[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.

[Accreditation in pathology and neuropathology : Paths and pitfalls]. / Akkreditierung in der Pathologie und Neuropathologie : Wege und Pitfalls.

There are many good reasons for accreditation in pathology or neuropathology as per DIN EN ISO/IEC 17020, regardless of the size and range of services of the facility. Only accreditation - in contrast to certification - also confirms professional competence. This article describes how to establish a quality management system that conforms to standards as effectively as possible and how to maintain it, involve staff, and avoid common pitfalls. Adequate resources and active management support are essential. In this way, not only can accreditation succeed, but the facility itself and its employees can benefit from quality management in their daily work.

[Verumontanum mucosal hyperplasia as a differential diagnosis of a local recurrence following radical prostatectomy]. / Verumontanum-Mukosahyperplasie als Differenzialdiagnose eines Lokalrezidivs nach radikaler Prostatektomie.

Verumontanum mucosal gland hyperplasia (VMGH) is a benign microacinar proliferative lesion, which occurs exclusively in the verumontanum and the posterior urethra and is one of the lesions that may be confused with a low-risk adenocarcinoma of the prostate gland.We present the case of a 72-year-old male patient who underwent radical prostatectomy due to an adenocarcinoma of the prostate gland (pT2c pN0 cM0 R0, Gleason Score: 3 + 3 = 6). Five years after the operation, we sonographically detected a 3x2 cm large tumour in the prostate bed. While our first assumption was a PSA-negative local recurrence following radical prostatectomy, a comprehensive histological examination along with the clinical evaluation led us to the diagnosis of a VMGH. VMGH is a less well-known differential diagnosis of PSA-negative local recurrence following radical prostatectomy, whose clinical manifestation should be presented.

[Persistent anemia after kidney transplantation in a 36-year-old male patient-an unusual cause]. / Persistierende Anämie nach Nierentransplantation bei einem 36-jährigen Patienten ­ eine ungewöhnliche Ursache.

An allogeneic kidney transplantation (match 1­1­0, cytomegalovirus, CMV, donor, D, +/recipient, R, - high risk) was performed in a 36-year-old patient. The patient was on dialysis due to a tubulointerstitial nephritis confirmed by biopsy 11 years previously. Posttransplantation there was a gradual decrease in the hemoglobin (Hb) level from 11.4 g/dl to 7.3 g/dl during the initial hospitalization period. Initially this was explained by the kidney transplantation and chronic fibrosing antral gastritis with erosions. Despite repeated transfusion of red cell concentrates, a refractory anemia persisted, which is why the patient presented several times at our clinic for further diagnosis and treatment. The presence of giant erythroblasts in the bone marrow and quantitative detection of parvovirus B19 (>900 million IU/ml DNA replications) was consistent with a virus-associated red cell aplasia. Intravenous immunoglobulin administration was established and showed long-term therapeutic success.

Increasing Operating Room Efficiency with Shop Floor Management: an Empirical, Code-Based, Retrospective Analysis.

With increasing economic pressure on health care, modern hospital management is focusing at industrial optimization techniques to improve efficiency while maintaining quality. Shop floor management, a technique of code-based, process-oriented guidance directly on site is a method of lean management intended to increase efficiency in the operating room. In the literature, there is only scant evidence that the introduction of this technique alone can increase efficiency. The aim of this retrospective study is to determine whether a single tool alone can significantly improve codes. We performed an empirical, retrospective analysis of a number of codes from 3800 operations during two periods of comparison: upon introduction of shop floor management, and one year thereafter. Data was extracted from the Hospital Information System and transferred to a database. There was no statistically significant change in the relevant codes chosen, whether specific to the operating room (turnover time, first patient in the room, waiting times for anesthesia and surgery (p = 0.637) or to planning stability (scheduled, cancelled (p = 0.505), unscheduled and total operations performed (p = 0.984)). There were absolute changes, such as a reduction in the turnover time from 17:37 min to 16:26 min, even though not statistically significant (p = 0.238). Implementation of shop floor management as a single intervention is not appropriate to achieve a significant, continuous improvement in codes. A combination with other techniques such as detailed process analyses is definitely required. This could be important additional information for units using Lean Health Care strategies.

[Principles and parallels of prevention and repair of parastomal hernia with meshes]. / Prinzipien und Parallelen der Prävention und Reparation parastomaler Hernien mit Netzen.

After formation of a permanent terminal stoma by enterostomy, parastomal hernia (PSH) occurs in up to 80% of cases and leads to a wide variety of symptoms and complications with a high rate of emergency operations due to incarceration (ca. 15%). Consequently, greater consideration should be given to PSH prevention even as early as the time of enterostomy and generously applied indications for elective repair of manifest PSH. The aim of this article is to summarize and evaluate the current evidence for PSH repair and prevention. Poor postoperative results after attempted repair of manifest PSH with slit meshes in different layers of the abdominal wall shift the focus onto stoma lateralization (sandwich and Sugarbaker techniques) or 3­dimensional tunnel-shaped implants with meshes to cover the stomal edges. To date, the best strategy for PSH prevention has still not been defined and techniques with slit meshes show different results. Nevertheless, 10 prospective randomized trials, meta-analyses, a Cochrane review and guidelines from the European Hernia Society (EHS) about various slit-mesh devices in sublay, onlay and intraperitoneal positions confirmed significantly reduced rates of PSH after mesh augmentation compared to conventionally sutured enterostomy without morbidity associated with the implanted material. Despite the positive data situation PSH prevention is seldom performed in daily practice, which is due to uncertainty surrounding the most suitable surgical strategy, the necessity to spend additional time at the end of a demanding operation, the aversion to implanting meshes into a contaminated operative field and the lack of remuneration of preventive surgical procedures. Future trials should, therefore, no longer compare standard enterostomy techniques with one prevention method in general but should have a new focus on techniques providing adequate results in PSH repair (Sugarbaker, sandwich and 3­D tunnel meshes), probe the advantages and evaluate the differences in outcome between these strategies.

Complexity of PEComas : Diagnostic approach, molecular background, clinical management.

Perivascular epithelioid cell neoplasms (PEComas) are a family of mesenchymal neoplasms with features of both melanotic and smooth muscle differentiation. PEComa morphology is highly variable and encompasses epithelioid to spindle cells often with clear cytoplasm and prominent nucleoli. Molecularly, most PEComas are defined by a loss of function of the TSC1/TSC2 complex. Additionally, a distinct small subset of PEComas harboring rearrangements of the TFE3 (Xp11) gene locus has been identified. By presenting a series of three case reports with distinct features, we demonstrate diagnostic pitfalls as well as the importance of molecular work-up of PEComas because of important therapeutic consequences.

[Preoperative conditioning and surgical strategies for treatment of complex abdominal wall hernias]. / Präoperative Konditionierung und operative Strategien zur Therapie komplexer Bauchwandhernien.

The successful treatment of complex abdominal wall hernias requires individualized and if necessary interdisciplinary treatment concepts. Due to the high potential for abdominal and cardiopulmonary complications, specialized centers with a high level of expertise and experience should undertake the care of patients. Prehabilitation and optimization of hernia-specific risk factors and comorbidities play an essential role in the treatment algorithm. Preoperative conditioning prior to surgery can be crucial for success. Bariatric surgery for weight loss and administration of botulinum toxin A in the lateral abdominal wall for stretching the musculature to provide myofascial advancement and enlargement of the torso diameter are parts of such strategies. The preoperative progressive pneumoperitoneum has its justification in massive evisceration, facilitates repositioning of the viscera and helps the patient to slowly adapt to the postoperatively changed abdominal pressure conditions. From a surgical technical point of view, the following principle should apply: "mesh augmentation comes before defect bridging". This means preference should be given to a morphological functional restoration of the myofascicular abdominal wall compared to procedures that merely bridge abdominal wall defects based on meshing. The retromuscular preperitoneal mesh strengthening in the sense of a sublay technique is the gold standard. This can be extended to anterior or posterior component separation techniques in order to achieve a reduction of tension to the midline and/or to achieve enlargement of the space for mesh placement.

Precostal top-down extended totally extraperitoneal ventral hernia plasty (eTEP): simplification of a complex technical approach.

PURPOSE: Retromuscular mesh augmentation is generally considered to be the ideal technique for repairing ventral hernias and can be performed laparoscopically by 'enhanced view totally extraperitoneal plasty' (eTEP)-a technically complex procedure that requires a high level of surgical expertise. We aimed to develop a simplified technical modification. METHODS: Thirty-one patients with ventral hernias were operated with a modified precostal, top-down eTEP approach, and prospectively recorded in our hernia registry. We describe this novel standardized precostal access and the bilateral development of both retromuscular compartments with a cylindrical dilating balloon port. Demographic-, hernia-specific-, and perioperative data were analyzed retrospectively. RESULTS: Twenty-two primary and 9 incisional hernias with an average defect size of 34.5 cm2 were repaired. An average implant of 420 cm2 always completely covered diastasis recti and/or scars from previous midline laparotomies. Average procedure time was 128 min. One conversion was required due to peritoneal injury. Postoperatively there was one local infection and one patient suffered an interparietal herniation. There were no recurrences during the average 8-month follow-up period. CONCLUSION: With technical modification of precostal access and pneumatic balloon dilation of both retro-rectus compartments, the complex procedure can be simplified through time saving and straightforward unidirectional 'top-down' dissection. The better overview facilitates the crossover for connecting both retro-rectus spaces. In addition, the cranial access allows the anterior- and posterior layers to be closed up to the xiphoid.

[Complexity of PEComas : Diagnostic approach, molecular background, clinical management (German version)]. / Komplexität von PEComen : Diagnose, Molekulargenetik, klinisches Management.

Perivascular epithelioid cell neoplasms (PEComas) are a family of mesenchymal neoplasms with features of both melanotic and smooth muscle differentiation. PEComa morphology is highly variable and encompasses epithelioid to spindle cells often with clear cytoplasm and prominent nucleoli. Molecularly, most PEComas are defined by a loss of function of the TSC1/TSC2 complex. Additionally, a distinct small subset of PEComas harboring rearrangements of the TFE3 (Xp11) gene locus has been identified. By presenting a series of three case reports with distinct features, we demonstrate diagnostic pitfalls as well as the importance of molecular work-up of PEComas because of important therapeutic consequences.

[New laparoendoscopic and minimally invasive extraperitoneal mesh augmentation techniques for ventral hernia repair]. / Neue laparoendoskopische und minimal-invasive extraperitoneale Netzaugmentationstechniken in der Ventralhernienchirurgie.

In recent years techniques for ventral hernia repair have undergone a dynamic evolution with the development of minimally invasive and laparoendoscopic techniques. Despite the multitude of methods, five main criteria for setting the target have emerged: 1) functional and morphological reconstruction of the abdominal wall, 2) extraperitoneal mesh augmentation, 3) abandonment of penetrating fixation elements, 4) minimal surgical access trauma of the abdominal wall and 5) minimized intraperitoneal dissection that jeopardizes adherent intestinal structures. The mesh position varies between preperitoneal retromuscular and supraneurotic or preaponeurotic on the anterior rectus sheath. The different approaches can be carried out transhernially or distant from the abdominal wall defect. The latter can be realized by laparoscopic transperitoneal, endoscopic subcutaneous and endoscopic retromuscular/preperitoneal approaches. Some techniques can be extended to anterior or posterior component separation to reduce tension and to enlarge the space for mesh placement. Robot-assisted surgery opens up new perspectives in laparoendoscopic abdominal wall surgery due to additional instrumental degrees of movement. This enables the possibility of preperitoneal ventral hernia operations also behind and lateral to the posterior rectus muscle compartments as was only previously known below the arcuate line from inguinal hernia surgery.

Retroperitoneal Liposarcoma: A Concern in Inguinal Hernia Repair.

BACKGROUND AND OBJECTIVES: The goal of the study was to evaluate retroperitoneal sarcomas with continuous growth into the scrotum through the inguinal canal with regard to diagnostic approach, surgical treatment, and outcome. The analysis is based on a comprehensively documented case and a complete systematic review of published literature. Potential pitfalls are highlighted. METHODS: We describe the case of a 57-year-old male Caucasian who presented with a swelling in the right groin. Suspecting a scrotal hernia, transabdominal preperitoneal plasty surgery was planned but intraoperatively a large retroperitoneal mass was revealed. After computed tomography scan and magnetic resonance imaging, a complete resection of the tumor was performed. Ten previously published cases describing the same pathology were retrieved from the PubMed database and analyzed systematically in a complete literature review. RESULTS: Histology showed a well-differentiated liposarcoma with tumor-free resection margins. Twenty-two months postoperatively, the patient is in complete clinical remission. CONCLUSION: Preoperative clinical suspicion of retroperitoneal involvement is paramount for developing of a surgical strategy and in unclear cases demands extended preoperative diagnostic workup. Following the appropriate patient management is crucial to prognosis.

Critical evaluation of an innovative mesh for bilateral transabdominal preperitoneal (TAPP) repair of inguinal hernias.

PURPOSE: Transabdominal preperitoneal hernia mesh plasty (TAPP) offers significant benefits to patients undergoing bilateral inguinal hernia repair. We evaluated a novel pre-shaped, large-pored, titanium-coated, lightweight polypropylene mesh for bilateral placement as an alternative to two separate meshes. METHODS: Thirty-six patients underwent elective surgical repair of bilateral inguinal hernias with the new mesh at three departments of surgery in Linz and Graz, Austria, between May 1, 2015 and June 30, 2017. RESULTS: All operations were completed without intraoperative complications or conversion to open procedures. The mean operation time was 74 min. There were no postoperative procedure-related complications with the exception of one hematoseroma of the spermatic cord. Two symptomatic medial recurrences (2/36 patients = 5.6%, 2/72 hernia repairs = 2.8%, respectively) after supravesical and medial hernia repair with the bilateral mesh were seen at structured follow-up examinations 6 and 12 months postoperatively. CONCLUSION: Treatment of bilateral inguinal hernias with the newly designed bilateral mesh for TAPP theoretically brings benefits in terms of resistance to forces acting on the mesh. The larger area may decrease the risk for mesh bulging and recurrence, and one large mesh might provide more stable support than two separate meshes overlapping at the midline. The results of our study do not confirm these theoretical benefits regarding a high recurrence rate (2.8%) after treatment of medial hernia defects. We recommend re-designing the mesh with only a small central slit, which would provide a broader mesh bridge with sufficient overlap for all types of inguinal and femoral hernias, including medial and supravesical defects. After the mesh has been re-designed, a new study should evaluate its real benefits before it is marketed.

Endoscopic anterior component separation: a novel technical approach.

PURPOSE: Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure. METHODS: A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach. RESULTS: Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8 kg/m2 (median; range 21.6-42.5). Transverse width of midline defect accounted for 7 cm (median; range 4-12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n = 13) or a laparoscopic intraperitoneal onlay mesh procedure (n = 2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively. CONCLUSIONS: Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

Seasonal phenology and abundance of Leucopis argenticollis, Leucopis piniperda (Diptera: Chamaemyiidae), Laricobius nigrinus (Coleoptera: Deridontidae) and Adelges tsugae (Hemiptera: Adelgidae) in the Pacific Northwest USA.

Adelges tsugae infested western hemlock trees were sampled periodically for 1 year at two locations in Oregon and Washington to compare the phenology and abundance of three associated predators (Leucopis argenticollis, Leucopis piniperda, and Laricobius nigrinus) and their host. On each sample date, two 3-10 cm long terminal twigs were collected from each tree and brought to the laboratory to count all life stages of A. tsugae and the three predators. Peak larval abundance of Leucopis spp. and La. nigrinus coincided with the presence of A. tsugae adults and eggs. Leucopis spp. larvae were present for a much longer period of time than were La. nigrinus larvae. Furthermore, Leucopis spp. larvae were present during both the progrediens and sistens egg stages, while La. nigrinus larvae were only present during the progrediens egg stage. Overall, we collected 2.3-3.5 times more Leucopis spp. of all life stages than La. nigrinus. These results support the continued study of Leucopis spp. from the Pacific Northwest as biological control agents for A. tsugae in the Eastern USA.

When is mesh fixation in TAPP-repair of primary inguinal hernia repair necessary? The register-based analysis of 11,230 cases.

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

The IL-33 receptor (ST2) regulates early IL-13 production in fungus-induced allergic airway inflammation.

Allergic airway inflammation (AAI) in response to environmental antigens is an increasing medical problem, especially in the Western world. Type 2 interleukins (IL) are central in the pathological response but their importance and cellular source(s) often rely on the particular allergen. Here, we highlight the cellular sources and regulation of the prototypic type 2 cytokine, IL-13, during the establishment of AAI in a fungal infection model using Cryptococcus neoformans. IL-13 reporter mice revealed a rapid onset of IL-13 competence within innate lymphoid cells type 2 (ILC2) and IL-33R(+) T helper (Th) cells. ILC2 showed IL-33-dependent proliferation upon infection and significant IL-13 production. Th cells essentially required IL-33 to become either GATA3(+) or GATA3(+)/Foxp3(+) hybrids. GATA3(+) Th cells almost exclusively contributed to IL-13 production but hybrid GATA3(+)/Foxp3(+) Th cells did not. In addition, alveolar macrophages upregulated the IL-33R and subsequently acquired a phenotype of alternative activation (Ym1(+), FIZZ1(+), and arginase-1(+)) linked to type 2 immunity. Absence of adaptive immunity in rag2(-/-) mice resulted in attenuated AAI, revealing the need for Th2 cells for full AAI development. Taken together, in pulmonary cryptococcosis ILC2 and GATA3(+) Th2 cells produce early IL-13 largely IL-33R-dependent, thereby promoting goblet cell metaplasia, pulmonary eosinophilia, and alternative activation of alveolar macrophages.

Rail or roll: a new, convenient and safe way to position self-gripping meshes in open inguinal hernia repair.

PURPOSE: In open inguinal hernia repair self-gripping meshes are currently commonly employed. Assumed benefits are saving of time, ease of handling and omission of fixation. Self-gripping meshes are, however, not as easy to handle and position as commonly stated. We describe a newly developed way of intra-operative mesh preparation and implantation and compare it to the conventional technique of insertion of self-gripping meshes. METHODS: A two-armed, randomized trial with 64 patients was performed. For implantation of the self-gripping, light weight and partially absorbable mesh we used either a newly described rolling technique (group 1: n = 32) or the conventional way of insertion (group 2: n = 32). Primary endpoints of the study were feasibility with regard to actual implantation time and surgeons' satisfaction with the methods. Secondary endpoints were total operating time, length of hospital stay, postoperative pain, duration of pain medication intake and postoperative morbidity. In addition all patients were prospectively followed up according to the Hernia Med® registry's standards. RESULTS: Implantation time (seconds) 140 ± 74 vs. 187 ± 84, p = 0.008, duration of pain medication intake (days) 3.6 ± 2.8 vs. 4.8 ± 2.6; p = 0.046 and postoperative morbidity 2 (6%) vs. 8 (25%) was significantly beneficial in group 1 (rolling technique) compared to group 2 (conventional method). Blinded questionnaire revealed that rolling the mesh is generally easier with less repositioning maneuvers than conventional placement. Neither overall procedure time, length of stay nor postoperative pain scores differed significantly between groups. CONCLUSION: The newly introduced rolling technique for the actual placement of self-gripping meshes in open inguinal hernia repair is technically less demanding and therefore significantly faster when compared to the conventional way of insertion of the same product. In addition the rolling technique has shown to be safe for the patients and to also provide higher surgeons' satisfaction.