text:
Date of Decision 08-Dec-2021
Date of Acceptance 13-Dec-2021
Date of Web Publication 31-Dec-2021
Keywords: History, implementation of laparoscopic techniques, inguinal hernia repair, laparoendoscopic techniques, TAPP, TEP
Bittner RR, Felix EL. History of inguinal hernia repair, laparoendoscopic techniques, implementation in surgical praxis, and future perspectives: Considerations of two pioneers. Int J Abdom Wall Hernia Surg 2021;4:133-55
Bittner RR, Felix EL. History of inguinal hernia repair, laparoendoscopic techniques, implementation in surgical praxis, and future perspectives: Considerations of two pioneers. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2022 Jan 20];4:133-55. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/4/133/334566
Hernia disease is as old as the mankind. The oldest reports date back to the time of Hammurabi of Babylon (1700 BC) and the Papyrus Elbers written in ancient Egypt in 1555 BC The first surgery seems to have been done in India during the Brahmanic period 800–500 BC. Currently, hernia repair is the most frequent procedure performed by general surgeons. It is estimated that about 20 million operations per year are performed worldwide. Four very different periods characterize the development of hernia surgery. Period 1: Ancient time and Middle Ages: Knowledge of the anatomy of the groin and the pathogenesis of hernia disease was limited. Repair was mostly done by "barber surgeons." The result was that the patients at best lost a lot of blood and their testis, but at the worst suffered from infection and passed away. Period 2: At the end of the nineteenth-century knowledge about pathogenesis and surgery of inguinal hernia disease dramatically changed. It was Eduardo Bassini (1844–1924) who recognized that a hernia is not only a simple hole in the pelvic floor but also a sequela of a weak back wall of the inguinal canal due to both a weak transversalis fascia and a weak conjoint tendon. In 1887, Bassini published a suture technique for reinforcement of the insufficiently strong back wall of the inguinal canal. His technique was rapidly adapted by the surgical community and persisted as a standard technique for more than 50 years.[1] In 1944, Edward Earl Shouldice[2],[3] described a modernized version of the Bassini repair by doubling the fascia transversalis, which up to now is recommended as the best suture technique to use in inguinal hernia repair.[4] Two problems became apparent with the Shouldice repair, however. First, the correct technique was difficult to learn and second when widely applied it resulted in a high recurrence rate,[5] more than 10%, especially in patients presenting with a large hernia opening (Type III, EHS classification[54]). Moreover, recently elaborated evidence shows that hernia disease may be caused by some disturbance of collagen metabolism;[6],[7] thus, the best suture technique will not be able to prevent recurrence in the long follow-up. Interestingly, already in 1878 Theodor Billroth postulated: "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". It took 80 years, for such a biocompatible artificial tissue (mesh) to be developed by Francis C. Usher[8] and was the advent of Period 3 in inguinal hernia surgery. An additional 30 years was needed to develop a reliable hernia repair technique based on the implantation of a mesh. Irving L. Lichtenstein[9] developed and published in 1989 his operation called "The tension-free hernioplasty" and he concluded that "With the use of modern mesh prosthetics, it is now possible to repair all hernias without distortion of the normal anatomy and with no suture line tension. The technique is simple, rapid, less painful, and effective, allowing prompt resumption of unrestricted physical activity". Today, however, we know that his conclusion was rather euphemistic than based on reliable scientific studies. Indeed, using mesh repair it is possible to reduce the recurrence rate to less than 2.7%–5%.[10],[11] However, in several studies a high percentage of surgical site occurrences (SSOs) was reported, mainly chronic pain between 12% and 54%.[12],[13],[14],[15] The high percentage of chronic pain after open mesh repair may be related to excessive foreign body reaction due to less biocompatible mesh structures, to direct damage of the inguinal nerves intraoperatively or involvement of the nerves within the chronic inflammatory process of mesh integration or may be caused by incorrect fixation techniques. Realistic assessment of the working mechanism of the Lichtenstein repair will reveal that the term "tension-free hernioplasty" is rather a myth than based on data. Of course, it is true when the patient is lying on the operation table there is no tension on the tissue, but the moment the patient stands up there will be a lot of pressure through the hernia defect onto the mesh, like a lid on a pot. In summary, although the Lichtenstein repair hernia recurrence rate is low, chronic pain remains a serious problem. Despite all the improvements in operative techniques as well as in mesh technology achieved during the last decades, the incidence of chronic pain remains as high as 20%.[4],[10],[16] With the advent of minimally invasive surgery (MIS), surgeons hoped using these new revolutionary techniques would overcome the high rate of chronic pain but continue the low incidence of recurrence. It was the dawn of Period 4 in inguinal hernia surgery. According to Stoppa et al.,[17] the preperitoneal position of the mesh [Figure 1] is based on the physical law of Pascal.[18] It is the working mechanism of both minimally invasive techniques (III): the transabdominal preperitoneal patch plasty (TAPP) and the totally extraperitoneal patch plasty (TEP). As stated by Nyhus,[19]
Figure 1: Schematic demonstration of the working mechanisms the currently most popular techniques in inguinal hernia repair: I––Shouldice, II––Lichtenstein, and III––Laparoendoscopic (TAPP/TEP)
"Stoppa reminded us of the Pascal hydrostatic principle and proved that a large prosthetic mesh placed in the preperitoneal space would remain fixed by intraabdominal pressure, the hernial orifice would be covered permanently and the mesh would be maintained in place without the need for suturing or tacking to the abdominal wall."
In contrast to the Stoppa procedure which needs a large midline incision and is burdened immanently by acute postoperative pain and several unpleasant side-effects like hematoma or even infection, minimally invasive repair requires three small incisions only and therefore carries a very low risk for such SSOs.
In summary, the advantages of minimally invasive repair of inguinal hernia are as follows: (1) minimal trauma to the abdominal wall due to minimized access (TAPP and TEP). (2) To implant the mesh healthy tissue like the external aponeurosis is not cut like it is in the Lichtenstein operation. (3) The right plane for the mesh is between the deep layer of the transversalis fascia and the peritoneum; therefore, any contact between the mesh and the inguinal nerves that are located behind the fascia can be avoided. (4) Costly fixation devices that in addition carry the risk for causing chronic pain are not required. (5) Because the mesh is between the intraabdominal pressure and the weak groin wall, tension on the abdominal wall is not created if a sufficiently large mesh is implanted. In conclusion, due to these characteristics of the MIS repairs, postoperative pain should be less after laparoendoscopic inguinal hernia repairs in comparison to suture or open mesh repairs.
Historical Development of Minimally Invasive Inguinal Hernia Repair
In the beginning of MIS of inguinal hernias, surgeons had to overcome the same problems that surgeons did in developing open hernia repairs. Surgeons were unfamiliar with the anatomy of the backside of the abdominal wall in the groin. It just seems that only little was learned from the past. W.J. Lytle[20] stated: "The operating surgeon knows little of the posterior wall of the inguinal canal, so well is it hidden from his view." Still in the beginning of the twenty-first century, Wright et al.[21] complained:
"this may be the most serious problem associated with laparoscopic hernia repair, the learning curve is long. The principal reasons for the long learning curve are the surgeon's lack of familiarity with the preperitoneal anatomy and the time it takes to develop the skills to operate in a confined space."
Most strikingly, a full exploration of the neuroanatomy in the preperitoneal space was not achieved until the mid of the 90s of the last century and the beginning of this century.[22],[23],[24] Therefore, it is not astonishing that during the first decades of MIS intraoperative complications and postoperative chronic pain were due to ignorance of the anatomical structures of the groin. The result was discrediting of the new technique and the hope of achieving a better outcome than open surgery. The second mistake was that like the surgeons of old, the pioneers of MIS inguinal hernia repair believed that closure of the hole in the groin was necessary. Therefore, they used a plug to close hole which resulted in new complications.
In 1982, Ralph Ger [Figure 2] published the first case of a laparoscopic repair of an inguinal hernia. After experience in 12 patients with open abdominal surgery and concomitant inguinal hernia that Ger had managed the hernia by closing the peritoneal opening of the sac by interrupted metal clips, he developed a method for closure of the neck of the sac via laparoscopy. Ger used this new laparoscopic repair technique in one patient. He was successful and published it as a case report in 1982.[25]
Figure 2: Ralph Ger
Ralph Ger's pioneering work was not really noticed for nearly one decade. It was not until 1989 with the advent of MIS and the presentation of a video S. Bogojavlensky at the occasion of the 18th Annual Meeting of the American Association of Laparoscopic Gynecologists in Washington, DC, that a few surgeons showed some interest in this completely new and revolutionary repair of inguinal hernias. In comparison to laparoscopic cholecystectomy, however, development and worldwide spread of laparoscopic hernia repair proceeded extremely slowly not at just due to the unfamiliar anatomy of the back wall of the groin as mentioned above, but more importantly, hernia repair is not a simple ablative procedure but rather an operative technique to reconstruct the pelvic floor by using the implantation of a mesh.
The next steps in laparoscopic inguinal hernia repair are published in 1990 by Popp and Schultz. Popp closed the hernia defect with catgut-sutures in one female patient, but additionally enforced the region of the inguinal canal by implantation of a 4 cm × 5 cm dura-patch like in the intraperitoneal onlay mesh (IPOM) technique, which is currently used in repair of incisional hernias.[26] Schultz [Figure 3] was the first who opened the peritoneum and implanted a marlex plug to obliterate the space (hernia defect) and then he reapproximated the edges of the peritoneum in a small series of 20 patients, but Schultz did not reduce the hernia sac.[27]
Figure 3: L. Schultz
In 1991, J.D. Corbitt [Figure 4] modified the Schultz technique. In 20 patients he opened the peritoneum using laser technology and resected the hernia sac with an Endo-GIA, then he put a Mersilene plug into the inguinal canal, but additionally he implanted a 5 cm × 5 cm patch over the inner inguinal ring.[28]
Figure 4: J.D. Corbitt
In the same year, 1991, F. Götz [Figure 5] published the first laparoscopic hernia repair in Germany. Götz closed the hernia sac at its basis with suture and fibrin injection.[29]
Figure 5: F. Götz
Again in 1991 Toy and Smoot ([Figure 6] F.K. Toy) performed in 11 patients a high ligation of the hernia sac and implanted a 5 cm × 7 cm PTFE-patch intraperitoneally (IPOM) without any dissection of the preperitoneal space, but they were the first who emphasized that "it was important to keep the patch larger than the defect so that increases in the intraabdominal pressure acted to secure the patch."[30] The patch was fixed using an Endo-Hernia Stapler.
Figure 6: F.K. Toy
Robert Fitzgibbons [Figure 7] advocated a pure IPOM technique because of its simplicity.[31] Without any opening of the peritoneum or touching the hernia sac he placed a prolene mesh, average size 9.2 cm × 6 cm, over the visible hernia opening and fixed it with several clips, but he also emphasized that a larger mesh should be used.
Figure 7: R. Fitzgibbons (2008, Stuttgart)
Epoch-making was the lecture of Maurice Arregui "Laparoscopic pre-peritoneal herniorraphy" about his experience in 52 patients [Figure 8] given at the SAGES meeting, April 1991 in Monterey, California, and on May 22, in Indianapolis at the "Advanced laparoscopic surgery meeting: International Experience," which were published 1 year later in 1992.[32] In several national and international meetings, "2nd G. I. Tract Laparoscopic Surgery International Meeting. Liege, Belgium, October 8–9, 1992"[37] and "American College of Surgeons 1992 Clinical Congress, New Orleans, Louisiana, October 11–16,"[38] the new technique was passionately discussed (personal communication E.L. Felix [Figure 10]). Arregui criticized the IPOM technique:
Figure 8: M. Arregui
Figure 10: E.L. Felix
"One must question the reliability of sewing mesh to peritoneum which has the tendency to stretch and has little strength. Moreover, placement of mesh in the peritoneal cavity invites adhesion formation. In my experience the mesh in IPOM technique is like a boat on a rough sea without any fixing point."
Arregui deserves credit for defining two key points of modern laparoscopic hernia repair (TAPP): (1) complete dissection of the whole pelvic floor, thus not missing atypical especially medially located hernia openings and (2) preperitoneal implantation of a large flat mesh, thus avoiding migration of small meshes and keeping down the foreign body reaction, which may be induced rather by more dense plugs.
Maurice Arregui combined the experiences of the French school of surgery (Stoppa) with the new minimal invasive (access) techniques and is rightly named as the father of laparoscopic hernia repair (TAPP), which also may be called "laparoscopic Stoppa."
Despite promising results of the new technique, the surgical community expressed severe concerns, above all about that hernia repair may change from a relatively harmless intervention outside of the abdominal cavity to a transabdominal operation burdened by the risk of potentially life-threatening damage to intraabdominal organs. To avoid these risks, a pure extraperitoneal approach to the inguinal region was developed first in France by Dulucq [Figure 11] and published in 1991,[33] 1 year later in the US by Ferzli [Figure 9] in 25 patients,[34] and in 1993 again in the US by McKernan in 34 patients.[35]
Figure 11: J-L. Dulucq, EAES 1998, Cologne
Figure 9: G. Ferzli
Although the principles of laparoendoscopic inguinal hernia repair being reliable for the surgical community, which were described for the first time by J.-L. Dulucq (TEP) and M. Arregui (TAPP), are still valid, the practical performance has been fundamentally improved during the following decades.
Both techniques are valuable alternatives to open inguinal hernia repair, but evidence shows advantages with respect to all postoperative pain-associated parameters. Therefore, current guidelines[4],[36] recommend:
For male patients with primary unilateral inguinal hernia, a laparo-endoscopic technique is suggested because of a lower postoperative pain incidence and a reduction 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.
In summary, today laparoendoscopic inguinal hernia repair is safe, effective, and cost-efficient. Milestones for improvement of the results are as follows:
Better knowledge of anatomy (especially neuroanatomy) of the groin and of the pathophysiology of hernia disease.
Finding the right plan for mesh implantation and improvement of dissection techniques accordingly.
Minimizing the size of the surgical instruments.
Increase of mesh size and avoidance of a slitted mesh for creation of a new inner inguinal ring. Although in the first publications[34],[35] a slitted mesh with creation of a new inner inguinal hernia ring was recommended, E. Felix recognized the slit as a weak point in the mesh and advocated a double buttress technique, which means to cover the slit with a second flat mesh[37],[38] to enforce the pelvic floor without any gap. Today we know that when performing a radical parietalization (see below) and when using a large mesh, the implantation of a slitted mesh that is secured by a second mesh is no longer needed.
Development of intraabdominal suture techniques.
Improvement of mesh technologies.
Regarding the question "Which technique is better?" the transabdominal approach (TAPP) or the totally extraperitoneal (TEP) HerniaSurge guidelines recommend: "In laparo-endoscopic inguinal hernia repair, as TAPP and TEP have comparable outcomes it is recommended that the choice of the technique should be based on the surgeon's skills, education and experience."[4]
Current Techniques in Minimal Invasive Inguinal Hernia Repair
Laparoendoscopic inguinal hernia repair is considered a safe, effective, and efficient technique. Furthermore, in comparison to open mesh-based repair the laparoendoscopic technique should be superior with respect to all postoperative pain. These advantages, however, are only realized if the operation can safely be performed without any severe unpleasant side-effects. Therefore, the optimal surgical technique is the key for success.
Transabdominal Preperitoneal Patch Plasty
In 1994, E. Felix [Figure 10] Department of Surgery, University of California-Fresno and Center for Hernia Repair, Fresno, CA 93710, USA. [email protected] was one of the first who showed that the laparoscopic technique is also applicable in patients suffering from recurrent hernia.[39] About 8 years later we confirmed his results in a large patient population and showed that nearly all types of inguinal hernias can be successfully treated by TAPP.[40] Since that time several technical innovations were introduced to make the performance of TAPP easier and safer. Details of this continuous improvement of our technique were recently described.[41],[42]
Technique Transabdominal Preperitoneal Patch Plasty
The patient is positioned flat on the operating table. Both arms are fixed to the body. The table is in head-down position by approximately 15° to 20°, and turned to the surgeon by approximately 15°. The surgeon stands on the side opposite of the hernia, and the camera guide is sitting on the contralateral side; thus, he can lean his elbow on the thorax of the patient. In this way, he is able to guide the camera much steadier without any stress.
The operation is performed in general anesthesia; thrombotic embolism prophylaxis is routinely given. Antibiotic prophylaxis is only given in patients having an increased risk for infection.[43] A urinary catheter is not routinely applied.
Step 1: Establishment of pneumoperitoneum: Which trocars are best suitable?
The establishment of the pneumoperitoneum and the introduction of the first trocar are the most important steps of the operation, because both parts of the procedure are performed blindly without a direct view. There is an extensive discussion in the world literature about which technique may be better, the closed entry using the Veress needle or the open access according to Hasson. Following the guidelines (IEHS), none of these techniques is superior to or inferior to the other entry techniques.
I prefer in all cases without previous periumbilical surgery the closed entry technique using the Veress needle. The advantage of this access is that only a very small incision (5 mm) to the ground of the umbilicus is needed to introduce a 5 mm 30° optic (our standard), whereas when applying the Hasson technique with finger exploration of the abdominal cavity to exclude adhesions, an incision of at least 15–20 mm is necessary which results in more pain, more wound complications, and more trocar hernias. I recommend always performing the safety tests according to Kurt Semm, a gynecologist from Kiel/Germany, who was the first who performed an appendectomy laparoscopically[44]––double click (snap) test, hanging drop (slurp) test, and the aspiration test. Evidence for doing these tests in favor of more safety is low; however, these tests should remind the surgeon of being very cautious, as the entry into the abdominal cavity is one of the most important steps of the operation. Furthermore, keep in mind, that more reliable information about the correct needle position is possible by observation of the initial intraabdominal pressure as well as the flow of the gas. The flow must be high and the pressure low.[45] If there are some uncertainties, I recommend an open-entry technique.[46] Alternative to the umbilicus as an entry point for the Veress needle Palmer's point below the left costal margin can be used.[47]
The use of three-edged cutting trocars is not recommended,[43] because in comparison to the blunt tip expanding working trocars they may cause more bleeding complications, more pain and more trocar hernias. The size of the trocars should be as small as possible. The limiting factor is given by the thickness and size of the mesh as well as by the possibility for introducing a gauze swap for bleeding control or the needle holder and the needle. Our standard [Figure 12] is as follows: 5 mm for the camera at the umbilicus, 5 mm working trocar left side perforating the rectus muscle at the level of the umbilicus, and 7 mm trocar on the right side, perforating the rectus muscle too at the level of the umbilicus, for implantation of the mesh or needle holder or some gauze [Figure 12].
Figure 12: Position and size of the trocars
Step 2: Introduction of the working trocars, first view to the abdominal cavity, and the groin: Is adhesiolysis always necessary?
Both of the working trocars must be introduced under direct view! The first view should be around the abdominal cavity to exclude other abdominal pathologies. If there are adhesions between the intraabdominal organs and the abdominal wall, it is not recommended to do an adhesiolysis except if the adhesions do not allow a sufficient view and access to the groin. If there are extensive adhesions preventing access to the lower abdomen it may be better to convert to a totally extraperitoneal approach or to open surgery depending on personal experience. It is not recommended to take down adhesions between omentum and parts of the bowel with the hernia sac composing the hernia content. This is unnecessary and burdens the risk of bowel lesion or bleeding. In these cases, the hernia sac including the contents is reduced "en bloc."
Advantageous in comparison to the TEP technique the first laparoscopic view to the groin allows immediately a precise diagnosis of the location of the hernia, the size of the hernia defect as well as the size of the hernia sac inclusive its content, not only on the side clinically the hernia was found but also on the contralateral side [Figure 13]. According to a recently published study in patients presenting clinically with a unilateral hernia, the occurrence of an occult hernia on the contralateral side may be up to 55%.[48]
Figure 13: First laparoscopic view to the left groin in a patient with recurrent inguinal hernia
Before opening the preperitoneal space I recommend to discuss with your camera guide the anatomical structures of the groin seen with the first view [Figure 13] and [Figure 14]. The identification of the iliopubic tract, which is a virtual line between the anterior superior iliac spine (ASIS) and the symphysis, corresponding to the inguinal ligament from outside view, is of paramount importance. Keep in mind: All important structures––great vessels and inguinal nerves––are located inferior to this tract. Therefore, all of the surgical maneuvers below the iliopubic tract should be done extremely carefully. Superior to the tract there is only one structure––the epigastric vessel––which needs special care.[49]
Figure 14: Right-sided groin. Incision line for TAPP (black line)
Step 3: Opening of the peritoneum and entering of the preperitoneal space
I recommend a wide incision of the peritoneum, starting in front of the ASIS and generously follow the black line [Figure 14] up to the plica umbilicalis medialis. If more space is needed, for example, in patients with a narrow pelvis, the plica umbilicalis must not be cut (umbilical vessels, danger of bleeding), but in this case the incision should parallel the plica upwards. The distance between the dissection line and the iliopubic tract at the level of the epigastric vessels should be 5–7 cm. I recommend the entry to the preperitoneal space from lateral because finding the right plane to create the bed for the mesh is easier in comparison to more medially located entries. This is due to the variable course of the deep layer of the transversalis fascia which is closer to the superficial layer in this region and therefore better to identify and to protect, whereas more medially this deep layer of the transversalis fascia ("extraperitoneal fascia") continues into the spermatic and urogenital fascia system. Keep in mind: The deep knowledge of the layers of the abdominal wall is of paramount importance [Figure 15].
Figure 15: Graphic account of the abdominal wall showing where the mesh should be placed
Step 4: Dissection of the whole pelvic floor
The ideal dissection plane is just in front of the deep layer of the transversalis fascia, which is rapidly reached from lateral and can be followed by mostly blunt dissection up to the epigastric vessels indicating the middle of the groin separating the groin into a lateral and a medial compartment. When crossing this "midline" special care is needed not to injure the vessels and staying close to the back wall of the rectus muscle, which in this region is not wrapped by the back wall of rectus sheath. By mostly blunt dissection the space of Retzius will be opened and the urinary bladder gently pushed away from the wall [Figure 16] without any danger for an injury of the bladder when following the right plane. For detection of atypical far medially located hernia defects (supravesical hernias, recurrence after Lichtenstein), it is important to proceed with the dissection as far as about 1–2 cm beyond the symphysis to the contralateral side. The dissection down to the pubic bone and Cooper's ligament (CL) is safe when staying close to the rectus muscle; however, when approaching the pubic bone it is important not to destroy a very thin fibrous tissue layer (extraperitoneal fascia), which protects all the tiny vessels surrounding the bone, thus avoiding unpleasant bleeding. The dissection should continue about 1–2 cm down to the pubic bone.
Figure 16: Opening of the space of Retzius
Although the dissection of the medial part of the space of Retzius located round the symphysis easily can be done, extreme caution is advised when approaching the iliac/femoral vessels [Figure 17]. In about 20% of the patients, there is a very strong pubic branch ("corona mortis") between the epigastric and the obturator vessels. Furthermore, in this groove between the pubic bone and the iliac/femoral vessels, and close to the lower rim of the bone, the obturator nerve and vessels are located traveling to the obturator foramen [Figure 17]; red circle].
Figure 17: Corona mortis
Step 5: Dissection of a direct hernia, the inner inguinal ring, and an indirect hernia sac
I recommend not dissecting the hernia sac before finishing the complete anatomical dissection of the lateral compartment (Bogros) and the medial compartment (Retzius). This is especially important in obese patients and patients with large hernia sacs or difficult anatomy, for example, in recurrent hernias. When dissecting a direct hernia pseudo-sac, it is important to stay close to the wall of the pseudo-sac (enlarged fascia transversalis) detaching all the fatty hernia content; I recommend abundant application of electrocoagulation to close all the tiny vascular and lymphatic vessels of the wall for prevention of formation of large sero-hematoma postoperatively [[Figure 18]. Furthermore, recently in large direct hernia pseudo-sacs in order to decrease seroma formation in the "dead space" produced by the reduction of the hernia content several new techniques are advocated:
Figure 18: Direct hernia sac
Inversion and fixation of the weakened transverse fascia to CL or to the rectus muscle.
Suture closure of the direct defect.
Inversion and closure of the sac using an endoloop.[50],[51],[52],[53]
All of these three maneuvers can be done without increasing postoperative pain.
The dissection of an indirect hernia sac is more difficult because of the close attachments of the sac to the cord structures and the risk for an injury of the testicular vessels and the vas deferens. The following five rules are important to keep in mind:
Before starting the reduction of the hernia sac I recommend to take down all the adhesions between the fascia spermatica and the inguinal ring, respectively, the deep layer of the transversalis fascia [Figure 19].
Next step should be the opening of the anterior part of the fascia spermatica, which is wrapping the cord structures inclusive the hernia sac by cutting all the connecting fibrous tissue between the deep layer of the transversalis fascia and the spermatic fascia [Figure 20].
In about 20% of the patients a lipoma accompanying the hernia sac or is located at the top of the sac may be present. It is necessary to reduce the lipoma out of the inguinal canal because if left in situ it may mimic a recurrence or cause pain in the postoperative course. My advice is at first to proceed with the dissection of the lipoma than the hernia sac will easily follow in most of the cases. In my practice, I try to preserve the vascular root of the lipoma which accompanies the testicular vessels. Therefore, it is not necessary to remove the lipoma out of the abdominal cavity and after mesh implantation the lipoma is put on top of the mesh which helps to keep the mesh in position [Figure 21].
In many cases the cord structures and the hernia sac are difficult to separate because of abundantly scarred and fatty tissue. In such confusing situations in order to avoid a lesion to the cord I recommend at first to identify the testicular vessels very lateral-caudally [Figure 22] before they accompany the hernia sac and then the vessels are used as guides for the dissection up to the top of the hernia sac.
In many countries like in Africa, Asia, and to some degree also in South-America children with a congenital hernia are not operated on in time, but develop step by step huge inguinoscrotal hernias during the later years and come to operation not before being in the second or third or fourth decade of life when they experience pain or incarceration. In these cases, which are rare in Germany but I have seen many times in my surgical activities in China, India, and Africa, it may be extremely difficult or even impossible to reduce the large indirect hernia sac completely. In order to perform a safe and time-effective operation, I recommend cutting the hernia sac at the level of the internal ring after careful identification and isolation of the cord structures. It is a pity that up to now there are no reliable studies with respect to possible long-term complications like formation of a hydrocele when the distal sac is left in situ.
Figure 19: Detachment of the adhesions round the inner inguinal ring
Figure 20: Fascia spermatica is opened
Figure 21: Big lipoma at the entrance to the inguinal canal
Figure 22: Showing the testicular vessels as guides for safe dissection of the hernia sac
Step 6: Parietalization of the cord structures
One of the most important operative steps to avoid a recurrent hernia is the abundant and carefully done parietalization of the cord. Parietalization means taking down all of the adhesions between the peritoneal sac (inclusive hernia sac) and the cord structures, respectively, the deep layer of the transversalis fascia in the region of Bogros and space of Retzius about 5–6 cm inferior to the ilio-pubic tract [Figure 23]A and B. After implantation of the mesh, the distance between the lower edge of the mesh and the peritoneal sac should be at least 1–2 cm. Tip: When closing the peritoneal flap the mesh must stay in place without any move. Then you can be sure that the parietalization was adequately done.
Figure 23: (A) Showing that there are still a lot of adhesions between the cord and the peritoneal sac. (B) The parietalization is completed. The mesh is attached flat to the abdominal wall. The lipoma with preserved vascular root is positioned on top of the mesh
Step 7: Implantation of the mesh (size at least 15 cm × 10 cm)
After finishing the dissection of the whole pelvic floor (medially 1–2 cm beyond the symphysis to the contralateral side and laterally up to the ASIS (the distance is just 15 cm in cadaver model), cranially up to 5–7 cm superior the ileopubic tract and caudally 5–7 cm inferior to the tract) the implantation of the mesh (15 cm × 10 cm) is quite easy. However, it should be noted that it is indispensable to measure the size of the hernia defect. In case the size of the defect is larger than 3–4 cm (EHS classification III[54)],[ it is recommended to choose a larger mesh],[ for example],[ 12 cm × 17 cm. The mesh should consist of large pores and should have an optimal grip on the abdominal wall. Special fixation devices are not necessary.
Step 8: Closure of the peritoneal flap
It is recommended to close the peritoneum by running suture using absorbable material],[ which is safe],[ cost-effective],[ and causes less pain. Keep in mind],[ suturing demands surgical skills],[ and for trainees it may be time-consuming and stressful; however],[ there are a lot of models [Figure 24] allowing extensive training activities.[55] Attention: It is important to close the peritoneum very tight without any gaps, because even through very small gaps (about 1 cm) some small bowel can slip and may cause an obstruction.
Figure 24: TAPP-training-model and right-side pelvic floor[55]
Results of Transabdominal Preperitoneal Patch Plasty
Between April 1993 and January 2008 in the surgical department (Marienhospital Stuttgart, Germany), 15 101 TAPP's were performed by the first author and his team. All the cases were prospectively documented creating a huge data base. From time to time the results were analyzed, failures were discussed, and our practice changed accordingly, mainly due to an intensive study of the anatomy and especially of the fascial structures in the groin. This led to an increase of the dissection area and more precise dissection within the anatomic layers. Moreover, slitted and heavyweight meshes were deleted, the size of the meshes was enlarged (from 8 cm × 12 cm to 10 cm × 15 cm), traumatic fixation devices were avoided, and suture closure of the peritoneum was introduced. In summary, the following overall results (in total 17 surgeons were involved) could be achieved: Duration of operation: 40 min (12–276); morbidity: 2.5%; reoperation rate: 0.44%; and recurrence rate: 0.70%. With respect to various questions arising out of daily clinical treatment of inguinal hernias these results were confirmed and published in more than 35 high-ranking journals.
Furthermore, it should be emphasized that out of this huge patient pool a total of six randomized controlled studies (RCTs) were performed and published.[56],[57],[58],[59],[60],[61]
Totally Extraperitoneal Patch Plasty
In the TEP the patient positioning is like the TAPP. It is essential that the arms are at the patient's side to allow enough room for the surgeon to stand at the side of the patient that is opposite the hernia. The arms should be protected to prevent nerve injury. If there are bilateral hernias, we suggest that the surgeon start with the more symptomatic hernia and switch sides after completing its dissection. The patient should be flat in slight Trendelenburg position.
Trocar placement
There are several accepted alternatives for trocar placement. The most common is the use of three trocars in the midline. The first trocar is placed at the level of the umbilicus, just off the midline to the side of the hernia to be repaired. The anterior rectus sheath is identified by retracting the fat with S-retractors. The fascia is incised with an eleven blade and the rectus muscle retracted laterally with the S-retractor to expose the posterior sheath. At this point, a balloon dilator can be inserted and slid down atop the posterior sheath until the pubis is palpated. Under direct vision from a zero-degree scope, the balloon is inflated to dissect the extra-peritoneal space. Care must be taken to not over inflate the balloon and to make sure it doesn't slide below the pubis to avoid injury to the bladder. If the surgeon does not want to use the balloon, the scope itself can be used to dissect the extra-peritoneal space as Co2 is slowly instilled. This approach however takes longer and is more tedious. After an adequate extra-peritoneal dissection is achieved the second trocar (5 mm) is placed under direct vision a few centimeters below the 10 mm camera trocar and the third trocar is placed in the midline at least 2 cm superior to the pubis. Some surgeons place the third 5 mm trocar in a lateral position on the side of the hernia.
The second alternative is to use the technique popularized by Dulucq,[33] in which the dissection is begun by inserting a Verres needle at the pubis. Another variation is to do the extraperitoneal dissection after placing a 5 mm trocar intraperitoneal to evaluate the anatomy of the hernias and watch the extraperitoneal dissection as it is performed with an endoscope or balloon.[62] The final variation is to place the ports high in the abdomen to perform an ETEP as described by Jorge Daes.[63]
Once the trocars are placed and the initial extra-peritoneal space has been dissected, the dissection of the critical view of the Myopectineal Orifice as described by Daes and Felix in the Annals of Surgery.[64] There are seven steps that must be completed as in the TAPP repair before mesh can be placed to repair the hernia. The order of the steps can be varied according to the anatomy of the hernia and surgeon preference, but usually the medial dissection is carried out first to identify the pubis which is always a constant. The lateral dissection (area 1) is next, followed by the central dissection (area 3), with the indirect hernia, lipoma of the cord and parietalization of the cord.[65],[66]
The first seven steps to achieve the critical view of the myopectineal orifice
Identify and dissect the pubic tubercle across the midline and CL. For large, direct hernias, extend the dissection to the contralateral CL [Figure 25].
Rule out a direct hernia. Visualize anatomy through the inflated balloon during totally extraperitoneal and extended totally extraperitoneal repairs to detect a direct hernia before dissection. Remove unusual fat in the Hesselbach triangle [Figure 26].
Dissect at least 2 cm between CL and the bladder to facilitate flat placement of the medial and inferior edge of mesh toward the space of Retzius, thereby avoiding mesh displacement caused by bladder distention [Figure 27].
Dissect between CL and the iliac vein to identify the femoral orifice and rule out a femoral hernia [Figure 28].
Dissect the indirect sac and peritoneum sufficiently to parietalize the cord's elements. This step is often not completed, especially in a small surgical field. To ensure compliance with this requirement, continue to dissect until the cord's elements lie flat. Then, visualize the psoas muscle and iliac vessels, pull the sac and peritoneum upward without triggering movement of the cord's elements, and dissect between the cord's elements to avoid missing a tail of the sac [Figure 29].
Identify and reduce cord lipomas (which may appear small and unimportant until reduced). Usually lateral to the cord's elements, they should not be confused with lymph nodes (which are generally spared). Most lipomas do not require removal but should be placed above the mesh to help prevent mesh rolling upward [Figure 30]A and B.
Dissect peritoneum lateral to the cord's elements laterally beyond the anterosuperior iliac spine (ASIS), sweeping it back cephalad well behind the mesh's posterior border [Figure 31].
Figure 25: Showing step 1 with the dissection of the pubis (P) across the midline and the space of Retzius
Figure 26: Showing step 2 with the dissection of the direct hernia (DH)
Figure 27: Showing step 3 with the dissection of 2–3 cm below the pubis for future placement of the mesh
Figure 28: Showing the reduction of a right femoral hernia (F) and the femoral defect (FD): step 4 in patients A and B
Figure 29: Showing step 6: parietalization of the cord and reduction of the sac in an indirect hernia. The pubis (P), the testicular vessels (TV), and the vas deferens (VAS) are labeled
Figure 30: (A and B) Showing the dissection of the lipoma of the cord (L) and the dotted line represents the location of the iliopubic tract
Figure 31: Showing the TEP approach to step 7 using a two-handed spreading technique to fully dissect the peritoneum (P) laterally. The lateral cutaneous nerve (LCN) is seen covered by microfascia. The testicular vessels (TV) and vas deferens (VAS) are well visualized
It is important to understand that the seven steps to complete the dissection for TEP are identical to the TAPP previously described but the initial technique or handling of the instruments varies slightly because the anatomy is not initially obvious as it is in the TAPP. It rather must be uncovered as the dissection is carried out. This makes the learning curve for the TEP longer and possibly steeper, but the TEP does have the advantage of not entering the peritoneal cavity thus avoiding some of the potential complications inherent in intra-peritoneal dissection. On the contrary, there are some circumstances when TAPP has definite advantages such as the incarcerated hernia or recurrent laparoscopic hernia. It is therefore important to the surgeon to pick the most appropriate MIS repair for the individual patient and surgeon expertise.
The final steps of the repair
8. Complete the dissection to achieve the critical view of the MPO [Figure 32], provide mesh coverage, and ensure that mesh and mechanical fixation are placed well above an imaginary inter-ASIS line and any defects, thereby avoiding recurrence and nerve injury, especially to the ilioinguinal and iliohypogastric nerves [Figure 33].
Figure 32: Showing step 8: Example of the completed dissection of the myopectineal orifice (MPO). The three hernia locations are labeled
Figure 33: Showing step 9 or placement of the mesh covering the entire MPO. The dotted line represents the imaginary inter-ASIS line. If penetrating fixation is used, it should be only placed above this line or in Cooper's ligament
9. Place the mesh only when items 1–7 are completed, and hemostasis has been verified. Mesh size should be at least 15 cm × 10 cm, although a larger piece of mesh is sometimes required to cover the MPO. Preferably, choose mesh that adapts to the contour of the space and the cord's elements. It should not have undue memory. Place it without creases or folds. Avoid splitting the mesh. Ensure that its later inferior corner lies deep against the wall and does not roll up during space deflation (use glue or careful suturing if necessary) [Figure 33].
The final two steps of the TEP repair are identifying that the first seven are complete and then placing the mesh with or without fixation. The mesh is placed through the camera port, advanced with the scope, and then manipulated into place. If at this point the surgeon finds that the landing zone dissection is not large enough to allow the mesh to lie flat without wrinkles and to be free of the peritoneal edge to avoid rolling up on deflation of the Co2, it is paramount that further dissection is performed. If penetrating fixation must be used sparingly and only well above the iliopubic tract and into CL. After mesh placement and any fixation, the gas is evacuated watching the peritoneum re-expand. If any portion of the mesh appears to become elevated by the release of the gas, further dissection of the space needs to be performed.
Results of Totally Extraperitoneal Patch Plasty
Multiple studies have been published comparing the TEP and ETEP repairs to both open and TAPP repairs.[67] As stated previously there are advantages and disadvantages to the TEP when compared to both approaches, but the results according to recurrence in the hands of surgeons well trained in the approaches is essentially identical.[68] Choosing which approach to apply depends on surgeon expertise and the clinical presentation of the hernia. Many surgeons now feel however that the ETEP approach will allow surgeons to use the extraperitoneal approach in a wider variety of circumstances including larger scrotal hernias and cases where the space may be limited that were previously better performed with a TAPP approach.
It has taken almost 30 years for MIS inguinal repairs to become accepted and possibly be viewed as the gold standard of inguinal hernia repair. Penetration of MIS repairs has only been 15%–25% depending on country or city of the surgeons, but with the advent of robotic TAPP repairs that penetration has grown rapidly. It has been reported to be approximately 50% in some areas in the USA. The sudden growth seems to be related to the ease of teaching the repair robotically and the shortening of the learning curve which has resulted in the adoption of the approach by surgeons previously resistant to MIS repairs. The major draw-back to R-TAPP initially was the cost and increase in operative time, but recent studies have shown that both impediments can be eliminated with experience as they were in the early days of the development of the TAPP and TEP approaches.
Implementation of Laparoendoscopic Inguinal Hernia Repair in Daily Clinical Praxis
[Figure 34] shows a dramatic increase of scientific interests in diagnostics and treatment of inguinal hernia during the past three decades in close correlation with the advent of MIS.
Figure 34: Development of research in treatment of inguinal hernias
Corresponding to a worldwide seen increase of the scientific activities shown in the figure, in Germany the frequency of laparoendoscopic inguinal hernia repair accelerated in the same remarkable way as the international research activities [Figure 35].
Figure 35: Paradigm change in inguinal hernia repair in Germany during the last three decades
Up to the middle of the 80s nearly all of German patients suffering from an inguinal hernia were operated on according to the Bassini technique. Due to the influence of Volker Schumpelick during the late 80s the Shouldice repair was introduced in Germany and developed in the following years to the most frequently used technique applied in nearly 54% of the patients in 1992. However, in rapid succession after the advent of MIS, laparoendoscopic inguinal hernia repair attained more and more popularity, whereas Shouldice operation dropped down. Currently, the data of the National Office for Statistics Wiesbaden 2019 show that in Germany nearly 67% of the in-hospital inguinal hernia repairs are performed laparo-endoscopically, but only less than 4% in Shouldice technique [Figure 35]. Notably, this dramatic increase is mainly due to the greater acceptance of the TAPP technique, whereas TEP remains constantly between 18% and 20.9% [Figure 36]. I believe, that the reason for this different development of both of the MIS methods maybe that TAPP is easier to perform, especially for beginner, and has a broader indication spectrum in comparison to TEP, however, there is no scientifically founded explanation. Experience from other countries or continents in which TEP is the predominant repair shows that the influence of specific surgical personalities and tradition may also play an important role.
Figure 36: Development of TAPP and TEP in Germany during the last 10 years
Although in Germany the penetration rate of laparoendoscopic inguinal hernia repair is relatively high, worldwide there are significant differences between continents and countries as well [Table 1]. Furthermore, in some countries there are huge differences between cities and rural regions (Russia), between different provinces (Spain), between different hospitals or surgeons (Slovenia, Indonesia), and between public and private hospitals (Mexico, HongKong, France). A recently published paper from Spain analyzed multiple factors which may influence the penetration rate of laparoendoscopic inguinal hernia repair in detail.[69] Guillaumes et al.[69] defined the factors associated with the choice of laparoscopic approach in a population-based study of 263,283 patients. The authors found on multivariate logistic regression analysis, the patient place of residence, with other words the specific surgeon, is the most important factor associated with the likelihood of receiving LAP-IHR (OR 4.96; P < 0.001). In decreasing significance the authors found further factors favoring LAP-IHR, for example, bilateral operation (OR 4.596; P < 0.001), insurance coverage (OR 4.439; P < 0.001) and self-pay patients (OR 2.317; P < 0.001), as well as a recurrent hernia (OR 1.780; P < 0.001), age younger than 65 years (OR 1.555; P < 0.001), and male sex (OR 1.162; P < 0.001). Out of the unilateral hernia group, only 4.3% were operated laparo-endoscopically, whereas in the bilateral group this percentage was 17.5%, thus more than four times higher. In the UK a similar situation can be observed, only 19.4% of the patients with a unilateral hernia are operated laparoendoscopically, but 67.7% of the bilateral. Furthermore, in Spain a significant difference between public and private hospitals, 4.3% vs. 16.1% was found. With respect to primary or recurrent hernia the percentages were 5.6% vs. 8.0%. Interestingly, in Spain the MIS-technique was more applied in males (5.8%) than in females (4.9%). However in Sweden about 50% of the female patients are operated on laparoscopically, and in male patients the percentage was only 23%. The reason for this remarkable difference might be that the Swedish surgeons are more willing to follow the guidelines[4],[36] compared to the Spanish surgeons. Regarding insurance coverage the Spanish data are confirmed by the France statistics (personal communication Jean Francois Gillion and Hubert Johanet), but on an essentially higher penetration level: currently in public hospital in France the MIS percentage is 34.7%, in private hospitals 52.3%, and Club Hernia institutions 63.5%. Like in Spain in many countries the place of residence of the patients and the specific hospital are of paramount importance for being operated in open or laparoendoscopic technique [Table 1], for example, in Russia the overall penetration rate is about 10%–12%; however, in the capitals Moscow and St. Petersburg this rate reaches 53%. In Slovenia the overall penetration rate is about 25%; however, in some hospitals the rate is less than 10%, but in other but few hospitals excels 50%. Confirming the Spanish study, a study from Canada concludes that "The surgeon was by far the most important predictor of the use of a laparoscopic approach"[70] rather than the indication appropriateness. In the same study the authors claim that lack of educational facilities may also be an important factor for a reluctant adaption of MIS in hernia repair. In their inquiry Trevisonno et al.[70] found that about 30% of the residents would be willing to learn but have no possibilities; thus, education is a further key factor, but not to forget the personal interest of the surgeon in hernia repair. The penetration rate in Poland shows that although the overall national frequency of laparoendoscopic hernia repair is only about 10%–12%, but surgeons participating in hernia meetings used this technique in about 30% of their patients. Last but not least in the line of the discussed reasons above, it must be emphasized the lack of financial resources in by far most parts of the world as well as badly organized health care systems and insufficient reimbursement. Admittedly, if you start laparoscopic hernia repair you need a first capital investment of €50,000–100,000 for video tower and instruments. This is no problem if you are working in a hospital or if you operate on a high case volume, because in a hospital the expensive video tower is used for many other procedures, for example, cholecystectomy, thus the high primary cost will rapidly being redeemed. Around the world there are still a countless number of hospitals that are not in the financial situation to afford modern medical equipment.
Table 1: Penetration rate of laparoendoscopic inguinal hernia repair worldwide
In summary, despite 30 years of experience with laparoendoscopic inguinal hernia repair and publication of countless studies, systematic reviews and meta-analyses, which clearly show that TAPP and TEP have similarly low recurrence rates and are significantly superior to open mesh repair with respect to all pain-related parameters[43] and despite the recommendation of the recently published International Guidelines "for male patients with primary unilateral inguinal hernia, a laparo-endoscopic technique because of a lower postoperative pain incidence and a reduction in chronic pain incidence, provided that the surgeon with specific expertise and sufficient resources is available,"[4] the overall worldwide acceptance rate is still remarkable low [Table 1]. One aspect which very often is not adequately discussed is related to the cost-efficiency of laparo-endoscopic inguinal hernia repair compared to open surgery. Due to less pain the patient is able to return to work earlier. In Germany per year about 210,000 inguinal hernia repairs are performed (in-hospital 177,000, praxis round 33,000). In Germany, one day of disability of work of a workman means a loss of about 200 € to the economic system. Thus, assuming that about 100,000 patients of the total population are still included in the working process, and who are able to return to work after minimal invasive surgery one day earlier compared to open repair, this would mean that about €20 million could be saved per year.
In summary, despite a dramatic increase of the frequency of laparoendoscopic inguinal hernia repair during the last years in many countries, the overall penetration rate is still disappointing. The main reasons for the reluctant adaption of the new patient-friendly technique are above all surgeon-related, but also related to economical resources of some national health care systems, lack of systematic educational programs as well as absence of strong protagonists. What to do?
In Germany, in 1998 the frequency of laparoendoscopic inguinal hernia repair was 33.5%; currently, it is 63.3%. Milestones in this development are as follows:
In 2000 foundation of the sub-society "Minimal Invasive Surgery" belonging to the German Society for General- and Visceral Surgery by two protagonists of laparo-endoscopic hernia repair (Reinhard Bittner, Ferdinand Köckeling).
In 2002 foundation of the German Hernia Society by Volker Schumpelick (President) and Reinhard Bittner (Vicepresident). The most important resolution, meeting president one year should be an open and the next year a laparoscopic surgeon. After 7 years this rule could be abandoned because all did open and laparoendoscopic surgery.
In 2004 foundation of the International Endohernia Society (IEHS) by Reinhard Bittner and Ferdinand Köckerling.
Seit 2007 German Hernia Days Berlin/Hamburg/Köln (Ralph Lorenz, Wolfgang Reinpold, Bernd Stechemesser).
In 2009 foundation of the "Herniamed" registry (Ferdinand Köckerling) with a scientific meeting every year.
Since 2011 yearly one three-days educational meeting "Hernia Compact" for 50 trainees in surgery inclusive cadaver operations, training at models and attending life surgery.
Since 1991 countless meetings and courses (e.g., MIC-Symposium Hamburg, Masterclass Courses Association of German Surgeons in Berlin) with life demonstration of laparoendoscopic hernia repair. Not only because of these manifold activities but also because many publications, reporting the results of specific scientific studies as well as the "real life" data documented in the "Herniamed" registry, which meanwhile includes nearly 800,000 Patients, the majority of the German surgeon could be convinced to adapt the minimal invasive operative technique in inguinal hernia repair.
Conclusion and Future Perspectives
Inguinal hernia repair is not a very spectacular operation; however, due to the tremendous number of patients worldwide this disease has a significant impact not only for the patient but also for the health-care system of each country. A cost-effective as well a cost-efficient repair is therefore of paramount importance. In countless studies, it could be shown that regarding cost-efficiency the minimally invasive techniques are superior to open repair. About three decades after introduction in clinical praxis TAPP and TEP are easy to perform, absolutely reproducible, safe, and effective, and can be done with low costs. Nevertheless, the penetration rate in many countries is inadequately low. The reasons for this depressing reality are extensively discussed in this article. It is highly questionable if new techniques like robot-assisted laparoscopic technique will essentially be able to promote at least TAPP. The data from the US may encourage; however, the financial situation of the US patients is not comparable to the rest of the world. Without any doubt, robot-assisted inguinal hernia repair is safe and can be adapted in a reasonable short time.[71],[72],[73],[74] The ergonomic advantages for the surgeon are undisputed. The main drawbacks are still higher costs[75],[76] and longer operation times. The conclusion of the only RCT which is published up to now is rather depressing:[71]
"Results of this study showed no clinical benefit to the robotic approach to straight forward inguinal hernia repair compared with the laparoscopic approach. The robotic approach incurred higher costs and more operative time compared with the laparoscopic approach, with added surgeon frustration and no ergonomic benefit to surgeons."
A detailed cost analysis done by Charles et al.[76] estimated incremental costs for the robot surgery in inguinal hernia of about 2,500 USD. Maybe in future, the cost for the robot will come down, however, at the current juncture robot surgery should be restricted to centers in order to precisely evaluate the benefits in terms of cost-efficiency. It is quite conceivable that already now that complex hernias like large inguinoscrotal hernias may be better operated with the assist of the robot. However, to prove the benefits properly conducted trials are urgently needed.
Many thanks to all of the colleagues who informed me about the penetration rate of laparoendoscopic inguinal hernia repair in their countries: Abolmasov A, Agresta F, Antonov A, Arregui M, Berrevoet F, Bisgaard T, Bowker A, Campanelli G, Chowbey P, Daes J, Dedemadi G, Felix EL, Fortelny R, Gillion JF, Goek H, Gonzalez JCM, Gorjanc J, Hachisuka T, Johanet H, Kukleta J, Lomanto D, Misra M, Mjåland O, Montgomery A, Morales-Conde S, Smietanski M, Qin Ch, Roberts R, Santilli O, Simons M, Smart N, Soltes M, Strupas K, Udomsawaengsup S, Tran H, Vironen J, and Yang G.
Prof. Reinhard R. Bittner is an Editor-in-Chief of International Journal of Abdominal Wall and Hernia Surgery. The article was subject to the journal's standard procedures, with peer review handled independently of this Editor-in-Chief and their research groups.
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Kraft BM, Jäger C, Kraft K, Leibl BJ, Bittner R. The AESOP robot system in laparoscopic surgery: Increased risk or advantage for surgeon and patient? Surg Endosc 2004;18:1216-23.
Bittner R, Schmedt CG, Leibl BJ, Schwarz J. Early postoperative and one year results of a randomized controlled trial comparing the impact of extralight titanized polypropylene mesh and traditional heavyweight polypropylene mesh on pain and seroma production in laparoscopic hernia repair (TAPP). World J Surg 2011;35:1791-7.
Leibl BJ, Däubler P, Schmedt CG, Kraft K, Bittner R. Long-term results of a randomized clinical trial between laparoscopic hernioplasty and Shouldice repair. Br J Surg 2000;87:780-3.
Leibl BJ, Kraft B, Redecke JD, Schmedt CG, Ulrich M, Kraft K, et al. Are postoperative complaints and complications influenced by different techniques in fashioning and fixing the mesh in transperitoneal laparoscopic hernioplasty? Results of a prospective randomized trial. World J Surg 2002;26:1481-4.
Leibl B, Däubler P, Schwarz J, Ulrich M, Bittner R. [Standardized laparoscopic hernioplasty vs. Shouldice repair: Results of a randomized comparative study]. Chirurg 1995;66:895-8.
Phillips EH, Carroll BJ, Fallas MJ. Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision: Technique and early clinical results. Surg Endosc 1993;7:159-62.
Daes J. The enhanced view-totally extraperitoneal technique for repair of inguinal hernia. Surg Endosc 2012;26:1187-9.
Daes J, Felix E. Critical view of the myopectineal orifice. Ann Surg 2017;266:e1-2.
Claus C, Furtado M, Malcher F, Cavazzola LT, Felix E. Ten golden rules for a safe MIS inguinal hernia repair using a new anatomical concept as a guide. Surg Endosc 2020;34:1458-64.
Claus C, Cavazolla LT, Furtado M, Malcher F, Felix E. Challenges to the 10 golden rules for a safe minimally invasive surgery (MIS) inguinal hernia repair: Can we improve? Arq Bras Cir Dig 2021;34:e1597.
Felix EL, Michas CA, Gonzalez MH Jr. Laparoscopic hernioplasty. TAPP vs TEP. Surg Endosc 1995;9:984-9.
Aiolfi A, Cavalli M, Ferraro SD, Manfredini L, Bonitta G, Bruni PG, et al. Treatment of inguinal hernia: Systematic review and updated network meta-analysis of randomized controlled trials. Ann Surg 2021;274:954-61.
Guillaumes S, Hoyuela C, Hidalgo NJ, Juvany M, Bachero I, Ardid J, et al. Inguinal hernia repair in Spain: A population-based study of 263,283 patients: Factors associated with the choice of laparoscopic approach. Hernia 2021;25:1345-54.
Trevisonno M, Kaneva P, Watanabe Y, Fried GM, Feldman LS, Andalib A, et al. Current practices of laparoscopic inguinal hernia repair: A population-based analysis. Hernia 2015;19:725-33.
Prabhu AS, Carbonell A, Hope W, Warren J, Higgins R, Jacob B, et al. Robotic inguinal vs transabdominal laparoscopic inguinal hernia repair: The RIVAL randomized clinical trial. JAMA Surg 2020;155:380-7.
Khoraki J, Gomez PP, Mazzini GS, Pessoa BM, Browning MG, Aquilina GR, et al. Perioperative outcomes and cost of robotic-assisted versus laparoscopic inguinal hernia repair. Surg Endosc 2020;34:3496-507.
Muysoms F, Vierstraete M, Nachtergaele F, Van Garsse S, Pletinckx P, Ramaswamy A. Economic assessment of starting robot-assisted laparoscopic inguinal hernia repair in a single-centre retrospective comparative study: The EASTER study. BJS Open 2021;5:zraa046.
Qabbani A, Aboumarzouk OM, ElBakry T, Al-Ansari A, Elakkad MS. Robotic inguinal hernia repair: Systematic review and meta-analysis. Anz J Surg 2021;91:2277-87.
Abdelmoaty WF, Dunst CM, Neighorn C, Swanstrom LL, Hammill CW. Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: A comprehensive cost analysis. Surg Endosc 2019;33:3436-43.
Charles EJ, Mehaffey JH, Tache-Leon CA, Hallowell PT, Sawyer RG, Yang Z. Inguinal hernia repair: Is there a benefit to using the robot? Surg Endosc 2018;32:2131-6.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27], [Figure 28], [Figure 29], [Figure 30], [Figure 31], [Figure 32], [Figure 33], [Figure 34], [Figure 35], [Figure 36]
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Q: How would I be able to use the Emmet tag "!" in Djang-html? I know that to fix the emmet abbreviations for most tags for Django-html is by going to preferences ---> settings ---> Emmet. After getting there I proceeded to add (Django-html, html) into the item and value area. After doing so I am able to use normal emmet abbreviations but I want to use the "!" tag. is there a reason why I cannot use it or is there a fix needed.
Thank y'all in advance.

A: go to settings or press Ctrl+, ->Extension -> Emmet
you want to use the Tab key for expanding the Emmet abbreviations, add the following setting in vscode:
"emmet.triggerExpansionOnTab": true

and Show Expanded Abbreviation
make it to always
this link is useful emmet for vscode
hopefully that is help you

redpajama_set_name: RedPajamaStackExchange


text:
namespace arua {

class ImmediateString : public Immediate {
public:
	ImmediateString(std::string str);
	virtual ~ImmediateString() = default;

	void setString(std::string str) throw();
	std::string getString() const throw();

private:
	std::string str;
};

}

#endif

redpajama_set_name: RedPajamaGithub


The Alaotra Grebe (Tachybaptus rufolavatus) is a species of concern belonging in the species group "birds" and found in the following area(s): Madagascar. This species is also known by the following name(s): Alaotra Dabchick, Delacour's Little Grebe, Madagascar Red-necked Grebe.
Copyright Notice: This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Alaotra grebe".
Glenn, C. R. 2006. "Earth's Endangered Creatures - Alaotra Grebe Facts" (Online) - Licensed article from Wikipedia: The Free Encyclopedia. Accessed 4/23/2019 at http://earthsendangered.com/profile.asp?sp=179&ID=1.
Need more Alaotra Grebe facts?


text:
Browse: Home » 2016 » August » 12 » Archaeologists Unearth Ancient 'Revenue Office' in Roman City Nicopolis ad Istrum near Bulgaria's Veliko Tarnovo
Archaeologists Unearth Ancient 'Revenue Office' in Roman City Nicopolis ad Istrum near Bulgaria's Veliko Tarnovo
August 12, 2016 · by Ivan Dikov · in Ancient Rome / Roman Empire, Antiquity, Byzantine Empire, Middle Ages
The unearthed ruins of the commerce control office in the Ancient Roman city of Nicopolis ad Istrum in Central North Bulgaria. Photo: TV grab from BNT
A public building which was an office exerting control over trade, also dubbed a "tax collection" or "revenue" office by the archaeologists, has been unearthed in the huge Ancient Roman city of Nicopolis ad Istrum whose ruins are located near Veliko Tarnovo and Nikyup in Central North Bulgaria.
Inside the Roman building, the team of lead archaeologist Assoc. Prof. Pavlina Vladkova from the Veliko Tarnovo Regional Museum of History has discovered a large number of weights and measuring devices, reports the Bulgarian National Television.
"This was a building [housing an office] for the control of commerce. At first, I named it the "ancient Revenue Service", Vladkova says.
"Anybody who was selling [goods] not just in the city square but also in the entire city, had to do it with exact weights and measurements in order to deceive the citizens, you know, this was the quality control," she elaborates.
The newly uncovered ruins of the public building in question are located north of the Forum of Nicopolis ad Istrum.
For controlling the commerce, the Ancient Romans used control weights known as egzagia (ekzagia). Such artifacts have been found in the commerce control office discovered in Nicopolis ad Istrum by the archaeologists.
The excavations of Nicopolis ad Istrum are yet to take many years, but after the research of the downtown of the Roman city is completed, Vladkova hopes to be able to excavate part of the residential buildings.
Aerial views of the ruins of the newly discovered commerce control office in the Roman city of Nicopolis ad Istrum (the structure on the right in the photo below). Photos: TV grab from BNT
The ruins of Nicopolis ad Istrum, whose name means "Victory City on the Danube River", are located near today's town of Nikyup, Veliko Tarnovo Municipality, 18 km northwest of the city of Veliko Tarnovo. It was founded by Roman Emperor Trajan (Marcus Ulpius Traianus) (r. 98-117 AD) to honor his victories over the Dacian tribes between 101 and 106 AD (most probably in 102 AD) at the intersection of the two main roads of the DanubianRoman provinces – the road from Odessus (Odessos) on the Black Sea (today's Varna) to the western parts of the Balkan Peninsula, and the road from the Roman military camp Novae (today's Svishtov) on the Danube to the southern parts of the Balkan Peninsula.
Nicopolis ad Istrum is sometimes described as the birthplace of Germanic literary tradition because in the 4th century AD Gothic bishop Ulfilas (Wulfila) (ca. 311-383 AD) received permission from Roman Emperor Constantius II (r. 324-361 AD) to settle with his flock of Christian converts near Nicopolis ad Istrum in the province of Moesia, in 347-8 AD. There Ulfilas invented the Gothic alphabet and translated the Bible from Greek into Gothic.
The Ancient Roman city was destroyed in 447 AD by the barbarian forces of Attila the Hun, even though it might have been abandoned by its residents even before that. It was partly rebuilt as a fortified post of the Eastern Roman Empire (Byzantium) in the 6th century AD which in turn was destroyed at the end of the 6th century AD by an Avar invasion. Later, it was settled as a medieval city in the Bulgarian Empire between the 10th and the 14th century.
The archaeological exploration of Nicopolis ad Istrum first started in 1900, while the presently ongoing excavation efforts were restarted in 2007.
Unfortunately, the Roman city of Nicopolis ad Istrum still remains a largely unknown destination for cultural tourism. Recent data has shown that in 2015, it was visited by fewer than 4,000 tourists, a number which is nonetheless an increase compared with previous years.
Lead archaeologist Pavlina Vladkova (above) showing one of the stone weights discovered in the commerce control office of Nicopolis ad Istrum (below). Photos: TV grabs from BNT
Between August 1 and August 14, 2016, Nicopolis ad Istrum is being excavated with the aid of a total of 26 volunteers from Bulgaria, Romania, Switzerland, and the USA who were selected after an application process.
As part of their program, the volunteers have been enjoying archaeology and history lectures and field trips to other major archaeological sites (including the Ancient Roman villa and pottery making factory in Pavlikeni, and Novae, another major Roman city whose ruins are found near the Danube town of Svishtov), and a Roman Heritage Festival to be held on August 13, 2016.
The archaeological team notes that while Nicopolis ad Istrum was destroyed and looted by the barbarian invasions of Slavs and Avars in the 7th century AD, the fact that it was not recovered as a medieval and/or Modern Era settlement means there are good opportunities for its excavations and research.
Learn more about the Ancient Roman city of Nicpolis ad Istrum in the Background Infonotes below!
Aerial views of the ruins of the Ancient Roman city of Nicopolis ad Istrum near Bulgaria's Veliko Tarnovo. Photos: TV grabs from BNT
Background Infonotes:
Nicopolis ad Istrum (also known as Ulpia Nicopolis ad Istrum) was an Ancient Roman and Early Byzantine city (not to be confused with Nicopolis ad Nestum in today's Southwest Bulgaria).
Its ruins are located near today's town of Nikyup, Veliko Tarnovo Municipality, 18 km northwest of the city of Veliko Tarnovo in Central Northern Bulgaria. Its name means "Victory City on the Danube River". It was founded by Roman Emperor Marcus Ulpius Traianus (r. 98-117 AD) to honor his victories over the Daciantribes between 101 and 106 AD (most probably in 102 AD) on a plateau on the left bank of the Rositsa River. This is where the two main roads of the DanubianRoman provinces intersected – the road from Odessus (Odessos) on the Black Sea (today's Varna) to the western parts of the Balkan Peninsula, and the road from the Roman military camp Novae (today's Svishtov) on the Danube to the southern parts of the Balkan Peninsula.
(Ulpia) Nicopolis ad Istrum was first part of the Roman province of Thrace but after 193 AD it was made part of the province of Moesia Inferior. Nicopolis ad Istrum flourished in the 2nd-3rd century, during the Nerva-Antonine Dynasty (96-192 AD) and the Severan Dynasty (193-235 AD). It further developed as major urban center after the reforms of Emperor Diocletian (r. 284-305). Its organization was similar to that of Roman cities in Thrace and Asia Minor such as Ephesus, Smyrna, Pergamon. It was ruled by a council of archons, a city council and an assembly, with local priests worshipping Ancient Roman and Greek deities such as Zeus, Hera, Athena, Asclepius, Dionysus, Mithras. At the time, Nicopolis ad Istrum was inhabited by Thracians, Roman military veterans, and settlers from Asia Minor. Nicopolis ad Istrum is known to have minted 900 different emissions of bronze coins. The city had orthogonal planning, with an agora (city square), a cardo maximus and a decumanus maximus (main streets), a market place, other public buildings and residential areas, limestone-paved streets and underground sewerage, as well as three aqueducts and several water wells, many of which has been unearthed in archaeological excavations.
The fortress walls of Nicopolis ad Istrum were erected only after the city was ransacked by a barbarian attack of the Costoboci, an ancient people possibly linked to the Getae (Gets) inhabiting an area in today's Western Ukraine. The city square (agora) featured a statue of Roman Emperor Trajan mounted on a horse, a number of other marble statues, a Ionic colonnade, a three-nave basilica, a bouleuterion (a public building housing the boule – council of citizens), a building to the cult of goddess Cybele, a small odeon (theater), thermae (public baths) as well as a building which according to an inscription was a "termoperiatos" which can be likened to a modern-day shopping mall – a heated building with shops and closed space for walks and business meetings. A total of 121 stone and brick tombs and sarcophagi have been found by the Bulgarian archaeologists excavating the city's necropolis. Some villas and other buildings in the residential parts of Nicopolis ad Istrum have also been excavated.
The Ancient Roman city Nicopolis ad Istrum was destroyed in 447 AD by the barbarian forces of Attila the Hun, even though it might have been abandoned by its residents even before that. It was rebuilt as a fortified post of the Eastern Roman Empire (Byzantium) in the 6th century AD. The Early Byzantine fort covered about one forth of the Ancient Roman city – 57.5 decares (app. 14.2 acres) out of a total of 215.5 decares (app. 53.2 decares), and was also the center of a bishopric. The Early Byzantine fort was destroyed at the end of the 6th century AD by an Avar invasion. Later, it was settled as a medieval cityin the Bulgarian Empire between the 10th and the 14th century.
Nicopolis ad Istrum was visited in 1871 by Austro-Hungarian geographer and archaeologist Felix Kanitz who found there a statue of the wife of Roman Emperor Septimius Severus (r. 193-211 AD). The city was first excavated in 1900 by French archaeologist J. Seur whose work, however, was not documented, and in 1906-1909 by Czech archaeologist B. Dobruski. In 1945 and 1966-1968, there were partial excavations led by T. Ivanov from the National Institute and Museum of Archaeology of the Bulgarian Academy of Sciences. Systematic excavations were started in 1970 and were led again by T. Ivanov. Between 1985 and 1992, Nicopolis ad Istrum was excavated by a joint Bulgarian-British expedition from the National Institute and Museum of Archaeology in Sofia and a team of the University of Nottingham. The joint Bulgarian-British excavations were resumed in 1996. The Nicopolis ad Istrum archaeological preserve is managed by the Veliko Tarnovo Regional Museum of History. In 1984, the Ancient Roman city Nicopolis ad Istrum was put on the Tentative List for consideration as a UNESCO World Heritage Site.
Tags: Ancient Rome, archaeologist, Byzantine Empire, Byzantium, commerce control office, egzagia, excavations, festival, measurements, Nicopolis Ad Istrum, Nikyup, Pavlina Vladkova, Roman Empire, Veliko Tarnovo, Veliko Tarnovo Regional Museum of History, volunteers, weights, Yantra River
← Archaeologists to Excavate Four Ancient Thracian Sites with Funding from Bulgarian State Mining Company
Largest Early Christian Basilica in Rhodope Mountains Discovered in Rock City Perperikon in Southern Bulgaria →

redpajama_set_name: RedPajamaCommonCrawl


Napoli two-tone bed is an artistic expression in contemporary furniture design. This attractive and charming bed provides both comfort and relaxation. It is all wooden frames and upholstered with durable synthetic leather.
Mattress is supported by slats. Slats height: 9 inch above the floor. This bed requires US standard Queen or King size mattress. Mattress is not included.
Mattress may be purchased at the discounted price, mattress offered is a Pandora 10″ memory foam available in Queen or King size.


Lady Tallowmere is looking for translators.
Thank you to everyone who has helped translate Tallowmere.
the enthusiasm to translate over 2,000 strings.
I am willing to pay for your translation work. Please email me to discuss your rates.
1. Get the master spreadsheet.
I've a Google Spreadsheet titled Tallowmere 1 - Language Spreadsheet containing all of Tallowmere's language strings in English.
Create a copy of the spreadsheet within your own Google Drive, or download the spreadsheet as an XLSX file to your own computer to use with Excel or other spreadsheet application.
2. Fill out the spreadsheet.
The first column contains the string IDs.
The second column contains the English strings.
The third column is where you come in!
Please fill out the "Other Language" column. There are over 2,000 lines.
For assistance with the context of most sections, I've created a String Contexts page with a lot of screenshots.
If you're not sure about something, please email me.
3. Save the spreadsheet as Tab-Separated Values.
When you're ready to try out your translation, download the spreadsheet as a Tab-separated Values (TSV) file. If you're using Google Docs, this is done via File > Download as > Tab-separated values.
It's okay if you test incrementally; you can test your translation even if the "Other Language" column is only partially filled out. Fields that have not been translated will show up as English in-game.
4. Convert the TSV file to INI here.
Once you have your TSV file, upload it using the form below. The form will look at the first column (stringIDs) and third column (your translated strings), and prompt you to download an INI file that the game will use.
If, for example, you selected Danish, the form will return a file named "Danish.ini". Do not edit the file name!
5. (Optional) Opt-into Tallowmere's beta branch on Steam.
It is recommended to use the beta branch of Tallowmere on Steam for testing.
Open your Steam client > Right-click Tallowmere > Properties > Betas tab > Choose "beta - Tallowmere beta" from the drop-down menu. Click the Close button, and restart Steam; Steam should then download the Tallowmere beta.
6. Copy the INI file to Tallowmere's LanguageFiles folder.
7. Launch Tallowmere and test.
After launching Tallowmere, you can load your language in-game by going Main Menu > Options > Language. You will have to restart Tallowmere to fully apply the language change.


What: Over seven editions, 361° Conference has evolved as the singular most relevant platform for discussion and discourse on architecture and design in India. Since its inception, the forum has captured the progressive nature of design creating in its wake an arena for the emerging and influential practices in India. As a thought-provoking platform, 361° in its eighth edition will continue to celebrate the power of thoughts and ideas and initiate a truly relevant dialogue on architecture and design.
What: The 17th International Conference on Humane Habitat shall focus on the Theme : 'Sustainable Architecture, Environment and Development in Rural, Urban and Regional Context.' The conference shall be organised by International Association for Humane Habitat (IAHH), and hosted by Rizvi College of Architecture at its premises in Bandra West, Mumbai, India in association with Council of Architecture (COA),Commonwealth Association of Architects (CAA), and World Society of Ekistics (WSE), and Maharashtra Chapter of the Indian Institute of Architects, Forum of Colleges of Architecture, Mumbai Region and Maharashtra Association of Schools of Architecture (MASA) and Practicing Architects, Engineers and Town Planners Association (PEATA) in Mumbai, India.
What: One of the world's biggest and best annual conferences on design, Kyoorius Designyatra features some of the biggest names in global creative and communications industry. The theme this year deliberates on "what if..?". The speaker line-up includes Patrick Burgoyne of Creative Review, Tim Malbon of Made by Many, Natasha Jen of Pentagram, and many others. The conference is organised by Kyoorius, a not-for-profit organisation initiated by Transasia Fine Papers to build a platform for the design, creative and communication community in India – providing information, inspiration & networking opportunities.


text:
Haiti: Politics or Internal Security
November 27, 2017 Crime , North America , Opinion , OPINION/NEWS
Ricardo Swire
A flashpoint for CARICOM internal security intelligence officials is Haiti's latest political decision to formally reconstitute the national military. The Defence Minister proclaimed "the Army's mission would be to fight against contraband smuggling and provide relief in case of natural disasters." More than 2,200 applications were received after Haiti's military recruitment first round. A similar concern, about this July 2017 Haiti Defence Ministry's intention, previously stated in the August 2016 United Nations Secretary-General's report.
The formal document identified shortcomings in the National Police of Haiti (PNH) and shared Dominican Republic (DR) border control modifications. CARICOM internal security intelligence data spotlighted the financial constraint on Haiti's coffers that only allows uniforms, equipment and salaries, for less than five hundred soldiers. Historically, Haiti's powerful drug trafficking networks incorporated rogue military participation. Counter-narcotics operations, conducted against transnational trafficking moving via neighboring DR alone, cost Haiti between US$200 million and US$500 million annually.
Patterns identify Haiti's corruption in Customs processes and its antiquated fiscal framework as the main catalyst for smuggling across the DR border. Local private security experts question the reintroduction of their country's military, rather than restructure and improve the 15,000 PNH compliment. For more than twenty years the CARICOM member's disbanded military was dormant. In the late 1980s the PNH was introduced, Haiti's 1987 Constitution separating police and military powers. Subtly the Fad'H or Armed Forces of Haiti continued to act as the government's main law enforcers.
Haitian Armed Forces soldiers functioned as security overseers in rural communities and sectors of the capital Port-au-Prince. In 2004 the UN Peacekeeping Force MINUSTAH was established, the multi-national force popularly considered by Haitians an affront to national sovereignty. 2013 internal security intelligence reports noted a continuation of home invasions in affluent Port-au-Prince communities, a prevalence of illegal guns and drug trafficking violence key concerns. The upsurge in Haiti's violent crime prompted international response.
During the period America's Drug Enforcement Administration's (DEA) "Operations Rum Punch and Rum Chaser" tracked 159 South American drug-planes that landed in Haiti and DR. The PNH's special Counter Narcotics Unit has 45 US vetted and trained officers. Within the unit the DEA manages a Sensitive Investigative Unit (SIU). These local detectives, in collaboration with MINUSTAH counterparts, collect intelligence and conduct operations against major transnational traffickers.
The UN's Disarmament, Demobilization and Reintegration (DDR) program, in concert with Haiti's government Commission for National Disarmament, Demobilization and Reintegration (CNDDR) program, did not yield expected results. According to the PNH's Director-General in 2015 between two hundred and fifty and two hundred and sixty thousand illegal guns circulated across Haiti. Internal security data indicated the PNH's MINUSTAH funded US$60,000 firearms incinerator, capable of destroying five hundred guns daily, is under-utilized.
Ricardo Swire is the Principal Consultant at R-L-H Security Consultants & Business Support Services and writes on a number of important issues.
Tags CARICOMCNDDRcrimeDEADemobilization and ReintegrationdisarmamentDominican Republicdrug traffickingFad'HHaitiMINUSTAHPNHRicardo Swiresecurity
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Still unsure what to choose - outsourcing or in-house production?
To give you an idea when and how you can benefit from working with an IT contractor, we have compiled the main advantages of IT outsourcing below.
When Is It Beneficial to Outsource?
Say, your company develops enterprise accounting software and you have quite a number of valuable clients in this industry. One of the clients asks you to develop a mobile app for them, but this is not what you specialize in. Learning and trying may be too long, expensive and even dangerous for your reputation, in case the client is not satisfied with the work and decides to leave you. Choose to outsource and keep your clients safe.
When you don't have enough qualified management resources to take control of the army of QA engineers and developers, who you need to produce your product. Poor IT management may result in doubled production costs. To avoid this, you'd better outsource production with pre-defined costs and guaranteed risk level.
IT outsourcing agencies usually have an impressive project portfolio. If the contactor works with a number of clients, the only way to retain and satisfy them all is to use cutting-edge technologies. This means that such people are qualified and can bring the latest approaches and technologies to your employees, thus increasing overall innovation level in your company.
For example, your support engineers leave company in just a year, however it takes them 3 months to learn internal processes only. In this case it is better to outsource, because your outsourcing partner will take care of their personnel learning, onboarding and assure works with zero downtime.
Assume, you need to roll out a new server software. You don't want to hire a full-time expensive specialist, who will only perform this task. You will either have to switch him to other regular tasks or fire afterwards, having invested in his recruiting, onboarding and learning. Outsourcing such task is a way to go.
For instance, while implementing a project, the scope of work unexpectedly increased or one of your key employees left you. To be able to meet the deadline, you urgently need a particular highly-qualified specialist in your team. As a rule it is time-consuming and sometimes tricky to recruit a real talent. An outsourcing partner will be a great support in this situation. You ask for a particular developer with proven project expertise and occupy him as much and as long as you need.
Fayrix Software is a young brand, emerged in a chain of merges and acquisitions in 2017, but we actually started our IT business back in 2005, having accumulated one of the largest IT human resource capital in Eastern Europe. We are 100% flexible and can offer our client from renting a single specific developer to building a whole offshore development center.
Fayrix has been specifically created to bring IT innovation to traditional commercial processes of IT companies. Because we are 100% online in terms of sales and marketing, Fayrix does not have any travel, representative or rental costs. This saves our budgets and lets us offer the most competitive rates, preserving the highest level of services provided, again confirming that Fayrix is the most innovative and digitally-advanced project.
At the same time, cooperating with Fayrix does not incur the same risks as working with a freelancer. All our processes are well-established, developers are properly-managed, motivated, comfortable with their colleagues and friends in office every day.
Fayrix is 100% flexible and can offer our client services from renting a single specific developer to building a whole offshore development center.