Shouldice standard 2020: review of the current literature and results of an international consensus meeting.

INTRODUCTION: For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current evidence and to define an updated standard with key principles of the Shouldice repair. METHODS: Because of unpublished evidence regarding many operative details the organizing group decided to create a technical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects. RESULTS: All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For 5 of 6 critical technical surgical steps a strong consensus could be defined in the group. There was no consensus among the group regarding the cremaster resection and the ideal indication for Shouldice repair. CONCLUSION: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.

Three-stage treatment of late mediastinitis after implantation of left ventricular assist device / Tratamiento en tres fases de mediastinitis retardada después de implantación de un dispositivo para asistencia del ventrículo izquierdo

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[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. / "Natural orifice transluminal endoscopic surgery" in Deutschland : Daten aus dem deutschen NOTES-Register.

BACKGROUND: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). AIM: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. MATERIAL AND METHODS: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. RESULTS: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. CONCLUSION: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

[Assessment of quality of life and gynaecological follow-up after transvaginal cholecystectomy]. / Untersuchungen zur Lebensqualität und gynäkologisches Follow-up nach transvaginaler Cholezystektomie.

BACKGROUND: It has been reported recently that transvaginal cholecystectomy (TV­ChE) has advantages over 'classic' laparoscopic cholecystectomy (LAP­ChE) because of its minimal invasiveness. TV­ChE seems to be associated with a lesser need for analgesics and faster reconvalescence of patients. However, substantial doubts about the transvaginal access and possibly associated complaints and complications of the procedure have been raised. PATIENT/MATERIAL AND METHODS: In this prospective case-control study 30 female patients undergoing transvaginal cholecystectomy (TV­ChE group) have been compared with 30 women undergoing conventional laparoscopic cholecystectomy (LAP­ChE group). Female patients were evaluated with special regard to health-related quality of life, outcome data such as surgical complications and gynaecological complaints and changes in sexual behaviour after surgery. Additional attention was given to the extent of postoperative pain, the analgesic consumption and the rate of postoperative nausea and vomiting (PONV). RESULTS: The demographic data of both groups were comparable to a great extent. Compared to the LAP­ChE group women of the TV­ChE group reported less postoperative pain, less PONV and a lower analgesic consumption (p < 0.001). There were no serious complications in the LAP­ChE group and also none in the TV­ChE group. In comparison with the preoperative status, the results regarding health-related quality of life and feeling of well-being were significantly better for both groups after a follow-up of 12 months (p < 0.01). However, this effect was especially pronounced in the TV­ChE group (p < 0.05). No infections of the surgical wound, wound healing problems or other complications were seen in the gynaecological follow-up examination 3 weeks after the TV­ChE. Two women reported slight and temporary colpotomy-related complaints without any consequences for their sexual behaviour. CONCLUSIONS: The transvaginal cholecystectomy is a safe and less invasive surgical technique providing for an excellent patient comfort and a fast reconvalescence. TV­ChE has a positive longterm effect on health-related quality of life. Doubts about transvaginal approach of this surgical technique with regard to an increased risk of infection or late gynaecological complications appear to be unfounded.

[Comparison between transvaginal and laparoscopic cholecystectomy - a retrospective case-control study]. / Vergleich zwischen transvaginaler und laparoskopischer Cholezystektomie - eine retrospektive Fall-Kontroll-Studie.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) appears to be established in specialised surgical centres. Potential advantages of these operating techniques include surgery without scars as well as faster and more comfortable recovery. However, to date there are no controlled studies evaluating the assumed advantages of NOTES compared with both minimally invasive and open surgery. PATIENT / MATERIAL AND METHODS: In this retrospective case-controlled study 47  women undergoing transvaginal cholecystectomy (TV-ChE) have been compared with 46 women undergoing conventional laparoscopic cholecystectomy (LAP-ChE). Both groups were evaluated with regard to intraoperative respiratory and oxygenation parameters, pain intensity and need for analgesics postoperatively, rate of postoperative nausea and vomiting (PONV), duration of stay in recovery room as well as hospital stay. RESULTS: Demographic data of both groups were comparable to a great extent. However, in comparison with the women of TV-ChE group those of the LAP-ChE group were 5  years older on average (49 ±â€Š15 vs. 54 ±â€Š16  years). Even so, there were no differences in preoperative risk assessment (ASA classification) as well as intraoperative respiratory and haemodynamic parameters. Compared to the LAP-ChE group, women of TV-ChE group reported less postoperative pain (p < 0.001), less nausea or vomiting (p < 0.001) and a lower analgesic consumption in both opiates (p < 0.001) and non-opiates (p < 0.001). Furthermore, the duration of stay in recovery room was shorter in the TV-ChE group (40  minutes vs. 60  minutes, p < 0.001). Hospital stay in the TV-ChE group was 3  days on average compared to 4  days for the LAP-ChE group. The rate of general and surgical complications was lower in TV-ChE group (1 / 47) compared to the LAP-ChE group (4 / 46). In 9  women undergoing transvaginal cholecystectomy negligible vaginal bleeding was seen which stopped spontaneously in each case. CONCLUSION: The transvaginal cholecystectomy is a safe and less invasive surgical technique. Compared to laparoscopic cholecystectomy, there seem to be some advantages such as better cosmetic results, lower need for analgesics, faster mobilisation, more comfortable recovery and shorter hospital stay. These effects should be confirmed in prospective controled studies.

[Laparoscopy for suspected appendicitis. Should an appendix that appears normal be removed?]. / Laparoskopie bei Verdacht auf akute Appendizitis. Soll die makroskopisch unauffällige Appendix entfernt werden?

The question whether an appendix found to be macroscopically normal at laparoscopy for suspected appendicitis should be removed remains open to debate. Potential advantages of appendicectomy in all cases include early diagnosis of neoplastic lesions that cannot be detected macroscopically, diagnosis and cure of neurogenic appendicectomy, avoidance of diagnostic confusion in later episodes of abdominal pain, and prevention of appendicitis developing later in life. Therefore, adopting a strategy of always removing the appendix even if it is found to be uninflamed at laparoscopy seems justified as long as it does not imply an increase in postoperative morbidity. We retrospectively studied all patients undergoing laparoscopic appendicectomy in which a "normal appendix" was found and all patients undergoing diagnostic laparoscopy in our hospital during a 7-year period. Our data as well as a critical review of the literature show that removal of the appendix does not increase morbidity compared to simple diagnostic laparoscopy and should always be done when performing laparoscopy for suspected acute appendicitis.

[APC resistance due to factor V Leiden mutation presenting as acute hemorrhagic jejunal infarction--case report]. / Akuter hämorrhagischer Jejunuminfarkt als Erstmanifestation einer APC-Resistenz bei Faktor-V-Leiden-Mutation--ein Fallbericht.

We report on a 43-year-old patient presenting to the emergency department with acute abdominal pain the source of which turned out to be acute hemorrhagic jejunal infarction due to portal and mesenteric vein occlusion with no apparent cause. In spite of a lacking history of hereditary thrombophilic risk factors, further diagnostic procedures revealed heterozygous factor V Leiden mutation. Diagnosis, therapy and clinical course are described. An overview on acute mesenteric venous occlusion with special reference to genetically determined thrombophilic disorders is given.

[Ultrasound during follow-up of carcinoma]. / Ultraschall in der Tumornachsorge.

According to the guidelines, ultrasonography (US) is now established as the cross-sectional imaging technique of choice in postoperative care of colorectal carcinoma. Although conventional percutaneous US is inferior to computed tomography (CT) and magnetic resonance imaging (MRI) for detecting hepatic metastases, the application of specific contrast media has significantly increased sensitivity and specificity to 87% and 88%, respectively. The combination of US and CT/MRI achieves the highest detection rates. During follow-up of rectal carcinoma, in up to 20% of locoregional recurrences are diagnosed solely by endorectal sonography and result in repeat resection with curative intention. In noncolorectal carcinoma, US is recommended in the guidelines for following up hepatocellular carcinoma and malignant thyroid disease, but the available data are insufficient to support those recommendations.

Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair.

BACKGROUND: Polymer mesh has been used to repair incisional hernias with lower recurrence rates than suture repair. A new generation of mesh has been developed with reduced polypropylene mass and increased pore size. The aim of this study was to compare standard mesh with new lightweight mesh in patients undergoing incisional hernia repair. METHODS: Patients were randomized to receive lightweight composite mesh, or standard polyester or polypropylene mesh. Outcomes were evaluated at 21 days, 4, 12 and 24 months from patient responses to the Short Form 36 (SF-36) and daily activity questionnaires. Complications and recurrence rates were recorded. RESULTS: A total of 165 patients were included in an intention-to-treat analysis (83 lightweight mesh, 82 standard mesh). Postoperative complication rates were similar. The overall hernia recurrence rate was 17 per cent with the lightweight mesh versus 7 per cent with the standard mesh (P = 0.052). There were no differences in SF-36 physical function scores or daily activities between 21 days and 24 months after surgery. CONCLUSION: The use of the lightweight composite mesh for incisional hernia repair had similar outcomes to polypropylene or polyester mesh with the exception of a non-significant trend towards increased hernia recurrence. The latter may be related to technical factors with regard to the specific placement and fixation requirements of lightweight composite mesh.

[The Shouldice repair for inguinal hernia--technique and results]. / Die Leistenhernienoperation nach Shouldice--Aktuelle Technik und Ergebnisse.

The technique of the Shouldice hernioplasty for primary and recurrent inguinal hernia is described on the basis of more than 3 500 procedures at the Surgical University Clinic of Aachen and 700 operations performed at the Surgical Department of the Park-Klinik Berlin-Weissensee. Local anesthesia is the preferred type of anesthesia with a good acceptance by the patients site (96 %). In compliant adults nearly all primary and about 50 % of the recurrent hernias can be repaired under local anesthesia. Essentials of the preparative phase are identification and preservation of the inguinal nerves, resection of the cremaster muscle and exposure of all three hernial sites (lateral, medial and femoral). For all primary hernias and indirect or small recurrent hernias a modified two-layer Shouldice repair of the transversalis fascia using a monofilament running suture (Polypropylene 0) is recommended. In the early postoperative period the physical activity is limited only by the patients complaints. Normal activity is gained back within 2 to 3 weeks. In a non selected group of patients 10-years recurrence rates are 2.6 % in primary hernia and 6.9 % in recurrent repair. The Shouldice repair is recommended as the procedure of choice for all primary and selected recurrent hernia. A mesh prosthesis may be necessary in large medial and combined recurrent hernia.

Incidence and pathophysiology of peptic ulcer bleeding.

Peptic ulcer accounts for about 50% of all cases of upper gastrointestinal bleeding. Acute mortality may be as high as 14%. Infection with Helicobacter plyori (Hp) and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the predominant risk factors. While the prevalence of Hp in ulcer bleeding is still debated, there is strong evidence that eradication of bacteria reduce the risk of re-bleeding significantly. The use of NSAIDs increases the frequency of ulcer bleeding about four- to sixfold on average. Additional factors such as advanced age, concomitant use of corticosteroids or anticoagulants, prior ulcer complications and co-morbid diseases may further increase the risk of bleeding. Whether or not Hp infection also represents an additive risk factor in NSAID-related bleeding remains to be clarified. The pathophysiologic action of both Hp and NSAIDs is quite complex. Hp promotes the aggressive factor acid and damages several mucosal defence mechanisms by liberating lipopolysaccharide, urease and vacuolating cytotoxin. In NSAID toxicity the cyclo-oxygenase enzymes (COX) have been studied intensively. With the advent of COX-2-selective NSAIDs, the clinical problem of NSAID-induced ulcer bleeding may be markedly reduced or abolished completely.

Electrophysiological and mechanical activity of the upper gastrointestinal tract after duodenoplasty or segmental resection of benign gastric outlet stenosis.

In an animal experimental study we examined the postoperative recovery of the motility of the upper gastrointestinal tract after operative treatment of a benign gastric outlet obstruction. At 45 Days after induction, a duodenal stenosis was resected in six dogs, and resolved by Finney's duodenoplasty in another six dogs. Fourteen days after segmental resection, the gastric emptying was faster [half evacuation time (T1/2) for semisolid food = 44.4 +/- 16.8 min] than following duodenoplasty [T1/2 = 56.8 +/- 25.3). Here motor migrating complexes (MMCs) started in the antrum and could be traced down to the jejunum. After segmental resection we recognized MMC only distal to the anastomosis. The duration of the whole MMC cycle (69.0 +/- 18.6 min) as well as of the single phases was significantly shorter in the resection group than after duodenoplasty (108.0 +/- 15.1 min). At 28 days after operation the differences in the electromyographic findings were smaller (82.0 +/- 15.1 min vs. 111.4 +/- 11.2 min), but still significant. Obviously humoral transmitters and the extrinsic neural system lead to good propagation of the MMC across the anastomosis, even before the intramural pathways are reestablished. Concerning the fast recovery of the motility of the upper gastrointestinal tract, duodenoplasty is superior to segmental duodenal resection.

Experimental studies on small intestinal pouch motility and evacuation.

UNLABELLED: The aim of the study was to investigate pouch motility and evacuation under standardised conditions with a minimum of external influence. METHODS: Ileal J-pouches had been constructed 30 cm proximal to the ileocecal valve in 10 dogs (6 pelvic/4 gastric configuration). After 8 weeks the following examinations were performed: (1) measurement of pouch compliance by balloon distension, (2) measurement of pouch contractions by strain gauge transducers, (3) radiological imaging of pouch contractions and evacuation, (4) evacuation scintigraphy and (5) radiological determination of small intestinal transit time. RESULTS: Compliance (2.3 +/- 1.1 mmHg/ml) and small intestinal transit time (31.6 +/- 7.5 h) were significantly higher in the pouch group than in controls (0.5 +/- 0.2 mmHg/ml, 8.0 +/- 2.8 h; p < 0.05). Scintigraphy and radiography showed delayed pouch evacuation (t(1/2) = 109 +/- 52 min). Strain gauge measurements revealed irregular pouch contractions without detectable propagation. Contraction amplitudes (40.4 +/- 22.9 g) and frequencies (10.4 +/- 1.0/min) were equal all over the pouch. There were no functional differences between gastric and pelvic pouch configuration. CONCLUSION: Small intestinal pouches act as reservoirs. Uncoordinated motility patterns contribute to this function. Other factors than pouch motility are responsible for evacuation.

Strong ultrasonic microwaves in ferroelectric ceramics.

It is well known that ferroelectric materials have piezoelectric properties which allow the transformation of electrical signals into mechanical signals and vice versa. The transducer action normally is restricted to frequencies up to the mechanical resonance frequency of the sample. There are, however, two mechanisms which allow transducer action in ferroelectric ceramics at much higher frequencies: one is the normal piezoelectric effect in a ferroelectric ceramic in which the crystallites have periodic domain structures, the other is a domain wall effect in which ferroelastic domain walls in a periodic domain structure are powerful shear wave emitters. Both mechanisms give rise to extensive dielectric losses in ceramics at microwave frequencies.

[Surgery of inguinal hernia with local anesthesia--technique and results of a minimal invasive procedure]. / Leistenhernienchirurgie in Lokalanaesthesie--Technik und Ergebnisse eines "minimal invasiven" Verfahrens.

In three prospective, randomized studies we analyzed the advantages of local anesthesia in patients with primary inguinal hernias. Each study consisted of 100 cooperative adults, using an open approach and the transinguinal procedure. Due to reduced postoperative complications, increased effectiveness of hospital resources, earlier discharges and a high acceptance by the patients, local anesthesia is the ideal treatment in adult hernia repair.

[Artificial pressure increase in subcutaneous abscess with evidence of general systemic reaction]. / Artifizielle Drucksteigerung im subkutanen Abszess mit Nachweis einer systemischen Allgemeinreaktion.

Abscess is customarily thought of as a collection of a large number of microorganisms, inflammatory cells and necrotic debris separated from the surrounding tissue by a fibrous capsule. Modern work focussed attention on more physico-chemical parameters in abscess pathogenesis. Recent experiences from animal models underline the impact of abscess pressure and bio-physicochemical parameters in the "abscess compartment" for systemic spreading. Artificial raising of abscess-pressure in pigs up to 80 mmHg was followed by increase of temperature and heartbeat rate and decrease of median arterial pressure. Elevated levels of TNF alpha, IL-1 and positive blood cultures support the theory of abscess pressure as a most important variable in abscess formation. We conclude that abscess pressure may play a pivotal role in systemic spreading of the primarily localized process.

[Transinguinal preperitoneal mesh-plasty (TIPP) in management of recurrent inguinal hernia]. / Die transinguinale präperitoneale Netzplastik (TIPP) in der Versorgung der Rezidivleistenhernie.

From 3 years' experience with nearly 100 transinguinal preperitoneal mesh prosthesis (TIPP) repairs for recurrent inguinal hernia the indication, anesthesia, modification of the technique, and results are reported. After intraoperative classification of the hernia, the TIPP repair is indicated especially in large defects of the posterior wall (L/M III). The procedure is easily performed under local anesthesia. During 52 local TIPP repairs, conversion of anesthesia was never necessary. Important technical details include the requirement for a sufficient size of mesh (10 cm x 15 cm) and a certain caudal and cranial fixation of the prosthesis using at least three interrupted stitches for each. Apart from an increased number of seromas (12%) in the early postoperative period, the results of the TIPP are comparable with those obtained after Shouldice repair for recurrent hernia. The rate of hematomas, infections, and testicular complications range between 1% and 3%. Considering the negative case selection of only large recurrent hernias, the TIPP repair reveals a favourably low 1-year recurrence rate of 1%.