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Ramser M, Baur J, Keller N, Kukleta JF, Dörfer J, Wiegering A, Eisner L, Dietz UA. Robotic hernia surgery I. English version : Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations. Chirurg 2021; 92:1-13. [PMID: 34185126 PMCID: PMC8695554 DOI: 10.1007/s00104-021-01446-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 11/01/2022]
Abstract
The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.
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Affiliation(s)
- Michaela Ramser
- Department of Visceral, Vascular and Thoracic Surgery, Cantonal Hospital Olten (soH), Baslerstrasse 150, 4600, Olten, Switzerland
| | - Johannes Baur
- Department of Visceral, Vascular and Thoracic Surgery, Cantonal Hospital Olten (soH), Baslerstrasse 150, 4600, Olten, Switzerland
| | - Nicola Keller
- Department of General, Visceral and Vascular Surgery, Cantonal Hospital Baden, Im Engel 1, 5404, Baden, Switzerland
| | - Jan F Kukleta
- Hernienzentrum Zurich, Grossmuensterplatz 9, 8001, Zurich, Switzerland
| | - Jörg Dörfer
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplant, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Straße 6, 97080, Wuerzburg, Germany.
| | - Lukas Eisner
- Department of Visceral, Vascular and Thoracic Surgery, Cantonal Hospital Olten (soH), Baslerstrasse 150, 4600, Olten, Switzerland
| | - Ulrich A Dietz
- Department of Visceral, Vascular and Thoracic Surgery, Cantonal Hospital Olten (soH), Baslerstrasse 150, 4600, Olten, Switzerland.
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Ramser M, Baur J, Keller N, Kukleta JF, Dörfer J, Wiegering A, Eisner L, Dietz UA. [Robotic hernia surgery : Part I: Robotic inguinal hernia repair (r‑TAPP). Video report and results of a series of 302 hernia operations]. Chirurg 2021; 92:707-720. [PMID: 34061241 PMCID: PMC8324587 DOI: 10.1007/s00104-021-01425-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/20/2023]
Abstract
The treatment of inguinal hernias with open and minimally invasive procedures has reached a high standard in terms of outcome over the past 30 years. However, there is still need for further improvement, mainly in terms of reduction of postoperative seroma, chronic pain, and recurrence. This video article presents the endoscopic anatomy of the groin with regard to robotic transabdominal preperitoneal patch plasty (r‑TAPP) and illustrates the surgical steps of r‑TAPP with respective video sequences. The results of a cohort study of 302 consecutive hernias operated by r‑TAPP are presented and discussed in light of the added value of the robotic technique, including advantages for surgical training. r‑TAPP is the natural evolution of conventional TAPP and has the potential to become a new standard as equipment availability increases and material costs decrease. Future studies will also have to refine the multifaceted added value of r‑TAPP with new parameters.
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Affiliation(s)
- Michaela Ramser
- Klinik für Viszeral‑, Gefäss- und Thoraxchirurgie, Kantonsspital Olten, Baslerstr. 150, 4600, Olten, Schweiz
| | - Johannes Baur
- Klinik für Viszeral‑, Gefäss- und Thoraxchirurgie, Kantonsspital Olten, Baslerstr. 150, 4600, Olten, Schweiz
| | - Nicola Keller
- Klinik für Allgemein‑, Viszeral- und Gefässchirurgie, Kantonsspital Baden, Im Engel 1, 5404, Baden, Schweiz
| | - Jan F Kukleta
- Hernienzentrum Zürich, Grossmünsterplatz 9, 8001, Zürich, Schweiz
| | - Jörg Dörfer
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - Armin Wiegering
- Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland.
| | - Lukas Eisner
- Klinik für Viszeral‑, Gefäss- und Thoraxchirurgie, Kantonsspital Olten, Baslerstr. 150, 4600, Olten, Schweiz
| | - Ulrich A Dietz
- Klinik für Viszeral‑, Gefäss- und Thoraxchirurgie, Kantonsspital Olten, Baslerstr. 150, 4600, Olten, Schweiz.
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Zipper CT, Friedrich U, Backhaus J, König S, Mavroveli S, Wiegering A, Olbrecht S, Puppe F, Günster SA, Dietz UA. Incisional hernia repair in a high-fidelity silicone model for open retro-muscular mesh implantation with preparation of the fatty triangle: validation and educational impact study. Hernia 2019; 24:1307-1315. [PMID: 31792801 DOI: 10.1007/s10029-019-02094-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 11/17/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Incisional hernia repair requires detailed anatomic knowledge. Regarding median subxiphoidal hernias, the proper preparation of the fatty triangle is challenging. To foster proficiency-based training, a cost-efficient model for open median retromuscular mesh repair resembling the human body was developed, including the main anatomical structures related to the procedure. The aim is to create and validate a high-fidelity model on open retromuscular mesh repair suitable for "training before doing". MATERIALS AND METHODS Different types of fabrics for imitation of connective tissue and 2-component silicones were used to construct the incisional hernia model. Sample size for validation of the model was determined by a triangular testing approach. Operations from six beginners and six experts were assessed by three blinded-raters. Reliability and construct-validity were evaluated on a behaviorally anchored rating scale (highest score: 4) for the criteria: "instrument use", "tissue handling", "near misses and errors", and "end-product quality". RESULTS The model authentically mimicked an open median retromuscular mesh repair. Participants considered the procedure realistic. Reliability was excellent, ranging from 0.811 to 0.974 for "end-product quality", and "tissue handling" respectively. Construct-validity was confirmed with experts significantly outperforming beginners in the "use of instruments" (Mbeg. = 2.33, Mexp. = 3.94, p < 0.001), "tissue handling" (Mbeg. = 2.11, Mexp. = 3.72, p < 0.001), "near misses and errors" (Mbeg. = 2.67, Mexp. = 3.67, p < 0.001), and "end-product quality" (Mbeg. = 2.78, Mexp. = 3.72, p < 0.001). Criterion-validity revealed a paradox effect: beginners performed significantly better than experts (p < 0.05) when preparing the fatty triangle. CONCLUSIONS The model covers all relevant aspects involved in median-open retromuscular incisional hernia mesh repair. Performance differences between beginners and experts confirm construct-validity and thereby realism of the model. It enables to efficiently improve and practice technical skills of the demanding surgery.
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Affiliation(s)
- C T Zipper
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany
| | - U Friedrich
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany
| | - J Backhaus
- Institute of Medical Teaching and Medical Education Research, University of Wuerzburg, Josef-Schneider Strasse 2, 97080, Wuerzburg, Germany
| | - S König
- Institute of Medical Teaching and Medical Education Research, University of Wuerzburg, Josef-Schneider Strasse 2, 97080, Wuerzburg, Germany
| | - S Mavroveli
- London General Surgical Skills Programme, Imperial College London, South Wharf Road, Paddington, London, W2 1BL, UK
| | - A Wiegering
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Wuerzburg, Am Hubland, 97074, Wuerzburg, Germany
| | - S Olbrecht
- Institute for Artificial Intelligence and Applied Informatics (VI), University of Wuerzburg, Am Hubland, 97074, Wuerzburg, Germany
| | - F Puppe
- Institute for Artificial Intelligence and Applied Informatics (VI), University of Wuerzburg, Am Hubland, 97074, Wuerzburg, Germany
| | - S A Günster
- Institut für Allgemeinmedizin, Friedrich-Alexander-Universitaet Erlangen-Nuernberg, Universitaetsstrasse 29, 91054, Erlangen, Germany
| | - U A Dietz
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Wuerzburg, Oberduerrbacher Strasse 6, 97080, Wuerzburg, Germany. .,Department of General, Visceral, Vascular and Thoracic Surgery, Kantonsspital Olten (soH), Baselstrasse 150, 4600, Olten, Switzerland.
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Dietz UA, Germer CT, Wiegering A. [Inguinal and femoral hernia surgery : Open mesh procedure. Video article]. Chirurg 2018; 87:938-947. [PMID: 27770141 DOI: 10.1007/s00104-016-0294-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
There are several techniques for repair of symptomatic inguinal and femoral hernias. There is an increased acceptance and tendency favoring minimally invasive procedures, such as plug or transinguinal preperitoneal mesh prosthesis (TIPP) and endoscopic procedures, such as totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair. In the present review the classical techniques of Irving L. Lichtenstein (1986) and Jean Rives (1965), two indispensable procedures, are presented and the results from the literature are discussed. The videos show the repair of three interesting and complex cases. The surgical techniques are demonstrated in detail with the help of a video of the operation and which is available online. It is essential that each hernia surgeon should have proficiency in performing both procedures in order to be able to counsel patients and tailor the procedure according to the clinical findings.
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Affiliation(s)
- U A Dietz
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland.
| | - C-T Germer
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
| | - A Wiegering
- Klinik und Poliklinik für Allgemein-, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Deutschland
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Abstract
Many publications are available on the best surgical techniques and treatment of incisional hernias with reports of experiences and randomized clinical studies at the two extremes of the evidence scale. The ultimate proof of the best operative technique has, however, not yet been achieved. In practically no other field of surgery are the variability and the resulting potential aims of surgery so great. The aim of surgery is to provide patients with the optimal recommendation out of a catalogue of possibilities from a holistic perspective. This article describes the surgical techniques using meshes for strengthening (in combination with an anatomical reconstruction) and for replacement of the abdominal wall (with bridging of the defect).
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Ludwig K, Scharlau U, Schneider Koriath S. [Management of more frequent complications of laparoscopic surgery. Minimally invasive or always open surgery?]. Chirurg 2015; 86:1105-13. [PMID: 26495447 DOI: 10.1007/s00104-015-0101-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Two decades after the far-reaching establishment of elective laparoscopic surgery, the questions arise whether and when the benefits of this technology can be sufficiently and safely implemented even in cases of complications. MATERIAL AND METHODS The currently available literature was analyzed in the context of recommendations for the management of complications in laparoscopic surgery. RESULTS Intraoperative and postoperative complications of minimally invasive surgery necessitating treatment are extremely rare and can be expected in only 0.1–5 % of interventions, depending on the complexity of the intervention. In addition to adhesion-related and anatomical limitations, they are responsible for the necessity to convert to open surgery in approximately 40–60 % of the cases. DISCUSSION Due to the relative rarity and great variety of potential complications, there is no scientific evidence at the study level that can give reliable recommendations for a management strategy in every situation. It still has to be decided on an individual basis and depending on the particular clinical situation if a successful laparoscopic management can be sufficiently and safely carried out. It has been found that a number of complications can be well controlled by minimally invasive procedures; however, in addition to a high level of personal experience in laparoscopy, optimal technical, institutional and instrumental conditions must be available. If these factors are not present in total, a conventional open approach should still be given preference.
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Abstract
Hernia surgeons and patients have learned to appreciate the advantages of minimally invasive laparoscopic procedures. After overcoming the early learning curve phase, smaller wound surface areas, shorter operation times and briefer hospital stays have become routine. Severe surgery-related complications are rare. Patients with poor risk profiles (e.g. age >70 years, BMI >30 and nicotine consumption) profit especially from these advantages. This positive picture is clouded, however, by the need for an intraperitoneal mesh and specifically by the unchanged recurrence rate. The latter is not significantly lowered even by laparoscopic intraperitoneal on-lay mesh (laparoscopic IPOM) procedures. The current literature shows that irrespective of surgical technique, e.g. retromuscular mesh or laparoscopic IPOM, the risk profile and size of the hernia defect are independent factors that determine the prognosis for recurrence. While a cure of incisional hernia is no longer the only goal, the new indication scenario has two main goals: (a) for young patients at low risk or in patients for whom functional and morphological reconstruction of the abdominal wall are of primary importance, an open retromuscular mesh procedure is indicated (despite the higher morbidity) and (b) for older patients and chiefly for patients with a complex risk profile for whom treatment of the ventral hernia symptoms is paramount, laparoscopic procedures are indicated (due to the lower morbidity). This algorithm assumes that the treating surgeons have the requisite expertise and is discussed using the examples of four complex case reports.
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