness, a good clinical practicability and a low complication rate of the Intraoperative fascia traction (IFT) method.

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, “RAD ± concomitant hernia” will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature. A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic. In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification. Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Groin hernia is one of the most common surgical conditions worldwide. Clinical examination can reveal the majority of inguinal hernias. Small inguinal and femoral hernias (in women) may be missed. Dynamic inguinal ultrasound (DIUS) can fill this diagnostic gap. A standardized technique of DIUS is, therefore, important and will be described. The results show high specificity (0.9980) and sensitivity (0.9758), demonstrating the value of the method (which is known to be highly examiner dependent).

Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (

How best to treat a small (

There are hardly any studies on the outcome of scrotal compared with medial and lateral inguinal hernias. Therefore, this present multivariable analysis of data from the Herniamed Registry compared the outcome of scrotal vs. lateral vs. medial inguinal hernias and explored the relationship between hernia localization and outcomes. Included in the analysis were all primary elective unilateral inguinal hernias in men with scrotal, lateral or medial defect localization whose details had been entered into the Herniamed Registry by 712 participating institutions (status February 1, 2019). The relation of the hernia localization with the outcome parameters adjusted for pre-defined confounding patient- and procedure-related variables was analyzed via multivariable binary logistic models. Details of 98,321 patients were thus available for multivariable analysis. These related to 65,932 (67.1%) lateral, 29,697 (30.2%) medial and 2,710 (2.7%) scrotal inguinal hernias. Scrotal hernias were associated with higher patient age, higher BMI, higher ASA score, larger defect, more risk factors and more frequent use of Lichtenstein repair. On the other hand, scrotal hernias were associated less commonly with preoperative pain. Multivariable analysis revealed that scrotal hernias had a highly significantly unfavorable association with postoperative complications, complication-related reoperations and general complications. But scrotal hernias had a highly significantly favorable relation with the pain rates at 1-year follow-up. Medial hernias were the hernia type most often related with recurrence and also had an unfavorable association with the pain rates at 1-year follow-up. Scrotal inguinal hernias demonstrated a very unfavorable relation with the postoperative complication rate, the rate of complication-related reoperations and the rate of general complications. But a very favorable association with chronic pain rates was identified at 1-year follow-up. Medial inguinal hernia had an unfavorable relation with the recurrence and pain rates.

Introduction The proportion of recurrent repairs in the total collective of inguinal hernia repairs among men is 11.3–14.3% and among women 7.0–7.4%. The rate of re-recurrences is reported to be 2.9–9.2%. To date, no case series has been published on second and ≥ third recurrences and their treatment outcomes. Only case reports are available. Materials and methods In an analysis of data from the Herniamed Registry the perioperative and 1-year follow-up outcomes of 16,206 distinct patients who had undergone first recurrent (n = 14,172; 87.4%), second recurrent (n = 1,583; 9.8%) or ≥ third recurrent (n = 451; 2.8%) inguinal hernia repair between September 1, 2009 and July 1, 2017 were compared. Results The intraoperative complication rate for all recurrent repairs was between 1–2%. In the postoperative complications a continuous increase was observed (first recurrence: 3.97% vs second recurrence: 5.75% vs ≥ third recurrence 8.65%; p p = 0.020). Likewise, the re-recurrence rate rose significantly (first recurrence: 1.95% vs second recurrence: 2.72% vs ≥ third recurrence 3.77; p = 0.005). Similarly, the rate of pain requiring treatment rose highly significantly with an increasing number of recurrences (first recurrence: 5.21% vs second recurrence: 6.70% vs ≥ third recurrence 10.86; p = Conclusion The repair of re-recurrences in inguinal hernia is associated with increasingly more unfavorable outcomes. For the first recurrence the guidelines should definitely be noted. For a second and ≥ third recurrence diagnostic laparoscopy may help to select the best possible surgical technique.

Aim We present our approach of treating a W3 (EHS-Classification) incisional hernia with heterotopic ossification in the abdominal wall. Material and Methods a 62-years-old female patient presented with a hernia in her inverted-T incision (midline and transverse) after undergoing multiple laparotomies. The CT-scan showed calcified structures within the abdominal wall. We planned the extensive reconstruction after preoperative Botox injections. Results The 20x25 cm hernial sack contained parts of the stomach and colon. The dissection of the midline and transverse scars was challenging with the needed removal of scattered pieces of heterotopic bone tissues. After dissecting the retro-muscular space, the fascial edges were 25 cm apart. With bilateral transversus abdominis release (TAR), It was reduced to 20 cm. The posterior fascia was approximated, leaving a central 12 cm defect, and a smaller lateral defect, which we covered using open-IPOM and underlay techniques respectively. A 30x40 cm mesh in sublay position was placed and fascial traction was applied on the anterior fascia. With the resulting defect of 16 cm, a tension-free closure was still not possible, and we bridged the gap with a mesh in inlay position. Conclusions Despite combining pre-operative Botox injection and fascial traction with TAR, complete closure of the fascia was not possible. IPOM, sublay, underlay and inlay bridging were needed. Specialized hernia surgeons should be familiar with a wide range of different techniques to deal with such cases.

Aim Measurable and controlled stretching of the fascia for 30 minutes during surgery to achieve primary tension-free abdominal wall closure in LOD hernias. This prospective observational study aimed to clarify the extent to which this traction method can function as an alternative to component separation methods. Material and Methods We have already applied this technique in > 50 procedures of LOD hernias. We published the data of first 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. The average patient age was 58 years with a gender ratio of 2.5 males: 1 female. ASA scores were III in 66.7% and II in 33.3%. The body mass index (BMI) averaged 32.5 kg/m2. Thirteen patients were treated with BTA 4 weeks before surgery. Results Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5–44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30–40 min), the fascial distance decreased by 9.8 cm (1–26 cm) to an average 7.5 cm (range 2–19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusions This method allows primary closure of complex LOD hernias and is potentially less prone to complications than component separation methods.

Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature.A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic.In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification.Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods.Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020.Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5–44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30–40 min), the fascial distance decreased by 9.8 cm (1–26 cm) to an average 7.5 cm (range 2–19 cm), which is a large effect (r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique.Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods.

How best to treat a small ( 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small ( 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors.The data of patients with primary elective umbilical hernia repair and defect size 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up.31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates.Suture repair continues to be used for 78% of umbilical hernias with a defect 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

The use of drains continues to be a controversial topic in surgery. In a review of that topic for incisional hernia it was not possible to find sufficient evidence of the need for a drain. Likewise, for inguinal hernia surgery the data available are insufficient. In a multivariable analysis of data from the Herniamed Registry for 98,321 patients with primary elective unilateral inguinal hernia repair in men, the role of a drain was investigated. A drain was used in 24.7% (n = 24,287/98,321) of patients. These patients were on average older, had higher BMI, longer operating time and received a smaller mesh. Drains were also used more often for patients with higher ASA score, risk factors, larger defects and scrotal hernia localization as well as for Lichtenstein, TEP and suture repair. The use of drains was highly significantly associated with intra- and postoperative complications as well as with complication-related reoperations. Hence, drains are used selectively in inguinal hernia repair for patients at higher risk of perioperative complications. Despite the use of drains, the outcome in this risk group is less favorable. It remains unclear if drains prevent further complications in high-risk patients. Drains are used selectively in high-risk men with primary elective unilateral inguinal hernia repair. Drains are associated with intra- and postoperative complications rates and complication-related reoperation rate. Drains can serve as an indicator for early detection of complications.

There are hardly any studies on the outcome of scrotal compared with medial and lateral inguinal hernias. Therefore, this present multivariable analysis of data from the Herniamed Registry compared the outcome of scrotal vs. lateral vs. medial inguinal hernias and explored the relationship between hernia localization and outcomes.Included in the analysis were all primary elective unilateral inguinal hernias in men with scrotal, lateral or medial defect localization whose details had been entered into the Herniamed Registry by 712 participating institutions (status February 1, 2019). The relation of the hernia localization with the outcome parameters adjusted for pre-defined confounding patient- and procedure-related variables was analyzed via multivariable binary logistic models.Details of 98,321 patients were thus available for multivariable analysis. These related to 65,932 (67.1%) lateral, 29,697 (30.2%) medial and 2,710 (2.7%) scrotal inguinal hernias. Scrotal hernias were associated with higher patient age, higher BMI, higher ASA score, larger defect, more risk factors and more frequent use of Lichtenstein repair. On the other hand, scrotal hernias were associated less commonly with preoperative pain. Multivariable analysis revealed that scrotal hernias had a highly significantly unfavorable association with postoperative complications, complication-related reoperations and general complications. But scrotal hernias had a highly significantly favorable relation with the pain rates at 1-year follow-up. Medial hernias were the hernia type most often related with recurrence and also had an unfavorable association with the pain rates at 1-year follow-up.Scrotal inguinal hernias demonstrated a very unfavorable relation with the postoperative complication rate, the rate of complication-related reoperations and the rate of general complications. But a very favorable association with chronic pain rates was identified at 1-year follow-up. Medial inguinal hernia had an unfavorable relation with the recurrence and pain rates.

In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included.Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields.Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Background The 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. Methods In total, 20,004 male patients with TAPP repair of primary unilateral inguinal hernia were included in uni- and multivariable analysis. Results Univariable 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

Background In 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. Methods In 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. Results Multivariable analysis revealed that onset of pain at rest, on exertion, and requiring treatment was highly significantly influenced, in each case, by younger age (p

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.

In den neuen weltweiten Guidelines aller internationalen Herniengesellschaften werden nur noch die netzbasierten Methoden total extraperitoneale Hernioplastik (TEP), transabdominelle praperitoneale Hernioplastik (TAPP) und Lichtenstein empfohlen. Die beste netzfreie Technik, die Shouldice-Operation, sollte nur noch eingesetzt werden, wenn der Patient eine Netzverwendung ablehnt oder kein Netz zur Verfugung steht. Der systematische Einsatz der Shouldice-Technik bei kleineren Leistenhernien und jungeren Mannern sollte nur innerhalb von Studien erfolgen. Zur Risikominimierung fur die Patienten sollen die netzbasierten Verfahren im Sinne des sog. „tailored approach“ differenziert eingesetzt werden. So stellen die laparoendoskopischen Techniken TEP und TAPP aufgrund geringerer Schmerzraten die bevorzugte Empfehlung bei der primaren unilateralen Leistenhernie beim Mann dar, aufgrund einer besseren Diagnosestellung von Schenkelhernien auch bei der Frau und ebenso bei bilateralen Leistenhernien bei der Frau und dem Mann. Bei der Skrotalhernie, nach Voroperationen im kleinen Becken, Gefasoperationen, Leberzirrhose, Radiatio und Unmoglichkeit einer Allgemeinnarkose wird eher die Lichtenstein-Operation angeraten. Dies gilt auch fur die Rezidivhernie nach vorausgegangener laparoendoskopischer Primaroperation. Das Rezidiv nach vorausgegangenem Naht- oder Netzverfahren soll dann wiederum in TEP- oder TAPP-Technik operiert werden. Bei Notfalleingriffen bei Inkarzeration sollte die diagnostische Uberlegenheit der Laparoskopie und Moglichkeit zur Reposition der eingeklemmten Organe genutzt werden. Die Versorgung der Leistenhernie kann dann in Abhangigkeit von der lokalen Infektsituation gleich oder zu einem spateren Zeitpunkt erfolgen.

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.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.METHODS: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included.RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields.CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

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

The HerniaSurge guidelines have the highest evidence with respect to a strong recommendation for mesh-based surgical techniques. This evidence is equally valid for the Lichtenstein procedure as for the minimally invasive procedures TEP/TAPP. In the case of discrete symptomatic or asymptomatic inguinal hernias, watchful waiting can be an option, taking into account health status and social circumstances. Femoral hernias, on the other hand, should be treated promptly with mesh insertion. Also favored are laparoendoscopic techniques. The Shouldice repair achieves the least recurrences from the suturing procedures and may be an acceptable alternative when indicated or when the patient does not desire mesh reinforcement. In this case, a detailed patient education is necessary.The complication potential of plastic meshes should be explained. The weight is no longer considered a suitable parameter for the classification of meshes and is no longer recommended for mesh selection. Large pore (1-1.5 mm) monofilament implants have the best integration potential and should have a tear strength of approximately 16 NmPerioperative antibiotic prophylaxis in open repair procedures is recommended only in patients with an increased risk of infections. In laparoendoscopic procedures, antibiotic prophylaxis should not be performed or used with the utmost restraint. Careful preparation reduces chronic inguinal and testicular pain. In the case of interference of mesh and nerve, the nerve can be resected. A return to daily activity is recommended within 3-5 days.The documentation of patient data should be done by establishing hernia registers for quality assurance and for the development of further treatment options. The implementation of the guidelines is supported by HerniaSurge.

A patient with inguinal complaints will visit his general practitioner (GP) at first. The GP will ask for the history and will undertake a clinical examination. Dependent on the results, the patient should be referred first to a specialized surgeon/hernia center ◘ Fig. 8.1.

Introduction: Worldwide, more than 20 million patients undergo groin hernia repair annually. The many different approaches, treatment indications and a significant array of techniques for groin hernia repair warrant guidelines to standardize care, minimize complications, and improve results. The main goal of these guidelines is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain, the most frequent problems following groin hernia repair. They have been endorsed by all five continental hernia societies, the International Endo Hernia Society and the European Association for Endoscopic Surgery. Methods: An expert group of international surgeons (the HerniaSurge Group) and one anesthesiologist pain expert was formed. The group consisted of members from all continents with specific experience in hernia-related research. Care was taken to include surgeons who perform different types of repair and had preferably performed research on groin hernia surgery. During the Group’s first meeting, evidence-based medicine (EBM) training occurred and 166 key questions (KQ) were formulated. EBM rules were followed in complete literature searches (including a complete search by The Dutch Cochrane database) to January 1, 2015 and to July 1, 2015 for level 1 publications. The articles were scored by teams of two or three according to Oxford, SIGN and Grade methodologies. During five 2-day meetings, results were discussed with the working group members leading to 136 statements and 88 recommendations. Recommendations were graded as “strong” (recommendations) or “weak” (suggestions) and by consensus in some cases upgraded. In the Results and summary section below, the term “should” refers to a recommendation. The AGREE II instrument was used to validate the guidelines. An external review was performed by three international experts. They recommended the guidelines with high scores. Results and summary: The risk factors for inguinal hernia (IH) include: family history, previous contra-lateral hernia, male gender, age, abnormal collagen metabolism, prostatectomy, and low body mass index. Peri-operative risk factors for recurrence include poor surgical techniques, low surgical volumes, surgical inexperience and local anesthesia. These should be considered when treating IH patients. IH diagnosis can be confirmed by physical examination alone in the vast majority of patients with appropriate signs and symptoms. Rarely, ultrasound is necessary. Less commonly still, a dynamic MRI or CT scan or herniography may be needed. The EHS classification system is suggested to stratify IH patients for tailored treatment, research and audit. Symptomatic groin hernias should be treated surgically. Asymptomatic or minimally symptomatic male IH patients may be managed with “watchful waiting” since their risk of hernia-related emergencies is low. The majority of these individuals will eventually require surgery; therefore, surgical risks and the watchful waiting strategy should be discussed with patients. Surgical treatment should be tailored to the surgeon’s expertise, patient- and hernia-related characteristics and local/national resources. Furthermore, patient health-related, life style and social factors should all influence the shared decision-making process leading up to hernia management. Mesh repair is recommended as first choice, either by an open procedure or a laparo-endoscopic repair technique. One standard repair technique for all groin hernias does not exist. It is recommended that surgeons/surgical services provide both anterior and posterior approach options. Lichtenstein and laparo-endoscopic repair are best evaluated. Many other techniques need further evaluation. Provided that resources and expertise are available, laparo-endoscopic techniques have faster recovery times, lower chronic pain risk and are cost effective. There is discussion concerning laparo-endoscopic management of potential bilateral hernias (occult hernia issue). After patient consent, during TAPP, the contra-lateral side should be inspected. This is not suggested during unilateral TEP repair. After appropriate discussions with patients concerning results tissue repair (first choice is the Shouldice technique) can be offered. Day surgery is recommended for the majority of groin hernia repair provided aftercare is organized. Surgeons should be aware of the intrinsic characteristics of the meshes they use. Use of so-called low-weight mesh may have slight short-term benefits like reduced postoperative pain and shorter convalescence, but are not associated with better longer-term outcomes like recurrence and chronic pain. Mesh selection on weight alone is not recommended. The incidence of erosion seems higher with plug versus flat mesh. It is suggested not to use plug repair techniques. The use of other implants to replace the standard flat mesh in the Lichtenstein technique is currently not recommended. In almost all cases, mesh fixation in TEP is unnecessary. In both TEP and TAPP it is recommended to fix mesh in M3 hernias (large medial) to reduce recurrence risk. Antibiotic prophylaxis in average-risk patients in low-risk environments is not recommended in open surgery. In laparo-endoscopic repair it is never recommended. Local anesthesia in open repair has many advantages, and its use is recommended provided the surgeon is experienced in this technique. General anesthesia is suggested over regional in patients aged 65 and older as it might be associated with fewer complications like myocardial infarction, pneumonia and thromboembolism. Perioperative field blocks and/or subfascial/subcutaneous infiltrations are recommended in all cases of open repair. Patients are recommended to resume normal activities without restrictions as soon as they feel comfortable. Provided expertise is available, it is suggested that women with groin hernias undergo laparo-endoscopic repair in order to decrease the risk of chronic pain and avoid missing a femoral hernia. Watchful waiting is suggested in pregnant women as groin swelling most often consists of self-limited round ligament varicosities. Timely mesh repair by a laparo-endoscopic approach is suggested for femoral hernias provided expertise is available. All complications of groin hernia management are discussed in an extensive chapter on the topic. Overall, the incidence of clinically significant chronic pain is in the 10–12% range, decreasing over time. Debilitating chronic pain affecting normal daily activities or work ranges from 0.5 to 6%. Chronic postoperative inguinal pain (CPIP) is defined as bothersome moderate pain impacting daily activities lasting at least 3 months postoperatively and decreasing over time. CPIP risk factors include: young age, female gender, high preoperative pain, early high postoperative pain, recurrent hernia and open repair. For CPIP the focus should be on nerve recognition in open surgery and, in selected cases, prophylactic pragmatic nerve resection (planned resection is not suggested). It is suggested that CPIP management be performed by multi-disciplinary teams. It is also suggested that CPIP be managed by a combination of pharmacological and interventional measures and, if this is unsuccessful, followed by, in selected cases (triple) neurectomy and (in selected cases) mesh removal. For recurrent hernia after anterior repair, posterior repair is recommended. If recurrence occurs after a posterior repair, an anterior repair is recommended. After a failed anterior and posterior approach, management by a specialist hernia surgeon is recommended. Risk factors for hernia incarceration/strangulation include: female gender, femoral hernia and a history of hospitalization related to groin hernia. It is suggested that treatment of emergencies be tailored according to patient- and hernia-related factors, local expertise and resources. Learning curves vary between different techniques. Probably about 100 supervised laparo-endoscopic repairs are needed to achieve the same results as open mesh surgery like Lichtenstein. It is suggested that case load per surgeon is more important than center volume. It is recommended that minimum requirements be developed to certify individuals as expert hernia surgeon. The same is true for the designation “Hernia Center”. From a cost-effectiveness perspective, day-case laparoscopic IH repair with minimal use of disposables is recommended. The development and implementation of national groin hernia registries in every country (or region, in the case of small country populations) is suggested. They should include patient follow-up data and account for local healthcare structures. A dissemination and implementation plan of the guidelines will be developed by global (HerniaSurge), regional (international societies) and local (national chapters) initiatives through internet websites, social media and smartphone apps. An overarching plan to improve access to safe IH surgery in low-resource settings (LRSs) is needed. It is suggested that this plan contains simple guidelines and a sustainability strategy, independent of international aid. It is suggested that in LRSs the focus be on performing high-volume Lichtenstein repair under local anesthesia using low-cost mesh. Three chapters discuss future research, guidelines for general practitioners and guidelines for patients. Conclusions: The HerniaSurge Group has developed these extensive and inclusive guidelines for the management of adult groin hernia patients. It is hoped that they will lead to better outcomes for groin hernia patients wherever they live. More knowledge, better training, national audit and specialization in groin hernia management will standardize care for these patients, lead to more effective and efficient healthcare and provide direction for future research.

Im vorliegenden Kapitel wird das perioperative Management fur eine laparoendoskopische Hernienoperation beschrieben. Detailliert wird der Verlauf einer (laparoskopischen) Hernienbehandlung vom ersten Kontakt bis zur abschliesenden postoperativen Sprechstunde erlautert. Ein Ablaufschema verdeutlicht den Verlauf. Die pra- und postoperative Diagnostik (klinische Untersuchung und DIUS-Ultraschalltechnik) werden vorgestellt und mit Ergebnisdaten belegt. Im Abschnitt „Behandlungsplan“ wird auf die Frage „ambulant oder kurzstationar“ eingegangen. Die perioperative Antibiotikatherapie und die Thromboembolieprophylaxe sind Themen eigener Abschnitte, ebenso die praoperative Haarentfernung und postoperative Schmerzbehandlung. Das notige Entlassungsmanagement ebenso thematisiert.

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.

Although 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). Between 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. The 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. To ensure high-quality hernia treatment, regular use of standardized ultrasound examinations is recommended.

Groin hernia is one of the most common surgical conditions worldwide with inguinal hernia repair being the most frequently undertaken operation in routine surgical practice. The lifetime ‘risk’ of inguinal hernia repair is high: 27 % for men and 3 % for women [1]. 10 % of groin hernia repairs are performed in emergency settings. Therefore, the appropriate diagnostics and due time treatment are important and should never be neglected. The diagnostic gold standard of groin hernia is clinical examination (CE). Nevertheless, as reported in literature, the sensitivity of CE when directly compared with ultrasound (US) in one group of patients was 80 % for CE versus 96.3 % for US [2]. Furthermore, our own study on a cohort of 2063 patients concerning the use of dynamic inguinal ultrasound (DIUS) of the groin showed that when performed well by the surgeon the specificity (0.9980) and sensitivity (0.9758) of DIUS were almost as high as of CT and MRI. The results were presented i.a. at 194. Wintertagung der Vereinigung Nordwestdeutscher Chirurgen, 2014 in Hamburg and will be published shortly in the literature [3]. The European Hernia Society (EHS) guidelines state that inguinal hernias with clear clinical features do not require any further investigation. However in clinical occult groin hernia, ultrasonography is a useful non-invasive adjunct to physical examination [4]. Interest must be focused on both, good diagnostic tools and the indications for treatment. After careful revision of the literature, we believe that proper diagnostics is a key element in developing good strategy for groin hernia treatment. Baukje van den Heuvel in her literature review on the appropriateness of an operational approach for an asymptomatic groin hernia came to the conclusion that watchful waiting was a safe and cost-effective modality in patients who were under 50 years, had an ASA class of 1 or 2, an inguinal hernia and duration of signs of more than 3 months [5]. This further shows that to safely choose a wait-and-see approach, we should perform proper diagnostics to eliminate the mentioned risk factors, such as femoral hernia and initiating hernias. We cannot safely assume that ‘‘If the pain is caused by a hernia in the early stage, the hernia will clearly manifest itself in very few weeks’’ and that ‘‘experienced surgeons, do not request complementary studies for hernia diagnosis’’ as C. Brandi writes in his letter. Moreover, in our opinion, it is good that general practitioners and radiologists are referring patients to surgical specialists. It is our duty to make a complete diagnosis and instruct the patients about their treatment possibilities. To achieve that, we as surgeons should be able to perform DIUS as well as physical examination. In conclusion, it is very motivating that the diagnostics of groin hernia have been called into question by many surgeons. In our practice we should follow guidelines, available literature and common sense; therefore, so-called ‘‘easy-going’’ inguinal hernias that can be diagnosed by clinical examination do not raise concerns. Nevertheless in M. Pawlak (&) Department of General Surgery, Ceynowa Hospital, Jagalskiego 10, 84-200 Wejherowo, Poland e-mail: pawlakmd@gmail.com

Die mogliche qualitative Verbesserung des Operationsergebnisses sowie der Zwang, weitere Rationalisierungspotentiale zu realisieren, sind Grunde fur die Entwicklung und Anwendung von Robotersystemen in der laparoskopischen Chirurgie. Ahmen die Robotersysteme weitgehend die Funktionen des menschlichen Kameraassistenten nach, basiert das Image Tracking System (ImagTrac, Olympus, Tokio) auf einem anderen Prinzip: Eine Zoomfunktion erlaubt bei starrer Kamera- und Teleskopmontage den durch „voice-control“ aktivierten Wechsel zwischen Ubersicht und Nahsicht. Bei Nahsicht konnen 4 verschiedene Bildausschnitte angesteuert werden. Die Ergebnisse einer klinischen Anwendungsstudie mit Kontrollgruppe zeigen, das das System 1. den Verzicht auf den menschlichen Kamerahalter ohne Sicherheitsverlust fur den Patienten bei zum Teil groserem Komfort fur den Operateur ermoglicht und 2. erlaubt, visceralchirurgische, laparoskopische Routineoperationen, wie laparoskopische Cholecystektomie und laparoskopische Hernienreparation, als „Operateur-Schwester-Operation“ (Solochirurgie) auszufuhren sowie 3. im Vergleich zu Robotersystemen, die ein ahnliches Leistungsspektrum aufweisen, kostengunstiger einzusetzen ist.

Die transperitoneale, praperitoneale laparoskopische Hernioplastik (TAPP) ist die am meisten praktizierte laparoskopische Hernienoperation. Bei 263 Operationen traten 37 Komplikationen (14%) auf, in 9% handelte es sich um groβere Komplikationen wie Rezidive oder Parasthesien. In 5% der Falle traten geringfugigere Komplikationen wie Hamatome auf. Die Rezidivrate betrug 4,5% (n = 12). Aufgrund der gewonnenen Erfahrungen laβt sich feststellen, daβ die laparoskopische Hernienreparation zumindest bei bestimmten Indikationen wie Rezidiv- oder doppelseitigen Hernien eine Alternative zu den bisher verwandten Verfahren darstellt. Operatives Training, Erfahrung und eine sorgfaltige Technik sowie exakte Praparation der anatomischen Verhaltnisse sind unbedingt notwendig.

Im Rahmen einer prospektiven Studie sind wir seit Einfuhrung der laparoskopischen Appendektomie in unserer Klinik im Februar 1991 der Frage nachgegangen, ob die laparoskopische Technik fur den Patient

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).

In einer Ubersicht wird uber die verschiedenen gebrauchlichen Verfahren der Reparatur der medialen Leistenhernie berichtet: Original-Bassini-Methode, modifizierte Bassini-Technik, Shouldice-Technik. D

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.

Im Zeitraum 1978 bis 1987 wurde in der Chirurgischen Abteilung des Allgemeinen Krankenhauses Heidberg in Hamburg bei 361 Patienten (312 weiblich, 49 mannlich) nach erlittener Schenkelhals- und schenkelhalsnaher Oberschenkelfraktur eine Variokopfendoprothese implantiert. Das Durchschnittsalter der Patienten betrug 83 Jahre. Wahrend des postoperativen Klinikaufenthaltes verstarben 73 Patienten (20,2%). 288 Patienten konnten entlassen werden. 98 dieser Patienten verstarben bis zum Zeitpunkt der Nachuntersuchung. Die Nachuntersuchung konnte in 103 Fallen durchgefuhrt werden. Ein gutes bis befriedigendes Ergebnis konnte in 91 Fallen (88%) gefunden werden. Die verbleibenden zwolf Patienten musten nach dem angewandten Score von Merle d'Aubigne mit schlecht bewertet werden, wobei es sich in diesen Fallen ausnahmslos bereits praoperativ um Pflegefalle handelte. Aus den Ergebnissen kann gefolgert werden, das 1. die Variokopfendoprothese als gunstige Alternative zu einer einfachen Hemiendoprothese anzusehen ist, 2. die Implantation einer Variokopfendoprothese zur Behandlung der Frakturen des koxalen Femurendes auch bei weiter Indikationsstellung berechtigt ist, 3. die Operation nach entsprechender Vorbereitung fruh posttraumatisch, das heist nach zirka zwei bis drei Tagen, stattfinden sollte und das 4. der dorsale Zugang wegen der kurzen Operationszeit und der moglichen Fruhmobilisierung der Patienten gungstig ist.

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.

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.