Trends in Emergent Groin Hernia Repair-An Analysis From the Herniamed Registry.

Introduction: While the proportion of emergency groin hernia repairs in developed countries is 2.5-7.7%, the percentage in developing countries can be as high as 76.9%. The mortality rate for emergency groin hernia repair in developed countries is 1.7-7.0% and can rise to 6-25% if bowel resection is needed. In this present analysis of data from the Herniamed Registry, patients with emergency admission and operation within 24 h are analyzed. Methods: Between 2010 and 2019 a total of 13,028 patients with emergency admission and groin hernia repairs within 24 h were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves. The total patient collective is broken down into the subgroups with pre-operative manual reduction (taxis) of the hernia content, operative reduction of the hernia content without bowel resection and with bowel resection. The explorative Fisher's exact test was used for statistical assessment of significant differences with Bonferroni adjustment for multiple testing. Results: The proportion of emergency admissions with groin hernia repair within 24 h was 2.7%. The percentage of women across the years was consistently 33%. The part of femoral hernias was 16%. The proportion of patients with pre-operative reduction (taxis) remained unchanged at around 21% and the share needing bowel resection was around 10%. The proportion of TAPP repairs rose from 21.9% in 2013 to 38.0% in 2019 (p < 0.001). Between the three groups with pre-operative taxis, without bowel resection and with bowel resection, highly significant differences were identified between the patients with regard to the rates of post-operative complications (4% vs. 6.5% vs. 22.7%; p < 0.0001), complication-related reoperations (1.9% vs. 3.8% vs. 17.7%; p < 0.0001), and mortality rate (0.3% vs. 0.9% vs. 7.5%; p < 0.001). In addition to emergency groin hernia repair subgroups female gender and age ≥66 years are unfavorable influencing factors for perioperative outcomes. Conclusion: For patients with emergency groin hernia repair the need for surgical reduction or bowel resection, female gender and age ≥66 years have a highly significantly unfavorable influence on the perioperative outcomes.

Open Intraperitoneal Onlay Mesh (IPOM) Technique for Incisional Hernia Repair.

In an Expert Consensus Guided by Systematic Review the panel agreed that for open elective incisional hernia repair sublay mesh location is preferred, but open intraperitoneal onlay mesh (IPOM) may be useful in certain settings. Accordingly, the available literature on the open IPOM technique was searched and evaluated. Material and Methods: A systematic search of the available literature was performed in July 2018 using Medline, PubMed, and the Cochrane Library. Forty-five publications were identified as relevant for the key question. Results: Compared to laparoscopic IPOM, the open IPOM technique was associated with significantly higher postoperative complication rates and recurrence rates. For the open IPOM with a bridging situation the postoperative complication rate ranges between 3.3 and 72.0% with a mean value of 20.4% demonstrating high variance, as did the recurrence rate of between 0 and 61.0% with a mean value of 12.6%. Only on evaluation of the upward-deviating maximum values and registry data is a trend toward better outcomes for the sublay technique demonstrated. Through the use of a wide mesh overlap, avoidance of dissection in the abdominal wall and defect closure it appears possible to achieve better outcomes for the open IPOM technique. Conclusion: Compared to the laparoscopic technique, open IPOM is associated with significantly poorer outcomes. For the sublay technique the outcomes are quite similar and only tendentially worse. Further studies using an optimized open IPOM technique are urgently needed.

Resection of Ileoinguinal and Ileohypogastric Nerves Combined with Gluing in Modified Lichtenstein Repair.

We conducted a cohort trial to investigate the relevance of resection of the ilioinguinal and iliohypogastric nerves in combination with mesh fixation with BioGlue™ (CryoLife® Inc., Kennsaw, Georgia) in modified Lichtenstein repair to the development of chronic pain and hernia recurrence.1 In all, 430 patients underwent Lichtenstein repair. In 247 patients the mesh was fixed by means of glue, and in 183 patients it was fixed with conventional sutures. In all cases the inguinal nerves N. ilioinguinalis and N. iliohypogastricus were located and resected after identification to prevent nerve reaction to the mesh. The pain intensity was measured with a numeric analogous scale (NAS) 24 hours after surgery. All complications were recorded with a follow-up of up to 5 years. There was a significantly lower pain intensity level in the gluing group compared with the suture group 24 hours after surgery (0.016 t test). The level was 3.8±2.4 in bilateral hernia and 3.3±2.1 in unilateral hernia in the gluing group. It was 4.7±3.3 in unilateral and 3.7±2.2 in bilateral hernia in the suture group. The cut-suture time was lower in the gluing group. There were no severe pain syndromes (NAS≥4) in the gluing group and only 1.1% in the suture group. There was a higher incidence of non-bacterial wound infections in the gluing group (3.6%) than in the suture group (1.1%). The rate of recurrence after 5 years amounted to 2.0% in the gluing group and 2.2% in the suture group. The technique of using BioGlue™ for mesh fixation combined with systematic nerve dissection reduces acute and chronic postoperative pain after modified Lichtenstein repair. Only 2 of 430 patients suffered from severe chronic pain. Combined gluing and systematic resection of the inguinal nerves is more comfortable than standard Lichtenstein repair.

Coating of mesh grafts for prolapse and urinary incontinence repair with autologous plasma: exploration stage of a surgical innovation.

PURPOSE: Optimized biocompatibility is a major requirement for alloplastic materials currently applied for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) repair. In the preliminary studies the mesh modification by coating with autologous plasma resulted in the increased adherence score in vitro and improved biocompatibility in an animal model. The first use of plasma coated meshes in human is presented. MATERIALS AND METHODS: Between 04/2013 and 05/2014, 20 patients with the indication for SUI and POP repair were selected in a single institution. The applied meshes were modified by autologous plasma coating prior to implantation. A retrospective chart review for peri- and early postoperative complications was performed. Functional outcome and QoL were evaluated pre- and postoperatively. RESULTS: The functional outcome and QoL improved significantly in all groups. Two reoperations (Grade IIIB) with the release of TVT-mesh in anesthesia due to the obstruction were needed. No other severe complications were registered. CONCLUSION: For the first time we applied a mesh modification in a human setting according to IDEAL criteria of surgical innovations. The procedure of mesh coating with autologous plasma is safe and a prospective randomized trial proving a positive effect of plasma coating on the biocompatibility and morbidity outcome with long-term registry is planned.

Postoperative vocal cord dysfunction despite normal intraoperative neuromonitoring: an unexpected complication with the risk of bilateral palsy.

BACKGROUND: Intraoperative neuromonitoring (IONM) has become standard practice in thyroid surgery for many surgeons. It reduces the risk of vocal cord palsy in high-risk patients and has led to two-stage operations to prevent bilateral palsies. The specificity of detecting nerve injuries is not 100 %, leading to patients with vocal cord dysfunction (VCD) despite regular neuromonitoring (false-negative IONM). We aimed to evaluate possible risk factors for this phenomenon and its importance regarding bilateral palsies. METHODS: We performed a retrospective analysis of all patients with false-negative IONM. RESULTS: A total of 2152 patients (3426 nerves at risk) underwent surgery for benign disease between January 2008 and October 2010. Sensitivity for predicting VCD was 85.4 % and specificity 99.0 %. The positive predictive value was 68.0 % and the negative predictive value 99.6 %. We were not able to identify risk factors for false-negative IONM. We found four patients with delayed occurrence of VCD after regular IONM (1-8 weeks). We registered two patients with bilateral VCD after false negative IONM on the first side of bilateral resections (2/7) and four patients with bilateral palsy after correct IONM (4/1256). The relative risk for bilateral VCD between patients with false-negative IONM on the primary resection side and patients with correct IONM was 89.7. CONCLUSIONS: Although seldom, false-negative IONM is of clinical importance as it bears a high risk of bilateral VCD if it occurs on the first side of a bilateral resection. It can also have a latent occurrence after surgery.

Functional long-term results after rectal cancer surgery--technique of the athermal mesorectal excision.

PURPOSE: The total mesorectal excision (TME), embedded in a multimodal therapeutic concept, is accepted as the standard therapy of the advanced adenocarcinoma of the middle and lower thirds. The thermal damages of the autonomous nerves in the little pelvis caused by dissection devices remains a large problem. For our patients, we use water-jet dissection (WJD)-aided TME with the intention to minimise the rate of bladder and sexual function disorders. METHODS: From October 2001 until June 2010, we recorded 125 patients with an adenocarcinoma of the middle and lower third of the rectum. Ninety deep anterior rectum resections and 35 abdominoperineal rectum extirpations by WJD were performed. Of the patients, 27.2 % received neoadjuvant radiochemotherapy. Bladder and sexual function disorders were assessed by International Prostate Symptom Score and International Index of Erectile Function. RESULTS: The median follow-up period was 46 (2-117) months. Considering a local recurrence rate of 9.6 %, the tumour-specific 5-year survival of the entire collective was 75.4 %. Long-term bladder function disorders showed in 6.0 % (4/64) and sexual function disorders in 25.0 % (9/36) of the male patients in the course of time. CONCLUSION: The specific advantage of the WJD technique is not only the facilitated dissection between the mesorectal fascia and the surrounding nervous structures in the little pelvis but also a completely athermal TME. The rate of bladder and sexual function disorders is an excellent result compared to that of international centres. Due to the size of the patient collective and the retrospective character of the study, further studies are necessary to validate the presented results.

Hedgehog-signaling is upregulated in non-producing human adrenal adenomas and antagonism of hedgehog-signaling inhibits proliferation of NCI-H295R cells and an immortalized primary human adrenal cell line.

Hedgehog (Hh)-signaling pathway is important in embryonic development. Activation of Hh-signaling is associated with tumorigenesis. Recent studies demonstrate that Hh-signaling is involved in the development of the adrenal gland in mice and is important in regulating adrenal proliferation. We studied the expression of Sonic hedgehog (SHH), Smoothened (SMO), Patched1 (PTCH1) and GLI family zinc finger 1 (GLI1) in human adrenal and in adrenocortical tumors using immunohistochemistry and semi-quantitative reverse transcriptase-polymerase chain reaction. Modulation of GLI1 and SMO messenger ribonucleic acid (mRNA) expression was investigated with forskolin. The role of Hh-signaling was studied in NCI-H295R cells and in an immortalized primary cell line using the Hh-agonist smoothened agonist (SAG) and the Hh-antagonist cyclopamine. The Hh-pathway components SHH, GLI1, PTCH1 and SMO were detectable in all adrenal glands. While in cortisol-producing adenomas (CPA), Hh-signaling expression levels were comparable to that in normal adrenal cortex, a much higher mRNA expression of GLI1, SMO and SHH was observed in non-producing adenomas (NPA). Interestingly, stimulation of cultured adrenal cells with forskolin led to a decrease in expression of GLI1 and SMO mRNAs. Antagonism of Hh-signaling resulted in a lower proliferation rate of adrenocortical cells, while Hh-agonism had no significant effect on adrenal cell proliferation. Our data show Hh-signaling activity in adult adrenal glands. Activation of the PKA pathway results in lower expression of Hh-signaling proteins. This might explain the lower expression of the Hh components GLI1 and SMO in CPA in comparison to the higher expression in NPA. Hh-signaling might be involved in the tumorigenesis of NPA.

Coating with autologous plasma improves biocompatibility of mesh grafts in vitro: development stage of a surgical innovation.

PURPOSE: To investigate mesh coating modalities with autologous blood components in a recently developed in vitro test system for biocompatibility assessment of alloplastic materials. MATERIALS AND METHODS: Seven different mesh types, currently used in various indications, were randomly investigated. Meshes were coated prior to cultivation with autologous peripheral blood mononuclear cells (PBMCs), platelets, and blood plasma. Pretreated meshes were incubated over 6 weeks in a minced tissue assay, representative for fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. Adherence of those tissues on the meshes was microscopically investigated and semiquantitatively assessed using a previously described scoring system. RESULTS: Coating with peripheral blood mononuclear cells did not affect the adherence score, whereas coating with platelets and blood plasma increased the score suggesting improved biocompatibility in vitro. The previous ranking of native meshes remained consistent after coating. CONCLUSION: Plasma coating of meshes improves their biocompatibility score in a novel in vitro test system.

Is the covering of the resection margin after distal pancreatectomy advantageous?

BACKGROUND: In recent years, many advances in pancreatic surgery have been achieved. Nevertheless, the rate of pancreatic fistula following pancreatic tail resection does not differ between various techniques, still reaching up to 30% in prospective multicentric studies. Taking into account contradictory results concerning the usefulness of covering resection margins after distal pancreatectomy, we sought to perform a systematic, retrospective analysis of patients that underwent distal pancreatectomy at our center. METHODS: We retrospectively analysed the data of 74 patients that underwent distal pancreatectomy between 2001 and 2011 at the community hospital in Neuss. Demographic factors, indications, postoperative complications, surgical or interventional revisions, and length of hospital stay were registered to compare the outcome of patients undergoing distal pancreatectomy with coverage of the resection margins vs. patients undergoing distal pancreatectomy without coverage of the resection margins. Differences between groups were calculated using Fisher's exact and Mann-Whitney U test. RESULTS: Main indications for pancreatic surgery were insulinoma (n=18, 24%), ductal adenocarcinoma (n=9, 12%), non-single-insulinoma-pancreatogenic-hypoglycemia-syndrome (NSIPHS) (n=8, 11%), and pancreatic cysts with pancreatitis (n=8, 11%). In 39 of 74 (53%) patients no postoperative complications were noted. In detail we found that 23/42 (55%) patients with coverage vs. 16/32 (50%) without coverage of the resection margins had no postoperative complications. The most common complications were pancreatic fistulas in eleven patients (15%), and postoperative bleeding in nine patients (12%). Pancreatic fistulas occurred in patients without coverage of the resection margins in 7/32 (22%) vs. 4/42 (1011%) with coverage are of the resection margins, yet without reaching statistical significance. Postoperative bleeding ensued with equal frequency in both groups (12% with coverage versus 13% without coverage of the resection margins). The reoperation rate was 8%. The hospital stay for patients without coverage was 13 days (5-60) vs. 17 days (8-60) for patients with coverage. CONCLUSIONS: The results show no significant difference in the fistula rate after covering of the resection margin after distal pancreatectomy, which contributes to the picture of an unsolved problem.

IDEAL in meshes for prolapse, urinary incontinence, and hernia repair.

PURPOSE: Mesh surgeries are counted among the most frequently applied surgical procedures. Despite global spread of mesh applying surgeries, there is no current systematic analysis of incidence and possible prevention of adverse events after mesh implantation. MATERIALS AND METHODS: Based on the recommendations of IDEAL an in vitro test system for biocompatibility of surgical meshes has been generated (Innovation). Coating strategies for biocompatibility optimization have been developed (Development). The native and modified alloplastic materials have been tested in an animal model over 2 years (Exploration and Assessment and Long-term study). RESULTS: In 3 meshes, implanted in sheep and explanted at 4 different time points (a, 3 months; b, 6 months; c, 12 months; and d, 24 months) over 24 months, thickness of inflammatory tissue (TVT a, 35 µm; b, 32 µm; c, 33 µm; d, 28 µm; UltraPro, a, 25 µm; b, 24 µm; c, 21 µm; d, 22 µm; PVDF a, 20 µm; b, 21 µm; c, 14 µm; d, 15µm), connective tissue (TVT a, 37 µm; b, 36 µm; c, 43 µm; d, 41 µm; UltraPro a, 33 µm; b, 32 µm; c, 40 µm; d, 38 µm; PVDF a, 25 µm; b, 22 µm; c, 22 µm; d, 24 µm), and macrophage infiltration (TVT a, 36%; b, 33%; c, 23%; d, 20%; UltraPro a, 34%; b, 28%; c, 25%; d, 22%; PVDF a, 24%; b, 18%; c, 18%; d, 16%) revealed comparable ranking characteristics at every time point after explantation. The in vivo performance of these meshes in a sheep model was predictable with a previously developed in vitro test system. Coating of meshes with autologous plasma prior to implantation seems to have a positive effect on the meshes biocompatibility. CONCLUSION: We have applied IDEAL criteria on a new innovation for surgical meshes. The results permit the generation of a ranking of currently available meshes with potential to optimize future meshes.

Cinacalcet effects on the perioperative course of patients with secondary hyperparathyroidism.

PURPOSE: Since its registration in 2004, the calcimimetic agent cinacalcet has been established as an alternative treatment for secondary hyperparathyroidism (SHPT). Working by allosteric activation of the calcium-sensing receptor, cinacalcet can lower parathyroid hormone (PTH) and calcium (Ca) in patients with SHPT. The influence of calcimimetics on the perioperative course has been unclear so far. METHODS: We retrospectively analyzed the data of patients with primary operation for SHPT between 2004 and 2011, comparing the perioperative course of patients with and without preoperative cinacalcet treatment. RESULTS: Fifty-six patients had cinacalcet therapy, and 54 patients had no calcimimetic medication prior to surgery. Gender, age, hemodialysis, and medical treatment were similar in both groups. Also, PTH levels were similar preoperatively and postoperatively (preoperative, 1,249 ± 676 vs. 1,196 ± 601 pg/ml; postoperative, 86 ± 220 vs. 62 ± 91 pg/ml). Patients with cinacalcet preoperatively had significant lower Ca levels preoperatively (2.49 ± 0.25 vs. 2.61 ± 0.24 mmol/l) and postoperatively (1.75 ± 0.37 vs. 1.86 ± 0.35 mmol/l) and had a higher rate of oral Ca substitution postoperatively (93 vs. 74 %). The risk for postoperative persistent disease was slightly higher in these patients compared to those without preoperative cinacalcet therapy (5 vs. 0 %, not significant). CONCLUSIONS: In our experience, cinacalcet did not alter the perioperative course in SHPT patients.

IONM-guided goiter surgery leading to two-stage thyroidectomy--indication and results.

PURPOSE: Intraoperative neuromonitoring (IONM) in thyroid surgery allows for changing the operative strategy during bilateral procedures to avoid bilateral recurrent laryngeal nerve palsy (RLNP). While this strategy is comprehendible for the surgeon, the question remains, whether it is always necessary. METHODS: Two thousand five hundred forty-six patients underwent surgery with IONM between January 2008 and October 2010 (4,012 nerves at risk). We performed a retrospective review of all patients after thyroid surgery. In 98 cases, signal loss occurred on the primary side. Of these patients, 64 required bilateral surgery. We proceeded with the contralateral surgery in 24 cases. Forty operations were ended unilaterally. The second operation was performed on 18 patients in total, 16 after confirmation of primarily intact (n = 8) or recovered vocal cord function (n = 8) and twice under persisting dysfunction. Patient satisfaction was evaluated using a five-point scale. RESULTS: We have shown a significant difference (p = 0.017) in the rate of bilateral RLNP when signal loss on the primary side resulted in termination of the procedure compared to continuation. Our evaluation of patient satisfaction did not show a significant difference when comparing the two-stage operation to other procedures. CONCLUSIONS: We have shown a significant difference in the rate of bilateral RLNP when comparing termination and continuation of a bilateral procedure after primary IONM signal loss. We strongly recommend a two-stage thyroidectomy after signal loss on the primary side of resection in benign bilateral goiter surgery.

Evaluation of Biocompatibility of Alloplastic Materials: Development of a Tissue Culture In Vitro Test System.

Optimized biocompatibility is a major requirement for alloplastic materials currently applied in surgical approaches for hernia, incontinence, and prolapse situations. Tissue ingrowth/adherence and formation of connective tissue seem to have important influence in mesh incorporation at the implant site. In an in vitro approach we randomly investigated 7 different mesh types currently used in surgeries with various indications with regard to their adherence performance. Using a tissue culture approach, meshes were incubated with tissue representative of fibroblasts, muscle cells, and endothelial cells originating from 10 different patients. After 6 weeks, the meshes were assessed microscopically and a ranking of their adherence performance was established. Tissue culture was successful in 100% of the probes. We did not remark on interindividual differences concerning the growth and adherence performance after incubation with the different meshes in the investigated 10 patients. The ranking was consistent in all patients. In this test system, PVDF Dynamesh® (FEG Textiltechnik, Aachen, Germany) was the mesh with the best growth-in score. The test system was feasible and reproducible. Pore size seems to be a predictor of adherence performance. The test system may be a helpful tool for further investigations, and the predictive value should be assessed in further in vitro and in vivo experiments.

Water-jet dissection in rectal cancer surgery: surgical and oncological outcomes.

UNLABELLED: These days the treatment of rectal cancer remains an encounter for various medical disciplines. A key position in the whole concept of therapy is still taken by surgery itself. To facilitate the advantages of the total mesorectal excision (TME) we used the water-jet dissector (WJD) in our surgical routine. Our object was to analyze perioperative data as well as oncological long-term results following WJD-assisted rectal resection. MATERIALS AND METHODS: A total of 226 patients underwent surgery for rectal cancer in our center between October 2001 and June 2009. A retrospective review was performed of all WJD-assisted rectal resections during this time. One hundred and five patients with adenocarcinoma of the lower and middle rectum were operated on by 7 surgeons according to the concept of TME. Seventy-six patients underwent a low anterior resection, 29 patients an abdominoperineal resection. Twenty-eight patients received preoperative radiochemotherapy. The median follow-up period amounted to 35 (2-96) months. Survival rates were calculated using the Kaplan-Meier method. RESULTS: Anastomotic leakage occurred in 5.7%, wound healing disturbance (including perineal wound infections) in 29.5%, intra-abdominal infections in 7.6% and urinary tract infections in 7.6%. Postoperative bladder dysfunction (requiring catheterization) occurred in 1.9%. Postoperative 30-day mortality was 0%, 60-day mortality 1%. The rate of local recurrence (including three patients who refused postoperative radiochemotherapy) was 8.5%. Cancer-specific survival at 5 years was 74% and differed significantly by stage. CONCLUSIONS: The particular advance of the WJD is the facile development of the embryological plane between the mesorectal fascia and the surrounding pelvic nerves. Without harming one of them, maximum radicality and excellent autonomic nerve preservation can be achieved. The WJD is a technique with acceptable postoperative morbidity and low mortality. Local control and survival are comparable to other surgical centers in international literature.

The impact of intraoperative neuromonitoring (IONM) on surgical strategy in bilateral thyroid diseases: is it worth the effort?

BACKGROUND: Intraoperative nerve monitoring (IONM) of the recurrent laryngeal nerve and the vagal nerve can detect nonfunctioning nerves (recurrent laryngeal nerve palsy, RLNP) that are visibly intact. The use of IONM is questionable, however, as we still lack evidence that it reduces the rate of postoperative nerve injuries. Since negative IONM results after thyroid dissection of the first side could change our surgical strategy and thus could prevent patients from bilateral RLNP, we questioned whether IONM results are reliable enough to base changes in surgical strategy and whether this has any effect on surgical outcome. METHODS: We retrospectively analyzed the data of 1333 consecutive patients with suggested benign bilateral thyroid disease who had been operated on under a defined protocol, including the use of a specific IONM technique (tube electrodes and stimulation of the vagal nerve and the inferior recurrent nerve before and after thyroid resection), between January 1, 2006 and December 31, 2008. RESULTS: In four patients the IONM system did not work, two nerves had not been found, and in eight patients the tube had to be readjusted. Of five permanent nerve injuries, four were visible during surgery and one was suspected. Sensitivity of IONM in detecting temporary nerve injuries of macroscopically normal-appearing nerves was 93%. Specificity was 75-83% at first side of dissection and 55-67% at the second side, with an overall specificity of 77%. In 11 of 13 patients (85%) with known nerve injury (preexisting or visible) and in 20 of 36 patients (56%) with negative IONM stimulation at the first side of dissection, the surgical strategy was changed (specific surgeon or restricted resection) with no postoperative bilateral RLNP. This was in contrast to 3 of 18 (17%) bilateral RLNP (p < 0.05), when surgeons were not aware of a preexisting or highly likely nerve injury at the first side of thyroid dissection. CONCLUSIONS: Failed IONM stimulation of the vagal or recurrent laryngeal nerve after resection of the first thyroid lobe is specific enough to reconsider the surgical strategy in patients with bilateral thyroid disease to surely prevent bilateral RLNP.

Less pain intensity after lichtenstein-repair by using BioGlue™ for mesh fixation.

A pre-trial was conducted to investigate the reliability of using the surgical adhesive, BioGlue™ (CryoLife®, Inc., Kennesaw, Georgia, USA) for mesh fixation in Lichtenstein repair of inguinal hernia. From February to August 2008, 60 patients with unilateral inguinal hernia underwent a Lichtenstein repair. In 30 of the patients, BioGlue™ was used for mesh fixation and in the other 30 cases a conventional suture was used. The patients were sorted into two groups (BioGlue™-group and suture-group). No differences were noted in demographic characteristics. The main criteria for dropout were incarceration, relapse, operation, and/or scrotal hernia. Twenty-four hours postoperative, pain intensity was measured with a numeric analogous scale (NAS) that reached from 0 (no pain) to 10 (heavy pain). The pain intensity in the BioGlue™-group was 2.4 points and 4.3 points in the suture-group. The cut-suture time was 30 minutes in the BioGlue™-group and 56 minutes in the suture-group. In the first nine months, no relapses, no mesh infections, nor serom-formations were reported; however, one superficial wound infection did occur in the BioGlue™-group. Lichtenstein-repair using BioGlue™ for mesh-fixation is a safe, new method without early recurrences and less pain-intensity in relation to suture-supported Lichtenstein repair.

Does multiple gland disease in primary hyperparathyroidism correlate with age or sex?

PURPOSE: Paediatric primary hyperparathyroidism (PHPT) patients suffer more often from multiple gland disease (MGD) than adults. The question occurs whether MGD in adult PHPT patients also correlates with age or sex and whether familial PHPT plays a decisive role. This is significant, as it would influence our decision for a focused approach or the bilateral cervical exploration. MATERIALS AND METHODS: We retrospectively analysed 465 consecutive PHPT patients who underwent surgery in our department between September 2001 and December 2008. RESULTS: PHPT patients aged 40 years or younger suffered significantly more often from MGD than older patients (22.9% versus 11.0%). If familial PHPT disorders, which were more common in young patients, were excluded, the divergence between these two groups vanished (12.5% versus 10.0%). There was no statistical significant difference in the frequency of MGD between men (12.2%) and women (12.3%). CONCLUSIONS: If familial PHPT can be ruled out, the frequency of MGD in adult PHPT patients does not correlate with age or with sex. Therefore, age and sex do not imply specific surgical approaches in adult PHPT patients.