In major surgery, several studies have shown a correlation between high annual hospital volume (hospital caseload) and better outcome. Therefore, centralization is recommended. However, in inguinal hernia surgery the data are limited. The study is based on a retrospective analysis of prospective data from the German Herniamed Registry collected between 2009 and 2018. Out of the total of 731,982 patients operated on in 737 institutions, patients who had undergone inguinal hernia repair in Lichtenstein or in laparo-endoscopic (TAPP/TEP) technique were included. Hospitals were divided into three annual caseload categories: Low volume: ≤ 75 cases; middle volume: 76–199 cases; high volume: ≥ 200 cases. The relationship between hospital volume and the outcome parameters was analyzed using multivariable binary logistic models. 222,487 patients were enrolled in analysis, with 70.4

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. 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. 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

Abstract Purpose There is a scarcity of studies on different surgical approaches for recurrent incisional hernia and associated complications. The aim of our study is to describe the management of recurrent incisional hernia repairs at a single institution over 5-year period. Methods Consecutive patients who received one of four surgeries of interest for recurrent incisional hernia were identified. Clinical outcomes were evaluated and compared across different approaches. A stratified analysis by defect size was conducted according to the European Hernia Society (EHS) width classification. Results A total of 292 patients were analyzed: 74 (25.3%) underwent open sublay repair without the component separation technique (CST; Group I), 50 (17.1%) had open sublay repair with CST (Group II), 131 (44.9%) had laparoscopic mesh repair (Group III), and 37 (12.7%) had a hybrid procedure (Group IV). Patients in Groups II and IV had higher rates of complications (48.0% and 54.1%, respectively) compared to those in Groups I (21.6%) and III (20.6%). Within a median follow-up period of 36 (12–70) months, four patients in Group I (5.4%), one in Group II (2.0%), five (3.8%) in Group III, and two (5.4%) in Group IV developed recurrence, and the between-group difference was not significant. Multivariate analysis identified higher body mass index, smoking, longer operative time, and EHS width class W3 ≥ 10 cm as the risk factors of postoperative complications. Conclusion Tailored surgery is recommended for repair of recurrent incisional hernias. Both CST and hybrid techniques are feasible approaches for complex hernias. Larger defects are associated with an increased risk of complications.

Introduction: Abdominal wall hernia and incisional hernia repair are among the most frequent operations in general surgery. However, despite the use of mesh and other recent improvements, the open mesh techniques and laparoscopic IPOM repair have specific disadvantages and risks. Materials and Methods: To minimize complications of the existing open and laparoscopic techniques we developed the endoscopic Mini- or Less Open Sublay (EMILOS) and endoscopically assisted Mini- or Less Open Sublay (MILOS) concept. We report on our large series of minimally invasive sublay repair of and ventral incisional hernias. The operation is performed transhernially with light-holding laparoscopic instruments either under direct, or endoscopic visualization, while the abdominal wall is circumferentially elevated with retractors. An endoscopic light tube was developed to facilitate this approach (Endotorch,TM Wolf Company). Each MILOS operation can be converted to standard total extraperitoneal gas endoscopy (EMILOS repair) once an extraperitoneal space of at least 8 cm has been created. The technique allows minimal invasive repair of ventral hernias with concomitant rectus diastasis. In large eventrations E/MILOS m. transversus abdominis release (TAR) can be performed. All MILOS operations were prospectively documented in the German Hernia registry Herniamed. Technical modifications and improvements from the inception of the E/MILOS concept including variants of the EMILOS technique are addressed. Results: The total and surgical complication rates of 1745 E/MILOS incisional hernia operations were 4.6% and 3.1%, respectively. The reoperation rate was 1.7%. Haemorrhage, seroma, enterotomy, infection and bowel obstruction were detected in 1.0, 0.9, 0.2, 0.3 and 0.4 percent of the cases, respectively. The recurrence rate after one year was 1.2%. Chronic pain at rest, at activities and chronic pain requiring therapy was reported in 3.8, 7.4 and 3.6 percent, respectively. Conclusion: The MILOS technique allows minimally invasive transhernial repair of incisional hernias using large retromuscular / preperitoneal meshes with low morbidity. The technique is reproducible, cost effective, easy to standardize and combines the advantages of open sublay and the laparoscopic IPOM repair.

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. 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. 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. 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.

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.

Abstract Aim Between 01/2011 and 12/2020 5,068 AWR-patients at our department (tertiary referral center) – 884 (17.4%) incisionals. Over this 10-years period considerable changes (patients characteristics, surgical techniques, results) were analyzed. Material and Methods Herniamed® offers an internet-based registry-platform to document all kinds of abdominal wall repairs on a voluntary basis since 2009. Demographic data, interventional details and outcomes are documented using the EHS-classification-system. Follow-up is standardized and sheduled for 10 years. Results Up to 54.7% of patients (in 2020) show at least one risk factor (diabetes, smoking ….), in contrast to the age pyramid patients >70 years are decreasing (47.2% in 2011 down to 29.3% in 2020), share of ASA III/IV is initially increasing (up to 42.9% in 2017) with a constant decrease after 2017 to 25.3% in 2020. Emergent cases are increasing (6.9% in 2011 up to 10.8% in 2019). Recurrent hernia repairs stays almost constant at median 21.7%. After 2015 we decided – for various reasons - not to routinely apply the laparoscopic IPOM-technique (with an interim ratio of up to 46.2%) – with a post-OP complication rate of median 23.3% anymore. From 2016 onwards we performed an increasing number of „other techniques“ (E-MILOS, E-TEP, ….) up to 36% in 2020 instead. Conclusions By analysing trends we recognized that patients show increasing numbers of risk factors and ASA-scores which led us to implement a prehabilitational strategy in clinical routine. However rate of post-OP complication is still high representing AWR as demanding in many aspects. A temporary cessation of MIS did not led to an extensive increase in post-OP wound complications.

In 1997, this concept of tension-free hernia repair surgery was introduced into China. Chinese hernia and abdominal wall surgery entered a new era and developed rapidly. In 2017, Chinese Hernia Registry was officially released online, and the Chinese Hernia Surgery Alliance was established at the same time. The Hernia Registry has been promoted and applied for over three years. The Hernia Registry database is very promising with the overall follow-up rate exceeding 70%. We expect that through this work, the treatment of hernia and abdominal wall disease can be improved and standardized in China. Based on China Hernia Registry with a total of 159,602 cases of Hernia cases, we found that the ratio of male to female in these seven types of external abdominal hernias is 6.23 to 1. The incidence of hernias in men is much higher than that in women. In particular, inguinal hernia is more prominent with a male-to-female ratio of 8.23 to 1. It is possible to have a preliminary understanding and epidemiological analysis of hernia disease in China.

Abstract Aim Aim of the analysis was to evaluate whether preoperative botulinum toxin infiltration may facilitate anatomical midline reconstruction without the need for – otherwise pre-operative assumed – surgical component separation. Material and Methods Total of 58 patients with complex abdominal wall hernias were included in our single-center retrospective analysis between 03/2015 and 12/2020. Size of the defect, HSV/ACV-ratio, rectus-to-defect-width-ratio (“Carbonell-Index”) as well as risk factors were analyzed. In all patients muscles of the lateral abdominal wall were infiltrated with 300-500 IE of botulinum toxin 4 weeks prior to the abdominal wall reconstruction. CT scans were performed before and 4 weeks after the botulinum toxin infiltration. Results Total of 58 patients (M/F-ratio 36:22), with a mean age of 63.8 years were included in our analysis. Mean BMI was 29.5 kg/m². Total of 50 incisional, 3 umbilical, 2 posttraumatic diaphragmatic hernias and 3 scrotal hernias were analyzed. Surgical component separation after the infiltration with botulinum toxin was necessary in 43% of the cases. Conclusions Preoperative infiltration of the lateral abdominal wall musculature with botulinum toxin facilitated midline reconstruction of the abdominal wall without the need for myofascial release in 57%. Reduction of surgical trauma could therefore be achieved in several patients.

The optimal surgical treatment for lateral hernias of the abdominal wall remains unclear. The presented prospective study assesses for the first time in detail the clinical value of a totally endoscopic sublay (TES) technique for the repair of these hernias. Twenty-four consecutive patients with a lateral abdominal wall hernia underwent TES repair. This technique is naturally combined with a transversus abdominis release maneuver to create a sufficient retromuscular/preperitoneal space that can accommodate, if necessary, a giant prosthetic mesh. The operations were successful in all but one patient who required open conversion because of dense intestinal adhesion. The mean defect width was 6.7 ± 3.9 cm. The mean defect area was 78.0 ± 102.4 cm2 (range 4–500 cm2). The mean mesh size used was 330.2 ± 165.4 cm2 (range 108–900 cm2). The mean operative time was 170.2 ± 73.8 min (range, 60–360 min). The mean visual analog scale score for pain at rest on the first day was 2.5 (range 1–4). The average postoperative stay was 3.4 days (range 2–7 days). No serious complications (Dindo–Clavien Grade 2–4) were seen within a mean follow-up period of 13.3 months. A totally endoscopic technique (TES) for the treatment of lateral hernias is described. The technique revealed to be reliable, safe and cost-effective. The first results are promising, but larger studies with longer follow-up periods are recommended to determine the real clinical value.

Introduction Immunosuppressive conditions and/or preoperative corticosteroid treatment have a negative influence on wound healing and can, therefore, lead to higher rates of surgical site infections (SSIs) and seromas. For inguinal hernia, no such studies have been carried out to date. Methods In an analysis of data from the Herniamed Registry, 2312 of 142,488 (1.6%) patients with primary unilateral inguinal hernia repair had an anamnestic history of an immunosuppressive condition and/or preoperative corticosteroid treatment. Using propensity score matching, 2297 (99.4%) pairs with comparative patient characteristics were formed. These were then compared using the following primary outcome criteria: intra- and postoperative complications, complication-related reoperations, recurrence at one-year follow-up, pain on exertion, pain at rest, and chronic pain requiring treatment at one-year follow-up. Of the 2297 matched pairs with primary unilateral inguinal hernia repair, 82.76% were male patients. 1010 (44.0%) were operated in laparo-endoscopic techniques (TEP, TAPP), 1225 (53.3%) in open techniques (Bassini, Shouldice, Lichtenstein, Plug, TIP, Gilbert, Desarda), and 62 (2.7%) in other techniques. Results The matched pair analysis results did not identify any disadvantage in terms of the outcome criteria for patients with an anamnestic history of immunosuppressive condition and/or preoperative corticosteroid treatment (yes vs no). In particular, no disadvantage was noted in the rate of surgical site infections (0.65% vs 0.70%; ns) or seromas (1.22% vs 1.57%; ns). The overall rates of postoperative complications were 3.40% vs 4.31% (p = ns) (plus 0.22% concordant events in five matched pairs). Conclusion In primary unilateral inguinal hernia surgery, an immunosuppressive condition and/or preoperative corticosteroid treatment does not appear to have a negative influence on wound complications.

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.

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.

AIM: Litigation is always a severe burden for every surgeon who is involved. The study aims to show the most important reasons for an allegation and how to prevent a lawsuit.METHODS: Based on the own experience as a medical advisor, ten medico-legal cases are analyzed and a systematic overview of the corresponding literature is given.RESULTS: Allegation for malpractice is not very frequent; in hernia surgery, <1% of the patients are involved. Furthermore, only in 20%–40% of these cases, the decision is in favor of the claimant. However, every case is associated with compensation ranging from roughly between $19,000 and $8,000,000. Totally the author had to perform 10 reports in legal cases for the court: In three cases, compensation had been refused, because informed consent had correctly been done, and the operative situs was clearly documented, and in the third case, the preoperative diagnostics and the operative performance had been according to the medical standard. The claim was successful in three patients because of technical failure, in two cases because of wrong indication, and in two cases because of delayed reoperation.DISCUSSION: There are five key features in the prevention of a lawsuit in surgery: (1) “informed consent:” Take the time, use a standard form, show pictures and make handwritten notes to explain in detail the indication for surgery, the technical performance of the planned intervention, and the steps of aftercare; (2) “technical performance” of the operation should follow the generally accepted medical standard. Deep knowledge of anatomy is an indispensable precondition of perfect operation; (3) a “delay in timely response” to a complication is not excusable; (4) “careful documentation” of all steps of the treatment may possibly avoid a legal case; and (5) “establishing an empathic relationship” between the surgeon and the patient and his/her relatives as well is essential for avoiding an accusation.CONCLUSION: Medico-legal implications in hernia surgery are rare, but a severe burden for every surgeon concerned and may be associated with damage to the reputation of the surgeon and high costs. The best ways of preventing such a disaster are the correct indications and operative performance according to the current medical standard and empathic aftercare.

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.

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, Settzer Z, Gebauer M, Michaelis M, Tal M, Dorfman R, Abitbul-Yarkoni M, Lu Y, Elahipanah T, delCanho 5, 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.

BACKGROUND:Currently, three different techniques are favored for repair of an inguinal hernia: (1) The suture repair described by Shouldice. (2) An open mesh repair according to Lichtenstein. (3) Laparo-endoscopic techniques TAPP and TEP. The aim of the presented paper was to describe the ranking of the Transabdominal Preperitoneal Patch Plasty (TAPP) in comparison to the other techniques for inguinal hernia repair.METHODS:The manuscript is based on the experiences gained in more than 15,000 TAPPs and numerous own studies as well. The technique of TAPP is described in detail and also the results which can be achieved with special reference to primary unilateral inguinal hernias in male patients. Moreover, a systematic review of the literature is done for the comparison with the other techniques.RESULTS:According to own experiences, 98% of all patients with an inguinal hernia admitted for surgery to Marienhospital Stuttgart could be operated on using the TAPP technique. The recurrence rate and the rate of severe chronic pain in this setting were below 1%. Due to the limited quality of most of the published studies an evidence-based comparison which is the best of the currently most recommended techniques is questionable. Therefore, when comparing TAPP with TEP, no definite conclusion about superiority of one technique over the other is possible. Both techniques are safe and effective if properly performed. The guidelines recommend that the surgeon should use the technique he had learned best and is familiar with. The comparison between TAPP and the Shouldice repair shows less pain and a higher effectivity after TAPP. The recurrence rate after Lichtenstein repair and after TAPP is similar, but pain and recovery time are significantly less after TAPP.CONCLUSION:Analyzing the own abundant experiences and the reports in the literature, the TAPP technique has the potential to become the standard operative technique for repair of inguinal hernias in future. However, due to the low level of evidence of most of the studies definite conclusions are difficult to draw at this point of time.

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.