Comparison of open preperitoneal and transabdominal preperitoneal hernia repair for primary unilateral femoral hernia: a retrospective cohort study of 132 case.

BACKGROUND: Femoral hernia (FH) is traditionally treated by open surgery (OS). Laparoscopic treatment has also shown good results in treating FH. However, there have been few comparative studies of these two techniques. Therefore, our aim was to compare the outcomes of open and laparoscopic surgical FH treatment. METHODS: Adult patients with primary unilateral FH undergoing OS or transabdominal preperitoneal (TAPP) hernia repair at our hospital from January 2013 to June 2018 were included in this study. Patients with history of abdominal surgery, contraindications to general anesthesia and those not wishing to receive general anesthesia received OS. Demographics, operation details and complications were compared retrospectively between the two groups. RESULTS: A total of 132 patients were recruited to the study, 62 and 70 of whom underwent OS and TAPP, respectively. Compared to OS group, the TAPP group had a significantly shorter hospital stay (3.0 vs. 2.0 days, respectively, P < 0.05) and a lower postoperative pain score (3.0 vs. 1.0, P < 0.05), and took less time to return to normal activities (13.0 vs. 6.0 days, respectively, P < 0.05). The overall complication rates were equivalent between the groups (10 vs. 9.7%, OR = 1.037, 95% CI 0.329-3.270). CONCLUSIONS: Both laparoscopic and open surgery appear to be safe and effective in a cohort of patients with femoral hernia and laparoscopic surgery might offer some advantages in reducing length of hospital stay, lower postoperative pain score and quicker return to activities.

Subxiphoid top-down endoscopic totally preperitoneal approach (eTPA) for midline ventral hernia repair.

PURPOSE: Midline abdominal wall hernia repair is among the most common surgical interventions performed worldwide. However, the optimal surgical technique remains controversial. To overcome the disadvantages of both open and transabdominal procedures, we developed a totally endoscopic preperitoneal approach (eTPA) with placement of a large mesh. METHODS: From December 2019 to October 2020, 20 consecutive patients with small to medium-sized midline ventral hernias underwent repair using a completely preperitoneal subxiphoid top-down approach. The preperitoneal space was entered directly below the xiphoid, and careful endoscopic development of the plane between the peritoneum and posterior sheath of the rectus fascia was then performed behind the linea alba. The hernia sac and its contents were identified and reduced. The hernia defect was closed with sutures, and a mesh with an adequate high defect: mesh ratio was placed in the newly created preperitoneal space. RESULTS: Twenty patients were enrolled in this study, including 14 with primary umbilical hernias, 4 with primary epigastric hernias, and 2 with recurrent umbilical hernias. 15 patients suffered from a mild concomitant diastasis recti. All operations were successfully completed without conversion to open repair. The mean operative time was 105.3 min (range, 60-220 min). Postoperative pain was mild, and the mean visual analog scale score for pain was 1.8 on the first postoperative day. The average postoperative hospital stay was 1.8 days (range, 1-4 days). One patient developed a minor postoperative seroma, but it had no adverse impact on the final outcome. No patients developed recurrence during the 3- to 10-month follow-up period. CONCLUSIONS: The subxiphoid top-down totally endoscopic preperitoneal approach (eTPA) technique is feasible and effective. It may become a valuable alternative for the treatment of primary small- (defect size < 2 cm) and medium-sized (2-4 cm) midline ventral hernias, particularly in presence of a concomitant diastasis recti.

Patient-centered developments in colon- and rectal cancer with a multidisciplinary international team: From translational research to national guidelines.

Rarely, scientific developments centered around the patient as a whole are published. Our multidisciplinary group, headed by gastrointestinal surgeons, applied this research philosophy considering the most important aspects of the diseases "colon- and rectal cancer" in the long-term developments. Good expert cooperation/knowledge at the Comprehensive Cancer Center Ulm (CCCU) were applied in several phase III trials for multimodal treatments of primary tumors (MMT) and metastatic diseases (involving nearly 2000 patients and 64 centers), for treatment individualization of MMT and of metastatic disease, for psycho-oncology/quality of life involving the patients' wishes, and for disease prevention. Most of the targets initially were heavily rejected/discussed in the scientific communities, but now have become standards in treatments and national guidelines or are topics in modern translational research protocols involving molecular biology for e.g., "patient centered individualized treatment". In this context we also describe the paths we had to tread in order to realize our new goals, which at the end were highly beneficial for the patients from many points of view. This description is also important for students and young researchers who, with an actual view on our recent developments, might want to know how medical progress was achieved.

Endoscopic totally extraperitoneal approach (TEA) technique for primary ventral hernia repair.

BACKGROUND: Up to now the totally extraperitoneal (TEP) technique is limited to the treatment of inguinal hernias. Applying this anatomical repair concept to the treatment of other abdominal wall hernias, we developed an endoscopic totally extraperitoneal approach (TEA) to treat primary midline ventral hernias, including umbilical and epigastric hernias, in which for mesh placement, an anatomical space is developed between the peritoneum and the posterior rectus sheath in the ventral part of the abdominal wall (preperitoneal space). METHODS: Between September 2017 and December 2019 according to the selection criterions, 28 consecutive primary midline ventral hernias were repaired using TEA. After extensive endoscopic development of the midline extraperitoneal plane, which was started in the suprasymphysic area, and reduction of the hernia sac, the hernia defect was closed and a large mesh was placed in the preperitoneal position to enforce the anterior abdominal wall. RESULTS: All operations were successfully performed without conversion to open surgery. The mean operation time was 103.3 min (range 85-145 min). Patient-reported postoperative pain was qualitatively mild with a mean pain visual analogue scale score of 1.9 on postoperative day 1. The average hospital stay was 1.9 days (range 1-3 days). Three patients developed minor complications and were treated with no long-term adverse effects. Readmissions within 30 days or hernia recurrences were not observed with a mean follow-up period of 18 months (range 10-27 months). CONCLUSION: In selected cases, TEA is a safe and feasible minimally invasive alternative in treating primary ventral hernias. This technique preserves the anatomical and physiological structure of the abdominal wall and may significantly reduce trauma and postoperative complications. Additionally, anti-adhesion-coated meshes and fixation tackers are not required, thus being cost-effective. Further studies are necessary to proof the true clinical efficacy in comparison to well-known alternative techniques.

Totally endoscopic sublay (TES) repair for midline ventral hernia: surgical technique and preliminary results.

BACKGROUND: The Rives-Stoppa procedure is used for ventral hernia repair but requires a large midline incision. This report describes a new, totally endoscopic approach to the retromuscular plane, corresponding to a reversed totally extraperitoneal procedure, to perform sublay repair of primary and secondary ventral hernias. This totally endoscopic sublay (TES) repair is described in detail, and its safety and efficacy were evaluated. METHODS: In this prospective study, we assessed 26 consecutive primary and secondary epigastric midline ventral hernias that were repaired between July 2017 and July 2018 using the TES procedure. A large mesh was placed in the retrorectus position using this minimally invasive approach. Indications for this procedure include umbilical, epigastric, incisional hernias, and rectus diastasis. RESULTS: All TES procedures were successfully performed without conversion to an open operation. The mean operative time was 106.6 ± 29.1 min (range 75-205), with average mesh area of 318.8 cm2 for an average defect area of 26.5 cm2. Postoperative pain was mild, and the mean visual analog scale (VAS) under physical stress (e.g., climbing stairs) was 2.4 at the third postoperative day. The average postoperative hospital stay was 2.8 ± 0.8 days (range 2-5). Two patients developed postoperative seroma, with no final adverse effect. No recurrence nor readmissions within 30 days was observed during a mean follow-up of 9.2 ± 4.4 months. CONCLUSIONS: Initial experiences with this technique show that the TES procedure is safe and reliable, requires no specific instruments, and is highly reproducible. There is no need for an expensive anti-adhesion mesh or fixation device, making it cost-effective.

Smaller Inguinal Hernias are Independent Risk Factors for Developing Chronic Postoperative Inguinal Pain (CPIP): A Registry-based Multivariable Analysis of 57, 999 Patients.

OBJECTIVE: Impact of inguinal hernia defect size as stratified by the European Hernia Society (EHS) classification I to III on the rate of chronic postoperative inguinal pain (CPIP). BACKGROUND: CPIP is the most important complication after inguinal hernia repair. The impact of hernia defect size according to the EHS classification on CPIP is unknown. METHODS: In total, 57,999 male patients from the Herniamed registry undergoing primary unilateral inguinal hernia repair including a 1-year follow-up were selected between September 1, 2009 and November 30, 2016. Using multivariable analysis, the impact of EHS inguinal hernia classification (EHS I vs EHS II vs EHS III and/or scrotal) on developing CPIP was investigated. RESULTS: Multivariable analysis revealed for smaller inguinal hernias a significant higher rate of pain at rest [EHS I vs EHS II: odds ratio, OR = 1.350 (1.180-1.543), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 1.839 (1.504-2.249), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.363 (1.125-1.650), P = 0.002], pain on exertion [EHS I vs EHS II: OR = 1.342 (1.223-1.473), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.002 (1.727-2.321), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.492 (1.296; 1.717), P < 0.001], and pain requiring treatment [EHS I vs EHS II: OR = 1.594 (1.357-1.874), P < 0.001; EHS I vs EHS III and/or scrotal: OR = 2.254 (1.774-2.865), P < 0.001; EHS II vs EHS III and/or scrotal: OR = 1.414 (1.121-1.783), P = 0.003] at 1-year follow-up. Younger patients (<55 y) revealed higher rates of pain at rest, pain on exertion, and pain requiring treatment (each P < 0.001) with a significantly trend toward higher rates of pain in smaller hernias. CONCLUSIONS: Smaller inguinal hernias have been identified as an independent patient-related risk factor for developing CPIP.

Classification of Rectus Diastasis-A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS).

Introduction: Recently, the promising results of new procedures for the treatment of rectus diastasis with concomitant hernias using extraperitoneal mesh placement and anatomical restoration of the linea alba were published. To date, there is no recognized classification of rectus diastasis (RD) with concomitant hernias. This is urgently needed for comparative assessment of new surgical techniques. A working group of the German Hernia Society (DHG) and the International Endohernia Society (IEHS) set itself the task of devising such a classification. Materials and Methods: A systematic search of the available literature was performed up to October 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. A meeting of the working group was held in May 2018 in Hamburg. For the present analysis 30 publications were identified as relevant. Results: In addition to the usual patient- and technique-related influencing factors on the outcome of hernia surgery, a typical means of rectus diastasis classification and diagnosis should be devised. Here the length of the rectus diastasis should be classified in terms of the respective subxiphoidal, epigastric, umbilical, infraumbilical, and suprapubic sectors affected as well as by the width in centimeters, whereby W1 < 3 cm, W2 = 3- ≤ 5 cm, and W3 > 5 cm. Furthermore, gender, the concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures and preoperative pain rate and localization of pain should be recorded. Conclusion: Such a unique classification is needed for assessment of the treatment results in patients with RD.

Lichtenstein Versus Total Extraperitoneal Patch Plasty Versus Transabdominal Patch Plasty Technique for Primary Unilateral Inguinal Hernia Repair: A Registry-based, Propensity Score-matched Comparison of 57,906 Patients.

OBJECTIVE: Outcome comparison of the Lichtenstein, total extraperitoneal patch plasty (TEP), and transabdominal patch plasty (TAPP) techniques for primary unilateral inguinal hernia repair. BACKGROUND: For comparison of these techniques the number of cases included in meta-analyses of randomized controlled trials is limited. There is therefore an urgent need for more comparative data. METHODS: In total, 57,906 patients with a primary unilateral inguinal hernia and 1-year follow up from the Herniamed Registry were selected between September 1, 2009 and February 1, 2015. Using propensity score matching, 12,564 matched pairs were formed for comparison of Lichtenstein versus TEP, 16,375 for Lichtenstein versus TAPP, and 14,426 for TEP versus TAPP. RESULTS: Comparison of Lichtenstein versus TEP revealed disadvantages for the Lichtenstein operation with regard to the postoperative complications (3.4% vs 1.7%; P < 0.001), complication-related reoperations (1.1% vs 0.8%; P = 0.008), pain at rest (5.2% vs 4.3%; P = 0.003), and pain on exertion (10.6% vs 7.7%; P < 0.001). TEP had disadvantages in terms of the intraoperative complications (0.9% vs 1.2%; P = 0.035). Likewise, comparison of Lichtenstein versus TAPP showed disadvantages for the Lichtenstein operation with regard to the postoperative complications (3.8% vs 3.3%; P = 0.029), complication-related reoperations (1.2% vs 0.9%; P = 0.019), pain at rest (5% vs 4.5%; P = 0.029), and on exertion (10.2% vs 7.8%; P < 0.001). CONCLUSIONS: TEP and TAPP were found to have advantages over the Lichtenstein operation.

Mini- or Less-open Sublay Operation (MILOS): A New Minimally Invasive Technique for the Extraperitoneal Mesh Repair of Incisional Hernias.

OBJECTIVE: Improvement of ventral hernia repair. BACKGROUND: Despite the use of mesh and other recent improvements, the currently popular techniques of ventral hernia repair have specific disadvantages and risks. METHODS: We developed the endoscopically assisted mini- or less-open sublay (MILOS) concept. The operation is performed transhernially via a small incision with light-holding laparoscopic instruments either under direct, or endoscopic visualization. An endoscopic light tube was developed to facilitate this approach (EndotorchTM Wolf Company). Each MILOS operation can be converted to standard total extraperitoneal gas endoscopy once an extraperitoneal space of at least 8 cm has been created. All MILOS operations were prospectively documented in the German Hernia registry with 1 year questionnaire follow-up. Propensity score matching of incisional hernia operations comparing the results of the MILOS operation with the laparoscopic intraperitoneal onlay mesh operation (IPOM) and open sublay repair from other German Hernia registry institutions was performed. RESULTS: Six hundred fifteen MILOS incisional hernia operations were included. Compared with laparoscopic IPOM incisional hernia operation, the MILOS repair is associated with significantly a fewer postoperative surgical complications (P < 0.001) general complications (P < 0.004), recurrences (P < 0.001), and less chronic pain (P < 0.001). Matched pair analysis with open sublay repair revealed significantly a fewer postoperative complications (P < 0.001), reoperations (P < 0.001), infections (P = 0.007), general complications (P < 0.001), recurrences (P = 0.017), and less chronic pain (P < 0.001). CONCLUSIONS: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular/preperitoneal meshes with low morbidity. The technique combines the advantages of open sublay and the laparoscopic IPOM repair.ClinicalTrials.gov Identifier NCT03133000.

Outcome of laparoscopic paraesophageal hernia repair in octogenarians: a registry-based, propensity score-matched comparison of 360 patients.

BACKGROUND: Paraesophageal hernias (PEH) tend to occur in elderly patients and the assumed higher morbidity of PEH repair may dissuade clinicians from seeking a surgical solution. On the other hand, the mortality rate for emergency repairs shows a sevenfold increase compared to elective repairs. This analysis evaluates the complication rates after elective PEH repair in patients 80 years and older in comparison with younger patients. METHODS: In total, 3209 patients with PEH were recorded in the Herniamed Registry between September 1, 2009 and January 5, 2018. Using propensity score matching, 360 matched pairs were formed for comparative analysis of general, intraoperative, and postoperative complication rates in both groups. RESULTS: Our analysis revealed a disadvantage in general complications (6.7% vs. 14.2%; p = 0.002) for patients ≥ 80 years old. No significant differences were found between the two groups for intraoperative (4.7% vs. 5.8%, p = 0.627) and postoperative complications (2.2% vs. 2.8%, p = 0.815) or for complication-related reoperations (1.7% vs. 2.2%, p = 0.791). CONCLUSIONS: Despite a higher risk of general complications, PEH repair in octogenarians is not in itself associated with increased rates of intraoperative and postoperative complications or associated reoperations. Therefore, PEH repair can be safely offered to elderly patients with symptomatic PEH, if general medical risk factors are controlled.

CACNG2 polymorphisms associate with chronic pain after mastectomy.

Chronic postmastectomy pain (PMP) imposes a major burden on the quality of life of the ever-increasing number of long-term survivors of breast cancer. An earlier report by Nissenbaum et al. claimed that particular polymorphisms in the gene CACNG2 are associated with the risk of developing chronic PMP after breast surgery (Nissenbaum J, Devor M, Seltzer Z, Gebauer M, Michaelis M, Tal M, Dorfman R, Abitbul-Yarkoni M, Lu Y, Elahipanah T, delCanho S, Minert A, Fried K, Persson AK, Shpigler H, Shabo E, Yakir B, Pisante A, Darvasi A. Susceptibility to chronic pain following nerve injury is genetically affected by CACNG2. Genome Res 2010;20:1180-90). This information is important because in principle, it can inform the surgical, radiological, and chemotherapeutic decision-making process in ways that could mitigate the increased risk of chronic pain. In this study, we revisited this claim by independently evaluating the proposed marker haplotype using 2 different patient cohorts recruited in different research settings. Meta-analysis of these new postmastectomy cohorts and the original cohort confirmed significant association of the CACNG2 haplotype with PMP. In addition, we tested whether the same markers would predict chronic postsurgical pain in men who underwent surgery for inguinal hernia repair, and whether there is significant genetic association with cutaneous thermal sensitivity in postmastectomy and postherniotomy patients. We found that the biomarker is selective because it did not predict pain after laparoscopic hernia repair and was not associated with pain sensitivity to experimentally applied noxious thermal stimuli. We conclude that the A-C-C haplotype at the 3 single-nucleotide polymorphisms (rs4820242, rs2284015, and rs2284017) in the CACNG2 gene is associated with increased risk of developing PMP. This information may advance current knowledge on pathophysiology of PMP and serve as a step forward in the prediction of clinical outcomes and personalized pain management.

Is antibiotic prophylaxis mandatory in laparoscopic incisional hernia repair? Data from the herniamed registry.

BACKGROUND: Several meta-analyses showed that laparoscopic incisional hernia repair is associated with lower surgical site infection (SSI) rates compared to open repair. However, the efficiency of antibiotic prophylaxis (AP) in laparoscopic incisional hernia repair alone is unknown and needs evaluation. Due to increasing antimicrobial resistance, a major global health care problem, AP needs to be critically evaluated. The aim of this study was to investigate the impact of AP on the rate of SSI and complication-related reoperations in patients undergoing laparoscopic incisional hernia repair. MATERIALS AND METHODS: Prospectively documented data from the Herniamed Hernia Registry from 2009 to 2017 were retrospectively analysed. Multivariable analyses were used to study the influence of AP as well as further patient and surgery-related risk factors on SSI and complication-related reoperation rates. This was verified in a sensitivity analysis using propensity-score matching. RESULTS: In the analysed time period 13'513 patients undergoing elective laparoscopic incisional hernia repair were recorded, of which 14.4% (n = 1949) did not receive AP. The overall SSI rate showed no significant difference when directly comparing patients with (0.74%) and without AP (0.97%; p = 0.262). In the multivariable analysis the presence of patient related risk factors (p = 0.015) and defect size >10 cm (p = 0.035) significantly increased the rates of SSI and complication-related reoperations. The propensity-score matching analysis verified that SSI rates are not significantly different between the two groups (p = 0.265). CONCLUSIONS: In cases of laparoscopic incisional hernia repair in patients without risk factors and moderate hernia diameter (<10 cm), routine administration of AP in laparoscopic incisional hernia repair does not seem to be justified.

Does coagulopathy, anticoagulant or antithrombotic therapy matter in incisional hernia repair? Data from the Herniamed Registry.

BACKGROUND: A considerable number of patients undergoing incisional hernia repair are on anticoagulant or antiplatelet therapy or have existing coagulopathy which may put them at higher risk for postoperative bleeding complications. Data about the optimal treatment of these patients are sparse. This analysis attempts to determine the rate of postoperative bleeding complications following incisional hernia repair and the consecutive rate of reoperation among patients with coagulopathy or receiving antiplatelet and anticoagulant therapy (higher risk group) compared to patients who do not have a higher risk (normal risk group). METHODS: Out of the 43,101 patients documented in the Herniamed Registry who had an incisional hernia repair, 6668 (15.5%) were on anticoagulant or antithrombotic therapy or had existing coagulopathy. The implication of that higher risk profile for onset of postoperative bleeding was investigated in multivariable analysis. Hence, other influential variables were identified. RESULTS: The rate of postoperative bleeding in the higher risk group was 3.9% (n = 261) and significantly higher compared to the normal risk group at 1.6% (n = 564) (OR 2.001 [1.699; 2.356]; p < 0.001). Additionally, male gender, use of drains, larger defect size, open incisional hernia repair, lower BMI, and higher ASA score significantly increased the risk of postoperative bleeding. The rate of reoperations due to postoperative bleeding was significantly increased in the higher risk group compared to the normal risk group (2.4 vs. 1.0%; OR 1.217 [1.071; 1.382]; p = 0.003). Likewise, the postoperative general complication rate (6.04 vs. 3.66%; p < 0.001) as well as the mortality rate (0.46 vs. 0.17%; p < 0.001) were significantly higher in the higher risk group. CONCLUSIONS: Patients with anticoagulant or antiplatelet therapy or existing coagulopathy who undergo incisional hernia repair have a significantly higher risk for onset of postoperative bleeding. The risk of bleeding complications and complication-related reoperations seems to be lower after laparoscopic intraperitoneal onlay mesh.

The Importance of Registries in the Postmarketing Surveillance of Surgical Meshes.

OBJECTIVE: To assess the role of registries in the postmarketing surveillance of surgical meshes. BACKGROUND: To date, surgical meshes are classified as group II medical devices. Class II devices do not require premarket clearance by clinical studies. Ethicon initiated a voluntary market withdrawal of Physiomesh for laparoscopic use after an analysis of unpublished data from the 2 large independent hernia registries-Herniamed German Registry and Danish Hernia Database. This paper now presents the relevant data from the Herniamed Registry. METHODS: The present analysis compares the prospective perioperative and 1-year follow-up data collected for all patients with incisional hernia who had undergone elective laparoscopic intraperitoneal onlay mesh repair either with Physiomesh (n = 1380) or with other meshes recommended in the guidelines (n = 3834). RESULTS: Patients with Physiomesh repair had a markedly higher recurrence rate compared with the other recommended meshes (12.0% vs 5.0%; P < 0.001). In the multivariable analysis, the recurrence rate was highly significantly influenced by the mesh type used (P < 0.001). If Physiomesh was used, that led to a highly significant increase in the recurrence rate on 1-year follow-up (odds ratio 2.570, 95% CI 2.057, 3.210). The mesh type used also had a significant influence on chronic pain rates. CONCLUSIONS: The importance of real-world data for postmarketing surveillance of surgical meshes has been demonstrated in this registry-based study. Randomized controlled trials are needed for premarket approval of new devices. The role of sponsorship of device studies by the manufacturing company must be taken into account.

Endoscopic mini/less open sublay technique (EMILOS)-a new technique for ventral hernia repair.

INTRODUCTION: The "MILOS concept" (mini/less open sublay repair) was developed to realize the benefits of minimally invasive surgery and avoid the disadvantages of traditional open techniques in repair of primary and secondary abdominal wall hernias. Utilizing the MILOS concept, the mesh can be placed in the retromuscular position without opening of the abdominal cavity or without the necessity to perform a large skin incision. The dissection of the retromuscular plane may be done by an open technique (MILOS) or endoscopically (EMILOS). PATIENTS AND METHODS: From June 2015 to July 2016, a total of 33 patients were operated using the MILOS concept, 8 patients underwent the original MILOS technique, and 25 patients had the EMILOS operation. The operative steps of this novel endoscopic variation, the EMILOS procedure (endoscopic mini/less open sublay), are described in detail. Operative indications were a midline umbilical, epigastric, or incisional hernia with a coexisting rectus diastasis. In all cases, a large mesh (20 × 30) was implanted in the retromuscular space without any fixation. RESULTS: The average skin incision was 5.2 cm; mean operative time was 157 min and 122 min in the last five cases. The average hospital stay was 3.2 days. The median pain score (VAS) under physical stress (e.g., climbing stairs) was 2.7. CONCLUSION: The EMILOS operation has the potential to become an important supplementary method in the spectrum of surgical techniques for repair of abdominal wall hernias. The technique is reliable, reproducible, and easy to standardize.

Effectivity of laparoscopic inguinal hernia repair (TAPP) in daily clinical practice: early and long-term result.

INTRODUCTION: The aim of the study was to investigate the effectiveness of laparoscopic inguinal hernia repair in daily clinical practice. PATIENTS AND METHODS: All patients admitted to the hospital for surgery of an inguinal hernia during a 1-year period were prospectively documented and included in a follow-up study. The follow-up was performed at least 5 years after surgery and consisted of a clinical examination, ultrasound investigation and a questionnaire. RESULTS: From January 2000 to January 2001 a total of 1208 inguinal hernias in 952 patients were consecutively operated by a total of 11 general surgeons in daily clinical routine. Of the patients, 98.02 % were operated on laparoscopically with the transabdominal preperitoneal patch plasty technique (TAPP) and 1.98 % had an open repair. The frequency of intraoperative and early postoperative complications was 2.8 %. The complication rate in the patients presenting a complex hernia was not higher than in patients with uncomplicated unilateral hernias. Life-threatening complications were seen in four patients (bowel lesion-0.4 %), but all four patients presented extensive adhesions in the abdominal cavity after previous abdominal surgery. The follow-up rate after 5 years was 85.3 %. After 5 years the recurrence rate was 0.4 % and the rate of severe chronic pain 0.59 %. None of the patients took analgesics or had to change his occupation. CONCLUSION: Laparoscopic repair can be applied to all types of inguinal hernia as a daily routine procedure with low rates of recurrences and chronic pain. Limiting factor may be extensive adhesions after previous major surgery in the lower abdomen.

The nicotinic α6 subunit gene determines variability in chronic pain sensitivity via cross-inhibition of P2X2/3 receptors.

Chronic pain is a highly prevalent and poorly managed human health problem. We used microarray-based expression genomics in 25 inbred mouse strains to identify dorsal root ganglion (DRG)-expressed genetic contributors to mechanical allodynia, a prominent symptom of chronic pain. We identified expression levels of Chrna6, which encodes the α6 subunit of the nicotinic acetylcholine receptor (nAChR), as highly associated with allodynia. We confirmed the importance of α6* (α6-containing) nAChRs by analyzing both gain- and loss-of-function mutants. We find that mechanical allodynia associated with neuropathic and inflammatory injuries is significantly altered in α6* mutants, and that α6* but not α4* nicotinic receptors are absolutely required for peripheral and/or spinal nicotine analgesia. Furthermore, we show that Chrna6's role in analgesia is at least partially due to direct interaction and cross-inhibition of α6* nAChRs with P2X2/3 receptors in DRG nociceptors. Finally, we establish the relevance of our results to humans by the observation of genetic association in patients suffering from chronic postsurgical and temporomandibular pain.

Association of functional variations in COMT and GCH1 genes with postherniotomy pain and related impairment.

Persistent postoperative pain is a well-established clinical problem with potential severe personal and socioeconomic implications. The prevalence of persistent pain varies across surgery types. Severe persistent pain and related impairment occur in 5% to 10% of patients after groin hernia repair. The substantial interindividual variability in pain-related phenotypes within each surgery type cannot be explained by environmental factors alone, suggesting that genetic variation may play a role. We investigated the contribution of COMT and GCH1 to persistent postherniotomy pain (PPP)-related functional impairment. Prospective data from 429 Caucasian male patients with hernia were collected. Three COMT and 2 GCH1 tagging single-nucleotide polymorphisms (SNPs) were genotyped and analyzed for association with PPP-related activity impairment at 6 months after herniotomy. Fifty-five (12.8%) patients had moderate-to-severe pain-related activity impairment 6 months postoperatively as measured by Activity Assessment Scale (≥8.3). Patients with the G allele of COMT SNP rs6269 and C allele of COMT SNP rs4633 had less impairment (P = 0.03 and 0.01, respectively); in addition, the COMT haplotype GCG was associated with less impairment. For GCH1, the A allele of SNP rs3783641, T allele of rs8007267, and AT haplotype showed a protective effect trend (although nonsignificant; P = 0.08, 0.06, and 0.08, respectively). A prediction model of substantial PPP-related activity impairment, combining COMT and GCH1 SNPs with clinical, psychophysical, and psychological risk factors, had a "good" (0.8 < area under curve < 0.9) discriminatory power. These data suggest that functional variations in COMT and GCH1 combined with clinical factors are predictive of PPP-related impairment after groin herniotomy.

Teaching and training in laparoscopic inguinal hernia repair (TAPP): impact of the learning curve on patient outcome.

BACKGROUND: On the basis of lower incidence of postoperative pain and faster recovery compared with open techniques, the laparoscopic transabdominal preperitoneal patch plastic (TAPP) technique was established as a leading mode of inguinal hernia repair. In contrast to open hernia repairs, which are well integrated in the training of young surgeons, TAPP is still considered a more difficult surgical procedure, raising the questions of how to include this technique in trainee programs and how to provide appropriate training. METHODS: Out of 15,101 TAPP procedures performed in our department between 1993 and 2007, we analyzed 254 operations that occurred from April 2004 to February 2007 by young trainees (between the second and fourth years of surgical training). The analysis compared the trainees' TAPP operations with 3,200 TAPP procedures performed by experienced surgeons in the same time period, and with the first 254 TAPP operations in our department performed by pioneers who introduced this technique in 1993. RESULTS: In the 254 operations performed by young trainees, the mean operation time was 59 min, the morbidity rate was 3.2 %, and the recurrence rate was 0.4 %. Compared to experienced surgeons, we found no significant difference in recurrence rate and morbidity. For operation time, however, the young trainees demonstrated a learning curve with continuous improvement until the end of the study period approaching expert level. Pioneers also demonstrated a clear learning curve in operation time and additionally also regarding morbidity and recurrence rate. CONCLUSIONS: Our study demonstrates that the TAPP learning curve of young trainees is only related to operation time. Therefore, TAPP is a safe and reproducible technique when performed by young trainees under the supervision of experienced laparoscopic surgeons. With an adequate program, the technique can be learned quickly, skillfully, and safely when a standardized technique is used. It should be included as a fundamental part of state-of-the-art trainee programs.

Lightweight mesh and noninvasive fixation: an effective concept for prevention of chronic pain with laparoscopic hernia repair (TAPP).

BACKGROUND: This prospective study aimed to evaluate the impact of transabdominal preperitoneal patch plasty (TAPP) with implantation of a lightweight mesh (<50 g/m²) fixed by fibrin glue on the occurrence of chronic pain and sexual dysfunction in hernia patients. METHODS: Patients were examined before TAPP, early and late postoperatively. The primary end point of the study was pain-related functional impairment 6 months after the operation as assessed by the validated assessment scale (AAS). For the first time, patients without any pain before surgery were compared with patients experiencing preoperative pain. Furthermore, the patients were asked about the frequency and extent of impairment in their sexual activities. A secondary end point was chronic pain in relation to the type of mesh fixation (glue vs clip). RESULTS: The study criteria was met by 276 patients. The dropout rate after 6 months was 2.9%. Mesh fixation was performed with glue for 212 patients and with clip for 64 patients. Chronic pain with significant impairment of daily activities was experienced by 42% of patients before the operation, which decreased to 8.3% after TAPP. The mean level of impairment, assessed by AAS, decreased from 11.2 preoperatively to 2 postoperatively (p < 0.001). The clip patients had more pain on days 4 and 7 postoperatively (p < 0.05) but not later. A majority of the patients (78%) experiencing pain before the operation were pain free 6 months after TAPP. New pain was seen in 7.4% of the patients but was only mild (numeric analog scale [NAS], 1-3; 78% of patients) or moderate (NAS, 4-6; 11% of patients). The only patient with severe pain (NAS, 8) had a clip fixation. Frequency of sexual dysfunction decreased after TAPP (p < 0.05). CONCLUSION: The TAPP procedure with implantation of a lightweight mesh fixed by glue is a highly effective option for preventing chronic pain in inguinal hernia repair. Fibrin fixation seems superior to clip fixation during the early postoperative period. However, for confirmation of results, a randomized study is recommended.