Stellenwert der offenen und laparoskopischen Steinchirurgie

Introduction: The increasing spread and technical enhancement of endourological methods has led to displacement of the surgical therapy of renal and ureteral calculi. Materials and methods: Based on a review of current literature, we describe indications, technique, and clinical importance of the open and laparoscopic management of urolithiasis. Results: In Europe and North America, the surgical therapy of urolithiasis only plays a role in cases of very large or hard stones, after failure of shock wave lithotripsy, percutaneous nephrolithotripsy, or ureteroscopic stone removal, and in cases of abnormal renal anatomy, i.e., only in a few percent of all stone therapies. However, in developing countries and emerging markets with different structure and funding of the health care system where the methods of endourology are not readily available, these techniques still have a higher importance. Particularly in Europe, laparoscopic surgery is emerging because calculi can be removed from almost all locations in the kidney and ureter using a transperitoneal or retroperitoneal access. Functional outcomes and complication rates are comparable. The benefits of laparoscopy are less postoperative pain, shorter hospital stay, faster convalescence, and better cosmetic results. Conclusions: Although procedures for open and laparoscopic removal of renal and ureteral calculi are only performed in rare cases in daily urological practice, they are superior to the endourological techniques in some circumstances. Therefore, they should still be part of the urologist’s skills.     

Roboterarm in der laparoskopischen Chirurgie

Zusammenfassung. Die laparoskopische Chirurgie ist gegenw?rtig noch durch eine Anzahl verschiedener Faktoren beschr?nkt, eine davon ist die jederzeit ad?quate Führung der Optik. Bislang wurden in unserem Haus 52 laparoskopische Eingriffe an Gallenblase, Magen, Dickdarm und Leistenbruch mit dem durch die Stimme des Operateurs gesteuerten Roboterarm für die Optikführung durchgeführt. Das Sichtfeld wird hierbei durch Befehle des Operateurs direkt bestimmt. Bei allen Eingriffen war die Steuerung des Roboterarms pr?zise, die Spracherkennung genau und ohne technische Probleme. 29 Eingriffe konnten von einem Operateur allein als „Solo-Chirurgie“ vorgenommen werden. Bei weiteren 20 Eingriffen wurde neben dem Operateur nur ein Assistent eingesetzt. Der Roboter kann problemlos und erfolgreich von jedem laparoskopisch t?tigen Chirurgen und in jedem Operationssaal eingesetzt werden.      

Single-port-Technik in der laparoskopischen Chirurgie

Laparoscopic operations using only one trocar (single-port technique) have the aim to further minimize the trauma of access incisions similar to NOTES. To carry this out special trocars and instruments are needed which are presented in this article with respect to application and function. The range of indications corresponds to the conventional laparoscopic surgery. Recent publications have shown that operations using a single-port technique are safe and efficient. Greater technical difficulties and higher costs must be considered. For the identification of significant advantages, randomized studies are still lacking.     

Technische Aspekte der laparoskopischen Leberchirurgie

Background

Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial.

Aims

The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS).

Methods

The technical variations reported in the literature as well as the own experience with LLS are reported.

Results

Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA?) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries.

Conclusion

The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.

     

Neue Technologien in der laparoskopischen Chirurgie

Die mit der endoskopischen Chirurgie verbundene Technologie ist das Ergebnis industrieller Forschung und Entwicklungsarbeit sowie das Ergebnis des besonderen Interesses verschiedener chirurgischer Zentren an der endoskopischen Chirurgie. Einige Entwicklungen der letzten 10 Jahre werden dargestellt. Das Problem des Medizin-Technologie-Assessment in Bezug auf neue Entwicklungen bzw. Instrumenten?nderungen und der Umgang damit wird diskutiert. Randomisierte kontrollierte klinische Studien sind in der Einsch?tzung der Medizintechnologie insbesondere der technologiebedingten Interventionen unüblich. Daher wird ein alternatives System der kontrollierten schrittweisen Evaluation vorgestellt.     

Neue Technologien in der laparoskopischen Chirurgie

The technology associated with endoscopic surgery continues to evolve as a result of industrial R & D and research within academic surgical departments with interest in surgical endoscopic and remote handling technology. Some of the developments in the last ten years are reviewed. The problem concerning health technology assessment (HTA) in relation to new devices/instrumentation and procedures is discussed. Randomised controlled clinical trials are unsuited for the initial HTA of technology-dependent interventions, and for this reason, an alternative system, controlled stepwise evaluation (CSE) is proposed.     

Technische Aspekte der laparoskopischen Heller-Myotomie bei der Achalasie

Minimally invasive surgery has influenced the treatment of achalasia more than that of any other gastrointestinal disorder. Laparoscopic Heller myotomy has thus evolved to the first-line therapy in patients with achalasia and led to a significant change in the treatment algorithm of this disorder. The aim of this article is to present technical aspects and pitfalls of Heller myotomy with combined antirefluxplasty. After injection of 0.9% NaCl into the muscularis and submucosa of the distal esophagus and proximal fundus, whereby the submucosal layer can be easily separated from the mucosa, myotomy of the longitudinal and circular musculature is performed up to 6–7 cm proximally to the esophagogastric junction and completed distally by 1,5–2 cm onto the fundus. We prefer the 180° anterior semifundoplication according to Dor as antirefluxplasty, which is sutured in a two-rowed manner into the two sites of the myotomy. The pitfalls are incomplete myotomy, especially at its distal, fundic site, with consecutive persistence or recurrence of symptoms, as well as occult mucosal perforations, which can be detected by intraoperative endoscopy.     

Spektrum der laparoskopischen Chirurgie bei Magentumoren

Minimally invasive operative procedures are increasingly being used for treating tumors of the upper gastrointestinal tract. While minimally invasive surgery (MIS) has become established as a standard procedure for benign tumors and gastrointestinal stromal tumors (GIST) based on current studies, the significance of MIS in the field of gastric cancer is the topic of heated debate. Until now the majority of studies and meta-analyses on gastric cancer have come from Asia and these indicate the advantages of MIS in terms of intraoperative blood loss, minor surgical complications and swifter convalescence although without any benefits in terms of long-term oncological results and quality of life. Unlike in Germany, gastric cancer in Asia with its unchanged high incidence rate, 50?% frequency of early carcinoma and predominantly distal tumor localization is treated at high-volume centres. Due to the proven marginal advantages of MIS over open resection described in the published studies no general recommendation for laparoscopic surgery of gastric cancer can currently be given.     

Evidenzlage der laparoskopischen Chirurgie beim Rektumkarzinom

Background

Innovative surgical techniques in colorectal surgery aim to provide diminished surgical injury and at least equivalent or even improved quality of treatment and oncological results. High level clinical studies are mandatory to examine the feasibility and advantages (or disadvantages) of new operative techniques.

Objectives

Laparoscopic colonic resection for cancer has been investigated with respect to safety and oncological quality in various prospective randomized studies (COST study, COLOR-I and CLASICC). The minimally invasive procedure is feasible and safe which was demonstrated in many studies but can these results be extrapolated to laparoscopic rectal cancer surgery?

Results

The short term outcomes of the COLOR-II trial were published recently and laparoscopic resection for rectal cancer was not found to be inferior compared to open resection. Recovery after laparoscopic surgery was better than after open surgery. Laparoscopic surgery was found to have significant advantages with respect to blood loss, operating time, use of pain medication, early restoration of bowel function and reduction of hospital stay as well as the lateral safety margins in the distal third of the rectum. The long-term results focussing on local recurrence showed a positive trend in favor of laparoscopic rectal surgery and will be published shortly.

Conclusion

Laparoscopic total mesorectal excision (TME) appears to have clinically measurable short-term advantages in patients with primary rectal cancer based on the evidence of randomized studies. Laparoscopic rectal cancer resection may become the gold standard in the future.     

Stellenwert der laparoskopischen Chirurgie des Kolonkarzinoms in der klinischen Routine

Background

Using data and analysis compiled in the nationwide German Colon/Rectal Cancer qualitative multicenter study, the aim of this study was to determine the value of laparoscopic surgery for colon cancer in clinical routine.

Methods

From 1 January 2000 to 31 December 2003, patients with colon cancer resections were evaluated for short-term postoperative and long-term oncologic results associated with operative approach (laparoscopic vs conversion vs open).

Results

Of 21,721 patients with colon cancer, 949 (4.4%) underwent laparoscopic resection. These patients were younger (P<0.001) with lower ASA risk factors (P<0.001) and earlier UICC tumor stages (P<0.001) than open resected patients. They also showed reduced overall morbidity (P<0.001), in-hospital mortality (P=0.001), and shorter hospital stays (P<0.001). The rates of intraoperative and specific complications remained unchanged. Nineteen percent of the patients had resections converted to open approaches. These had the highest overall morbidity and longest hospital stays. Their mortality was three times that of the group with complete laparoscopic resection.

Conclusions

The open approach remained the standard of surgical care in colon cancer for the study duration. Laparoscopic surgery was used in only a small number of patients. By virtue of preferential patient selection, better early postoperative and long-term results could be achieved for the laparoscopic group than with the open approach. Conversions were shown to be associated with inferior results at the high rate of 19%. To ensure optimal results, laparoscopic surgery for colon carcinoma should be conducted by an experienced surgeon in an appropriately selected patient pool.     

Lokale Antiseptika in der Chirurgie-Wiedergeburt und Weiterentwicklung

The history of antisepsis is marked by names such as Pringle, Lister, Billroth, Koch, Kocher, von Volkmann, von Nussbaum, Schloffer and Carrel. The revolutionary initial success of Lister's method was followed by severe setbacks because persisting biological intolerance of the chemical and physical antiseptics prevented the main purpose of application: killing bacteria without damaging cells. Until the, discovery of penicillin the predominantly used antiseptics were perubalsam (balsamum peruvianum), azo-dyes (Rivanol^®) and sulphonamides (Cibazol). The dawn of the “antibiotic age” demonstrated once more the limits of locally applied therapeutic effectiveness of these substances (antiseptics, antibiotics) and was often outweighed by the damage caused. For the same reason systemicly applied substances frequently lack satisfactory effectiveness in the area of tissue damage. Experiences with intraoperative and postoperative wound lavage have shown that favourable results achieved by this surgical procedure are more likely due to the mechanical cleaning process than to the effectiveness, of the locally applied substances being limited by the restricted duration of influence and the restricted depth of tissue penetration. Taking into account earlier studies and long-term experiences, antiseptic solutions were tested in view of their tissue compatibility, their biologic availability, and their effectiveness in close cooperation of clinic, bacteriology and laboratory medicine. The coordinated investigations resulted in a solution of biguanid (Lavasept^®) which is free from iodine, quicksilver, PVP and aldehyde. It can be applied for local treatment of wounds liable to infection, as an adjuvant for wound treatment in cases of acute tissue infections, as well as in the surgival practise to take care of acute and chronic infections of soft tissue. Sofar locally applied antiseptics in surgery have proved to be less satisfactory than considered in the course of their history due to side effects, e.g. tissue damage. Coordinated investigations now present an antiseptic solution of biguanid which can be used in various cases of wound treatment to prevent or counteract infections.     

Weiterentwicklung der PET und des PET/CT beim Prostatakarzinom

Functional imaging of prostate carcinoma was examined with the metabolic substrates 2-¹⁸F-fluorodeoxyglucose, ¹¹C-methionine, ¹⁸F-fluorodihydrotestosterone, ¹¹C-acetate and ¹¹C/¹⁸F-choline. Based on upregulated enzymes of phospholipid metabolism in prostate carcinoma, ¹¹C/¹⁸F-choline is preferentially incorporated into phosphatidylcholine of membrane lipids of prostate cancer cells. PET allows sensitive detection of the ¹¹C/¹⁸F-choline signal and PET/CT fusion imaging enables intraprostatic signal localisation. Most published studies report a high detection rate of prostate carcinoma with ¹¹C/¹⁸F-choline PET/CT. Differentiation of prostate carcinoma from benign hyperplasia and from focal chronic prostatitis may be difficult; acute prostatitis accumulates ¹¹C/¹⁸F-choline with an intensity comparable to prostate carcinoma.     

ACTH und Cortison in der Chirurgie

Zusammenfassung Nach kurzer Schilderung der Literatur über die bisherigen Behandlungsergebnisse der ACTH- und Cortisontherapie in der Chirurgie, wie ihrer theoretischen Grundlagen, werden eigene Ergebnisse mitgeteilt. Es werden hauptsächlich 2 in der Chirurgie erstrebte Effekte unterschieden. Die allgemeine, das HV-NNR-System in der Abwehr größerer Schädlichkeiten unterstützende Wirkung und die eine rein örtliche Beeinflussung erstrebende Hormongabe. Strenge Indikationsstellung und genaue Kenntnis der Gefahren dieser Hormone müssen uns vor unliebsamen Überraschungen bei der Anwendung dieser hochwirksamen Substanzen bewahren. Wir befinden uns mit der Therapie in einem tastenden Versuchsstadium. Diese Tatsache stellt an unser ärztliches Verantwortungsbewußtsein hohe Anforderungen. Das Risiko, welches wir eingehen, muß dem zu erwartenden Erfolg entsprechen.     

Histamin und Antihistamine in der Chirurgie

Ohne Zusammenfassung Mit 5 Textabbildungen     

71a. Rundgespräch: Technische Hilfsmittel in der Chirurgie —Möglichkeiten und Grenzen

Ohne Zusammenfassung     

Diagnostik und Chirurgie der Leberechinococcen

Zusammenfassung Von 1970 bis April 1975 wurden in der Chirurg. Univ. Klinik Bonn 42 Patienten wegen histologisch gesicherter Leber-Echinococcose stationär behandelt; in 33 Fällen handelte es sich umE, cysticus, in 9 Fällen umE. alveolaris. Die beiden parasitologisch und epidemiologisch verschiedenen Echinococcusarten präsentieren klinisch verschiedene Krankheitsmanifestationen mit unterschiedlicher Verlaufsform und Prognose. Diagnostisch sind Angiographie mit Coeliaco- und superselektiver Hepaticographie entscheidend. Die Therapie ist nur chirurgisch, angestrebt wird die Totalausräumung der Parasiten. Sie gelingt beiE. cysticus meist durch Enukleationsresektion oder Pericystektomie nach vorheriger Punktionssaugung und Instillierung von 20 %iger NaClLösung oder Formalin. Solche Radikalität ist beiE. alveolaris die Ausnahme. Hier stehen Teilresektionen, biliodigestive und hepatodigestive Anastomosen als Palliativmaßnahmen zur Sicherung des Galleabflusses im Vordergrund.

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Diagnosis and therapy of liver echinococcus

Summary From 1970 to April 1975 42 patients were treated for Echinococcus of the liver at the Bonn University Dept. of Surgery. There were 33 cases ofE. cysticus and 9 cases ofE. alveolaris. These two types of Echinococcus, different in parasitology and epidemiology present different clinical manifestation of disease with different course and prognosis. Angiography with celiaco- and superselective hepaticography are decisive for diagnosis. Therapy can only be surgical with total removal of the parasites. InE. cysticus this is almost always possible by enucleation-resection or pericystectomie following evacuation of the cyst and instillation of 20 % sodium-chloride or formaldehyde. Such radicality is the exception inE. alveolaris. Here partial resections, biliodigestive and hepatodigestive anastomoses as palliative measures are carried out predominantly to ensure bile passage.