Performing over 600 hernia operations a year, the certified center of excellence for hernia surgery at the Cantonal Hospital of Baselland is one of the largest in Switzerland. Under the leadership of Chief Physician Professor Dr Robert Rosenberg and Dr Dietmar Eucker (Senior Consultant), the center offers the highest level of internationally renowned expertise – with a team of proven specialists: Dr Christine Glaser, Dr Bernd Schenkluhn, Dr Andres Heigl and Dr Sebastian Lamm.
The KSBL Hernia Center offers a highly specialized range of diagnostic and treatment services for patients with hernias or pain in the abdominal wall and groin. The Surgical Clinic at the Cantonal Hospital of Baselland, with its sites in Liestal and Bruderholz, covers the entire spectrum of general and visceral surgery, also known as abdominal surgery. This primarily includes operations on the organs of the digestive tract – i.e. the stomach, intestines and esophagus – as well as operations on the gallbladder, liver and pancreas.
Diseases affecting organs outside the abdominal cavity are also treated surgically within the scope of general and visceral surgery. These include, in particular, diseases of the hormone-producing organs – the thyroid, parathyroid and adrenal glands – which are addressed by the specialists at the Surgical Clinics of the Cantonal Hospital of Baselland within the scope of what is known as endocrine surgery.
Dr Eucker first developed the method of intraoperative abdominal wall extension/fascial traction (IFT) at the Reference Center for Hernia Surgery at the Cantonal Hospital of Baselland. The editorial team of the Leading Medicine Guide wanted to find out more about this and spoke to Dr Eucker about the wide-ranging topic of hernias and their treatment options.
“A hernia is a weak spot in the abdominal wall and most commonly occurs in the groin, the navel, a scar or the upper abdomen. The peritoneum and, in some cases, internal organs push through the abdominal wall, causing a bulge – the hernia,” Dr Eucker begins our conversation and explains: “The hernia usually does not cause pain, grows slowly, and gradually a swelling becomes noticeable. Strangulation is rather rare. The most common type of hernia is an inguinal hernia, which affects on average one in three men during their lifetime. Here at the Cantonal Hospital of Baselland, we operate on around 400 male patients a year for inguinal hernias.”
The symptoms of a hernia can vary depending on the type and location of the hernia. In the case of an inguinal, umbilical or incisional hernia, a noticeable bulge or lump generally appears in the affected area. Hernias can cause pain, but more often they cause discomfort, such as a feeling of pressure, particularly when pressure in the abdomen increases due to prolonged walking or standing, carrying heavy objects, coughing or passing stools.
Significant progress has been made in hernia surgery in recent years.
“Hernia surgery has now developed into a specialist discipline. This makes sense when you consider that inguinal hernia surgery, for example, is the most common procedure in general surgery. What is done frequently should also be developed to a particularly high standard. Consequently, hernia surgery has, in some cases, given rise to entirely new surgical techniques in recent years. What was considered state-of-the-art just ten years ago may now be outdated. Keeping pace with developments and being able to offer all technical options now requires a certain degree of specialization. Minimally invasive and robotic surgical methods are just one part of the spectrum,” explains Dr Eucker.
What exactly is minimally invasive hernia surgery?
Most patients are now familiar with the terms ‘minimally invasive surgery’, ‘laparoscopic surgery’ and ‘keyhole surgery’, and they are often asked about them. There is usually an assumption that this is the opposite of ‘open’ surgery. The fact is, however, that even in ‘open’ surgery, incisions and access points are kept as small as possible. Even a so-called open technique should be kept as minimally invasive as possible. The principle of using the smallest possible incisions and working partly with cameras and special instruments is therefore almost always followed in specialist centers and has the advantage of reduced pain, faster recovery and minimal infection rates.
Typical operations that represent a combination of minimal access and yet a so-called open operation are MILOS operations:
MILOS surgical technique (MILOS: Mini or Less Open Sublay Operation)
The MILOS procedure combines the advantages of minimally invasive and open surgical techniques. In the MILOS procedure, the synthetic mesh required to stabilize the abdominal wall is placed via the smallest possible incisions in the abdominal wall, but outside the abdominal cavity, for example in the layer between the peritoneum and the supporting abdominal wall. It is therefore a minimally open procedure: this combines the advantages of conventional methods while avoiding potential disadvantages.
A smooth transition from open to minimally invasive surgery
“Minimally invasive surgery is not limited to laparoscopy, i.e. the keyhole technique. Explaining this to the patient is often not easy, as the terms are frequently misleading. With the MILOS technique, the operation is performed open, but with the smallest possible access. This allows, for example, the meshes used to be placed exactly where they belong, namely between the muscles and other layers of the abdominal wall. A 30 cm mesh, for example, can be inserted through a small 6 cm incision. MILOS is therefore a hybrid technique,” says Dr Eucker, explaining the effective surgical method.
Intraoperative Abdominal Wall Extension/Fascial Traction (AWEX/IFT), fasciotens®
Dr Dietmar Eucker has particular expertise in complex abdominal wall reconstructions, i.e. the restoration of the abdominal wall in cases of large and extreme incisional hernias. As early as 2012, the KSBL team developed and published a technique that has since spread worldwide: intraoperative abdominal wall extension/intraoperative fascial traction.
“The problem with reconstruction in cases of very large abdominal wall hernias is that the abdominal muscles shorten and retract. This is not easy to reverse. Technically, with AWEX/IFT, the shortened abdominal wall is gently lengthened again during the operation through stretching, without the need for additional incisions. The method is characterized by an exceptionally low complication rate and time efficiency. As a supportive measure, Botox can be injected into the abdominal wall four weeks before the operation. This relaxes the muscle somewhat even before the operation, allowing for greater length,” begins Dr Eucker in his explanation of this absolutely fascinating surgical method.
AWEX stands for Abdominal Wall Extension (a stretching technique) and was developed as an innovative surgical method by Dr Dietmar Eucker and his team at the Center of Excellence for Hernia Surgery at the Cantonal Hospital of Baselland. In the meantime, the name IFT (intraoperative fascial traction) has been agreed upon. The technique is now performed using specially developed devices: fasciotens® is the company name of the device manufacturer.
AWEX/IFT/fasciotens® is a method used to stretch the abdominal wall so that abdominal wall surgery can be performed with minimal tension. This involves the use of an external device that applies traction to the abdominal wall by gently pulling the abdominal wall structures toward the front of the body. The traction device allows for precise adjustment of the traction forces and controlled re-tensioning during the operation. This traction can be maintained until the abdominal wall is sufficiently stretched to perform the necessary closure procedure. The traction can be directed either straight from top to bottom or diagonally from top to bottom.
“With fasciotens®, we have already been able to repair many large hernias without additional measures (e.g. so-called component separations). Patients generally report very little post-operative pain and can be discharged after a few days. This is an impressive result for large hernias. In particular, the risk of complications is significantly lower due to the avoidance of additional procedures. Based on these experiences, I am absolutely convinced of the effectiveness and benefits of fasciotens® in the management of complex abdominal wall hernias,” Dr Eucker emphasises, adding: “Furthermore, the device is easy to use. Unfortunately, we were unable to renew the patent in 2014 for our proprietary device due to a lack of sponsor interest, so we are now collaborating with the company faciotens. However, we have no stake in the company! The device is now known worldwide, from Norway to Portugal and Greece, but also in India, Australia and the USA. This has also brought the KSBL Hernia Center to global attention.”
Baselland Cantonal Hospital – Certified Reference Center for Hernia Surgery
“Ten years ago, we began using the Herniamed database for quality assurance and in 2015 became Switzerland’s first certified hernia center (center of excellence). Today, we are one of the largest hernia centers and hold the status of a reference center for hernia surgery (and, incidentally, for minimally invasive surgery as well). A reference center is characterized by high case numbers, offering clinical placements and training, conducting scientific work and publishing findings. Quality comes first, and our expertise is passed on, for example through our annual surgical workshops,” reports Dr Eucker on the Cantonal Hospital of Baselland. Looking to the future, he concludes: “Knowledge about the abdominal wall should be disseminated widely so that standards of quality improve. Specialization should be encouraged. Here at the Cantonal Hospital of Baselland, there is hardly an abdominal wall that we cannot reconstruct!”
Dr Eucker – thank you very much for such a valuable insight into the complex field of hernia surgery!
