Laparoskopische Adrenalektomie in Seitenlage – ein Vergleich mit der konventionellen dorsalen Technik

OBJECTIVES: Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib. METHODS: Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm. RESULTS: Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection). CONCLUSION: LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.     

Technik der Mitralklappenrekonstruktion

Repair is meanwhile the most frequent surgery done on the mitral valve. In industrialized countries about 70 % of incompetent mitral valves can be repaired. Numerous reconstructive techniques have been described and a selection is discussed in this article. Prerequisites for mitral valve repair are a profound knowledge of anatomy and mechanisms of failure. Good exposure is the key to achieve reliable results.     

Technik der Trikuspidalklappenrekonstruktion

Malformations of the tricuspid valve are less commonly observed than diseases of the valves of the left ventricle. In particular, for a long time little attention was paid to the mostly secondary tricuspid valve regurgitation and the general opinion was that the secondary tricuspid valve insufficiency would be automatically improved by correction of the left ventricular pathology. After experiences from cardiac surgery of congenital defects and the long-term practice to completely or extensively resect the tricuspid valve in drug addicts with endocarditis, the assumption developed that the heart can adequately function without this valve. This line of thought was supported by the functionality of the Fontan circulation with passive perfusion without the function of the right ventricle and right ventricular valves; however, the processing of long-term results showed that most of these patients develop a relevant right heart decompensation. Currently, particular attention is paid to the “prophylactic” correction of the tricuspid valve during other cardiac surgery interventions because the number of postoperatively developing or aggravating secondary tricuspid valve regurgitations is considerable with an underlying left ventricular or pulmonary pathology. Particular problems are the technique and the indications for tricuspid valve reconstruction by high-grade impairment of right ventricular function.     

Technik der papilloduodenektomie

Zusammenfassung Die Lokalexzision von periampulldren Tumoren, erstmals 1898 beschrieben, ist nach Einführung der Pankreatikoduodenektomie 1935 in den Hintergrund gedrdngt worden. Neuere Berichte lassen vermuten, daß die ampullary Exzision gute Resultate erreicht. Um den Platz dieser Operation zu bestimmen, welche eine einfache Mukosaexzision (Ampullektomie) oder eine weite Exzision der Papille zusammen mit der Duodenalhinterwand und den distalen Anteilen von Gallen- und Pankreasgang sein kann (Papilloduodenektomie), ist es wichtig, these Technik genau zu definieren. Wir beschreiben deshalb die Papilloduodenektomie und bestimmen den Platz dieser Operation, die in ausgewählten Fällen nützlich sein kann.

---

Technique of papilloduodenectomy

Summary Local excision of preiampullary tumours first described in 1898 has been relegated in the background after introduction of pancreaticoduodenectomy in 1935. Recent reports suggest that ampullary excision may give good results. In order to define the place of this operation which may be a simple excision of the duodenal mucosa (ampullectomy) or a wide excision of the papilla encompassing the posterior duodenal wall and the distal bile and pancreatic ducts (papilloduodenectomy) it is important to make a clear distinction between these two techniques. We describe the technique of papilloduodenectomy and define the place of this operation, which may be useful in selected cases.

     

Technik der Thymuschirurgie

The group of thymic tumors includes thymomas, thymic carcinomas and neuroendocrine thymic tumors (NETT). They are rare tumor entities but represent the majority of malignant tumors of the anterior mediastinum in adult patients. The biological behavior is characterized by slow tissue infiltration and locoregional tumor spread. Complete surgical resection is the foundation of the treatment of thymic tumors. Early tumor stages can be addressed by minimally invasive surgical procedures. In 30?% of patients the tumors already infiltrate additional mediastinal structures, the lungs or the chest wall warranting extended surgical approaches. This review article summarizes the operative approaches available for thoracic surgeons. Knowledge of the available surgical techniques in thymic surgery can be transferred to other mediastinal tumors.     

Technik der Leberresektion

Hepatic surgery has grown considerably in importance during the past two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care as well as general advancements in hepatic surgical technique. Enormous strides in liver transplantation resulted in new methods also finding use in resective surgery. We present findings on functional and segmental anatomy of the liver on which current hepatic surgery is based, along with technical and oncological aspects requiring consideration for indication. Operative planning and anesthesiological management are discussed.     

Technik der Transkatheter-Aortenklappenimplantation

Catheter-based aortic valve implantations are innovative and truly minimally invasive procedures. Their use is currently limited to patients with a significantly increased perioperative risk for conventional aortic valve replacement, mainly due to lack of long-term follow-up data. Therefore, a critical evaluation of indications is warranted. Nevertheless, in clinical practice their use has become of increasing importance to patients and physicians alike. To be able to employ these techniques successfully, knowledge of the operational steps and interventional techniques is paramount. To avoid complications, careful preoperative work up and an experienced and well-trained team of surgeons, cardiologists, and anesthetists are necessary.     

Technik der Leberresektion

Hepatic surgery has grown considerably in importance during the last two decades. Major roles in this development have been played by improvements in imaging diagnostics and intensive care and particularly advancements in general hepatic surgical techniques. We present the terminology of functional and segmental anatomy of the liver on which current hepatic surgery is based, along with operative strategies for standard, nonconventional, and repeat resections. Intraoperative complications are also discussed.     

Zur Technik der Massage der Schultermuskulatur

Ohne Zusammenfassung Mit 2 Textabbildungen.     

Technik der laparoskopischen Rektumresektion

The quality of radical oncological operations for patients with rectal cancer determines the rate of local recurrence and long-term survival. Neoadjuvant chemoradiotherapy for locally advanced tumors, a standardized surgical procedure for rectal tumors less than 12 cm from the anus with total mesorectal excision (TME) and preservation of the autonomous nerve system for sexual and bladder function have significantly improved the oncological results and quality of life of patients. The TME procedure for rectal resection has been performed laparoscopically in Germany for almost 20 years; however, no reliable data are available on the frequency of laparoscopic procedures in rectal cancer patients in Germany. The rate of minimally invasive procedures is estimated to be less than 20?%. A prerequisite for using the laparoscopic approach is implicit adherence to the described standards of open surgery. Available data from prospective randomized trials, systematic reviews and meta-analyses indicate that in the early postoperative phase the generally well-known positive effects of the minimally invasive approach to the benefit of patients can be realized without any long-term negative impact on the oncological results; however, the results of many of these studies are difficult to interpret because it could not be confirmed whether the hospitals and surgeons involved had successfully completed the learning curve. In this article we would like to present our technique, which we have developed over the past 17 years in more than 1000 patients. Based on our experiences the laparoscopic approach can be highly recommended as a suitable alternative to the open procedure.     

Technik der brusterhaltenden Behandlung

Ohne Zusammenfassung     

Zur Technik der Kielbrustoperation

Zusammenfassung Im Einzelfall kann bei besonders stark ausgeprägter Kielbrust eine operative Korrektur der kosmetisch erheblich beeinträchtigenden Thoraxdeformität in Frage kommen. Die Technik der Beseitigung des Kieles und der Stabilisierung der Thoraxvorderwand wird geschildert.

---

Summary In single cases it may be necessary to correct the pigeon breast. The operative technique to remove the carina and to stabilize the chest wall has been described.

---

Résumé En quelques cas d'une pectus carinatum la correcture opératoire sera nécessaire. La technique de l'opération avec la stabilisation est décrivée.

     

Zur Technik der Gastroenterostomie

Ohne Zusammenfassung     

Zur Technik der Appendektomie

Ohne Zusammenfassung     

Zur Technik der Antro-atticotomie

Ohne Zusammenfassung (Mit 3 Abbildungen.)     

Die Technik der Fibrinspongiosaplastik

Zusammenfassung Es wird über die klinische Anwendung eines Fibrinklebesystems in Verbindung mit Knochentransplantaten zur Auffüllung von Knochendefekten berichtet. Neben der genauen Beschreibung der Klebetechnik, wird über 11 klinische Fälle mit einem Nachbeobachtungszeitraum von 9–21 Monaten berichtet. Durch die Anwendung des biologischen Klebesystems kam es zu einem beschleunigten, homogenen Einbau des transplantierten Knochens, wobei das Ausbleiben einer Sklerosierung der Plomben bemerkenswert erschien. Als weitere Vorteile werden die hämostyptische, die adhäsive und die Eigenschaft der plastischen Formbarkeit hervorgehoben.

---

The technic of fibrin glue in cancellous bone transplants

Summary The paper deals with the clinical experience in the use of a biological adhesive system in conjunction with bone transplants to close large bone defects. The gluing technique has been exactly described, 11 patients with a follow-up between 9 and 21 months are being presented. The application of this system which consists of highly concentrated native fibronogen, thrombin, and clotting factor XIII results in an acceleration of homogenous incorporation of the implants. No deterioration of wound healing occurred. The advantages of this method are: exact local hemostasis, adhesive strength, and plasticity.

---

---

Herrn Professor Dr. Karl Chiari zum 65. Geburtstag gewidmet     

Zur Technik der Patellarnaht

Ohne Zusammenfassung (Mit 1 Abbildung.)     

Zur Technik der Magenresektion

Ohne Zusammenfassung