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Background: Incisional hernia is a frequent complication of abdominal wall incision. Surgical technique is an important risk factor for the development of incisional hernia. The aim of these updated guidelines was to provide recommendations to decrease the incidence of incisional hernia. Methods: A systematic literature search of MEDLINE, Embase, and Cochrane CENTRAL was performed on 22 January 2022. The Scottish Intercollegiate Guidelines Network instrument was used to evaluate systematic reviews and meta-analyses, RCTs, and cohort studies. The GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) was used to appraise the certainty of the evidence. The guidelines group consisted of surgical specialists, a biomedical information specialist, certified guideline methodologist, and patient representative. Results: Thirty-nine papers were included covering seven key questions, and weak recommendations were made for all of these. Laparoscopic surgery and non-midline incisions are suggested to be preferred when safe and feasible. In laparoscopic surgery, suturing the fascial defect of trocar sites of 10 mm and larger is advised, especially after single-incision laparoscopic surgery and at the umbilicus. For closure of an elective midline laparotomy, a continuous small-bites suturing technique with a slowly absorbable suture is suggested. Prophylactic mesh augmentation after elective midline laparotomy can be considered to reduce the risk of incisional hernia; a permanent synthetic mesh in either the onlay or retromuscular position is advised. Conclusion: These updated guidelines may help surgeons in selecting the optimal approach and location of abdominal wall incisions. [ABSTRACT FROM AUTHOR]

Introduction: Despite the well-documented safety and effectiveness of laparoscopic colorectal surgery in curative intention, the role of conversion and its impact on short- and long-term outcome after resection of a carcinoma are unclear and continue to give rise to controversial discussion. Methods: Within the framework of a prospective, multicenter observational study (Laparoscopic Colorectal Surgery Study Group), into which a total of 5,863 patients from 69 hospitals were recruited over a period of 10 years, a subgroup of all patients who had undergone curative resection was analyzed with regard to the effects of conversion. Results: Of the 1409 patients who had undergone curative resection for colorectal carcinoma, conversion had to be performed in 80 (5.7%) cases for the most diverse reasons. The duration of surgery (median: 183 vs. 241 minutes; P<.001) was significantly longer in the conversion group. Perioperatively, significant disadvantages were noted in converted patients in terms of intraoperative blood loss (median: 243 vs. 573 mL, P<.001), need for perioperative blood transfusion (10.8% vs. 33.8%; P<.001), and resumption of bowel movement (median: after 3 vs. 4 days; P<.001). With regard to postoperative morbidity, significant disadvantages were observed in converted patients, in particular in terms of specific surgical complications, including a higher rate of anastomotic insufficiency (5.0% vs. 13.8%; P=.003) and a higher reoperation rate (4.9% vs. 15.0%; P=.001). In the long term, conversion was associated with lower overall survival, but not with poorer disease-free survival. Conclusion: Significantly higher postoperative morbidity was observed in patients after conversion, in particular in terms of specific surgical complications. In addition, conversion is associated with overall lower survival but not with poorer disease-free survival. [ABSTRACT FROM AUTHOR]

In recent years, laparoscopic repair of abdominal wall hernias has become increasingly established in routine clinical practice thanks to the myriad advantages it confers. Apart from the risk of intestinal damage following adhesiolysis, to date no information is available on the best way of preventing the formation of new adhesions in the vicinity of the implanted meshes. Numerous experimental investigations, mainly conducted on an open small-animal model, have demonstrated the advantages of coating meshes, inter alia with absorbable materials, compared with uncoated polypropylene meshes. In our established laparoscopic porcine model we set about investigating three of these meshes, which are already available on the market. In total, 18 domestic pigs underwent laparoscopic surgery and three different composite meshes were tested in each case on six animals (Dynamesh IPOM, Proceed, Parietene Composite). At 4 months, postmortem diagnostic laparoscopy was carried out, followed by full-wall excision of the specimens. Planimetric analysis was conducted to investigate the size of the entire surface area and the extent of adhesions. Histological investigations were performed on five sections for each specimen. These focused on the partial volumes of inflammatory cells, the proliferation marker Ki67, apoptotic index, inflammatory cell marker CD68 and transforming growth factor beta (TGF-β) as a marker of the extracellular matrix. A similar value of 14% was obtained for shrinkage of Dynamesh IPOM and Parietene Composite, while Proceed showed a 25% reduction in its surface area. Markedly lower values of 12.8% were obtained for Parietene Composite in respect of adhesions to the greater omentum, compared with 31.7% for Proceed and 33.2% for Dynamesh IPOM ( p = 0.01). Overall, Parietene Composite performed best in the histological and immunhistochemistry tests. On the whole, all composite meshes showed evidence of good biocompatibility. However, none of the coatings was completely able to prevent adhesions. Coating of polypropylene meshes with collagen appears to confer significant advantages compared with other coatings. [ABSTRACT FROM AUTHOR]

For the management of endoscopically irretrievable polyps, several minimally invasive procedures are currently available as alternatives to conventional laparotomy. However, the high rate of malignant transformation despite initially benign histology continues to be a problem. Within the framework of a prospective multicenter observational study, all patients with adenomatous polyps unsuitable for endoscopic removal and with benign histology were investigated. In addition to an analysis of the perioperative course and the definitive histology, the overall and disease-free survival rates of patients with malignant transformation of colorectal adenomas were also calculated. A total of 525 patients (median age 65.3 years; median body mass index 25.6 kg/m2) underwent a laparoscopic resection. Conversion to laparotomy became necessary in 17 (3.2%) cases. The perioperative morbidity rate was 20.8%, and malignant transformation occurred in a total of 18.1% of the adenomatous polyps. The median number of lymph nodes removed was 12, and lymph node metastases were seen in a total of 14.8% of the patients (T1 – 4.8%, T2 – 19.4%, T3 – 25%, T4 – 100%). Estimated 5-year overall and disease-free survival rates were 92.4% and 80.6%, respectively. For the management of endoscopically unresectable polyps, laparoscopic resection is currently the technique of choice. In addition to the benefits of minimally invasive surgery, in the hands of an experienced surgeon it achieves results comparable with those of open surgery. In view of the high rate of malignant transformation and the absence of unequivocal factors predictive of already present malignant transformation, an oncologically radical operation is essential. In the elderly patient presenting with comorbidities limited resection aiming to minimize surgical trauma in potentially benign disease may be considered. In such a case, however, frozen-section histology is obligatory. [ABSTRACT FROM AUTHOR]

PURPOSE: The need for a conversion is a problem inherent in laparoscopic surgery. The present study points up the significance of conversion for the results obtained with laparoscopic colorectal surgery and identifies the risk factors that establish the need for conversion. METHOD: The study took the form of a multicentric, prospective, observational study within the Laparoscopic Colorectal Surgery Study Group. A total of 33 institutions in Germany, Austria, and Switzerland participated. The study period was 3.5 years. Cases were documented with the aid of a standardized questionnaire. RESULTS: Within the framework of the Laparoscopic Colorectal Surgery Study Group, a total of 1,658 patients were recruited to a multicenter study over a period of three and one-half years (from August 1, 1995 to February 1, 1999). The observed conversion rate was 5.2 percent (n = 86). The patients requiring a conversion were significantly heavier (body mass index, 26.5 vs. 24.9) than those undergoing pure laparoscopy. Resections of the rectum were associated with a higher risk for conversion (20.9 vs. 13 percent). Intraoperative complications occurred significantly more frequently in the conversion group (27.9 vs. 3.8 percent). The duration of the operation was significantly increased after conversion in a considerable proportion of the procedures performed. Postoperative morbidity (47.7 vs. 26.1 percent), mortality (3.5 vs. 1.5 percent), recovery time, and postoperative hospital stay were all negatively influenced by conversion, in part significantly. Institutions with experience of more than 100 laparoscopic colorectal procedures proved to have a significantly lower conversion rate than those with experience of fewer than 100 such interventions (4.3 vs. 6.9 percent). CONCLUSION: Although, of itself, conversion is not considered to be a complication of laparoscopic surgery, it is true that the postoperative course after conversion is associated with appreciably poorer results in terms of morbidity, mortality, convalescence, blood transfusion requirement, and postoperative hospital stay. The importance of experience in laparoscopic surgery can be demonstrated on the basis of the conversion rates. Careful patient selection oriented to the experience of the surgeon is required if we are to keep the conversion, morbidity, and mortality rates of laparoscopic colorectal procedures as low as possible. [ABSTRACT FROM AUTHOR]

PURPOSE: Although laparoscopic colorectal surgery is attracting ever more attention, its use for curative treatment of colorectal carcinoma in particular continues to be controversial. The present study was an attempt to analyze the results of the perioperative course, oncologic quality, and preliminary long-term results. METHOD: The data considered here were collected within the framework of a prospective, observational study initiated on August 1, 1995, and involving a total of 18 institutions in Germany and Austria. At the end of three years, the results are now being presented selectively, i.e., focusing only on abdominoperineal resection. RESULTS: A total of 116 patients underwent laparoscopic abdominoperineal resections, 98 (84.5 percent) of which were performed with curative intent. The mean operating time was 226 (confidence interval, 140-365) minutes. Seven patients (6 percent) experienced an intraoperative complication, which in more than one-half of the cases was a vascular injury involving the presacral venom plexus; the conversion rate was 3.4 percent. Postoperatively, 40 patients developed 97 complications--including those of a very minor nature--giving an overall morbidity rate of 34.4 percent. Reoperation in six patients (5.2 percent) had to be performed for an afterbleed in one-half of the cases and ileus in the other one-half. Postoperative mortality was a low 1.7 percent. In most of the curative resections, an oncologically radical operation with high transection of the inferior mesenteric artery and a complete dissection of the pelvis down to the floor was performed. The median number of lymph nodes investigated was 11.5, and there was wide fluctuation in the numbers among the individual institutions. Tumor cell dissemination occurred intraoperatively in five patients. In the meantime, 79 patients (81 percent) underwent at least one follow-up examination, the mean follow-up period being 491 days. Seven patients developed a local recurrence, and a further six patients developed distant metastases. For recurrence-free survival rate, the Kaplan-Meier estimation calculated a probability of 71 percent. CONCLUSION: Not all of the reservations about laparoscopic abdominoperineal resection, in particular with regard to resection with curative intent, have yet been eliminated. The present study does, however, show that a laparoscopic approach can in principle meet oncologic requirements of radicality and, with regard to the postoperative course, is associated with considerable benefits to the patient. [ABSTRACT FROM AUTHOR]

A response by Dietmar Jacob and collagues to a letter to the editor about their article "Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia," in the 2011 issue is presented.