Search

Enhanced recovery after surgery (ERAS®) describes a multimodal, interdisciplinary and interprofessional treatment concept that optimizes the postoperative convalescence of the patient through the use of evidence-based measures.The aim of this article is to present the experiences of our center certified by the ERAS® Society for colorectal resections 18 months after successful implementation.Since the beginning of the certification 261 patients have been treated in our clinic according to the specifications of the ERAS® concept. As a comparison group the last 50 patients prior to implementation were evaluated in terms of compliance with ERAS® requirements, length of hospital stay and readmission rate, the need for care in an intensive or intermediate care ward, the number of necessary reoperations and the complication rate.Compliance increased from 39.3% preERAS® to 81.1% after ERAS® implementation (p 0.001). At the same time the length of stay of ERAS® patients was reduced from 7 days to 5 days (p = 0.001). While the rate of surgical complications was the same between the two groups (p = 0.236), nonsurgical complications occurred significantly less frequently in the ERAS® cohort (p = 0.018).There are well-known stumbling blocks in implementing and maintaining an ERAS® concept; however, it is worthwhile for the patient to circumnavigate this and establish ERAS® as the standard treatment path.HINTERGRUND: ERAS® (Enhanced Recovery After Surgery) beschreibt ein multimodales, interdisziplinäres und interprofessionelles Behandlungskonzept, welches die postoperative Rekonvaleszenz des Patienten durch den Einsatz evidenzbasierter Maßnahmen optimiert.Ziel dieses Artikels ist es, die Erfahrungen unseres von der ERAS® Society für kolorektale Resektionen zertifizierten Zentrums 18 Monate nach erfolgreicher Implementierung darzulegen.Seit Beginn der Zertifizierung wurden in unserer Klinik 261 Patienten nach den Vorgaben des ERAS®-Konzeptes behandelt. Als Vergleichsgruppe wurden die letzten 50 Patienten vor Beginn der Implementierung hinsichtlich der Compliance an ERAS®-Vorgaben, Liegedauer im Krankenhaus und Wiederaufnahmerate, der Notwendigkeit der Betreuung auf einer Intensiv- oder Intermediate-Care-Station, Anzahl notwendiger Reoperationen und Komplikationsrate ausgewertet.Die Compliance ist von 39,3 % vor der ERAS®- (Prä-ERAS) auf 81,1 % nach der ERAS®-Implementierung gestiegen (p 0,001). Zeitgleich trat eine Reduktion der Liegedauer von 7 Tagen Prä-ERAS® auf 5 Tage bei den ERAS®-Patienten auf (p = 0,001). Während die Rate an chirurgischen Komplikationen zwischen beiden Gruppen gleich war (p = 0,236), traten nichtchirurgische Komplikationen in der ERAS®-Kohorte signifikant seltener auf (p = 0,018).Es gibt gut bekannte Stolpersteine in der Implementierung und Aufrechterhaltung eines ERAS®-Konzeptes. Es lohnt sich allerdings im Sinne des Patienten, diese zu umschiffen und ERAS® als Standardbehandlungspfad zu etablieren.

Morbus Crohn ist eine zur Rezidiven neigende chronische Erkrankung, die bei vielen der betroffenen Patienten mit der Notwendigkeit einer chirurgischen Therapie einhergeht. Sowohl beim Ersteingriff als auch bei jedem Rezidiveingriff werden an den Chirurgen besondere Anforderungen gestellt, die dem rezidivierenden und panenterischen Charakter der Erkrankung Rechnung tragen. Die Crohn-Chirurgie ist eine spezialisierte Viszeralchirurgie, die immer in einem interdisziplinaren Kontext mit der Gastroenterologie steht. Durch die praoperative Anpassung der Ernahrungssituation und der immunsuppressiven Medikation lassen sich postoperative Komplikationen reduzieren. Die intraoperative Beachtung chirurgischer Prinzipien ermoglicht primar und beim Rezidiv eine geringe Invasivitat, den weitgehenden Erhalt gesunden Darms, einen komplikationsarmen Verlauf und die Reduktion von Rezidiven.

For more than a decade the evolving concept of fast track surgery has been implemented, predominantly in colorectal surgery. The practice of fast track surgery has yielded excellent results concerning reduction of postoperative complications and hospital stay and has been shown to increase patient satisfaction; however, several studies have shown a sometimes alarmingly low rate of implementation of the individual fast track measures and the rate is a maximum of 44%.In this review, obstacles for implementation of fast track surgery are investigated. Advice is given on possible solutions to circumvent obstacles and facilitate successful establishment of multimodal recovery protocols in individual institutions.The current international literature is critically evaluated and discussed with a particular focus on prospective clinical trials and expert recommendations.The reasons for a lack of adherence to fast track surgery principles have been shown to be multifactorial. Time-consuming expenditure, logistic difficulties, lack of support by colleagues as well as limitations in the healthcare system and patient-dependent factors appear to complicate implementation of fast track programs.Successful implementation and long-term perpetuation can be achieved only by an interdisciplinary team with a low level hierarchy, continuous training and a positive feedback culture. An early inclusion and clarification of personnel and patients should be firmly integrated into the fast track concept. This results in a higher satisfaction of patients and personnel and subsequently stronger adherence to the fast track concept.

Jeder operative Eingriff ist mit dem Risiko intraoperativer Komplikationen behaftet. Diese treten bei etwa 2–12 % der Patienten auf, beeinflussen aber wesentlich das postoperative Outcome, Gesamtkomplikationsrate und Letalitat. Diese Arbeit stellt die Behandlung der typischen intraoperativen Komplikationen bei Operationen am unteren Gastrointestinaltrakt dar. Einen Schwerpunkt bildet dabei die Prophylaxe und Beschreibung von Risikofaktoren. Besonders bei einer Veranderung der normalen Anatomie durch Voroperationen, Entzundungen oder Tumoren sowie in Notfallsituationen oder einer nicht abgeschlossenen Lernkurve steigt das Risiko fur Verletzungen an Darm, Milz, Ureter oder Gefasen. Diese Risikofaktoren mussen bei der Wahl des operativen Vorgehens, des operativen Zugangsweges und des geeigneten Operateurs berucksichtigt werden. Die fruhzeitige Erkennung der Komplikation mit einer definitiven Versorgung moglichst schon beim Primareingriff ist der wesentliche Schritt fur die erfolgreiche Therapie ohne Langzeitfolgen. Die verzogerte Therapie ist mit einer ungleich hohen Morbiditat und Letalitat behaftet und sollte vermieden werden.

Incisional hernias are one of the the most frequent complications in visceral surgery and incisional hernia repair has a relevant complication rate. Therefore, there have to be solid indications before carrying out incisional hernia repair. To date, there is a lack of evidence concerning the correct indications for surgical repair of incisional hernias. The AWARE trial compares watchful waiting to surgical repair of incisional hernias.The AWARE trial is a prospective randomized multicenter trial. Patients with asymptomatic or oligosymptomatic incisional hernia are randomized into the watchful waiting or the surgical repair group with a follow-up of 2 years. The primary endpoint is pain during normal activities due to the hernia or the hernia repair after 2 years measured on the hernia-specific surgical pain scale (SPS).In this study 36 centers are participating throughout Germany, more than 1600 patients had been screened up to 31 December 2014 and 234 (14.6%) of the screened patients could be recruited.The AWARE study will provide evidence concerning the two therapeutic options of watchful waiting and surgical repair of incisional hernia.

Every surgical intervention is associated with the risk of intraoperative complications. These occur in approximately 2-12% of patients but significantly influence the postoperative outcome, overall complication and mortality rates. This article presents the treatment of typical intraoperative complications during surgery of the lower gastrointestinal tract with a focus on the prevention and identification of risk factors. Especially changes in the regular anatomy caused by previous surgery, inflammation, tumors and emergency situations carry the risk of iatrogenic injuries to the bowels, spleen, ureter and blood vessels. These risk factors must be considered when choosing a surgical procedure, a surgical approach or an appropriate surgeon. The early detection of complications with a definitive restoration is the essential step for a successful treatment without long-term sequelae. Every delay in therapy is associated with an increased morbidity and mortality and should be avoided.

Background The aim of this study was to evaluate the influence of in situ ablation and hepatic resection of experimental liver metastases on residual intrahepatic tumour growth and macroscopic peritoneal tumour spread. Methods Two colonic carcinomas (CC 531) were implanted into 90 WAG rat livers, one in the right liver lobe (untreated tumour) and one in the left liver lobe (treated tumour) of each rat. The animals were randomized into two test groups and a sham-operated control group. Animals in group 1 received in situ ablation (laser-induced thermotherapy) of the treated tumour. Rats in group 2 were submitted to partial hepatectomy. Untreated tumour volumes were calculated and the incidence of macroscopic peritoneal spread was determined at different times. Results After 21 days median (95 per cent confidence interval) volumes of untreated tumours were 507 (282) mm3 in group 1, 2096 (994) mm3 in group 2 and 1896 (755) mm3 in group 3. Compared with values obtained before treatment, growth of the untreated tumours had increased significantly after 4 days in group 2, after 7 days in group 3 and after 10 days in group 1. Macroscopic peritoneal tumour spread was detected in six of 30 animals in group 1 (laser), in 20 of 30 in group 2, and in 24 of 30 in group 3. Conclusion Compared with hepatic resection, in situ ablation of experimental liver metastases delays and reduces residual intrahepatic tumour growth and macroscopic peritoneal tumour spread.

A newly developed diffusing laser applicator was examined for interstitial laser coagulation (ILC) of liver tumours. The applicator consisted of a matted quartz core and a quartz glass dome, also matted on its inner surface and sealed to the fibre. The applicator provided a homogeneous light intensity distribution over an active length of about 20 mm. Lesions were created in an ex-vivo porcine liver model using a Nd-YAG laser comparing the new diffusing tip with a Ringmode(®)-ITT applicator in order to find optimal laser parameters and damage thresholds. The lesions were investigated using macroscopic size measurement, volume calculation and histological examination (HE, NADPH-dehydrogenase). The damage threshold of the diffusing tip was 6 W at 14 min exposure time whereas the Ringmode(®)-ITT applicator had its limit at 5 W and 12 min exposure. Comparing various exposure times showed that treatment over a time of more than 840 s did not significantly increase the lesion volume. At 5 W and 720 s the mean lesion volume was 6.9±1.1 cm(3) with the diffusing tip and 6.3±0.6 cm(3) with the Ringmode(®)-ITT applicator, both having a slight ellipsoidal shape. Hence, the created lesions were not significantly different for both applicators when the same laser parameters were applied. On the other hand, the new diffusing tip had a higher damage threshold and was therefore capable of producing maximal coagulation volumes of up to 7.9±0.5 cm(3) at 5 W and 20 min. The experiments showed that lesions with a dimension of 31×22 mm can be achieved with the diffusing applicator which seem suitably sized for treating small human liver metastases in a single laser session.

Purpose: The aim of this study was to determine the energy (J/mm3 tumor volume) and temperature required for a complete laser-induced thermotherapy (LITT) of experimental liver tumors, and to find out causes and areas of local recurrence followed by incomplete treatment. Methods: In VX-2 tumor-bearing rabbits LITT was performed using neodymium:yttrium-aluminum-garnet (Nd:YAG) laser (1064 nm) with a diffuser-tip applicator and a temperature feedback system. The animals were randomized into four groups (n = 20) that differed in the target temperature at the tumor border as follows: 45°C, 50°C, 55°C and 60°C. The target temperature was held for 10 min constant. Histologic examination (hematoxylin and eosin [H&E], nicotinamide adenine dinucleotide phosphate [NADPH]-dehydrogenase) was performed at 0 h, 24 h, 96 h, and 14 days after LITT. Results: The pretreatment tumor volume of 2191 ± 61 mm3 was the same for all groups (p > 0.05). Energy up to target temperature and total energy required, lesion size, and the rate of incomplete tumor ablation (recurrences) are listed below (ap < 0.05, Kruskal-Wallis test). Histologically, two forms of local recurrences could be differentiated intralesionary and extralesionary. Conclusions: To achieve complete in situ ablation under the given conditions, it is necessary to apply laser energy of 3 J/mm3 tumor volume. A minimum temperature of 60°C on the tumor border presumed an application of 10 min. Recurrence was found outside the coagulation zone (extralesionary) and in high vascularized areas within the coagulation zone (intralesionary).

Summary A new scattering applicator for use in laser-induced thermotherapy (LITT) is presented. The applicator is mounted in front of a 400 μm quartz fiber and consists of a temperature stable plastic material with deposited scattering particles. The applicator provides a homogeneous axial scattering profile over an active length of 30 mm. The maximum power settings in porcine liver (in vitro) using a Nd:YAG-Laser and a cooled protective catheter were 31 W over an exposure period of 10 minutes. The resulting thermal lesions showed axial extensions of up to 50 mm and diameters of up to 33 mm, representing a total volume of 28.6 cm 3 .

Summary A dosimetry model was developed for the thermal laser treatment of biological tissue and applied to laser-induced thermotherapy of organ tumors. This model combines a Monte Carlo simulation for calculating photon distribution in the target volume, a finite difference method for computing heat dissipation and the Arrhenius formalism for predicting protein denaturation and subsequent tissue damage. Implementation was carried out on a Windows-based platform and enabled the three-dimensional control of the target volume. An in vitro evaluation in porcine liver revealed a difference of less than 7% with regard to the ablation volume.

Summary Introduction: For prediction of the effectiveness of laser-induced thermotherapy (LITT) of liver metastases and for the Planning of laser treatment it is indispensable to achieve knowledge about the intrahepatic light and temperature distribution in order to obtain data for an optimally adapted dosimetry. Material and methods: We evaluated the optical properties of normal and tumorous rabbit-liver ex-vivo using a double integrating sphere technique as well as a Monte-Carlo-simulation. These data were correlated with the measurement of the intrahepatic temperature ditrsibution in-vivo during LITT. Results: In our study we were able to show a positive correlation between ex-vivo results of optical properties and in-vivo results in temperature distribution. The absorption coefficient and scattering coefficients were significantly smaller in tumor tissue than in normal liver. This resulted in a higher optical penetration depth of the laser light into the tumor tissue (p Conclusions: These results provide a better understanding of laser-tissue interaction and may be helpful to investigators in the field of light dosimetry in liver tissue.

Qualitativ hochwertige klinische Forschung bietet die Chance, einen unmittelbaren Einfluss auf die medizinische Entscheidungsfindung zu nehmen. Um eine Bestandsaufnahme der aktuellen Situation in der klinischen gastroenterologischen Chirurgie aufzuzeigen, wurde im November 1999 eine Umfrage an 171 chirurgischen Kliniken mit visceralchirurgischem Schwerpunkt durchgefuhrt. Von den 93 antwortenden Kliniken fuhrten 45,2 % insgesamt 91 klinische Studien durch. Nur 8,8 % dieser Studien wurden als prospektiv-randomisierte Multicenterstudien beschrieben, 60 % waren reine Singlecenterstudien. Die Studienfinanzierung erfolgte in 60 Fallen aus dem klinikeigenen Budget, in 27 Fallen durch Industrieunterstutzung und in 4 Fallen durch unabhangige Institutionen, wie die Deutsche Forschungsgemeinschaft oder das BMBF. Von den Studien wurden 7,7 % durch freigestellte Mitarbeiter betreut, in 92,3 % war dies zusatzlich zur klinischen Routine erforderlich. Die Mehrzahl der klinischen Studien in Deutschland befasst sich mit Erkrankungen des Oesophagus, des Pankreas oder Chronisch Entzundlichen Darmerkrankungen. Zwischen den alten und neuen Bundeslandern zeigen sich keine wesentlichen Unterschiede in der Entwicklung und Durchfuhrung klinischer Studien.

To evaluate gadolinium (Gd)-diethylenetriamine-pentaacetic-acid (DTPA)-enhanced magnetic resonance imaging (MRI) for follow-up monitoring of laser-induced thermotherapy (LITT) and to determine a useful examination schedule.LITT of the liver was performed in 55 rabbits using a neodymium: yttrium-aluminum-garnet (Nd:YAG) laser (4-W power output, 840-s exposure time). Gd-DTPA MRI and histologic examinations were performed at different times (0-168 days).Laser-induced lesions underwent regeneration and volume size reduction (69% after 168 days). The correlation coefficient (MR vs. macroscopic analysis) for the mean lesion diameter was r = 0.96. Histology of lesions comprised the four zones that correlated best with MRI findings. Coagulation necroses immediately after LITT was seen as an area of no enhancement on Gd-DTPA MRI. Circular enhancement was first seen 72-96 h after LITT, which was due to early mesenchymal proliferation.Gd-DTPA MRI is a good monitoring procedure for LITT. MRI should be performed 24 and 96 h after LITT.

Laser-induced thermotherapy is an in situ ablation method for the local treatment of liver tumors. The basic prerequisite for induction of adequate treatment volumes for clinical use was the development of a thermostable application system. In an ex vivo test series, the specially developed application system (diffuser tip) with 5760 J had a higher thermic loading capacity than the Ringmode applicator with 4200 J, thus enabling the induction of significantly larger lesions with a volume of 7.6 cm3. The results of a further in vivo test series demonstrated that the lesions were subject to a four-phase connective-tissue organization within a 6-month period. Furthermore, the same laser energy (4200 J) was associated with a significantly lower lesion volume of 2.5 cm3 in the in vivo than in the ex vivo test series. The influence of liver perfusion on the inducible lesion volume was examined in a further animal experimental study. By temporarily interrupting hepatic blood perfusion (Pringle's maneuver) during laser application, the effective volume could be increased to 50.3 cm3 (P < 0.01) using an optical beam splitter. These results show that the technical prerequisites for reliable clinical application of laser-induced thermotherapy have been fulfilled.

Percutaneous endoscopic gastrostomy is not suitable for all patients requiring gastrostomies. Patients with endoscopically impassable tumors require a safe and effective alternative procedure for paraesophageal alimentation. We present the surgical technique and results of the laparoscopic gastrostomy according to Janeway. Using an endoscopic stapling device a gastric tube is created from a stomach fold, led out through the trocar site, and fixed to the skin in the left upper quadrant. Via an inserted catheter enteral alimentation can be performed intermittently since the gastrostoma is continent. Between July 1995 and November 1996 laparoscopic gastrostomy was performed in 15 patients (10 male, five female) with tumors in the pharynx or esophagus. Mean operation time was 35 min. One stoma necrosis developed; the other postoperative courses were complication-free. All gastrostomies were continent. Laparoscopic gastrostomy is easy to perform and involves minimal discomfort and complications for the patient.

BACKGROUND AND OBJECTIVE: The effect of temporarily interrupted hepatic blood flow and multiple-fiber application on necrosis volume in interstitial laser coagulation (ILC) was investigated. STUDY DESIGN/MATERIALS AND METHODS: Single- and multiple-fiber ILC were performed in porcine livers with normal as well as interrupted perfusion. Temperatures were determined. Lesions were measured and studied by light microscopy 4 hours post-treatment. RESULTS: ILC with multiple-fiber application led to significantly greater individual lesion volumes (3.7 +/- 0.5 cm3) than single-fiber application (2.5 +/- 0.5 cm3) (P < .01). The interruption of hepatic perfusion led to a significant increase in lesion volume with single- (7.5 +/- 1.0 cm3) as well as multiple-fiber application (12.6 +/- 2.2 cm3) (P < .01). Superposition of the lesions in the multiple-fiber application mode was only determined with interrupted perfusion (total volume: 50.3 +/- 6.6 cm3). CONCLUSION: Interruption of hepatic perfusion increases lesion volumes significantly. ILC for treating liver tumors should preferably be performed by application routes that permit temporary interruption of hepatic perfusion.

The coloproctomucosectomy (CPM) is the procedure of the choice for the surgical treatment of ulcerative colitis (UC). In cases with pronounced immunosuppression (IS), a 3-step (3S) procedure [i.e., subtotal colectomy and ileal pouch-anal anastomosis (IPAA) and finally ileostomy reconstruction] is often selected. Fewer perioperative complications can be expected compared to the 2-step (2S) procedure; however, an additional in-hospital stay and surgical intervention are necessary. The aim of the present study was to compare both approaches using the clinical outcome of our patients undergoing IPAA to determine efficacy of these two concepts.From 1997-2010, a total of 225 patients were operated using a 2S or 3S IPAA procedure. Clinical outcomes were evaluated based on the number of surgical steps for the ileoanal pouch procedure and IPAA. The survey was performed within the scope of prospective study.Of the 225 patients with CPM, 66 were excluded due to a diagnosis other than UC (familial adenomatous polyposis, indeterminate colitis, Crohn's disease) and patients with permanent ILS procedures without the possibility or wish for an IPAA (n = 54). Included were 71 patients with 2S (w = 30, m = 41) and 34 patients with 3S procedures (w = 21, m = 13). Compared to the 2S procedure, the 3S procedure was shown to have shorter operation times (246 versus 296 min; p = 0.05), shorter hospital stays (15.5 versus 24.6 days; p = 0.05), shorter intensive care unit stays (3.3 versus 7.2 days; p = 0.05), and fewer major complications (5.9 % versus 22.5 %; p = 0.035). Patients with 3S procedures had a higher BMI (26.2 versus 23.1 kg/m²; p = 0.05) and fewer required IS (10 % vs. 62 %; p 0.05).The decision for a 3S procedure in UC and pronounced IS is advisable and justified. Using a 3S procedure, immunosuppression and its influence on perioperative morbidity are thus reduced. The IPAA can be performed with shorter operation times, shorter hospital stays and fewer major complications.

The correct therapeutic management of acute sigmoid diverticulitis (SD) is still controversially discussed. Essential to the success of therapy is primarily the long-term resolution of Patient symptoms after surgical or conservative therapy. The aim of this study was to compare the long-term outcome after conservative and surgical treatment of Patients with acute SD.Consecutive admissions of all Patients with acute SD were prospectively recruited from January 2005 to June 2008 with the exception of a free perforation. The following data were recorded: age, sex, first or recurrent episode of SD, computed tomography (CT) stage, white blood cell count, C-reactive protein, persistent symptoms and recurrence after conservative and surgical therapy. Furthermore, information on the rates of postoperative sexual and bladder dysfunction was collected. The long-term outcome was evaluated by a standardized questionnaire. In June 2008 all Patients were contacted using a standardized questionnaire.A total of 153 Patients were included in the study of whom 70 (45.8 %) presented with the first episode, 83 (54.2 %) had a prior history of SD and 40 Patients were treated conservatively whereas 113 Patients were surgically treated by sigmoid resection. Uncomplicated SD was seen in 16 Patients (conservative 4, surgical 12, p = 0.961), phlegmonous SD was seen in 88 cases (conservative 29, surgical 59, p = 0.026) and covered perforated SD in 49 cases (conservative 7, surgical 42, p = 0.022). The median follow-up was 32 months (range 12-52 months). At follow-up 25 % of conservative and 8.8 % of Patients treated surgically complained about persistent symptoms (p = 0.009). The following symptoms occurred (conservative vs. surgery): painful defecation (22.5 % versus 8.8 %, p = 0.024.), constipation (25 % versus 8.8 %, p = 0.009), abdominal cramp (22.5 % versus 4.4 %, p = 0.001) and painful flatulence (25 % versus 8.8 %, p = 0.009). Sexual or bladder dysfunction occurred postoperatively in 7 % and 9 %, respectively. Of the conservatively treated Patients 32.5 % had a recurrence of SD during follow-up compared to 3.5 % of surgically treated Patients (p 0.001).Surgical treatment of acute SD is more effective than conservative therapy for the prophylaxis of recurrent SD and avoidance of persistent symptoms.

Training and simulation are gaining importance in surgical education. Today, virtual reality surgery simulators provide sophisticated laparoscopic training scenarios and offer detailed assessment methods. This also makes simulators interesting for the application in surgical skills courses. The aim of the current study was to assess the suitability of a virtual surgery simulator for training and assessment in an established surgical training course.The study was conducted during the annual "Practical Course for Visceral Surgery" (Warnemuende, Germany). 36 of 108 course participants were assigned at random for the study. Training was conducted in 15 sessions over 5 days with 4 identical virtual surgery simulators (LapSim) and 2 standardised training tasks. The simulator measured 16 individual parameters and calculated 2 scores. Questionnaires were used to assess the test persons' laparoscopic experience, their training situation and the acceptance of the simulator training. Data were analysed with non-parametric tests. A subgroup analysis for laparoscopic experience was conducted in order to assess the simulator's construct validity and assessment capabilities.Median age was 32 (27 - 41) years; median professional experience was 3 (1 - 11) years. Typical laparoscopic learning curves with initial significant improvements and a subsequent plateau phase were measured over 5 days. The individual training sessions exhibited a rhythmic variability in the training results. A shorter night's sleep led to a marked drop in performance. The participants' different experience levels could clearly be discriminated ( ≤ 20 vs. 20 laparoscopic operations; p ≤ 0.001). The questionnaire showed that the majority of the participants had limited training opportunities in their hospitals. The simulator training was very well accepted. However, the participants severely misjudged the real costs of the simulators that were used.The learning curve on the simulator was successfully mastered during the course. Construct validity could be demonstrated within the course setting. The simulator's assessment system can be of value for the assessment of laparoscopic training performance within surgical skills courses. Acceptance of the simulator training is high. However, simulators are currently too expensive to be used within a large training course.

Acute mesenteric ischemia (AMI) is a rare cause of acute abdomen. Coupled with a high patient age, non-specific clinical symptoms and a significant co-morbidity the disease is still associated with a significant mortality of 60-85%. With a combination of preexisting cardiac arrhythmia and sudden abdominal pain AMI should always first be ruled out. Contrast-enhanced computed tomography (CT) scanning has replaced angiography as the first diagnostic step, largely because both intravascular and intra-abdominal pathologies can be diagnosed. In the case of an acute abdomen or lack of immediate access to diagnostic tools, rapid surgical exploration should be preferred. Surgical therapy includes embolectomy and resection of ischemic bowel segments. There should be a wide indication for second-look surgery. The most important prognostic factor and the only factor that can be influenced by the surgeon is the time interval between onset of symptoms and surgery. Therefore angiography or laparotomy should be performed as early as possible in cases of suspected AMI.

Sigmoid resection is now considered as a standard procedure for acute and recurrent sigmoid diverticulitis (SD). In the last decade significant changes in preoperative diagnosis with computed tomography (CT) scanning and surgical access (laparoscopy) have been implemented. The aim of this study was to examine whether this has led to changes in the indications for surgical therapy.Consecutive admissions of 1,154 patients from January 1995 to December 2009 with acute SD were prospectively included. In terms of pre-operative and intraoperative findings and postoperative course 3 treatment periods (TP) were distinguished: TP I 1995-1999, TP II 2000-2004 and TP III 2005-2009.CT scanning was used in more than 90% of cases since TP II compared to 51% during TP I (p0.001). The ratio of emergency versus elective surgery significantly increased in favor of elective surgery (p0.001). The rate of laparoscopy-assisted sigmoid resections showed a continuous increase from 53% in TP I to 71% in TP III (p0.001) while the rate of Hartmann's procedures decreased over time (p0.001). Overall, the rate of surgically treated patients decreased during the time periods studied despite an increase in the total number of patients with SD (TP III versus TP I +41%.) The rate of conservatively treated patients increased significantly (p0.001). The morbidity rate decreased (p0,001) whereas mortality rates remained at a constantly low level (p=0.175).The increasing use of CT diagnosis and the laparoscopic approach led to a shift from emergency surgery with a high complication rate to elective surgery with a high rate of primary restoration of continuity and low morbidity. However, the indications for surgery and therefore the overall rate of patients who underwent surgery did not increase due to these changes.

Inguinal hernia (IH) surgery has changed fundamentally during the last 25 years due to tension-free repair, minimally-invasive approaches and growing influence of economy in medical decision making. Aim of the study was the documentation and analysis of changes in IH surgery during the last 15 years in our patient cohort.Patients undergoing elective or emergency inguinal/femoral hernia repair from January 1995 to December 2009 were included in the study. Analysis of patient data was carried out by prospective online recording.A total of 1,908 patients with 2,124 IHs were treated in the study period and the number of IH repairs decreased continuously. The number of recurrent hernias peaked in 2005-2009 with 16.4%. The average preoperative hospital stay decreased from 2.4 to 0.4 days and the postoperative hospital stay from 7.0 to 3.3 days. The percentage of suture repairs declined from 54.9% in 1995 to 4.1% in 2009 and the percentage of open tension-free repairs rose to 52.9% in 1998. In the following years the majority of repairs were performed by minimally invasive procedures but in 2009 the percentage of conventional hernia repairs exceeded the rate of minimally invasive repairs.The main reason for these changes is the implementation of diagnosis-related groups which hampers inpatient repair of "simple" inguinal hernias, favors short hospital stay and does not adequately reimburse minimally invasive repairs.

It is often postulated that younger patients with acute sigmoid diverticulitis (SD) have an increased risk of perforation which constitutes an indication for early surgery. The aim of this study was to correlate the severity of sigmoid diverticulitis with patient age in order to check the surgical indication in younger patients.Patients with acute SD from January 1998 to June 2009 were included. Two age groups were distinguished: group I (GI) ≤40 years in age and group II (GII)40 years. The perforation risk associated with first episode SD was determined by multivariate analysis. SD was classified according to Hansen and Stock (H/S).In the total cohort of 959 patients, including 86 in GI (8.9%) and 873 in GII (91.1%) 468 had a first episode, with 64 in GI (13.7%) and 404 in GII (86.3%). The proportion of first episodes was 74.4% in GI and 46.3% in GII (p0.001). The perforation risk did not differ (H/S IIb: 29.7% in GI vs. 29.2% in GII, p=0.938; H/S IIc: 25% in GI vs. 25% in GII, p=1). Treatment regimes were (GI vs. GII) emergency operations 25% vs. 25% (p=1), elective operations 17.2% vs. 10% (p=0.096) and conservative treatment 57.8% vs. 64.9% (p=0.276).First episodes of SD were more frequent in younger patients (≤40) and did not involve a higher risk of perforation. The indication for treatment of acute SD should not be based on age but on the severity of inflammation and the individual situation of patients.

The demand for high quality evidence-based surgical treatment in Germany and awareness of the poor quality of surgical trials highlight the basic necessity of randomized controlled trials. In six surgical trial centers a professional infrastructure for surgical trials is in the process of being established since 2006.The aim is the initiation of surgical multicenter trials which can be effectively conducted by local networking. To accomplish a timely recruitment of patients it is necessary to integrate surgical departments outside university hospitals into multicenter trials. With a questionnaire survey of non-university surgical departments in the federal states of Berlin and Brandenburg, interest, experience in clinical trials and structural conditions in these departments were evaluated. Based on the results of this survey the possibilities to integrate non-university surgical departments into multicenter trials and how a high recruitment of patients can be motivated will be discussed in this article.

Skill courses for surgery offer a good but cost and personnel-intensive possibility to obtain practical and theoretical knowledge by the employment of a close teacher-pupil contact of a large group of surgeons. The goal of the study presented here was to evaluate the satisfaction and benefits of the practical course for visceral surgery in Warnemünde after 10 years of course experience.All participants in the annual course for visceral surgery were included since 1999. During this 1-week course conventional and laparoscopic exercises are performed under direct guidance of an experienced tutor. The participants are divided into 3 groups based on their surgical experience (e.g.3 years, 3-5 years,5 years). All participants received a standardised questionnaire before and after successful course completion for the collection of relevant data (e.g. demography, training, surgical experience and course evaluation).A total of 1,062 participants (435 female, 627 male, mean age 37 years) participated in the course. The average surgical experience of the participants was 5 years. Of the participants 489 came from a hospital of basic medical care, 499 from a hospital of maximum medical care and 74 from a university hospital. Of the participants 96% had no or only little experience with skill courses (1,020 out of 1,065) and 827 participants had no or only few possibilities for training outside of the operation room (78%). The conventional part of the course was evaluated by 77% of the participants as very good and by 50% as very good for the laparoscopic part. Only 8.3% of the participants were willing to finance the costs of the course by themselves.The practical course for visceral surgery leads to a subjective success in learning. Participation in the course leads to a high satisfaction and offers a cost-intensive possibility for a standardised surgical training. But there are too few experiences with skill courses and possibilities for surgical training outside the operation room so far.

Laparoscopic colorectal surgery is nowadays also widely used in surgery of inflammatory bowel disease. With the correct indications laparoscopic surgery is an attractive cosmetic alternative for the predominantly juvenile patients. Refractory fistulizing Crohn's proctocolitis is a very severe disease with a maximal limitation on the quality of life. Proctocolectomy with a Brooke ileostomy represents a very effective option for these patients. The laparoscopic technique can at least spare the patients a salvage laparotomy incision. We report about our preliminary experiencesA total of 8 patients (mean age 25 years, range 19 Background 31 years, female:male ratio 5:3) were operated on. The mean preoperative time course of the disease was 28 months (range 12 Background 156 months). All patients had received long-term prednisolone therapy of15mg, 2 patients received azathioprine medication, 2 underwent anti TNF-alpha therapy and 6 received 5-aminosalicylic acid (5-ASA). The mean preoperative BMI was 19 (range 15 Background 21). All patients suffered from Crohn's pancolitis with anorectal fistulas. Laparoscopic proctocolectomy was performed using 4 trocars place in a semicircular fashion. The resected tissue was salvaged transanally and the Brooke ileostomy was drained via the right lateral trocar. The terminal exit of the rectum occurred transanally with preservation of the pelvic floor and the anal sphincter and the anal fistulas were separated. The small pelvis was filled by a transanally fixed omentum.The median time for surgery was 236.5 mins (range 220-330 mins). A complication of postoperative paralysis of the bowel occurred in two patients and 4 patients could be discharged problem-free according to the fast-track concept. Cosmetic results were excellent in all cases. Perianal and perirectal manifestations healed completely after a median of 4 weeks.Incisionless proctocolectomy represents a good and realizable alternative to open surgery. The main advantages are excellent cosmetic results and a better preservation of the external integrity of the abdomen.

Minimally invasive repair with alloplastic material for inguinal hernia has become a method with few complications and a low recurrence rate. Persistent pain and dysesthesia years after the procedure are however of growing clinical interest. It is still unknown to what degree initial pain or dysesthesia change in the long term. Therefore this study was done to evaluate patient complaints following total extraperitoneal repair (TER) over a long observation period.Included in the study were patients from January 2000 to December 2006 who were treated electively for uni- or bilateral inguinal hernia using TER. Exclusion criteria were emergency procedures, incarcerated hernia, and scrotal hernia. The patient data were collected using a prospective online data system and evaluation of long-term results via standardized questionnaires determining persisting pain, dysesthesia, physical limitations from the surgery, satisfaction with the operation, and recurrences. The patients were grouped according to length of follow-up after surgery: 12-36 months (group 1), 37-60 months (group 2), and 61-96 months (group 3).Since January 2000, 484 patients 18 to 97 years old with 620 inguinal hernias were operated. Of those, 349 were evaluated for this study (proportion of returned questionnaires: 72.1%). No significant differences were noted in patient characteristics or early postoperative complications. The percentage of patients suffering from relevant pain (moderate to severe) dropped significantly: 10.3% (group 1) vs 1.0% (group 2) (P0.05) and 3.4% (group 3) (P0.05). No significant differences were found concerning dysesthesia (19.6% in group 1 vs 19.2% in group 3). There were no significant differences in satisfaction with the operation, as 73.8% in group 1, 67.7% in group 2, and 73.3% in group 3 were very satisfied with the results. The number of recurrences increased during the observation period: 1.9% in group 1, 3.1% in group 2, and 5.5% in group 3 (P0.05).Total extraperitoneal repair is a reliable method with low recurrence rate and high patient satisfaction. A relevant proportion of patients complain however of pain and dysesthesia persisting over years. The data from this study show that in the long term, pain incidence drops significantly while the rate of dysesthesia remains constant. Long follow-up is needed to evaluate the long-term course of persistent pain. For more precise understanding of the long-term results of herniotomy, prospective randomized studies are needed with accordingly long follow-up.

Objective: During RF ablation of liver tumours it is a risk of incomplete tumor areas along the liver vessels. Up to now, there is no systematically analysis of the influence of vessel diameter and flow velocity on the intensity of heat dissipation during therapy available. The objective of this study was to quantify this cooling effect in an ex vivo model. Methods: In our experimental setup with fresh porcine liver we used a bipolar applicator with 30W output power and 15 kJ energy. For the simulation of different vessel diameters, glass tubes with different diameters (di=1.0–8.0 mm) were inserted. The distance between RF applicator and glass tubes was 5 mm. For the simulation of different flow velocities, for the glass tube with diameter di=3,4 mm we varied the flow velocity from 0–917.35 mms−1. After the ablation, the dimensions of the resulting lesion were digitally measured. Results: 144 lesions were induced in 48 porcine livers with 6 repetitions for each parameter setting. In the results for the different vessel diameters, there is no significant difference between the lesion sizes. But the flow velocities are clearly influencing the lesion size. Already with a flow of 1.84mms−1 we could measure a significant area reduction of 16.2% compared to zero flow, which stepped up to 33.6% area reduction for 917.35 mms−1 flow velocity. Conclusion: In a standardised ex vivo model could be shown, that the main influence is not the vessel diameter but rather the blood flow. Even for low flow rates, the heat reduction is enough to significantly reduce the lesion size. These results could be helpful for clinical therapy planning when the tumor is close to liver vessels with significant blood flow.

The aim of this study was to check the results of laparoscopic sigmoid resection for sigmoid diverticular disease with respect to stage of inflammation and time of surgical intervention.All patients were divided into four groups: uncomplicated (Group 1) vs complicated diverticular disease (Group 2), and depending on surgical intervention in early elective (4-8 days, Group A) vs late elective sigmoid resection (4-6 weeks, Group B).At total of 244 patients underwent laparoscopically-assisted resection during the examination period. Differences in favor of Group 1 were found in duration of surgery (153 min vs 167 min), postoperative wound infections (3.55% vs 15.5%), and postoperative hospitalization period (12.2 days vs 14.6 days). Group A had more conversions (7.8% vs 0.9%), more minor complications (25.9% vs 12.9%), and more wound infections (16.4% vs 4.6%) than Group B.Laparoscopic sigmoid resection can be performed in cases of complicated diverticulitis without significantly increasing their overall morbidity. Because of the lower complication rate, we recommend that patients with acute sigmoid diverticulitis receive initial antibiotic treatment and then undergo late elective laparoscopic sigmoid resection.

Minimally invasive surgery (MIS) is now accepted as equally valid as the use of a standard access in some areas of surgery. It is not possible to decide whether this access is economically worthwhile and if so for whom without a full economic cost-benefit analysis, which must take account of the hospital's own characteristics in addition to the cost involved for surgery, staff, infrastructure and administration. In summary, the main economic advantage of MIS lies in the patient-related early postoperative results, while the main disadvantage is that the operative material costs are higher. At present, the payment made for each procedure performed under the DRG system includes 14-17% of the total cost for materials, regardless of the access route and of the technical sophistication of the operation. The actual material costs are greater by a factor of 2-50 for MIS than for a conventional procedure. The task of the hospital is thus to lower the costs for material and infrastructure; that of industry is to offer less expensive alternatives; and that of our politicians, to implement better remuneration of the material costs.

Interstitial thermal therapies such as laser induced interstitial thermal therapy (LITT) and radio frequency induced interstitial thermal therapy (RFITT) are widely used in treatment of focal lesions of tumors and metastasis. For improving the results and the safety of these therapies it is necessary to optimize the precise heat applicator placement and to control the energy deposition into the tissue. In this paper we present a dedicated system for navigation and therapy control of thermal ablation therapies for liver applications based on ultrasound technology. The navigation scenario offers the possibility to use single or multiple applicators and allows on line three-dimensional puncturing guidance inside and outside the imaging plane of the transducer. Using attenuation changes as an ultrasound parameter for defining the thermal ablation zone the therapy process can be controlled and monitored. Differential attenuation data are derived by using a coded excitation scheme for acquiring multi band attenuation images, which are reconstructed into 3d volume data. The volume data sets are then coregistered with and compared to pretreatment data. A strong increase in attenuation change correlates with tissue coagulation

In about 10 % of all patients with colorectal cancer, the primary invention already discloses adhesions or infiltration of adjacent organs. En bloc resection of the tumor-bearing bowel segment with adjacent organs is done to give patients a chance for curation, since intraoperative differentiation is not possible. The aim of this study is characterization of the patient population as well as evaluation of the morbidity and mortality associated with this type of extensive intervention.Between 1/95 and 6/04, we analyzed all patients with progressive primary colorectal cancer, who underwent multivisceral surgery with en bloc resection of at least one other organ. The target parameters were tumor characteristics as well as postoperative morbidity and mortality.A total of 1 001 patients with colorectal cancer underwent surgery. 101 patients (10 %) required multivisceral resection. In 17 % the indication was exigent. About 70 % of the interventions involved the colon. Tumor perforation was seen in 17 % of patients with colon cancer and 16 % with rectal cancer. Resection of the inner genitals was most frequent in both colon and rectal cancer (26 and 84 %) followed by small bowel resection (21 %) and partial bladder resection (19 %). Other organs play a secondary role in rectal cancer while partial bladder resection (20 %) and abdominal wall resection (14 %) is observed more frequently in colon cancer. Resection of parenchymatous organs (kidney, suprarenal gland, spleen, pancreas, liver) and others like the stomach is quite rare in colon cancer. Actual tumor infiltration (T4 situation) was observed in 51 % of patients with colon cancer and in 64 % of those with rectal cancer. Local R0 resection (97 vs. 96 %) was successfully performed in nearly all colon and rectal cancer patients. The surgical major complication rate was 9 % in colon cancer and 19 % in rectal cancer. The mortality rate was 4 %.Multivisceral en-bloc resection enables local R0 resection in the majority of cases with primary colorectal cancer. Despite sometimes extensive surgery, this type of procedure is associated with an acceptable morbidity and mortality. Since long-term survival is comparable to that in the T category (T3 or T4), multivisceral en-bloc resection is not only justified but also absolutely required in interventions with curative intention.

Die Hernienchirurgie wurde durch 2 Entwicklungen in den letzten 20 Jahren nahezu revolutioniert. Hierzu zahlt einerseits die Entwicklung und der Einsatz alloplastischer Materialien und andererseits die Einfuhrung der minimalinvasiven Operationstechnik in der Hernienchirurgie. Durch die Kombination dieser Entwicklungen werden die Vorteile einer spannungsfreien Reparation mit den Vorteilen der minimalinvasiven Chirurgie kombiniert. Dadurch entsteht eine Methode, die mit einer niedrigen Rezidivquote behaftet ist und den Patienten wenig belastet, wenig Schmerzen zufuhrt und zu einer raschen Mobilisierung fuhrt.

Die Ergebnisse nach der operativen Versorgung von abdominellen Hernien sind von einer Vielzahl von Faktoren abhangig. Zu diesen Faktoren zahlen neben patientenabhangigen Faktoren die Art der Hernie, die Art des operativen Verfahrens und die Wahl des alloplastischen Materials. Ein wesentlicher Punkt, die chirurgischen Ergebnisse nach Hernienchirurgie zu verbessern, liegt jedoch in der korrekten Platzierung des einzubringenden Netzes bei Versorgung mit alloplastischen Materialien