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The surgical treatment of parastomal hernias is considered complex and is known to be prone to complications. Traditionally, this condition was treated using relocation techniques or local suture repairs. Since then, several mesh-based techniques have been proposed and are nowadays used in minimally invasive surgery. Since the introduction of robot-assisted surgery to the field of abdominal wall surgery, several adaptations to these techniques have been made, which may significantly improve patient outcomes. In this contribution, we provide an overview of available techniques in robot-assisted parastomal hernia repair. Technical considerations and preliminary results of robot-assisted modified Sugarbaker repair, robot-assisted Pauli technique, and minimally invasive use of a funnel-shaped mesh in the treatment of parastomal hernias are presented. Furthermore, challenges in robot-assisted ileal conduit parastomal hernia repair are discussed. These techniques are illustrated by photographic and video material. Besides providing a comprehensive overview of robot-assisted parastomal hernia repair, this article focuses on the specific advantages of robot-assisted techniques in the treatment of this condition.

Die chirurgische Behandlung parastomaler Hernien gilt als komplex und ist bekanntermaßen komplikationsträchtig. In der Vergangenheit wurden diese Hernien durch die Relokation des Stomas oder Nahtverfahren der Austrittstelle versorgt. In den letzten Jahren wurden verschiedene netzbasierte Techniken vorgeschlagen, die heute in der minimal-invasiven Chirurgie eingesetzt werden. Mit der Verbreitung der roboterassistierten Hernienchirurgie wurden die Netzverfahren weiterentwickelt und die Ergebnisse für die Patienten erheblich verbessert. In diesem Beitrag wird ein Überblick über die verfügbaren Techniken der roboterassistierten Versorgung parastomaler Hernien präsentiert. Es werden technische Überlegungen und erste Ergebnisse des roboterassistierten modifizierten Sugarbaker-Verfahrens, der roboterassistierten Pauli-Technik und der Verwendung des trichterförmigen Netzes IPST vorgestellt. Darüber hinaus werden die Herausforderungen bei der roboterassistierten Versorgung parastomaler Hernien am Ileum-Conduit diskutiert. Die Operationstechniken werden durch Foto- und Videomaterial veranschaulicht.

Background: AirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2insufflators in patients undergoing the most frequently performed laparoscopic procedures. Methods: One hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien–Dindo grade complications, surgical side effect and length of hospital stay. Results: Patients were randomized to either group A (n= 101) or group S (n= 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56–94] in group A vs. 69 min [52–93] in group S; p= 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0–3] in group S vs. 2 [0–4] in group A; p= 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay. Conclusion: This randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2insufflator for short elective surgeries.

Obesity has been reported to adversely affect the outcome of laparoscopic antireflux surgery (LARS). This study examined pre- and postoperative clinical and objective outcomes and quality of life in obese and normal-weight patients following LARS at a specialized centre. Prospective data from patients subjected to LARS (Nissen or Toupet fundoplication) for symptomatic gastroesophageal reflux disease in the General Public Hospital of Zell am See were analyzed. Patients were divided in two groups: normal weight [body mass index (BMI) 20–25 kg/m2] and obese (BMI ≥30 kg/m2). Gastrointestinal quality of life index (GIQLI), symptom grading, esophageal manometry and multichannel intraluminal impedance monitoring data were documented and compared preoperatively and at 1 year postoperatively. The study cohort included forty normal-weight and forty obese patients. Mean follow-up was 14.7 ± 2.4 months. The mean GIQLI improved significantly after surgery in both groups (p< 0.001, for both). Clinical outcomes improved following surgery regardless of BMI. There were significant improvements of typical and atypical reflux symptoms in normal weight and obese (p= 0.007; p= 0.006, respectively), but no difference in gas bloat and bowel dysfunction symptoms could be found. No intra- or perioperative complications occurred. A total of six patients had to be reoperated (7.5 %), two (5 %) in the obese group and four (10 %) in the normal-weight group, because of recurrent hiatal hernia and slipping of the wrap or persistent dysphagia due to closure of the wrap. Obesity is not associated with a poorer clinical and objective outcome after LARS. Increased BMI seems not to be a risk factor for recurrent symptomatology and reoperation.

Patients with incisional hernias (IH) and risk factors for surgical site occurrences (SSOs) such as defined comorbidities and/or potential contaminations are considered to be treated with bioprosthetics. A retrospective analysis of consecutive patients who had undergone elective IH repair with synthetic mesh materials between 2009 and 2013 was conducted. Only patients who were classified into Grades II and III according to the classification of the Ventral Hernia Working Group (VHWG) were considered for the study. Primary outcome parameter was the incidence of SSO. The relationships among demographics, hernia characteristics, surgical technique, and SSOs were also evaluated. Overall, 108 patients were included (Grade II: 68, Grade III: 40). SSO was identified in 14 patients. Having two or more comorbidities (P= 0.04), an open sublay technique (P= 0.005), duration of operation (P= 0.02), larger hernia defects (P= 0.001), and using larger mesh sizes (P= 0.01) were associated with significantly higher rates of SSO. Affiliation to VHWG Grading II or III showed no impact on SSO occurrence. Synthetic mesh repair both in an “open sublay” and laparoscopic intraperitoneal technique is safe regarding patients with risk factors for SSO. The recommendations of the VHWG must be declined and a modification of the grading system is warranted overlooking a more liberal use of synthetic meshes.

A percutaneous endoscopic gastrostomy (PEG) can be performed as a direct stomach puncture, known as Seldinger technique (“push”) or a thread pulling method (“pull”). The aim of this study was to compare the final results deriving from both application methods. Data of all pull-through-PEG and push-PEG applications, which had been carried out in our department from 2009 to 2012, were analyzed and compared retrospectively. Data collection included patients’ demographics, indications, comorbidities, peri-interventional chemotherapy, and/or radiotherapy. The complications were graded according to the Clavien–Dindo classification and divided in early- and late-term complications (before and after 10 days after PEG insertion). A total of 231 patients received a PEG. Of these, 131 (56.7 %) were treated with pull-through-PEGs and 100 (43.3 %) with the push-PEG method. Overall, in 61 of 231 (26.4 %) patients, a complication was documented and 37 of 61 (60.6 %) were assigned to Clavien–Dindo grade 1. Only 5 of 231 patients (2.2 %) required a re-intervention or surgical treatment under general anesthesia. The overall complication rate was significantly increased by the type of push-PEG tube used (push 33/100 = 33 vs. pull 28/131 = 21.4 %, p= 0.047). A dislocation of the tube was noticed in 5/131 (3.8 %) cases of pull-PEGs and 12/100 (12 %) cases of push PEGs (p= 0.018). An occlusion of the PEG also occurred significantly more frequent in connection with the push-PEG (10/100 = 10 vs. 1/131 = 0.8 %; p< 0.001). Both PEG techniques are safe and well established. Push PEG showed a significantly higher rate of overall complications, dislocations, and occlusions. The decision which PEG tube should be used depends on individual conditions with preference of push-PEGs in patients with head, neck, and esophageal cancer.

Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect.The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1–4 using Hill’s classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a pvalue of 0.05.A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly.The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

This paper presents an unconventional view of economics. It attempts to explain post–1973 stagflation – the combination of slower economic growth, higher unemployment, and higher inflation – in terms of a new paradigm that attaches central importance to the power of expectations. Several new concepts are developed – notably, the ‘decelerator’. ‘induced’ and ‘autonomous’ inflation, the ‘energy accelerator’ and the ‘energy mutiplier’. Using these concepts and supporting evidence, the paper shows how impending energy scarcity has created stagflation and how we can develop a possible escape route. The paradigm thus explains why, despite ideological differences, the East and West are hit by economic crises at the same time. The paper notes that the Third World has also been affected by the energy crisis, but not in exactly the same way as the First World. Finally, the paper argues that the present difficulties can be overcome only if macroeconomic management makes a subtle but, in its consequences, revolutionary adjustment in its central goals, and moves from the pursuit of growth, employment, price stability and social equity to the pursuit of sustainablegrowth, employment, price stability and social equity.

The concept of apartheid has significance far beyond the situation in South Africa which coined the term. Indeed, the concept can be generalized to apply to the present world situation. It provides both a better understanding of the present human condition and more effective guidelines for action to change it. The processes of interdependence, interpenetration and intercommunication in the present era have made the entire humanity into one global society. The present nation-state system, which obscures the appearance of this society, fails miserably in responding to the concerns and needs of the global community. The concept of global apartheid provides a more realistic and comprehensive view of the world and suggests appropriate ways of so acting as to make a beginning toward realizing a just, participatory, peaceful and humane global society.

Ausgehend von allgemeinen überlegungen zur Kapitalbewertung wird festgestellt, daß die sinnvolle Anwendung von Kapitalbewertungsfunktionen nicht aus dem Rahmen der jeweils benutzten Methode zur Darstellung versicherungstechnischer Vorgänge herausführen sollte. Anschließend wird gezeigt, daß dieses bei Verwendung der in [4] beschriebenen Methode, nämlich mittels Versicherungsfunktionen und dem Stieltjes-Schärfschen-Integralbegriffs, auch tatsächlich der Fall ist. Proceeding from a general consideration of the valuation of capital, the author concludes that a consistent application of capital valuation functions should stay within the framework of the associated method for the representation of technical insurance processes. He then shows that this is indeed the case with the method described in [4], i.e. the use of insurance functions and Stieltjes-Schärf integrals.

This paper uses the term "violence" in the broader sense, monitors the changing magnitudes of armed violence and structural violence at the global and regional levels for the 20th century. It compares the magnitudes of the two types of violence and, discerns long-term trends in the magnitudes of armed and structural violence that may exist in this century.

This essay on international economic order and foreign policy theory takes its departure from the observation that foreign policy theory and action are today confronted with a global economic problematique of revolutionary proportions, and therefore need to be re-examined. It finds that the classical concepts of sovereignty, national interest, and power, though still valid, are too narrowly defined by the Realist school to be of much use. It holds that the principle of politico-military ‘balance of power’ must be applied in conjunction with the principle of ‘optimal interdependence’. Using a cognitive map which identifies the principal actors and cleavages (global apartheid being judged to be the most dominant), and learning from socialist and capitalist theoreticians about possible solutions, it elaborates the meaning of ‘optimal interdependence’. It then presents an alternative theory of foreign policy and makes six strategic suggestions from that principle.