Purpose Results of the most commonly used inguinal hernia repair techniques often originate from expert centers or from randomized controlled studies. In this study, we portray daily-practice results of a high-volume, regional surgical group in the Netherlands, comparing TREPP (open (posterior) transrectus sheath pre-peritoneal) with Lichtenstein (open anterior) and TEP (endoscopic (posterior) totally extraperitoneal). We hypothesize that the TREPP shows more favorable outcome compared to the current gold standard procedures: TEP and Lichtenstein. Methods Between January 2016 and December 2018, 3285 consecutive patients underwent surgical treatment and were included for analysis. The outcome measures were postoperative pain, recurrence rate and other surgical complications. Propensity-score matching was used to address potential selection bias. Results After propensity-score matching, there was no statistically significant difference in postoperative pain in the TREPP group compared to the Lichtenstein group (TREPP 7.3% versus Lichtenstein 6.3%; p = 0.67) nor in TREPP compared to TEP (TREPP 7.4% versus TEP 4.1%; p = 0.064). There was no statistically significant difference in recurrences in the TREPP group compared to Lichtenstein (3.8% vs 2.5%; p = 0.42), nor in the TREPP versus TEP comparison (3.9% vs 2.8%; p = 0.55) Conclusion This study compares TREPP with Lichtenstein and TEP in the presence of postoperative pain, recurrences and other adverse outcomes. After propensity-score matching, no statistically significant difference in postoperative pain or recurrences remained between either TREPP compared to Lichtenstein, or TREPP compared to TEP. Based on these results, TREPP, Lichtenstein and TEP showed comparable results in postoperative pain, recurrences and other surgical site complications.

Introduction One anastomosis gastric bypass (OAGB) is an effective and safe treatment for morbidly obese patients. Longer biliopancreatic (BP) limb length is suggested to result in better weight loss outcomes, but to date, no data are available for the OAGB to substantiate this. We hypothesized that applying a longer BP-limb length in the higher BMI classes would result in more weight reduction so that the attained BMI would be comparable to patients with a lower BMI, thereby compensating for differences in baseline BMI. Method A retrospective cohort study in patients who underwent a primary OAGB at a teaching hospital in the Netherlands between January 2015 and December 2016. BP-limb length was tailored based on preoperative BMI. Patients were divided into three different groups depending on the length of the BP-limb: 150, 180, and 200 cm. Weight loss outcomes after 1 and 3 years and resolution of comorbidities were compared between these groups. Results Of the 632 included patients, a BP-limb length of 150 cm was used in 172 (27.2%), 180 cm in 388 (61.4%), and 200 cm in 72 (11.4%) patients. Despite more BMI loss, %EWL was lower and attained BMI remained higher in the groups with longer BP-limb lengths. After adjustment for the confounder preoperative BMI, longer BP-limb lengths were not associated with higher BMI loss. There was no difference in remission rates of comorbidities. Conclusion Attained BMI remained higher in spite of tailoring BP-limb length according to baseline BMI with no differences in remission rates of comorbidities. Graphical Abstract

Introduction The one anastomosis gastric bypass (OAGB) is an effective treatment to induce sustained weight loss in morbidly obese patients. Concerns remain regarding the development of reflux. The aim of this study was to investigate the effect of an "anti-reflux suture" as anti-reflux modification to prevent reflux. Method This is a single-center retrospective cohort study of patients who underwent a primary OAGB at the Center Obesity North-Netherlands (CON) between January 2015 and December 2016. Reflux was defined as symptoms of acid/bilious regurgitation or pyrosis. This was consequently asked and reported at each follow-up visit. Outcomes of patients with an anti-reflux suture were compared to those without. Results In 414 (59%) of the 703 included patients, an anti-reflux suture was applied. Follow-up at 3 years was 74%. The incidence of reflux did not differ between patients with or without an anti-reflux suture (57 versus 56%, respectively; P = 0.9). The presence of an anti-reflux suture was significantly associated with a lower incidence of conversion to Roux-en-Y gastric bypass (RYGB) for reflux (OR 0.56, 95%CI 0.34-0.91). Patients preoperatively diagnosed with gastroesophageal reflux disease (GERD) were 5.2 times more likely to need a conversion to RYGB for reflux (95%CI 2.7-10.1). ConclusionThe presence of preoperative GERD should be weighted heavily in the decision to perform an OAGB as this is a major risk factor for conversion surgery due to reflux. The anti-reflux suture might be a valuable addition to the procedure of the OAGB because it results in fewer conversion surgeries for reflux.

Introduction Tailoring limb length in bariatric surgery is a subject of many studies. To acquire the optimal limb length, accurate measurement of the small bowel length is essential. Objective To assess the intra- and inter-individual variability of laparoscopic bowel length measurement using a hand-over-hand technique with marked graspers. Method Four bariatric surgeons and four surgical residents performed measurements on cadaver porcine intestine in a laparoscopic box using marked graspers. Each participant performed 10 times a measurement of three different lengths: 150, 180, and 210 cm. Acceptable percentage deviation from the goal lengths was defined as less than 10%, while unacceptable deviations were defined as more than 15%. Results The bariatric surgeons measured the 150-, 180-, and 210-cm tasks with 4% (CI 0.4, 9), − 6% (CI − 11, − 0.8), and 1% (CI − 4, 6) deviation, respectively. In total, the bariatric surgeons estimated 58 out of 119 times (49%) between the margins of 10% deviation and 36 times (30%) outside the 15% margin. Considerable inter-individual differences were found between the surgeons. The surgical residents underestimated the tasks with 12% (CI − 18, − 6), 16% (CI − 19, − 13), and 18% (CI − 22, − 13), respectively. Conclusion Bariatric surgeons estimated bowel length with on average less than 10% deviation. However, this still resulted in 30% of the measurements with more than 15% deviation. There were considerable inter-individual differences between the surgeons and residents structurally underestimated the bowel length. Ascertainment of measurement accuracy and adequate training is essential for bariatric procedures in which limb length is of importance. Graphical abstract