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Aim: The aim of this study was to clarify the length of the bowel specimen and to assess if the length was affected by certain characteristics. Methods: Eligible patients were adults who had undergone right hemicolectomy for cancer in caecum, appendix, ascending colon or transverse colon from September 2019 to September 2020 at Herlev Hospital, Denmark. Data were collected from medical records. The primary outcome was the length of the resected terminal ileum. Secondary outcomes were to assess if body mass index (BMI), surgical approach, and neoadjuvant chemotherapy affected the length of the terminal ileum specimen, and to report the length of the colon specimen subdivided on the cancer locations. Results: In total, 50 patients were included. The median age was 74 years (range 36–91), 30 patients (60%) were females, and BMI was median 26 (range 17–45). The variation in the length of terminal ileum specimen was median 5 cm (range 1–17). The explorative analyses showed significant positive correlation between the length of terminal ileum specimen and BMI (P = 0.050) but not surgical approach (P = 0.23) nor neoadjuvant chemotherapy (P = 0.51). The length of the colon specimen naturally differed according to the cancer location with a median length of 26 cm (range 14–90). Conclusion: We found a variation in the length of the terminal ileum specimen without an apparent explanation for this variation. The colon specimen also varied naturally according to cancer location.

Background: Recent international hernia guidelines state that work and leisure activities after inguinal hernia repair can be resumed after a convalescence of three to five days for most patients. There is no specific recommendation for convalescence duration before resuming sport and heavy lifting. This nationwide survey aimed to assess leading hernia surgeons’ recommendations for convalescence after groin hernia repair and to explore their general opinions regarding convalescence. Methods: A validated questionnaire was sent to 32 leading groin hernia surgeons covering all Danish private and public hospitals. The primary outcome was convalescence recommendations following Lichtenstein and laparoscopic groin hernia repair for activities of daily living, light work, sport, and heavy lifting. Results: A total of 29 surgeons (91%) responded to the questionnaire. The surgeons generally agreed on resuming daily activities and light work as soon as possible according to the level of pain. For resumption of sport, the surgeons recommended a median convalescence of 14 days (IQR 10–23, range 7–30) after Lichtenstein repair and 14 days (IQR 10–21, range 7–30) after laparoscopic repair. Most of the surgeons instructed patients with a defined number of days before resuming heavy lifting, which after Lichtenstein repair was median 14 days (IQR 8–28, range 2–30) and after laparoscopic repair was median 21 days (IQR 14–30, range 7–30). None of the surgeons routinely prescribed sick leave. Seventeen surgeons (61%) thought that recommending a too short convalescence could cause complications, primarily recurrence, hematoma, and pain. Conclusion: This study revealed that surgeons agreed on the resumption of daily activities and light work as soon as possible according to the level of pain. However, a broad spectrum of convalescence recommendations was revealed for sport and heavy lifting.

NTRODUCTION: The most common laparo-endoscopic groin hernia repair techniques are TEP (total extraperitoneal) and TAPP (transabdominal preperitoneal) repair. Despite geographic proximity, Swedish surgeons distinctively favour TEP, whereas Danish surgeons prefer TAPP. The aim of this study is to analyse the risk of reoperation for recurrence after TAPP, TEP and Lichtenstein repair using data from two nationwide registers. We also aim to discuss advantages of international collaboration between nationwide registers. METHODS: All groin hernia operations registered as TEP, TAPP or Lichtenstein repair in the Swedish Hernia Register and the Danish Hernia Database between January 2004 and December 2020 will be included. Cumulative hazard rate of reoperation for recurrence will be estimated using Cox-regression analyses adjusted for age and anatomy. CONCLUSION: Approximately 400,000 operations are estimated to have been registered prospectively in the inclusion period in the registers. The merging of two nationwide registers was made possible owing to close cooperation between the register steering committees and by obtaining the necessary approvals. This unique collaboration between nationwide registers will make it possible to compare the risk of reoperation for recurrence after TAPP, TEP and Lichtenstein repair on an international level. In future, similar collaboration may be established to explore other outcomes such as complication rates and chronic pain.

Background: The groin is a complex anatomical area with multiple structures that can be injured and cause pain. One condition with groin pain is the so-called “sports groin,” which can be treated with a groin hernia repair even though no hernia is present. The aim of this study was to assess the prevalence of chronic groin pain several years after a groin hernia repair performed in patients with a sports groin. Methods: This nationwide cohort study included adults who had a groin hernia repair for a sports groin through the years 1998–2011. The patients were identified through the Danish Hernia Database and in surgical records. Patients were asked to fill out four questionnaires several years after the repair: a visual analogue scale, the Activity Assessment Scale, the Inguinal Pain Questionnaire, and a questionnaire about treatment satisfaction. Results: Of 118 contacted patients, 71 gave informed consent and were included in the study (60%), and of these the response rate was 100%. The questionnaires were filled out median 14 years after surgery. Most of the patients were pain-free in the operated groin (87%), and only a few had physical impairment caused by groin pain (20%). Prior to surgery, 79% had groin pain that they could not ignore. Overall, 90% of the patients were satisfied with the treatment. Conclusions: Most patients were pain-free and without physical impairment several years after groin hernia repair for a sports groin and with high satisfaction rate.

A rapid review is a synthesis of available evidence in which some components of the review process are modified slightly to shorten the process. This will require tight control as well as day-to-day scientific mentoring. The typical rapid review has a focused research question covering a narrow and well-defined clinical problem. With a continuous focus on some elements in the planning and production phases, it is realistic to produce a rapid scoping or systematic review with or without meta-analysis within three months without compromising on scientific quality.

Introduction: Groin hernia repair can relieve pain from conditions other than groin hernias, such as “sports groin.” The aim of this study was to assess the nationwide frequency of surgically treated sports groins and identify conditions found during groin hernia surgery with no hernia present. Materials and Methods: In this nationwide cohort study, we included patients with no hernia found during groin hernia repair. Patients were identified in the nationwide Danish Hernia Database. Outcomes were assessed from medical and surgical records. Medical history, preoperative examinations, and operative details were extracted. Results: Data from 259 patients were included. Of these, 152 (58%) were considered to have a sports groin. A weak posterior inguinal wall was identified in 41 sports groins, a wide profound inguinal ring in 10, and no specific anatomic pathology was described in the remaining patients with a sports groin. A lipoma was found in addition to a sports groin in 60 patients. Findings in patients without a sports groin were predominantly lipomas, and less frequent findings were a cyst and hydrocele. Conclusions: More than half of the patients were assessed to have a sports groin. Frequent findings that co-existed with a sports groin were weak posterior inguinal wall and/or lipoma.

The main symptom of a groin hernia is a bulge in the groin. The clinical examination is often sufficient for thediagnosis. Imaging is only necessary when the diagnosis is uncertain, where ultrasound is the first choice, butone must also consider differential diagnoses in these cases. Children, women, and men with symptoms shouldbe referred for elective surgery while watchful waiting can be used in asymptomatic men. However, if a hernia isincarcerated and the clinical examination suggests possible strangulation, the patient should immediately bereferred to a hospital, as argued in this review.

An inguinal hernia is a very common condition, with 27 per cent of men and 3 per cent of women undergoing repair during their lifetime1. Thus, inguinal hernias have a high societal cost. Historically, hernia surgery was frequently performed by the most inexperienced surgeons, but is now considered a highly specialized field with substantial research activity, specialist societies, and national clinical hernia databases. A variety of operative techniques have been described that aim to improve operative outcomes and recovery. The routine use of mesh and minimally invasive surgery have arguably had the greatest impact on hernia surgery outcomes to date. However, despite these improvements, chronic pain and recurrence still occur with a consequent negative impact on patient quality of life and increased cost to society. Inguinal hernias are difficult to prevent, and the only curative treatment is surgery. Numerous repair methods have been described in in adults, but the most common ones worldwide are Lichtenstein repair and laparoscopic transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repairs1 (Fig. 1). This Young BJS article discusses some of the surgical controversies in contemporary inguinal hernia surgery.

Rectus diastasis is characterized by widening and laxity of the linea alba, causing the abdominal content to bulge. Rectus diastasis is treated either conservatively with physiotherapy, or surgically, surgical treatment showing especially convincing results. The primary aim of this study was to describe surgical techniques used to correct abdominal rectus diastasis. Secondary, we wished to assess postoperative complications in relation to the various techniques. A systematic scoping review was conducted and reported according to the PRISMA-ScR statement. PubMed, Embase, and Cochrane Library were searched systematically. Studies were included if they described a surgical technique used to repair abdominal rectus diastasis, with or without concomitant ventral hernia. Secondary outcomes were recurrence rate and other complications. A total of 61 studies were included: 46 used an open approach and 15 used a laparoscopic approach for repair of the abdominal rectus diastasis. All the included studies used some sort of plication, but various technical modifications were used. The most common surgical technique was classic low abdominoplasty. The plication was done as either a single or a double layer, most commonly with permanent sutures. There were overall low recurrence rates and other complication rates after both the open and the laparoscopic techniques. We identified many techniques for repair of abdominal rectus diastasis. Recurrence rate and other complication rates were in general low. However, there is a lack of high-level evidence and it is not possible to recommend one method over another. Thus, further randomized controlled trials are needed in this area.

Purpose: There are cases where surgeons repair a recurrent inguinal hernia using a second Lichtenstein repair (Lichtenstein–Lichtenstein) or a second laparoscopic repair (Laparoscopy–Laparoscopy) in the same groin even though this contradicts current guideline recommendations. The aim of this study was to provide an overview of surgical modifications and findings during these reoperations. Methods: Patients in this observational study were identified in the nationwide Danish Hernia Database during a 6-year period. Outcomes were identified in medical records. The primary outcome was the prevalence of tailored reoperations and standard reoperations for Lichtenstein–Lichtenstein and Laparoscopy–Laparoscopy, respectively. The secondary outcomes were findings during the reoperation such as inguinal hernia type and size, fibrosis, and difficulty to identify anatomical landmarks. Results: Of the 102 Lichtenstein reoperations, 43 (42%) were tailored repairs and 59 (58%) were standard repairs. The most common modifications were posterior wall reinforcement with permanent sutures, dividing a structure to enable sufficient hernioplasty, and a modification of the new mesh size and/or shape. There were no differences in the findings during tailored- and standard Lichtenstein reoperations. Of the 58 laparoscopic reoperations, 35 (60%) were tailored repairs and 23 (40%) were standard repairs. The most common modifications were necessitation of a coated mesh due to insufficient peritoneal coverage and use of unusual mesh sizes and/or shapes. Fibrosis was more commonly described during the tailored laparoscopic reoperations. Conclusions: A substantial part of the Lichtenstein- and the laparoscopic reoperations was tailored approaches, and various modifications were used. Fibrosis was more commonly described during tailored laparoscopic reoperations.

BACKGROUND: The best repair of a recurrent inguinal hernia after primary laparoendoscopic repair is debatable. The aim was to assess chronic pain after two laparoendoscopic repairs in the same groin compared with Lichtenstein reoperation preceded by a laparoendoscopic repair.METHODS: This cohort study included adult patients who had received two laparoendoscopic repairs (Lap-Lap) or a laparoendoscopic repair followed by the Lichtenstein repair (Lap-Lich). Eligible patients were identified in the Danish and the Swedish hernia databases. Lap-Lap was matched 1:3 with Lap-Lich, and patients were sent validated questionnaires. The primary outcome was the proportion with chronic pain-related functional impairment, compared between the two groups. Secondary outcomes included chronic pain during various activities.RESULTS: In total, 74% (546 patients) responded to the questionnaires with a median follow-up since the second repair of 4.9 years (0.9-21.9 years). Regarding the primary outcome, 21% in Lap-Lap and Lap-Lich had chronic pain-related functional impairment of daily activities (p = 0.94). More patients in Lap-Lap compared with Lap-Lich reported pain ≥ 20 mm measured by the visual analog scale, 11% versus 5%, p = 0.04. However, there was no difference in the median VAS score or in the vast majority of the remaining secondary outcomes.CONCLUSIONS: There was no overall difference in chronic pain between patients who had received Lap-Lap compared with Lap-Lich. Choice of operative strategy for the second repair should, therefore, not be based on risk of chronic pain.

INTRODUCTION: No recent guidelines exist for surgical treatment of paediatric inguinal hernias. Internationally, there is disagreement about both the preferred approach and the details of the surgical procedure. The aim of this nationwide survey study was to assess variations in Danish surgeons' technique when repairing inguinal hernias in children.METHODS: A questionnaire was sent to all surgeons in Denmark performing paediatric inguinal hernia repair, including questions about demographic details, choice of open or laparoscopic repair, and technical details of the chosen surgical approach. In the questionnaire, each item was repeated for children aged les than 2, 2-12, and 13-18 years of age.RESULTS: In total, 48 of 59 surgeons responded (81%). For children 12 years of age, the majority of surgeons only performed open repair, whereas none performed laparoscopic repair only. For children aged 13-18 years of age, two thirds of the surgeons performed open repair only, 6% performed laparoscopic repair only and the rest used both methods. We found considerable variations in the execution of both open and laparoscopic repair. The variations regarded incision of the external fascia, nerve identification, division of the cremaster muscle, and exploration of the contralateral groin and repair of an asymptomatic hernia.CONCLUSIONS: This study found considerable variation in the execution of both open and laparoscopic repair of inguinal hernias in children of different age groups. Research into inguinal hernia repair in children is needed to rationalise and update guidelines in order to improve quality and facilitate research.FUNDING: none.TRIAL REGISTRATION: not relevant.

Background: The aim was to assess chronic pain after two Lichtenstein repairs for inguinal hernias (Lichtenstein-Lichtenstein) compared with Lichtenstein followed by a laparoscopic reoperation (Lichtenstein-Laparoscopy). Methods: In this cohort study, adults having an inguinal hernia reoperation were identified in a nationwide database. Lichtenstein-Lichtenstein was matched 1:3 with Lichtenstein-Laparoscopy and sent validated pain questionnaires. The primary outcome was difference in proportion of patients with chronic pain-related functional impairment. Secondary outcomes were differences in chronic pain prevalence and severity. Results: In total, 196 patients having Lichtenstein-Lichtenstein and 777 patients having Lichtenstein-Laparoscopy were included. There was no difference in the primary outcome, 26% with pain in Lichtenstein-Lichtenstein versus 19% in Lichtenstein-Laparoscopy (p = 0.051). However, a few of the secondary outcomes favored Lichtenstein-Laparoscopy. Conclusions: A high proportion of patients in both groups had pain several years after the second repair. None of the analyses favored Lichtenstein-Lichtenstein, but a few of the secondary outcomes favored Lichtenstein-Laparoscopy.

BACKGROUND: Compression stockings reduce the risk of thromboembolic complications, leg edema, and edema-related pain and discomfort during long-haul flights. The aim of this study was to assess if compression stockings reduce leg edema, pain, and discomfort during a three-hour flight.METHODS: This randomized controlled trial had a paired design as participants were randomized to wear a compression stocking on one leg during a three-hour flight with the other leg acting as control. Eligibility criteria were adults aged 18-60 years living in Denmark without medical indication for wearing compression stockings during flights. The primary outcome was the change in difference of ankle circumference between legs with and without compression stocking pre- and post-flight. Secondary outcomes were changes in difference of calf circumference, pain, and discomfort pre- and post-flight. All outcomes were self-reported with measurements and questionnaires.RESULTS: A total of 34 participants, median age 31 years (range 25-54), were randomized with complete follow-up. Difference in ankle circumference was median 5 mm larger post-flight compared with pre-flight (interquartile range (IQR) = 0-9, p = .001) and the corresponding change in calf circumference difference was median 5 mm (IQR = 1-12, p < .001). Ankle- and calf circumferences decreased in the leg wearing compression stocking and increased in the other leg. There was no change in difference of pain and discomfort and no adverse events.CONCLUSION: Compression stockings reduced edema formation in young healthy passengers during a three-hour flight. Passengers experiencing edema-related discomfort during short-haul flights may benefit from wearing compression stockings during air travel.TRIAL REGISTRATION: clinicaltrials.gov: NCT03546725.

This review summarises aetiology, diagnostic approach, and treatment of longstanding groin pain, which can be divided in adductor-related, pubis-related, iliopsoas-related, and inguinal-related pain. Among the diagnoses included in the inguinal-related entity is the so-called sports hernia. However, the terminology is a misnomer since sports hernia is characterised by not being a hernia. Both athletes and non-athletes are affected, and the condition may cause long sick leaves. The treatment is primarily exercise treatment. If this treatment is unsuccessful after 2-6 months, surgery is an option.

Background: Abdominal rectus diastasis is a condition where the abdominal muscles are separated by an abnormal distance due to widening of the linea alba causing the abdominal content to bulge. It is commonly acquired in pregnancies and with larger weight gains. Even though many patients suffer from the condition, treatment options are poorly investigated including the effect of physiotherapy and surgical treatment. The symptoms include pain and discomfort in the abdomen, musculoskeletal and urogynecological problems in addition to negative body image and impaired quality of life. The purpose of this review was to give an overview of treatment options for abdominal rectus diastasis. Results: The first treatment step is physiotherapy. However, evidence is lacking on which regimen to use and success rates are not stated. The next step is surgery, either open or laparoscopic, and both surgical approaches have high success rates. The surgical approach includes different plication techniques. The recurrence and complication rates are low, complications are minor, and repair improves low back pain, urinary incontinence, and quality of life. Robotic assisted surgery might become a possibility in the near future, but data are still lacking. Conclusions: Evidence on what conservatory treatment to use is sparse, and more research needs to be done. Both open and laparoscopic surgery have shown positive results. Innovative treatment by robotic assisted laparoscopic surgery has potential, however, more research needs to be done in this area as well. An international guideline for the treatment of rectus diastasis could be beneficial for patients and clinicians.

Groin hernia is a common condition in children. However, in Denmark, no national guideline for treatment exists, and the evidence is sparse regarding optimal timing and preferred surgical technique. Almost all Danish children are treated with open surgery, even though the complication rate is similar for laparoscopy. Correct timing of repair of an asymptomatic reducible groin hernia is controversial, and the benefits of waiting versus the risk of incarceration should be considered. In this review, we summarise the evidence and give our proposal for a treatment flow chart.

BACKGROUND: Few studies have described recurrence rates after groin hernia repair in women. Our aim was to investigate if laparoscopic repair of primary groin hernias in women results in a lower reoperation rate for recurrence compared with open repairs. Furthermore, we wished to compare hernia subtypes at primary repair and reoperation.METHODS: This nationwide cohort study was reported according to the RECORD statement. We used prospectively collected data from the Danish Hernia Database to generate a cohort of females operated for a primary groin hernia from 1998 to 2017. Our primary outcome was reoperation for recurrence. The secondary outcome was subtype of hernia at primary repair and reoperation. All females had at least 6-month follow-up.RESULTS: We included 13,945 primary groin hernia operations in women, of whom 649 had undergone a reoperation for recurrence. Median follow-up time was 8.8 years. The cumulative reoperation rates were lower after laparoscopic repair compared with the open techniques, for both inguinal hernias (1.8 vs. 6.3%, p < 0.001) and femoral hernias (2.2 vs. 5.5%, p = 0.005). After laparoscopic repair, 25% of inguinal hernias recurred as femoral, compared with 47% after Lichtenstein (p < 0.001). Direct inguinal hernias and femoral hernias had higher risk of reoperation for recurrence after open repair compared with indirect inguinal hernias. For laparoscopic procedures, hernia subtypes at the primary groin hernia repair had similar reoperation rates.CONCLUSION: Laparoscopic repair of primary groin hernia in women had lower reoperation rates and fewer femoral recurrences than open repair techniques.

BACKGROUND: Laparoscopic groin hernia repair has become increasingly popular. In Denmark, all groin hernia repairs are registered in the Danish Hernia Database. However, many surgical technical parameters are not registered in neither the hernia database nor in other national registries or the patient files. Our aim was to characterize differences in surgical techniques and variations in convalescence recommendations in laparoscopic groin hernia repair that are not available elsewhere.METHODS: A questionnaire was sent to all surgeons in Denmark regularly performing unsupervised laparoscopic groin hernia repair. The questionnaire was developed in collaboration with an experienced chief surgeon and face-validated on the target group. It contained demographic details and items on surgical parameters such as the creation of pneumoperitoneum, size of the optic, choice of closure methods, preoperative information, and postoperative recommendation of convalescence.RESULTS: A total of 71 surgeons were eligible for inclusion, and 61 (86%) responded. We found large variations in almost all surgical parameters, i.e. there was no uniform way of performing laparoscopic groin hernia repair. The variation was not due to the level of experience. The median recommended convalescence period was 1.5 (range 0-28) days for activities of daily living, 4.5 (range 0-28) days for light physical activity, and 14 (range 0-35) days for hard physical activity. Three percent of surgeons routinely informed patients about the risk of sexual dysfunction prior to operation, and 98% informed about the risk of chronic pain.CONCLUSIONS: Surgical technical parameters and convalescence recommendations in laparoscopic groin hernia surgery vary widely in a national cohort of experienced hernia surgeons.

BACKGROUND: Regarding groin hernia repair in children, guidelines do not favor open or laparoscopic repair. Even so, most surgeons prefer an open technique. The aim of this systematic review was to compare short- and long-term outcomes after laparoscopic and open groin hernia repair in children.METHODS: Systematic searches were conducted in three databases, and all randomized controlled trials comparing laparoscopic and open groin hernia repair in children under 18 years were included. Outcomes were postoperative complications, intraoperative complications, operative time, length of hospital stay, time to recovery, and wound appearance. The outcomes were compared between open and laparoscopic repairs in meta-analyses.RESULTS: We included ten studies with 1270 patients involving 1392 hernias. We found no differences in recurrence rate, testicular atrophy, hydrocele, hematoma, seroma, infection, pain, length of hospital stay, or time to full recovery. Laparoscopic repair was superior regarding wound appearance. Laparoscopic repair had shorter operative time than open repair for bilateral groin hernias. For unilateral groin hernias, extraperitoneal laparoscopic repair was faster than open repair, but open repair was faster than intraperitoneal laparoscopic repair.CONCLUSION: Our results indicate similar outcome after laparoscopic and open techniques for groin hernia repair in children. The surgeon's preference as well as the wishes of the patient and parents should therefore determine the surgical approach.