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Wilhelm Waldeyer was one of the most important anatomists of his time. The year 2021 marks the 100th anniversary of his death. His name not only lives on in terms such as "Waldeyer's pharyngeal ring" or "Waldeyer's fascia," he also coined the terms "neuron" and "chromosome." He produced monumental monographies such as "The Pelvis" and "Ovary and Egg". Waldeyer's legacy is a large body of lifetime work that continues to impress to this day. However, he also published works that today would be described as racist. His view of a woman's role was and is also controversial. Nevertheless, reading his autobiography ( Lebenserinnerungen ) today is still beneficial because it vividly illustrates the academic life and a scholarly existence of that era., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Scheuerlein, Pape-Köhler and Köckerling.)

Background: The practice of bariatric surgery was studied using the German Bariatric Surgery Registry (GBSR). The focus of the study was to evaluate whether revision surgery One-Step (OS) or Two-Step (TS) sleeve gastrectomy (SG) has a large benefit in terms of perioperative risk in patients after failed Adjustable Gastric Banding (AGB). Methods: The data collection includes patients who underwent One-Step SG (OS-SG) or Two-Step SG (TS-SG) as revision surgery after AGB and primary SG (P-SG) between 2005 and 2019. Outcome criteria were perioperative complications, comorbidities, 30-day mortality, and operating time. Results: The study analyzed data from 27,346 patients after P-SG, 320 after OS-SG, and 168 after TS-SG. Regarding the intraoperative complication, there was a significant difference in favor of P-SG and TS-SG compared to OS-SG ( p < 0.001). The incidence of pulmonary complications was significantly higher in the OS-SG ( p < 0.001). There was also a significant difference in occurrence of staple line stenosis in favor of TS-SG ( p = 0.005) and the occurrence of sepsis ( p = 0.008). The mean operating time was statistically longer in the TS-SG group than in the OS-SG group ( p < 0.001). The 30-day mortality was not significantly different between the three groups ( p = 0.727). Conclusion: In general, our study shows that converting a gastric band to a SG is safe and feasible. However, lower complications were obtained with TS-SG compared to OS-SG. Despite acceptable complication and mortality rates of both procedures, we cannot recommend any surgical method as a standard procedure. Proper patient selection is crucial to avoid possible adverse effects., Competing Interests: MH was employed by the company StatConsult GmbH, Magdeburg. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Thaher, Driouch, Hukauf, Köckerling and Stroh.)

Introduction: While the proportion of emergency groin hernia repairs in developed countries is 2.5-7.7%, the percentage in developing countries can be as high as 76.9%. The mortality rate for emergency groin hernia repair in developed countries is 1.7-7.0% and can rise to 6-25% if bowel resection is needed. In this present analysis of data from the Herniamed Registry, patients with emergency admission and operation within 24 h are analyzed. Methods: Between 2010 and 2019 a total of 13,028 patients with emergency admission and groin hernia repairs within 24 h were enrolled in the Herniamed Registry. The outcome results were assigned to the year of repair and summarized as curves. The total patient collective is broken down into the subgroups with pre-operative manual reduction (taxis) of the hernia content, operative reduction of the hernia content without bowel resection and with bowel resection. The explorative Fisher's exact test was used for statistical assessment of significant differences with Bonferroni adjustment for multiple testing. Results: The proportion of emergency admissions with groin hernia repair within 24 h was 2.7%. The percentage of women across the years was consistently 33%. The part of femoral hernias was 16%. The proportion of patients with pre-operative reduction (taxis) remained unchanged at around 21% and the share needing bowel resection was around 10%. The proportion of TAPP repairs rose from 21.9% in 2013 to 38.0% in 2019 ( p < 0.001). Between the three groups with pre-operative taxis, without bowel resection and with bowel resection, highly significant differences were identified between the patients with regard to the rates of post-operative complications (4% vs. 6.5% vs. 22.7%; p < 0.0001), complication-related reoperations (1.9% vs. 3.8% vs. 17.7%; p < 0.0001), and mortality rate (0.3% vs. 0.9% vs. 7.5%; p < 0.001). In addition to emergency groin hernia repair subgroups female gender and age ≥66 years are unfavorable influencing factors for perioperative outcomes. Conclusion: For patients with emergency groin hernia repair the need for surgical reduction or bowel resection, female gender and age ≥66 years have a highly significantly unfavorable influence on the perioperative outcomes., Competing Interests: FK reports grants to fund Herniamed from Johnson & Johnson, Norderstedt, grants from Karl Storz, Tuttlingen, grants from pfm medical, Cologne, grants from Dahlhausen, Cologne, grants from B Braun, Tuttlingen, grants from MenkeMed, Munich, grants from Bard, Karlsruhe, during the conduct of the study; personal fees from Bard, Karlsruhe, outside the submitted work. DA was employed by the company StatConsult GmbH. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Köckerling, Heine, Adolf, Zarras, Weyhe, Lammers, Mayer, Reinpold and Jacob.)

Incisional hernias are common late complications of abdominal surgery, with a 1-year post-laparotomy incidence of about 20%. A giant hernia is often preceded by severe peritonitis of various causes. The Fasciotens® Abdomen device is used to stretch the fascia in a measurably controlled manner during surgery to achieve primary tension-free abdominal closure. This prospective observational study aims to clarify the extent to which this traction method can function as an alternative to component separation (CS) methods. Methods: We included data of 21 patients treated with intraoperative fascia stretching in seven specialized hernia centers between November 2019 and August 2020. Results: Intraoperatively-measured fascial distance averaged 17.3 cm (range 8.5-44 cm). After application of diagonal-anterior traction >10 kg for an average duration of 32.3 min (range 30-40 min), the fascial distance decreased by 9.8 cm (1-26 cm) to an average 7.5 cm (range 2-19 cm), which is a large effect ( r = 0.62). The fascial length increase (average 9.8 cm) after applied traction was highly significant. All hernias were closed under moderate tension after the traction phase. In 19 patients, this closure was reinforced with mesh using a sublay technique. Conclusion: This method allows primary closure of complex (LOD) hernias and is potentially less prone to complications than component separation (CS) methods., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Niebuhr, Aufenberg, Dag, Reinpold, Peiper, Schardey, Renter, Aly, Eucker, Köckerling and Eichelter.)

Introduction: The repair of subxiphoidal incisional hernia following median sternotomy is technically demanding due to the specific anatomic situation and the lateral distracting forces in this region. Published data are available from retrospective reports with limited number of patients only. The aim of this study was to evaluate the outcome of subxiphoidal hernia repair comparing laparoscopic and open surgical approach. Materials and Methods: This analysis of Herniamed registry data of patients with subxiphoidal incisional hernia following sternotomy for coronary bypass assesses the perioperative and 1 year follow-up outcome of laparoscopic and open repair. Demographic data and perioperative outcomes were stratified by surgical approach (laparoscopic vs. open) and compared as unadjusted analyses using Chi square and Students t -tests. Results: Of 208 patients identified for the analysis 69 patients (33.2%) underwent laparoscopic and 139 (66.8%) patients had open repair. Concerning demographic data (gender, age, BMI, ASA score), risk factors and hernia size there were no significant differences between laparoscopic and open repair group. For intraoperative, postoperative and general complications as well as complication related re-operations no significant differences were seen between the groups. No significant advantage could be stated for laparoscopic repair regarding duration of operation and hospital stay. The recurrence rate at 1 year follow-up was higher in the laparoscopic group (7.2 vs. 2.2%; p = 0.072). No significant differences were reported in the 1 year follow-up evaluation of pain at rest, pain on exertion and pain requiring treatment. Conclusion: The repair of subxiphoidal incisional hernia is safe in both open and laparoscopic technique. With regard to the lower recurrence rate preference can be given to open repair., (Copyright © 2020 Albrecht, Trawa, Köckerling, Hukauf and Gretschel.)

Introduction: To date, the guidelines for surgical repair of hiatal hernias do not contain any clear recommendations on the hiatoplasty technique with regard to the use of a mesh or to the type of fundoplication (Nissen vs. Toupet). This present 10-years analysis of data from the Herniamed Registry aims to investigate these questions. Methods: Data on 17,328 elective hiatal hernia repairs were entered into the Herniamed Registry between 01.01.2010 and 31.12.2019. 96.4% of all repairs were completed by laparoscopic technique. One-year follow-up was available for 11,280 of 13,859 (81.4%) patients operated during the years 2010-2018. The explorative Fisher's exact test was used for statistical calculation of significant differences with an alpha = 5%. Since the annual number of cases in the Herniamed Registry in the years 2010-2012 was still relatively low, to identify significant differences the years 2013 and 2019 were compared. Results: The use of mesh hiatoplasty for axial and recurrent hiatal hernias remained stable over the years from 2013 to 2019 at 20 and 45%, respectively. In the same period the use of mesh hiatoplasty for paraesophageal hiatal hernia slightly, but significantly, increased from 33.0 to 38.9%. The proportion of Nissen and Toupet fundoplications for axial hiatal hernia repair dropped from 90.2% in 2013 to 74.0% in 2019 in favor of "other techniques" at 20.9%. For the paraesophageal hiatal hernias (types II-IV) the proportion of Nissen and Toupet fundoplications was 68.1% in 2013 and 66.0% in 2019. The paraesophageal hiatal hernia repairs included a proportion of gastropexy procedures of 21.7% in 2013 and 18.7% in 2019. The recurrent hiatal hernia repairs also included a proportion of gastropexies 12.8% in 2013 and 15.1% in 2019, Nissen and Toupet fundoplications of 72.7 and 62.7%, respectively, and "other techniques" of 14.5 and 22.2%, respectively. No changes were seen in the postoperative complication and recurrence rates. Conclusion: Clear trends are seen in hiatal hernia repair. The use of meshes has only slightly increased in paraesophageal hiatal hernia repairs. The use of alternative techniques has resulted in a reduction in the use of the "classic" Nissen and Toupet fundoplication surgical techniques., (Copyright © 2020 Köckerling, Zarras, Adolf, Kraft, Jacob, Weyhe and Schug-Pass.)

Introduction: A spermatic cord lipoma is found in 20-70% of all inguinal hernia repairs. The clinical picture of an inguinal hernia with bulging and pain but without an actual indirect hernia sac may become manifest in up to 8% of these cases. Missed spermatic cord lipoma can result in recurrence or pseudo-recurrence. This review presents the relevant literature on this topic. Materials and Methods: A systematic search of the available literature was performed in February 2020 using Medline, PubMed, Google Scholar, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. Forty-two publications were identified as relevant for this topic. Results: Spermatic cord lipoma seems to originate from preperitoneal fatty tissue within the internal spermatic fascia in topographical proximity to the arteries, veins, lymphatics, nerves, and deferent duct within the spermatic cord. Reliable diagnosis cannot be made clinically, but rather with ultrasound, CT, or MRI. In the absence of a real hernia sac, a spermatic cord lipoma is classified as a lateral inguinal hernia with a defect size <1.5 cm according to the European Hernia Society (EHS LI). Missed or inadequately treated spermatic cord lipoma results in recurrence or pseudo-recurrence. Since spermatic cord lipoma obtains its vascular supply from the preperitoneal space, it can be reduced or resected. Conclusion: Spermatic cord lipoma is a common finding in inguinal hernia repairs and must be properly diagnosed and treated with care respecting the anatomy of the spermatic cord., (Copyright © 2020 Köckerling and Schug-Pass.)

Introduction: Recurrent incisional hernias with a rate of around 20% account for a relatively large proportion of all incisional hernias. It is difficult to issue any binding recommendations on optimum treatment in view of the relatively few studies available on this topic. This review now aims to collate the data available on recurrent incisional hernia. Material and Methods: A systematic search of the available literature was performed in January 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals and reference lists. For the present analysis, 47 publications were identified as relevant. Results: There are mainly case series available on the treatment of recurrent incisional hernia. Eight evaluable case series and two prospective comparative studies report on treatment of between 27 and 85 recurrent hernias. After primary open repair of incisional hernia and defect sizes of < 8-10 cm, the recurrence operation can be performed in laparoscopic technique provided the surgeon has sufficient experience in that procedure. That also applies to multiple recurrences after exclusively open repair. There are no evaluable data on a repeat laparoscopic approach after minimally invasive repair of primary incisional hernia. Such an approach should only be chosen by very experienced laparoscopic surgeons and based on a well-founded indication. Further data are urgently needed on treatment of recurrent incisional hernia. Conclusion: Very little data are available on the treatment of recurrent incisional hernia. Based on the tailored approach concept, a laparoscopic approach undertaken by an experienced laparoscopic surgeon can be recommended for recurrent hernias after primary open repair and for defects of up to 8-10 cm.

Introduction: In publications on ventral incisional hernia repair, the Chevrel technique and the onlay operation are often equated. This present review now aims to present the difference between these surgical techniques and analyze the findings available on the Chevrel technique. Materials and Methods: A systematic search of the available literature was performed in January 2019 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library, as well as a search of relevant journals, books, and reference lists. Thirty-four publications were identified as relevant for this review. For assessment of the Chevrel-technique with other surgical procedures there are no randomized controlled trials, prospective or retrospective comparative studies available but only case series. In the majority of case series the follow-up procedure is not reported. Results: In the onlay technique the defect is closed with direct suture or it is omitted altogether. Whereas, in the Chevrel technique this is done with sliding myofascial flaps harvested from the rectus sheaths. In the few case series available this appears to result in a lower recurrence rate for the Chevrel technique compared with the onlay technique. However, the rates of postoperative complications, surgical site occurrences (SSOs), surgical site infections (SSIs), seroma, and skin necrosis are as high as in the onlay technique. The reason for this is that both techniques require subcutaneous undermining with severance of perforator vessels. Conclusion: If mesh placement in onlay position has been chosen for specific reasons, preference can be given to the Chevrel technique over the standard onlay technique, although the study quality is limited.

Introduction: This review aimed to present common points, intersections, and potential interactions or mutual effects for hernia and cancer. Besides direct relationships, indirect connections, and possible involvements were searched. Materials and Methods: A literature search of PubMed database was performed in July 2018 as well as a search of relevant journals and reference lists. The total number of screened articles was 1,422. Some articles were found in multiple different searches. A last PubMed search was performed during manuscript writing in December 2018 to update the knowledge. Eventually 427 articles with full text were evaluated, and 264 included, in this review. Results: There is no real evidence for a possible common etiology for abdominal wall hernias and any cancer type. The two different diseases had been found to have some common points in the studies on genes, integrins, and biomarkers, however, to date no meaningful relationship has been identified between these points. There is also some, albeit rather conflicting, evidence for inguinal hernia being a possible risk factor for testicular cancer. Neoadjuvant or adjuvant therapeutic modalities like chemotherapy and radiotherapy may cause postoperative herniation with their adverse effects on tissue repair. Certain specific substances like bevacizumab may cause more serious complications and interfere with hernia repair. There are only two articles in PubMed directly related to the topic of "hernia and cancer." In one of these the authors claimed that there was no association between cancer development and hernia repair with mesh. The other article reported two cases of squamous-cell carcinoma developed secondary to longstanding mesh infections. Conclusion: As expected, the relationship between abdominal wall hernias and cancer is weak. Hernia repair with mesh does not cause cancer, there is only one case report on cancer development following a longstanding prosthetic material infections. However, there are some intersection points between these two disease groups which are worthy of research in the future.

Background: To date, there are few studies and no systematic reviews focusing specifically on groin hernia in women. Most of the existing knowledge comes from registry data. Objective: This present review now reports on such findings as are available on groin hernia in women. Materials and Methods: A systematic search of the available literature was performed in September 2018 using Medline, PubMed, Google Scholar, and the Cochrane Library. For the present analysis 80 publications were identified. Results: The lifetime risk of developing a groin hernia in women is 3-5.8%. The proportion of women in the overall collective of operated groin hernias is 8.0-11.5%. In women, the proportion of femoral hernias is 16.7-37%. Risk factors for development of a groin hernia in women of high age and with a positive family history. A groin hernia during pregnancy should not be operated on. The rate of emergency procedures in women, at 14.5-17.0%, is 3 to 4-fold higher than in men and at 40.6% is even higher for femoral hernia. Therefore, watchful waiting is not indicated in women. During surgical repair of groin hernia in females the presence of a femoral hernia should always be excluded and if detected should be repaired using a laparo-endoscopic or open preperitoneal mesh technique. A higher rate of chronic postoperative inguinal pain must be expected in females. Conclusion: Special characteristics must be taken into account for repair of groin hernia in women.

Introduction: Recently, the promising results of new procedures for the treatment of rectus diastasis with concomitant hernias using extraperitoneal mesh placement and anatomical restoration of the linea alba were published. To date, there is no recognized classification of rectus diastasis (RD) with concomitant hernias. This is urgently needed for comparative assessment of new surgical techniques. A working group of the German Hernia Society (DHG) and the International Endohernia Society (IEHS) set itself the task of devising such a classification. Materials and Methods: A systematic search of the available literature was performed up to October 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. A meeting of the working group was held in May 2018 in Hamburg. For the present analysis 30 publications were identified as relevant. Results: In addition to the usual patient- and technique-related influencing factors on the outcome of hernia surgery, a typical means of rectus diastasis classification and diagnosis should be devised. Here the length of the rectus diastasis should be classified in terms of the respective subxiphoidal, epigastric, umbilical, infraumbilical, and suprapubic sectors affected as well as by the width in centimeters, whereby W1 < 3 cm, W2 = 3- ≤ 5 cm, and W3 > 5 cm. Furthermore, gender, the concomitant hernias, previous abdominal surgery, number of pregnancies and multiple births, spontaneous birth or caesarian section, skin condition, diagnostic procedures and preoperative pain rate and localization of pain should be recorded. Conclusion: Such a unique classification is needed for assessment of the treatment results in patients with RD.

Introduction: A meta-analysis that compared the onlay vs. sublay technique in open incisional hernia repair identified better outcomes for the sublay operation. Nonetheless, an Expert Consensus Guided by Systematic Review found the onlay mesh location useful in certain settings. Therefore, all studies on the onlay technique were once again collated and analyzed. Materials and Methods: A systematic search of the available literature was performed in August 2018 using Medline, PubMed, Scopus, Embase, Springer Link, and the Cochrane Library. For the present analysis 42 publications were identified as relevant. Results: In five prospective randomized trials and 17 observational studies the postoperative complication rates ranged between 5 and 76%, with a mean value of 33.5%. The recurrence rates in these studies also ranged between 0 and 32%, with a mean value of 9.9%. Hence, compared with the literature data on the sublay operation, more post-operative complications, in particular wound complications and seroma, with a comparable recurrence rate, were identified. Conclusion: When the onlay technique is used in certain settings for incisional hernia repair, a careful dissection technique and prophylactic measures (drainage, abdominal binders, fibrin sealant) should be employed to prevent wound complications and seroma formation.

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

Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified. Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant. Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery. Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.

Introduction: There continues to be very little agreement among experts on the precise treatment strategy for incisional hernias. That is the conclusion drawn from the very limited scientific evidence available on the repair of incisional hernias. The present review now aims to critically assess the data available on the sublay/retro-rectus technique for repair of incisional hernia. Materials and Methods: A systematic search of the literature was performed in May 2018 using Medline, PubMed, and the Cochrane Library. This article is based on 77 publications. Results: The number of available RCTs that permit evaluation of the role of the sublay/retro-rectus technique in the repair of only incisional hernia is very small. The existing data suggest that the sublay/retro-rectus technique has disadvantages compared with the laparoscopic IPOM technique for repair of incisional hernia, but in that respect has advantages over all other open techniques. However, the few existing studies provide only a limited level of evidence for assessment purposes. Conclusion: Further RCTs based on a standardized technique are urgently needed for evaluation of the role of the sublay/retro-rectus incisional hernia repair technique.

Introduction: In a systematic review of the surgical treatment of large incisional hernia sublay repair, the sandwich technique and aponeuroplasty with intraperitoneal mesh displayed the best results. In this systematic review only the sandwich technique, which used the hernia sac as an extension of the posterior and anterior rectus sheath and placement of a non-absorbable mesh in the sublay position, was included. Other modifications of the sandwich technique are published in the literature and were also analyzed in this literature review., Methods: A systematic search of the available literature was performed in November 2017 using Medline, PubMed, and the Cochrane Library using the terms "sandwich technique", "double prosthetic repair", "double mesh intraperitoneal repair", and "component separation technique with double mesh". This review is based on 24 relevant publications. Unfortunately, the evidence of the available studies is not very high since only prospective and retrospective case series have been published. There are no comparative studies at all. Therefore, the findings of the published case series must be viewed in a critical light., Results: The published studies report a remarkably low recurrence rate of 0-13% with a follow-up of 1-7 years. One limitation that must be mentioned here is that in around half of the studies the method of follow-up was not specified and in the remaining cases this was based on clinical examination by the surgical team. This puts into perspective the reported results, which appear to be too favorable given the complex nature of the hernias involved.The major disadvantage of the sandwich technique is a very high rate of wound complications of up to 68%, mainly induced by creation of large skin and subcutaneous cellular tissue flaps., Conclusion: It is difficult to evaluate the significance of the various modifications of the "sandwich technique" based on the available literature since it includes only case series and no comparative studies. The techniques used are associated with very high wound complication rates but with only relatively low recurrence rates despite the complexity of the cases involved. This must be verified in studies with a well-designed methodology.

Introduction: The component separation technique (CST) was introduced to abdominal wall reconstruction to treat large, complex hernias. It is very difficult to compare the published findings because of the vast number of technical modifications to CST as well as the heterogeneity of the patient population operated on with this technique., Material and Methods: The main focus of the literature search conducted up to August 2017 in Medline and PubMed was on publications reporting comparative findings as well as on systematic reviews in order to formulate statements regarding the various CSTs., Results: CST without mesh should no longer be performed because of too high recurrence rates. Open anterior CST has too high a surgical site occurrence rate and henceforth should only be conducted as endoscopic and perforator sparing anterior CST. Open posterior CST and posterior CST with transversus abdominis release (TAR) produce better results than open anterior CST. To date, no significant differences have been found between endoscopic anterior, perforator sparing anterior CST and posterior CST with transversus abdominis release. Robot-assisted posterior CST with TAR is the latest, very promising alternative. The systematic use of biologic meshes cannot be recommended for CST., Conclusion: CST should always be performed with mesh as endoscopic or perforator sparing anterior or posterior CST. Robot-assisted posterior CST with TAR is the latest development.

Wilhelm Waldeyer was, at his time, one of the most well-known authors in the field of Anatomy, Pathology, and Embryology. He held various distinguished academic positions. He was Professor of (Pathological) Anatomy in Breslau, Strasbourg, and Berlin. He remained in Berlin for the unusually long period of 33.5 years, as Full Professor for Anatomy and Director of the Anatomical Institute. His great talent as a teacher ensured that his lectures were always filled to the brim. Between 1862 and 1920, he published 270 works, including classics such as "Das Becken" (The Pelvis). The portrayal of this most important area is counted as one of the most complete which has ever been accomplished in the field of topographic anatomy, it includes the description of the fascia of Waldeyer. He also coined the phrases "chromosome" and "neuron" with their anatomical-morphological concepts. Already during his lifetime, his teaching ability significantly preceded the research capacity. It would, however, be false to overshadow Waldeyer's merits as a researcher. His main scientific merit is in his excellent summarizing interpretations of current questions of anatomy and evolution, which particularly shows his simultaneous gift as a researcher and a teacher.

Introduction: Severe postoperative pain is an important risk factor for onset of chronic inguinal pain following inguinal hernia repair. All measures must be taken to eliminate postoperative pain., Materials and Methods: This case report highlights the problems of severe postoperative pain following transabdominal preperitoneal patch plasty (TAPP) inguinal hernia repair and describes a systematic treatment path that may include surgical intervention., Results: Following TAPP operation for lateral inguinal hernia, this patient who had been operated on in an external hospital still experienced intense, stabbing inguinal pain on postoperative day 7 during movement, despite optimal pain treatment. Diagnostic examination did not reveal any findings of note. The surgical report documented that the surgeon had used metallic tacks for mesh fixation, i.e., at the pectineal line of the pubic bone, pubic symphysis, upper margin of the mesh, and for closure of the peritoneum. During surgical revision on postoperative day 7, eight tacks and the mesh were removed and, following further dissection, a new mesh was placed and fixed with glue. The patient's intense stabbing pain resolved immediately after surgery., Conclusion: Since the results of late intervention for chronic inguinal pain are anything but satisfactory, early surgical intervention should be considered for patients with severe postoperative pain >3 days of suspected surgical origin.

Introduction: The guidelines of the international hernia societies recommend posterior repair in laparo-endoscopic technique for recurrent inguinal hernia after open anterior mesh repair and, conversely, open anterior repair for recurrence after laparo-endoscopic primary repair. Even when these guidelines are followed, already 1 year after repair a re-recurrence rate of 1-2% must be expected, with that rate rising further in the subsequent years. Accordingly, increasingly more patients with re-recurrence after anterior and posterior mesh implantation must be treated, which constitutes a problem that to date has been investigated in only very few studies. Hence, there are no well-founded recommendations. This paper now presents a number of case reports aimed at identifying the role of explorative laparoscopy as decision tool for re-recurrent inguinal hernia treatment., Patients and Methods: Based on three case reports the role of explorative laparoscopy as decision tool for re-recurrent inguinal hernia treatment is presented below., Results: In all the three cases described explorative laparoscopy played a key role as decision tool when deciding how best to treat re-recurrence after anterior and posterior inguinal hernia repair. In one case severe adhesions after robotic prostatectomy and in another case correct placement of the mesh in the posterior plane, adhesions from the cecum to the groin region and no definitive finding of a re-recurrence resulted in an open repair. In the third case, an insufficient laparoscopic posterior mesh placement made the re-recurrent TAPP procedure relatively easy., Conclusion: Explorative laparoscopy is an important decision tool for re-recurrent inguinal hernia treatment to minimize the risks of the procedure for the patients.

Background: Prophylactic mesh-augmented reinforcement during closure of abdominal wall incisions has been proposed in patients with increased risk for development of incisional hernias (IHs). As part of the BioMesh consensus project, a systematic literature review has been performed to detect those studies where MAR was performed with a non-permanent absorbable mesh (biological or biosynthetic)., Methods: A computerized search was performed within 12 databases (Embase, Medline, Web-of-Science, Scopus, Cochrane, CINAHL, Pubmed publisher, Lilacs, Scielo, ScienceDirect, ProQuest, Google Scholar) with appropriate search terms. Qualitative evaluation was performed using the MINORS score for cohort studies and the Jadad score for randomized clinical trials (RCTs)., Results: For midline laparotomy incisions and stoma reversal wounds, two RCTs, two case-control studies, and two case series were identified. The studies were very heterogeneous in terms of mesh configuration (cross linked versus non-cross linked), mesh position (intraperitoneal versus retro-muscular versus onlay), surgical indication (gastric bypass versus aortic aneurysm), outcome results (effective versus non-effective). After qualitative assessment, we have to conclude that the level of evidence on the efficacy and safety of biological meshes for prevention of IHs is very low . No comparative studies were found comparing biological mesh with synthetic non-absorbable meshes for the prevention of IHs., Conclusion: There is no evidence supporting the use of non-permanent absorbable mesh (biological or biosynthetic) for prevention of IHs when closing a laparotomy in high-risk patients or in stoma reversal wounds. There is no evidence that a non-permanent absorbable mesh should be preferred to synthetic non-absorbable mesh, both in clean or clean-contaminated surgery.

Introduction: Perineal hernia (PerH) following abdominoperineal excision (APE) procedure is a recognized complication. PerH was considered an infrequent complication of APE procedure; however, PerH rates of up to 45% have been reported in recent publications following a laparoscopic APE procedure. Various methods of repair of PerH with the use of synthetic meshes or myocutaneous flap have been described, although there is no general agreement on an optimal strategy. The use of biological meshes for different operations is growing in popularity, and these have been promoted as being superior and safer when compared to synthetic meshes. Although the use of biologics is becoming popular claims of better outcomes are largely unsupported by evidence. The aim of this systematic review is to evaluate the currently available evidence supporting the use of biologic or biosynthetic meshes for the repair of PerH that develop following an APE., Methods: A systematic review of all English language literature relevant to repair of PerH following APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE, EMBASE, and the Cochrane Library of Systematic Reviews for relevant literature. Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words "PerH," "APE," "morbidity," "biologics," "biosynthetic," and "hernia." Studies in which the use of biological meshes was not reported were excluded from the review. Various outcome measures, including operative technique, complication rates, recurrence rates, type of mesh, management of recurrences, and risk factors, were extracted. Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) was used to assess the quality of evidence., Results: The systematic review of the literature identified three case reports, four case series, and one pooled analysis that were included in the final review. Overall, these studies were of poor quality providing level 4 evidence. Various different approaches and techniques of repair of PerH were described; however, it was difficult to extract information with regard to the primary and secondary outcome measures., Conclusion: There is no general agreement to the optimal operative strategy to repair PerH following an APE. There is insufficient evidence to recommend any specific operative approach or repair technique for PerH following an APE.

Introduction: The learning curve in minimally invasive surgery is much longer than in open surgery. This is thought to be due to the higher demands made on the surgeon's skills. Therefore, the question raised at the outset of training in laparoscopic surgery is how such skills can be acquired by undergoing training outside the bounds of clinical activities to try to shorten the learning curve. Simulation-based training courses are one such model., Methods: In 2011, the surgery societies of Germany adopted the "laparoscopic surgery curriculum" as a recommendation for the learning content of systematic training courses for laparoscopic surgery. The curricular structure provides for four 2-day training courses. These courses offer an interrelated content, with each course focusing additionally on specific topics of laparoscopic surgery based on live operations, lectures, and exercises carried out on bio simulators., Results: Between 1st January, 2012 and 31st March, 2016, a total of 36 training courses were conducted at the Vivantes Endoscopic Training Center in accordance with the "laparoscopic surgery curriculum." The training courses were attended by a total of 741 young surgeons and were evaluated as good to very good during continuous evaluation by the participants., Conclusion: Training courses based on the "laparoscopic surgery curriculum" for acquiring skills in laparoscopy are taken up and positively evaluated by young surgeons.

Introduction: Symptomatic umbilical and/or epigastric hernias are often seen concomitantly with rectus abdominis diastasis (RAD), and suture repair of such defects has a high recurrence rate. In the literature, there are reports of both endoscopic and open techniques for repair of symptomatic umbilical and/or epigastric hernias in association with RAD. This paper now reports on the early results of a hybrid technique used for reconstruction of the linea alba and mesh augmentation [endoscopic-assisted linea alba reconstruction plus mesh augmentation (ELAR plus)]., Materials and Methods: Between 15 June 2015 and 31 January 2016, 40 patients with symptomatic umbilical and/or epigastric hernia and concomitant RAD underwent reconstruction of the linea alba using a hybrid technique involving a small umbilical incision and the use of video-endoscopic equipment. The patients comprised 29 men and 11 women with a mean age of 53.6 years and mean BMI of 32.6. The mean operating time was 120 min. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm., Results: Thirty-day follow-up results are available for all patients. Thirty-seven out of 40 patients (92.5%) experienced no postoperative complication. Two cases of discrete impaired umbilical wound healing and one seroma were successfully managed with conservative treatment. On 30-day follow-up, 3 out of 40 patients (7.5%) complained of intermittent pain on exertion, and 2 out of 40 patients (5%) still took painkillers when required., Conclusion: ELAR plus is a novel minimally invasive procedure for repair of symptomatic umbilical and/or epigastric hernias with concomitant RAD. Reconstruction of the linea alba via a minimally invasive access route is able to restore the normal anatomy of the abdominal wall.

Background: The aim of this observational study is to analyze the results of patients with large hiatal hernia and upside-down stomach after surgical closure with a biological mesh (Permacol(®), Covidien, Neustadt an der Donau, Germany). Biological mesh is used to prevent long-term detrimental effects of artificial meshes and to reduce recurrence rates., Methods: A total of 13 patients with a large hiatal hernia and endothoracic stomach, who underwent surgery between 2010 and 2014, were included. Interviews and upper endoscopy were conducted to determine recurrences, lifestyle restrictions, and current complaints., Results: After a mean follow-up of 26 ± 18 months (range: 3-58 months), 10 patients (3 men, mean age 73 ± 13, range: 26-81 years) were evaluated. A small recurrent axial hernia was found in one patient postoperatively. Dysphagia was the most common complaint (four cases); while in one case, the problem was solved after endoscopic dilatation. In three cases, bloat and postprandial pain were documented. In one case, an explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis, pyloroplasty was performed without success. The data are compared to the available literature. It was found that dysphagia and recurrence rates are unrelated both in biological and in synthetic meshes if the esophagus is encircled. In series preserving the esophagus at least partially uncoated, recurrences after the use of biological meshes relieve dysphagia. After the application of synthetic meshes, dysphagia is aggravated by recurrences., Conclusion: Recurrence is rare after encircling hiatal hernia repair with the biological mesh Permacol(®). Dysphagia, gas bloat, and intra-abdominal pain are frequent complaints. Despite the small number of patients, it can be concluded that a biological mesh may be an alternative to synthetic meshes to reduce recurrences at least for up to 2 years. Our study demonstrates that local fibrosis and thickening of the mesh can affect the outcome being associated with abdominal discomfort despite a successful repair. The review of the literature indicates comparable results after 2 years with both biologic and synthetic meshes embracing the esophagus. At the same point in time, reconstruction with synthetic and biologic materials differs when the esophagus is not or only partially encircled in the repair. This is important since encircling artificial meshes can erode the esophagus after 5-10 years.

Introduction: Although recently published guidelines recommend against the use of synthetic non-absorbable materials in cases of potentially contaminated or contaminated surgical fields due to the increased risk of infection (1, 2), the use of bio-prosthetic meshes for abdominal wall or ventral hernia repair is still controversially discussed in such cases. Bio-prosthetic meshes have been recommended due to less susceptibility for infection and the decreased risk of subsequent mesh explantation. The purpose of this review is to elucidate if there are any indications for the use of biological and biosynthetic meshes in incarcerated abdominal wall hernias based on the recently published literature., Methods: A literature search of the Medline database using the PubMed search engine, using the keywords returned 486 articles up to June 2015. The full text of 486 articles was assessed and 13 relevant papers were identified including 5 retrospective case cohort studies, 2 case-controlled studies, and 6 case series., Results: The results of Franklin et al. (3-5) included the highest number of biological mesh repairs (Surgisis(®)) by laparoscopic IPOM in infected fields, which demonstrated a very low incidence of infection and recurrence (0.7 and 5.2%). Han et al. (6) reported in his retrospective study, the highest number of treated patients due to incarcerated hernias by open approach using acellular dermal matrix (ADM(®)) with very low rate of infection as well as recurrences (1.6 and 15.9%). Both studies achieved acceptable outcome in a follow-up of at least 3.5 years compared to the use of synthetic mesh in this high-risk population (7)., Conclusion: Currently, there is a very limited evidence for the use of biological and biosynthetic meshes in strangulated hernias in either open or laparo-endoscopic repair. Finally, there is an urgent need to start with randomized controlled comparative trials as well as to support registries with data to achieve more knowledge for tailored indication for the use of biological meshes.

Introduction: The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE)., Methods: A systematic search of PubMed was conducted using the search terms: "ELAPE," "extralevator abdominoperineal excision of rectum," or "extralevator abdominoperineal resection." The search yielded 17 studies., Results: Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality., Conclusion: Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.

Introduction: The incidence of deep infection using a synthetic mesh in inguinal hernia repair is low and reported to be well below 1%. This is in contrast to incisional hernia surgery where the reported incidence is 3% respective 13% comparing laparoscopic to open mesh repair reported in a Cochrane review. Main risk factors were long operation time, surgical site contamination, and early wound complications. An infected mesh can be preserved using conservative treatment were negative pressure wound therapy (VAC(®)) could play an important role. If strategy fails, the mesh needs to be removed. This review aims to look at evidence for situations were a biological mesh would work as a replacement of a removed infected synthetic mesh., Materials and Methods: A literature search of the Medline database was performed using the PubMed search engine. Twenty publications were found relevant for this review., Results: For studies reviewed three options are presented: removal of the infected synthetic mesh alone, replacement with either a new synthetic or a new biological mesh. Operations were all performed at specialist centers. Removal of the mesh alone was an option limited to inguinal hernias. In ventral/incisional hernias, the use of a biological mesh for replacement resulted in a very high recurrence rate, if bridging was required. Either a synthetic or a biological mesh seems to work as a replacement when fascial closure can be achieved. Evidence is though very low., Conclusion: When required, either a synthetic or a biological mesh seems to work as a replacement for an infected synthetic mesh if the defect can be closed. It is, however, not recommended to use a biological mesh for bridging. Mesh replacement surgery is demanding and is recommended to be performed in a specialist center.

Introduction: The aim of this review is to provide an overview of the use of biological materials in the augmentation of the anal sphincter either as part of an overlapping sphincter repair (OSR) or anal bulking procedure., Methods: A systematic search of PubMed was conducted using the search terms "anal bulking agents," "anal sphincter repair," or "overlapping sphincter repair." Five studies using biological material as part of an overlapping sphincter repair (OSR) or as an anal bulking agent were identified., Results: 122 patients underwent anal bulking with a biological material. Anorectal physiology was conducted in 27 patients and demonstrated deterioration in maximum resting pressure, and no significant change in maximum squeeze increment. Quality of life scores (QoLs) demonstrated improvements at 6 weeks and 6 months, but this had deteriorated at 12 months of follow up. Biological material was used in 23 patients to carry out an anal encirclement procedure. Improvements in QoLs were observed in patients undergoing OSR as well as anal encirclement using biological material. Incontinence episodes decreased to an average of one per week from 8 to 10 preoperatively., Conclusion: Sphincter encirclement with biological material has demonstrated improvements in continence and QoLs in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As an anal bulking agent the benefits are short-term.

Introduction: In the field of hernia prevention, the prophylactic mesh-reinforcement of stoma-sites is one of the most controversially discussed issues. The incidence of parastomal hernias in the literature reported to be up to 48.1% after end colostomy and up to 30.8% after loop of colostomy, but still remains uncertain due to diagnostic variety of clinical or radiological methods, heterogeneous patient groups and variable follow-up intervals. Anyway, the published data regarding the use of synthetic or bio-prostethic meshes in the prevention of parastomal hernia at the primary operation are very scarce., Methods: A literature search of the Medline database in terms of biological prophylactic mesh implantation in stoma creation identified six systematic reviews, two randomized controlled trials (RCT), two case-controlled studies, and one technical report., Results: In a systematic review focusing on the prevention of parastomal hernia including only RCTs encompassing one RCT using bio-prosthetic mesh the incidence of herniation was 12.5% compared to 53% in the control group (p < 0.0001). In one RCT and two case-control studies, respectively, there was a significant smaller incidence of parastomal herniation as well as a similar complication rate compared to the control group. Only in one RCT, no significant difference regarding the incidence of parastomal hernia was reported with comparable complication rates., Conclusion: Thus, so far two RCT and two case-control studies are published with prophylactic bio-prosthetic reinforcement in stoma sites. The majority revealed significant better results in terms of parastomal herniation and without any mesh-related complications in comparison to the non mesh group. Further, multicenter RCT are required to achieve a sufficient level of recommendation.

The widespread use of meshes for hiatal hernia repair has emerged in the era of laparoscopic surgery, although sporadic cases of mesh augmentation of traumatic diaphragmatic rupture have been reported. The indications for biologic meshes in diaphragmatic repair are ill defined. This systematic review aims to investigate the available evidence on the role of biologic meshes in diaphragmatic rupture and hiatal hernia repair. Limited data from sporadic case reports and case series have demonstrated that repair of traumatic diaphragmatic rupture with biologic mesh is safe technique in both the acute or chronic setting. High level evidence demonstrates short-term benefits of biologic mesh augmentation in hiatal hernia repair over primary repair, although adequate long-term data are not currently available. Long-term follow-up data suggest no benefit of hiatal hernia repair using porcine small intestine submucosa over suture repair. The effectiveness of different biologic mesh materials on hernia recurrence requires further investigation.

Introduction: Ventral mesh rectopexy (VMR) is a recognized treatment for posterior compartment pelvic organ prolapse (POP). The aim of this review is to provide a synopsis of the evidence for biological mesh use in VMR, the most widely recognized surgical technique for posterior compartment POP., Methods: A systematic search of PubMed was conducted using the search terms "VMR," "ventral mesh rectopexy," or "mesh rectopexy." Six studies were identified., Results: About 268/324 patients underwent ventral rectopexy using biological mesh with a further 6 patients having a combination of synthetic and biological mesh. Recurrence was reported in 20 patients; however, 6 were from studies where data on biological mesh could not be extracted. There are no RCTs in VMR surgery and no studies have directly compared types of biological mesh. Cross-linked porcine dermal collagen is the most commonly used mesh and has not been associated with mesh erosion, infection, or fistulation in this review. The level of evidence available on the use of biological mesh in VMR is of low quality (level 4)., Conclusion: Ventral mesh rectopexy has become prevalent for posterior compartment POP. The evidence base for its implementation is not strong and the quality of evidence to inform choice of mesh is poor.

Introduction: In a recent Cochrane review, the authors concluded that there is an urgent need for well-powered, well-conducted randomized controlled trials comparing various modes of treatment of fistula-in-ano. Ten randomized controlled trials were available for analyses: There were no significant differences in recurrence rates or incontinence rates in any of the studied comparisons. The following article reviews the studies available for treatment of fistula-in-ano with a fistula plug with special attention paid to the technique., Material and Methods: PubMed, Medline, Embase, and the Cochrane medical database were searched up to July 2015. Sixty-four articles were relevant for this review., Results: Healing rates of 50-60% can be expected for treatment of complex anal fistula with a fistula plug, with a plug-extrusion rate of 10-20%. Such results can be achieved not only with plugs made of porcine intestinal submucosa but also those made of other biological or synthetic bioabsorbable mesh materials. Important technical steps are firm suturing of the head of the plug in the primary opening and wide drainage of the secondary opening., Discussion: Treatment of a complex fistula-in-ano with a fistula plug is an option with a success rate of 50-60% with low complication rate. Further improvements in technique and better studies are needed.

Introduction: Biological meshes are a potential alternative to the synthetic meshes to avoid complications and are used in a contaminated field for incarcerated inguinal hernias. The clinical experiences gained with biological meshes for repair of inguinal hernias are presented in this review., Materials and Methods: In a literature search of the Medline database using the key word "Biological mesh," 2,277 citations were found. There remained 14 studies in which biological meshes had been used to repair inguinal hernias., Results: In prospective randomized trials, the use of polypropylene vs. biological meshes was compared in open inguinal hernia repair. There was no difference in the recurrence rate, but differences were observed in the postsurgical pain incidence in favor of the biological mesh. In the remaining retrospective studies, the recurrence rates were also acceptable. The biological mesh was used successfully in a potentially contaminated setting., Conclusion: Inguinal hernias can be repaired with biological meshes with reasonable recurrence rate, also as an alternative in a potentially contaminated field.

Introduction: It is known that recurrences continue to occur after the follow-up period of 1-5 years usually used in most hernia studies. By reviewing the data in the Herniamed Hernia Registry documenting the time interval between the recurrent operation and previous inguinal hernia repair, the present study identifies the temporal course of onset of recurrence., Patients and Methods: Prospective data were recorded in the Herniamed Registry between 1 September 2009 and 4 May 2015 on a total of 145,590 patients with 171,143 inguinal hernia operations. These included 18,774 operations due to an inguinal hernia recurrence (10.94%). During the same period, prospective data were collected on 24,385 incisional hernia operations. The latter cases included 5,328 patients with a recurrent incisional hernia (21.85%)., Results: Only 57.46% of all inguinal hernia recurrences occurred within 10 years of the previous inguinal hernia operation. Some of the remaining 42.54% of all recurrences occurred only much later, even after more than 50 years. The course of onset of recurrence is markedly different for incisional hernia. About 91.87% of such recurrences occur already within 10 years of the last operation., Conclusion: Ascertainment of the actual recurrence rate after hernia repair calls for a follow-up of 10 years for incisional hernia and of 50 years for inguinal hernia. The data collected can be used to give an approximate estimate with a shorter follow-up.

Purpose: In meta-analyses and systematic reviews comparing laparoscopic with open repair of ventral hernias, data on umbilical, epigastric, and incisional hernias are pooled. Based on data from the Herniamed Hernia Registry, we aimed to investigate whether the differences in the therapy and treatment results justified such an approach., Methods: Between 1st September 2009 and 31st August 2013, 31,664 patients with a ventral hernia were enrolled in the Herniamed Hernia Registry. The implicated hernias included 16,206 umbilical hernias, 3,757 epigastric hernias, and 11,701 incisional hernias. Data on the surgical techniques, postoperative complication rates, and 1-year follow-up results were subjected to statistical analysis to identify any significant differences between the various hernia types., Results: The laparoscopic IPOM technique was used significantly more often for incisional hernia than for epigastric hernia, 31.3 vs. 24.0%, respectively, and was used for 12.9% of umbilical hernias (p < 0.0001). Likewise, the open technique with suturing of defect was used significantly more often for umbilical hernia than for epigastric hernia, 56.1 vs. 35.4%, respectively, and was used for 12.5% of incisional hernias (p < 0.0001). The postoperative complication rates of 3.2% for umbilical hernia and 3.5% for epigastric hernia were significantly lower than for incisional hernia, at 9.2% (p < 0.0001). That was also true for the reoperation rates due to postoperative complications, of 1.0 vs. 1.2 vs. 4.2% (p < 0.0001). The 1-year follow-up revealed significantly higher recurrence rates as well as rates of chronic pain needing treatment of 6.3 and 7.9%, respectively, for incisional hernia, compared with 4.1 and 4.3%, respectively, for epigastric hernia, and 2 and 1.9%, respectively, for umbilical hernia (p < 0.0001)., Conclusion: Since significant differences were identified in the therapy and treatment results between umbilical hernia, epigastric hernia, and incisional hernia, scientific studies should be conducted comparing the various surgical techniques only for a single hernia type.

To date, the scientific definition "hernia center" does not exist and this term is being used by hospitals and private institutions as a marketing instrument. Hernia surgery has become increasingly more complex over the past 25 years. Differentiated use of the various techniques in hernia surgery has been adopted as a "tailored approach" program and requires intensive engagement with, and extensive experience of, the entire field of hernia surgery. Therefore, there is a need for hernia centers. A basic requirement for a credible certification process for hernia centers involves definition of requirements and its verification by hernia societies and/or non-profit organizations that are interested in assuring the best possible quality of hernia surgery. At present, there are two processes for certification of hernia centers by hernia societies or non-profit organizations.

The endoscopic procedures TEP and TAPP and the open techniques Lichtenstein, Plug and Patch, and PHS currently represent the gold standard in inguinal hernia repair recommended in the guidelines of the European Hernia Society, the International Endohernia Society, and the European Association of Endoscopic Surgery. Eighty-two percent of experienced hernia surgeons use the "tailored approach," the differentiated use of the several inguinal hernia repair techniques depending on the findings of the patient, trying to minimize the risks. The following differential therapeutic situations must be distinguished in inguinal hernia repair: unilateral in men, unilateral in women, bilateral, scrotal, after previous pelvic and lower abdominal surgery, no general anesthesia possible, recurrence, and emergency surgery. Evidence-based guidelines and consensus conferences of experts give recommendations for the best approach in the individual situation of a patient. This review tries to summarize the recommendations of the various guidelines and to transfer them into a practical decision tree for the daily work of surgeons performing inguinal hernia repair.

Purpose: New technical approaches involving biologically derived products have been used to treat complex anal fistulas in order to avoid the risk of fecal incontinence. The least invasive methods involve filling out the fistula tract with fibrin glue or introduction of an anal fistula plug into the fistula canal following thorough curettage. A review shows that the new techniques involving biologically derived products do not confer any significant advantages. Therefore, the question inevitably arises as to whether the combination of a partial or limited fistulectomy, i.e., of the extrasphincteric portion of the fistula, and preservation of the sphincter muscle by repairing the section of the complex anal fistula running through the sphincter muscle and filling it with a fistula plug produces better results., Methods: A modified plug technique was used, in which the extrasphincteric portion of the complex anal fistula was removed by means of a limited fistulectomy and the remaining section of the fistula in the sphincter muscle was repaired using the fistula plug with fixing button., Results: Of the 52 patients with a complex anal fistula, who had undergone surgery using a modified plug repair with limited fistulectomy of the extrasphincteric part of the fistula and use of the fistula plug with fixing button, there are from 40 patients (follow-up rate: 77%) some kind of follow-up informations, after a mean of 19.32 ± 6.9 months. Thirty-two were men and eight were women, with a mean age of 52.97 ± 12.22 years. Surgery was conducted to treat 36 transsphincteric, 1 intersphincteric, and 3 rectovaginal fistulas. In 36 of 40 patients (90%), the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. None of these patients complained about continence problems., Conclusion: A modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of the plug with fixing button seems to increase the healing rate in comparison to the standard plug technique.

Introduction: Laparoscopic surgery is subject to certain limitations that can be a problem when performing complex minimally invasive operations. Robotic surgery was developed precisely to overcome such technical limitations. The question therefore arises whether robotic surgery leads to significantly better results compared with standard laparoscopic surgery., Methods: Based on comparative systematic reviews and meta-analyses, this paper examines whether the robotic technique when used for abdominal and visceral surgery procedures confers advantages on the patient compared with the standard laparoscopic technique., Results: Even for demanding visceral surgery procedures, the perioperative complication rate for robotic surgery is not higher than for open or laparoscopic surgical procedures. In cancer cases, the oncological accuracy of robotic resection for gastric, pancreatic, and rectal resection is seen to be adequate. Only the operating time is generally longer than for standard laparoscopic and open procedures. But, on the other hand, in some procedures blood loss is less, conversion rates are lower and hospital stay shorter., Conclusion: To evaluate the future role of the robotic technique for visceral surgery, high-quality prospective randomized trials are urgently needed.