Search

Anastomotic leakage in visceral surgery is associated with a large number of known and also unknown or even unmeasurable parameters. Furthermore, the associations between the individual factors are intertwined and complex. According to current data a preoperative prediction is not reliably possible and should be distinguished from intraoperative or postoperative prediction models. Most studies on this topic do not exceed an area under the curve (AUC) of 0.70. A thorough understanding of statistics and prediction models is necessary to correctly interpret the published works. Due to the relatively low incidence rate of anastomotic leakage from a statistical point of view, large datasets are required for adequate prediction. Multimodal data and complex algorithms can potentially handle big data more accurately and improve predictability; however, these models have so far not been applied in the clinical routine., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Complications are common after major visceral surgery. Besides the patients, also surgeons may experience negative feelings by the patients suffering. Some studies have evaluated the mental burden caused by complications, mainly focusing on residents in different surgical specialties. No evidence exists on the mental burden of board-qualified visceral surgeons in Germany., Materials and Methods: A point prevalence study was conducted using an online questionnaire. For the inclusion of participants, all departments of visceral surgery at German university hospitals were addressed. The objective of the online questionnaire was to elaborate the perception of complications and the coping mechanisms used by the surgeons with the aim to characterize the mental burden and possible improvement strategies., Results: A total of 113 questionnaires were answered, 98 being complete. 73.2% of the participants were male, 46.9% were consultants and had a working experience of 11-20 years. Most common specialties were colorectal and general surgery and 91.7% claimed to have caused complications Clavien-Dindo grade IV or V. Subsequently, predominant feelings were anger, grief, self-doubt and guilt. The fear of being blamed by colleagues or to lose reputation were high. Especially female and younger surgeons showed those fears. Coping mechanisms used to overcome those negative feelings were interaction with friends and family (60.6%) or proactive training (59.6%). Only 17.2% of the institutions offered professional support. In institutions where no support was offered, 71.6% of the surgeons asked for support., Conclusion: Surgical complications cause major psychological burden in surgeons in German university hospitals. Main coping mechanisms are communication with friends and families and professional education. Vulnerable subgroups, such as younger surgeons, may be at risk of suffering more from perceived mental distress. Nonetheless, the majority did not receive but asked for professional counselling. Thus, structured institutional support may ameliorate care for both surgeon and patient., (© 2024. The Author(s).)

Besides sepsis and malignancy, malperfusion is the third leading cause of tissue degradation and a major pathomechanism for various medical and surgical conditions. Despite significant developments such as bypass surgery, endovascular procedures, extracorporeal membrane oxygenation, and artificial blood substitutes, tissue malperfusion, especially of visceral organs, remains a pressing issue in patient care. The demand for further research on biomedical processes and possible interventions is high. Valid biological models are of utmost importance in enabling this kind of research. Due to the multifactorial aspects of tissue perfusion research, which include not only cell biology but also vascular microanatomy and rheology, an appropriate model requires a degree of biological complexity that only an animal model can provide, rendering rodents the obvious model of choice. Tissue malperfusion can be differentiated into three distinct conditions: (1) isolated arterial ischemia, (2) isolated venous congestion, and (3) combined malperfusion. This article presents a detailed step-by-step protocol for the controlled and reversible induction of these three types of visceral malperfusion via midline laparotomy and clamping of the abdominal aorta and caval vein in rats, underscoring the significance of precise surgical methodology to guarantee uniform and dependable results. Prime examples of possible applications of this model include the development and validation of innovative intraoperative imaging modalities, such as Hyperspectral Imaging (HSI), to objectively visualize and differentiate malperfusion of gastrointestinal, gynecological, and urological organs.

Background: eHealth applications can support early mobilization and physical activity (PA) after surgery. This systematic review provides an overview of eHealth services to enhance or record PA after visceral surgery interventions., Methods: Two electronic databases (MEDLINE PubMed and Web of Science) were systematically searched (November 2023). Articles were considered eligible if they were controlled trials and described digital devices used to promote PA after visceral surgery. The Cochrane risk of bias (RoB-2) tool was used to determine the methodological quality of studies., Results: A total of nine randomized controlled studies (RCT) were included in this systematic review. The studies differed with respect to the interventions, surgical indications and evaluation variables. The risk of bias of the individual studies was moderate. The six studies using activity trackers (AT) predominantly showed insignificant improvements in the postoperative step count. The more complex fitness applications could partially reveal significant advantages compared to the control groups and the home-based online training also showed a significant increase in functional capacity., Conclusion: Activity tracking alone has so far failed to show clinically relevant effects. In contrast, the more complex eHealth applications revealed advantages compared to usual postoperative care. More high-quality studies are needed for evidence-based recommendations for eHealth services in conjunction with visceral surgery., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Minimally invasive surgery (MIS), such as laparoscopic and robotic surgery for rectal cancer, is performed worldwide. However, limited information is available on the advantages of MIS over open surgery for multivisceral resection for cases clinically invading adjacent organs., Patients and Methods: This was a retrospective propensity score-matching study of consecutive clinical T4b rectal cancer patients who underwent curative intent surgery between 2006 and 2021 at the University of Tokyo Hospital., Results: Sixty-nine patients who underwent multivisceral resection were analyzed. Thirty-three patients underwent MIS (the MIS group), while 36 underwent open surgery (the open group). Twenty-three patients were matched to each group. Conversion was required in 2 patients who underwent MIS (8.7%). R0 resection was achieved in 87.0% and 91.3% of patients in the MIS and open groups, respectively. The MIS group had significantly less blood loss (170 vs. 1130 mL; p < 0.0001), fewer Clavien-Dindo grade ≥ 2 postoperative complications (30.4% vs. 65.2%; p = 0.0170), and a shorter postoperative hospital stay (20 vs. 26 days; p = 0.0269) than the open group. The 3-year cancer-specific survival rate, relapse-free survival rate, and cumulative incidence of local recurrence were 75.7, 35.9, and 13.9%, respectively, in the MIS group and 84.5, 45.4, and 27.1%, respectively, in the open group, which were not significantly different (p = 0.8462, 0.4344, and 0.2976, respectively)., Conclusion: MIS had several short-term advantages over open surgery, such as lower complication rates, faster recovery, and a shorter hospital stay, in rectal cancer patients who underwent multivisceral resection., (© 2024. The Author(s).)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Aim: As multidisciplinary treatment strategies for colorectal cancer have improved, aggressive surgical resection has become commonplace. Multivisceral and extended resections offer curative-intent resection with significant survival benefit. However, limited data exist regarding the feasibility and oncological efficacy of performing extended resection via a minimally invasive approach. The aim of this study was to determine the perioperative and long-term outcomes following robotic extended resection for colorectal cancer., Method: We describe the population of patients undergoing robotic multivisceral resection for colorectal cancer at our single institution. We evaluated perioperative details and investigated short- and long-term outcomes, using the Kaplan-Meier method to analyse overall and recurrence-free survival., Results: Among the 86 patients most tumours were T3 (47%) or T4 (47%) lesions in the rectum (78%). Most resections involved the anterior compartment (72%): bladder (n = 13), seminal vesicle/vas deferens (n = 27), ureter (n = 6), prostate (n = 15) and uterus/vagina/adnexa (n = 27). Three cases required conversion to open surgery; 10 patients had grade 3 complications. The median hospital stay was 4 days. Resections were R0 (>1 mm) in 78 and R1 (0 to ≤1 mm) in 8, with none being R2. The average nodal yield was 26 and 48 (55.8%) were pN0. Three-year overall survival was 88% and median progression-free survival was 19.4 months. Local recurrence was 6.1% and distant recurrence was 26.1% at 3 years., Conclusion: Performance of multivisceral and extended resection on the robotic platform allows patients the benefit of minimally invasive surgery while achieving oncologically sound resection of colorectal cancer., (© 2024 Association of Coloproctology of Great Britain and Ireland.)

Background: In surgical advancements, robot-assisted surgery (RAS) holds several promises like shorter hospital stays, reduced complications, and improved technical capabilities over standard care. Despite extensive evidence, the actual patient benefits of RAS remain unclear. Thus, our systematic review aimed to assess the effectiveness and safety of RAS in visceral and thoracic surgery compared to laparoscopic or open surgery., Methods: We performed a systematic literature search in two databases (Medline via Ovid and The Cochrane Library) in April 2023. The search was restricted to 14 predefined thoracic and visceral procedures and randomized controlled trials (RCTs). Synthesis of data on critical outcomes followed the Grading of Recommendations, Assessment, Development, and Evaluation methodology, and the risk of bias was evaluated using the Cochrane Collaboration's Tool Version 1., Results: For five out of 14 procedures, no evidence could be identified. A total of 20 RCTs and five follow-up publications met the inclusion criteria. Overall, most studies had either not reported or measured patient-relevant endpoints. The majority of outcomes showed comparable results between study groups. However, RAS demonstrated potential advantages in specific endpoints (e.g., blood loss), yet these findings relied on a limited number of low-quality studies. Statistically significant RAS benefits were also noted in some outcomes for certain indications-recurrence, quality of life, transfusions, and hospitalisation. Safety outcomes were improved for patients undergoing robot-assisted gastrectomy, as well as rectal and liver resection. Regarding operation time, results were contradicting., Conclusion: In summary, conclusive assertions on RAS superiority are impeded by inconsistent and insufficient low-quality evidence across various outcomes and procedures. While RAS may offer potential advantages in some surgical areas, healthcare decisions should also take into account the limited quality of evidence, financial implications, and environmental factors. Furthermore, considerations should extend to the ergonomic aspects for maintaining a healthy surgical environment., (© 2024. The Author(s).)

Background: Liposuction is among the most popular esthetic procedures worldwide. With growing demand and popularity, reports of serious complications accumulate. Despite being a rare complication of the procedure, visceral perforation is associated with morbidity and severe debilitation., Methods: The authors conducted a literature search for reported cases of perforation of abdominal viscera following liposuction procedures in the electronic databases of PubMed, Scopus and Cochrane Library databases., Results: The authors found 22 publications; 19 cases case reports and three studies, reporting a total of 49 cases of visceral perforation following abdominal liposuction procedures. Average age of patients was 50 years (range 24-72). Twenty-seven patients (73%) were female, and 10 were male (27%). Forty (81%) patients underwent isolated liposuction, and nine (19%) had multiple procedures carried out in a single surgery. Twenty patients (42%) had undergone previous abdominal surgery, 13 (27%) suffered abdominal wall weakness or deformities, and 7 (14%) suffered from obesity. 25 (52%) ileal perforations occurred, 6 jejunal (12.5%), 5 colic (10%) and 2 (4%) each of splenic and hepatic. Seven patients (14%) died during their hospitalization, 20 (41%) were discharged with no sequelae complications, and 22 (45%) developed complications after discharge., Conclusions: Liposuction is a popular esthetic procedure that underwent numerous changes over the past century since its introduction. Despite its widely accepted reputation of a safe procedure with minimal complications, a growing number of reports on visceral perforation following liposuction have emerged. Scrupulous pre-operative evaluation and high index of suspicion are crucial for avoiding complications and unfavorable outcomes., Level of Evidence Iii: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Purpose: Visceral and renal artery aneurysms (VAA, RAA) are very rare pathologies. Both surgical and endovascular therapies are discussed as therapeutic options for ruptured and non-ruptured aneurysm repair; we describe our experience in the open and endovascular management of these entities., Methods: Retrospective database analysis of 60 treated VAA and RAA in 59 patients between 1994 and 2020. Outcome data was descriptively analyzed., Results: Thirty-seven aneurysms were surgically treated and 23 interventionally. In the total study cohort, we observed a mortality of 1.7% and a morbidity of 18.6%. One major complication occurred. The morbidity was higher after surgical repair in ruptured and non-ruptured cases. The mean aneurysm diameter was 30.5 ± 15.6 mm. Patients with hepatic or pancreaticoduodenal artery aneurysms presented more often in the stage of rupture, without differences in aneurysm size. The length of hospital stay after endovascular repair was significantly shorter compared to open surgical treatment (7.2 ± 6.9 days versus 11.8 ± 6.7 days, p = 0.014), but only in elective cases. Primary technical success was significantly better in patients that underwent surgical repair in an intention to treat analysis (100% versus 79.3%). The mean follow-up of the cohort was 53.5 months (range 3-207 months)., Conclusion: Elective endovascular therapy and open surgery of VAA and RAA are safe procedures with a good periprocedural and long-term outcome. Surgical revascularization showed a better primary technical success but was associated with longer length of hospital stays.

Background: Cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is a procedure that has had encouraging results for peritoneal metastases (PM) from diverse tumour origins, but it is not exempt from high morbidity. Recently, the important role of laparoscopy in oncologic surgeries and its benefits have been evaluated for CRS + HIPEC in selected patients, which has yielded promising results. The aim of our study is to analyse the use of laparoscopy for CRS + HIPEC in patients with limited peritoneal disease., Methods: We have conducted a retrospective study from a prospective database in our tertiary referral hospital within the period of January 2009 to July 2019, which includes 825 patients who had PM from varying tumour origins. We have compared the patients treated with the laparoscopic approach (L-CRS-HIPEC) to a matched population who have undergone the open approach (O-CRS-HIPEC) and fulfil the same selection criteria. We have analysed the postoperative outcomes and survival results., Results: We have confirmed the homogeneity between the sample of the O-CRS + HIPEC (n = 42) and the L-CRS + HIPEC (n = 18) regarding preoperative and intraoperative features. The L-CRS + HIPEC group had shorter hospital stays, (median of 4 [2-10] days versus 9 [2-19] days) and reduced wait time to return to chemotherapy (median of 4 [3-7] weeks and a median of 8 [4-36] weeks) than the O-CRS + HIPEC group. No differences were found regarding the need for perioperative blood transfusion, surgery time or postoperative morbi-mortality. No early locoregional relapse occurred in the L-CRS + HIPEC group and short term disease-free survival did not differ between groups., Conclusions: Laparoscopy for CRS + HIPEC is feasible and safe in highly selected patients, with no significant differences concerning postoperative morbi-mortality or early oncological results. We have found that patients who have undergone laparoscopic operations have shorter hospital stays and that they return to adjuvant chemotherapy sooner. Further investigation is required to confirm the benefits of minimally invasive procedures for the management of PM.

Background: Compromised tissue perfusion is a significant risk factor for anastomotic leakage after intestinal resection, leading to prolonged hospitalization, risk of recurrence after oncologic resection, and reduced survival. Thus, a tool reducing the risk of leakage is highly warranted. Quantitative indocyanine green angiography (Q-ICG) is a new method that provides surgeons with an objective evaluation of tissue perfusion. In this systematic review, we aimed to determine the optimal methodology for performing Q-ICG., Method: A comprehensive search of the literature was performed following the PRISMA guidelines. The following databases were searched: PubMed, Embase, Scopus, and Cochrane. We included all clinical studies that performed Q-ICG to assess visceral perfusion during gastrointestinal surgery. Bias assessment was performed with the Newcastle Ottawa Scale., Results: A total of 1216 studies were screened, and finally, 13 studies were included. The studies found that intensity parameters (maximum intensity and relative maximum intensity) could not identify patients with anastomotic leakage. In contrast, the inflow parameters (time-to-peak, slope, and t 1/2 max) were significantly associated with anastomotic leakage. Only two studies performed intraoperative Q-ICG while the rest performed Q-ICG retrospectively based on video recordings. Studies were heterogeneous in design, Q-ICG parameters, and patient populations. No randomized studies were found, and the level of evidence was generally found to be low to moderate., Conclusion: The results, while heterogenous, all seem to point in the same direction. Fluorescence intensity parameters are unstable and do not reflect clinical endpoints. Instead, inflow parameters are resilient in a clinical setting and superior at reflecting clinical endpoints.

Background: Colorectal cancer (CRC) is common and often presents with advanced disease in Africa. Multivisceral resection (MVR) improves survival in locally advanced (T4b) CRC. The aim was to describe the management and outcomes of patients with clinical T4b CRC without metastatic disease who underwent MVR., Methods: A retrospective review of patients with T4 CRC who underwent MVR between January 2008 and December 2013., Results: Four hundred and ninety-four patients were included. Of the 158 with suspected T4 cancer, 44 had MVR, of which one was excluded due to metastases. The mean age was 64 years. The male to female ratio was 1:1. The most commonly resected extra-colorectal structure was the abdominal wall (21%). The median survival was 68 months (SD 13.9). The 5-year disease free (DFS) and overall survival (OS) were 46% and 55%, respectively. Survival of patients with colon and rectum cancer was similar. Intraoperative tumour spillage, vascular/perineural invasion, and anastomotic leakage were independent predictors of survival., Conclusion: Multivisceral resection of locally advanced (T4b) CRC is feasible in the African context. Complete resection improves survival and should be the goal., (Copyright© Authors.)

Background: A Total Retroperitoneal en bloc resection Of Multivisceral-Peritoneal packet (TROMP operation) is a no-touch isolation technique in a retroperitoneal space to resect the parietal peritoneum and the affected organs in advanced ovarian cancer. The study prescribed and analysed the results of this novel technique for primary cytoreductive surgery., Methods: The study included 208 patients operated between January 2015 and December 2017 in Charité, Berlin. The TROMP operation was performed in 58 patients, whereas the other 150 patients were operated with the conventional cytoreductive method., Results: The complete tumor resection rate accounts for 87.9% in TROMP group and 61.3% in the conventional surgery group. (p=0.001). This difference was even stronger in the sub-group of very advanced stages (T3c+T4) (85.1% of TROMP group and in only 53.1% in the conventional surgery group, p=0.001). The duration of the primary cytoreductive surgery was about 33 minutes shorter in TROMP group (median: 335 minutes vs 368 minutes; TROMP vs conventional, respectively) in spite of the fact that the most advanced cytoreductive procedures were performed statically significant more in TROMP operation arm in comparison with the conventional surgery arm. There was no statistically significant difference between the groups regarding the postoperative complication, blood loss or the length of stay in intensive care unit., Conclusion: Total retroperitoneal en bloc resection of multivisceral-peritoneal packet (TROMP operation) is a feasible and very effective technique of surgical therapy in advanced ovarian cancer. This technique increased the complete tumor resection rate to 87.9% without increasing the blood loss, postoperative complications or the duration of surgery. A prospective randomized study is advised to validate these results., Competing Interests: Competing interests: M-ZM is an adviser for Stryker. In the last 2 years he has received honoraria from Olympus, Ethicon (Johnson & Johnson), Roche and AstraZeneca. JS has received honoraria from AstraZeneca, Eisai, Clovis, Olympus, Johnson & Johnson, PharmaMar, Pfizer, TEVA, TESARO, and MSD, and performs advisory roles for AstraZeneca, Clovis, Lilly, PharmaMar, Pfizer, Roche, TESARO, and MSD. He has received research funding (not for this study) from AstraZeneca, Clovis, Merck, Bayer, PharmaMar, Pfizer, TESARO, and MSD. He has disclosed travel, accommodation, and other expenses paid or reimbursed by AstraZeneca, Clovis, PharmaMar, Roche, Pfizer, TESARO, and MSD, and were part of his scientific activities in the last 2 years. AM, RR and JM have no conflicts of interest., (© IGCS and ESGO 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

The objective of this study is to analyze noise patterns during 599 visceral surgical procedures. Considering work-safety regulations, we will identify immanent noise patterns during major visceral surgeries. Increased levels of noise are known to have negative health impacts. Based on a very fine-grained data collection over a year, this study will introduce a new procedure for visual representation of intra-surgery noise progression and pave new paths for future research on noise reduction in visceral surgery. Digital decibel sound-level meters were used to record the total noise in three operating theatres in one-second cycles over a year. These data were matched to archival data on surgery characteristics. Because surgeries inherently vary in length, we developed a new procedure to normalize surgery times to run cross-surgery comparisons. Based on this procedure, dBA values were adjusted to each normalized time point. Noise-level patterns are presented for surgeries contingent on important surgery characteristics: 16 different surgery types, operation method, day/night time point and operation complexity (complexity levels 1-3). This serves to cover a wide spectrum of day-to-day surgeries. The noise patterns reveal significant sound level differences of about 1 dBA, with the most-common noise level being spread between 55 and 60 dBA. This indicates a sound situation in many of the surgeries studied likely to cause stress in patients and staff. Absolute and relative risks of meeting or exceeding 60 dBA differ considerably across operation types. In conclusion, the study reveals that maximum noise levels of 55 dBA are frequently exceeded during visceral surgical procedures. Especially complex surgeries show, on average, a higher noise exposure. Our findings warrant active noise management for visceral surgery to reduce potential negative impacts of noise on surgical performance and outcome.

Study Objective: To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically., Design: Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration., Setting: Tertiary care academic center., Patients: A patient undergoing pelvic exenteration for uterine leiomyosarcoma., Interventions: Robotic total supralevator pelvic exenteration., Measurements and Main Results: In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL., Conclusion: Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks., (Copyright © 2019. Published by Elsevier Inc.)

Recent developments in the field of augmented reality (AR) have enabled new use cases in surgery. Initial set-up of an appropriate infrastructure for maintaining an AR surgical workflow requires investment in appropriate hardware. We compared the usability of the Microsoft HoloLens and Meta 2 head mounted displays (HMDs). Fifteen medicine students tested each device and were questioned with a variant of the System Usability Scale (SUS). Two surgeons independently tested the devices in an intraoperative setting. In our adapted SUS, ergonomics, ease of use, and visual clarity of the display did not differ significantly between HMD groups. The field of view (FOV) was smaller in the Microsoft HoloLens than the Meta 2 and significantly more study subjects (80% vs. 13.3%; P < 0.001) felt limited through the FOV. Intraoperatively, decreased mobility due to the necessity of an AC adapter and additional computing device for the Meta 2 proved to be limiting. Object stability was rated superior in the Microsoft HoloLens than the Meta 2 by our surgeons and lead to increased use. In summary, after examination of the Meta 2 and the Microsoft HoloLens, we found key advantages in the Microsoft HoloLens which provided palpable benefits in a surgical setting., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Introduction: The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited., Materials and Methods: We reviewed our experience of 244 consecutive patients with established indications for laparotomy over an eight year period at a major trauma centre in South Africa., Results: Of the 244 patients (93% male, mean age: 27 years), 224 (92) underwent immediate laparotomy (IL). Twenty were initially observed and eventually required a laparotomy (delayed laparotomy, DL). The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), <6 h in 6% (14/244), <12 h 2% (4/244) and <18 h in 1% (2/244). Ninety-eight per cent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. The mostly commonly injured organ encountered on laparotomy were small bowel, stomach and colon., Conclusions: The most commonly injures encountered are intestinal and gastric. Clinicians must remain vigilant as injuries may be subtle., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited., Materials and Methods: We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa., Results: Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%., Conclusions: The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Several changes introduced in the management of trauma during the last two decades have considerably decreased the practical exposure to bleeding trauma patients by residents and young surgeons. Hemorrhage still represents the second cause of death from trauma worldwide, and the surgical maneuvers required for its control must be learned and practised in specific courses. These courses address the "second hour" of trauma, beyond ATLS © , and also emphasize the decision-making process, communication among team members, and discussion of clinical scenarios. The significant progress made in simulation technologies and virtual reality systems have yet to replace living tissue models to train surgeons in the rapid control of active bleeding, although that replacement is probably not far away., (Copyright © 2018 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: For pancreatic tumors located in the body or tail of the pancreas, distal pancreatectomy (DP) remains the surgical procedure of choice to achieve radical tumor removal. Purpose of this study was to evaluate outcome and overall survival of patients who underwent DP combined with multivisceral resection (MVR)., Methods: Retrospective single-center case-matched analysis. Between January 1994 and June 2014, 494 consecutive patients were entered into a prospective database, and 126 patients undergoing DP + MVR (cases) were matched with 126 patients undergoing DP (controls) for gender, age, and underlying final diagnosis., Results: There were no significant differences in patient demographics. Rates of postoperative pancreatic fistula (POPF) (36 (28.6%) vs. 29 (23.0%); p = 0.388) and postpancreatectomy hemorrhage (PPH) (7 (5.5%) vs. 5 (3.9%); p = 0.769) did not reveal any significant differences. Although operative time (237.8 ± 57.9 vs. 203.5 ± 34.5; p < 0.001) and the necessity for intraoperative transfusions (18 (14.3%) vs. 5 (4.0%); p < 0.001) was significantly higher, the number of patients with major complications (the Clavien-Dindo ≥ 3) was not increased (27 (19.8%) vs. 20 (15.9%); p = 0.332) in the DP + MVR group. Midterm survival analysis indicated no significant difference for adenocarcinoma and neuroendocrine tumors for either group., Conclusion: DP + MVR is a feasible and safe surgical procedure to achieve radical tumor removal and can offer beneficial survival outcomes. Although operative time and intraoperative transfusions are enhanced, POPF, PPH, or major complications (the Clavien-Dindo ≥ 3) are not significantly increased after DP + MVR. DP + MVR can therefore be recommended in selected patients for resection of extended tumors within the concept of interdisciplinary strategies.

Introduction: Intrahepatic cholangiocarcinoma (ICC) is a rare malignancy, and therefore large unicenter series on the surgical outcome are rare in the literature, and prognostic factors for overall survival in the literature vary widely., Methods: All patients who underwent surgery for ICC were prospectively recorded. The type of resection, operative details, histological results, morbidity, mortality, overall and recurrence-free survivals as well as prognostic factors were assessed. Prognostic factors were examined by univariate and multivariate analyses. P-values <0.05 were considered significant., Results: Between January 2008 and December 2015, 102 patients underwent a resection with curative intent and were included in this analysis. Major and extended hepatectomies were performed in 19 and 53 cases, respectively. Twenty-eight patients had additional vascular and 35 patients additional visceral resections. R0-resections were achieved in 87 patients (85.3%). Median recurrence-free and overall survivals were 9.3 and 20.8 months, respectively. N-stage, infiltration of surrounding structures and UICC stage were significant prognostic factors in the univariate analysis. Multivariate analysis depicted only visceral infiltration (p = 0.011) as independent predictor for overall survival, and tumor size (p < 0.001), N-stage (p = 0.007), R-stage (p = 0.008) and M-stage (p = 0.009) for recurrence-free survival., Conclusion: An aggressive surgical approach achieves a high rate of R0 resections even in advanced ICC. Visceral infiltration is an independent predictor for overall survival for ICC after curative resection., (Copyright © 2018 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Regionalization of complex visceral surgery across the US has followed identification of a volume to outcomes association. However, a simultaneous trend toward improved surgical outcomes might have attenuated this relationship. We hypothesize that the difference in adjusted postoperative mortality between low- (LV), medium- (MV), and high-volume (HV) hospitals has decreased over time., Study Design: The National Inpatient Sample (NIS) was used to identify patients undergoing bladder, esophageal, pancreatic, liver, lung, and rectal surgery from 2003 to 2011. Hospitals were divided into LV (<33 rd centile), MV (34 th to 66 th ), and HV (>67 th centile) groups. Annual organ-specific adjusted in-hospital mortality (AIHM) for each volume strata was calculated and the difference in AIHM between volume strata was plotted over time., Results: The proportion of hospitals classified as HV was 6% for lung; 5% for rectal; 3% for esophageal, pancreatic, and bladder; and 2% for liver surgery patients. The AIHM after operation was higher in LV compared with HV hospitals in 2003 to 2005 for all visceral resections except liver surgery. The difference in AIHM between LV, MV, and HV hospitals showed a decreasing trend from 2003 to 2005 to 2009 to 2011 for pancreatic, esophageal, bladder, and lung surgery. For patients undergoing rectal resections, the difference in AIHM was low and stable, and increased for liver resections only., Conclusions: A reduction in the differences in AIHM among LV, MV, and HV hospitals for 5 of 6 organs studied suggests attenuation of the volume to outcomes relationship with time. This is likely due to system-wide improvements in surgical care., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Protease-activated receptor 4 (PAR4) is implicated in the inhibition of visceral hyperalgesia. In the present study, the effects of PAR4 activation on visceral hypersensitivity and expression of inflammatory mediators, including interleukin-1 β (IL-1 β ), P2RX7 purinergic receptor (P2X7), inducible nitric oxide synthase (iNOS), and tryptase, in mast cells (MCs) were investigated via in vivo and in vitro studies. The numbers of tryptase-positive MCs with extensive PAR4, P2X7, and iNOS expression were increased in the colons of visceral hyperalgesia rats compared with controls. Intracolonic administration of PAR4-activating peptide (PAR4-AP) significantly attenuated the visceral hypersensitivity to colorectal distention and reduced the iNOS, IL-1 β , P2X7, and tryptase protein and mRNA levels in the colonic mucosa. Treatment of rat bone marrow MCs (BMMCs) with PAR4-AP also reduced the iNOS, IL-1 β , P2X7, and tryptase protein and mRNA levels. ERK1/2 and p38 activators (t-butylhydroquinone, tBHQ, and U-46619) reversed the suppressive effect of PAR4 activation on IL-1 β and iNOS expression, whereas ERK1/2 and p38 inhibitors (PD98059 and SB203580) reversed the suppressive effect of PAR4 activation on P2X7 and tryptase expression. Our results indicate that the downregulation of inflammatory mediators, including iNOS, IL-1 β , P2X7, and tryptase, in MCs that are mediated by PAR4 activation could inhibit visceral hyperalgesia via the mitogen-activated protein kinase (MAPK) signal pathway.

Introduction: Multivisceral resection is occasionally needed to obtain clear margins in patients with transmural rectal cancer. Most series demonstrate equivalent outcomes between those patients who undergo multivisceral resections and those who do not, provided an R0-resection is achieved. This study focuses solely on patients who received neoadjuvant treatment for clinically transmural rectal cancers and underwent a local multivisceral R0-resection., Methods: A retrospective, single center analysis of consecutive series of patients who received a surgical R0-resection after neoadjuvant treatment for a clinically transmural, non-metastatic, primary rectal cancer. All patients were operated on between 2004 and 2015., Results: A total of 279 patients was included, of whom 29 patients underwent a local multivisceral R0-resection (LMVR). These patients were more often female and less often diagnosed through screening. Pathologic AJCC-staging was significantly lower for non-LMVR patients, with more favorable tumor characteristics. LMVR patients demonstrated higher rates of distant disease recurrence, and impaired survival, even after adjusting for disease stage., Conclusion: An R0-resection after neoadjuvant therapy led to comparative local control of disease; however, patients with multivisceral resection had more distant recurrence and impaired survival, compared to those did not undergo a multivisceral resection. Further research should determine optimal postoperative care., (© 2017 Wiley Periodicals, Inc.)

Introduction: Although multi-organ resections (MOR) are recommended by international guidelines for advanced colorectal cancer, the literature shows that the morbidity and mortality that accompanies these complex interventions limits the number of patients receiving this treatment. The purpose of our study was to analyse the immediate and remote results obtained after MOR and to identify potential factors that might influence the outcome., Material and Method: Our study is a retrospective cohort which included patients surgically treated in our service for locally advanced colorectal cancer. We excluded patients with hepatic metastatic tumors and those who needed pelvic exenteration. Between 2006 and 2010, in our service, have been treated with MOR 146 patients, 107 being included in our study. We analysed morbidity, mortality and survival after MOR and the factors that could have influenced the postoperative course., Results: Identified risk factors that negatively influenced the postoperative outcome were: diabetes, personal neoplastic pathologies, associated cardiovascular disease, history of major surgeries, intraoperative blood loss, number of resected organs. Survival was negatively influenced by positive resection margins, the presence of lymph node metastases and the presence of complications in the postoperative period., Conclusions: The data of this study support the indication for routine MOR for patients diagnosed with locally advanced colorectal cancer with the condition that R0 resection margins are achieved. All mentioned above underline the importance of the experience that the surgical team has in this type of surgeries, in order to achieve optimum results. This experience must concern the preoperative management, surgical technique and postoperative care., Key Words: Colo-rectal cancer, Multi-organ resections, Risk factors.

Background: Multivisceral resections combined with pancreatectomy have been proposed in selected patients with tumor invasion into adjacent organs, in order to allow complete tumor resection. Some authors have also reported multivisceral resection combined with metastasectomy in very selected cases. The utility of this practice is debated. The aim of the review is to compare the postoperative results and survival of pancreatectomies combined with multivisceral resections with those of standard pancreatectomies., Methods: A systematic literature search was performed to identify all studies published up to February 2017 that analyzed data of patients undergoing multivisceral and standard pancreatectomies. Clinical effectiveness was synthetized through a narrative review with full tabulation of results., Results: Three studies were retrieved, including 713 (80%) patients undergoing standard pancreatectomies and 176 (20%) undergoing multivisceral resections (MVR). Postoperative morbidity ranged from 37% to 50% after standard resections and from 56% to 69% after MVR. In-hospital mortality ranged from 4% after standard pancreatectomies to 10% after MVR. Median survival ranged from 20 to 23 months in standard resections and from 12 to 20 months after MVR, without significant differences., Discussion: The current literature suggests that multivisceral pancreatectomies are feasible and may increase the number of completely resected patients. Morbidity and mortality are higher than after standard pancreatectomies, and these procedures should be reserved to selected patients in referral centers. Further studies on the role of neoadjuvant therapy in this setting are advisable., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background Cut-throat competition, cost pressure, generation Y, shortage of qualified staff and feminisation influence human resources management in visceral surgery. The assessment of the current situation by chief surgeons (CS) as well as proof of transferability of strategies from industry and service business (ISB) have not yet been investigated. Material and Methods The CS of university hospitals and large referral centres (> 800 beds) were interviewed (n = 100) on the basis of a standardised questionnaire including 43 items. Closed questions were designed with a 5-point Likert scale and their analysis was presented as means (MW) and standard deviations (±). Ten human resources manager (HMR) of ISB were invited to participate in 45-minute telephone interviews. Results Thirty-seven CS participated in the survey, 15 of whom were full professors. Unsolicited applications (100%), job advertisements (78%) and direct approaches to final year students (78%) were the most common ways of recruitment. Only 17% of CS used a standardised form for preparation. Professional expertise (MW 2.2 ± 0.9), social skills (MW 1.9 ± 0.6) and excellent German language skills (MW 1.8 ± 0.8) were named as important qualifications for employment, while references and certificates were regarded as being less important (MW 3.2 ± 0.9). Personal development was regarded as important (MW 1.1 ± 0.2), but a defined period for residency was not guaranteed (MW 3.0 ± 1.5). Transparent selection criteria for career opportunities (MW 2.5 ± 1.1) and different career models (MW 2.7 ± 1.2) were only rarely available. Six HRM participated in the interviews. Active head-hunting (75%), Internet platforms (75%), presentations at conferences (75%), as well as hiring trainees (50%), job advertisements (50%) and social media (50%) were established options to find qualified employees. Professional and management careers were often separate career paths, while social expertise was regarded as being crucial for filling management positions. Conclusion In visceral surgery, unsolicited applications, job advertisements and direct approaches to final year students are the most common ways for recruitment. Diversified professional and management careers are not yet established. Recruiting strategies that are successful in ISB - such as active scouting and use of social media - should be evaluated for visceral surgery, as well as diversified career models., Competing Interests: Interessenkonflikt: Nein., (Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Interessenkonflikt: Zusammenarbeit mit der Firma BBraun-Aesculap im Rahmen der Short Stitch Studie.

Background: The prognosis and survival of patients with advanced gastric cancer is poor. Although completeness of resection (R0) is one of the most important factors affecting survival, multivisceral resection (MVR) for locally advanced (clinical T4b, cT4b) gastric cancer remains controversial. The aim of this study was to evaluate the factors affecting prognosis and survival after MVR in patients with cT4b gastric cancer., Methods: Between 2005 and 2015, we retrospectively reviewed the medical records of 103 patients who underwent MVR for cT4b gastric cancer with suspected direct invasion to adjacent organs. Patient characteristics, related complications, long-term survival, and prognostic factors of cT4b gastric cancer were analyzed., Results: Postoperative mortality and morbidity rates of patients after MVR were 1.0 and 37.9%, respectively. R0 resection was achieved in 82.5% patients, all of whom had a significantly improved survival rate. Overall survival rates at 1 and 3 years were 78.3 and 47.7% for R0 resection and 46.6 and 14.3% for R1 resection, respectively (R0 vs. R1, P < 0.002). Multivariate analysis revealed that completeness of resection (R0) was an independent prognostic factor associated with longer survival., Conclusions: In patients with cT4b gastric cancer, gastrectomy with MVR to achieve an R0 resection can be performed with acceptable postoperative morbidity and mortality rates and can have a positive impact on long-term survival.

From a sociopolitical aspect there is increasing interest in the quality of healthcare. In this context valid, reproducible, comparable and risk-adjustable markers that are easily identified have become crucial for consistent documentation of quality. We recommend MTL30 (mortality, transfer, length of stay) as one of these markers to consistently measure the quality of large visceral surgical interventions. The MTL30 subsumes a number of known markers that may help to predict postoperative complications. The MTL30 is considered to be fulfilled when a patient on the 30th day following surgery, a) has died b) is still in the hospital or c) has been transferred to another acute care hospital. The evaluation of the StuDoQ register of the German Society for General and Visceral Surgery (DGAV) shows that MTL30 occurs significantly more often than any of the individual parameters. The correlation between MTL30 and other patient-specific risk factors, e.g. American Society of Anesthesiologists classification (ASA), age, etc. enables a risk adjustment.

Vaginal evisceration of the small bowel is a rare and potentially life-threatening complication after hysterectomy. This complication requires prompt surgical management and methods of surgical repair include abdominal, vaginal or laparoscopic approaches. We report the first case of robotic approach for repair of vaginal evisceration and intraoperative use of near-infrared fluorescence imaging for the assessment of bowel perfusion in a 63-year-old postmenopausal woman with a history of robotic hysterectomy for cervix cancer. This case demonstrates the safety and feasibility of robotic surgery and the advantage of using intraoperative near-infrared fluorescence imaging for bowel perfusion, a critical factor for surgical decision-making.

Background: Multivisceral resection (MVR) is considered a radical operation with many surgeons only using it as a last resort. However, when locally advanced colorectal cancers invade adjacent organs, MVR is an important consideration for select patients. The current study addresses the outcomes of MVR in locally advanced recto-sigmoid cancer patients subsequent to these recommendations and hypothesizes that MVR yields improved survival., Method: SEER data (1988-2008) was used to identify all eligible patients with MVR. Patients were limited to single primary locally advanced non-metastatic colorectal cancers originating from the sigmoid and rectum., Results: A total of 4111 locally advanced non-metastatic recto sigmoid cancer patients were included in the study. Cox regression analysis showed variables predictive of MVR were female (OR = 1.95) and late year period (OR = 1.90). Kaplan Meier analysis showed that five-year survival was highest for MVR (52.7%, 48 months), followed by standard surgery (SS; 38.9%, 32 months) and no surgery (NS; 16.6%, 12 months, P < 0.001). With radiation treatment, five year survival improved for all groups, with the highest being MVR (57%, 52 months). With no radiation treatment, five year survival decreased for all groups, with the highest being MVR (45.1%, 44 months), followed by SS (27.3%, 19 months), and NS (8.7%, 6 months, P < 0.001)., Conclusion: The present study supports that MVR offers greater survival advantage in patients with locally advanced colorectal cancer. MVR are extensive surgical procedures with significant associated morbidity that usually require specialized training and sometimes the coordination of multiple surgical specialists., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Abdominoperineal Resection (APR) remains an important option for patients with advanced rectal cancer though some may require multivisceral resection (MVR) in addition to APR. We hypothesized that oncological outcomes would be worse with MVR., Methods: A retrospective review from 2006 to 2015 of 161 patients undergoing APR or MVR for rectal cancer, of whom 118 underwent curative APR or APR with MVR. Perioperative, oncologic and survival metrics were evaluated., Results: There were 82 patients who underwent APR and 36 who underwent MVR. Surgical approach and incidence of complications were similar (All P > 0.05). There was 1 local recurrence in each of the APR and MVR groups at a mean follow-up of 34 and 32 months, respectively. Distant recurrences occurred in 3 APR patients and 4 MVR patients., Conclusions: APR and APR with MVR can be performed with comparable morbidity and oncologic outcomes., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Tumors arising in the body/tail of the pancreas tend to be diagnosed at a more advanced stage, with a lower rate of resectability compared to disease of the head. Distal pancreatectomy (DP) associated to multivisceral resections (MVR) can represent a surgical option for selected patients with advanced tumors., Methods: We retrospectively analyzed data of patients who underwent DP associated with MVR at our Institution over a 9-year period, and compared them to standard DP. MVR was defined as resection of at least one additional organ or vascular structure because of neoplastic involvement., Results: Out of 508 DP, in 59 cases MVR was performed. The absolute incidence of complications was comparable between the two groups (69.5 % in MVR arm vs. 57.2 % in control arm, p = 0.072) but more patients in the study group had a Clavien-Dindo class ≥3 (18.6 vs. 9.8 %, p = 0.04). A longer operative time (291 ± 91 vs. 227 ± 67, p < 0.001), an increased need for intraoperative transfusions (21.4 vs. 3.3 %, p < 0.001) and a slightly longer hospitalization (9 [7-16] days vs. 8 [7-10]; p < 0.001) were observed in the MVR group. In patients with ductal adenocarcinoma (n = 118), mortality was comparable between groups (p = 0.44) over a median follow up of 26 [16-41] months. In contrast, among patients with neuroendocrine neoplasms, mortality was higher in the study group (p = 0.002)., Conclusion: Multivisceral resection for cancer of body and tail of the pancreas is feasible in selected cases, with an acceptable surgical complication rate compared to standard procedures and a favorable long-term survival in ductal cancer.

Introduction: Laparoscopic (Lap) surgery has not been established as a standard procedure for locally advanced colon cancers. Here, we evaluated the safety and feasibility of Lap multivisceral resection (MVR) for tumors that had invaded adjacent organs (T4b)., Methods: We performed retrospective analyses using a single institutional database. Eighty-four patients who underwent Lap or open MVR for surgical T4b primary colon cancers satisfied the inclusion criteria., Results: Among the 84 patients, 48 underwent Lap MVR and 36 underwent open MVR. More patients in the open group were clinical T4b and were receiving neoadjuvant chemotherapy. Patients in the open group had worse performance status (P = 0.037) and tumors of greater diameter. Lap completion was achieved in 42 cases (87.5%); the conversion rate was highest in cases involving the urinary tract (40.0%). Lap reconstruction of the bladder or ureter was extremely challenging, and therefore, adjacent organ reconstruction influenced Lap completion. Regarding perioperative outcomes, Lap was superior to open surgery in terms of intraoperative blood loss, morbidity, and postoperative hospital stay. Conversion was required in six cases; five were strategic conversions, and conversion was not associated with severe morbidity. The microscopic positive surgical margin rate was not higher in the Lap group than in the open group. Kaplan-Meier analyses of overall and disease-free survival were comparable between the groups. Cox regression analyses revealed that the operative approach did not have a significant adverse effect on long-term outcomes., Conclusion: The Lap approach could be considered for surgical T4b cancers, except for urinary tract invasion cases that require complicated reconstruction., (© 2017 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

Objectives:: This study sought to determine the clinical and pathological factors associated with perioperative morbidity, mortality and oncological outcomes after multivisceral en bloc resection in patients with colorectal cancer., Methods:: Between January 2009 and February 2014, 105 patients with primary colorectal cancer selected for multivisceral resection were identified from a prospective database. Clinical and pathological factors, perioperative morbidity and mortality and outcomes were obtained from medical records. Estimated local recurrence and overall survival were compared using the log-rank method, and Cox regression analysis was used to determine the independence of the studied parameters. ClinicalTrials.gov: NCT02859155., Results:: The median age of the patients was 60 (range 23-86) years, 66.7% were female, 80% of tumors were located in the rectum, 11.4% had stage-IV disease, and 54.3% received neoadjuvant chemoradiotherapy. The organs most frequently resected were ovaries and annexes (37%). Additionally, 30.5% of patients received abdominoperineal resection. Invasion of other organs was confirmed histologically in 53.5% of patients, and R0 resection was obtained in 72% of patients. The overall morbidity rate of patients in this study was 37.1%. Ureter resection and intraoperative blood transfusion were independently associated with an increased number of complications. The 30-day postoperative mortality rate was 1.9%. After 27 (range 5-57) months of follow-up, the mortality and local recurrence rates were 23% and 15%, respectively. Positive margins were associated with a higher recurrence rate. Positive margins, lymph node involvement, stage III/IV disease, and stage IV disease alone were associated with lower overall survival rates. On multivariate analysis, the only factor associated with reduced survival was lymph node involvement., Conclusions:: Multivisceral en bloc resection for primary colorectal cancer can be performed with acceptable rates of morbidity and mortality and may lead to favorable oncological outcomes.

Objective: To investigate the effect of peritonization at cesarean section on postoperative vital signs which was thought to be an indirect finding secondary to increased sympathetic activity originated from pain caused by stretched peritoneum., Methods: One hundred and thirty-three pregnant women were randomized to four groups; Closure of parietal peritoneum only (group 1; n = 32), closure of visceral and parietal peritoneums (group 2; n = 32), no closure of peritoneums (group 3; n = 32) and closure of the visceral peritoneum only (group 4; n = 32). All participants were monitored for blood pressure, pulse activity and hourly urinary output during the first postoperative 24 h. Postoperative pain was measured using a Visual Analogue Scale 6th and 24th hours after surgery. Return of bowel function was measured from the end of the operation to the first passage of flatus. Operating time, pre- and postoperative hemoglobin, postoperative complications, length of hospital stay and postoperative urine osmolarity were noted., Results: The mean surgery duration was significantly longer in group 2. Diuresis was found significantly decreased in group 2. Pulse rate and systolic and diastolic blood pressure were significantly higher in group 2. Closure of both peritoneums was associated with higher post-operative pain as assessed using Visual analogue scale score analyses in group 2., Conclusion: Both visceral and parietal membrane closure in cesarean section should be avoided in women with hypertensive disorders, renal function abnormalities and autonomic dysfunction because of increased postoperative pain and associated sympathetic overactivity.

Background: Enhanced recovery after surgery (ERAS) programs are aimed at minimizing postoperative stress and accelerating postoperative recovery by implementing multiple perioperative principles. "Early mobilization" is one such principle, but the quality of assessment and monitoring is poor, and evidence of improved outcome is lacking. Activity trackers allow precise monitoring and automatic feedback to the patients to enhance their motivation for early mobilization. The aim of the study is to monitor and increase the postoperative mobilization of patients by giving them continuous automatic feedback in the form of a step count using activity-tracking wristbands., Methods/design: Patients undergoing elective open and laparoscopic surgery of the colon, rectum, stomach, pancreas, and liver for any indication will be included. Further inclusion criteria are age between 18 and 75 years, American Society of Anesthesiologists Physical Status class less than IV, and a signed informed consent form. Patients will be stratified into two subgroups, laparoscopic and open surgery, and will be randomized 1:1 for automatic feedback of their step count using an activity tracker wristband. The control group will have no automatic feedback. The sample size (n = 30 patients in each of the four groups, overall n = 120) is calculated on the basis of an assumed difference in step count of 250 steps daily (intervention group versus control group). The primary study endpoint is the average step count during the first 5 postoperative days; secondary endpoints are the percentage of patients in the two groups who master the predefined mobilization (step count) targets, assessment of additional activity data obtained from the devices, assessment of preoperative mobility, length of hospital and intensive care unit stays, number of patients who receive physiotherapy, 30-day mortality, and overall 30-day morbidity., Discussion: Early mobilization is a key element of ERAS. However, enhanced early mobilization is difficult to define, to assess objectively, and to implement in clinical practice. Consequently, there is a discrepancy between ERAS targets and actual practice, especially in patients undergoing major visceral surgery. This study is the first randomized controlled trial investigating the use and feasibility of activity tracking to monitor and enhance postoperative early mobilization., Trial Registration: ClinicalTrials.gov identifier: NCT02834338 . Registered on 15 June 2016.

In the last few years robotic surgery has progressed from being confined to a small niche to a widespread application in routine visceral surgery; however, evidence for superiority of robotic surgery compared to laparoscopy from randomized studies with a sufficient number of patients is still lacking in most fields of visceral surgery. For complex operations that necessitate an extensive reconstruction phase, such as pancreatectomy, gastrectomy and esophagectomy, there is a potential benefit for the permanent and justified use of robotic surgery. Even in operations where delicate nerve preparation and radical surgical resection are simultaneously necessary, such as rectal resection, robotic surgery may provide certain benefits. In the long term there is a great potential for the integration of innovative techniques, such as navigation or other medical imaging procedures into robotic surgery, which can currently only partially be estimated. Care must be taken to avoid premature euphoria; however, due to the assumed great potential there is an urgent need for randomized studies to evaluate the possible benefits of robotic surgical techniques in visceral surgery in order to generate evidence for the welfare of patients.

Background: Practical operative training in the discipline of visceral surgery is currently under discussion. Aside from surveys, data on this topic in Germany are sparse. The aim of the study was an objective collation of surgical residents' practical training in the operating room in our department., Methods: All surgical cases from 2015 were prospectively included. Procedures were stratified into resident and non-resident operations and complex cases with sub-steps which could potentially be performed by residents. We analyzed whether an operation or surgical sub-steps were performed by a resident. If this was not achieved, the reasons were analyzed. An anonymous online survey was conducted among employees in the surgery department regarding surgical training., Results: Out of 2896 surgical cases 1141 (39.4 %) were classified as potential resident training operations, which were actually performed by a resident in 743 cases (65.1 %). The survey showed an underestimation of this proportion, where sub-steps were assisted in 30.3 % (n = 265) of 876 potential cases. This proportion significantly increased during the observation period (p < 0.001); however, it was highly overestimated by residents as well as fellows and senior consultants. Often organizational reasons were responsible when resident operations or sub-steps were not performed by a trainee (13.1 % and 30.0 %, respectively)., Conclusion: The monocentric analysis per se resulted in an improvement in practical surgical training. In the training environment, assisting with sub-steps provides a great potential. Multicenter studies are needed.

Background: The operation robot is the most advanced technology available in minimally invasive surgery for facilitating complex surgical procedures and is increasingly used in visceral surgery; however, to date no data are available concerning its use in visceral surgery in Germany., Objective: The aim of the survey was to document the development and current state of the art of robotics for visceral surgery in Germany., Material and Methods: All 41 surgical departments with access to the da Vinci robot were invited to participate in the survey. Data were acquired with a specially designed Excel spreadsheet, documenting all procedures and also the dignity in gastrointestinal operations for each year since inception of the robot program up to 2015., Results: Of the 41 surgical departments with an active robotic program only 23 participated in the analysis. The overall volume rose steadily from 4 procedures in 2010 to 50 in 2012, 106 in 2013, 441 in 2014 and reached 819 in 2015. In this period 2 centers had > 200 operations, 1 center had 150, 3 centers had ≥ 100, 3 departments had ≥ 50 and 14 departments had < 50 operations. The type of robotic procedures used encompassed the full scope of laparoscopic surgery. Colorectal surgery was predominant with 50 % of all procedures and was performed in 87 % of the departments. Thymus resections amounted to 10 % of all surgical procedures and gastric surgery to 9 %. Approximately 5 % of all cases involved the esophagus, gall bladder and pancreas. Hepatic surgery amounted to only 2.4 % and all other operations even less and were performed in only a few departments., Conclusion: Despite a doubling of procedures in recent years, robotics is still in the initial phase for visceral surgery in Germany.