Theodor Kocher (1841-1917) and his outstanding contributions to surgery

Theodor Kocher (1841-1917), an exceptional Swiss surgeon who described a technique for the safe removal of enlarged thyroid unraveled the true function of this endocrine gland but also made significant contributions to many other fields of surgery. Kocher was the first surgeon awarded the Nobel prize in Physiology and Medicine in 1909 for his work on the physiology, pathology, and surgery of the thyroid gland. He was professor and clinical director at Insel Hospital during 45 years. Kocher created the prominent Surgeon's School in Bern. He was the first president of the International Society of Surgery in 1903 and the founding president of the Swiss Society of Surgery in 1913.

Theodor Kocher (1841-1917), excepcional cirujano suizo que describió una técnica para la extirpación segura del agrandamiento del tiroides y desentrañó la verdadera función de esta glándula endocrina, pero también hizo importantes aportaciones a muchos otros campos de la cirugía. Kocher fue el primer cirujano galardonado con el premio Nobel de Fisiología y Medicina en 1909 por sus trabajos sobre la fisiología, patología y cirugía de la glándula tiroides. Fue profesor y director clínico del Hospital Insel durante 45 años. Kocher creó la destacada Escuela de Cirujanos de Berna. Fue el primer presidente de la Sociedad Internacional de Cirugía en 1903 y el presidente fundador de la Sociedad Suiza de Cirugía en 1913.

Atipicidad en el hipotiroidismo congénito: síndrome de Kocher-Debré-Semelaigne. Reporte de caso / Atypicality in congenital hypothyroidism: Kocher-Debré-Semelaigne. Case report

El síndrome de Kocher Debré Semelaigne (SKDS) se describe dentro de las formas clínicas atípicas asociadas al hipotiroidismo congénito (HC) severo, no tratado y de larga evolución, con manifestaciones de pseudohipertrofia muscular difusa y debilidad muscular predominantemente proximal, reversible al reemplazo con tiroxina. Es raro en países con programas de pesquisa neonatal. Objetivo: reportar el caso de un niño con diagnóstico de HC por disembriogenesis (atireosis), que se mantuvo con mal control de la enfermedad durante el primer año de vida y manifestaciones miopáticas desde la etapa neonatal. Resultados: se confirma el diagnóstico a través de estudios específicos, con evidencias de patrones miopáticos característicos. Se logra regresión clínica parcial a los nueve meses de mantener estabilidad de la TSH y las hormonas tiroideas (HT), coincidiendo con la normalización de la enzima de músculo creatinfosfoquinasa (CPK). A los 12 años de seguimiento, mantenía ligera hipertrofia de la musculatura de las extremidades superiores, dorsales y glúteos, a pesar de mantenerse eutiroideo. Conclusiones: la presencia de hipertrofia muscular debe considerarse un dato clínico de sospecha de hipotiroidismo, aun con la implementación de los programas de pesquisa neonatal. Es posible la regresión parcial de la pseudohipertrofia muscular con el restablecimiento de la función tiroidea. Se debe tomar en cuenta en el diagnóstico diferencial de otras miopatías primarias

Kocher-Debré-Semelaigne Syndrome (SKDS) is described within the atypical clinical forms associated with severe, untreated and long-standing congenital hypothyroidism with manifestations of diffuse muscle pseudohypertrophy and predominantly proximal muscle weakness, reversible to replacement with levothyroxine. objective: To report the case of a child with congenital hypothyroidism due to disembriogenesis (atyreosis), who remained with poor control of the disease during the 1st year of life and myopathic manifestations from de neonatal stage. Results: The diagnosis is confirmed through specific studies, with evidence of characteristic myopathic patterns. Partial clinical regression is achieved 9 months after maintaining stability of TSH and thyroid hormones, coinciding with the normalization of the muscle enzyme creatine phosphokinase (CPK). At 12 years of follow-up, he maintained slight hypertrophy of the muscle of the upper extremities, dorsal and buttocks, despite remaining euthyroid. Conclusions: The presence of muscular hypertrophy should be considered a clinical finding of suspected hypothyroidism, even with the implementation of neonatal screening programs. Partial regression of muscle pseudohypertrophy is possible with restoration of thyroid function, and should be taken into account in the differential diagnosis of other primary myopathies

Fixation with cannulated screws alone via the Kocher approach for humeral capitulum fractures in adults / 中华创伤骨科杂志

Objective:To investigate the efficacy of fixation with cannulated screws alone via the Kocher approach in the treatment of adult humeral capitulum fractures.Methods:From August 2016 to August 2020, 16 patients with humeral capitulum fracture were treated at Department of Upper Limb Orthopedics, Zhengzhou Orthopaedic Hospital. They were 10 males and 6 females, aged from 36 to 62 years (average, 45 years). The left side was affected in 10 cases and the right side in 6. According to the Ring classification, 3 cases were type Ⅰ, 3 cases type Ⅱ, 6 cases type Ⅲ, and 4 cases type Ⅳ. All patients were treated with the Kocher approach on the lateral side of the elbow. After reduction under direct vision, the fractures were fixated temporarily with Kirschner wires and finally with cannulated screws. On the second postoperative day, the patients started active flexion and extension of the elbow joint and took indomethacin orally to prevent heterotopic ossification. At the last follow-up, the curative efficacy was evaluated according to the Mayo elbow performance score (MEPS). The flexion and extension of the elbow joint and the rotation of the forearm were also recorded.Results:All patients were followed up for 10 to 19 months (mean, 14.3 months) after surgery. Bony union was achieved after 7 to 12 monthes (average, 11.3 monthes) in all the 16 patients, 2 of whom developed heterotopic ossification. By the MEPS evaluation at the last follow-up, 8 cases were excellent, 6 good and 2 fair, scoring an average of 89.5 points (from 73 to 95 points). At the last follow-up, the elbow flexion ranged from 80° to 130° (averaging 113°), extension from 5° to 30° (averaging 15°), forearm pronation from 62° to 75° (averaging 67°), and forearm supination from 50° to 90° (averaging 75°).Conclusion:When the fracture ends are exposed through the lateral Kocher approach, the fracture fragments fixated with cannulated screws only, and the patients encouraged to start elbow joint exercises in the early stage, the treatment of adult humeral capitulum fractures can result in satisfactory curative effects.

El carácter científico de la Cirugía. Historia y Filosofía / The Scientific Nature of Surgery. History and Philosophy

RESUMEN ¿Se puede hablar de ciencia cuando nos referimos a la cirugía? No, de acuerdo con la epistemología clásica, que dice que para que una disciplina sea considerada científica debe alcanzar requisitos que la cirugía parecería no cumplir. Esto es, ser parte de un paradigma y crear conocimiento científico. Por lo que, si queremos afirmar la cientificidad de la cirugía, debemos investigar la existencia de ejem plares que podrían ser paradigmáticos, ya que son ellos los que fundamentan su estructura epistémi ca. Junto a esto debemos demostrar que su práctica crea conocimiento científico. Para ello, postulamos cinco objetivos que la cirugía debe cumplir. Además, a los personajes históricos clásicos a quienes se les atribuye haber fundado la cirugía moderna ‒Ambrosio Paré y John Hunter‒, solo pudieron alcanzar los tres primeros. Pero esto no basta para que se considere a la cirugía como parte de la ciencia. Debimos avanzar en la historia y encontrar esos ejemplares paradigmáticos. El primero corresponde al trabajo de investigación en fase animal, previa a la realización de la primera gastrectomía exitosa rea lizada en seres humanos por el cirujano alemán Theodor Billroth, en el año 1882. El segundo corres ponde a la investigación en fisiología tiroidea realizada por Emil T. Kocher, con la que ganó el premio Nobel en Medicina y Fisiología en año 1909. Se hace un análisis del desarrollo epistémico de la cirugía a partir de ellos y se evalúan las consecuen cias mediante el concepto de ciclo epistémico. Hipótesis clave para entender la creación del conoci miento científico a partir de disciplinas técnicas como la cirugía.

ABSTRACT Can we talk about science when we speak about surgery? Not, accordingly to classical epistemology. To consider a discipline as scientific, it must meet certain requirements that surgery would not seem to satisfy: being part of a paradigm and creating scientific knowledge. Therefore, if we want to affirm the scientific nature of surgery, we must investigate the existence of exemplars that could be paradigmatic, since they are the ones that support its epistemic structure. Along with this, we must demonstrate that their practice creates scientific knowledge. We've postulated five objectives that surgery had to satisfy. We've seen in classic history, that the main characters which are considered founders of modern surgery -Ambrosio Pare and John Hunter- were only able to reach the first three, and as we'll see, were not enough to consider surgery as part of science. Moving forward in history, we are able to find the first paradigmatic exemplars. The first corresponds to the research work in the animal phase, prior to the first successful human gastrectomy performed by the German surgeon Theodor Billroth, in 1882. The second corresponds to the research in thyroid's physiology carried out by Emil T. Kocher; thanks to this, he won the Nobel Prize in medicine and phy siology in 1909. An analysis of the epistemic development of surgery is made from them, and the consequences are analyzed using the concept of the epistemic cycle. Those key hypotheses are important to understand the creation of scientific knowledge in technical disciplines as surgery.

Abordaje medial modificado para dislocación codo crónico: un abordaje quirúrgico novedoso con buen resultado funcional / Modified medial approach for chronic elbow dislocation: a novel surgical approach with good functional outcome

Background : Chronic elbow dislocation is defined as untreated elbow dislocation for longer than 2 weeks. Goal of treatment is stable reduction of elbow joint and facilitation of early elbow motion for optimal end result. Known operative methods is the Kocher posterolateral approach.which can accumulate hematome, and longer time needed to identify Ulnar nerve. Therefore, we would like to introduce the new modified medial elbow joint incision approach. Methodology: This study utilized a cross-sectional review of patients with surgical treatment of simple chronic elbow dislocation. Questionnaires were taken using Oxford Elbow Score, Mayo Elbow Performance Index, and Disability of Arm, Shoulder, and Hand Questionnaire to assess current elbow status Result : Utilizing Oxford elbow score, the analytic group score value ranged from 21-46, while control group's score value were 37-42 (P-value <0.0001). Mayo Elbow Performance Index score, from the analytic group, scored ranges from 45 - 82. the control group, a mean value of 85 were scored (P-value <0.0001), the DASH score revealed total mean value of 8.3 in the analytic group, compared to score 6 in the control group (P-value = 0.0468 ). The range of motion is increased in total flexion and extension from both groups(P-value <0.0001) Conclusion: Modified medial elbow approach provides faster method of identifying ulnar nerve, requires less skin flap for closure and less space for blood accumulation. Modified medial elbow approach provides good functional outcome with no complications related to ulnar nerve reported in this study.

Comparison of effectiveness between two combined anterior and posterior approaches for complicated acetabular fractures / 中国修复重建外科杂志

Objective: To compare the effectiveness between modified ilioinguinal approach combined with Kocher-Langenbeck (K-L) approach and Stoppa approach combined with K-L approach for the treatment of complicated acetabular fractures. Methods: Between May 2011 and May 2016, Sixty-two patients with complicated acetabular fractures were treated with operation via combined anterior and posterior approaches. Thirty-four cases (group A) were treated with modified ilioinguinal approach combined with K-L approach, and 28 cases (group B) were treated with Stoppa approach combined with K-L approach. There was no significant difference in gender, age, injury causes, the type of fracture, time from injury to operation, and associated injury between 2 groups ( P>0.05). The operation time, intraoperative blood loss, and hospitalization time were recorded. X-ray film was performed to evaluate the fracture reduction according to the Matta reduction criteria and observe the fracture healing, osteoarthritis, and heterotopic ossification. Clinical results were evaluated according to the grading system of modified d'Aubigne and Postel. Results: There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups ( P>0.05). Postoperative incision fat liquefaction occurred in 2 cases in group A and group B respectively, and deep vein thrombosis of lower extremity occurred in 1 case in group A. No iatrogenic injury was found in 2 groups. Fifty-six patients were followed up after operation. Thirty patients in group A were followed up 12-48 months (mean, 31.8 months). Twenty-six patients in group B were followed up 12-46 months (mean, 30.2 months). At 12 months after operation, according to the grading system of modified d'Aubigne and Postel, the hip function was rated as excellent in 9 cases, good in 16 cases, fair in 3 cases, and poor in 2 cases, with the excellent and good rate of 83.3% in group A; the hip function was rated as excellent in 7 cases, good in 14 cases, fair in 2 cases, and poor in 3 cases, with the excellent and good rate of 80.8% in group B. There was no significant difference in the hip function between 2 groups ( Z=0.353, P=0.724). The X-ray films showed that there were 23 cases of anatomical reduction, 6 cases of satisfactory reduction, and 1 case of unsatisfactory reduction in group A, and 20 cases, 5 cases, and 1 case in group B, respectively. There was no significant difference in the results of fracture reduction between 2 groups ( Z=0.011, P=0.991). Fracture healing was observed in both groups. There was no significant difference in fracture healing time between 2 groups ( t=0.775, P=0.106). During follow-up, 5 cases of osteoarthritis changes, 2 cases of heterotopic ossification, and 2 cases of avascular necrosis of femoral head occurred in group A, and 4 cases, 2 cases, and 1 case in group B, respectively. The difference between 2 groups was not significant ( P>0.05). Conclusion: According to the location and type of fracture, making a choice between the modified anterior approach and Stoppa approach, and then combined with K-L approach for treatment of complicated acetabular fracture, can obtain satisfactory effectiveness.

The role of trochanteric flip osteotomy in fixation of certain acetabular fractures / 中华创伤杂志(英文版)

<p><b>PURPOSE</b>Complete visualization of certain acetabular fractures of posterior wall or column with cranial extension involving superior dome from standard surgical exposures is a challenge. Osteotomy of the greater trochanter has been used to enhance fracture visualization, especially the dome, in posterior and lateral exposures of the acetabulum. It also decreases the need for excessive muscle retraction. The purpose of the study was to investigate the outcome associated with trochanteric flip osteotomy in the management of certain acetabulum fractures.</p><p><b>METHODS</b>From January 2011 to December 2013, 25 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a Kocher-Langenbeck approach along with trochanteric flip osteotomy. At 3rd, 6th and 24th month follow-up, all patients had radiographic examination and underwent a final clinical evaluation based on the modified Merle d'Aubigne and Postel score. The strength of the abductors was assessed according to the Medical Research Council (MRC) grading system.</p><p><b>RESULTS</b>Congruent reduction was achieved in all patients and all osteotomies healed within an average period of 3.8 months. All our patients were allowed full weight bearing at the end of 3 months and with no abductor lurch at the end of 6 months follow-up. There were no cases of avascular necrosis of femoral head. None of the patients had any neurovascular complication or infection by the end of the follow-up period.</p><p><b>CONCLUSION</b>Trochanteric flip osteotomy is a very effective technique to fix certain acetabular fractures especially those with dome involvement. It is more accurate and associated with no significant complications compared with conventional way.</p>

Unusual manifestations associated with primary hypothyroidism: Experience from a tertiary care health center / Journal of the ASEAN Federation of Endocrine Societies

@#Hypothyroidism is a commonly diagnosed endocrine disorder. Typical signs and symptoms of hypothyroidism include lethargy, cold intolerance, hoarseness, dry skin, constipation, delayed relaxation phase of deep tendon reflexes, and bradycardia. However, some patients may present with unusual signs and symptoms of hypothyroidism which can result in diagnostic confusion. Besides the usual clinical manifestations of primary hypothyroidism, some signs are very unusual and not commonly recorded. The treating physician may not be familiar with them. Hence, timely identification of these unusual presentations is very important for early intervention and treatment.

Abordaje de Kocher-Langenbeck en el manejo quirúrgico de las fracturas posteriores del acetábulo / Kocher-Langenbeck approach in the surgical management of posterior wall fractures of the acetabulum

Resumen: Las fracturas de acetábulo son lesiones articulares que en la mayoría de los casos requieren manejo quirúrgico para restablecer la integridad de la articulación de la cadera y el anillo pélvico. Las fracturas de elementos posteriores del acetábulo deben ser tratadas por abordajes posteriores. El de Kocher-Langenbeck es el más recomendado en la mayoría de los casos.

Abstract: Surgical treatment of acetabular fractures is indicated in displaced cases in order to restore and stabilize the hip joint and the pelvic ring integrity. Posterior structure fractures must be treated through posterior pelvic surgical approaches. The Kocher-Langenbeck is the most recommended approach for the majority of posterior acetabular fractures.

Unstable posterior acetabular fractures: Early results of delayed reduction and fracture fixation using the Kocher-Langenbeck approach with trochanteric flip osteotomy

@#<p style="text-align: justify;">Unstable posterior acetabular fractures resulting from high energy trauma present major challenges to any orthopedic surgeon especially if the treatment has been delayed.<br /><strong>OBJECTIVE:</strong> The purpose of this paper is to describe the early results of delayed treatment of a series of patients with posterior acetabular fractures with concomitant hip dislocations, surgically approached using the Kocher-Langenbeck with a trochanteric flip osteotomy.<br /><strong>METHODS:</strong> Five (5) male patients (mean age 35.6 years, range 23-58 years) who sustained unstable posterior acetabular fractures, underwent surgical treatment using the Kocher-Langenbeck approach with the trochanteric flip osteotomy, during the period of May 2014 to October 2015. Clinical and radiographic evaluations of each patient were performed, while complications were documented.<br /><strong>RESULTS:</strong> Mean follow-up was 8 weeks (range 2-12 weeks). There was adequate exposure of the posterior and superior acetabulum in all patients. Post-operative radiographs in four of five patients were graded "anatomic" while hip range of motion of these four patients averaged 78.7% of the uninjured hip. One patient with "poor" reduction underwent a second operation to reserve a failure of the initial fixation using the same surgical approach. No other complications were reported.<br /><strong>CONCLUSION:</strong> This modified approach provides adequate exposure of both posterior and superior acetabulum and also allows inspection of the articular surfaces of both acetabulum and femoral head, which are limited in the standard Kocher-Lagenbeck approach. With excellent exposure, congruent reduction can readily be achieved while permitting early hip range of motion post-surgery.</p>

Treatment of posterior dislocation and acetabular posterior column (wall) fracture with greater trochanteric os-teotomy via Kocher-Langenbeck approach / 局解手术学杂志

Objective To introduce the operation method and curative effect of posterior dislocation and acetabular posterior column ( wall) fracture with greater trochanteric osteotomy via Kocher-Langenbeck approach. Methods 14 cases of posterior dislocation and ace-tabular posterior column( wall) fracture who were treated by greater trochanteric osteotomy via Kocher-Langenbeck approach were collected, and the surgical methods, intraoperative situation and postoperative recovery were analyzed. Results The mean operating time is 105 min and the mean bleeding volum is 600 mL. After operation, there were 5 cases of anatomical reduction;8 cases of good reduction;1 cases of unsatisfactory reduction. Among the patients, 7 cases were of excellent clinical effect;4 cases were of good clinical effect, 3 cases were of medium clinical effect. Heterotopic ossification occurred in 3 cases and traumatic arthritis occurred in 4 case. Both acetabular posterior col-umn ( wall) and trochanter osteotomy ends were healed, and there was no iatrogenic sciatic nerve and femoral head necrosis injury. Conclu-sion In treatment of posterior dislocation and acetabular posterior column ( wall) fracture, greater trochanteric osteotomy via Kocher-Lange-nbeck approach can provide excellent exposure, and it is conducive to the reduction and fixation of fracture and dislocation.

“Kocher debre semelaigne syndrome” : a case report.

We report a case of 12 year old male child with Kocher-Debré-Semelaigne syndrome (KDSS) which is a rare clinical presentation of hypothyroidism associated with muscular pseudo-hypertrophy. The main differential diagnosis is Duchenne Muscular Dystrophy. Pseudomuscular hypertrophy of KDSS is an acquired type of myopathy associated with severe and long standing hypothyroidism and is reversible with thyroxine supplement.

Extended Kocher Approach for Total Elbow Arthroplasty

PURPOSE: Total elbow arthroplasty is most commonly performed through a posterior approach by splitting or reflecting the triceps off the olecranon, but triceps avulsion, triceps weakness, and wound healing problems have been reported. We present the clinical results of total elbow arthroplasty using extended Kocher approach. MATERIALS AND METHODS: From September 2005 to October 2007, five patients who underwent total elbow arthroplasty using triceps preserving approach were evaluated. There were 4 women and 1 man. The mean age of the patients was 58 years (range, 36~68). The mean follow- up was 10 months. The patients were placed in the lateral decubitus position, and lateral Kocher interval is made through a straight posterior incision. Elbow joint is exposed by supinating the forearm and prosthesis was inserted. Postoperatively, the elbow was immobilized in extension for 1 week, and active range of motion exercise was begun. Range of motion, triceps strength, Mayo elbow performance score, Korean DASH questionnaire were evaluated at the last follow-up. RESULTS: Average operation time was 115 minutes (range, 97~138). Postoperative complications such infection, skin necrosis were not developed. Triceps strength was measured as grade IV in all patients except one who has triceps insufficiency preoperatively. Mean elbow range of motion was from 8 degrees to 124 degrees. Mean Mayo elbow performance score was 87 (range 75~95), and DASH score was 18 (range 9~34). CONCLUSIONS: Extended Kocher approach can be a reasonable alternative for total elbow arthroplasty. Linking the assembly can be difficult, so modification of the implant design is needed to solve this problem.

Serum creatine kinase activity in untreated primary hypothyroid children.

Objectives To determine association between primary hypothyroidism and serum creatine kinase (CK) activity in children. Design and Setting Prospective study of patients seen at university paediatric unit, Galle for a period of 4 years starting from January 1998. Method Primary hypothyroidism was confirmed by presence of elevated serum thyroid stimulating hormone and low thyroxine for age. All newly diagnosed patients with primary hypothyroidism were tested for serum CK activity. Levels were compared with serum CK activity in normal euthyroid children. Serum CK levels were repeated 6 weeks after starting thyroxine therapy. Results 19 children presented with primary hypothyroidism during study period. All had elevated serum CK levels. 2 patients showed clinical evidence of muscular hypertrophy. There were 7 neonates with congenital hypothyroidism. Conclusions: Elevated levels of CK activity were seen in all children with untreated primary hypothyroidism in this series. CK activity became normal 4-6 weeks after starting therapy. Hence elevated serum CK could be used as an indicator for diagnosis of untreated hypothyroidism or to assess adequacy of therapy in primary hypothyroidism.