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Laparoscopic cholecystectomy is one of the most frequently performed procedures worldwide. Therefore, iatrogenic injury to the choledochal duct, although rare, remains a surgical risk that should not be underestimated. Over the years, various methods have been described to avoid this serious complication, with its high morbidity and even mortality. One of the safest methods to avoid bile duct lesions is to establish the so called "critical view of safety" before cutting any structures. This method shall be demonstrated in this instructional video., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

The gastric hormone ghrelin is known as an important factor for energy homeostasis, appetite regulation and control of body weight. So far, ghrelin has mainly been examined as a serological marker for gastrointestinal diseases, and only a few publications have highlighted its role in local effects like mucus secretion. Ghrelin can be regarded as a gastroprotective factor, but little is known about the distribution and activity of ghrelin cells in pathologically modified tissues. We aimed to examine the morphological changes in ghrelin expression under several inflammatory, metaplastic and carcinogenic conditions of the upper gastrointestinal tract. In particular, autoimmune gastritis showed interesting remodeling effects in terms of ghrelin expression within neuroendocrine cell hyperplasia by immunohistochemistry. Using confocal laser microscopy, the gastrin/cholecystokinin receptor (CCKB) could be detected on normal ghrelin cells as well as in autoimmune gastritis. Functionally, we found evidence for a physiological interaction between gastrin and ghrelin in a primary rodent cell culture model. Additionally, we gathered serological data from patients with different basic gastrin levels due to long-term autoimmune gastritis or short-term proton pump inhibitor treatment with slightly reactive plasma gastrin elevations. Total ghrelin plasma levels showed a significantly inverse correlation with gastrin under long-term conditions. Autoimmune gastritis as a relevant condition within gastric carcinogenesis therefore has two effects on ghrelin-positive cells due to hypergastrinemia. On the one hand, gastrin stimulates the proliferation of ghrelinpositive cells as integral part of neuroendocrine cell hyperplasia, while on the other hand, plasma ghrelin is reduced by gastrin and lost in pseudopyloric and intestinal metaplastic areas. Ghrelin is necessary for the maintenance of the mucosal barrier and might play a role in gastric carcinogenesis, if altered under these pre neoplastic conditions.

The management of hepatocellular adenoma (HA) is dependent on several parameters, which are influencing the decision for further management. The aim of this study was to evaluate the clinical presentation, indications, and long-term outcome of surgical treatment in a single-institution analysis. Forty-nine patients underwent elective hepatectomy for HA between 1990 and 2007. Analysis parameters included demographic data, lesion number and size, diagnostic method, mode of surgery, and postoperative outcome. Mean follow-up was 108 months. Thirty-six patients underwent hormone therapy and four patients had a history of cancer before surgical treatment. The mean tumor diameter was 9.8 cm. Mild or moderate postoperative complications were recorded in 16 patients. There was no perioperative mortality. Symptoms were relieved in 95 per cent of the patients. Intratumoral hemorrhage was detected in 21 specimens (43%); malignant transformation was detected in zero specimens. Among patients with HA with clinical symptoms, tumor diameter greater than 5 cm and in male patients the indication for surgery should be given because of the high risk of tumor-related complications. Elective liver resection for HA is a safe procedure and results in a good long-term outcome.

In exceptional cases bleeding of the femoral arteries after surgical interventions in the inguinal area can occur and in some cases can result in critical consequences with potential loss of limbs or fatal outcome. To prevent complications, especially after radical oncological surgery, a muscle flap is inserted to protect the vessel. In most cases the sartorius muscle is used because of its proximity to the operation area. This muscle also has the ideal size and a reliable and predictable position of nerves and vessels. The method of an incomplete sartorius muscle flap has considerable advantages in comparison with the complete method. The case presented is an example of modification of an incomplete sartorius muscle flap, which has been successfully applied in our clinic for extended inguinal dissection.