Correction to: Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A.

This article was updated to include the middle initial of author L. N. Jorgensen's name.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B.

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

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A.

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

Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1.

Guidelines are increasingly determining the decision process in day-to-day clinical work. Guidelines describe the current best possible standard in diagnostics and therapy. They should be developed by an international panel of experts, whereby alongside individual experience, above all, the results of comparative studies are decisive. According to the results of high-ranking scientific studies published in peer-reviewed journals, statements and recommendations are formulated, and these are graded strictly according to the criteria of evidence-based medicine. Guidelines can therefore be valuable in helping particularly the young surgeon in his or her day-to-day work to find the best decision for the patient when confronted with a wide and confusing range of options. However, even experienced surgeons benefit because by virtue of a heavy workload and commitment, they often find it difficult to keep up with the ever-increasing published literature. All guidelines require regular updating, usually every 3 years, in line with progress in the field. The current Guidelines focus on technique and perioperative management of laparoscopic ventral hernia repair and constitute the first comprehensive guidelines on this topic. In this issue of Surgical Endoscopy, the first part of the Guidelines is published including sections on basics, indication for surgery, perioperative management, and key points of technique. The next part (Part 2) of the Guidelines will address complications and comparisons between open and laparoscopic techniques. Part 3 will cover mesh technology, hernia prophylaxis, technique-related issues, new technologic developments, lumbar and other unusual hernias, and training/education.

Combined laparoscopic and open extraperitoneal approach to scrotal hernias.

BACKGROUND: Laparoscopic repair of scrotal hernias is often a difficult endeavor to successfully complete. The longstanding nature of these hernias often results in significant adhesions and anatomic distortion of the inguinal floor. These two issues make reduction of the hernia arduous and subsequent reinforcement of the parietal sac difficult. We have previously described techniques to increase the chances of success when attempting laparoscopic repair of scrotal hernias. Here, we describe some of those techniques as well as a combined laparoscopic and open approach to achieve a robust preperitoneal repair of incarcerated scrotal hernias when the usual totally extraperitoneal approach does not work. PATIENTS AND METHODS: We performed a retrospective review of 1890 TEP hernia repairs we performed from 1990 to 2010. Rate of conversion to an open approach or a combined laparoscopic and open approach was examined. Incidence of complications or recurrences was assessed over a 12-month follow-up period. RESULTS: Among the 1890 TEP repairs, 94 large scrotal hernias were identified. Of these, nine cases (9.5 %) required conversion to an open procedure due to an incarcerated and indurated omentum. Three were completed with a conventional open preperitoneal whereas six patients (6.4 %) underwent repair with the combined approach. In this group, no recurrences or complications were found over a 12-month period. CONCLUSION: In cases where a large scrotal hernia may be difficult or dangerous to reduce laparoscopically, immediate conversion to an open repair may not be necessary. A combined laparoscopic and open approach can greatly assist in the visualization and dissection of the preperitoneal space, thereby facilitating reduction of the hernia and placement of the mesh.

Clinical improvement after duodenojejunal bypass for nonobese type 2 diabetes despite minimal improvement in glycemic homeostasis.

BACKGROUND: Glycemic control of type 2 diabetes mellitus (T2DM) remains a dilemma to physicians. Although gastric bypass surgery undertaken for morbid obesity has been shown to resolve this disease well, data on the effectiveness of duodenojejunal bypass in improving or resolving T2DM and the metabolic syndrome (MS), especially in nonobese patients are scarce. This study was intended to evaluate the clinical effects of laparoscopic duodenojejunal bypass (LDJB) in patients with T2DM and a body mass index of <35 kg/m(2). METHODS: We conducted a 12-month prospective study on the changes in glucose homeostasis and the MS in seven T2DM subjects undergoing LDJB with similar DM duration, type of DM treatment, and glycemic control. Laboratory values including glycosylated hemoglobin A (HbA1c), fasting blood glucose, cholesterol, triglyceride, and C-peptide were followed throughout the 12 months. Serum levels of gastric inhibitory peptide and ghrelin were followed for 1 month. Serum levels of gastrin and glucagon-like peptide were followed for 3 months. RESULTS: At 12 months after surgery, all subjects consistently felt relief from fatigue, pain and/or numbness in the extremities, polyuria, and polydypsia. Clinical resolution was obtained for one patient, and the preoperative diabetic medication requirements decreased for most of the other patients. The subjects demonstrated an overall improved HbA1c (from 9.4% to 8.5%) and fasting blood glucose level (from 209 to 154 mg/dl). Although the change in fasting blood glucose approached statistical significance, these measures of glucose homeostasis did not achieve significance. Cholesterol and triglycerides increased slightly, and C-peptide decreased slightly over 1 year. These changes were not statistically significant. CONCLUSIONS: Although this is a small series, our data show that at 12 months after surgery, clinical improvement was obvious in all of our seven patients, but LDJB may not be effective at inducing remission of T2DM and the MS in certain patients undergoing this operation. This suggests that larger patient studies should be conducted, before concluding that surgery may offer clinical and biochemical resolution to a disease once treated only medically. Longer follow-up is required for better evaluation.

Medial-to-lateral laparoscopic colon resection: a view beyond the learning curve.

BACKGROUND: Since the authors' report on the lateral approach to laparoscopic colon resection (LCR), medial-to-lateral (M-L) segmental resection has continued to evolve. This report analyzes their learning curve experience with a standardized three-trocar M-L technique, which demonstrates the influence of operative volume on proficiency and outcome. METHODS: From January 1999 to December 2004, 100 consecutive patients underwent a standardized three-trocar M-L segmental LCR. Patient demographics, indications for surgery, operative proficiency (time), and outcome (i.e., blood loss, conversion to open surgery, length of hospital stay, morbidity, and mortality) were recorded. A learning curve analysis was performed using a t-test and analysis of variance (ANOVA). RESULTS: The 100 M-L LCRs included sigmoid (55%), right (34%), left (6%), and transverse (5%) approaches. Overall learning curve proficiency was influenced by increasing operative experience (p = 0.02). However, significant and consistent improvement in the learning curve occurred only after 38 LCRs (p < 0.008). Notably, all conversions to open surgery (3%) occurred during the early learning curve. Similarly, early LCR patients experienced greater morbidity (mean, 21% vs 12%) and mortality (mean, 5% vs 2%) than their later counterparts. CONCLUSION: To obtain optimum proficiency in performing LCR, a minimum of 38 M-L procedures is required. Operative and patient outcomes improve beyond the early learning curve.

The role of endoscopic extraperitoneal herniorrhaphy: where do we stand in 2005?

Inguinal hernia repair is a common surgical procedure, but the most effective surgical technique remains controversial. The evolution of laparoscopic techniques has allowed reproduction of open preperitoneal repair via an endoscopic total extraperitoneal (TEP) approach. More recently, the advent of comprehensive training in laparoscopy has allowed TEP to continue evolving as the feasibility of this approach gains recognition as a preferable technique. Once considered very difficult to learn, TEP currently is adequately taught in many surgical training programs. This report reviews the fundamentals and details various modifications that make this procedure more desirable than open procedures and other laparoscopic techniques. A resultant decrease in operative time, cost of the procedure, and morbidity to the patient is routine. In addition, the authors review their institutional experience and examine other current evidence-based data.

Treating recurrence after a totally extraperitoneal approach.

BACKGROUND: One of today's most highly regarded procedures for treating inguinal hernia is the totally extraperitoneal approach (TEP), but it can on occasion lead to recurrence. This is commonly managed with an open repair, a transabdominal preperitoneal procedure (TAPP), or another TEP. We report here on our years of experience with the latter. METHODS: The endeavor to a secondary TEP is much the same as to a primary one, but certain differences are encountered as the operation proceeds. For example, many anatomical landmarks found in a first TEP cannot be seen in a second. There can also be a diminished amount of working space, and this occasionally leads to an open conversion. RESULTS: From September 1991 to September 2005, we repaired 1,526 hernias in 1,156 male patients, using the TEP in every case. Of these, 21 were TEPs after a previous TEP. In 3 cases, the space could not be opened, and they were converted to the open Lichtenstein. One patient had peritoneal tears that led to conversion and another had conversion because of excessive bleeding. There were no complications, no bladder or bowel injuries, no transfusions, no preperitoneal hematomas, and no fatalities. All patients were discharged the same day. CONCLUSIONS: A secondary TEP, open repair, and TAPP are alternative solutions to the problem of recurrence after TEP. However, any TEP involves a very prolonged learning curve for general surgeons, since they must learn the anatomy as well as the procedure, both at the same time. This is doubly true for the TEP after a previous TEP.

Totally extraperitoneal repair of obturator hernia.

BACKGROUND: One distinct advantage of the 1aparoscopic inguinal hernia repair is the opportunity for clear visualization of the direct, indirect, femoral, and obturator spaces. The surgeon should routinely inspect all of them. Obturator hernia accounts for as few as 0.073% of all hernias, but the mortality rate when it is acutely incarcerated can be as high as 70%. There is only one previous report of a totally extraperitoneal repair for obturator hernia. Five such procedures are described. METHODS: A retrospective review was undertaken to evaluate one surgeon's experience with the totally extraperitoneal repair of obturator hernia over a 4-year period. Four of five cases were completed, and the remaining case was converted to an open procedure. RESULTS: Three hernias were on the right side, and two on the left. One patient presented with an acutely incarcerated obturator hernia and underwent a small bowel resection for strangulated bowel within the obturator space. The other four hernias were found during totally extraperitoneal repair, and the patients were discharged home several hours later. There was one complication, a midline wound infection in the patient with strangulated bowel. It was treated with dressing changes. There were no other complications, and during a follow-up period of 3 to 48 months, there was no recurrence. CONCLUSIONS: The laparoscopic totally extraperitoneal approach allows inspection and repair of direct, indirect, femoral, and obturator hernias. This study found this procedure to be feasible, safe, and highly effective for the diagnosis and repair of obturator hernias.

Investigating a possible cause of mesh migration during totally extraperitoneal (TEP) repair.

BACKGROUND: In experienced hands, laparoscopic inguinal hernia repair has a low rate of recurrence, but it still can recur, and a number of reasons for this have been identified. In published studies, the majority of such cases seem to result from inadequate dissection leading to missed hernias or suboptimal mesh placement. But even with adequate dissection and proper placement of a sufficiently large mesh, recurrence sometimes happens. A number of investigators have cited mesh migration or dislocation as a possible cause, and this study examined how hip flexion affects the position of newly placed meshes and staples in totally extraperitoneal (TEP) repair of inguinal hernia. METHODS: After completion of the dissection and reduction of discovered hernias, a 15 x 15-cm polypropylene mesh was placed either unilaterally or bilaterally, as indicated. The preperitoneal space then was desufflated. The operating table, in an extended -20 degrees position during surgery, was placed in a 90 degrees position for approximately 15 s. After reinsufflation, the possibility of mesh migration and folding was investigated. Finally, the mesh was stapled, the table again extended and flexed, and the possibility of mesh migration and staple dislodgement investigated once more. RESULTS: The mesh did not migrate or become displaced from any potential hernia area, nor did any of the staples become dislodged. CONCLUSIONS: Concern about mesh migration attributable to patients sitting up immediately after surgery appears to be unfounded, at least according to the findings for the current, small, simulated study group.

Totally extraperitoneal (TEP) hernia repair after an original TEPIs it safe, and is it even possible?

BACKGROUND: There are only scant published reports of totally extraperitoneal (TEP) repair of recurrence after a primary TEP procedure. Furthermore, at least two authors have made the statement that such an operation is virtually impossible. METHODS: We have been performing TEP repair of recurrence after TEP since we 1996, and here we present a retrospective review of our experience with the procedure. We employ a method not varying greatly from the standard TEP done for primary hernia. RESULTS: All cases were started laparoscopically, and only one of 20 had to be converted to open. Of these cases, 12 were for same-side recurrence and eight for a contralateral new hernia. With a follow-up of 28-74 months, there have been no fatalities, no complications, and no re-recurrence. CONCLUSION: We have found that TEP repair of recurrent inguinal hernia after a primary TEP repair is entirely feasible technically as well as entirely safe.

Obstructive symptoms associated with the Lap-Band in the first 24 hours.

BACKGROUND: The Lap-Band is a gastric restrictive procedure for the treatment of morbid obesity. We review the etiology of obstructive complications that present in the first postoperative 24 h. METHODS: Fifty-six Lap-Band procedures were performed by one surgeon between January and September 2002. RESULTS: Six patients presented with obstruction within 24 h of surgery: gastric slippage in three patients, gastric edema in one patient, and esophageal hypomotility in two patients. CONCLUSIONS: Placing the band in an esophagogastric position as per Belachew and Weiner reduced our incidence of gastric slippage to none. Endoscopy with placement of a nasogastric feeding tube can relieve obstruction caused by esophageal hypomotility. Gastric edema with no clinical signs of obstruction will resolve with time. Clinicians must be aware of the unique complications that come with the advent of this new procedure.

Laparoscopic adjustable gastric banding: is there a learning curve?

BACKGROUND: To be certified for laparoscopic placement of adjustable gastric banding, surgeons must have advanced laparoscopic experience. Despite previous exposure to other kinds of laparoscopy, there may a learning curve specific to Lap-Band placement. METHODS: Sixty consecutive patients were prospectively separated into two groups: the first 30 patients operated on (group 1) and the second 30 patients operated on (group 2). RESULTS: Both groups were similar statistically in regard to gender, age, and body mass index. Operative time for group 1 was 79 +/- 31.1 min. There were 11 (37%) complications in 10 patients. Operative time for group 2 was 59 +/- 19.9 min. There were two complications (7%). All operations were completed laparoscopically. Operative time was significantly lower in group 2 ( t-test; p = 004). Complications were also significantly lower (chi-square; p = 0.005). The number of reoperations was also reduced and approached statistical significance (chi-square; p = 0.054). Readmissions, although reduced, were not statistically significant. There were no deaths in either group. CONCLUSIONS: Despite a surgeon's history of advanced laparoscopic experience, there is a definite learning curve associated with the laparoscopically placed adjustable gastric band.

Laparoscopic extraperitoneal approach to acutely incarcerated inguinal hernia.

BACKGROUND: Laparoscopic treatment of acutely incarcerated inguinal hernia is uncommon and still controversial. Those being performed almost all use the transabdominal (TAPP) approach. The authors here present their experience with totally extraperitoneal (TEP) repair of acutely incarcerated hernia. METHODS: A retrospective review was undertaken to evaluate the authors' experience with this procedure over a 4-year period. There were 16 cases, 5 of which were performed using a conventional anterior repair. These 5 cases were excluded from the review. The surgery for all of the remaining 11 acutely incarcerated hernias was started laparoscopically using the TEP approach. Eight of the cases were completed this way, whereas three were converted to the open procedure. In addition to standard TEP repair techniques, a releasing incision is required for acutely incarcerated direct, indirect, or femoral hernias. With a direct hernia, the opening of the defect is enlarged to allow safe dissection of its contents. A releasing incision is made at the anteromedial aspect of the defect to avoid injury to the epigastric or iliac vessels. With an indirect hernia, several additional steps are required. The epigastric vessels may be divided; an additional trocar may be placed laterally below the linea semicircularis to facilitate dissection of the sac and to assist with suturing of the divided sac; and the deep internal ring is divided anteriorly at the 12 o'clock position toward the external ring, facilitating dissection of the indirect sac. With a femoral hernia, a releasing incision is made by carefully incising the insertion of the iliopubic tract into Cooper's ligament at the medial portion of the femoral ring. RESULTS: The mean operative time was 50 min (range, 20-120 min), and the length of hospital stay was 5.4 days (range, 1-29 days). During a follow-up period of 9 to 69 months, there was no recurrence, and only two complications. One of these complications was an infected mesh that occurred in a case involving cecal injury. It was treated with continuous irrigation and salvaged. The other complication was a midline wound infection after a small bowel resection for a strangulated obturator hernia. CONCLUSIONS: Familiarity with the anatomy involved leads to the conclusion that the laparoscopic approach, specifically the TEP procedure, can be used without hesitation even in cases of acutely incarcerated hernia.