Systematic review and comparison of national and international guidelines on diverticular disease.

PURPOSE: Diverticular disease is common and of increasing medical and economical importance. Various practice guidelines on diagnostic and treatment on this disease exist. We compared current guidelines on the disease in order to identify concordant and discordant recommendations. METHOD: Eleven national and international guidelines on diverticular disease published over the last 10 years have been identified by a systematic literature review on PubMed and compared in detail for 20 main and 51 subtopics. RESULTS: The available evidence for the most aspects was rated as moderate or low. There was concordance for the following items: Diagnosis of diverticulitis should be confirmed by imaging methods (10 of 10 guidelines). Mild forms may be treated out-patient (10/10). Abscesses are treated non-surgically (9/9). Elective surgery should be indicated by individual patient-related factors, only, and be performed laparoscopically (10/10, 9/9 respectively). Main differences were found in the questions of appropriate classification, imaging diagnostic (computed-tomography versus ultra-sound), need for antibiotics in out-patient treatment and mode of surgery for diverticular perforation. Despite growing evidence that antibiotics are not needed for treating mild diverticulitis, only 3/10 guidelines have corresponding recommendations. Hartmann's procedure has been abandoned several years ago and is now recommended for feculent peritonitis by the three most recent guidelines. In contrast, laparoscopic lavage without resection is not recommended anymore. CONCLUSION: There are dissents in the recommendations for central aspects regarding the diagnostic and treatment of diverticular disease in recently published guidelines.

ECSPECT prospective multicentre registry for single-port laparoscopic colorectal procedures.

BACKGROUND: The international multicentre registry ECSPECT (European Consensus of Single Port Expertise in Colorectal Treatment) was established to evaluate the general feasibility and safety of single-port colorectal surgery with regard to preoperative risk assessment. METHODS: Consecutive patients undergoing single-port colorectal surgery were enrolled from 11 European centres between March 2010 and March 2014. Data were analysed to assess patient-, technique- and procedure-dependent parameters. A validated sex-adjusted risk chart was developed for prediction of single-port colorectal surgery-related conversion and complications. RESULTS: Some 1769 patients were enrolled, 937 with benign and 832 with malignant conditions. Procedures were completed without additional trocars in 1628 patients (92·0 per cent). Conversion to open surgery was required in 75 patients (4·2 per cent) and was related to male sex and ASA fitness grade exceeding I. Conversions were more frequent in pelvic procedures involving the rectum compared with abdominal procedures (8·1 versus 3·2 per cent; odds ratio 2·69, P < 0·001). Postoperative complications were observed in a total of 224 patients (12·7 per cent). Independent predictors of complications included male sex (P < 0·001), higher ASA grade (P = 0·006) and rectal procedures (P = 0·002). The overall 30-day mortality rate was 0·5 per cent (8 of 1769 patients); three deaths (0·2 per cent; 1 blood loss, 2 leaks) were attributable to surgical causes. CONCLUSION: The feasibility and safety, conversion and complication profile demonstrated here provides guidance for patient selection.

[Hybrid TAMIS total mesorectal excision. A new perspective in treatment of distal rectal cancer - Technique and results]. / Hybrid-TAMIS totale mesorektale Exzision. Neue Perspektive in der Behandlung des distalen Rektumkarzinoms - Technik und Ergebnisse.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) represents a promising technique for total mesorectal excision (TME) with respect to radicalness and preservation of function. There are only few publications in the literature describing results in patients with distal rectal cancer. METHODS: Between May 2013 and March 2015, 24 selected patients with a rectal carcinoma < 6 cm from the anal verge underwent a laparoscopically assisted TAMIS TME (Hybrid-TAMIS TME) procedure. This prospective observational study was conducted to examine the safety of the technique and the quality of TME surgery in distal rectal cancer and to assess the short-term postoperative outcome. RESULTS: The median age of patients (18 male and 6 female) at the time of surgery was 57 years (range 35-77 years) and 7 patients (29 %) had a body mass index (BMI) > 30 kg/m(2). Specimen excision was carried out transanally in 19 patients. Pathological grading of TME specimens was good in 22 (92 %) and moderate in 2 cases. After neoadjuvant radiochemotherapy a complete pathological remission was identified in five patients. The median distal resection margin was 7 mm (range 2-30 mm), the median circumferential resection margin was 6 mm (range <1 mm-30 mm) and in 2 patients the tumor was ≤ 1 mm from the positive circumferential margin. A colonic reservoir was created in 19 patients (79 %) and no 30-day mortalities occurred. Morbidity was 29 %, including 1 anastomotic leak, 2 hematomas and 1 neurogenic bladder. CONCLUSION: Hybrid-TAMIS TME for distal rectal cancer is safe and can provide a sphincter-preserving high-quality TME in difficult cases. Studies with long-term follow-up assessing oncological and functional results are mandatory.

Lymph node harvest in single incision laparoscopic surgery for colorectal malignancy.

AIM: Single incision laparoscopic surgery (SILS) has not been sufficiently evaluated with respect to its oncological equivalence to conventional laparoscopic or open surgery. METHOD: Of 507 patients who had SILS for colorectal diseases in our institution, 87 had segmental resection for colorectal adenocarcinoma. For each of the surgical specimens the number of lymph nodes which can be expected to be identified by the pathologist was calculated using the ACPGBI lymph node harvest model, which was developed from a nationwide database of 5845 surgical specimens. The predicted number of lymph nodes was compared with the number identified in our SILS specimens. RESULTS: The median predicted number of lymph nodes was 11 (4.5-14.8) compared with 18 (5-44) in the SILS specimens (P < 0.001). In all subgroups analysed for various operations, the lymph node harvest in the SILS specimens was significantly higher than predicted. CONCLUSION: In terms of lymph node harvest SILS seems to be comparable to conventional open or laparoscopic surgery.

[Single-port colonic surgery : techniques and indications]. / Single-Port-Kolonchirurgie : Techniken und Indikationen.

Colonic surgery is feasible with the single-port technique using standard laparoscopic instruments. Operative time and complication rates are comparable to conventional standard laparoscopic procedures. Position of instruments (crossed over) and orientation are somewhat different and need to be trained and practiced. In this patient collective 200 colon resections covering the complete spectrum of colonic surgery were done in our department. Of these 120 patients were operated on because of sigma diverticulitis. The average operative time was 149 min whereby 6 patients (5.0%) had to be converted to an open procedure, 12 (10.0%) patients had early complications, of which 6 (5.0%) had minor wound complications which were treated conservatively and 4 (3.3%) patients had late complications (2 stenoses and 2 hernias) during the mean follow-up time of 7.5 months (range 6-14 months). The cosmetic effect was very good and functional results were good. Single-port colon operations are the least invasive procedure available at the moment.

Differences in ano-neorectal physiology of ileoanal and coloanal reconstructions for restorative proctectomy.

OBJECTIVE: Restorative proctectomy with straight coloanal anastomosis (CAA) and restorative proctocolectomy with ilealpouch-anal anastomosis (IPAA) are options for maintaining bowel integrity after rectal resection. The aim of this study was to compare clinical function and anorectal physiology in patients treated with CAA and IPAA. METHOD: Three-dimensional vector-manometry and neorectal volumetry were performed in straight CAA [53 patients (34 male)] and IPAA [61 patients (39 male)] for ulcerative colitis. Function was assessed using a 14 day incontinence diary. RESULTS: Function was similar in both groups, but neorectal compliance and threshold volumes for sensation, urge and maximum tolerated volume (MTV) were significantly higher after IPAA than after CAA. Mean pressure, vector volume and sphincter symmetry at rest were significant determinants of continence in both groups but squeeze pressure did not correlate significantly with function in either group. Threshold volume, MTV, and compliance were significantly correlated with frequency of defecation in patients with IPAA but not with CAA. CONCLUSION: A strong consistent resting anal sphincter pressure is one determinant of continence after both IPAA and CAA. Squeeze pressures do not influence the functional result. In IPAA but not CAA, the neorectum has a reservoir function which correlates with the postoperative frequency of defaecation.

Laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy for diverticular disease? A prospective randomized trial on postoperative pain and analgesic consumption.

PURPOSE: Laparoscopic-assisted sigmoidectomy is an attractive but sometimes challenging operative technique for the treatment of diverticulitis of the sigmoid colon. The aim of this study was to compare, with respect to early postoperative analgesic demand and postoperative pain, laparoscopic-assisted sigmoidectomy with a laparoscopic-facilitated technique. In the laparascopic-facilitated technique, the sigmoid colon is removed conventionally via a cosmetically inconspicuous incision after prior laparoscopic mobilization. PATIENTS AND METHODS: Patients subjected to elective sigmoidectomy for diverticulitis were randomized to either laparoscopic-assisted or laparoscopic-facilitated sigmoidectomy. All patients had piritramide-based, patient-controlled analgesia. The cumulative postoperative consumption over 96 hours was defined as the primary end point. Postoperative pain, fatigue, pulmonary function, and resumption of bowel function were secondary endpoints. RESULTS: : Forty-five patients were randomized according to the protocol to laparoscopic-assisted sigmoidectomy (n = 22) or laparoscopic-facilitated sigmoidectomy (n = 23). The analgesic consumption between the two groups was equivalent (61.3 (9-171) mg piritramide/96 hours vs. 64.3 (18-150) mg piritramide/96 hours; P = 0.827). Patients with laparoscopic-assisted sigmoidectomy had lower pain levels on Day one and Day two. Cumulative pain levels over 96 hours and over the whole 7-day observation period, however, were not significantly different, although postoperative fatigue and pulmonary function were significantly different. Duration of surgery was slightly shorter for laparoscopic-assisted sigmoidectomy (127 (47-200) vs. 135 (60-239) minutes; P = 0.28), but recovery of bowel activity was faster after laparoscopic-facilitated surgery. There was no significant difference in morbidity. CONCLUSION: Overall, the postoperative outcome was roughly equivalent after both techniques of laparoscopic sigmoidectomy. Therefore, laparoscopic-facilitated sigmoidectomy could be considered as an alternative to laparoscopic-assisted sigmoidectomy in technically difficult cases of diverticulitis subjected to laparoscopic surgery.

Prospective randomised trial comparing ileocaecal interposition and colon-J-pouch as rectal replacement after total mesorectal excision.

BACKGROUND: Ileocaecal interposition (ICI) is a technique of rectal replacement after total mesorectal excision (TME), but the method has never been evaluated in a randomised fashion. We performed a randomised, controlled trial to compare ICI and colon-J-pouch (CJP) for rectal replacements after TME for rectal cancer. MATERIALS AND METHODS: Fifteen patients were enrolled into each treatment group of the trial according to the protocol. Follow-up evaluations were performed 3 months and 1 year after ileostomy closure and at a mean of 5 years after initial surgery. RESULTS: Similar results between the groups were found for incontinence, urgency, constipation and quality of life at all follow-ups. The frequency of defecation was slightly lower in the CJP group at 3 months [3 (2-6) vs 5 (2-11) (p=0.043)] and at 1 year [3 (2-5) vs 5 (2-8) (p=0.034)]. However, this difference lost significance if patients who had postoperative radiotherapy were excluded from the analysis. Four out of the 15 patients treated with ICI experienced bowel obstruction, which required open surgery in two, endoscopic dilatation in one or maintenance of the ileostomy in one patient. None of the patients treated with CJP had similar complications. CONCLUSIONS: ICI and CJP reconstruction result in a similar functional outcome and quality of life. As ICI did not show any benefit over CJP and tended to result in a higher frequency of defecation, it should not be used as a first choice treatment. In addition, ICI was associated with significant complications after radiotherapy. Therefore, it must not be used if postoperative radiochemotheray is intended.

Pharmacokinetics and peritoneal penetration of moxifloxacin in peritonitis.

OBJECTIVES: To investigate the penetration of moxifloxacin into peritoneal exudate in patients with complicated intra-abdominal infections (cIAIs). PATIENTS AND METHODS: Patients (n = 10) with evidence of peritonitis who required surgery with drainage of the abdominal cavity received a single intravenous infusion of moxifloxacin, 400 mg, over 1 h. Plasma and peritoneal exudate samples were obtained over 24 h, and moxifloxacin concentrations were measured by HPLC with fluorescence detection. RESULTS: Plasma moxifloxacin concentrations decreased from a geometric mean of 3.61 mg/L at 1 h to 0.36 mg/L at 24 h. Concentrations in peritoneal exudate were highest 2 h after the start of the infusion, reaching a geometric mean of 3.32 mg/L, and declined to a geometric mean of 0.69 mg/L at 24 h. The exudate/plasma concentration ratio rose from 1.45 at 2 h to 1.91 at 24 h; the 95% confidence intervals for the ratio excluded unity at all time points, suggesting that moxifloxacin penetrates and accumulates in peritoneal exudate. The area under the concentration-time curve (AUC) tended to be greater in exudate; the time to peak concentrations (T(max)) was longer in exudate than in plasma, as were half-life and mean residence time (MRT). CONCLUSIONS: Following intravenous administration, moxifloxacin penetrated peritoneal exudate in patients with peritonitis, achieving and maintaining concentrations that exceed the MICs for pathogens commonly isolated in cIAIs. These findings support the clinical use of moxifloxacin as treatment for cIAIs.

ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation.

Enhanced recovery of patients after surgery ("ERAS") has become an important focus of perioperative management. From a metabolic and nutritional point of view, the key aspects of perioperative care include: Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and if necessary tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in surgical patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1980. The guideline was discussed and accepted in a consensus conference. EN is indicated even in patients without obvious undernutrition, if it is anticipated that the patient will be unable to eat for more than 7 days perioperatively. It is also indicated in patients who cannot maintain oral intake above 60% of recommended intake for more than 10 days. In these situations nutritional support should be initiated without delay. Delay of surgery for preoperative EN is recommended for patients at severe nutritional risk, defined by the presence of at least one of the following criteria: weight loss >10-15% within 6 months, BMI<18.5 kg/m(2), Subjective Global Assessment Grade C, serum albumin <30 g/l (with no evidence of hepatic or renal dysfunction). Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent.

Adenocarcinoma of the ileoanal pouch for ulcerative colitis--a complication of severe chronic atrophic pouchitis?

BACKGROUND: The appearance of a carcinoma in the ileal pouch after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative proctocolitis is rare. Most of these adenocarcinomas previously described in literature develop from residual viable rectal mucosa. We report a case of an adenocarcinoma arising in all probability from the ileal pouch after malignant transformation of the ileal pouch mucosa based on a chronic atrophic pouchitis. PATIENT AND METHODS: A 34-year-old man developed an adenocarcinoma after a double-stapled ileorectal J-pouch for ulcerative colitis (UC) proceeded from malignant ileal transformation. Before surgery, he had a 20-year history of UC refractory to medical therapy, but no occurrence of backwash ileitis, dysplasia or colitis-associated illness. He experienced severe pouchitis after IPAA since the ileostomy closure. Carcinoma was ensured by endoscopy, and the patient underwent an abdominoperineal pouch extirpation combined with excision of perirectal tissues and anal canal. Histology after surgery showed a pT4,pN2(4/16)pM0,G3 adenocarcinoma with global severe chronic atrophic pouchitis (CAP), villous atrophy and malignant ileal transformation. No metaplasia of the rectal mucosa was found, not even malignant epithelial transformation of the anal canal. CONCLUSION: This case suggests that a malignant transformation of the ileal pouch mucosa may occur as a pure complication of severe CAP, even in the absence of backwash ileitis or a previous history of cancer. The absence of metaplasia of the rectal mucosa revealed the passage from CAP to dysplastic epithelium and to cancer. A multifactorial development of carcinogenesis is supposed, but we emphasize the importance of severe CAP, and that careful surveillance is needed in patients after IPAA. We must submit that this is just a case report and cannot stand for general cancer development in ulcerative colitis, but it may point out the risk factor of chronic inflammation and leads the surgeon to skillful working when building the pouch.

[Contraction of the hip and fecal drainage via a fistula tract 30 years after "appendectomy"]. / Stuhlfistel und Hüftgelenkskontraktur 30 Jahre nach "Blinddarmoperation".

A 46-year-old female was admitted with increasing fecal drainage via a fistula tract in the right inguinal region. She had a history of surgery for appendicitis 30 years previously, from which there was disturbed wound healing resulting in a blunt fistula, and the patient suffered from contraction of the right hip. Computed tomographic scan and ultrasound demonstrated an inflammatory mass in the right inguinal region. Colonoscopy demonstrated a stenosis of the rectosigmoid junction but did not provide any further specific information. Surgery revealed the presumed diagnosis of complicated Crohn's disease, but an advanced squamous cell carcinoma was also identified. The patient died 23 months later due to generalized tumor. Although malignant transformation of a fistula tract is rare, this case demonstrates that long-standing fistulas should be cured as far as possible without significant morbidity. In the case of incurable fistulas, malignancy must definitely be excluded if the clinical appearance of the fistula changes.

Prospective pilot study of neoadjuvant chemotherapy with 5-fluorouracil, folinic acid and oxaliplatin in resectable liver metastases of colorectal cancer. Analysis of 42 neoadjuvant chemotherapies.

PURPOSE: Since there are currently no data available from a prospective trial, the primary objective of this prospective study was to investigate whether the rate of R0-liver resections without morbidity would be at least 50 % in patients with neoadjuvant chemotherapy for colorectal liver metastases. PATIENTS AND METHODS: 42 patients were treated with a biweekly FOLFOX regimen. Chemotherapy consisted of a 2-hour infusion of folinic acid (FOL) 500 mg/m2, followed by a 24-hour infusion of 5- fluorouracil (F) 2000 mg/m2 daily for two days. Oxaliplatin (OX) 85 mg/m 2 was given simultaneously with FOL. Treatment allocation was randomized with either 3 or 6 cycles for the final 30 patients. A liver resection was performed 2 to 5 weeks after the final infusion. RESULTS: An objective response was observed in 20 of 42 patients (response rate was 27 % higher after 6 cycles). Liver resection (R0) could be performed in 34 patients. Postoperative complications were reported in 14 patients (13 occurring within 30 days after resection) and severe complications in 5 cases (including two deaths after extended resection). Liver failure and persistent biliary fistula were the most frequently documented complications. There was no relevant difference in safety criteria between 3 and 6 applications. CONCLUSION: The use of neoadjuvant chemotherapy in resectable liver metastases induced significant remissions without increasing morbidity. The rate of severe complications and cases of no R0-resection in this study was 31 % and was with that significantly lower than 50 % (95 % CI 17.6 %-47.1 %). The risk to the patient is therefore acceptable when undergoing neoadjuvant treatment in a prospective intergroup trial.

[Vulnerability of ileocoecal interposition pouch and colonic J-pouch to postoperative adjuvant radiotherapy]. / Vulnerabilität von ileocoecalem Interpositionspouch und Colon-J-Pouch gegenüber der postoperativen, adjuvanten Strahlentherapie.

AIM: The interposition of an ileocoecal segment has been introduced as an alternative procedure to impair the functional outcome following total mesorectal excision (TME). Up to now, there is no information concerning the effect of postoperative radiotherapy on the functional outcome of this method. PATIENTS AND METHODS: We compared functional outcome, anorectal physiology, and radiation therapy-related morbidity of 18 patients treated with TME und ileocoecal interposition (ICI) of which ten had postoperative radiotherapy, with 15 patients who had TME and colonic J-pouch (CJP) reconstruction of which 7 were subjected to radiotherapy. RESULTS: Patients with no radiotherapy revealed a satisfying functional result with a similar median frequency of defecation of 4.25 (2-5) and 3 (2-6) and an incontinence-score of 2.8 (0-6) and 1.0 (0-2) after ICI and CJP, respectively. Median stool frequency (7 (2-11) (ICI) and 5 (2.5-11) (CJP)) and incontinence score (6 (0-12) (ICI) and 7 (6-12) (CJP)) were markedly increased in both groups after radiotherapy. Besides a reduced anal resting pressure, a lower compliance and a smaller volume of the neorectum were observed in the irradiated patients. A radiogenic injury which required surgery was seen in 4/10 patients after ICI. In three of these four patients the interposed ileocoecal segment was mainly affected. None of the patients treated with a CJP suffered a similar complication. DISCUSSION: These data indicate that postoperative radiotherapy severely impairs the functional outcome after TME independent of the type of surgery used for reconstruction, and causes a significant morbidity after ICI. CONCLUSION: Postoperative radiotherapy following TME should be indicated cautiously, and ICI should not be used if postoperative radiotherapy is intended.

[Surgical approach is toxic colitis]. / Operative Strategie bei toxischer Colitis.

Toxic colitis is still a major diagnostic and therapeutic challenge. Mortality rates depend on the severity of the disease and range from 2% to 30%. Interdisciplinary approaches are necessary and structured therapeutic steps from conservative to operative treatment seem to be most effective. The surgical option for toxic colitis usually is subtotal colectomy with closure of the rectal stump or mucus fistula and ileostomy. This procedure allows the reconstructive operation later on. In selected cases and suitable situations a primary colectomy with ilealpouch are also possible depending on local and general effects.

Negative side-effects of retention sutures for abdominal wound closure. A prospective randomised study.

OBJECTIVE: To assess the effect of retention sutures on the postoperative course of patients after major abdominal operations. DESIGN: Prospective, randomised study. SETTING: Teaching hospital, Germany. SUBJECTS: 95 patients who were at increased risk of wound failure after major abdominal operations. INTERVENTION: Conventional mass closure either with (n = 44) or without (n = 51) reinforcement by wire retention sutures. MAIN OUTCOME MEASURES: Pain intensity on postoperative days 3, 6, 9, and 12, patients' acceptance, retention-suture-related morbidity, general morbidity. RESULTS: Postoperative pain was overall more severe with retention sutures. On day 6, 31/49 control patients but only 13/41 patients with retention sutures were pain-free (p = 0.003, 95% CI 0.12 to 0.51). Twelve of 44 patients with retention sutures developed local complications of the sutures, and 21 of the 44 had to have them removed prematurely, in most cases because of intolerable pain. CONCLUSIONS: Retention sutures used to close abdominal wounds cause inconvenience, pain, and specific morbidity.

Stoma care nurses: good value for money?

Decreasing financial resources in health services often lead to wholesale budget reducing in hospitals. Enterostomal therapists are more and more concerned by this situation. Data on the cost-effectiveness of stoma therapy have not existed, a gap filled by the present study. From January to December 1996 data from 94 patients about therapy-related costs, outcome, and evaluation of stoma therapy from the patient's point of view were ascertained prospectively. For an average (SD) of 14.6 (7.1) patient contacts for stoma planning, advice, care, and so on the average duration was 12.9 (9.1) minutes per contact. At an average exchange rate of 1.50 German marks (DM) per US dollar in 1996 the enterostomal therapist's part of the total staff costs was US$15,212 (2.7%), the cost of stoma products was US$7750 (4.5% of the total costs of medical supplies). About 89.3% of the patients classified the enterostomal therapist necessary and indispensable; 70.3% of the patients said they could cope with their stoma very well to well at the time of questioning. In contrast, 69.2% of those questioned declared that without the care by the enterostomal therapist in hospital they would be able to cope with their stoma only poorly to very poorly. We conclude that from the patient's point of view the costs of our stoma therapy are justifiably low. Therefore we see no reason for a discussion about rationalization measures regarding our stoma therapy staff.

[Problems in calculating and recalculating case fees and special reimbursements exemplified by a general surgery clinic]. / Probleme bei der Kalkulation bzw. Nachkalkulation von Fallpauschalen und Sonderentgelten am Beispiel einer allgemeinchirurgischen Klinik.

A calculation of costs for the not perforated appendicitis was performed. The main costs are the nursing costs on ward. As one of the consequences we have to prove the intensity of nursing and the resulting classification to reduce the depending more costs of 200 DM.

[Mesh-plasty for recurrent abdominal wall hernias--results]. / Netzplastiken bei Bauchwand-Rezidivhernien--Ergebnisse.

The rates of re-recurrent hernias after initial abdominal wall hernia repair are high. To reduce this intolerable high recurrence rate, 31 patients were treated by polypropylene-mesh implantation and followed up for about 3 years. Two new hernias could be diagnosed and were treated without problems by repeated implantation of Prolene-mesh. About 50% of patients complain of some pain at the edges of the implanted mesh--usually this makes only very few discomfort for the patients. The Polypropylene (Prolene) mesh implantation seems to reduce re-recurrence rates compared to published results of hernia repair without mesh implantation.