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IntroductionSymptomatic 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 (ELAR plus).Material and methodsBetween 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 minutes. The mesh had a mean longitudinal extension of 18.6 cm and transverse extension of 9.1 cm. ResultsThirty-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, three out of 40 patients (7.5 %) complained of intermittent pain on exertion, and two out of 40 patients (5 %) still took painkillers when required.ConclusionEndoscopic-assisted linea alba reconstruction plus mesh augmentation (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 biologic mesh (Permacol®, Covidien, Neustadt an der Donau, Germany). Biologic 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 recurrence, lifestyle restrictions and current complaints. Results: After a mean follow-up of 26+18 months (range 3-58) months 10 patients (three 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 explantation of the mesh was necessary due to mesh migration and painful adhesions. In one further case with gastroparesis pyloroplasty was performed without success.Conclusion: Recurrence was rare after hernia repair with the biologic mesh Permacol®. Dysphagia, gas bloat and intraabdominal pain were frequent complaints. Despite the small number of patients it can be concluded that a biologic mesh may be an alternative to synthetic meshes to reduce recurrences. Long-term results should be studied in the future in order to assess the potential of biologic meshes to preserve esophageal function as well. This is important since artificial meshes are known to 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, 6 case series.Results: The results of Franklin et al [23, 24, 25] 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 [26] 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 [3]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.

IntroductionThe 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).MethodsA 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.ResultsBiologic 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 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.ConclusionsBiologic 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.

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. Material and MethodsA literature search of the Medline database was performed using the PubMed search engine. Twenty publications were found relevant for this review.ResultsFor 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. ConclusionWhen required, either a synthetic or a biological meshes 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.

IntroductionThe 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.MethodsA 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.Results122 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 in scores at 6 weeks and 6 months, but this had deteriorated at 12 month 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.ConclusionsSphincter encirclement with biological material has demonstrated improvements in continence and quality of life scores in the short term compared to traditional repair alone. Long-term studies are necessary to determine if this effect is sustained. As a bulking agent, benefits are short-term.

IntroductionVentral mesh rectopexy (VMR) is a recognised treatment for posterior compartment pelvic organ prolapse (POP). The aim of this review is to provide a synopsis of the evidence for biologic mesh use in VMR, the most widely recognised surgical technique for posterior compartment POP.MethodsA systematic search of PubMed was conducted using the search terms ‘VMR’, ‘ventral mesh rectopexy’ or ‘mesh rectopexy’. Six studies were identified.Results268/324 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 biologic 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 biologic mesh in VMR is of low quality (level 4).ConclusionsVMR 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 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 of loop colostomy respectively, but still remains uncertain due to diagnostic variety of clinical or radiological methods, heterogeneous patient groups and variable follow-up intervals respectively. 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 6 systematic reviews, 2 randomized controlled trials (RCT), 2 case controlled studies and 1 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

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.

IntroducationIn 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 incontinuence rates in any of the studied comparisons. The following article reviews all studies available for treatment of fistula-in-ano with a fistula plug.Material and MethodsPubMed, Medline, Embase and the Cochrane medical database were searched up to December 2014. 47 articles were relevant for this review.ResultsHealing 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 mesh materials, such as acellular dermal matrix. Important technical steps in the performance of a complex anal fistula plug repair need to be followed.SummaryTreatment 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

IntroductionBiological meshes are a potential alternative to the synthetic meshes to avoid complications and 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.Material and MethodsIn a literature search of the Medline database using the key word Biological mesh 2,277 citations were found. There remained seven studies and two abstracts in which biological meshes had been used to repair inguinal hernias.ResultsIn 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 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.ConclusionInguinal hernias can be repaired with biological meshes with reasonable recurrence rate, also as an alternative in a potentially contaminated field.

IntroductionIt is known that recurrences continue to occur after the follow-up period of one to five 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 MethodsProspective data was 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 %).ResultsOnly 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. 91.87 % of such recurrences occur already within 10 years of the last operation.ConclusionAscertainment 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.

AbstractPurpose: 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 Registry, we aimed to investigate whether the differences in the therapy and treatment results justified such an approach.Methods: Between 1 September 2009 and 31 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 one-year follow-up results were subjected to statistical analysis.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 one-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 outcome between umbilical, epigastric and incisional hernias, scientific studies should be conducted only for a single hernia type.

To date the scientific definition Hernia Center does not exist and this term is beeing used by hospitals and private institutions as a marketing instrument. Hernia surgery has become increasingly more complex over the pass 25 years. Differenciated use of the various techniques in hernia surgery has been adopted as a taillord 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 there 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. 82 % 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 anaesthesia 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 summarized the recommendations of the various guidelines and to transfer them into a practical dicision tree for the daily work of surgeons performing inguinal hernia repair.

AbstractPurposeNew 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 a 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.MethodsA 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.ResultsOf 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 month. 32 were men and eight were women, with a nean age of 52,97 ± 12,22 years. Surgery was conducted to treat 36 transsphincteric, one intersphinteric and three rectovaginal fistulars. In 36 of 40 patients (90 %) the complex anal fistulas or rectovaginal fistulas were completely healed without any sign of recurrence. Non of these patients complained about continence problems. ConclusionA modification of the plug repair of complex anal fistulas with limited fistulectomy of the extrasphincteric part of the fistula and use of th

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.