Total extraperitoneal endoscopic hernioplasty (TEP)

One can no longer think about modern hernia surgery without mentioning endoscopic techniques. But due to their high technical demands the learning curve is comparatively long. And by technical mistakes and their consequences (pain, recurrence, complications) the benefits of the endoscopic techniques can easily be turned to drawbacks. The following text explains the steps of the total extraperitoneal endoscopic hernioplasty (TEP) technique in detail pointing out alternatives and risks. From preparation, indication and positioning, from trocar placement to extraperitoneal dissection and mesh placement, the principles of TEP are elucidated in respect of local anatomy and possible complications. The text as well as the accompanying video in the Mediathek are based on the authors' 20 years of experience in the TEP technique. Both of them may help in safe TEP application to minimise the complication rate as well as recurrences. Then patients can benefit from the advantages of this technique.

The preperitoneal loop in inguinal hernia repair following the totally extraperitoneal technique

BACKGROUND

With increasing experience in totally extraperitoneal (TEP) hernia repair, we observed an anatomical structure not described in the literature. It is a loop-like structure under the ductus deferens or ligamentum teres uteri anchored laterally and medially to the peritoneum. Relatively constant in distance to the inner inguinal ring and individual in the grade of prominence, it inhibits correct patch placement medially. To identify and describe this so-called preperitoneal loop (pl), we performed this study.

METHODS

Between February 2nd and July 15th 2006, all patients undergoing a TEP procedure at our institution in primary inguinal hernia without previous operations in the lower abdomen were included. The main topic was the prominence and distance to the inner inguinal ring of the pl and histological examinations were made.

RESULTS

A total of 219 patients (194 male, 25 female) were included, with 97 right-side, 64 left-side and 58 bilateral hernias. The pl could be shown in 206 cases (94%), the distance to the inner ring was up to 1.5 cm in 60, between 1.5 and 3.0 cm in 112, and over 3 cm in 34 cases. Anatomical examinations showed smaller blood vessels embedded in fatty tissue and surrounded by collagen fibres (standard haematoxylin eosin [HE]) and collagen connective tissue strongly filled with elastic fibres and, occasionally, nerve fibres and lymphatic capillaries (van Gieson).

CONCLUSIONS

The pl is a very constant structure that is independent of gender and hernia type and size. In most cases, it is found close to the inner inguinal ring and, therefore, has to be cut for adequate parietalisation of cord structures/ligamentum teres uteri and correct mesh placement medially. As no mesothel was found, the origin of pl might be the deeper sheet of transversalis fascia.

Evidence of thromboembolism prophylaxis in bariatric surgery-results of a quality assurance trial in bariatric surgery in Germany from 2005 to 2007 and review of the literature

BACKGROUND

Since January 1st, 2005, the current situation for bariatric surgery has been examined by means of a voluntary quality assurance study in Germany with a multicenter design in which 38 hospitals and surgical departments participated. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

Data describing peri-interventional characteristics were prospectively documented in an internet online data registry. All primary bariatric procedures performed since January 1st, 2005, were registered. In addition, reoperations in patients who had previously undergone primary surgical intervention were included. As a representative excerpt from the overall prospective multicenter observational study on obesity surgery, data on the type, regimen, and time course of deep venous thrombosis (DVT) prophylaxis were documented. From the number and spectrum of complications, the incidences of clinically manifest DVT or pulmonary embolism (PE) were derived during the in-hospital course and follow-up in conjunction with the type of surgical procedure and body mass index (BMI).

RESULTS

Overall, 3,122 bariatric procedures were performed at 38 German hospitals between January 2005 and December 2007. These procedures were subdivided into 2,869 primary operations and 253 revisions (sex ratio, male to female = 25.6:74.4%). The average BMI of all patients was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. In 2005 and 2006, gastric banding (GB) was the most commonly performed operation, followed by Roux-en-Y gastric bypass (RYGBP). In 2007, RYGBP was carried out in 42.1% of all bariatric procedures. Interestingly, the incidence of deep venous thrombosis (DVT) was only 0.06%, whereas PE occurred in 0.06% of patients only after hospital discharge. The DVT prophylaxis protocol used has been changed for the last 2 years: the majority of patients with a BMI above 50 kg/m(2) received low-molecular-weight heparin twice a day.

CONCLUSION

In Germany, a trend from GB to sleeve gastrectomy (SG) and malabsorptive approach has been evaluated. This trend is associated with differences of the DVT prophylaxis regimen in the profile of bariatric surgical patients depending on BMI and the type of bariatric procedure. Despite the low incidence of DVT and pulmonary embolism (PE) detected, there is a lack of evidence on a reasonable regimen for sufficient DVT prophylaxis in bariatric surgery; instead, there are only recommendations from the guidelines and statements of a specific medical society. Therefore, prospective studies are necessary to determine the optimal DVT prophylaxis for bariatric surgical patients as well as obese patients undergoing surgery.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

[Quality assurance in bariatric surgery in Germany--results of the German multicentre trial 2005 and 2006]

BACKGROUND

Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg.

METHODS

The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before.

RESULTS

629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures.

CONCLUSION

A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006

BACKGROUND

Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery.

MATERIALS AND METHODS

All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial.

RESULTS

In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%).

CONCLUSION

Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

[Total extraperitoneal endoscopic hernioplasty (TEP) in the treatment of incarcerated and irreponible inguinal and femoral hernias]

To estimate the value of TEP in the treatment of incarcerated and irreponible inguinal and femoral hernias more exactly we prospectively collected and evaluated the data of our clinic for the period of Oct. 1999 until Dec. 2003. In this period we performed in total 1 671 hernia repairs including 79 patients suffering from an incarcerated (n = 33) or irreponible (n = 46) inguinal or femoral hernia. Using only the TEP-technique we treated mainly the irreponible hernias (46 patients). In the combination of LAP (laparoscopy) and TEP (27 patients) the laparoscopy provided the possibility to classify as well the incarcerated tissue as the result of the reposition. With this combined technique we treated the majority of the incarcerated hernias. To confirm the recovery of the incarcerated tissue laparoscopy can be of high value at the end of the combined LAP + TEP (2 patients). Thus TEP was performed in 92 % of the cases. In 2 cases we performed a conventional hernioplasty and one operation was finished conventionally after switching from endoscopic to conventional procedure. In 2 patients we performed a laparoscopically supported resection of the incarcerated tissue without patch implantation. 1 patient acquired TAPP. The use of different operative techniques and their combinations demonstrates as well the possibility as the necessity of a differentiated and case adapted proceeding in the treatment of incarcerated hernias. Lethality with 1.2 % and early postoperative morbidity with only 5.0 % were low. The hospitalisation period was 4.7 d on average. Our results are comparable to results of literature and show that TEP-technique and combined TEP + LAP-technique are possible and reasonable for the treatment of incarcerated and irreponible hernias.

[Laparoscopic appendectomy with mini-instruments]

In the period 01/00-12/01 in 35 out of 199 patients the laparoscopic appendectomy was performed with mini-instruments. This paper gives the prospectively registered data as well as our standardized technique of laparoscopic appendectomy with mini-instruments. The operations were performed via a 12 mm umbilical trocar and two suprapubic mini-trocars. Preparation was done with mini-instruments guided by 10 mm/30 degrees optic. Stapling of appendix and ligature of mensenteriolum via the 12 mm umbilical trocar was guided by 30 degrees -mini-optics. There was only one change of a mini-trocar to a 10 mm trocar for better view. 33 patients were female, mean age 23.4 years, mean BMI 21.1, mean operation time 41.1 minutes, mean post-op stay 3.3 days. There were no intra- or postoperative complications. The laparoscopic appendectomy with mini-instruments can be done by experienced surgeons in slender patients with low inflammation grade of the appendix without an increased complication rate and with a very good cosmetic result.