[Laparoscopic Herniotomia and Closure in Case of Appendicitis within the Hernia Sac (Amyand's hernia): Is Use of Mesh Contraindicated?] / Laparoskopischer Bruchlückenverschluss bei Appendizitis im Leistenhernienbruchsack (Amyand-Hernie): Ist der Einsatz eines Netzes kontraindiziert?

Amyand's hernia is defined as an appendix vermiformis - inflamed or not - within the hernia sac at the ipsilateral groin. The occurrence of this specific type of hernia is extremely low; clinical presentation is preoperatively characterised by signs and symptoms of an incarcerated inguinal hernia. There is a controversial debate on the use of prosthetic material for mesh-based hernioplasty; actually, the majority of surgeons reject it. However, in the area of predominantly prosthetic hernioplasty, this question has been raised again. Based on the approximately 150 published cases so far and their detailed analysis, this controversial issue in Amyand's hernia is reassessed, also on the basis of our own clinical experience in the treatment of two representative cases. Even in the case of a coincident finding of appendicitis within the sac of an inguinal hernia, laparoscopic hernioplasty using alloplastic meshes appears possible after simultaneous appendectomy if, in addition, the adhesive hernia sac is also resected. If prosthetic material is implanted, only low weight and large-porous meshes should be used.

Factors influencing the quality of total mesorectal excision.

BACKGROUND: Total mesorectal excision (TME) has become the standard of care for rectal cancer. Incomplete TME may lead to local recurrence. METHODS: Data from the multicentre observational German Quality Assurance in Rectal Cancer Trial were used. Patients undergoing low anterior resection for rectal cancer between 1 January 2005 and 31 December 2009 were included. Multivariable analysis using a stepwise logistic regression model was performed to identify predictors of suboptimal TME. RESULTS: From a total of 6179 patients, complete data sets for 4606 patients were available for analysis. Pathological tumour category higher than T2 (pT3 versus pT1/2: odds ratio (OR) 1.22, 95 per cent confidence interval 1.01 to 1.47), tumour distance from the anal verge less than 8 cm (OR 1.27, 1.05 to 1.53), advanced age (65-80 years: OR 1.25, 1.03 to 1.52; over 80 years: OR 1.60, 1.15 to 2.22), presence of intraoperative complications (OR 1.63, 1.15 to 2.30), monopolar dissection technique (OR 1.43, 1.14 to 1.79) and low case volume (fewer than 20 procedures per year) of the operating surgeon (OR 1.20, 1.06 to 1.36) were independently associated with moderate or poor TME quality. CONCLUSION: TME quality was influenced by patient- and treatment-related factors.

[Meshes in abdominal wall surgery - an overview]. / Prothetische Materialien in der Bauchwandchirurgie - ein Überblick.

Abdominal wall surgery and hernia repair is nowadays not conceivable without the use of mesh prosthetics. There are countless products from various health-care companies available. This article gives an overview of meshes currently in use, describes their characteristics and indicates the relevant differences between the various groups of implants.

[Acute abdomen in a patient with ANCA-associated vasculitis]. / Akutes Abdomen bei ANCA-Assoziierter Vaskulitis.

HISTORY AND FINDINGS: A 49-year-old man complained of increasing pain in the lower left abdomen. Three weeks previously joint pain had developed, and in the last 7 days the patient had noted a cutaneous rash at the lower legs. Within three days after admission a paralytic ileus developed, progressed and culminated in a small bowel perforation. In the 60 cm ileum specimen as well as in the skin lesions there was marked intra- und perivascular infiltration with neutrophil granulocytes and focal necrosis, but no granuloma. DIAGNOSIS, TREATMENT AND COURSE: As the proteinase 3 subtype of antineutrophil cytoplasmic antibodies (ANCA) was positive ANCA-associated vasculitis with gastrointestinal, cutaneous and kidney involvement was diagnosed. After initiation of cytostatic treatment with methylprednisolone boli und cyclophosphamide the patient's condition improved. The post-operative course was uneventful. CONCLUSION: ANCA-associated vasculitis rarely presents with severe gastrointestinal complications. The disease represents an interdisciplinary challenge because of its variable clinical presentation and the possibly lethal outcome if not adequately treated.

[Peritoneal splenosis 26 years after traumatic splenic rupture--rare differential diagnosis of a subepithelial gastric mass--case report and review of the literature]. / Peritoneale Splenose 26 Jahre nach traumatischer Milzruptur--seltene Differenzialdiagnose eines submukösen Magentumors--Fallbericht und Literaturübersicht.

Differential diagnoses of subepithelial gastric masses include benign (leiomyoma, lipoma, haemangioma, lymphangioma, neurogenic tumours, glomus tumour) and malignant (leiomyosarcoma, gastric Kaposi's sarcoma, metastases) neoplastic lesions, gastrointestinal stromal tumours (GIST) and lesions of non-neoplastic origin (heterotopic pancreatic tissue, intramural pseudocysts, intramural haematoma). Occasionally, however, suspected gastric wall tumours are caused by extragastral lesions that are not always easily distinguished from genuine gastric wall lesions by endoscopy or radiological imaging. We report the case of a 77-year-old patient undergoing laparoscopy for suspected gastric GIST in our institution in whom splenectomy had been performed 26 years prior to presentation due to traumatic splenic rupture. The tumour revealed to be ectopic splenic tissue located at the parietal peritoneum of the ventral abdominal wall, thereby fulfilling the definition of splenosis. Epidemiology, pathogenesis, diagnostics and therapy of splenosis are discussed in the context of a review of the relevant literature.

[Quality evaluation in colorectal surgery in dependence on health-care categories of hospitals - minor differences in outcome with room for improvement in process quality]. / Qualität der Kolorektalchirurgie in Abhängigkeit von der Versorgungsstufe - geringe Unterschiede in der Ergebnisqualität bei Verbesserungspotenzial in der Prozessqualität leisten der Zertifizierung an deutschen Krankenhäusern Vorschub.

BACKGROUND: In the present study, different variables focusing on quality of colorectal surgery were investigated with respect to hospital categories: university hospital - U; hospital with maximum care responsibility (with a full spectrum of medical disciplines) - M; secondary care hospital with central regional responsibility (6-9 departments) - S; primary care hospital with local responsibility (2-5 departments) - G; The primary goal of this study was to analyse the current standard of care in patients with colorectal carcinoma in Germany. METHODS: From 2000-2004, data of 47 435 patients with colorectal cancer were evaluated, using data compiled in the German multi-centred observational study "Colon/Rectal Carcinoma". Analysis was performed for all variables with respect to hospital categories. Due to the remarkable number of patients, differences between the groups were to be regarded as significant if p<0.01. RESULTS: Preoperative colonoscopy (U: 70.1% M: 70.4% S: 67.9% G: 67.2) and preoperative determination of serum tumour markers (U: 83.8% M: 80.1% S: 81.9% G: 77.1) mainly indicate the quality of gastroenterological work-up before surgical intervention. In general, standards established by the "German Cancer Association" were not met and showed significantly lower rates for primary and secondary care hospitals. In contrast, variables indicating quality of perioperative course and outcome: rate of anastomotic leak (U: 2.1% M: 2.8% S: 2.1% G: 3.1%), rate of surgical intervention (U: 4.3% M: 3.1% S: 3.5% G: 3.1%) and mortality rate (U: 4.4% M: 2.2% S: 3.5% G: 4.1%) were in accordance with the requirements and did not differ significantly between all groups. However, an analysis of surgical and histopathological process quality (complete histology: U: 96.3% M: 93.6% S: 91.9% G: 90.9%) revealed significant differences with results being significantly lower for primary care hospitals. CONCLUSION: There is in principle no necessity to centre colorectal surgery in tertiary care hospitals as quality parameters focusing on results and outcome are comparable. However, in primary care hospitals, there are deficits with regards to process quality. Therefore, all measures aiming to enhance in particular process quality, i. e., hospital certification or participation with quality assurance studies, are highly desirable to further improve patient care.

[Revision after failed bariatric surgery--review of complications and current therapeutic options]. / Revisionseingriffe nach bariatrischen Operationen--Uberblick über Komplikationsspektrum und derzeitige therapeutische Optionen.

BACKGROUND: Obesity is increasing worldwide at an alarming rate. Particularly in Western countries, obesity and related problems have become a serious medical problem and an enormous socio-economic burden. DISCUSSION: Currently, surgery is the only avail-able treatment for patients with severe obesity which leads to sustained weight loss and cure of co-morbidities in the majority of the patients. The increase in the number of bariatric operations and the occasional failure and complications of these surgical procedures have resulted in an increased need for revision surgery. Overall, 10-25 % of patients are expected to need a revision for failure of the primary bariatric procedure. The main indications for revision procedures are inadequate weight loss, surgery-related complications as well as surgical emergencies and long-term complications caused by malnutrition or -vitamin deficiencies. Unfortunately, there are currently no randomised trials to answer the question as to which operation should be performed in which patient and after which procedure. Decisions are often influenced by the expertise and preference of the operating surgeon as well as by patient's preference. Thus, a systematic review of published data to this complex issue appears to be helpful and important for daily surgical practise. CONCLUSIONS: Revision bariatric procedures are technically more complex and associated with increased postoperative complications. These operations should basically be performed in centres with profound expertise in this field of surgery, and - whenever possible - laparoscopically. However, every abdominal surgeon should be able to diagnose and treat some acute complications. After failed restrictive procedures, revision is recommended only in cases of complications but with adequate weight loss at the time of failure. Otherwise, conversion to combined procedures should be considered. After the failure of combined procedures, further weight loss or successful treatment of complications can be achieved by adding more restriction and/or malabsorption components. The latter is associated with an increased risk of nutritional sequelae.

Palliative stoma creation: comparison of laparoscopic vs conventional procedures.

BACKGROUND: The creation of a stoma is an established therapeutic concept for the palliation of non-resectable rectal carcinomas and advanced tumours infiltrating the pelvis. MATERIALS AND METHODS: In two prospective country-wide multicentre studies, each conducted over a similar period of time, the peri-operative course and postoperative short-term outcomes of laparoscopic vs laparotomy-based stoma construction were compared. RESULTS: A total of 90 patients underwent palliative laparoscopic construction; 550 patients received a stoma via a laparotomy. The intra-operative complication rate was lower after open surgery than after laparoscopic surgery (2.7 vs 5.6%; p = 0.15), although the difference was not significant. With regard to general (30.9 vs 15.6%; p = 0.003) and also specific postoperative complications (13.8 vs 5.6%; p = 0.029), however, a significant advantage of the laparoscopic approach was seen. Furthermore, mortality in the laparoscopic group was also significantly lower (4.4 vs 14.0%; p = 0.011). CONCLUSION: Palliative stoma done via laparoscopy had significantly better outcomes in terms of postoperative morbidity and mortality in comparison with the open surgical procedure.

[Endoscopic treatment of mediastinal anastomotic leaks]. / Endoskopische Therapieoptionen bei mediastinaler Anastomoseninsuffizienz.

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic anastomotic leaks are often associated with poor results and carry a high morbidity and mortality. This report describes our results with the endoscopic treatment of intrathoracic anastomotic leakages. PATIENTS: 27 consecutive patients presenting with clinically apparent intrathoracic anastomotic leak, caused by resection of an epiphrenic diverticulum (n=1), esophagectomy for esophageal cancer (n=19), limited resection for carcinoma of the gastroesophageal junction (n=1) or gastrectomy for gastric cancer (n=6) were endoscopically treated. The extent of the dehiscences ranged from about 10-70%. After endoscopic lavage and debridement of the leakage (mean duration: 16,8 days) the leaks were closed with fibrin clue (n=9) or endoclips (n=2) in cases of smaller leaks or by stent placement (n=11), stent placement after unsuccessful fibrin clue injections (n=3) or stent placement and endoclipping (n=1) in patients with a large leakage. Simultaneously the periesophageal mediastinum was drained by chest drains. RESULTS: 25 of 27 patients were successfully treated endoscopically. Under endoscopic treatment one patient died due to septic multiorgan failure. Another patient developed a refractory, persistent leak. Procedure related complications (stent migration, anastomotic stenosis) were obtained in 6 patients. CONCLUSION: An endoscopic approach is successful and safe to treat symptomatic intrathoracic anastomotic leaks smaller than 70% of the circumference. An endoscopic lavage and debridement of the leak, prior to leak closure, seems to be helpful to reduce mediastinal and pleural inflammation. In patients with smaller leaks (<30%) fibrin clue injections and endoclipping is recommended. Patients with a dehiscence from 30-70% of the circumference profit from stent placement.

Oncologic surgery: the advantages and disadvantages of minimally invasive surgery.

For the last 15 years, the minimalized traumatization of laparoscopic surgical procedures has changed the treatment of numerous diseases. As a result, the method has also become an interesting therapeutic alternative for oncological indications, too. Nevertheless, its use in the special field of oncology, in particular when applied in curative intent, continues to give rise to controversial discussion. This paper takes a look at the potential advantages and disadvantages of the laparoscopic modality with regard to immune function and staging laparoscopy. In view of the fact that, at the present time, curative resections are being carried out in relevant numbers, in particular in the field of colorectal surgery, the technical feasibility, oncological radicality and oncological long-term outcomes are discussed on the basis of the data reported in the relevant literature on laparoscopic colorectal surgery.

Laparoscopic surgery in the old patient: do indications and outcomes differ?

BACKGROUND AND AIMS: In view of the increasing numbers of old and very old people in the general population, we evaluated the short-term outcomes of laparoscopic colorectal surgery for differences between younger and older patients. METHODS: A total of 4,823 patients with complete data sets from a prospective, clinical observational multicentre study initiated by the "Laparoscopic Colorectal Surgery Study Group" were analysed for this investigation. RESULTS: Of the patients, 909 (18.8%) were older and 3,914 (81.2%) younger than 75 years. In the older patient group, malignant disease was a significantly more common indication for surgery. As was expected, the rate of general complications (pneumonia, cardiopulmonary problems, urinary tract infection) was significantly higher in the older patient group with its greater prevalence of preoperative comorbidity, but there no differences in terms of intraoperative or postoperative surgical complications or conversion rate between the groups. CONCLUSION: The higher rate of postoperative complications resulting from preoperative comorbidity in the older patients makes it necessary that the indication for surgery be established with care. In view of the advantages of the laparoscopic approach with regard to the postoperative course, the preferential use of laparoscopy for the treatment of colorectal problems requiring surgery in older patients should receive serious consideration.

Influence of titanium coating on the biocompatibility of a heavyweight polypropylene mesh. An animal experimental model.

INTRODUCTION: In light of the fact that, to date, no information is available about titanium relative to its application in prosthetic material employed for hernial repair, the aim of the present work was to evaluate the fundamental possibilities of titanium-coated polypropylene meshes. MATERIALS AND METHODS: In experiments with animals, two groups, each containing 11 pigs, received either a heavyweight polypropylene mesh (Atrium) or an identical but titanium-coated mesh (titanium-coated Atrium) implanted into the left groin using the totally endoscopic extraperitoneal patchplasty technique. RESULTS: A significant difference in the shrinkage behavior between conventional Atrium and titanium-coated Atrium was found (14.9 vs. 8.8%, p < 0.05). Furthermore, the partial volume of the inflammatory infiltrate also proved to be smaller with the titanium-coated mesh (14.9 vs. 12.4%). In addition, Ki-67 expression was lower in the group implanted with titanium-coated mesh (21.0 vs. 15.0%). No difference was observed with regard to the apoptosis index (7.6 vs. 6.5). CONCLUSIONS: Heavyweight titanium-coated polypropylene meshes induce a less pronounced foreign body reaction in comparison with identical meshes with no titanium coating, which, since the amount of material implanted is identical, must be attributed solely to the titanium coating.

In vivo studies comparing the biocompatibility of various polypropylene meshes and their handling properties during endoscopic total extraperitoneal (TEP) patchplasty: an experimental study in pigs.

BACKGROUND: Polypropylene (PP) meshes are currently being used in millions of operations for hernial repair. We tested several recently modified PP meshes to evaluate them in terms of their biocompatibility and handling characteristics during minimally invasive procedures. METHODS: Four different PP meshes (a heavyweight PP, Atrium; a lightweight PP incorporating absorbable polyglactic acid, Vypro II; a lightweight PP, Parietene; and a titanium-coated lightweight PP, Ti-Mesh Extralight), all implanted using the endoscopic total extrapreperitoneal (TEP) technique, were investigated in groups comprising 11 pigs each. After 94 +/- 5 days, the animals were autopsied and tissue samples were studied histologically, immunohistochemically, and electron-microscopically. RESULTS: Whereas endoscopic handling of the Vypro II mesh proved difficult, the already good properties of the Atrium mesh were significantly improved on by Parietene and the Ti-Mesh. Clear differences were also found in the shrinkage characteristics of the implant materials. In comparison with Atrium (12%), Vypro II mesh shrinkage was significantly greater (28%), whereas Parietene (7%) and Ti-Mesh (5%) incurred less shrinkage. With regard to the chronic inflammatory reaction, the titanium-coated mesh showed a significantly lower inflammatory activity (13.1% partial volume [%PV] vs 34.1%PV and 29.0%PV) than the lightweight meshes Vypro II and Parietene, but-with the exception of the monocytic (0.2 vs 9.1, 5.1, and 7.9) and B-lymphocytic reaction (1.1 vs 18.0, 11.7, and 12.2)-no significant difference was seen in comparison with Atrium. The various mediators in the extracellular matrix (matrix metalloproteinases 1 [MMP-1 transforming growth factor beta [TGF-beta], urokinase plasminogen activator [uPA], and type I collagen) tended to show the highest expression with Vypro II (13.6, 113.2, 132.7, and 139.5, respectively) and the lowest expression with Ti-Mesh (11.9, 68.5, 92.8, and 75.0, respectively). With regard to cell proliferation, Parietene and Ti-Mesh appeared to have slight advantages, but no differences were observed in the apoptotic rate. CONCLUSION: In our opinion, despite a reduction in material, Vipro II, on account of the inflammatory reaction, does not represent a true improvement over the meshes currently used for hernia repair. In comparison, the two lightweight PP patches are characterized by a more favorable foreign body reaction, with the titanium coating of the Ti-Mesh providing an additional advantage in terms of its biocompatibility.

Total mesorectal excision with the water-jet-dissection. Technique and results.

BACKGROUND: The introduction of total mesorectal excision (TME), in particular, has resulted in a dramatic decrease in postoperative functional disorders. Strict adherence to the dissection planes described above, is the prerequisite for good oncological and functional outcome. To facilitate dissection, we have introduced the high-pressure water jet dissector into our surgical routine for the treatment of rectal cancer. Below, we describe the technique of total mesorectal excision we employ in our department and present our perioperative surgical results. METHODS: We performed total mesorectal excision for rectal cancer on 49 patients, comprising 32 males and 17 females aged between 34 and 88 years. 38 patients underwent low anterior resection of the rectum and 11 patients abdominoperineal resection. RESULTS: The mean operating time was 282 min, mean intraoperative administration of red cell concentrates was 0.55 units. The mean postoperative stay in the ICU was 1.92 days. Anastomotic leakage occurred in 6.1%, wound healing disturbances in 12.2%, urinary tract infection in 12.2% intra-abdominal infection in 4.1% and faecal fistula in 4.1%. Urinary tract infections occurred in 12.2%. Postoperative temporary neurogenic voiding disturbances occurred in 14.3%. Persistent neurogenic bladder dysfunction after three months could be observed in 6.1%. CONCLUSIONS: The perioperative results are comparable to those of centres of excellence in the international literature. The Hydro-Jet dissector significantly facilitated TME. The particular feature of this technical aid is that it permits the rapid early development of the embryological plane between the pelvic nerves and the mesorectal fascia, without doing damage to either of them. This leads to optimal radicality and 1 maximum preservation of the autonomic nerves. Before a definitive pronouncement on voiding disturbances can be made, however, we consider it necessary to carry out a prospective randomised study with preoperative and postoperative urodynamic investigations.

Results of laparoscopic treatment of rectal cancer: analysis of 520 patients.

BACKGROUND: To evaluate short- and long-term outcomes of laparoscopic resection of rectal carcinoma in curative intent. METHODS: Within a subgroup analysis of a multicentre study, initiated by the "Laparoscopic Colorectal Surgery Study Group (LCSSG)", 520 patients with rectal cancer were included in a prospective, clinical observational study. RESULTS: One hundred and ninety patients underwent an abdominoperineal resection (APR) and 330 patients an anterior resection (AR) of the rectum. The demographic parameters, intraoperative complication rates, morbidity and mortality rates were comparable in both groups. In patients undergoing AR a trend towards limited oncologic radicality, and a significant increase in the anastomotic leak rate related to the distance of the tumour from the anal verge were observed. Calculated survival data revealed stage-related survival rates for UICC stages I, II and III of 82.0%, 68.8% and 63.3%, respectively. CONCLUSIONS: While APR is highly suited to the laparoscopic approach, laparoscopic AR cannot at present be generally recommended.

Complications in laparoscopic colorectal surgery: results of a multicentre trial.

BACKGROUND: We present a prospective observational multicentre study of 4834 consecutive cases undergoing laparoscopic colorectal procedures. METHODS: The study was initiated on 1 August 1995, with centres from Germany, Austria and Switzerland participating. All patients undergoing laparoscopic colorectal surgery were included, and no selection criteria were applied. RESULTS: Between August 1995 and April 2004, the participating centres treated 4834 patients. Three thousand, one hundred and sixty-six operations were performed for benign indications, and 1668 for cancer, with most operations being done for diverticulitis (2019, 41.8%). The conversion rate was 5.6%, and the overall morbidity was 20.1%. Intra-operative complications occurred in 5.9%, postoperative complications in 14.0%, and the overall anastomotic leak rate was 3.1% (colon 2.6%, rectum 11.9%). The 30-day mortality rate was 1.3%. CONCLUSIONS: It has been our experience that laparoscopic surgery for colorectal disease is safe. Morbidity and mortality are comparable to those of conventional colorectal surgery.

Laparoscopic colorectal resection with curative intent. Own results and review of the literature.

AIM: Laparoscopic surgery is without a doubt one of the most important innovations in the field of surgery in the last 15 years. Since the 1st laparoscopic colorectal resection in 1991, this modality has spread like wildfire. Nevertheless, laparoscopic surgery in the field of oncology is still regarded as controversial. On the basis of our current knowledge, the present study considers the advantages and disadvantages of laparoscopic surgery performed with a curative intent - with emphasis on oncological radicalness and long-term outcome - and evaluates them against our own results. METHODS: In principle, the extent of the resection, compliance with margins of clearance, radicalness of lymphadenectomy and the avoidance of intra-abdominal tumour dissemination (for example, no touch technique) must be applied equally to the laparoscopic modality, too. RESULTS: At present there would not appear to be any restrictions vis-à-vis open surgery in any of the oncological parameters. Nor do currently available long-term results provide any evidence that laparoscopic colorectal surgery is in any way inferior. CONCLUSION: Colorectal oncological interventions with curative intent are still recommended to be done only in controlled studies. A final assessment will not be possible until the results of ongoing prospective randomized multicentre studies become available.

Totally extraperitoneal repair of recurrent inguinal hernia.

BACKGROUND: A variety of procedures with substantial differences in results are employed to treat recurrent inguinal hernia. The advantages of totally extraperitoneal patch repair (TEP) are even more evident when it is applied to recurrent compared to primary hernias. To investigate the superiority of this method more closely, we reviewed our results obtained for recurrent inguinal hernias over a period of 2 years. METHODS: We performed a prospective single-center study using data obtained in consecutive patients with recurrent inguinal hernia who were operated on in 1997 and 1998. RESULTS: A total of 179 patients with recurrent inguinal hernia were recruited. Overall, 1329 patients with inguinal hernia were treated in the 2-year period, of whom 1270 underwent TEP. The percentage of recurrent hernias was 14%. The average age of the patients was 56 years. The follow-up rate was 87.5%, and the mean follow-up period was 2.3 years. The 154 patients who were followed up underwent a total of 225 hernia repairs, of which 181 were for recurrent hernias. The average operating time was 57 min. In 68% (104/154) of the patients, adhesions, adherent epigastric vessels, or cicatricial changes were found, which resulted in the inadvertant opening of the peritoneum in 26.3% of the patients. All the openings in the peritoneum were closed by endoscopic suturing. Intraoperative complications developed in 4 patients (2.3%), including one injury to the bladder and three cases of bleeding from side branches of the epigastric vessels. The conversion rate was 0%. The sole postoperative complication was treatment requiring hematomas in 7 patients, in 2 of whom reoperation became necessary. In both cases, a diffuse hemorrhage due to a preoperatively undiagnosed coagulation disorder was found. No cases of wound or patch infection were observed. In a patient undergoing both primary and recurrent hernia repair, displacement of a mesh led to a recurrence on the primary hernia side (recurrence rate, 0.4%; re-recurrence rate, 0%). CONCLUSIONS: Although for its definitive management, recurrent hernia requires a reliable operative technique, current data do not support the recommendation of any of the currently available procedures as the gold standard. In a representative patient population with recurrent hernia, we were able to demonstrate that TEP achieves very good results in terms of re-recurrence rate, intraoperative and postoperative complications, and rehabilitation. Prerequisites for the reliable and low-complication application of the method are a high level of standardization of the procedure and an advanced learning curve.