Leberresektionen

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Leberresektionen

Ohne Zusammenfassung     

Anatomiegerechte und atypische Leberresektionen

Liver resection has evolved to an established treatment for various malignant primary and secondary hepatic tumours, some benign tumours, and other conditions. The anatomical approach, the preferred concept of the author, rests on knowledge of the intrahepatic segmentation according to the portal structure branching and the course of major hepatic veins. As most of the malignant tumours respect the corresponding intrahepatic boundaries this resectional approach offers superior tumour clearance and, probably, better long-term outcome. Besides the four standard resections along the main fissure and left intersectorial plane, respectively, there are less common sector-orientated procedures including central hepatectomies and operations along the right intersectorial plane. Segment-orientated resections are defined by additional use of the transverse boundary according to the cranially and caudally directed third-order ramification of the portal trunks. Despite the advantage of anatomical resections there are rational indications for non-anatomical procedures such as removal of small benign tumours, excision of HCC in liver cirrhosis, re-resection following major hepatectomies, an excision biopsy in a non-resectable situation, and liver trauma care. Irrespective of the resectional approach, routine use of intraoperative ultrasound, maintenance of a low central venous pressure during parenchyma transsection, intermittent hilar clamping, and ischemic preconditioning all contribute to a safe and oncologically effective operation. In the future, augmentation of the liver remnant by preoperative portal vein embolisation, and multicentre trials on multidisciplinary strategies, may help to enhance resectability and to improve both safety and long-term outcome.     

Infektionen nach Leberresektionen im Alter

From 1986 to 1995, 97 patients older than 65 years of age underwent hepatic resection at the Department of General Surgery, Hospital Lainz, Vienna. The population consisted of 39 men and 58 women with a mean age of 74±5.5 years. Primary neoplasia was the cause of resection in 35 patients, gallbladder cancer in 16 patients, and metastatic disease to the liver in 40 patients. Six patients underwent hepatic resection because of benign disease. The overall rate of major resections (≥3 liver segments) was 73% and the overall mortality was 13.5%. Sixty-five postoperative complications were recorded in 42 patients, and infection was the leading problem in nearly all of these patients (95%). The histologic type of tumor rather than the magnitude of resection had an influence on clinical mortality and morbidity. All complications occurred in patients with malignant disease (P=0.03). Adverse effects on postoperative morbidity were observed in adenocarcinoma of the hepatic ducts, gallbladder carcinoma, and cholangiocellular carcinoma (P=0.003). Intra-abdominal infections were found in 25% of our patients and were due to biliary leakage in 58%, but had no significant impact on survival. Pneumonia was the leading complication in association with patient survival. All patients who developed pneumonia as a late complication during a complicated course died postoperatively (P=0.0001). All of these patients had a reduced grade of mobilization. Severe preoperative liver dysfunction carried a significantly higher risk for postoperative morbidity and mortality (P=0.003 and 0.01), which showed an incremental risk with age >80 (P=0.002 and 0.0004). Right lobectomies and extended right lobectomies carried a significantly increased risk for postoperative morbidity (P=0.004). Infection is associated with nearly every complication recorded after hepatic resection in the elderly. Pneumonia as a late complication poses a worse prognosis in elderly patients who underwent hepatic resection. Patients older than 65 years of age and especially those older than 80 years of age are more liable to succumb to complications that are predominantly infectious. Better local drainage procedures may reduce intra-abdominal infectious complications and early mobilization of the patients may improve the rate of systemic infectious complications and final outcome.     

Inkarzerierte Hernie nach laparoskopischer Lymphozelenfensterung

Laparoscopic lymphocele drainage is considered the gold standard for the treatment of lymphoceles after kidney transplantation. We report on a female patient who developed a symptomatic posttransplant lymphocele. After laparoscopic lymphocele drainage the patient presented with acute pain in the left lower abdomen. A CT scan showed a hernia into the peritoneal window. This is a rare but potentially severe complication after intraperitoneal lymphocele drainage. CT imaging and swift reoperation with enlargement of the peritoneal window are critical to avoid serious complications. To avoid bowel incarceration, the peritoneal window should be as large as possible.     

Nekrotisierende Fasciitis nach laparoskopischer Cholecystektomie

Zusammenfassung. Die nekrotisierende Fasciitis ist eine seltene chirurgische Erkrankung. Pr?disponierende Faktoren, einhergehend mit einer Immunsuppression und Durchblutungsst?rung, begünstigen in Kombination mit einem Keimspektrum aus aeroben und anaeroben Keimen ihr Auftreten. Nach laparoskopischen Eingriffen wurde die nekrotisierende Fasciitis bisher nur vereinzelt beobachtet. Urs?chlich wird eine Kontamination der Bauchdecke im Bereich der Trokarincisionen durch in einem Aerosol aufgel?ste Keime aus der Abdominalh?hle diskutiert. Wesentlich für die Prognose der Patienten ist die frühe Diagnosestellung, ein aggressives, ggf. wiederholtes chirurgisches Wunddébridement unter gleichzeitiger breiter antibiotischer Therapie. Anhand eines Fallberichtes nach laparoskopischer Cholecystektomie sollen Pathogenese, Verlauf und Therapie dieser schwerwiegenden Komplikation dargestellt werden.      

140. Zeit- und blutsparende Leberresektionen

Zusammenfassung Seit 1970 führte ich 27 Leberresektionen überwiegend unter Verschluß des Ligamentum hepato-duodenale aus. Die Abklemmung mit einem Tourniquet wird aufrecht erhalten bis zur vollendeten Resektion, Ligatur der durch Fingerfraktion-Technik isolierten Gefäße und bis nach erfolgter Lebernaht. Die Resektionszeit beträgt 10–20 min, die Operationszeit unter 1 h bis zu 2 h. Durchblutungsunterbrechungen der Leber werden bis zu 40 min vom Menschen folgenlos vertragen. Blutkonserven werden nicht benötigt.     

Extrahepatische Pfortaderthrombose nach laparoskopischer Cholezystektomie

Postoperative portal vein thrombosis is a rare complication, which occurs most often after hepatic surgery, but has not yet been described in combination with laparoscopic cholecystectomy. We present a case where thrombotic occlusion of the portal vein was diagnosed on the 6th day following laparoscopic cholecystectomy. Treatment with high-dose anticoagulant and antibiotic therapy was successful and without further complications.     

Urologische Symptome nach laparoskopischer Leistenhernienversorgung

In the context of a prospective, randomized, controlled double-blind study concerning a reduction of postoperative, urogenital affections after laparoscopic hernia repair using a polypropylene mesh, laparoscopic polypropylene implantation was performed in 40 male patients. Twenty patients received a heavyweight, rigid polypropylene mesh (group A) and the remainder a heavyweight, but softer polypropylene mesh (group B). Questionnaires were used to assess the severity of pain, impairment of sexual life, appearance of urogenital affections, and general condition. On the 3rd postoperative day, testicle blood circulation and testicle volumes were documented by ultrasound, and a congestion of the plexus pampiniformis was excluded by ultrasound with 5 MHz. Starting in the 1st postoperative week, a prevalence of affections such as testicular sensitivity to touch, pain upon ejaculation, and a pulling sensation during urination became apparent in group A. In the 12th postoperative week, 20% in group A still described testicular sensitivity to touch and 10% pain upon ejaculation and a pulling sensation during urination but only 5% in group B. It is essential to reduce urogenital affections after laparoscopic hernia repair by strict indications and appropriately adapted polypropylene meshes.     

Enterothorax nach laparoskopischer Nephrektomie

Diaphragmatic hernia can be inborn as well as acquired. We report on the manifestation of an intrathoracic hernia after laparoscopic nephrectomy. Intraoperative and postoperative complications could make intense medical treatment or further surgery necessary. In cases of lasting abdominal discomfort or pulmonary symptoms after abdominal surgery, radiological investigation to exclude intrathoracic hernia should be considered.     

Physiologische Adaptationsmechanismen bei laparoskopischer Cholezystektomie

Zusammenfassung Grundlagen Die CO₂-Insufflation bei endoskopischen Operationsmethoden kann zu negativen Ver?nderungen der Herzkreislaufsituation führen. Daher wurde das Ausma? der kardiorespiratorischen Beeinflussung der Patienten untersucht. Methodik Monitiert wurden Herzfrequenz, arterieller Systemdruck, periphere Sauerstoffs?ttigung, endexspiratorisches CO₂, Atemwegsdrucke, Atemminutenvolumen und K?rpertemperatur an 35 Patienten (ASA II, medianes Alter 51 Jahre, medianes Gewicht 74 kg). Bei 6 Patienten wurde mittels eines, in die obere Hohlvene vorgeschobenen, Katheters der zentralven?se Druck bzw. Blutgase bestimmt. Als Ausma? für die Invasivit?t der Operationstechnik, wurde der Verlauf von C-reaktivem Protein und Interleukin-6 bestimmt. Ergebnisse Trotz Erh?hung des Atemminutenvolumens stieg der APCO₂ signifikant an. Auch Atemwegsmitteldruck, mittlerer arterieller Druck, Herzfrequenz und ZVD stiegen signikifant an. In den übrigen gemessenen Parametern kam es zu keinen signifikanten Ver?nderungen. Schlu?folgerungen Der Beatmungsaufwand mu?te erh?ht werden, um einen physiologischen arteriellen CO₂Spiegel zu erhalten. Damit stieg auch der mittlere Atemwegsdruck. W?hrend unserer Untersuchung kam es zu keinem Zeitpunkt zu einer Gef?hrdung eines Patienten aufgrund der CO₂-Insufflation. Bei pulmonalen Problempatienten ist aufgrund des erh?hten CO₂-Anfalls abzuw?gen, ob das intraoperative Risiko oder die schnellere postoperative Erholung im Vordergrund steht. Im Einklang mit der geringen Invasivit?t der Methode zeigt sich ein geringerer Anstieg von Interleukin-6 und C-reaktivem Protein als bei konventionnell durchgeführten Operationen.      

Langzeitergebnisse nach laparoskopischer Resektion colorectaler Carcinome

Hintergrund: Die laparoskopische Operationstechnik wird zur Behandlung des colorectalen Carcinoms eingesetzt, obwohl noch keine Langzeitergebnisse aus kontrollierten Studien vorliegen, die belegen, da? diese Methode zur kurativen Behandlung des Carcinoms geeignet ist. Methode: Alle Patienten, die sich von 1995 bis 1997 einer laparoskopischen Resektion wegen eines colorectalen Tumors unterzogen, wurden in eine prospektive Beobachtungsstudie aufgenommen. Die Langzeitergebnisse wurden zur Qualit?tskontrolle überprüft. Ergebnisse: In dem Zeitraum wurden 68 Patienten laparoskopisch reseziert. Bei 3 Patienten fanden sich histologisch lediglich Adenome und bei 10 Patienten lag zum Zeitpunkt des Ersteingriffs bereits eine diffuse Lebermetastasierung vor. Bei 55 Patienten wurde eine R0-Resektion vorgenommen. Das Durchschnittsalter der 55 Patienten (29 Frauen und 26 M?nner) betrug 62,8 ± 14,6 Jahre. Es wurden 11 Hemicolektomien rechts, eine Hemicolektomie links, 21 Sigmaresektionen, 16 anteriore Rectumresektionen und 6 abdominoperineale Rectumexstirpationen durchgeführt. Bei 2 Patienten (3,6 %) waren die Langzeitergebnisse nicht erhebbar. Die Nachbeobachtungszeit betrug im Median 27,1 Monate (Bereich 9,1–45,1 Monate). Trokarmetastasen traten nicht auf. Bei 2 noch lebenden Patienten (3,6 %) wurde nach laparoskopischer Sigmaresektion ein Tumorrückfall diagnostiziert. Ein Patient, bei dem wegen eines synchronen malignen Lymphoms keine systematisch-region?re Lymphadenektomie durchgeführt wurde, erlitt ein locoregion?res Rezidiv und eine Patientin entwickelte Lungenmetastasen. Eine Patientin verstarb in der Nachbeobachtungszeit an einem Myokardinfarkt. Schlussfolgerungen: Trotz der relativ kurzen Nachbeobachtungszeit scheint die Rezidvrate nach laparoskopischer Resektion nicht erh?ht zu sein. Ob die laparoskopische Methode onkologisch gleichwertig ist, wird zur Zeit in multizentrischen Studien gekl?rt.     

Langzeitergebnisse nach laparoskopischer Resektion colorectaler Carcinome

BACKGROUND: Laparoscopic techniques are currently used for curative resection of colorectal cancer although long-term results from controlled clinical trials are not available yet that prove laparoscopic procedures are adequate. METHODS: All patients who under-went a curative resection of a colorectal tumor from 1995 to 1997 were included in a prospective cohort study to evaluate the short- and long-term results. RESULTS: Laparoscopic colorectal resections were accomplished in 68 patients. In only 3 patients was an adenoma (stage 0) found, and 10 patients had multiple liver metastases at the time of palliative resection. An oncological resection was performed in 55 patients. The average age was 62.8 +/- 14.6 years (29 female and 26 male patients). Eleven right colectomies, 1 left colectomy, 21 sigmoid resections, 16 proctosigmoidectomies and 6 abdominoperineal resections were carried out. Two patients (3.6%) were lost during follow-up. The median follow-up was 27.1 months (range 9.1-45.1 months). No port-site metastases were found. Two patients who are still alive after sigmoid resection suffered from a recurrence. The first patient underwent only limited lymphadenectomy because of synchronous malignant lymphoma. The second patient developed bilateral lung metastases. Only one patient died during the follow-up period because of myocardial infarction. CONCLUSION: Although the follow-up is short, it seems that the recurrence rate is low. Controlled multicenter clinical trials are currently performed to evaluate whether laparoscopic surgery is really adequate to treat colorectal cancer.     

Arzthaftung bei Gallengangsverletzungen nach laparoskopischer Cholezystektomie

Background

Injuries to the bile duct during laparoscopic cholecystectomy are often a cause of malpractice litigations.

Methods

A total of 13 legal verdicts as a result of bile duct injury from 1996 to 2009 were reviewed. Comments on the verdicts and the opinions of expert witnesses were analyzed.

Results

Out of 13 claims, 7 were upheld and 6 were rejected. Most expert witnesses from 1996 to 2002 stated that not carrying out a cholangiography and insufficient preparation of the cystic duct constituted a performance below the standard of care expected. Expert witness testimonies from 2004 to 2009, however, regarded injury to the bile duct as predominantly inherent to treatment.

Conclusion

With the expansion and acceptance of laparoscopic interventions, changes in the results of malpractice litigation have become evident. In contrast to the phase during establishment of the technology, an injury to the bile duct is nowadays judged predominantly as inherent to treatment.     

Zeitgerechtes Management von Gallengangkomplikationen nach laparoskopischer Cholecystektomie

INTRODUCTION: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. METHODS: Eleven patients (median age 43.8 +/- 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. RESULTS: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 +/- 8.4 months and were discharged from hospital after 10.6 +/- 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 +/- 1.0 days). However, a retrocolic Roux-Y end-to-side hepaticojejunostomy was performed in all cases with a larger defect (n = 5; hospital stay 14.8 +/- 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedochostomy or hepaticojejunostomy (hospital stay 11.2 +/- 0.6 days). CONCLUSIONS: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.     

216a. Interpretation laparoskopischer Befunde

Ohne Zusammenfassung