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Surgical Endoscopy

, Volume 31, Issue 10, pp 3872–3882 | Cite as

TEP or TAPP for recurrent inguinal hernia repair—register-based comparison of the outcome

  • F. KöckerlingEmail author
  • R. Bittner
  • A. Kuthe
  • M. Hukauf
  • F. Mayer
  • R. Fortelny
  • C. Schug-Pass
Open Access
Article

Abstract

Introduction

The guidelines of the international hernia societies recommend laparo-endoscopic inguinal hernia repair for recurrent hernias after open primary repair. To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. A Swiss registry study identified only minor differences between the two techniques, thus suggesting the equivalence of the two procedures.

Materials and Methods

Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

Results

Univariable and multivariable analysis did not find any significant difference between TEP and TAPP with regard to the intraoperative complications, complication-related reoperations, re-recurrences, pain at rest, pain on exertion, or chronic pain requiring treatment. The only difference identified was a significantly higher postoperative seroma rate after TAPP, which was influenced by the surgical technique, previous open primary operation and EHS-classification medial and responded to conservative treatment.

Conclusion

TEP and TAPP are equivalent surgical techniques for recurrent inguinal hernia repair following previous open primary operation. The choice of technique should be tailored to the surgeon’s expertise.

Keywords

Hernia Recurrent inguinal hernia TEP TAPP Seroma 

In the updated guidelines on laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia, the International Endohernia Society states as grade A recommendation for primary inguinal hernias, following comparison of the two laparo-endoscopic techniques, that both techniques are acceptable treatment options for inguinal hernia repair and there are sufficient data to conclude that both TAPP and TEP are effective methods of laparo-endoscopic primary inguinal hernia repair (1). A comparative Swiss registry study with a large proportion of TEP operations identified for primary inguinal hernias higher perioperative complication rates for TEP (2), whereas a German registry study with a large proportion of TAPP operations detected a higher perioperative complication rate for TAPP (3). Comparison of the outcome of laparo-endoscopic inguinal hernia repair for primary inguinal hernias with that of recurrent inguinal hernias revealed that recurrent procedures are associated with significantly higher postoperative complication rates, complication-related reoperation rates, and higher pain and recurrence rates (4).

There are six meta-analyses available for comparison of laparo-endoscopic with open repair of recurrent inguinal hernias (5, 6, 7, 8, 9, 10). The meta-analysis by Pisanu (8) contained the largest number of exclusively prospective randomized trials (RCTs) (11, 12, 13, 14, 15, 16, 17). All the RCTs included in that meta-analysis compared the laparo-endoscopic procedures with the open Lichtenstein technique. Three RCTs compared the Lichtenstein operation with TAPP (13, 15, 17), two RCTs compared it with TEP (11, 16), and two RCTs compared it with both TEP and TAPP (12, 14).

In the meta-analysis, only joint comparison of the two laparo-endoscopic techniques (TEP, TAPP) with the open Lichtenstein technique was performed. There was no high risk of bias in any of the included trials (8). The meta-analysis by Pisanu et al. (8) detected for laparo-endoscopic repair of recurrent hernias a significantly lower chronic pain rate and significantly earlier resumption of normal everyday activities. Compared with the Lichtenstein operation, the operative time for laparo-endoscopic procedures was significantly longer (8). On the basis of the meta-analyses, the European Hernia Society recommends laparo-endoscopic inguinal hernia repair for recurrent hernias after conventional open repair (10, 18). No distinction is made here between the laparo-endoscopic TEP and TAPP techniques.

To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair following previous open repair. A Swiss registry study (19) compared the outcome of a total of 1309 laparo-endoscopic recurrent operations, of which 1022 used the TEP technique and 287 the TAPP technique. A significantly higher intraoperative complication rate and longer operative time was identified for the TEP group. The postoperative length of hospital stay was longer for patients undergoing TAPP (19). Surgical postoperative complications, general postoperative complications, and conversion rates were not significantly different (19). The authors concluded that the absolute outcome differences are small and that both techniques appear to be safe and effective for patients undergoing laparo-endoscopic repair for unilateral recurrent inguinal hernia (19).

Based on data from the Herniamed Registry (20), the present analysis now compares the outcome of elective laparo-endoscopic recurrent unilateral inguinal hernia repair in men following previous open operation.

Patients and methods

The Herniamed Registry is a multicenter, internet-based hernia registry (20) into which 427 participating hospitals and surgeons engaged in private practice (Herniamed Study Group) have entered data prospectively on their patients who had undergone hernia surgery. All postoperative complications occurring up to 30 days after surgery are recorded. On one-year follow-up, postoperative complications are once again reviewed when the general practitioner and patient complete a questionnaire. They are also asked about any re-recurrence, pain at rest, and on exertion as well as pain requiring treatment. This present analysis compares the prospective data collected for all male patients with a minimum age of 16 years who had undergone elective recurrent unilateral inguinal hernia repair using either transabdominal preperitoneal patch plasty (TAPP) or total extraperitoneal patch plasty (TEP).

In total, 2,246 patients were enrolled between September 1, 2009, and August 31, 2013 (Fig. 1). Of these patients, 782 (34.8%) had TEP and 1,464 (65.2%) TAPP repair. All the patients had to have one-year follow-up data available (follow-up-rate: 100%).

Fig. 1

Flowchart of patient inclusion

The majority of primary unilateral repairs in the Herniamed Registry have been performed as open mesh repair (Lichtenstein) with 32.5% and laparo-endoscopic mesh repair (TAPP, TEP) with 49.9%. Non-mesh repairs (Shouldice, Bassini) in primary unilateral inguinal hernia repair in the Herniamed Registry make only a contribution of 4.7% of all cases.

The demographic and surgery-related parameters included age (years), BMI (kg/m2), ASA-score (I, II, III, IV) as well as EHS classification (hernia type: medial, lateral, femoral, scrotal) and defect size: grade I = < 1.5 cm, grade II: 1.5–3 cm, grade III: > 3 cm) (21) and general risk factors (nicotine, COPD, diabetes, cortisone, immunosuppression, etc.). Risk factors were dichotomized, i.e., ‘yes’ if at least one risk factor is positive and ‘no’ otherwise.

The dependent variables were intra- and postoperative complication rates, number of reoperations due to complications as well as the one-year results (re-recurrence rate, pain at rest, pain on exertion, and pain requiring treatment).

All analyses were performed with the software SAS 9.2 (SAS institute Inc. Cary, NY, USA) and intentionally calculated to a full significance level of 5%, i.e., they were not corrected in respect of multiple tests, and each p value ≤ 0.05 represents a significant result. To discern differences between the groups in unadjusted analyses, Fisher’s exact test was used for categorical outcome variables, and the robust t test (Satterthwaite) for continuous variables.

To rule out any confounding of data caused by different patient characteristics, the results of unadjusted analyses were verified via multivariable analyses in which, in addition to TEP or TAPP operation, other influence parameters were simultaneously reviewed.

To identify influence factors in multivariable analyses, the binary logistic regression model for dichotomous outcome variables was used. Estimates for odds ratio (OR) and the corresponding 95% confidence interval based on the Wald test were given. For influence variables with more than two categories, one of the latter forms was used in each case as reference category. For age (years) the 10-year OR estimate and for BMI (kg/m2) the 5-point OR estimate were given. Results were presented in tabular form, sorted by descending impact.

Results

Univariable analysis

In the TEP group, recurrent repair was performed for n = 554/782 (70.8%) patients following previous suture repair and for n = 228/782 (29.2%) after mesh repair. In the TAPP group, recurrent repair was performed for n = 974/1,464 (66.5%) patients after suture and n = 490/1,464 (33.5%) after mesh repair (Table 1).

Table 1

Laparo-endoscopic recurrent unilateral inguinal hernia repair in men and previous operation

 

Previous operation

Total

Suture

Open mesh

N

%

N

%

N

%

Procedure

554

36.3

228

31.8

782

34.8

TEP

TAPP

974

63.7

490

68.2

1464

65.2

Total

1528

100.0

718

100.0

2246

100.0

No significant difference in mean age and BMI was found between the recurrent operations in TEP and TAPP technique (Table 2). That was also true for the ASA-score, defect size, and risk factors (Table 3). With regard to EHS localization, there were significantly more medial recurrent inguinal hernia defects (52.2% vs. 44.8%; p < 0.001) and significantly fewer lateral defects (55.4% vs. 68.8%; p < 0.001) in the TAPP group (Table 3).

Table 2

Age and BMI of patients with laparo-endoscopic recurrent unilateral inguinal hernia repair in men

 

TEP

TAPP

p

Age [years]

Mean ± STD

58.3 ± 15.8

59.2 ± 15.4

0.186

BMI

Mean ± STD

26.1 ± 3.5

25.9 ± 3.3

0.152

Table 3

Demographic- and surgery-related parameters and risk factors of patients with laparo-endoscopic recurrent unilateral inguinal hernia repair in men

 

TEP

TAPP

p

n

%

n

%

ASA-score

I

186

23.79

376

25.63

0.467

II

454

58.06

849

57.87

III/IV

142

18.16

242

16.50

Defect size

I (< 1,5 cm)

137

17.52

282

19.22

0.524

II (1,5–3 cm)

510

65.22

950

64.76

III (>3 cm)

135

17.26

235

16.02

Risk factors

Total

yes

249

31.84

438

29.86

0.330

no

533

68.16

1029

70.14

COPD

yes

63

8.06

88

6.00

0.063

no

719

91.94

1379

94.00

Diabetes

yes

45

5.75

84

5.73

0.978

no

737

94.25

1383

94.27

Aortic aneurysm

yes

6

0.77

10

0.68

0.818

no

776

99.23

1457

99.32

Immunosuppression

yes

5

0.64

9

0.61

0.941

no

777

99.36

1458

99.39

Corticoid

yes

9

1.15

11

0.75

0.335

no

773

98.85

1456

99.25

Smoking

yes

88

11.25

174

11.86

0.669

no

694

88.75

1293

88.14

Coagulopathy

yes

11

1.41

22

1.50

0.861

no

771

98.59

1445

98.50

Antiplatelet medication

yes

73

9.34

129

8.79

0.669

no

709

90.66

1338

91.21

Anticoagulation therapy

yes

16

2.05

28

1.91

0.823

no

766

97.95

1439

98.09

EHS-classification medial

yes

350

44.76

765

52.15

<0.001

no

432

55.24

702

47.85

EHS-classification lateral

yes

538

68.80

813

55.42

<0.001

no

244

31.20

654

44.58

EHS-classification femoral

yes

22

2.81

55

3.75

0.245

no

760

97.19

1412

96.25

EHS-classification scrotal

yes

6

0.77

21

1.43

0.168

no

776

99.23

1446

98.57

As regards the target parameters, no differences were found between TEP and TAPP recurrent inguinal hernia repair in the intraoperative complications (Table 4). For the postoperative complications, significantly lower values (1.7% vs. 4.6%; p < 0.001) were identified for TEP, but that was mainly due to the difference in the seroma rate (0.5% vs. 3.2%; p < 0.001) (Table 4).

Table 4

Univariable analysis of intra- and postoperative complications, complication-related reoperations, and 1-year follow-up results of patients with laparo-endoscopic recurrent unilateral inguinal hernia repair in men

 

TEP

TAPP

p

n

%

n

%

Intraoperative complication

Total

yes

13

1.66

13

0.89

0.101

no

769

98.34

1454

99.11

Bleeding

yes

7

0.90

8

0.55

0.332

no

775

99.10

1459

99.45

Injury

Total

yes

8

1.02

9

0.61

0.286

no

774

98.98

1458

99.39

Vascular

yes

4

0.51

4

0.27

0.365

no

778

99.49

1463

99.73

Bowel

yes

0

0.00

5

0.34

0.102

no

782

100.0

1462

99.66

Bladder

yes

2

0.26

0

0.00

0.053

no

780

99.74

1467

100.0

Postoperative complication

Total

yes

13

1.66

67

4.57

<0.001

no

769

98.34

1400

95.43

Bleeding

yes

10

1.28

19

1.30

0.974

no

772

98.72

1448

98.70

Seroma

yes

4

0.51

47

3.20

<0.001

no

778

99.49

1420

96.80

Infection

yes

0

0.00

1

0.07

0.465

no

782

100.0

1466

99.93

Bowel injury

yes

0

0.00

1

0.07

0.465

no

782

100.0

1466

99.93

Wound healing disorders

yes

0

0.00

1

0.07

0.465

no

782

100.0

1466

99.93

Reoperation

yes

11

1.41

16

1.09

0.512

no

771

98.59

1451

98.91

Recurrence on follow-up

yes

7

0.90

21

1.43

0.275

no

775

99.10

1446

98.57

Pain in rest on follow-up

yes

54

6.91

79

5.39

0.146

no

728

93.09

1388

94.61

Pain on exertion on follow-up

yes

92

11.76

158

10.77

0.475

no

690

88.24

1309

89.23

Pain requiring treatment on follow-up

yes

35

4.48

50

3.41

0.206

no

747

95.52

1417

96.59

However, since this did not result in any difference in the complication-related reoperation rate, it only meant that TAPP was associated with a higher seroma rate, which responded to conservative treatment.

On one-year follow-up no differences were detected in the re-recurrence rate after recurrent inguinal hernia repair following TAPP and TEP, or in the rates of pain at rest, pain on exertion, or chronic pain requiring treatment (Table 4).

Multivariable analyses

For the intraoperative complications, complication-related re-reoperations, and recurrences on follow-up it was not possible to calculate a valid model since the number of positive cases was too small.

Postoperative complications

The results of the model that explored how the variables related to patient and operation characteristics (surgical technique, previous open primary operation, age, BMI, ASA-score, defect size, and defect localization as well as the presence of risk factors) impacted onset of postoperative complications are illustrated in Table 5 (model matching: p < 0.001).

Table 5

Multivariable analysis of postoperative complications

Parameter

p value

Category

OR estimate

95% CI

Procedure

<0.001

TAPP vs TEP

3.010

1.636

5.538

Previous operation

0.044

Suture vs open mesh

1.753

1.016

3.025

EHS-classification medial

0.049

yes vs no

0.457

0.209

0.997

Defect size

0.055

II (1,5–3 cm) vs I (<1,5 cm)

1.052

0.539

2.055

III (>3 cm) vs I (<1,5 cm)

2.012

0.935

4.329

Risk factors

0.165

yes vs no

1.428

0.864

2.360

Age [10-years-OR]

0.270

 

1.107

0.924

1.326

EHS-classification femoral

0.297

yes vs no

1.717

0.621

4.746

BMI [5-points-OR]

0.394

 

0.857

0.601

1.223

ASA-score

0.414

II vs I

0.896

0.473

1.695

III/IV vs I

1.340

0.592

3.034

EHS-classification scrotal

0.552

yes vs no

1.500

0.394

5.715

EHS-classification lateral

0.646

yes vs no

0.827

0.368

1.860

The postoperative complications, primarily seromas, were affected by the surgical technique. Conduct of TAPP operation (OR = 3.010 [1.636; 5.538]; p < 0.001) increased the risk of postoperative complications. With a prevalence of 3.6%, this would amount to 53 postoperative complications for every 1000 patients undergoing TAPP operation compared with 18 complications for patients operated on in TEP technique. The risk for development of postoperative complications was also increased in patients with previous open suture repair (OR = 1,753 [1.016; 3.025]; p = 0.044) and decreased in EHS medial classification (OR = 0.457. [0.209; 0.997].

Pain at rest

The results of multivariable analysis of pain at rest are presented in Table 6 (model matching: p = 0.009). Here BMI was the only influence factor identified (p < 0.001). A five-point higher BMI increased pain at rest (5-point OR = 1.483 [1.176; 1.170], but there was no evidence of the surgical technique or previous open primary repair having impacted pain at rest.

Table 6

Multivariable analysis of pain at rest in 1-year follow-up

Parameter

p value

Category

OR estimate

95%-CI

BMI [5-points-OR]

<0.001

 

1.483

1.176

1.870

Defect size

0.065

II (1,5–3 cm) vs I (<1,5 cm)

0.786

0.511

1.210

III (>3 cm) vs I (<1,5 cm)

0.444

0.225

0.877

Procedure

0.124

TAPP vs TEP

0.751

0.521

1.082

Previous operation

0.232

Suture vs open mesh

0.798

0.551

1.155

EHS-classification lateral

0.248

yes vs no

0.692

0.370

1.292

Risk factors

0.328

yes vs no

1.222

0.818

1.827

EHS-classification medial

0.372

yes vs no

0.758

0.412

1.394

Age [10-years-OR]

0.513

 

0.957

0.837

1.093

EHS-classification femoral

0.869

yes vs no

1.081

0.431

2.709

ASA-score

0.899

II vs I

0.941

0.595

1.490

III/IV vs I

0.851

0.427

1.694

EHS-classification scrotal

0.980

yes vs no

0.000

0.000

I

Pain on exertion

The results of multivariable analysis of pain on exertion are shown in Table 7 (model matching: p < 0.001). These were significantly influenced by age, BMI, and defect size. A higher age (10-year OR = 0.846 [0.767; 0.933]; p < 0.001) as well as larger hernias (II vs I: OR = 0.699 [0.508; 0.964]; III vs I: OR = 0.517 [0.318; 0.840]; p = 0.018) reduced the risk of pain on exertion. Conversely, a five-point higher BMI (5-point OR = 1.289 [1.073; 1.549]; p = 0.007) increased the pain risk, but there was no evidence of the surgical technique or previous open primary repair having impacted the postoperative complication rate.

Table 7

Multivariable analysis of pain on exertion in 1-year follow-up

Parameter

p value

Category

OR estimate

95%-CI

Age [10-years-OR]

<0.001

 

0.846

0.767

0.933

BMI [5-points-OR]

0.007

 

1.289

1.073

1.549

Defect size

0.018

II (1,5–3 cm) vs I (<1,5 cm)

0.699

0.508

0.964

III (>3 cm) vs I (<1,5 cm)

0.517

0.318

0.840

EHS-classification lateral

0.066

yes vs no

0.646

0.406

1.029

EHS-classification scrotal

0.295

yes vs no

0.338

0.044

2.577

Procedure

0.365

TAPP vs TEP

0.878

0.664

1.163

EHS-classification medial

0.405

yes vs no

0.823

0.520

1.302

ASA-score

0.471

II vs I

0.870

0.623

1.217

III/IV vs I

1.075

0.646

1.787

Risk factors

0.632

yes vs no

0.925

0.674

1.270

EHS-classification femoral

0.797

yes vs no

1.096

0.543

2.214

Previous operation

0.826

Suture vs open with mesh

0.968

0.727

1.290

Chronic pain requiring treatment

The results of multivariable analysis of chronic pain requiring treatment are presented in Table 8 (model matching: p = 0.020). Here BMI was the only significant influence factor identified (p = 0.006). Accordingly, a five-point higher BMI increased the rate of chronic pain requiring treatment (5-point OR = 1.477 [1.121; 1.948]), but there was no evidence of the surgical technique or previous open primary repair having impacted the rate of chronic pain requiring treatment.

Table 8

Multivariable analysis of chronic pain requiring treatment in 1-year follow-up

Parameter

p-value

Category

OR estimate

95%-CI

BMI [5-points-OR]

0.006

 

1.477

1.121

1.948

Previous operation

0.076

Suture vs open mesh

0.666

0.425

1.043

EHS-classification medial

0.088

yes vs no

0.501

0.227

1.108

Procedure

0.195

TAPP vs TEP

0.742

0.473

1.165

EHS-classification lateral

0.246

yes vs no

0.615

0.270

1.399

Defect size

0.287

II (1,5–3 cm) vs I (<1,5 cm)

0.836

0.486

1.438

III (>3 cm) vs I (<1,5 cm)

0.515

0.225

1.179

EHS-classification femoral

0.382

yes vs no

1.556

0.578

4.190

Age [10-years-OR]

0.446

 

0.937

0.793

1.107

Risk factors

0.544

yes vs no

1.166

0.710

1.915

ASA-score

0.842

II vs I

1.048

0.584

1.881

III/IV vs I

1.252

0.547

2.865

EHS-classification scrotal

0.983

yes vs no

0.000

0.000

I

Discussion

In the Guidelines of the European Hernia Society (EHS) and the International Endohernia Society (IEHS), TEP and TAPP are recommended as equivalent procedures for recurrent hernia repair following the previous open mesh and suture repair of primary inguinal hernias (1, 10, 18). To date, no prospective randomized trials have been conducted to compare TEP and TAPP for recurrent inguinal hernia repair following previous open primary repair. A Swiss registry study that compared laparo-endoscopic recurrent hernia operations identified a significantly higher intraoperative complication rate and longer operative time for TEP operations, which were much more common than TAPP procedures in the patient group analyzed (19). The postoperative length of hospital stay was longer for patients undergoing TAPP (19). Surgical postoperative complications, general postoperative complications, and conversion rates were not significantly different (19). The authors concluded that the absolute outcome differences are small and that both techniques appear to be safe and effective for patients undergoing laparo-endoscopic repair for unilateral recurrent inguinal hernia (19).

Likewise, the present analysis of data from the Herniamed Registry, in which the proportion of TAPP operations was higher than that of the TEP operations, revealed similar outcomes for the laparo-endoscopic recurrent operations following previous open primary operation. Based on the Herniamed Registry data, no significant differences were found between the recurrent operations in TEP vs TAPP technique with regard to the intraoperative complications, complication-related reoperations, re-recurrence rates, rates of pain at rest, pain on exertion, or chronic pain requiring treatment. Unfavorable results were identified only with regard to the higher seroma rates associated with TAPP; these responded to conservative treatment. The influence variables identified here on multivariable analysis were, in addition to the surgical technique, the previous open primary operation and the EHS-classification medial. A previous open primary suture repair has a higher risk for development of a postoperative complication as a previous open primary mesh repair and the EHS-classification medial a lower risk. The results of multivariable analysis of the other parameters did not find any evidence of any impact exerted by the surgical technique.

Accordingly, this analysis of data from the Herniamed Registry corroborates the findings of the Swiss registry study. Similarly, the Herniamed Registry did not detect any significant differences between TEP and TAPP for recurrent unilateral inguinal hernia repair in men following previous open suture or mesh primary operation. That was true for the intraoperative complications, complication-related reoperations, re-recurrence, pain at rest, pain on exertion, and chronic pain requiring treatment on one-year follow-up. The only difference was that TAPP was associated with a higher seroma rate, which responded to conservative treatment. There was no difference in the other postoperative complications between TEP and TAPP for recurrent repair.

In summary, both TEP and TAPP can be recommended as effective techniques for treatment of recurrent inguinal hernia following previous open primary operation. The decision to use one or the other technique should be based solely on the surgeon’s expertise. The registry study presented here thus confirms the recommendations in the guidelines on laparo-endoscopic treatment of recurrent inguinal hernia following previous open primary operation.

Notes

Acknowledgements

Ferdinand Köckerling – Grants to fund the Herniamed Register from Johnson & Johnson, Norderstedt, Karl Storz, Tuttlingen, pfm medical, Cologne, Dahlhausen, Cologne, B Braun, Tuttlingen, MenkeMed, Munich and Bard, Karlsruhe.

Compliance with ethical standards

Disclosures

R. Bittner, A, Kuthe, M. Hukauf, F. Mayer, R. Fortelny, C. Schug-Pass have no conflicts of interest or financial ties to disclose.

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© The Author(s) 2017

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors and Affiliations

  • F. Köckerling
    • 1
    Email author
  • R. Bittner
    • 2
  • A. Kuthe
    • 3
  • M. Hukauf
    • 4
  • F. Mayer
    • 5
  • R. Fortelny
    • 6
  • C. Schug-Pass
    • 1
  1. 1.Department of Surgery and Center for Minimally Invasive Surgery, Academic Teaching Hospital of Charité Medical SchoolVivantes HospitalBerlinGermany
  2. 2.Winghofer Medicum, Hernia CenterRottenburg am NeckarGermany
  3. 3.Department of General and Visceral SurgeryGerman Red Cross HospitalHanoverGermany
  4. 4.StatConsult GmbH,MagdeburgGermany
  5. 5.Department of SurgeryParacelsus Medical UniversitySalzburgAustria
  6. 6.Department of General-, Visceral- and Oncologic SurgeryWilhelminen HospitalViennaAustria

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