STRONGHOLD first-year results of biomechanically calculated abdominal wall repair: a propensity score matching.

PURPOSE: Every year around 70,000 people in Germany suffer from an abdominal incisional hernia that requires surgical treatment. Five years after reconstruction about 25% reoccur. Incisional hernias are usually closed with mesh using various reconstruction techniques, summarized here as standard reconstruction (SR). To improve hernia repair, we established a concept for biomechanically calculated reconstructions (BCR). In the BCR, two formulas enable customized patient care through standardized biomechanical measures. This study aims to compare the clinical outcomes of SR and BCR of incisional hernias after 1 year of follow-up based on the Herniamed registry. METHODS: SR includes open retromuscular mesh augmented incisional hernia repair according to clinical guidelines. BCR determines the required strength (Critical Resistance to Impacts related to Pressure = CRIP) preoperatively depending on the hernia size. It supports the surgeon in reliably determining the Gained Resistance, based on the mesh-defect-area-ratio, further mesh and suture factors, and the tissue stability. To compare SR and BCR repair outcomes in incisional hernias at 1 year, propensity score matching was performed on 15 variables. Included were 301 patients with BCR surgery and 23,220 with standard repair. RESULTS: BCR surgeries show a significant reduction in recurrences (1.7% vs. 5.2%, p = 0.0041), pain requiring treatment (4.1% vs. 12.0%, p = 0.001), and pain at rest (6.9% vs. 12.7%, p = 0.033) when comparing matched pairs. Complication rates, complication-related reoperations, and stress-related pain showed no systematic difference. CONCLUSION: Biomechanically calculated repairs improve patient care. BCR shows a significant reduction in recurrence rates, pain at rest, and pain requiring treatment at 1-year follow-up compared to SR.

The effect of an abdominal binder on postoperative outcome after open incisional hernia repair in sublay technique: a multicenter, randomized pilot trial (ABIHR-II).

INTRODUCTION: Although the evidence is minimal, an abdominal binder is commonly prescribed after open incisional hernia repair (IHR) to reduce pain. This study aimed to investigate this common postoperative treatment. METHODS: The ABIHR-II trial was a national prospective, randomized, multicenter non-AMG/MPG pilot study with two groups of patients (wearing an abdominal binder (AB) for 2 weeks during daytime vs. not wearing an AB following open IHR with the sublay technique). Patient enrollment took place from July 2020 to February 2022. The primary endpoint was pain at rest on the 14th postoperative day (POD) using the visual analog scale (VAS). The use of analgesics was not systematically recorded. Mixed-effects linear regression models were used. RESULTS: A total of 51 individuals were recruited (25 women, 26 men; mean age 61.4 years; mean body mass index 30.65 kg/m2). The per-protocol analysis included 40 cases (AB group, n = 21; No-AB group, n = 19). Neither group showed a significant difference in terms of pain at rest, limited mobility, general well-being, and seroma formation and rate. Patients among the AB group had a significantly lower rate of surgical site infection (SSI) on the 14th POD (AB group 4.8% (n = 1) vs. No-AB group 27.8% (n = 5), p = 0.004). CONCLUSION: Wearing an AB did not have an impact on pain and seroma formation rate but it may reduce the rate of postoperative SSI within the first 14 days after surgery. Further trials are mandatory to confirm these findings.

[Inguinal hernia operations-Always outpatient?] / Leistenhernienoperationen ­ immer ambulant?

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

Perioperative outcome in groin hernia repair: what are the most important influencing factors?

INTRODUCTION: Using registry analyses, a large number of influencing factors on the perioperative outcome of groin hernia repair has been identified. The interactions between several influencing factors and differences in the influencing value have to date been inadequately investigated. METHODS: This retrospective analysis of prospectively collected data from the Herniamed Registry included all fully documented cases with minimum age of 16 years and groin hernia repair. Patients were assigned to the risk groups unilateral, bilateral, recurrent and emergency groin hernia repair. Multivariable analysis was performed to investigate the influence of confirmatory defined patient- and procedure-related characteristics on the outcome parameters intraoperative, postoperative general and postoperative surgical complications, complication-related reoperation and total perioperative complications. RESULTS: A highly significantly unfavorable association with the total perioperative complication rate was identified for emergency groin hernia repair, scrotal hernia, anticoagulant medication and coagulopathy. A significantly unfavorable relation with the total perioperative complication rate was found for recurrence procedure, bilateral repair, high age, ASA score III/IV, femoral hernia, antithrombotic medication, smoking, COPD and corticosteroid medication. A significantly favorable correlation with the total perioperative complication rate was observed for the laparo-endoscopic techniques, smaller defects, female gender, normal weight and medial hernia. CONCLUSION: Both the number of potential influencing factors and their influencing value on the perioperative outcome should be considered when estimating the individual risk of a patient with groin hernia repair.

What is the reality in outpatient vs inpatient groin hernia repair? An analysis from the Herniamed Registry.

INTRODUCTION: Groin hernia repair is performed increasingly more often as an outpatient procedure across the world. However, the rates are extremely different and vary between below 10% and above 90%. The outpatient procedure appears to negatively impact the proportion of laparo-endoscopic repairs. To date, only very few studies have compared inpatient vs outpatient groin hernia repair. METHODS: All outpatient and inpatient primary elective unilateral groin hernia repairs performed between 2010 and 2019 were identified in the Herniamed Registry and their treatment and outcomes compared. RESULTS: The 737 participating hospitals/surgeons performed a total of 342,072 primary elective unilateral groin hernia repairs from 2010 to 2019. The proportion of outpatient repairs was 20.2% in 2013 and 14.3% in 2019. Whereas the proportion of laparo-endoscopic repairs among the inpatient cases was 71.9% in 2019, the last year for which data are available, it was only 34.3%.for outpatient repairs. In outpatient groin hernia repairs, the rates of patients aged ≥ 60 years, with ASA score III and IV and risk factors were highly significantly lower. Given this rigorous patient selection for outpatient groin hernia repair, a more favorable perioperative outcome was achieved. At 1-year follow-up there were no significant differences in the pain and recurrence rates. CONCLUSION: With an appropriate patient selection, outpatient primary elective unilateral groin hernia repair can be performed with acceptable risks and good outcomes. Since to date no studies have compared inpatient vs outpatient groin hernia repair, the impact of a higher rate of outpatient groin hernia repair cannot currently be evaluated.

Comparison of outcomes in rectus abdominis diastasis repair-which data do we need in a hernia registry?

INTRODUCTION: Rectus abdominis diastasis (RAD) ± concomitant hernia is a complex hernia entity of growing significance in everyday clinical practice. Due to a multitude of described surgical techniques, a so far missing universally accepted classification and hardly existing comparative studies, there are no clear recommendations in guidelines. Therefore, "RAD ± concomitant hernia" will be documented as a separate hernia entity in the Herniamed Registry in the future. For this purpose, an appropriate case report form will be developed on the basis of the existing literature. METHODS: A systematic search of the available literature was performed in March 2021 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library. 93 publications were identified as relevant for this topic. RESULTS: In total 45 different surgical techniques for the repair of RAD ± concomitant hernia were identified in the surgical literature. RAD ± concomitant hernia is predominantly repaired by plastic but also by general surgeons. Classification of RAD ± concomitant hernia is based on a proposal of the German Hernia Society and the International Endohernia Society. Surgical techniques are summarized as groups subject to certain aspects: Techniques with abdominoplasty, open techniques, mini-less-open and endoscopic sublay techniques, mini-less-open and endoscopic subcutaneous/preaponeurotic techniques and laparoscopic techniques. Additional data impacting the outcome are also recorded as is the case for other hernia entities. Despite the complexity of this topic, documentation of RAD ± concomitant hernia has not proved to be any more cumbersome than for any of the other hernia entities when using this classification. CONCLUSION: Using the case report form described here, the complex hernia entity RAD ± concomitant hernia can be recorded in a registry for proper analysis of comparative treatment options.

What is the reality in epigastric hernia repair?-a trend analysis from the Herniamed Registry.

INTRODUCTION: The proportion of epigastric hernias in the total collective of all operated abdominal wall hernias is 3.6-6.9%. The recently published guidelines for treatment of epigastric hernias of the European Hernia Society and the Americas Hernia Society recommend the use of a mesh for defect size of ≥ 1 cm, i.e., a preperitoneal flat mesh technique for sizes 1-4 cm, and laparoscopic IPOM technique for defects > 4 cm and/or obesity. Against that background, this analysis of data from the Herniamed Registry now aims to explore trends in epigastric hernia repair. METHODS: To detect trends, the perioperative outcome was calculated separately for the years 2010 to 2019 and the 1-year follow-up for the years 2010 to 2018 and significant differences were identified. Analysis was based on 25,518 primary elective epigastric hernia repairs. The rates of postoperative surgical complications, pain at rest, pain on exertion, chronic pain requiring treatment and recurrence associated with the various surgical techniques were calculated separately for each year. Fisher's exact test for unadjusted analysis between years was applied with Bonferroni adjustment for multiple testing. RESULTS: The proportion of laparoscopic IPOM repairs declined from 26.0% in 2013 to 18.2% in 2019 (p < 0.001). Instead, the proportion of open sublay repairs rose from 16.5% to 21.8% (p < 0.001). That was also true for innovative techniques such as the EMILOS, MILOS, eTEP and preperitoneal flat mesh technique (8.3% vs 15.3%; p < 0.001). This change in indication for the various surgical techniques led to a significant improvement in the postoperative surgical complication rate (3.8% vs 1.9%; p < 0.001). CONCLUSION: The trend is for epigastric hernia repair to be performed less often in laparoscopic IPOM technique and instead more often in open sublay technique or the new innovative techniques.

Treatment of small (< 2 cm) umbilical hernias: guidelines and current trends from the Herniamed Registry.

INTRODUCTION: Based on meta-analyses and registry data, the European Hernia Society and the Americas Hernia Society have published guidelines for the treatment of umbilical hernias. These recommend that umbilical hernia should generally be treated by placing a non-absorbable (permanent) flat mesh into the preperitoneal space with an overlap of the hernia defect of 3 cm. Suture repair should only be considered for small hernia defects of less than 1 cm. Hence, the use of a mesh in general is subject to controversial debate particularly for small (< 2 cm) umbilical hernias. This analysis of data from the Herniamed Registry now presents data on the treatment of small (< 2 cm) umbilical hernias over the past 10 years. METHODS: Herniamed is an Internet-based hernia registry in which hospitals and surgical centers in Germany, Austria and Switzerland can voluntarily enter data on their routine hernia operations. Between 2010 and 2019, data were entered into the Herniamed Registry by 737 hospitals/surgery centers on a total of 111,765 patients with primary elective umbilical hernia repair. The prospective data were analyzed retrospectively for each year and statistically compared. Due to a higher number of cases, the years 2013 and 2019 were compared for the perioperative outcome and the years 2013 and 2018 for 1-year follow-up. Fisher's exact test was applied for unadjusted analyses between the years, using a significance level of alpha = 5%. For post hoc tests of single categories, a Bonferroni adjustment for multiple testing was implemented. RESULTS: A mesh technique was used to treat 45.4% of all umbilical hernias. The proportion of small (< 2 cm) umbilical hernias in the total collective of umbilical hernias was 55.6%. Suture repair was used consistently over the 10-year period to treat around 75% of all small (< 2 cm) umbilical hernias. Preperitoneal mesh placement as recommended in the guidelines was used only in 1.8% of cases. Between 2013 and 2019, stable values of 2 and 0.7% were observed for the postoperative complications and complication-related reoperations, respectively, with no relevant effect identified for the surgical technique. At 1-year follow-up, significantly higher rates of pain at rest (2.6 vs. 3.3), pain on exertion (5.7 vs. 6.6), and recurrences (1.3 vs. 1.8) (all p < 0.05) were identified for 2018 compared with 2013. CONCLUSIONS: A suture technique is still used to treat 75% of patients with small (< 2 cm) umbilical hernias. The pain and recurrence rates are significantly less favorable for 2018 compared with 2013.

Assessment of potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair: a registry-based multivariable analysis of 31,965 patients.

INTRODUCTION: How best to treat a small (< 2 cm) umbilical hernia continues to be the subject of controversial debate. The recently published guidelines for treatment of umbilical hernias from the European Hernia Society and Americas Hernia Society recommend open mesh repair for defects ≥ 1 cm. Since the quality of evidence is limited for hernias with defect sizes smaller than 1 cm, suture repair can be considered. To date, little is known about the potential influencing factors on the outcome in small (< 2 cm) umbilical hernia repair. This multivariable analysis of data from the Herniamed Registry now aims to assess these factors. METHODS: The data of patients with primary elective umbilical hernia repair and defect size < 2 cm entered into the Herniamed Registry from September 1, 2009 to December 31, 2018 were analyzed to assess through multivariable analysis all confirmatory pre-defined potential influencing factors on the primary outcome criteria intraoperative and postoperative complications, general complications, complication-related reoperations, recurrence rate and rates of pain at rest, pain on exertion and chronic pain requiring treatment at 1-year follow-up. RESULTS: 31,965 patients (60%) met the inclusion criteria. The proportion of suture repairs was 78.6% (n = 25,119), of open mesh repairs 15.2% (n = 4853), and of laparoscopic mesh repairs 6.2% (n = 1993). Compared with open mesh repair, suture repair had a highly significantly unfavorable association with the recurrence rate (OR = 1.956 [1.463; 2.614]; p < 0.001). Female gender also had an unfavorable relation to the recurrence rate (OR = 1.644 [1.385; 1.952]; p < 0.001). Compared with open mesh repair, open suture repair had a highly significantly favorable association with the rate of postoperative complications (OR = 0.583 [0.484; 0.702]; p < 0.001) and complication-related reoperations (OR = 0.567 [0.397; 0.810]; p = 0.002).While laparoscopic IPOM showed a favorable relationship with the postoperative complications and complication-related reoperations, it demonstrated an unfavorable association with the intraoperative complications, general complications, recurrence rate and pain rates. CONCLUSION: Suture repair continues to be used for 78% of umbilical hernias with a defect < 2 cm. While suture repair has a favorable influence on the rates of postoperative complications and complication-related reoperations, it has a higher risk of recurrence. Female gender also has an unfavorable influence on the recurrence rate. Laparoscopic IPOM appears to be indicated only in settings of obesity (BMI ≥ 30).

What is the outcome of the open IPOM versus sublay technique in the treatment of larger incisional hernias?: A propensity score-matched comparison of 9091 patients from the Herniamed Registry.

INTRODUCTION: 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. This analysis of data from the Herniamed Registry aimed to compare the outcomes of open IPOM and sublay technique. METHODS: Propensity score matching of 9091 patients with elective incisional hernia repair and with defect width ≥ 4 cm was performed. The following matching variables were selected: age, gender, risk factors, ASA score, preoperative pain, defect size, and defect localization. RESULTS: For the 1977 patients with open IPOM repair and 7114 patients with sublay repair, n = 1938 (98%) pairs were formed. No differences were seen between the two groups with regard to the intraoperative, postoperative and general complications, complication-related reoperations and recurrences. But significant disadvantages were identified for the open IPOM repair in respect of pain on exertion (17.1% vs. 13.7%; p = 0.007), pain at rest (10.4% vs. 8.3%; p = 0.040) and chronic pain requiring treatment (8.8% vs. 5.8%; p < 0.001), in addition to rates of 3.8%, 1.1% and 1.1%, respectively, occurring in both matched patients. No relationship with tacker mesh fixation was identified. There are only very few reports in the literature with comparable findings. CONCLUSION: Compared with sublay repair, open IPOM repair appears to pose a higher risk of chronic pain. This finding concords with the Expert Consensus recommending that incisional hernia should preferably be repaired using the sublay technique.

What are the trends in incisional hernia repair? Real-world data over 10 years from the Herniamed registry.

INTRODUCTION: There is an increasingly controversial debate about the best possible incisional hernia repair technique. Despite the good outcomes of laparoscopic IPOM, concerns about the intraperitoneal mesh placement and its potential intraabdominal complications have risen. Against that background, this paper now analyzes changes and trends in incisional hernia repair techniques in the recent decade. METHODS: Between 2010 and 2019 a total of 61,627 patients with primary elective incisional hernia repair were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves to visualize trends. The explorative Fisher's exact test was used for statistical calculation of significant differences. Since the number of cases entered into the Herniamed Registry for the years 2010-2012 was still relatively small, the years 2013 and 2019 were compared for statistical analysis. RESULTS: In the analyzed time period, the proportion of incisional hernias repaired in open suture technique remained unchanged at about 10%. The proportion of laparoscopic IPOM repairs decreased significantly from 33.8% in 2013 to 21.0% (p < 0.001) in 2019. Conversely, the proportion of open sublay repairs increased significantly from 32.1% in 2013 to 41.4% (p < 0.001) in 2019. Starting in 2015, there has also been the introduction and increasing use (4.5% in 2013 vs. 10.0% in 2019; p < 0.001) of new minimally-invasive techniques with placement of a mesh into the sublay/retromuscular/preperitoneal abdominal wall layer (E/MILOS, eTEP, preperitoneal mesh technique). CONCLUSION: Analysis of data from the Herniamed Registry shows a significant trend to the disadvantage of the laparoscopic IPOM and to the advantage of the open sublay operation and the new minimally-invasive techniques (E/MILOS, eTEP, preperitoneal mesh technique). Despite all the recommendations in the guidelines, 10% of incisional hernias continue to be treated by means of a suture technique.

Do drains have an impact on the outcome after primary elective unilateral inguinal hernia repair in men?

INTRODUCTION: The use of drains continues to be a controversial topic in surgery. In a review of that topic for incisional hernia it was not possible to find sufficient evidence of the need for a drain. Likewise, for inguinal hernia surgery the data available are insufficient. METHODS: In a multivariable analysis of data from the Herniamed Registry for 98,321 patients with primary elective unilateral inguinal hernia repair in men, the role of a drain was investigated. RESULTS: A drain was used in 24.7% (n = 24,287/98,321) of patients. These patients were on average older, had higher BMI, longer operating time and received a smaller mesh. Drains were also used more often for patients with higher ASA score, risk factors, larger defects and scrotal hernia localization as well as for Lichtenstein, TEP and suture repair. The use of drains was highly significantly associated with intra- and postoperative complications as well as with complication-related reoperations. Hence, drains are used selectively in inguinal hernia repair for patients at higher risk of perioperative complications. Despite the use of drains, the outcome in this risk group is less favorable. It remains unclear if drains prevent further complications in high-risk patients. CONCLUSION: Drains are used selectively in high-risk men with primary elective unilateral inguinal hernia repair. Drains are associated with intra- and postoperative complications rates and complication-related reoperation rate. Drains can serve as an indicator for early detection of complications.

Single-Center Retrospective Analysis of the Outcomes of Patients Undergoing Staged Peritoneal Lavage for Secondary Peritonitis.

BACKGROUND: Secondary peritonitis is associated with high rates of morbidity and mortality. Data on the effect of staged re-laparotomy or re-laparoscopy as a surgical option in the management of abdominal sepsis due to secondary peritonitis are limited and conflicting. Herein, we report the outcomes of patients undergoing staged peritoneal lavage (SPL) for secondary peritonitis in our department. METHODS: This is a single-center retrospective analysis of the data of patients undergoing SPL for secondary peritonitis. SPL was performed via either re-laparotomy or re-laparoscopy. The simplified acute physiology score (SAPS II) was calculated at the time of the initial operation and for each SPL. The end points of interest included: the evolution of sepsis characterized by the SAPS II score, the mortality rate and the rate of definitive abdominal wall closure. RESULTS: The data of 74 patients with a median age of 73 years requiring at least one SPL between 2012 and 2019 were analyzed. The median number of SPL performed was three (range 1-12). A sequential drop of SAPS II score from 41 at the initial procedure to 32 at the third SPL was documented. The overall mortality rate was 16.2%, definitive abdominal closure was achieved in all surviving patients and the median length of stay was 17.5d CONCLUSION: Staged re-laparotomy or re-laparoscopy with peritoneal lavage may reduce the severity of peritonitis and reduce the risk of mortality in patients with abdominal sepsis. Maintaining the abdominal wall under constant retraction using a rigid mesh while creating an open abdomen is a crucial step in achieving definite abdominal wall closure. Thus, staged peritoneal lavage may be a good surgical option for selected patients with peritonitis.

[HerniaSurge: international guidelines on treatment of inguinal hernia in adults : Comments of the Surgical Working Group Hernia (CAH/DGAV) and the German Hernia Society (DHG) on the most important recommendations]. / HerniaSurge: internationale Leitlinie zur Therapie der Leistenhernie des Erwachsenen : Kommentar der Chirurgischen Arbeitsgemeinschaft Hernie (CAH/DGAV) und der Deutschen Herniengesellschaft (DHG) zu den wichtigsten Empfehlungen.

SURGICAL TECHNIQUES: The HerniaSurge guidelines have the highest evidence with respect to a strong recommendation for mesh-based surgical techniques. This evidence is equally valid for the Lichtenstein procedure as for the minimally invasive procedures TEP/TAPP. In the case of discrete symptomatic or asymptomatic inguinal hernias, watchful waiting can be an option, taking into account health status and social circumstances. Femoral hernias, on the other hand, should be treated promptly with mesh insertion. Also favored are laparoendoscopic techniques. The Shouldice repair achieves the least recurrences from the suturing procedures and may be an acceptable alternative when indicated or when the patient does not desire mesh reinforcement. In this case, a detailed patient education is necessary. MESH CHOICE: The complication potential of plastic meshes should be explained. The weight is no longer considered a suitable parameter for the classification of meshes and is no longer recommended for mesh selection. Large pore (>1-1.5 mm) monofilament implants have the best integration potential and should have a tear strength of approximately 16 Nm2. Traumatic mesh fixation is only recommended for large medial hernias (M3-EHS). Primarily not recommended are Plug & Patch, double-layered plastic implants (such as the PHS system) or other three-dimensional devices, as this could affect both the anterior and posterior planar layers and complicate the complementary surgical technique in the event of recurrence. In addition, the higher costs have to be considered. PERIOPERATIVE AND POSTOPERATIVE ASPECTS: Perioperative antibiotic prophylaxis in open repair procedures is recommended only in patients with an increased risk of infections. In laparoendoscopic procedures, antibiotic prophylaxis should not be performed or used with the utmost restraint. Careful preparation reduces chronic inguinal and testicular pain. In the case of interference of mesh and nerve, the nerve can be resected. A return to daily activity is recommended within 3-5 days. QUALITY ASSURANCE: The documentation of patient data should be done by establishing hernia registers for quality assurance and for the development of further treatment options. The implementation of the guidelines is supported by HerniaSurge.

What are the differences in the outcome of laparoscopic axial (I) versus paraesophageal (II-IV) hiatal hernia repair?

INTRODUCTION: Comparison of elective laparoscopic repair of axial vs paraesophageal hiatal hernias reveals relevant differences in both the patient collectives and the complexity of the procedures. MATERIALS AND METHODS: The present uni- and multivariable analysis of data from the Herniamed Registry compares the outcome for 2047 (67.3%) (type I) axial with 996 (32.7%) (types II-IV) paraesophageal primary hiatal hernias following laparoscopic repair. RESULTS: Compared with the patients with axial hiatal hernias, patients with paraesophageal hiatal hernia were nine years older, had a higher ASA score (ASA III/IV: 34.8 vs 13.7%; p < 0.001), and more often at least one risk factor (38.8 vs 21.4%; p < 0.001). This led in the univariable analysis to significantly more general postoperative complications (6.0 vs 3.0%; p < 0.001). Reflecting the greater complexity of the procedures used for laparoscopic repair of paraesophageal hiatal hernias, significantly higher intraoperative organ injury rates (3.7 vs 2.3%; p = 0.033) and higher postoperative complication-related reoperation rates (2.1 vs 1.1%; p = 0.032) were identified. Univariable analysis did not reveal any significant differences in the recurrence and pain rates on one-year follow-up. Multivariable analysis did not find any evidence that the use of a mesh had a significant influence on the recurrence rate. CONCLUSION: Surgical repair of paraesophageal hiatal hernia calls for an experienced surgeon as well as for corresponding intensive medicine competence because of the higher risks of general and surgical postoperative complications.

The Prevention of Positioning Injuries during Gynecologic Operations. Guideline of DGGG (S1-Level, AWMF Registry No. 015/077, February 2015).

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Positioning injuries after lengthy gynecological procedures are rare, but the associated complications can be potentially serious for patients. Moreover, such injuries often lead to claims of malpractice and negligence requiring detailed medical investigation. To date, there are no binding evidence-based recommendations for the prevention of such injuries. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. The recommendations cover.

[Recurrent varicose veins. Surgical procedure--results]. / Rezidiv-Varikose. Operatives Vorgehen--Ergebnisse.

We report 96 patients (107 legs) with recurrence after varicose vein surgery. We define a recurrent varicose vein as a new transfascial insufficiency after incomplete interruption of the saphenofemoral as well as popliteal junction with reflux in the epifascial venous system. 92 patients underwent external primary surgery. Morphologically an insufficient high ligation of the V. saphena magna (Moszkowicz's operation) led in 30 cases to a recurrent varicose vein. In 47 cases an incomplete isolated, in 29 cases an incomplete saphenofemoral ligation during a Babcock procedure and in one case an incomplete saphenopopliteal ligation for V. saphena parva insufficiency were the reasons for the recurrence. As recurrent surgery we performed 106 ligations of the saphenofemoral junction. In 38 of these cases an isolated saphenofemoral ligation and in 68 cases an additional stage-adjusted ligation of the V. saphena magna were carried out. In one case of recurrent saphenopopliteal insufficiency a repeated ligation of the V. saphena parva was performed. The recurrence is an avoidable complication of a not perfect primary surgery. The main cause is an inadequate access with incomplete saphenofemoral or -popliteal ligation.

[Varicose and ascending thrombophlebitis--surgical planning for emergency crossectomy by duplex ultrasound]. / Varikose und ascendierende Thrombophlebitis--Operationsplanung zur Notfallcrossektomie durch Duplexsonographie.

Ascending thrombophlebitis of the superficial leg veins is known to pass into the deep veins, causing an embolism to develop. Duplex ultrasonography has been shown to be a reliable technique for the evaluation of superficial venous thrombosis. If progression is noted, crossectomy proved to be effective in preventing passage of thrombi into the deep veins.

[Late abscess after laparoscopic cholecystectomy caused by lost gallstones]. / Spätabscess nach laparoskopischer Cholecystektomie durch verlorene Gallensteine.

A possible intraoperative complication of laparoscopic cholecystectomy is opening of the gallbladder with subsequent loss of gallstones. We report on a 61-year-old woman who was hospitalised with an obscure subhepatic tumor. Intraoperatively an abscess was found that had been caused by lost gallstones following after laparoscopic cholecystectomy 3 years previously. There is a low incidence of late abscesses caused by loss of gallstones, but because of the long latency and unspecific symptoms there may be problems in diagnosis. Taking into consideration possible complications caused by intraoperative loss of gallstones, all concrements should be retrieved, even though there is no indication for changing to an open procedure.

[Surgical treatment of diverticulitis of the large intestine--a plea for early elective resection]. / Die chirurgische Behandlung der Dickdarmdivertikulitis--Ein Plädoyer für die frühe elektive Resektion.

PURPOSE: Diverticulitis of the colon is observed more and more frequently in highly developed countries. The spontaneous course of the disease is not predictably; an exact definition of risk factors for perforated diverticulitis is missing. Therefore the decision for the conservative therapy or for an early elective resection is subject of a controversial discussion. The results of an offensive surgical concept, aiming at an early elective resection for definite therapy of diverticulitis have been analysed in a retrospective study. RESULTS: From 1980-1995 337 patients were operated due to diverticular disease (rate of resection: 98.8%). In spite of the increase of cases with severe complicated diverticulitis from 36.2% (1980-1985) to 45.8% (1991-1995; p = 0.05) the incidence of protective colostomies decreased from 18.8% in the first six years to 0.6% (n = 1) in the last 4 1/2 years (p < 0.001). After elective resection general complications occurred in 30.1% (n = 101), local complications in 17.0% (n = 57). The clinical anastomotic leakage rate was 2.1% (n = 7). During the study the morbidity rate decreased significantly (p < 0.005). Especially the incidence of nosocomial infections was reduced from 37.7% (1980-1985) to 14.8% (1991-1995); severe local complications (anastomotic leakage, bowel obstruction, peritonitis, hemorrhage, abscess) were reduced from 10.1% (1980-1985) to 3.2% (1991-1995). The mortality rate was 1.2% (n = 4). CONCLUSION: By consistent early elective resection of diverticulitis together with a standardized surgical management a definitive treatment of diverticulitis with a high and safe standard is possible. Already after the first severe attack of the disease, which leads to hospitalization, the early elective resection allows the definite cure for diverticular disease analogous to cholecystectomy or appendectomy, avoiding the life threatening complications.