[Show abstract][Hide abstract] ABSTRACT: Selection of an optimal surgical technique for inguinal hernia repair, allowing safe performance and rapid recovery without long-term complaints, may contribute significantly to the reduction of national health care costs.
An analysis of current literature regarding surgical techniques, properties of modern meshes, operative complications, recurrence rates, occurrence of chronic pain, and quality of life after different surgical procedures was made. Evidence-based comparisons of suture and mesh techniques of open mesh and laparoscopic mesh repair and of laparoscopic (TAPP) and endoscopic (TEP) operation were made.
Recurrence rates after mesh implantation are significantly lower than after suture repair. Recurrence rates after flat open mesh repair are similar to those of laparoscopic techniques, but there is a significantly faster recovery after laparoscopy, and chronic pain is also present less frequently. Both TAPP and TEP are acceptable treatment options, but there is insufficient evidence to show superiority of one technique over the other. Material-reduced meshes seem to have advantages, at least during the early postoperative period. Besides the properties of the mesh implanted, the surgical technique applied and the skills of the surgeon performing the operation are the most important factors for achieving optimal and cost-efficient results.
With regard to recovery and occurrence of chronic pain, TAPP and TEP are superior to open mesh repair in most cases. Greater efforts should be undertaken to make laparoscopic repair easier, safer, and less expensive. If this can be achieved, health care costs could ultimately be reduced.
Langenbeck s Archives of Surgery 11/2011; 397(2):271-82. · 1.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Today the main goals of inguinal hernia repair are maximum postoperative comfort and a minimal rate of chronic pain. This randomized trial compares these parameters after laparoscopic hernia repair (TAPP) using an extralight titanized polypropylene mesh (ELW group) TiMesh(®) 16 g/m(2) without any fixation with those using a standard heavyweight mesh (HW) Prolene 90 g/m(2) fixed in a standardized way with two absorbable sutures.
Three hundred patients with an inguinal hernia and a defect diameter ≤3 cm were included in the trial. Patients were assessed for pain, foreign body sensation, and physical activities preoperatively, early postoperatively, at 4 weeks, 6 months, and 1 year by questionnaire and were examined clinically. Postoperatively, seroma formation was measured by ultrasound.
One year after TAPP, the frequency of chronic pain was not greater than 3%, with no difference between the two mesh groups; in no patient was intensity of pain higher than VAS 40. In the early postoperative period, 40% of the patients in the titanized ELW group needed pain medication compared with 52.7% in the HW group (P = 0.0378). Foreign body sensation was not different between the groups but there was significantly less impairment of physical activities (P = 0.0425) and seroma production (P = 0.0415) in the titanized ELW group compared to the HW group in the early postoperative period.
Use of titanized ELW mesh for laparoscopic hernia repair did not affect the rate of chronic pain but it seems to improve early postoperative convalescence. Its use without any fixation can be recommended in TAPP for inguinal hernia patients with a defect size ≤3 cm.
World Journal of Surgery 05/2011; 35(8):1791-7. · 2.23 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A low rate of chronic pain and maximum postoperative comfort are the main goals today in inguinal hernia repair. This four-arm randomised trial compares these parameters after laparoscopic hernia repair (TAPP) with a standard heavyweight mesh (HW), a pure middleweight polypropylene mesh (MW), a lightweight composite polypropylene mesh (LW), or a titanised lightweight mesh (TLW). The primary endpoint of the study was the incidence of chronic pain of any severity at the site of hernia repair at 1 year.
A total of 600 patients with a laparoscopic inguinal hernia repair and a defect diameter of 3-5 cm were included in the trial. In all patients, a non-invasive mesh fixation technique was performed using fibrin glue. Patients were assessed for pain, foreign body sensation, and physical activities preoperatively, early postoperatively, at 4 weeks, at 6 months, and at 1 year by questionnaire, and were examined clinically. Postoperatively, seroma formation was measured by ultrasound.
At 1 year after TAPP, frequency of pain did not differ statistically between the four groups (depending on type of activity: between 6-8% with HW mesh, 2-4% with middleweight mesh, and 2-4.7% with both lightweight meshes); average intensity of pain was very low, at between VAS 0.4 ± 3.1 and 1.5 ± 7.8 (MW, LW, TLW) and between 1.9 ± 8.6 and 2.3 ± 9.1 (HW) depending on activity (n.s.). Early postoperatively between 31.3% (LW) and 21.3% (TLW) of the patients needed pain medication (n.s.); at 1 year this percentage had dropped to 0.3% (one HW, one MW). Foreign body sensation did not differ but impairment of physical activities (P = 0.0437) was significantly less in the MW, LW, and TLW group (6-12.7%) compared to HW (15.3%) at 4 weeks; at 1 year this percentage was between 0 and 1.3% (n.s.).
Compared to HW mesh, the use of MW, LW, and TLW meshes for laparoscopic hernia repair did not significantly affect rate of chronic pain, but seemed to improve early postoperative convalescence. No difference was found between middleweight pure polypropylene (MW), composite lightweight (LW), or titanised lightweight polypropylene (TLW) meshes.
[Show abstract][Hide abstract] ABSTRACT: Diagnostic and treatment of rectal cancer need a continuous quality assessment. Indicators of quality were compiled as indicator profile for a summarizing evaluation. The indicators selected should potentially show an appreciable variation of the quality target and in addition should be decisive for the outcome. For the evaluation of the clinical diagnostic the frequency of the determination of the pretherapeutic T, N and M categories and the proportion of pT 1-tumors were chosen, for the pathological diagnostic the number of histologically examined lymph nodes and the proportion of lymphnode positive patients. Process quality of treatment was defined by the following indicators: proportion of tumor excision, of definite therapy by local tumor removal, of neo-adjuvant long-term radiochemotherapy, of adjuvant treatment in patients not selected for neoadjuvant therapy, of total / partial mesorectal excision, of abdomino-perineal resection, postoperative mortality, frequency of clinically apparent anastomotic leakage, and of neurogenic bladder dysfunction at hospital discharge. The indicators for the quality of the performance of treatment were differentiated between surrogate indicators that can be determined immediately after accomplishment of primary surgical therapy giving strong clues for the further course of disease at an early date, and definite indicators. Important surrogate indicators comprise the occurrence of intraoperative local tumor cell dissemination, R 1 / 2-resection, pathohistologically CRM-positive tumor resection, and the quality of mesorectal excision (proportion of incomplete mesorectal excision). The definite indicators include the 5-year local recurrence rate and the 5-year overall survival rate. The corresponding quantifying parameters for the individual indicators are specified in this paper with precise figures.
Zentralblatt für Chirurgie 05/2007; 132(2):85-94. · 0.69 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The prevalence of sigmoid diverticular disease is increasing in western, industrialised countries. Practice parameters recommend surgical treatment for complicated disease or after the second episode of chronic recurrent disease. Surgical intervention should also be considered for younger patients after a first episode severe enough to require treatment. The preferred surgical procedure is elective sigmoid resection with primary anastomosis. Additional resection of the lower colon descendens is necessary when this region is also affected. Two-stage surgery is recommended for patients in emergency situations, i. e. severe or generalized peritonitis or extensive localized abscess formation, especially when the treating hospital is non-specialized. Segmentary resection without anastomosis and Hartmann's procedure is performed first (blind closure of the rectum with terminal colostomy). Restoration of colorectal continuity is performed at the earliest three months postoperatively. The preferred surgical technique is laparoscopy, provided the surgeon has the necessary expertise. Numerous studies have proven significant advantages of laparoscopy, although it is a completely new procedure with a long learning curve of 50-60 operations. Therefore, conversion to the conventional method should not be seen as a personal failure but rather as a responsible decision in favor of the patient's well-being.
[Show abstract][Hide abstract] ABSTRACT: The goal of our study was to evaluate the morphine-sparing effect of nonsteroidal anti-inflammatory drugs (NSAIDs) following both conventional and laparoscopic colon surgery.
In this prospective, randomized clinical trial, 180 patients were assigned to three groups. Two groups received either paracetamol or parecoxib/valdecoxib in addition to piritramid via patient-controlled or nurse-controlled analgesia pump. Patients in the control group received piritramid only. The total piritramid consumption during hospital stay was recorded.
Total opioid consumption was significantly lower in the two groups who received NSAIDs. Comparing conventional and laparoscopic surgery, the latter group had much lower opioid consumption.
The use of NSAIDs following colon surgery significantly reduces postoperative opioid consumption.
Der Chirurg 11/2006; 77(10):913-8. · 0.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic hernioplasty is assessed as a difficult operation. Operative technique determines the frequency of complications, the time of recovery and the rate of recurrences. A proper technique is absolutely necessary to achieve results that are superior to open hernia surgery.
The key points in our technique are 1) use of nondisposable instruments; 2) use of blunt trocars, consisting of expanding and non-incisive cone-shaped tips; 3) spacious and curved opening to the peritoneum, high above all possible hernia openings; 4) meticulous dissection of the entire pelvic floor; 5) complete reduction of the hernial sac; 6) wide parietalization of the peritoneal sac, at least down to the mid of psoas muscle; 7) implantation of a large mesh, at least 10 cm × 15 cm; 8) fixation of the mesh by clip to Cooper's ligament, to the rectus muscle and lateral to the epigastric vessels, high above the ileopubic tract; 9) the use of glue allows fixation also to the latero-caudial region; and 10) closure of the peritoneum by running suture.
With this technique in 12,678 hernia repairs, the following results could be achieved: operating time - 40 min; morbidity - 2.9%; recurrence rate - 0.7%; disability of work - 14 days. In all types of hernias (recurrence after previous open surgery, recurrence after previous preperitoneal operation, scrotal hernia, hernia in patients after transabdominal prostate resection), similar results could be achieved.
Laparoscopic hernia repair can be performed successfully in clinical practice even by surgeons in training. Precondition for the success is a strictly standardized operative technique and a well-structured educational program.
Journal of Minimal Access Surgery 09/2006; 2(3):155-9.
[Show abstract][Hide abstract] ABSTRACT: Ziel unserer Studie war es, die analgetische Wirkung verschiedener Nichtopioidanalgetika anhand der zu erzielenden Reduktion des Opioidbedarfs nach konventioneller und laparoskopischer Kolonchirurgie zu evaluieren.In einer prospektiv randomisierten 3-armigen Studie erfassten wir insgesamt 180 Patienten. Die Patienten erhielten Paracetamol bzw. Parecoxib/Valdecoxib als periphere Basisschmerzmedikation und zusätzlich über eine PCA-Pumpe oder auf peripherer Station durch die Schwester Piritramid. Die Patienten im Kontrollarm erhielten nur Piritramid. Gemessen wurde der Gesamtbedarf an Piritramid während des stationären Aufenthaltes.Bei Basisschmerztherapie mit den genannten Nichtopioiden konnten wir eine signifikante Reduktion des Opioidbedarfs erreichen. Vergleicht man die laparoskopische mit der konventionellen Operationsmethode, so verbrauchten die laparoskopisch operierten Patienten deutlich weniger Opioide.Durch eine Basisschmerztherapie mit Nichtopioiden kann der Gesamtopioidbedarf signifikant reduziert werden.
[Show abstract][Hide abstract] ABSTRACT: We performed a scientific evaluation of the efficacy of different surgical techniques for inginual hernia repair and supported our findings by conducting a systematic review of randomized studies comparing endoscopic with open nonmesh suture techniques.
After an extensive search of the literature, a total of 27 studies (41 publications) with evidence level lb were identified. These studies randomly compared endoscopic with open nonmesh suturing techniques. The quality of data sufficed to enable a quantitative meta-analysis of various parameters using the original software of the Cochrane Collaboration. Due to its superiority in comparison to other open nonmesh suturing techniques, the Shouldice repair technique was analyzed separately.
The systematic comparison of endoscopic techniques with the Shouldice repair showed that these techniques had significant advantages in terms of the following parameters: total morbidity, hematoma, nerve injury, and pain-associated parameters such as time to return to work, and chronic groin pain. The Shouldice operation has the advantages of a shorter operating time and a lower incidence of wound seroma. There was no difference regarding the incidence of major complications, wound infection, testicular atrophy, or hernia recurrence. Open non-Shouldice suturing techniques are associated with higher recurrence rates and more wound infections than endoscopic operations.
In comparison to open nonmesh suture repair techniques, endoscopic repair techniques have significant advantages in terms of pain-associated parameters. For the revaluation of long-term complications such as hernia recurrence and chronic groin pain, further clinical examination of the existing study collectives is needed.
[Show abstract][Hide abstract] ABSTRACT: Of various endoscopic hernia repair procedures, TAPP and TEP have been selected for routine use.
Results from Medline research were analysed.
There is a similar risk for postoperative morbidity for both techniques. The recurrence rate in large single-centre series is between 0% and 3.4%. There were numerous indications for both procedures, whereby a transperitoneal TAPP can also be applied in cases of previous preperitoneal operations.
Randomised trials comparing both methods of hernia repair are lacking. Seven non-randomised studies showed no differences in recurrence rate and morbidity. In general the learning curve for is shorter in favour of TAPP repair.
Langenbeck s Archives of Surgery 05/2005; 390(2):77-82. · 1.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: For the scientific evaluation of the endoscopic and open mesh techniques for the repair of inguinal hernia, meta-analyses of randomized controlled trials (RCT) are necessary. The Lichtenstein repair is one of the most common open mesh techniques and therefore of special interest.
After an extensive search of the literature and a quality assessment, a total of 34 RCT comparing endoscopic procedures both transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP)--with various open mesh repairs were deemed to be suitable for a formal meta-analysis of the relevant parameters. These studies included data for 7,223 patients. Trials that used the Lichtenstein repair for the control group (23 of 34 trials) were analyzed-separately.
Significant advantages for the endoscopic procedures compared with the Lichtenstein repair include a lower incidence of wound infection (Peto odds ratio, 0.39; 95% confidence interval, 0.26, 0.61), a reduction in hematoma formation (0.69 [0.54, 0.90]) and nerve injury (0.46 [0.35, 0.61]), an earlier return to normal activities or work (-1.35[-1.72, -0.97]), and fewer incidences of chronic pain syndrome (0.56[0.44, 0.70]). No difference was found in total morbidity or in the incidence of intestinal lesions, urinary bladder lesions, major vascular lesions, urinary retention and testicular problems. Significant advantages for the Lichtenstein repair include in a shorter operating time (5.45[1.18, 9.73]), a lower incidence of seroma formation (1.42[1.13, 1.79]), and fewer hernia recurrences (2.00[1.46, 2.74]). Similar results are seen when endoscopic procedures are compared with other open mesh repairs. However, in this comparison, total morbidity was lower with the endoscopic operations (0.73[0.61, 0.89]). The incidence of seroma formation, chronic pain syndromes, and hernia recurrence was not significantly different.
Endoscopic repairs do have advantages interms of local complications and pain-associated parameters. For more detailed evaluation further well-structured trials with improved standardization of hernia type, operative technique, and surgeons' experience are necessary.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to examine the advantages and risks of the Automated Endoscopic System for Optical Positioning (AESOP) 3000 robot system during uncomplicated laparoscopic cholecystectomies or laparoscopic hernioplasty.
In a randomized study, we examined two groups of 120 patients each with the diagnosis cholecystolithiasis respectively the unilateral inguinal hernia. We worked with the AESOP 3000, a robotic arm system that is voice-controlled by the surgeon. The subjective and objective comfort of the surgeon as well as the course and length of the operation were measured.
The robot-assisted operations required significantly longer preparation and operation times. With regard to the necessary commands and manual camera corrections, the assistant group was favored. The same was true for the subjective evaluation of the surgical course by the surgeon.
Our study showed that the use of AESOP during laparoscopic cholecystectomy and hernioplasty is possible in 94% of all cases. The surgeon must accept a definite loss of comfort as well as a certain loss of time against the advantage of saving on personnel.
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic cholecystectomy today is the standard operation for all gall stone disease. Nevertheless, a number of questions are still being discussed: What are the optimal steps? Or, more important, is the laparoscopic technique really superior to the open procedure according to the criteria of evidence-based medicine? How should we proceed in case of an occult choledocholithiasis? Is intraoperative cholangiography mandatory, and does the concept for the treatment of silent gall stones need to be revised in the era of laparoscopic cholecystectomy?
Eleven randomised studies show the superiority of the laparoscopic technique. Only one study shows no advantage provided the length of the incision in the open procedure is less than 8 cm. According to our own experience, up to 98% of all gall bladders can be removed laparoscopically when following the described standard technique, with a conversion rate of less than 1%. In the case of an occult choledocholithiasis the concept of "therapeutic splitting" has proved successful; the risk of a residual stone is below 1%. Routine intraoperative cholangiography is not cost effective. The risk of complications for a silent gall stone in the long term is higher than for laparoscopic cholecystectomy in young patients with incidental gall stones.
The laparoscopic technique has given new impulses to the surgery of the gall bladder and has proven to be an effective, patient-friendly alternative to open surgery.
Langenbeck s Archives of Surgery 07/2004; 389(3):157-63. · 1.89 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There is consensus that symptomatic cholecystolithiasis presents an indication for cholecystectomy. Today the surgical method of choice is the laparoscopic technique, which has proven its superiority in numerous randomized studies. Epidemiologic studies showed that 10-15% of all gallstone patients develop complications so that a prophylactic cholecystectomy is repeatedly being discussed. A few older studies based on conventional cholecystectomies, however, showed no decisive advantage for a prophylactic cholecystectomy, but rather clearly higher costs. Therefore a wait-and-see policy is generally recommended for asymptomatic gallstones. The analysis of our large group of patients showed that acute cholecystitis as well as common bile duct stones occur significantly more often with increasing duration of the gallstone disease. The older the patient, the longer the operation time, the more frequent a conversion, and the higher the morbidity of the procedure. Considering the minor impairment of daily activities with the laparoscopic technique, the present concept of treatment for asymptomatic and mildly symptomatic cholecystolithiasis needs to be scrutinized.
Der Internist 02/2004; 45(1):8-15. · 0.33 Impact Factor