Is mesh pore size in polypropylene meshes associated with the outcome in Lichtenstein inguinal hernia repair: a registry-based analysis of 22,141 patients.

INTRODUCTION: Experimental data show that large-pored meshes reduce foreign body reaction, inflammation and scar bridging and thus improve mesh integration. However, clinical data on the effect of mesh porosity on the outcome of hernioplasty are limited. This study investigated the relation of pore size in polypropylene meshes to the outcome of Lichtenstein inguinal hernioplasty using data from the Herniamed registry. METHODS: This analysis of data from the Herniamed registry evaluated perioperative and 1-year follow-up outcomes in patients undergoing elective, primary, unilateral Lichtenstein inguinal hernia repair using polypropylene meshes. Patients operated with a non-polypropylene mesh or a polypropylene mesh with absorbable components were excluded. Polypropylene meshes with a pore size of 1.0 × 1.0 mm or less were defined as small-pored meshes, while a pore size of more than 1.0 × 1.0 mm was considered large-pored. Unadjusted analyses and multivariable analyses were performed to investigate the relation of pore size of polypropylene meshes, patient and surgical characteristics to the outcome parameters. RESULTS: Data from 22,141 patients were analyzed, of which 6853 (31%) were operated on with a small-pore polypropylene mesh and 15,288 (69%) with a large-pore polypropylene mesh. No association of mesh pore size with intraoperative, general or postoperative complications, recurrence rate or pain requiring treatment was found at 1-year follow-up. A lower risk of complication-related reoperation tended to be associated with small-pore size (p = 0.086). Furthermore, small-pore mesh repair was associated with a lower risk of pain at rest and pain on exertion at 1-year follow-up. CONCLUSION: The present study could not demonstrate an advantage of large-pore polypropylene meshes for the outcome of Lichtenstein inguinal hernioplasty.

Assessment of myofascial medialization following intraoperative fascial traction (IFT) in a cadaveric model.

PURPOSE: Intraoperative fascial traction (IFT) for the treatment of large ventral hernias and loss of domain (LOD) hernias is a promising tool in abdominal wall surgery. However, little is known about the extent of gain in myofascial advancement especially for the anterior rectus sheath. We, therefore, used a cadaveric model to determine the medialization during IFT. METHODS: 4 fresh frozen specimens were used. Retromuscular preparation was carried out followed by IFT with diagonal vertical traction for 30 min. Medial advancement of the anterior rectus sheath was measured after 15 and 30 min as well as traction forces. RESULTS: Total medialization for anterior rectus sheath after 30 min of IFT was 10.5 cm (mean). The mean traction force was 16.28 kg. Total medialization was significantly higher during the first 15 min of vertical fascial traction (p < 0.05). CONCLUSIONS: IFT provides significant medialization for the anterior rectus sheath in the cadaveric model. The findings align with results from a retrospective case study. Therefore, we see IFT as a beneficial tool in abdominal wall surgery.

Open transversus abdominis release in incisional hernia repair: technical limits and solutions.

INTRODUCTION: Incisional hernias with a defect width of more than10 cm are considered complex. The European Hernia Society guidelines recommend that such hernias should only be repaired by surgeons with experience of component separation. The standard component separation technique now is posterior component separation with transversus abdominis release (PCSTAR). Questions are raised about the limits of this technique. METHODS: A literature search of publications on PCSTAR was performed for any references to the limits of this technique in open incisional hernia repair. We found 26 publications relevant to answer this research questions. RESULTS: The standard PCSTAR can generally be used for a defect width of up to 15-17 cm. For defects greater than 17 cm problems must be expected with procedural tasks involving closure of the posterior layer and anterior fascia. No data are available in the literature on the bridging rate for the posterior layer. However, our own experiences show that gaps (holes) occur in the very thin peritoneum/fascia transversalis during dissection and these must be carefully closed. Furthermore, bridging with an absorbable synthetic mesh is needed not so rarely. Closure of the anterior fascia is successful in 81.0-97.2% of cases. In addition to a further mesh for anterior fascial closure, the hernia sac bound with multiple, accordion-like stitches can also be used. For a defect width greater than 17 cm, the limits of PCSTAR become increasingly evident and can be overcome through special technical solutions for closure of the posterior layer and the anterior fascia.

Three-year follow-up analysis of the short-stitch versus long-stitch technique for elective midline abdominal closure randomized-controlled (ESTOIH) trial.

BACKGROUND: Clinical trials have shown reduced incisional hernia rates 1 year after elective median laparotomy closure using a short-stitch technique. With hernia development continuing beyond the first postoperative year, we aimed to compare incisional hernias 3 years after midline closure using short or long stitches in patients from the ESTOIH trial. METHODS: The ESTOIH trial was a prospective, multicenter, parallel-group, double-blind, randomized-controlled study of primary elective midline closure. Patients were randomized to fascia closure using a short- or long-stitch technique with a poly-4-hydroxybutyrate-based suture. A predefined 3-year follow-up analysis was performed with the radiological imaging-verified incisional hernia rate as the primary endpoint. RESULTS: The 3-year intention-to-treat follow-up cohort consisted of 414 patients (210 short-stitch and 204 long-stitch technique) for analysis. Compared with 1 year postoperatively, incisional hernias increased from 4.83% (20/414 patients) to 9.02% (36/399 patients, p = 0.0183). The difference between the treatment groups at 3 years (short vs. long stitches, 15/198 patients (7.58%) vs. 21/201 (10.45%)) was not significant (OR, 1.4233; 95% CI [0.7112-2.8485]; p = 0.31). CONCLUSION: Hernia rates increased significantly between one and 3 years postoperatively. The short-stitch technique using a poly-4-hydroxybutyrate-based suture is safe in the long term, while no significant advantage was found at 3 years postoperatively compared with the standard long-stitch technique. TRIAL REGISTRY: NCT01965249, registered on 18 October 2013.

Laparoscopic total (Nissen) versus posterior (Toupet) fundoplication for gastroesophageal reflux disease: a propensity score-matched comparison of the perioperative and 1-year follow-up outcome.

INTRODUCTION: The debate continues as to whether laparoscopic total Nissen (LNF) versus partial posterior Toupet fundoplication (LTF) leads to better outcomes in the surgical treatment of axial hiatal hernia with gastroesophageal reflux disease. In the most recent meta-analysis including 13 RCTs with 1564 patients, no significant difference was found between the two procedures in terms of perioperative complications and recurrent reflux rates. Further comparative analyses are urgently needed. METHODS: This retrospective analysis of prospectively recorded data from the Herniamed Registry compared the perioperative and 1-year follow-up outcomes after total Nissen versus partial Toupet fundoplication. Propensity score matching was chosen as the statistical method. Matching was performed for n = 2290 pairs. RESULTS: No systematic discrepancy was found between the Nissen and Toupet fundoplication for any of the outcome parameters (intraoperative complications LNF 2.10% vs LTF 1.48%, general complications 2.27% vs 2.88%, postoperative complications 1.44% vs 1.18%, complication-related reoperation 1.00% vs 0.91%, recurrence on 1-year follow-up 6.55% vs 5.33%, pain on exertion on 1-year follow-up 12.49% vs 9.52%, pain at rest on 1-year follow-up 10.44 vs 9.52% and pain requiring treatment on 1-year follow-up 9.61% vs 8.17%). Also the postoperative dysphagia rate showed with 5.34% after LNF and with 4.64% after LTF no significant difference. CONCLUSION: The findings presented here did not show any significant difference up to 1 year after Nissen or Toupet fundoplication. This is in concordance with the findings of the meta-analyses. However, the perioperative and 1-year follow-up outcomes demonstrate that both operation techniques should be carried out by experienced surgeons.

Mesh vs. non-mesh repair of type I hiatal hernias: a propensity-score matching analysis of 6533 patients from the Herniamed registry.

INTRODUCTION: Surgical treatment of type I hiatal sliding hernias aims to control the gastroesophageal reflux symptoms and prevention of hernia recurrence. Usually, a cruroplasty is performed to narrow the hiatal orifice. Here, it remains controversial if a mesh reinforcement of the cruroplasty should be performed, since benefits as well as mesh-associated complications have been described. METHODS: We performed a propensity-score matching analysis with data derived from the Herniamed registry comparing patients undergoing laparoscopic type I hiatal hernia repair with and without synthetic mesh. We analyzed perioperative, intraoperative, and postoperative data including data derived from the 1-year follow-up in the registry. RESULTS: 6.533 patients with an axial, type I hiatal hernia and gastroesophageal reflux are included in this analysis. Mesh augmentation of the hiatoplasty was performed in n = 1.252/6.533 (19.2%) of patients. The defect size in the subgroup of patients with mesh augmentation was with mean 16.3 cm2 [14.5; 18.2] significantly larger as in the subgroups without mesh augmentation with 10.8 cm2 [8.7; 12.9]; (p < 0.001). In patients with mesh hiatoplasty n = 479 (38.3%) Nissen and n = 773 (61.7%) Toupet fundoplications are performed. 1.207 matched pairs could be analyzed. The mean defect size after matching was with 15.9 cm2 comparable in both groups. A significant association was seen regarding recurrence (4.72% mesh vs. 7.29% non-mesh hiatoplasty, p = 0.012). The same relation can be seen for pain on exertion (8.78% vs 12.10%; p = 0.014) and pain requiring treatment (6.13% vs 9.11%; p = 0.010). All other outcome parameter showed no significant correlation. CONCLUSIONS: Our data demonstrate that mesh-reinforced laparoscopic type I hiatal hernia repair in larger defects is associated with significantly lower rates for recurrence, pain on exertion and pain requiring treatment.

Long-term evaluation of the Hernia Compact course of the German Hernia School.

INTRODUCTION: Since 2011, the German Hernia Society has developed the German Hernia School (GHS) as a standardized hernia surgery training program for younger surgeons, consisting of the Hernia Compact basic module. It is a standardized three day training program (cadaver workshop, ultrasound simulation training, and hands-on training). After 12 years of experience, a survey was conducted to evaluate the long term effect of this training. METHOD: Using an anonymous online-questionnaire, we contacted from September 2023 to October 2023 the Hernia Compact course participants via the congress organizer "Weitmeer" and the German Hernia Society. This online questionnaire contains 18 multiple choice questions regarding participants' age, gender, professional experience, participation in other modules of the German Hernia School, the effect of the course on their daily practice and their specific interest in hernia and abdominal wall surgery. RESULTS: A total of 146 participants responded to the anonymous online questionnaire. A majority of 132 of 146 participants (90.42%) responded that this course improved the quality of surgical and hernia training (n = 146, no missing data). 141 of 146 individuals (96.58%) recommended the course to surgical colleagues (n = 146, no missing data). There were 89.73% of participants, (n = 146, no missing data) that developed a specific interest in hernia and abdominal wall surgery after the course. For 78.08% (n = 146, no missing data) of participants hernia and abdominal wall surgery was one of the most important activities in their daily surgical practice. CONCLUSION: The standardized Hernia Compact basic course of the German Hernia School appears to have a huge impact on the quality of hernia surgery training in Germany and Austria. It might also help generate a specific interest in hernia surgery among participants.

STRONGHOLD first-year results of biomechanically calculated abdominal wall repair: a propensity score matching.

PURPOSE: Every year around 70,000 people in Germany suffer from an abdominal incisional hernia that requires surgical treatment. Five years after reconstruction about 25% reoccur. Incisional hernias are usually closed with mesh using various reconstruction techniques, summarized here as standard reconstruction (SR). To improve hernia repair, we established a concept for biomechanically calculated reconstructions (BCR). In the BCR, two formulas enable customized patient care through standardized biomechanical measures. This study aims to compare the clinical outcomes of SR and BCR of incisional hernias after 1 year of follow-up based on the Herniamed registry. METHODS: SR includes open retromuscular mesh augmented incisional hernia repair according to clinical guidelines. BCR determines the required strength (Critical Resistance to Impacts related to Pressure = CRIP) preoperatively depending on the hernia size. It supports the surgeon in reliably determining the Gained Resistance, based on the mesh-defect-area-ratio, further mesh and suture factors, and the tissue stability. To compare SR and BCR repair outcomes in incisional hernias at 1 year, propensity score matching was performed on 15 variables. Included were 301 patients with BCR surgery and 23,220 with standard repair. RESULTS: BCR surgeries show a significant reduction in recurrences (1.7% vs. 5.2%, p = 0.0041), pain requiring treatment (4.1% vs. 12.0%, p = 0.001), and pain at rest (6.9% vs. 12.7%, p = 0.033) when comparing matched pairs. Complication rates, complication-related reoperations, and stress-related pain showed no systematic difference. CONCLUSION: Biomechanically calculated repairs improve patient care. BCR shows a significant reduction in recurrence rates, pain at rest, and pain requiring treatment at 1-year follow-up compared to SR.

Mini- or less-open sublay (E/MILOS) operation vs open sublay and laparoscopic IPOM repair for the treatment of incisional hernias: a registry-based propensity score matched analysis of the 5-year results.

BACKGROUND: Open sublay and laparoscopic IPOM repair have specific disadvantages and risks. In recent years, this evidence led to a paradigm shift and induced the development of new minimally invasive techniques of sublay mesh repair. METHODS: Pioneering this trend, we developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed trans-hernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. After dissection of an extra-peritoneal space of at least 8 cm, port placement and CO2 insufflation, each MILOS operation can be continued endoscopically (EMILOS repair). All E/MILOS operations were prospectively documented in the Herniamed Registry with 1- and 5-year questionnaire follow-ups. Propensity score matching of incisional hernia operations comparing the results of the E/MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from all other institutions participating in the Herniamed Registry was performed. The results with perioperative complications and 1-year follow-up have been published previously. RESULTS: This paper reports on the 5-year results. The 5-year follow-up rate was 87.5% (538 of 615 patients with E/MILOS incisional hernia operations). Comparing E/MILOS repair with laparoscopic IPOM and open sublay operation, propensity score matching analysis was possible with 448 and 520 pairs of operations, respectively. Compared with laparoscopic IPOM incisional hernia operation, the E/MILOS repair is associated with significantly fewer general complications (P = 0.004), recurrences (P < 0.001), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.016) and tends to result in fewer postoperative complications (P = 0.052), and less pain at rest (P = 0.053). Matched pair analysis with open sublay repair revealed significantly fewer general complications (P < 0.001), postoperative complications (P < 0.001), recurrences (P = 0.002), less pain at rest (P = 0.004), less pain on exertion (P < 0.001), and less chronic pain requiring treatment (P = 0.014). A limitation of this analysis is a relative low 5-year follow-up rate for laparoscopic IPOM and open sublay. CONCLUSIONS: The E/MILOS technique allows minimally invasive trans-hernial repair of incisional hernias using large standard meshes with low morbidity and good long-term results. The technique combines the advantages of sub-lay repair and a mini- or less-invasive approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT03133000.

Incisional hernia repair following pancreatic surgery-open vs laparoscopic approach.

INTRODUCTION: For pancreatic procedures, transverse and midline or combined approaches are used. Having an increased morbidity after pancreatic surgery, these patients have an increased risk of developing an incisional hernia. In the following, we will analyze how the results of incisional hernia surgery after pancreatic surgery are presented in the Herniamed Registry. METHODS: Hospitals and surgeons from Germany, Austria and Switzerland can voluntarily enter all routinely performed hernia operations prospectively into the Herniamed Registry. All patients sign a special informed consent declaration that they agree to the documentation of their treatment in the Herniamed Registry. Perioperative complications (intraoperative complications, postoperative complications, complication-related reoperations and general complications) are recorded up to 30 days after surgery. After 1, 5, and 10 years, patients and primary care physicians are contacted and asked about any pain at rest, pain on exertion, chronic pain requiring treatment or recurrence. This retrospective analysis of prospectively collected data compares the outcomes of minimally invasive vs open techniques in incisional hernia repair after pancreatic surgery. RESULTS: Relative to the total number of all incisional hernia patients in the Herniamed Registry, the proportion after pancreatic surgery with 1-year follow-up was 0.64% (n = 461) patients. 95% of previous pancreatic surgeries were open. Minimally invasive incisional hernia repair was performed in 17.1% and open repair in 82.9% of cases. 23.2% of the defects were larger than 10 cm and 32.8% were located laterally or were a combination of lateral and medial defects. Among the few differences between the collectives, a significantly higher rate of defect closure (58.1% vs 25.3%; p < 0.001) and drainage (72.8% vs 13.9%; p < 0.001) was found in the open repairs, and larger meshes were seen in the minimally invasive procedures (340.6 cm2 vs 259.6 cm2; p < 0.001). No difference deemed a risk factor for chronic postoperative pain was seen in the rate of preoperative pain between the open and minimally invasive procedures (Appendix Table 4) No significant differences were found in either the perioperative complications or at 1-year follow-up. CONCLUSIONS: Incisional hernias after complex pancreatic surgery can be repaired safely and with a low recurrence rate in both open and minimally invasive techniques.

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair.

Objective: To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh. Summary Background Data: Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce. Methods: Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10]. Results: In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2). Conclusions: Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Drain versus no drain in elective open incisional hernia operations: a registry-based analysis with 39,523 patients.

PURPOSE: Elective open incisional hernia operations are a frequently performed and complex procedure. Prophylactic drainage is widely practised to prevent local complications, but nevertheless the benefit of surgical drain placement remains a controversially discussed subject. Objective of this analysis was to evaluate the current status of patient care in clinical routine and outcome in this regard. METHODS: The study based on prospectively collected data of the Herniamed Register. Included were all patients with elective open incisional hernia between 1/2005 and 12/2020 and completed 1-year follow-up. Multiple linear and logistic regression analysis was performed to assess the relation of individual factors to the outcome variables. RESULTS: Analysed were data from 39,523 patients (28,182 with drain, 11,341 without). Patients with drain placement were significantly older, had a higher BMI, more preoperative risk factors, and a larger defect size. Drained patients furthermore showed a significant disadvantage in the outcome parameters intraoperative complications, general complications, postoperative complications, complication-related reoperations, and pain at the 1-year follow-up. No significant difference was observed with respect to the recurrent rate. CONCLUSION: With 71.3%, the use of surgical drainages has a high level of acceptance in elective open incisional hernia operations. The worse outcome of patients is associated with the use of drains, independent of other influencing factors in the model such as patient or surgical characteristics. The use of drains may be a surrogate parameter for other unobserved confounders.

Laparoscopic transversus abdominis release for complex ventral hernia repair: technique and initial findings.

PURPOSE: The open Rives-Stoppa retrorectus and transversus abdominis release (TAR) techniques are well established in open ventral and incisional hernia repair. The principles are currently being translated into minimally invasive surgery with different concepts. In this study, we investigate our initial results of transperitoneal laparoscopic TAR for ventral incisional hernia repair (laparoscopic TAR). METHODS: Over a 20-month period, 23 consecutive patients with incisional hernias underwent surgery. Laparoscopic TAR was performed transperitoneally with adhesiolysis from the anterior abdominal wall, development of the retrorectus space and TAR, midline reconstruction and extraperitoneal mesh reinforcement. RESULTS: There were 23 incisional hernias, of which 70% were M2-M4 and 60% were W3. Median patient age was 68 years and the median BMI was 31. Median operating time was 313 min, and hospital stay was 4 days. Morbidity was 26% (Clavien-Dindo 1: n = 4 and 2 + 3b: n = 2). CONCLUSION: With the laparoscopic TAR, it was possible to treat a series of patients with ventral incisional hernias. The operating times were long. However, with a low rate of perioperative complications the hospital stay was short As feasibility is demonstrated, the clinical relevance of the method has to be further evaluated.

Outcome of incisional hernia repair in patients 80 years and older: results from the Herniamed-Registry.

INTRODUCTION: More and more often complex abdominal surgeries are performed in the elderly. Together with the ageing population these patients are at risk for incisional hernias. We aimed on assessing outcomes following incisional hernia surgery in patients 80 years and older. MATERIAL AND METHODS: Using the Herniamed-Registry, a prospective multi-institutional database, data on patients undergoing surgery for incisional hernias were retrospectively assessed. 46,040 patients were included and divided by age. Intraoperative-, general-, and postoperative complications as well as 1-year follow-up outcomes were assessed and compared between patients 80 years and older vs younger than 80 years. RESULTS: Intra- (2.3% vs 1.5%; p < 0.001) and postoperative (8.6% vs 7.2%; p = 0.001) complications, general complications (5.5% vs 3.0%; p < 0.001), as well as reoperations (3.8% vs 3.0%; p = 0.007) were more likely to occur in elderly patients. By contrast, recurrences (3.6% vs 4.5%; p = 0.007), pain at rest (7.3% vs 10.1%; p < 0.001) and on exertion (11.3% vs 18.3%; p < 0.001), as well as pain requiring treatment (5.4% vs 7.7%; p < 0.001) was less likely in the group of patients aged ≥ 80 years. CONCLUSION: Incisional hernia repair in patients 80 years and older is associated with a slightly higher complication risk but is quite acceptable and also have improved pain scores. The recurrence difference is also clinically unimportant.

Gender differences in epigastric hernia repair: a propensity score matching analysis of 15,925 patients from the Herniamed registry.

INTRODUCTION: In recent surgical literature, gender-specific differences in the outcome of hernia surgery has been analyzed. We already know that female patients are at higher risk to develop chronic postoperative pain after inguinal, incisional, and umbilical hernia surgery. In this study, we evaluated the impact of gender on the outcome after epigastric hernia surgery. METHODS: A covariable-adjusted matched-paired analysis with data derived from the Herniamed registry was performed. In total of 15,925 patients with 1-year follow-up data were included in the study. Propensity score matching was performed for the 7786 female (48.9%) and 8139 male (51.1%) patients, creating 6350 pairs (81.6%). RESULTS: Matched-paired analysis revealed a significant disadvantage for female patients for pain on exertion (12.1% vs. 7.6%; p < 0.001) compared to male patients. The same effect was demonstrated for pain at rest (6.2% in female patients vs. 4.1% in male patients; p < 0.001) and pain requiring treatment (4.6% in female patients vs. 3.1% in male patients; p < 0.001). All other outcome parameters showed no significant differences between female and male patients. CONCLUSIONS: Female patients are at a higher risk for chronic pain after elective epigastric hernia repairs compared to the male patient population. These results complete findings of previous studies showing the same effect in inguinal, umbilical, and incisional hernia repair.

[Inguinal hernia operations-Always outpatient?] / Leistenhernienoperationen ­ immer ambulant?

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

What are the influencing factors on the outcome in lateral incisional hernia repair? A registry-based multivariable analysis.

INTRODUCTION: Incisional hernias following lateral abdominal wall incisions with an incidence of 1-4% are less common than following medial incisions at 14-19%. The proportion of lateral incisional hernias in the total collective of all incisional hernias is around 17%. Compared to midline defects, lateral incisional hernias are more difficult to repair because of the more complex anatomy and localization. A recent systematic review identified only 11 publications with a total of 345 patients reporting on lateral incisional hernia repair. Therefore, further studies are urgently needed. METHODS: Multivariable analysis of the data available for 6,306 patients with primary elective lateral incisional hernia repair was performed to assess the confirmatory pre-defined potential influence factors and their association with the perioperative and one-year follow-up outcomes. RESULTS: In primary elective lateral incisional hernia repair, open onlay, open IPOM and suture procedures were found to have an unfavorable effect on the recurrence rate. This was also true for larger defect sizes and higher BMI. A particularly unfavorable relationship was identified between larger defect sizes and perioperative complications. Laparoscopic-IPOM presented a higher risk of intraoperative, and open sublay of postoperative, complications. The chronic pain rates were especially unfavorably influenced by the postoperative complications, preoperative pain and female gender. CONCLUSION: Open-onlay, open IPOM and suture procedures, larger defect sizes, female gender, higher BMI, preoperative pain and postoperative complications are associated with unfavorable outcomes following primary elective lateral incisional hernia repair.

Outcome of inguinal hernia repair after previous radical prostatectomy: a registry-based analysis with 12,465 patients.

INTRODUCTION: Following radical prostatectomy, the rate of inguinal hernias is fourfold higher compared to controls. Laparo-endoscopic repair after previous radical prostatectomy is considered complex. Therefore, the guidelines recommend open Lichtenstein repair. To date, there are limited data on inguinal hernia repair after prior prostatectomy. METHODS: In a retrospective analysis from the Herniamed Registry, the outcomes of 255,182 primary elective unilateral inguinal hernia repairs were compared with those of 12,465 patients with previous radical prostatectomy in relation to the surgical technique. Furthermore, the outcomes of laparo-endoscopic versus open Lichtenstein repair techniques in the 12,465 patients after previous radical prostatectomy were directly compared. RESULTS: Comparison of the perioperative complication rates for primary elective unilateral inguinal hernia repair with and without previous radical prostatectomy demonstrated for the laparo-endoscopic techniques significantly higher intraoperative complications (2.1% vs 0.9%; p < 0.001), postoperative complications (3.2% vs 1.9%; p < 0.001) and complication-related reoperations (1.1% vs 0.7%; p = 0.0442) to the disadvantage of previous prostatectomy. No significant differences were identified for Lichtenstein repair. Direct comparison of the laparo-endoscopic with the open Lichtenstein technique for inguinal hernia repair after previous radical prostatectomy revealed significantly more intraoperative complications for TEP and TAPP (2.1% vs 0.6%; p < 0.001), but more postoperative complications (4.8% vs 3.2%; p < 0.001) and complication-related reoperations (1.8% vs 1.1%; p = 0.003) for open Lichtenstein repair. CONCLUSION: Since there are no clear advantages for the laparo-endoscopic vs the open Lichtenstein technique in inguinal hernia repair after previous radical prostatectomy, the surgeon can opt for one or the other technique in accordance with their experience.

What is the reality in outpatient vs inpatient groin hernia repair? An analysis from the Herniamed Registry.

INTRODUCTION: Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%. The outpatient procedure appears to negatively impact the proportion of laparo-endoscopic repairs. To date, only very few studies have compared inpatient vs outpatient groin hernia repair. METHODS: All outpatient and inpatient primary elective unilateral groin hernia repairs performed between 2010 and 2019 were identified in the Herniamed Registry and their treatment and outcomes compared. RESULTS: The 737 participating hospitals/surgeons performed a total of 342,072 primary elective unilateral groin hernia repairs from 2010 to 2019. The proportion of outpatient repairs was 20.2% in 2013 and 14.3% in 2019. Whereas the proportion of laparo-endoscopic repairs among the inpatient cases was 71.9% in 2019, the last year for which data are available, it was only 34.3%.for outpatient repairs. In outpatient groin hernia repairs, the rates of patients aged ≥ 60 years, with ASA score III and IV and risk factors were highly significantly lower. Given this rigorous patient selection for outpatient groin hernia repair, a more favorable perioperative outcome was achieved. At 1-year follow-up there were no significant differences in the pain and recurrence rates. CONCLUSION: With an appropriate patient selection, outpatient primary elective unilateral groin hernia repair can be performed with acceptable risks and good outcomes. Since to date no studies have compared inpatient vs outpatient groin hernia repair, the impact of a higher rate of outpatient groin hernia repair cannot currently be evaluated.

Slowly resorbable biosynthetic mesh: 2-year results in VHWG grade 3 hernia repair.

INTRODUCTION: Information on the long-term performance of biosynthetic meshes is scarce. This study analyses the performance of biosynthetic mesh (Phasix™) over 24 months. METHODS: A prospective, international European multi-center trial is described. Adult patients with a Ventral Hernia Working Group (VHWG) grade 3 incisional hernia larger than 10 cm2, scheduled for elective repair, were included. Biosynthetic mesh was placed in sublay position. Short-term outcomes included 3-month surgical site occurrences (SSO), and long-term outcomes comprised hernia recurrence, reoperation, and quality of life assessments until 24 months. RESULTS: Eighty-four patients were treated with biosynthetic mesh. Twenty-two patients (26.2%) developed 34 SSOs, of which 32 occurred within 3 months (primary endpoint). Eight patients (11.0%) developed a hernia recurrence. In 13 patients (15.5%), 14 reoperations took place, of which 6 were performed for hernia recurrence (42.9%), 3 for mesh infection (21.4%), and in 7 of which the mesh was explanted (50%). Compared to baseline, quality of life outcomes showed no significant difference after 24 months. Despite theoretical resorption, 10.7% of patients reported presence of mesh sensation in daily life 24 months after surgery. CONCLUSION: After 2 years of follow-up, hernia repair with biosynthetic mesh shows manageable SSO rates and favorable recurrence rates in VHWG grade 3 patients. No statistically significant improvement in quality of life or reduction of pain was observed. Few patients report lasting presence of mesh sensation. Results of biosynthetic mesh after longer periods of follow-up on recurrences and remodeling will provide further valuable information to make clear recommendations. TRIAL REGISTRATION: Registered on clinicaltrials.gov (NCT02720042), March 25, 2016.