Does the hernia surgery that we

have done so far reached our

expectations.
Reinhard Bittner
Standard repair in inguinal hernia disease in
Germany 1982

% Operations

100 91,8

80
60 53,8
41,536,4
40 31,3 33,5 32,3
23,1 22,1
20 6,1
0 0 0,4 0,7 0,2 0,4
0
1982 1992 1998 2006 Pavia
E. Bassini 1844-1924

TAPP/TEP Lichtenstein Shouldice Bassini

 Quality control Baden-Württemberg *
Surgery of inguinal hernia 1988/89
Problem:
Primary Recurrent
hernia hernia
[n=4045] [n=516]
Recurrence rate 8.1% 36,2%

Testicular atrophy 7.3% 14.7%

* Seidel W, Scheibe O (1993)

Ergebnisse der Leistenhernienchirurgie beim Erwachsenen
Langenbecks Arch Chir Suppl (Kongressbericht 1993): 234-237
 E. Shouldice
Bassini Shouldice

1939

Is the Shouldice repair the better solution?

% Operations

V. Schumpelick
 Results of Shouldice repair

Follow-up: time 10 years

rate 65 % (171 / 293)

recurrence rate
Primary hernia 7,7 %
Recurrent hernia 22,0 %
Overall 11,1 %
If it would be possible
to produce artificial tissue
showing the properties
of human fascia or tendon,
we would
have detected the secret
of radical hernia repair.

Theodor Billroth, 1878

 Marlex Mesh, a New Plastic
Mesh for Replacing Tissue Defects.
Experimental Studies
FRANCIS C. USHER, M.D.; JOHN P. GANNON,
M.D.
AMA Arch Surg. 1959;78(1):131-137.

Francis C. Usher

Was this the solution ?

Lichtenstein – Enforcement of the
anterior wall of the
1986 inguinal canal
open, anterior
- „tension free“?

I. Lichtenstein 1929-2000

Open operation = 4-10 cm skin incision

 Advantage of mesh repair?

“There is evidence that the use

of mesh repair is associated with
a reduction in the risk of
recurrence of between 50% and
75%”.
(Cochrane Database
Syst Rev 2002;(4) CD002197)
I. Lichtenstein 1929-2000
 Comparison: Mesh vs.- Suture repair

Shouldice Lichtenstein
Lichtenstein operation – Recurrence rate 1-3%

However, new problems: Foreign body

reaction and
Chronic
[Bay-Nielsen, Nilsson, Nordin, Kehlet
pain 23% Br. J. Surg 2004; 91:1372-1376]

No ideal reparation – what can we do ?

 First summary:
Disadvantages in open inguinal
hernia repair ?

Suture repair High recurrence rate:

10-15%

Open mesh repair High frequency of chronic pain

(up to 23%)
and wound problems.
Question:
„What is it, what the patient wants?“

Safety

Patient

rapid
recovery

Good quality may save a lot of money!

 Laparo-endoscopic inguinal
hernia repair !
TAPP

TEP

M.E. Arregui (1992) Laparo- J.-L. Dulucq (1992)

scopic mesh repair of inguinal hernia Treatment of inguinal hernia by
using a preperitoneal approach: A insertion of a subperitoneal patch
preliminary report. Surg Laparosc under pre-peritoneoscopy.
Endosc 2:53-58 Chirurgie 118:83-85
Second summary: Inguinal hernia repair –
current most recommended
surgical techniques:
 Open with suture (Shouldice)

 Open with mesh (Lichtenstein)

- mesh anterior

 Laparoendoscopic (TAPP/TEP)
Which technique is best? – Working-
mechanism?
Tension in rest
Suture
and under
physical stress!

Tension when
Mesh
resting only !
ant.

Tension-free
in rest and Pascal:
Mesh Pressure = force/
post.
under physical area
stress!
Did laparoendoscopic hernia surgery
comes up with our
expectations? ?
 15 years laparoscopic hernioplasty (TAPP) Marienhospital
Stuttgart, 3 / 1993 – 12 / 2007
(Bittner R, Schmedt CG, Schwarz J, Kraft K, Leibl BJ. Laparoscopic
transperitoneal procedure for routine repair of groin hernia. Br J Surg. 2002
Aug;89(8):1062-6)- at that time 8050 cases)

1200 n = 15101
[n]
II (indirekt) 4537 32.2 %
1000
IIIa (direkt) 5594 40.8 %

800 IIIb (ind./komb.) 3096 22.9 %

IIIc (femoral) 483 3.6 %
600 Perfectly standardized IV (Rec. Hernie) 1965 13.0 %

400
technique! scrotal 807 5,3%
irreducable 477 3.2 %

200 strangulated 161 1.1 %

Documentation of cases
0
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07
Follow-up
offen [Shouldice, Lichtenstein] laparoskopisch [TAPP] Quality control
 Annual recurrence rate after TAPP [n=15101]
% All Hernias Actual technique:
4/03 – 12/07 n=15101  Mini- access
9 n =15
Operation time 40(12-276) min  Mesh 10x15cm
8
Morbidity 2.5%
7  Mesh not slitted
6 Reoperation 0.44%
 Mesh material reduced
5 Recurrence rate 0.70%
 Selective or atraumatic fix.
4 n =16
3  Suture closure of
peritoneum
2
n=7 n=10 n=10 n=4 n=7 n=4 n=8 n=0 n=8 n=4 n=6 n=3 n=4
1

0
'93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 '07 [Year]
 Effectivity of TAPP in daily clinical routine.
( F.Muschalla,J.Schwarz, R.Bittner, Surg Endosc 2016; 30(11):4985-4994.)
1208 Hernia repairs (January 2000 – January 2001)
in 952 patients

Open
24 (1.98%)
Very young patients < 19yrs Laparoscopic
High cardio-pulmonary risk 1184 (98.02%) Hernias in 928 patients assigned
Not wanting mesh to follow-up.
Drop out: 66 patients with 80 hernias died
before follow-up.
49 patients with 63 hernias
withdrew consent.
26 patients with 31 hernias
were lost after inter-
Clinical follow-up
vention but before
1010 (85.3%) Hernias (787 patients) 5-year follow-up.
(at least after 5 years)
TAPP: Chronic pain after 5 years: 8,02 %
F.Muschalla,J.Schwarz, R.Bittner. Surg Endosc 2016; 30(11):4985-94

Chronic pain :
VAS > 0 - 30 6,34%

VAS 31 - 60 1,09 %

VAS > 60 0,59 %

Nobody needed pain killer, or had to change his profession!

TAPP: Recurrence rate after 5 years: 0,4 %
F.Muschalla,J.Schwarz, R.Bittner, Surg Endosc 2016; 30(11):4985-4994.
Strength of the study:
1. Great number of patients ( n= 928) ; Hernias n= 1184
2. All patients are consecutively operated on in one year!
3. 98 % of the patients are operated in TAPP technique.
4. All types of hernias are included.
5. 23 surgeons are involved in the hernia program.
6. Follow-up time at least 5 years!
7. 85,3 % of the patients completed clinical follow-up.

All TAPP`s were done in the same

strictly standardized technique!
Predictive Risk Factors for Persistent Postherniotomy Pain
Eske K. Aasvang, M.D.,* Eliza Gmaehle, Dpl. Psychol.,† Jeanette B. Hansen,
R.N.,‡Bjorn Gmaehle, Dpl. Psychol.,† Julie L. Forman, M.Sc., Ph.D.,§ Jochen
Schwarz, M.D., Reinhard Bittner, M.D., Henrik Kehlet, M.D.

Comparison of two Expert Clinics:

What is the frequency of chronic pain?

Lichtenstein

vs.

TAPP
Anesthesiology 2010; 112:1–13 (Impact Factor 5.5)
 Chronic pain in hernia surgery
Strength of the Study
 Measurement of pain threshold by
temperature stimulation ( 45°,46°,47°,48°C).
 KoSt – Pain Trial
Meaningful pain after 6 Months

Comparison: Lichtenstein vs. TAPP

Lichtenstein Laparosc. hernioplasty
Copenhagen Stuttgart
n= 244 n= 198 (only fibrin-pat.)

AA – Score >8.33* 16.0% 8.1% p < 0.014

Pain intensity : After laparoscopic hernioplasty

significantly less ( p < 0.001 )
AAS = Activity Assessment Score* meaningful pain
 What about chronic pain?
Comparison to suture repair:
Bittner R, CG; Sauerland, S; Schmedt CG: Comparison of endoscopic tech-
niques vs Shouldice and other open nonmesh techniques for inguinal hernia repair:
A metaanalysis of randomized controlled trials. Surg Endosc 2005, 19:
Peto 605-615
OR

Peto OR
TAPP/TEP vs. Shouldice
Total 25/1114 vs. 58/1079
p<0.00007 2.2% vs. 5.4% .1 .2 5 10
Favours treatment Favours control

18 RCT´s Less chronic pain

 What about recovery time?
Comparison to suture repair:
Bittner R, CG; Sauerland, S; Schmedt CG: Comparison of endoscopic techniques vs
Shouldice and other open nonmesh techniques for inguinal hernia repair:
A metaanalysis of randomized controlled trials. Surg Endosc 2005, 19: 605-615

Peto OR
TAPP/TEP vs. Shouldice
Total 21.2 d vs. 31.2 d
p<0.00001
- 10 -5 5 10
Favours treatment Favours control

18 RCT´s More rapid recovery

 Comparison to open mesh repair ?
Metaanalysis (34 trials)
Frequency of chronic pain?
Schmedt, CG; Sauerland, S; Bittner, R; Comparison of endoscopic procedures vs
Lichtenstein and other open mesh techniques for inguinal hernia repair:
A metaanalysis of randomized controlled trials. Surg Endosc 2005, 19: 188-199
Peto OR

TAPP/TEP vs. Lichtenstein

overall 125/1650 vs. 208/1642

p<0.00001 7.6% vs. 12.5% .1 .2

Favours treatment
5 10
Favours control

Less chronic pain!

 Comparison to open mesh repair?
Metaanalysis (34 trials)

Duration of disability of work?

Schmedt, CG; Sauerland, S; Bittner, R; Comparison of endoscopic procedures vs
Lichtenstein and other open mesh techniques for inguinal hernia repair:
A metaanalysis of randomized controlled trials. Surg Endosc 2005, 19: 188-199

Peto OR
TAPP/TEP vs. Lichtenstein
Overall 14.8 d vs. 21.4 d
p<0.00001 .1 .2 5 10

Favours treatment Favours control

More rapid recovery !

 Third summary:

Did laparoendoscopic hernia surgery comes

up with our expectations?

Yes, according to all pain-related parameters

laparoendoscopic inguinal hernia repair
is superior to open surgery !

(shown by own experiences and evidence based data)

European Hernia Society guidelines on the treatment
of inguinal hernia in adult patients.

(Hernia 2009; 13: 343- 403)

M.P.Simons, T.Aufenacker, M.Bay-Nielsen, J.L.Bouillot, G. Campanelli,
J. Conze, D. de Lange, R. Fortelny, T. Heikkinen, A. Kingsnorth, J. Kukleta,
S. Morales-Conde, P. Nordin, V. Schumpelick, S. Smedberg, M. Smietanski,
G. Weber, M. Miserez.

Update: Hernia 2014; 18: 151- 163

 Guidelines for laparoscopic (TAPP) and endoscopic (TEP)
treatment of inguinal hernia [International Endohernia Society (IEHS)].
Bittner R, Arregui ME, Bisgaard T, Dudai M, Ferzli GS, Fitzgibbons RJ,
Fortelny RH, Klinge U, Kockerling F, Kuhry E, Kukleta J, Lomanto D,
Misra MC, Montgomery A, Morales-Conde S, Reinpold W, Rosenberg J,
Sauerland S, Schug-Pass C, Singh K, Timoney M, Weyhe D, Chowbey P.
Surg Endosc. 2011 Sep; 25(9):2773-843.

www.iehs.de
 Update conference on the “Guidelines for laparoscopic (TAPP)
and endoscopic (TEP) treatment of inguinal hernia
[International Endohernia Society (IEHS)]” in
Windhoek/Namibia, 23th to 26th of October 2013.

Update of guidelines on laparoscopic (TAPP) and endoscopic (TEP)

treatment of inguinal hernia (International Endohernia Society). Bittner R,
Montgomery MA, Arregui E, Bansal V, Bingener J, Bisgaard T, Buhck H, Dudai M,
Ferzli GS, Fitzgibbons RJ, Fortelny RH, Grimes KL, Klinge U, Köckerling F, Kumar S,
Kukleta J, Lomanto D, Misra MC, Morales-Conde S, Reinpold W, Rosenberg J,
Singh K, Timoney M, Weyhe D, Chowbey P; International Endohernia Society.
Surg. Endosc. 2015 Feb; 29(2):289-321. www.iehs.de
 HerniaSurge Group

International guidelines for groin hernia management.

HerniaSurge Group. Hernia. 2018 Feb;22(1):1-165. doi:
10.1007/s10029-017-1668-x. Epub 2018 Jan 12.
International guidelines for groin hernia management.
HerniaSurge Group. Hernia. 2018 Feb;22(1):1-165.
doi: 10.1007/s10029-017-1668-x. Epub 2018 Jan 12.

What are the conclusions and

recommendations for your daily
clinical praxis :
 International guidelines for groin hernia management. HerniaSurge Group.
Hernia. 2018 Feb;22(1):1-165.
Key questions
1. Which is the preferred repair method for inguinal
hernias: mesh or non-mesh?
Recommendation A mesh-based repair technique is ☐ Strong
recommended for patients with inguinal *upgraded
hernias.

Recommendation Hernia surgeons are recommended to be aware of ☐☐

Strong
the clinical characteristics of the meshes they use. *upgraded
 International guidelines for groin hernia management.
HerniaSurge Group. Hernia. 2018 Feb;22(1):1-165. doi:
10.1007/s10029-017-1668-x. Epub 2018 Jan 12.
Key-question:
2. When considering recurrence, pain, learning curve, postoperative
recovery and costs which is preferred technique for inguinal hernias:
best open mesh (Lichtenstein) or a laparo-endoscopic (TEP and
TAPP) technique?
For male patients with primary unilateral inguinal
hernia, a laparo-endoscopic technique is suggested because of
a lower postoperative pain incidence and a reduction
Recommendation
in chronic pain incidence, provided that a surgeon with ☐
specific and sufficient resources is available. However, there are
patient and hernia characteristics that warrant a Lichtenstein as
first choice.

Consensus at EHS and EAES

Male patients = about 70% of all inguinal hernia patients!

 Key-question:
3. Which is the preferred technique in bilateral
hernia? Open mesh or laparo-endoscopic
approach?
Laparo-endoscopic repair is recommended for the
Recommendation repair of primary bilateral inguinal hernias provided Strong
surgical expertise, cognisent of patient/surgeon/local ☐☐ *upgraded
resource suitability to the surgical approach is
available.

Bilateral hernias = about 20% of all inguinal hernia patients!

 Key-question:
4. What is the optimal treatment for women with groin hernias?
Provided that expertise is available, women
with groin hernias are recommended to
☐ Strong
Recommendation undergo laparo- endoscopic repair with mesh *upgraded
implantation.

Female patients =
Consensus at
about 10% of
EHS and EAES
all inguinal hernia patients!

Caspar Strohmayer Lindau 1559

 Surgical technique:
Key-question:
5. Which is the preferred mesh for open inguinal hernia repair:
anterior flat mesh or three dimensional implants (plug-and-
patch and bilayer) via an anterior approach?
Despite comparable results, three dimensional implants
(plug- and-patch and bilayer) are not recommended ☐☐ Strong
Recommendation
because of the excessive use of foreign material, the need to *upgraded
enter both the posterior and anterior plane and the
additional cost.
Consensus at EHS and EAES

or Plug

Sigma
 Does it make sense to implant a plug??

In 9% of our patients
we found intraoperatively
R more than one
hernia opening!

Diagnosis and classification of inguinal hernias

Accuracy of clinical, ultrasonographic, and laparoscopic findings
B. M. Kraft, H. Kolb, B. Kuckuk, S. Haaga, B. J. Leibl, K. Kraft, R.
Bittner. Surg Endosc (2003) 17: 2021–2024
 Is there a place for
plug-and-patch
and bilayer devices?

Plug/Patch (PHS/UHS)
techniques destroy
the external and
the internal
compartment as well!
 Surgical technique:
Key Question:
6. Which is the preferred open mesh technique for inguinal hernias:
Lichtenstein or any open pre-peritoneal technique?
Statement In open surgery there is insufficient evidence to ☐☐☐

recommend a pre-peritoneal mesh repair over

Lichtenstein repair.

Consensus at EHS and EAES

L.M. Nyhus
 Surgical technique:
Key Question:
7. In males with unilateral primary inguinal hernias
which is the preferred repair technique, laparo-
endoscopic (TEP/TAPP) or open pre-peritoneal?
Statement With regards to visualization, laparoscopic pre-peri- ☐☐☐

toneal repair is a safe and standardized operation with

possible advantages over open.

or
Ugahary ? Laparoscopy ?
 Surgical technique:
Key-question:
8. In inguinal hernia repair,
when should treatment be individualized?
Since a generally accepted technique, suitable for all
inguinal hernias, does not exist, it is recommended that ☐☐☐ Strong
Recommendation *upgraded
surgeons/surgical services provide both an anterior and
a posterior approach option.

Shouldice Lichtenstein TAPP/TEP

Is the tailored approach realized in clinical routine?

 Surgical technique:
Key question:
8. In inguinal hernia repair, when should treatment
be individualized?
It is recommended that surgeons tailor treatments Strong
Recommendation based on expertise, local/national resources, and ☐☐☐ *upgraded
patient- and hernia-related factors.

Surgeons were able to choose between open, TAPP or

TEP repair in a variety of patient scenarios. Eighty-two
percent of the surgeons chose a tailored approach and
indicated that their choice of repair depended on the
listed patient characteristics. Interestingly, only 6%
of the surgeons were able to routinely offer
patients all three techniques.
(Survey questionnaire in 100 endoscopic surgeons at the 2010 European
Association of Endoscopic Surgery (EAES) annual meeting.)
 Key question:
9. In inguinal hernia repair, when should treatment
be individualized?
Recommendation strong:
1.In patients with pelvic pathology or scarring due to radiation
or pelvic surgery, or for those on peritoneal dialysis, consider
an anterior approach.

Netz

Rezidiv

2. In recurrent hernia after an anterior approach, choose a

laparoendoscopic technique !
In recurrent hernia after a posterior approach, choose an anterior
technique !
 Key-question:
10. Is mesh fixation necessary in laparoendoscopic
inguinal/femoral hernia repair in adults?
In almost all cases, any type of mesh ☐
Statement
fixation is unnecessary.
Mesh fixation is recommended in patients Strong
Recommendation ☐☐☐ *upgraded
With large direct hernias (M3-EHS classi-
fication to reduce recurrence risk.
Consensus at EHS and EAES

Rezidiv
Current surgery of inguinal hernias in
Germany in comparison to 1992.
I came up with my expectations!
Conclusion I.
45

% TAPP
40

35

30

25

20
TEP
15

10

0
2016
 Conclusion II (international)
I do not yet come up with my expectations ?

Germany 60%
New Zealand 54%
Denmark >50%
Netherlands 45 %
Penetration rate Switzerland 40 %
TAPP/TEP Belgium 36 %
Austria >30 %
worldwide: Sweden 30 %
France - privat 40 %
- comm. 10 %
USA 20-30 %
UK 20%
Indonesia ?
 My family 2018

Many thanks for your great hospitality and best greetings!