Search

Introduction: Polypropylene material is commonly used for posterior wall reconstruction in hernia repair, in contrast with the classically described stainless-steel wire used at Shouldice Hospital. This study was conducted to evaluate possible differences in Shouldice Repair outcomes using polypropylene or stainless-steel wire sutures., Methods: A prospective follow-up of consecutive patients who underwent elective unilateral Shouldice primary inguinal hernia repair at Shouldice Hospital between December 6, 2021, and September 1, 2022, was conducted. Data was collected from follow-up telephone calls as well as manually reviewing patient's charts. The primary objective was to determine whether the use of polypropylene was non-inferior to the use of stainless-steel wire, regarding the recurrence rate reported by the patients with a minimum follow-up of 1 year after Shouldice primary inguinal hernia repair., Results: A total of 1120 patients were contacted by telephone (polypropylene: 560; stainless-steel wire: 560). The median follow-up period was 16 months (interquartile range: 15-18). In 22 (1.96%) cases a surgical site infection was diagnosed. There was a total of 18 recurrences reported by the patients (1.6%). There was no statistical difference between the groups (polypropylene: 7 (1.25%) vs. stainless steel wire: 11 (1.96%), p > 0.05) for the recurrence rate., Conclusion: The use of polypropylene is non-inferior to the use of stainless-steel wire regarding recurrence rate at a median follow-up period of 16 months after elective unilateral Shouldice primary inguinal hernia repair. This finding may encourage other centers where stainless-steel wire is not easily available to perform the Shouldice Repair., (© 2024. The Author(s).)

Purpose: There is limited research on the impact of an ilioinguinal-iliohypogastric nerve block on intraoperative opioid consumption when conducting groin hernia repair in adults. Thus, the aim was to evaluate ilioinguinal-iliohypogastric nerve block for groin hernia patients at Shouldice Hospital., Methods: The study was a pilot retrospective chart review on patients who underwent a Shouldice Repair from November 2023 to December 2023. This study compared individuals receiving an ilioinguinal-iliohypogastric nerve block with local anesthesia and fentanyl analgesia to those who received local anesthesia and fentanyl analgesia, by manually matching 1:1 on 12 demographic and intraoperative characteristics. Comparison between groups was performed using chi-square/Fisher Exact test for categorical and t-test/Mann-Whitney test for numerical variables depending on data distribution. Multivariable regression analysis was used to examine predictors of intraoperative use of fentanyl., Results: In this study 50 matched pairs of unilateral primary inguinal hernia patients were analyzed. The ilioinguinal-iliohypogastric nerve block patients had lower recorded intraoperative fentanyl (85mcg less than control, p < .001) and dimenhydrinate (13 mg less than control, p < .001) than the control group patients. No differences were found in postoperative day 0 to 3 for acetaminophen, non-steroidal anti-inflammatory drug, and opioid consumption between the patients who did receive an ilioinguinal-iliohypogastric nerve block prior to surgery and those that did not., Conclusion: The administration of an ilioinguinal-iliohypogastric nerve block prior to primary inguinal hernia repair using a Shouldice Repair is associated with a significantly lower intraoperative fentanyl consumption compared to non-administration., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Studies have shown that surgical treatment of colorectal carcinomas in certified centers leads to improved outcomes. However, there were considerable fluctuations in outcome parameters. It has not yet been examined whether this variability is due to continuous differences between hospitals or variability within a hospital over time., Materials and Methods: In this retrospective observational cohort study, administrative quality assurance data of 153 German-certified colorectal cancer centers between 2010 and 2019 were analyzed. Six outcome quality indicators (QIs) were studied: 30-day postoperative mortality (POM) rate, surgical site infection (SSI) rate, anastomotic insufficiency (AI) rate, and revision surgery (RS) rate. AI and RS were also analyzed for colon (C) and rectal cancer operations (R). Variability was analyzed by funnel plots with 95% and 99% control limits and modified Cleveland dot plots., Results: In the 153 centers, 90 082 patients with colon cancer and 47 623 patients with rectal cancer were treated. Average QI scores were 2.7% POM, 6.2% SSI, 4.8% AI-C, 8.5% AI-R, 9.1% RS-C, and 9.8% RS-R. The funnel plots revealed that for every QI, about 10.1% of hospitals lay above the upper 99% and about 8.7% below the lower 99% control limit. In POM, SSI, and AI-R, a significant negative correlation with the average annual caseload was observed., Conclusion: The analysis showed high variability in outcome quality between and within the certified colorectal cancer centers. Only a small number of hospitals had a high performance on all six QIs, suggesting that significant quality variation exists even within the group of certified centers., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Shouldice Repair for inguinal hernias results in a low recurrence rate; however, little is known about the risk factors for these relapses. In the present study, we reviewed all patient's undergoing a reoperation for recurrence after a primary Shouldice Repair., Methods: Patients undergoing recurrent inguinal hernia repair from 2013 to 2017 were identified. The subgroup of patients with the first recurrence after a Shouldice Repair at this institution was selected and included. Data collection from the index and the reoperation surgery were performed, as well as statistical analysis., Results: A total of 125 patients were included in the analysis. The mean age was 50.8 ± 13.9 (body mass index: 24.6 ± 2.6 kg/m 2 ), 97% were male. The most common interval for a recurrence reoperation was in the first 5 years following the initial surgery (37.6% of patients; mode: 1 year; median: 7 years; mean: 13.7 ± 13.8 years). A temporal median pattern for recurrence reoperation according to age interval was noted (patients < 41 years old: 20 years; patients aged 41-60 years old: 10 years and patients > 61 years: 2 years))., Conclusion: Patients undergoing reoperations for recurrent inguinal hernias after a primary Shouldice Repair presented a pattern of temporal recurrence according to age. Older patients present with earlier recurrences than younger ones, an important consideration in the assessment of patients postoperatively., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult., Methods: We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits., Results: Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation., Conclusion: We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion., (© 2024. The Author(s).)

Shouldice Hospital has grown beyond its beginnings in the 1940s to become a leading centre of excellence for mesh-free hernia repair. Little is known to the international surgical community about the preoperative and postoperative care at Shouldice Hospital, and colleagues working at Shouldice Hospital have been repeatedly asked to provide more details at international and national congresses. Therefore, this article aims to summarize preoperative and postoperative care at Shouldice Hospital based on previously published literature. The authors believe that the long-standing tradition of prehabilitation and postoperative treatment may play a role in facilitating patient satisfaction and superior postoperative results after hernia surgery., Competing Interests: Marguerite Mainprize, Christoph Paasch, and Fernando AC Spencer Netto declare that they have no conflict of interests.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Perforated colonic diverticulitis with purulent or fecal contamination (PCD) is a surgical emergency with high morbidity and mortality. Traditionally, open surgery as a Hartmann procedure (HP) has been performed. Feasibility of the laparoscopic approach (LA) either with primary anastomosis (PA) or as an HP has been shown, but evidence and implementation into daily routine remain low. We analysed all patients with PCD and emergency surgery at our institution to compare post-operative outcomes between LA and open surgery. Our results should add more evidence about the potential benefit of LA in treating PCD., Methods: This retrospective analysis conducted at a tertiary care centre in Germany included all patients with PCD undergoing emergency surgery between June 2007 and February 2019. Mortality and postoperative morbidity according to Clavien-Dindo-Classification are the primary endpoints. Secondary endpoints were stoma-free survival and length of hospital stay., Results: Seventy-seven patients were identified (41 female/36 male; median age 67.9 years). Sixty patients underwent a LA (conversion in 9 of 60, 15%). PA has been performed in 25 of 77 patients (22 LA, 3 with open surgery). Severe complications and death (Clavien-Dindo-Classification grade IIIb-V) were lower in patients with LA (17/60, 28%) compared to open surgery (9/17, 53%; p  = 0.082) as well as the length of hospital stay (LOS; LA 9 days vs. open surgery 17 days; p  = 0.016)., Conclusion: The LA is feasible in the majority of patients with PCD and may be warranted as a routine in emergency surgery. Although limited by a selection bias of this retrospective study, the LA seems to reduce morbidity and LOS.

Background: Studies have evaluated long-term occurrence of incisional hernia, cosmesis, and postoperative pain after single-incision laparoscopic cholecystectomy (SILC). However, the follow-up periods were rarely defined longer than 12 months. The authors performed a cohort study to evaluate hernia rate and cosmesis in a prolonged follow-up period., Methods: All patients that underwent SILC at the University Hospital Brandenburg an der Havel Hospital between December 2008 and November 2014 were evaluated in terms of postoperative complications, and a follow-up telephone interview including the existence of hernias and chronic pain was performed. Cosmesis and the overall satisfaction of the scar was measured by POSAS (Patient and Observer Scar Assessment Scale)., Results: In total 125 patients underwent SILC. The single-incision approach was completed in 94.4%, an additional trocar was necessary in 3.2% ( n =4) and a conversion to 4 trocar cholecystectomy was required in 2.4% ( n =3). Intraoperative complications occurred in 0.8% and postoperative complication in 12.8% of all patients. Follow-up telephone interview was performed in 49.6% of 125 patients. The mean follow-up period was 138.9 months (11.6 years). Overall, in 3.6%, an incisional hernia was diagnosed. A total of 3.6% reported pain in the region of the umbilicus with a mean VAS (visual analog scale) of 2/10. The mean POSAS score was 7.8. Overall, 82.3% of this cohort rate their satisfaction of the scar with a 1/7, resembling the best possible result of the scar., Conclusion: The present study demonstrates that SILC is a safe alternative in terms of incisional hernia rate and complications with a high satisfaction of the scar even after one decade after surgery. In comparison to shorter follow-up period and multiport laparoscopic cholecystectomy, our result is comparable., Competing Interests: All authors declare that they have no conflicts of interest.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: The integration of artificial intelligence (AI) into surgical laparoscopy has shown promising results in recent years. This survey aims to investigate the inconveniences of current conventional laparoscopy and to evaluate the attitudes and desires of surgeons in Germany towards new AI-based laparoscopic systems., Methods: A 12-item web-based questionnaire was distributed to 38 German university hospitals as well as to a Germany-wide voluntary hospital association (CLINOTEL) consisting of 66 hospitals between July and November 2022., Results: A total of 202 questionnaires were completed. The majority of respondents (88.1%) stated that they needed one assistant during laparoscopy and rated the assistants' skillfulness as "very important" (39.6%) or "important" (49.5%). The most uncomfortable aspects of conventional laparoscopy were inappropriate camera movement (73.8%) and lens condensation (73.3%). Selected features that should be included in a new laparoscopic system were simple and intuitive maneuverability (81.2%), automatic de-fogging (80.7%), and self-cleaning of camera (77.2%). Furthermore, AI-based features were improvement of camera positioning (71.3%), visualization of anatomical landmarks (67.3%), image stabilization (66.8%), and tissue damage protection (59.4%). The reason for purchasing an AI-based system was to improve patient safety (86.1%); the reasonable price was €50.000-100.000 (34.2%), and it was expected to replace the existing assistants' workflow up to 25% (41.6%)., Conclusion: Simple and intuitive maneuverability with improved and image-stabilized camera guidance in combination with a lens cleaning system as well as AI-based augmentation of anatomical landmarks and tissue damage protection seem to be significant requirements for the further development of laparoscopic systems., (© 2023. The Author(s).)

Aim: The aim of the manuscript is to discuss and assess the implications and opportunities as well as dangers of "outpatientization" of surgical and inpatient services for general and abdominal surgery., Method: Narrative overview with literature reference based on a PubMed search with the search terms: outpatient operations and inpatient interventions, AOP catalog, hybrid DRG, outpatient hernia surgery, outpatient proctological surgery, selective sector-equal reimbursement and day-care forms of care. RESULTS (KEY POINTS): - In the Anglo-American area, the treatment of inguinal hernias is predominantly carried out on an outpatient clinic basis. In the USA, Sweden and Denmark, for example, over 70% of all hernias are treated in an outpatient clinic setting, in Germany it is only 20%. In Germany, the catalog of operations that can be performed on an outpatient basis and other department-replacing interventions in hospitals defines outpatient interventions in accordance with § 115b Social Security Code (SGB) V (Germany). - The conversion from inpatient to outpatient hernia surgery has also failed so far due to an enormous difference in revenues. According to the will of the Federal Ministry of Health, the planned forms of semistationary care are intended to relieve the nursing staff in the hospitals and thus relieve the tense situation of nursing professionals. By the end of March 2023, a special industry-specific reimbursement, so-called hybrid DRGs, is to be agreed, which applies regardless of whether a paid service is provided on an outpatient or inpatient basis. - According to § 115b SGB V, whether a hernia can be performed under inpatient or outpatient conditions is also decided according to the location of the hernia. In the new AOP catalog, frailty is operationalized in the context factors via the degree of care and the Barthel index. If one compares the number of encryption procedures for the 5‑530 procedure (closure of an inguinal hernia) in 2005 (184,679) with the pre-corona year 2019 (179,851), it can be seen that the proportion of hernias treated in hospital remained approximately the same over a period of 14 years. - Most elective proctological procedures can be performed on an outpatient basis. For reasons of safety (bleeding) and practicality (pain management, dressing change of large abscesses), inpatient surgery is preferred: extensive hemorrhoidectomy in the case of massive findings, large abscesses, extensive perianal fistula corrections, particularly high transsphincteric or suprasphincteric fistulas. - Guidelines based on the British Guidelines for Ambulant Surgery should be required for comprehensive outpatient treatment in surgery. The introduction of corresponding hybrid DRGs seems to be the right way to cover the costs of outpatient surgery in hospitals., Conclusion: The restructuring of the hospital landscape and the nationwide expansion of outpatient operations is an unavoidable requirement in view of rising costs in the healthcare system and impending financing bottlenecks, which will pose challenges for the surgical disciplines in the years to come. Outpatient surgery is already practiced in many areas but has not become established due to the different remuneration. The flat rates for the same branches can be a starting point here. Furthermore, evidence-based framework conditions must be created along the lines of the British Guidelines for Ambulant Surgery., (© 2023. The Author(s).)