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Rolf Hunkeler’s corner

Vom 13.05.19 – 15.05.19 fand der von Filip Muysoms (Ghent) exzellent organisierte Kongress über «Robotic Abdominal Wall Surgery» in Ghent, Belgien statt. Wir berichten zusammenfassend über einige Highlights dieser Veranstaltung.

Archana Rawaswamy (Minneapolis), eigentlich eine TEPP’erin, zeigt auf, wie die Robotic ihre Indikationen zur minimal invasiven Hernienchirurgie erweitert hat und sie jetzt auch kompliziertere Fälle (st.n. Unterbaucheingriffen, st.n. radikaler Prostatektomie, …) vermehrt mittels rTAPP angeht.

Auch Inan Ihsan (Genf) demonstriert, wie er dieses neue Tool schon seit 2007 einsetzt und mit der rTAPP auch für die ventralen Hernien, rStoppa-Rives und re-TEPP die besseren Resultate mit noch bequemerem Handling für den Chirurgen erreicht. Er erwähnt auch einige seiner Tipps und Tricks.

Filip Muysoms (Ghent) stellt ein neues Sytem, das Versius von CMR Surgical, vor. Dieses wurde von einer Gruppe aus Manchester entwickelt und bis jetzt bei 30 Patienten im Deenanath Mangeshkar Hospital and Resaerch Center von in Pune, Indien erfolgreich eingesetzt.

Ulli Dietz (Olten) stellt die von ihm entwickelten Silikonmodelle zum Training sowohl der offenen, der laproskopischen als auch der robotischen Hernienchirurgie vor. Er zeigt den Sinn und den  Erfolg des Teachings virtuell und an Modellen vor dem «Üben» am Patienten auf (vgl. Dunning-Kruger Effekt). Wahrscheinlich wird die Lernphase am Patienten bei der Roboterchirurgie durch die virtuelle Vorbereitung verkürzt.

Äusserst hervorragend war der anatomische Vortrag von Yohann Renard (Reims) über den Aufbau der Bauchdecke und seine Demonstration einer Anterior Component Separation an einem Leichenpräparat.

Die Livedemonstration des Masters Conrad Ballecer (Phoenix) einer rTAPP, bei welcher ebenfalls einige Tricks gezeigt wurden, war wie immer überzeugend und zeigte deutlich einige Vorteile der Robotic Surgery. Dennoch betont auch Ballecer, dass dies nur ein weiteres neues Instrument ist, welches einen allein nicht zum besseren Chirurgen macht.

Überzeugend war auch die live rTARUP von Filip Muysoms und Conrad Ballecer, bei welcher auch für den «Nicht-Robotiker» bedeutende anatomische Hinweise und Tricks/Pit-falls einer solchen Operation gezeigt wurden.

Eine perfekte Vorstellung seiner Resultate betreffend Milos/e-Milos lieferte Wolfgang Reinpold (Hamburg). Er ist zwar kein Robotiker, aber einer der Vorreiter der Idee, Meshes bei Möglichkeit nicht intraperitoneal legen zu müssen.

Die anschliessende Roundtable-Diskussion über die Einführung der Robotischen Chirurgie in Europa führte uns die Problematik der finanziellen Aspekte vor Augen. Wenn zum Beispiel in Tschechien die Abgeltung eines Hospitalisationstages total 40 Euro beträgt, wird dies folglich nie finanzierbar sein. Auch gibt es bis jetzt keine Studie, die für den Patienten tatsächlich einen wirklichen Benefit der Robotics zeigt. Fraglich finden sich etwas kürzere Hospitalisationszeiten, aber sicherlich deutlich höhere Kosten. Dies war auch die Aussage der Präsentation von Nadia Henriksen (Kopenhagen). Die bis jetzt vorliegenden Studien ergeben keinen Vorteil betreffend des postoperativen Outcomes, jedoch höhere Kosten und längere OP-Zeiten.

Eric Pauli (Hershey) zeigt die Vorteile der CT bei der Beurteilung der Abdominalwand auf, da bei dieser Technik die Anatomie genauestens nachvollzogen werden kann und insbesondere, im Gegensatz zur Sonografie, nicht untersucherabhängig ist. Sie soll ergänzend zur Anamnese (inklusive eventuell bestehender OP-Berichte) und zur klinischen Untersuchung eingesetzt werden. Meist ist sogar das Netz erkennbar. Sie ist das ideale Instrument zur OP-Planung. Kontrastmittel  ist normalerweise nicht notwendig.

Brian Jacob (New York) berichtet über die Schmerzproblematik und wie wichtig hier insbesondere die Anamnese ist. Frühes Auftreten spricht für eine Fixationsproblematik oder technische Fehler, mittelfristiges für Tacks oder Netzprobleme. Bei bildgebender Diagnostik sollte immer der Schmerzpunkt markiert sein. Sehr zurückhaltend ist er bei der Indikation zur Operation, welche er erst ab VAS 7 stellt! Offen eingelegte Netze werden normalerweise offen, endoskopisch eingelegte eher endoskopisch und dann meist robotisch entfernt.

Die SAHC gratuliert Filip Muysoms zu diesem hervorragend organisierten Meeting. Wir freuen uns bereits auf die kommende Veranstaltung im nächsten Jahr.

Rolf Hunkeler

 

 

Daes J, Telem D. The principled approach to ventral hernia repair.
Abstract
Standardization of ventral hernia repair remains elusive. Surgeons use a plethora of techniques, tools, and technology to repair similar defects. Nevertheless, evidence-based principles exist that should be applied to all repairs irrespective of technique allowing standardization and improved outcomes. Six principles are proposed as the basis for complex abdominal wall reconstruction.
Keywords: hernia, ventral; abdominal wall reconstruction; surgical procedures; herniorrhaphy; surgical mesh; prostheses and implants.

Classification of Rectus Diastasis—A Proposal by the German Hernia Society (DHG) and the International Endohernia Society (IEHS)
Reinpold W, Köckerling F, Bittner R, Conze J, Fortelny R, Koch A, Kukleta J, Kuthe A, Lorenz R, Stechemesser B.
Abstract
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.
Keywords: rectus diastasis, classification, concomitant hernia, pregnancy, defect width

 

Laparoscopic IPOM versus open sublay technique for elective incisional hernia repair: a registry-based, propensity score-matched comparison of 9907 patients. Köckerling F, Simon T, Adolf D, Köckerling D, Mayer F, Reinpold W, Weyhe D, Bittner R
Abstract
Background For comparison of laparoscopic IPOM versus sublay technique for elective incisional hernia repair, the number of cases included in randomized controlled trials and meta-analyses is limited. Therefore, an urgent need for more comparative data persists.
Methods: In total, 9907 patients with an elective incisional hernia repair and 1-year follow-up were selected from the Herniamed Hernia Registry between September 1, 2009 and June 1, 2016. Using propensity score matching, 3965 (96.5%) matched pairs from 4110 laparoscopic IPOM and 5797 sublay operations were formed for comparison of the techniques.
Results: Comparison of laparoscopic IPOM versus open sublay revealed disadvantages for the sublay  regarding postoperative surgical complications (3.4% vs. 10.5%; p < 0.001), complication-related reoperations (1.5% vs. 4.7%; p < 0.001), and postoperative general complications (2.5% vs. 3.7%; p = 0.004). The majority of surgical postoperative complications were surgical site infection, seroma, and bleeding. Laparoscopic IPOM had disadvantages in terms of intraoperative complications (2.3% vs. 1.3%; p < 0.001), mainly bleeding, bowel, and other organ injuries. No significant differences in the
recurrence and pain rates at 1-year follow-up were observed.
Conclusion: Laparoscopic IPOM was found to have advantages over the open sublay technique regarding the rates of both surgical and general postoperative complications as well as complication-related reoperations, but disadvantages regarding the rate of intraoperative complications.
Keywords Incisional hernia · Laparoscopic IPOM · Sublay · Complications · Hernia registry

 

Köckerling F, Bittner R, Kraft B, Hukauf M, Kuthe A, Schug-Pass C.
Does surgeon volume matter in the outcome of endoscopic inguinal hernia repair?
Abstract
Introduction: For open and endoscopic inguinal hernia surgery, it has been demonstrated that low-volume surgeons with fewer than 25 and 30 procedures, respectively, per year are associated with significantly more recurrences than high-volume surgeons with 25 and 30 or more procedures, respectively, per year. This paper now explores the relationship between the caseload and the outcome
based on the data from the Herniamed Registry.
Patients and methods: The prospective data of patients in the Herniamed Registry were analyzed using the inclusion criteria minimum age of 16 years, male patient, primary unilateral inguinal hernia, TEP or TAPP techniques and availability of data on 1-year follow-up. In total, 16,290 patients were enrolled between September 1, 2009, and February 1, 2014. Of the participating surgeons, 466 (87.6 %) had carried out fewer than 25 endoscopic/laparoscopic operations (low-volume surgeons) and 66 (12.4 %) surgeons 25 or more operations (high-volume surgeons) per year.
Results: Univariable (1.03 vs. 0.73 %; p = 0.047) and multivariable analysis [OR 1.494 (1.065–2.115);
p = 0.023] revealed that low-volume surgeons had a significantly higher recurrence rate compared with the highvolume surgeons, although that difference was small. Multivariable analysis also showed that pain on exertion was negatively affected by a lower caseload \25 [OR 1.191 (1.062–1.337); p = 0.003]. While here, too, the difference was small, the fact that in that group there was a greater proportion of patients with small hernia defect sizes may have also played a role since the risk in that group was
higher. In this analysis, no evidence was found that pain at rest [OR 1.052 (0.903–1.226); p = 0.516] or chronic pain requiring treatment [OR 1.108 (0.903–1.361); p = 0.326] were influenced by the surgeon volume.
Summary: As confirmed by previously published studies, the data in the Herniamed Registry also demonstrated that the endoscopic/laparoscopic inguinal hernia surgery caseload impacted the outcome. However, given the overall high-quality level the differences between a ‘‘low-volume’’ surgeon and a ‘‘high-volume’’ surgeon were small. That was due to the use of a standardized technique, structured
training as well as continuous supervision of trainees and surgeons with low annual caseload.
Keywords: Inguinal hernia, TEP, TAPP, Surgeon, volume, Outcome

Lundström KJ , Holmberg H, Montgomery A, Nordin P. Patient-reported rates of chronic pain and recurrence after groin hernia repair.
Abstract
Background: The effectiveness of different procedures in routine surgical practice for hernia repair  with respect to chronic postoperative pain and reoperation rates is not clear.
Methods: This was prospective cohort study based on a unique combination of patient-reported outcomes and national registry data. Virtually all patients with a groin hernia repair in Sweden between
September 2012 and April 2015 were sent a questionnaire 1 year after surgery. Persistent pain, defined as at least ‘pain present, cannot be ignored, and interferes with concentration on everyday activities in
the past week was the primary outcome. Reoperation for recurrence recorded in the register was the secondary outcome.
Results: In total, 22 917 patients (response rate 75⋅5 per cent) who had an elective unilateral groin hernia
repair were analysed. Persistent pain present 1 year after hernia repair was reported by 15⋅2 per cent of
patients. The risk was least for endoscopic total extraperitoneal (TEP) repair (adjusted odds ratio (OR)
0⋅84, 95 per cent c.i. 0⋅74 to 0⋅96), compared with open anterior mesh repair. TEP repair had an increased risk of reoperation for recurrence (adjusted OR 2⋅14, 1⋅52 to 2⋅98), as did open preperitoneal mesh repair (adjusted OR 2⋅34, 1⋅42 to 3⋅71) at 2⋅5-year follow-up. No other methods of repair differed significantly from open anterior mesh repair.
Conclusion: The risk of significant pain 1 year after groin hernia repair in routine surgical practice was
15⋅2 per cent. This figure was lower in patients who had surgery by an endoscopic technique, but at the
price of a significantly higher risk of reoperation for recurrence.

Köckerling F, Koch A and Lorenz R. (2019) Groin Hernias in Women
– A Review of the Literature.
Abstract
Background: To date, there are few studies and no systematic reviews focusing specifically on groin hernia in women. Most of the existing knowledge comes from registry data.
Objective: This present review now reports on such findings as are available on groin hernia in women.
Materials and Methods: A systematic search of the available literature was performed in September 2018 using Medline, PubMed, Google Scholar, and the Cochrane Library. For the present analysis 80 publications were identified.
Results: The lifetime risk of developing a groin hernia in women is 3–5.8%. The proportion of women in the overall collective of operated groin hernias is 8.0–11.5%. In women, the proportion of femoral hernias is
16.7–37%. Risk factors for development of a groin hernia in women of high age and with a positive family history.
A groin hernia during pregnancy should not be operated on. The rate of emergency procedures in women, at
14.5–17.0%, is 3 to 4-fold higher than in men and at 40.6% is even higher for femoral hernia. Therefore, watchful waiting is not indicated in women. During surgical repair of groin hernia in females the presence of a femoral hernia should always be excluded and if detected should be repaired using a laparo-endoscopic or open preperitoneal mesh technique. A higher rate of chronic postoperative inguinal pain must be expected in females.
Conclusion: Special characteristicsmust be taken into account for repair of groin hernia in women.
Keywords: groin hernia, women, femoral hernia, emergency, inguinal hernia

Kukleta JF (2019) Why I prefer TAPP repair for uncomplicated unilateral groin hernia in adults

My first choice of repair of an uncomplicated unilateral groin hernia of an adult person is the transabdominal preperitoneal patch technique—TAPP. Over the past 27 years, since I have started this minimal invasive repair, my conviction in making this choice became stronger and stronger, being nourished by the very good clinical outcomes and high patient’s satisfaction. Based on my personal experience TAPP is the logic of groin hernia repair