Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons.

BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

[The Open Retromuscular Preperitoneal Mesh Repair of the Incisional Lateral Hernia - Technique and Results of a Prospective Cohort Study]. / Offene Reparation der inzisionalen Flankenhernie mit retromuskulärer präperitonealer Netzimplantation ­ Beschreibung der Technik und Ergebnisse einer prospektiven Kohortenstudie.

INTRODUCTION: Surgical approaches to flank hernias have been poorly standardised. The most demanding issues in intermuscular net insertion are the limited area in the dorsal direction and the difficulties in fixing the net to the costal arch or the iliac crest. This is why many different surgical procedures have been published. PATIENTS/MATERIAL AND METHODS: From August 2015 to October 2016, nine patients with a primary incisional lateral hernia received open retromuscular preperitoneal mesh repair. In intermuscular mesh placement, the mesh size must be smaller at smaller values of the CPA (costopelvic angle). On the dorsal side of the reference stretch RS of 10 cm between costal arch and iliac crest, fixations are necessary to achieve stability. Retroperitoneal preperitoneal net implantation is unrestricted by the patient's anatomy. The placement of the mesh is similar to the Stoppa procedure and almost any size can be used with little fixation. Remodeling of the abdominal wall can be comfortably achieved. RESULTS: All 9 patients underwent retromuscular preperitoneal mesh repair. The hernia size was 92.85 cm2 with a corresponding mesh size of 426.22 cm2. No adverse side effects or surgical complications were observed; the length of hospital stay was between 3 to 7 days; the follow up was 3 to 18 months, with a mean follow-up of 9.1 months. In a follow-up questionnaire, the patients reported a high satisfaction rate with a grade of 1,2 (school mark); there was no recurrence. The pain level decreased from VAS grade 4 preoperatively to 1.2 postoperatively. 7 patients had no pain at all. SUMMARY: In conclusion, adequate overlap of the implanted mesh can be achieved in the preperitoneal retromuscular space even in large hernias. Fixation of the mesh to the costal arch or the iliac crest is not necessary and would only induce postoperative pain. Long-term stability depends on the size of the mesh. Remodeling of the abdominal wall with closure of the fascia above the mesh can be easily achieved.

[Without Net and Double Floor: Comparison of Umbilical Hernia Repair by Spitzy in Children and Adults]. / Ohne Netz und doppelten Boden: Vergleich der Nabelherniotomie nach Spitzy im Kindes- und Erwachsenenalter.

Umbilical hernia occur in both adults and children. For over 100 years, umbilical hernia in children has been treated surgically by the Spitzy method. With adult patients, meshes are being increasingly used. The purpose of our study was to analyse Spitzy herniotomy with respect to the recurrence rate in children and adults. MATERIAL AND METHODS: Over a period of 7 years, 383 children (age < 16 years) with umbilical hernia were treated surgically; after applying the exclusion criteria, 370 patients were evaluated. At the same time, 106 adult patients (age > 16 years) were operated for an umbilical hernia: 31 patients were treated with direct suture and thus are included in our study as comparison group. RESULTS: The young patients had an average age of 33.81 months and were 44% female and 56% male. After direct Spitzy suture, a low recurrence rate of 1.1% (n = 4) in infancy could be achieved. The average age of the adult patients was 54.55 years; 32% were female, 68% male. In comparison to the group of children, the recurrence rate in adult surgery was 12.9% (n = 4) after direct suture. CONCLUSION: As confirmed in our study, umbilical herniotomy by direct suture in childhood has been the method of choice and gold standard for more than 100 years. Mesh implantation is still not necessary in childhood.

[Day surgery for inguinal hernia]. / Update ambulante Leistenhernienchirurgie.

Day surgery for inguinal hernia Abstract. Hernia surgery has experienced a very positive development in the past 30 years: better meshes, better understanding of the anatomy and the nerves, improved skills-training, minimally invasive and more precise operations (e. g. also with the robot), just to name a few. This directly results in fewer recurrences, less chronic pain and better quality of life. In the current article, the growing importance day-care surgery of inguinal hernias is discussed - not least because of the statutory AVOS regulation that came into effect in Switzerland on 01.01.2019. This article reviews the indication and the most important surgical procedures for day-care groin hernia repair. There is no single standard procedure (no one-fits-all), since according to today's knowledge every patient is an individual case and must have access to an individually tailored procedure. For day-surgery inguinal hernia repair with mesh, both conventional and minimally invasive procedures are suitable. When planning outpatient hernia repairs, it must also be taken into account that acute postoperative pain is of negative prognostic significance, which is why optimal postoperative pain therapy should be well coordinated with the general practitioner in the first days after the operation. With all the positive aspects of AVOS, it is still not clear how the further training of the young generation will take place under the current conditions, as it is no longer provided for in the structural and reimbursement regulations. There is an urgent need for improvement here.

Nitrated Fatty Acids Modulate the Physical Properties of Model Membranes and the Structure of Transmembrane Proteins.

Nitrated fatty acids (NO2 -FAs) act as anti-inflammatory signal mediators, albeit the molecular mechanisms behind NO2 -FAs' influence on diverse metabolic and signaling pathways in inflamed tissues are essentially elusive. Here, we combine fluorescence measurements with surface-specific sum frequency generation vibrational spectroscopy and coarse-grained computer simulations to demonstrate that NO2 -FAs alter lipid organization by accumulation at the membrane-water interface. As the function of membrane proteins strongly depends on both, protein structure as well as membrane properties, we consecutively follow the structural dynamics of an integral membrane protein in presence of NO2 -FAs. Based on our results, we suggest a molecular mechanism of the NO2 -FA in vivo activity: Driven by the NO2 -FA-induced lipid layer reorganization, the structure and function of membrane-associated (signaling) proteins is indirectly affected.

Impact of incisional negative pressure wound therapy on perineal wound healing after abdominoperineal rectum extirpation.

INTRODUCTION: Perineal wound healing disorders are one of the major complications following abdominoperineal rectum extirpation. METHODS AND RESULTS: We evaluated the impact of an "incisional negative pressure wound therapy" (iNPWT) system after abdominoperineal rectum extirpation in six patients. All patients had a neoadjuvant radiochemotherapy with 50.4 Gy and 5-FU. Five of the six patients (83%) experienced complication-free healing of the perineal wound after 5 to 12 days of iNPWT. One patient developed a wound healing disorder 8 days after abdominoperineal rectum extirpation during current iNPWT. DISCUSSION: Use of an iNPWT system can be of favor after abominoperineal rectum extirpation.

Original article: role of adjuvant chemotherapy in a perioperative chemotherapy regimen for gastric cancer.

BACKGROUND: Multimodal treatment strategies - perioperative chemotherapy (CTx) and radical surgery - are currently accepted as treatment standard for locally advanced gastric cancer. However, the role of adjuvant postoperative CTx (postCTx) in addition to neoadjuvant preoperative CTx (preCTx) in this setting remains controversial. METHODS: Between 4/2006 and 12/2013, 116 patients with locally advanced gastric cancer were treated with preCTx. 72 patients (62 %), in whom complete tumor resection (R0, subtotal/total gastrectomy with D2-lymphadenectomy) was achieved, were divided into two groups, one of which receiving adjuvant therapy (n = 52) and one without (n = 20). These groups were analyzed with regard to survival and exclusion criteria for adjuvant therapy. RESULTS: Postoperative complications, as well as their severity grade, did not correlate with fewer postCTx cycles administered (p = n.s.). Long-term survival was shorter in patients receiving postCTx in comparison to patients without postCTx, but did not show statistical significance. In per protocol analysis by excluding two patients with perioperative death, a shorter 3-year survival rate was observed in patients receiving postCTx compared to patients without postCTx (3-year survival: 71.2 % postCTx group vs. 90.0 % non-postCTx group; p = 0.038). CONCLUSION: These results appear contradicting to the anticipated outcome. While speculative, they question the value of post-CTx. Prospectively randomized studies are needed to elucidate the role of postCTx.

Improved survival of patients with colon cancer detected by screening colonoscopy.

BACKGROUND: Screening for colon cancer (CC) may not only reduce its occurrence but has also the potential to reduce the overall mortality. So far, there has been little evidence that detection of colon cancer by screening colonoscopy results in different survival rates compared to symptomatic patients. PATIENTS AND METHODS: Clinical, histological, diagnostic, and survival data of 1016 consecutive patients with CC from a prospectively expanded single-institutional database were analyzed for diagnostic, treatment, and prognostic factors. Findings were then stratified according to detection by screening colonoscopy vs. patients who became symptomatic prior to further diagnostic work-up. RESULTS: 7.1 % of all patients were identified by screening colonoscopy for colon cancer. Screened patients were younger (68.2 vs. 64.8 years), had smaller T stage (p = 0.032), lower tumor stage (p = 0.009), and a tendency to less lymph node metastasis. Overall survival was superior in screened patients, and stage-specific survival showed a tendency to improved survival, which was not statistically significant. Furthermore, a higher percentage of screened patients underwent adjuvant chemotherapy (84.6 vs. 55.0 %, p = 0.032). CONCLUSION: Survival outcome and enrollment in a multimodal treatment was higher in screening-detected patients compared to patients diagnosed after the onset of clinical symptoms. Besides a potential occurrence of lead time bias, these findings strongly support the need for continued improvement of screening programs and the recruitment of more patients for colorectal cancer screening.

Diagnostic value of preoperative CT scan to stratify colon cancer for neoadjuvant therapy.

BACKGROUND AND OBJECTIVE: Neoadjuvant therapy could improve oncological outcome of patients suffering from colon cancer. An accurate staging method is needed to define suitable patients. The aim of this retrospective study was to validate the value of CT for identifying patients with local advanced (T3/4) or nodal-positive colon cancer. METHODS AND MATERIAL: Preoperative abdominal CT scans of 210 patients with colon cancer were evaluated by two radiologists independently for the T stage and N stage. Results were compared to pathology. Patients were stratified according to the guidelines for rectal cancer into patients with low risk (T0/1/2 and N0) or high risk (T3/4 or N+). RESULTS: Inter-observer correlation was high with over 90 %. Overall sensitivity T stage was 93.0 % and for N stage 76.9 %. Using CT scan to identify local advanced (T3/4 or N+) tumors, the consensus sensitivity was 94.9 %, the specificity 53.6 %, the positive predictive value (PPV) 92.8 %, and the negative predictive value (NPV) 62.5 %. CONCLUSION: Computer tomography represents an effective tool for identifying patients with colon cancer suitable for neoadjuvant therapy according to the guidelines for rectal cancer.

Multimodal therapy in treatment of rectal cancer is associated with improved survival and reduced local recurrence - a retrospective analysis over two decades.

BACKGROUND: The management of rectal cancer (RC) has substantially changed over the last decades with the implementation of neoadjuvant chemoradiotherapy, adjuvant therapy and improved surgery such as total mesorectal excision (TME). It remains unclear in which way these approaches overall influenced the rate of local recurrence and overall survival. METHODS: Clinical, histological and survival data of 658 out of 662 consecutive patients with RC were analyzed for treatment and prognostic factors from a prospectively expanded single-institutional database. Findings were then stratified according to time of diagnosis in patient groups treated between 1993 and 2001 and 2002 and 2010. RESULTS: The study population included 658 consecutive patients with rectal cancer between 1993 and 2010. Follow up data was available for 99.6% of all 662 treated patients. During the time period between 2002 and 2010 significantly more patients underwent neoadjuvant chemoradiotherapy (17.6% vs. 60%) and adjuvant chemotherapy (37.9% vs. 58.4%). Also, the rate of reported TME during surgery increased. The rate of local or distant metastasis decreased over time, and tumor related 5-year survival increased significantly with from 60% to 79%. CONCLUSION: In our study population, the implementation of treatment changes over the last decade improved the patient's outcome significantly. Improvements were most evident for UICC stage III rectal cancer.

Influence of a paclitaxel coated balloon in combination with a bare metal stent on restenosis and endothelial function: comparison with a drug eluting stent and a bare metal stent.

AIMS: Different approaches of local intravascular drug delivery may influence endothelial and microvascular function. The aim of this trial was to study the influence of a paclitaxel coated balloon in combination with a bare metal stent (DCB + BMS) versus a bare metal stent (BMS) or a sirolimus-eluting stent (DES) on coronary restenosis and endothelial function. METHODS AND RESULTS: This prospective trial included 77 patients with coronary de novo lesions. The patients were assigned to either one of the treatment groups. After 9 months, patients underwent angiographic follow-up including invasive measurement of coronary endothelial function. After 9 months, late lumen loss in-stent was highest in the BMS group (0.85 ± 0.73 mm), lower in DCB + BMS (0.36 ± 0.46 mm); and lowest in the DES group (0.25 ± 0.34 mm; P = 0.001 [ANOVA]). When compared to the BMS group, in-segment late lumen loss was significantly reduced in the DCB + BMS group (0.27 ± 0.43 mm vs. 0.60 ± 0.55 mm, P = 0.029) and the DES group (0.28 ± 0.40 mm, P = 0.045). Coronary flow reserve was significantly higher with the DCB + BMS treatment (3.16 ± 0.97 vs. 2.42 ± 0.99 [BMS], P = 0.036) whereas the increase in the DES group did not reach the significance level (3.06 ± 1.39, P = 0.144 vs. BMS). Parameters of endothelial function like intracoronary flow velocity and vessel diameter distal to the stented area showed similar patterns of response to adenosine, acetylcholine, and nitro in all groups. CONCLUSION: DES and the combination of DCB + BMS showed a significant reduction of late lumen loss as compared to a BMS alone. Furthermore, both types of local drug delivery were not associated with a deterioration of microvascular function at 9 months [ClinicalTrials.gov Identifier: NCT00473499].

Laparoscopic TAPP to treat inguinal hernia. Is the robot preferable? A review and cohort-study on anatomical landmarks of robotic-assisted transabdominal preperitoneal groin hernia repair (r-TAPP).

In this review, the advantages of the robotic platform in rTAPP are presented and discussed. Against the background of the unchanged results of conventional TAPP for decades (approx. 10% chronic pain and approx. 3.5% recurrence), a new anatomy-guided concept for endoscopic inguinal hernia repair with the robot is presented. The focus is on the identification of Hesselbach's ligament. The current results give hope that the results of TAPP can be improved by rTAPP and that rTAPP is not just a more expensive version of conventional TAPP. To support the rationale presented here, we analyzed 132 video recordings of rTAPP's for the anatomical structures depicted therein. The main finding is, that in all cases (132/132 or 100%) Hesselbach's ligament was present and following its lateral continuity with the ileopubic tract offered a safe framework to develop all the critical anatomical structures for clearing the myopectineal orifice, repair the posterior wall of the groin and perform a flawless mesh fixation. Future studies are needed to integrate all the resources of the robotic platform into an rTAPP concept that will lead out of the stalemate of the indisputably high rate of chronic pain and recurrences.

Robotic hernia surgery IV. English version : Robotic parastomal hernia repair. Video report and preliminary results.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

[Robotic hernia surgery IV. German version : Robotic parastomal hernia repair. Video report and preliminary results]. / Robotische Hernienchirurgie Teil IV : Roboterassistierte endoskopische parastomale Hernienversorgung. Videobericht und Ergebnisse.

The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

[Laparostoma-Avoidance and treatment of complications]. / Laparostoma ­ Vermeidung und Therapie von Komplikationen.

The open abdomen (OA) is an established concept for treating severe abdominal diseases. The most frequent reasons for placement of an open abdomen are abdominal sepsis (e.g. from intestinal perforation or anastomotic leakage), severe abdominal organ injury and abdominal compartment syndrome. The pathophysiology is much more complex than the surgeon's eye can see in an OA. The temporary closure of the abdominal wall ensures sufficient drainage of infected ascites, protection of the intestinal loops and conditioning of the abdominal wall in order to be able carry out definitive closure of the abdominal wall at the end of the surgical treatment. Negative peritoneal pressure therapy combined with fascia traction (with or without mesh) is well-established in the management of an open abdomen.

Robotic hernia repair II. English version : Robotic primary ventral and incisional hernia repair (rv­TAPP and r­Rives or r­TARUP). Video report and results of a series of 118 patients.

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r­ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r­TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.

Excess Body Weight and Abdominal Hernia.

BACKGROUND: Obese patients have an increased incidence of ventral hernias; in over 50% of these cases, patients are symptomatic. At the same time, morbid obesity is a disease of epidemic proportions. The combination of symptomatic hernia and obesity is a challenge for the treating surgeon, because the risk of perioperative complications and recurrence increases with increasing BMI. SUMMARY: This review outlines this problem and discusses interdisciplinary approaches to the management of affected patients. In emergency cases, the hernia is treated according to the surgeon's expertise. In elective cases, an individual decision must be made whether bariatric surgery is indicated before hernia repair or whether both should be performed simultaneously. After bariatric surgery a weight reduction of 25-30% of total body weight in the first year can be achieved and it is often advantageous to perform a bariatric operation prior to hernia repair. Technically, the risk of complications is lower with minimally invasive procedures than with open ones, but laparoscopy is challenging in obese patients, and meshes can only be implanted in intraperitoneal position. This mesh position has to be questioned because of adhesions, recurrence rate, and risk of contamination during re-interventions in patients who are often still relatively young. KEY MESSAGES: Obese patients with hernia need to be approached in an interdisciplinary manner, in some patients a weight loss procedure may be advantageous before hernia repair. Recent data show the benefits of robotic hernia surgery in obese patients, as not only haptic advantages result, but especially the mesh can be implanted in a variety of extraperitoneal positions in the abdominal wall with low morbidity.

[Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r­TAPP). Video report and results of a series of 302 hernia operations]. / Robotische Hernienchirurgie : Teil I: Robotische Leistenhernienversorgung (r­TAPP). Videobeitrag und Ergebnisse einer Kohortenstudie an 302 operierten Hernien.

The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r­TAPP) and illustrates the surgical steps of r­TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r­TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r­TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r­TAPP with new parameters.

[Robotic hernia repair : Part II: Robotic primary ventral and incisional hernia repair (rv-TAPP and r-Rives or r-TARUP). Video report and results of a series of 118 patients]. / Robotische Hernienchirurgie : Teil II: Robotische primär ventrale und inzisionale Hernienversorgung (rv-TAPP und r-Rives/r-TARUP). Videobeitrag und Ergebnisse einer Kohortenstudie an 118 Patienten.

Endoscopic management of umbilical and incisional hernias has adapted to the limitations of conventional laparoscopic instruments over the past 30 years. This includes the development of meshes for intraperitoneal placement (intraperitoneal onlay mesh, IPOM), with antiadhesive coatings; however, adhesions do occur in a significant proportion of these patients. Minimally invasive procedures result in fewer perioperative complications, but with a slightly higher recurrence rate. With the ergonomic resources of robotics, which offers angled instruments, it is now possible to implant meshes in a minimally invasively manner in different abdominal wall layers while achieving morphologic and functional reconstruction of the abdominal wall. This video article presents the treatment of ventral and incisional hernias with mesh implantation into the preperitoneal space (robot-assisted transabdominal preperitoneal ventral hernia repair, r­ventral TAPP) as well as into the retrorectus space (r-Rives and robotic transabdominal retromuscular umbilical prosthetic repair, r­TARUP, respectively). The results of a cohort study of 118 consecutive patients are presented and discussed with regard to the added value of the robotic technique in extraperitoneal mesh implantation and in the training of residents.