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Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: In recent decades, developments in drug therapy have significantly postponed the need for surgery. Nevertheless, the majority of patients with Crohn's disease still require one or more surgical interventions during the course of their disease. An analysis of epidemiological data as well as the surgical results of our own patients should help to identify risk factors for early surgery, re-operations and perioperative complications., Methods: A retrospective analysis including 120 consecutive patients with Crohn's disease and needing surgical intervention was carried out at the University Hospital of Rostock (UMR), Germany. Statistical analysis was performed using SPSS., Results: A total of 284 operations were recorded in 120 patients, of which 207 were performed on the UMR. The mean age at first surgery was 38 years (range: 17 - 66); initial diagnosis of Crohn's was on average at the age of 30 (range: 9 - 62). Each patient was operated 2 - 3 times during the course of their disease (range 1 - 9). Patients older than 30 years had significantly shorter time interval to the first operation. The number of operations per patient was significantly influenced by the localisation and behaviour of the disease. Penetrative behavior was associated with more frequent operations and terminal ileum involvement (L1) with significantly less frequent operations. Risk factors for complication of at least grade III according to Clavien-Dindo included greater age at surgery and at first diagnosis, decreased albumin levels and increased CRP. Anastomotic leakages were also associated with these risk factors as well as preoperative intake of > 20 mg prednisolone equivalent per day or cumulative dosage of 280 mg over the last 14 days prior to surgery. Anastomosis configuration and microscopic involvement of the resection margins had no statistically significant influence on the development of anastomotic leakage., Conclusion: Diagnosis after the age of 30 was associated with a significantly earlier need for surgery in this analysis. Patients with terminal ileum involvement (L1) had a significantly lower surgical frequency than patients with colon or combined Crohn's disease. Age, albumin, CRP and a steroid medication > 20 mg per day were predictors for perioperative complications., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Every surgical problem that increases the likelihood of intraoperative and postoperative complications is considered to be a difficult surgical situation. Based on this definition, Korenkov et al. proposed to classify patients according to the following intraoperative difficulty levels (I to IV): (I) ideal situation (easy to operate, no problems), (II) fairly easy/manageable/simple (some minor difficulties may occur), (III) difficult/problematic (difficult to operate; some operative techniques are considerably more difficult than others), and (IV) very difficult (every operative step is difficult/challenging). Kaafrani et al. proposed a severity classification for intraoperative adverse events. Depending on the severity level, classes range from I (injury requiring no repair) to VI (intraoperative death). Clavien and colleagues published a globally established classification system for postoperative complications. In this classification, the severity of postoperative complications ranges from severity grade I (minimal deviation from the normal postoperative course) to severity grade V (death of patient). Based on the proposed classifications and the problems of individual surgical decision-making, we had the idea to create a Register of Difficult Intraoperative Situations (DIS register). The basic principle of such a register is the collection of an individual expert's experiences. The scientific analysis should focus on patients with apparent modifications in treatment due to difficult intraoperative situations. Registration and processing of enrolled cases will be performed anonymously based on an appropriate IT platform. The main goal of this register is to develop an accessible database for practising surgeons. This will provide an opportunity for every surgeon to find out what other surgeons did in similar situations., Competing Interests: Nein., (Georg Thieme Verlag KG Stuttgart · New York.)

Aim: The aim of this study was the analysis of total, early and late complications following venous access port implantation between 1998 and 2008 at the Department of Surgery of the University of Rostock, Germany. A comparison between different implantation techniques addressing success rate, complication rate and duration of operation was performed. These results were further analysed in regard to the level of training of the participating surgeons., Material and Methods: A retrospective analysis of 1423 venous access port implantations between 1998 and 2008 was performed., Results: The rate of total complications was 13.8%. Among 4.7% early complications pneumothorax was the most common. The rate of late complications was 9.1%. Most common were infection (4.9%) followed by dysfunction of the catheter (3.5%). 1322 venous access port implantations were performed using puncture of the subclavian vein and Seldinger's technique. 101 operations were performed by direct access through dissection of the cephalic vein and open introduction of the catheter. Operation time in the open group was significantly longer than in the puncture group (46.5 min vs. 38.7 min, p = 0.005). There were significantly more late complications (9.6% vs. 2%, p = 0.01) and total complications (14.5% vs. 4%, p = 0.005) in the puncture group vs. the open access group. Primary success rates of open access vs. puncture were 100% and 96.8%, respectively. The rate of complications was independent of the experience status of the surgeon. However, the rate of total and late complications significantly decreases with number of performed operations., Conclusion: Venous port implantation is a relatively simple procedure despite its possible complications. An open access technique is safer than puncture. The rate of complications significantly decreases with increasing number of performed operations. Therefore venous port implantation and especially the open access method is an ideal teaching operation in a structured surgical training programme., (Georg Thieme Verlag KG Stuttgart · New York.)

Inguinal hernia repair shows a clear tendency towards mesh-based as well as laparoscopic approaches. This is widely reflected in data-based statistics and guidelines. In contrast we have initiated and hereby illustrate the surgical method according to Desarda using autologous fascia to repair inguinal hernia., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Haemodynamic monitoring of septic patients is impeded by the discrepancy between the macrohaemodynamics and the microcirculation of internal organs. Pulse contour analysis (PiCCO) provides new parameters for an improved assessment of the volume status of critically ill patients. However, changes in regional circulation, in particular those affecting the splanchnic perfusion, have proven to be especially important. The aim of our study was to compare macrohaemodynamic parameters (PiCCO) with microcirculation (OPS imaging) in severely septic patients with multiple organ failure., Patients and Methods: In seven patients suffering from septic shock and multiple organ failure (APACHE II score > 25) repeated examinations at a twenty-four hour interval were carried out by PiCCO monitoring and OPS imaging. OPS data were recorded for twenty seconds at 6 different buccal and sublingual localisations, adequately reflecting microvascular perfusion of the liver and the small intestine. Data were videotaped for off-line analysis, calculating current velocity in small and large venules (< 25 and > 25 microm), as well as functional capillary density., Results: Significant correlations were found for current velocity in small venules with systemic vascular resistance (r(2) = 0.252, p < 0.05), mean arterial blood pressure (r(2) = 0.259, p < 0.05), and pH value (r(2) = 0.265, p < 0.05). In addition, a significant correlation was found between the oxygen transport index and the density of small vessels (r(2) = 0.355; p < 0.05)., Conclusion: According to our findings, data acquired through PiCCO monitoring may be used for a rough estimation of the microcirculation during severe sepsis and multiple organ failure. For an assessment of the local conditions of perfusion, however, there are limits in the use of the parameters that were the object of our research. For the measurement at localisations which are accessible non-invasively and representative of the splanchnic perfusion, OPS is the more accurate method for characterisation of the microcirculation, although a more extensive and time-consuming analysis is needed.

In this review, standards of diagnosis and treatment of colorectal liver metastases are described on the basis of a workshop discussion. Algorithms of care for patients with synchronous / metachronous colorectal liver metastases or locoregional recurrent tumour are presented. Surgical resection is the procedure of choice in the curative treatment of liver metastases. The decision about the resection of liver metastases should consider the following parameters: 1. General operability of the patient (comorbidity); 2. Achievability of an R 0 situation: i. if necessary, in combination with ablative methods, ii. if necessary, neoadjuvant chemotherapy, iii. the ability to eradicate extrahepatic tumour manifestations; 3. Sufficient volume of the liver remaining after resection ("future liver remnant = FLR): i. if necessary, in combination with portal vein embolisation or two-stage hepatectomy; 4. The feasibility to preserve two contiguous hepatic segments with adequate vascular inflow and outflow as well as biliary drainage; 5. Tumour biological aspects ("prognostic variables"); 6. Experience of the surgeon and centre! Extrahepatic disease does not contraindicate hepatectomy for colorectal liver metastases provided a complete resection of both intra- and extrahepatic disease is feasible. Even in bilobar colorectal metastases and 5 or more tumours in the liver, a complete tumour resection has been described. The type of resection (hepatic wedge resection or anatomic resection) does not influence the recurrence rate. Preoperative volumetry is indicated when major hepatic resection is planned. The FLR should be 25 % in patients with normal liver, 40 % in patients who have received intensive chemotherapy or in cases of fatty liver, liver fibrosis or diabetes, and 50-60 % in patients with cirrhosis. In patients with initially unresectable colorectal liver metastases, preoperative chemotherapy enables complete resection in 15-30 % of the cases, whereas the value of neoadjuvant chemotherapy in patients with resectable liver metastases has not been sufficiently supported. In situ ablative procedures (radiofrequency ablation = RFA and laser-induced interstitial thermotherapy = LITT) are local therapy options in selected patients who are not candidates for resection (central recurrent liver metastases, bilobar multiple metastases and high-risk resection or restricted patient operability). Patients with tumours larger than 3 cm have a high local recurrence rate after percutaneous RFA and are not optimal candidates for this procedure. The physician's experience influences the results significantly, both after hepatectomy and after in situ ablation. Therefore, patients with colorectal liver metastases should be treated in centres with experience in liver surgery.

Even though intraoperative fluid management during major intraabdominal surgery has frequently been addressed in the past, there is a lack of evidence-based recommendations. This report elucidates the topic from the surgeon's view. For the surgeon, the influence of larger fluid amounts on wound and anastomotic healing, bleeding complications and postoperative outcome (time of extubation, postoperative gastrointestinal function, hospital stay, etc.) is of interest. To clarify the question as to what a perioperative fluid regime should be composed of from a surgical point of view, data from the literature and our own studies were evaluated. The retrospective analysis of 98 pancreas resections that had been performed in our hospital revealed no significant differences concerning the occurrence of postoperative bleeding (8.2 %), wound infection (4.1 %), pancreatic fistula (9.4 %) and mortality (2.0 %) based on the administered intraoperative fluid amount. These results were comparable to those of other authors. The average intraoperatively infused fluid amount was 13.9 +/- 0.9 mL / kg / h. Catecholamines were administered in 74 % of all operations, while noradrenaline was used in 54 % of all cases. Although other factors might play a role in this setting, we can deduce from these data that application of a volume of 10-15 mL / kg / h has no negative influence on the outcome following pancreas resections and that the intraoperative fluid therapy should be targeted at these values.

Survival of patients with acute mesenteric ischaemia is decisively dependent upon early diagnosis and non-delayed treatment. Maximum shortening of the admission-to-treatment-time is the main task, as the prehospital phase (e. g. symptom-to-admission-interval) varies considerably and is hardly to be influenced. "Acute mesenteric ischaemia" should early be considered as a possible diagnosis in patients presenting with abdominal symptoms of unknown cause bearing risk-factors for intestinal ischaemic disorders. In such cases an immediate angiography is the method of choice to confirm the diagnosis. To avoid irreversible intestinal damage, immediate laparotomy is induced if competent conducted angiography is not available within one hour after suspicion of intestinal ischaemia.

Aim: Usually, in-situ preparation of the hepatic hilar structures is performed prior to the perfusion with preservation solution. Aim of this study was to investigate mechanical effects of liver preparation on the hepatic microcirculation., Methods: 16 pigs (German landrace) were randomized in two groups. In both groups, laparotomy was performed after intratracheal intubation. Subsequently, a thermal diffusion probe was implanted into the medial left liver lobe for quantification of microperfusion. In group A (n = 8), bile duct, hepatic artery, and portal vein were exposed and the lesser omentum transsected thereafter. Ultrasound-volume-probes were placed around the hepatic artery and portal vein. Simultaneous measurement of hepatic microperfusion and total liver blood flow was performed five minutes after the end of liver preparation. In group B (n = 8) hepatic microperfusion was quantified 45 minutes after laparotomy without further manipulations., Results: By the preparation, liver perfusion was significantly reduced in group A from 78 +/- 13 ml/100g/min to 61 +/- 16 ml/100g/min. After preparation a total liver blood flow of 137 +/- 46 ml/100g/min was recorded indicating a shunt fraction of 51 +/- 21%. In contrast, hepatic microperfusion in group B remained at baseline during the whole observation period (79 +/- 3 ml/100g/min vs. 78 +/- 5 ml/100g/min)., Conclusion: In-situ liver preparation induces a relevant disturbance of hepatic microcirculation. Preservation perfusion shortly after surgical manipulation could become ineffective because of an increase in shunt flow. If the regeneration period is too short, e.g. lack of heart explantation, the quality of the liver graft could be limited.