[Laparoscopic hand-assisted operation. Review of the literature and initial personal experiences with the HandPort System]. / Laparoskopische handassistierte Operationen. Literaturübersicht und erste eigene Erfahrungen mit dem HandPort-System.

BACKGROUND: During complex laparoscopic operations sometimes the situation of a "missing hand" will occur. Using a device for hand assistance, the surgeon can place one hand into the abdominal cavity to assist the laparoscopic procedures. METHOD: After a laparotomy of 7-8 cm length, the surgeon can bring one hand into the abdomen via a special device maintaining the pneumoperitoneum. This hand can be helpful, i.e. for exploration, for retraction of gut and organs or for extraction of the specimen. Indications are complex laparoscopic operations such as stomach or colonic resections or splenectomies. In obese patients or patients with extended adhesions, preparation can be facilitated. RESULTS: The literature review and the author's own results with 10 patients since 2000 show remarkable advantages in operative situations when the laparoscopic procedure is complicated or even impossible. In our 10 patients, all operations could be managed laparoscopically by using the HandPort device. CONCLUSIONS: Complicated operations can be performed laparoscopically without conversion to conventional laparotomy by using the hand assistance. These patients do not have to forgo to the benefit of minimally invasive operations.

[Laparoscopic appendectomy in advanced stages of appendicitis]. / Die laparoskopische Appendektomie bei fortgeschrittenen Stadien der Appendizitis.

The laparoscopic stapling appendectomy (LA) is a safe and efficient procedure for all forms of appendicitis. Overall, LA was performed in 51.8% of 280 patients with advanced appendicitis, in 1998 in more than 85%, due to increasing experience. In these cases, the appendix was dissected in double-staple technique and extracted in an endo-bag. The postoperative outcome was uncomplicated even in advanced appendicitis, a reoperation had to be done in 2 patients (1.4%). Wound infections occurred only in 3.5% of patients with LA compared to 8.2% with open appendectomy, the mortality was 0%.

[Laparoscopy in intra-abdominal infection. Its diagnostic value and therapeutic possibilities]. / Laparoskopie bei intraabdomineller Infektion. Diagnostischer Stellenwert und therapeutische Möglichkeiten.

In 550 patients with the clinical features of acute abdomen a surgical laparoscopy was performed. In 121 cases there was found an unspecific reason of the acute abdominal disease that did not require surgical therapy. In 349 cases a regional peritonitis was found, 80 times a diffuse peritonitis. The diagnostic validity of laparoscopy was 96% as compared to 42% for sonography. The laparoscopic access resulted in a complication rate of 0.2%. In 239 cases (43%) the disease could be managed laparoscopically, 190 cases (35%) required open surgery.

[Surgical laparoscopy in acute abdomen]. / Chirurgische Laparoskopie beim akuten Abdomen.

In 582 patients, laparoscopy was performed for acute abdominal pain and symptoms of acute abdomen. It allowed a clear diagnosis in 96% as compared to 42% by sonography and 25% by X-ray. In 134 cases (22%) laparotomy (i.e. unnecessary appendectomy) could be avoided. In 42% surgery could be performed laparoscopically, and 36% required surgery by laparotomy.

[Value of laparoscopy in suspected appendicitis]. / Stellenwert der Laparoskopie bei Appendicitisverdacht.

By laparoscopy the rate of negative appendectomies was reduced to 3.4%. Decision-making regarding open or laparoscopic appendectomy and selection of suitable cases has improved the results in operating time and complication rate. In patients with non-typical clinical signs of suspected appendicitis the therapeutic decision was influenced in 30% or 6%, respectively.

Laparoscopic colon resection and intracorporeal hand-sewn anastomosis.

The application of laparoscopic surgical techniques to colonic surgery is restricted to selected cases and to rather few surgical centers. On the one hand, the disadvantages of the open approach involves the sizable laparotomy incision for mobilization of the viscera, especially if the colonic flexures are to be mobilized. On the other hand, in the minimally invasive approach the extent of dissection requires additional skills and a well honed endoscopic surgical team is needed especially if laparoscopic reconstruction of the large colon is to be accomplished. The teamwork is more critical for colon procedures than for laparoscopic gallbladder surgery.

[Complications after severe corrosive lesion due to acid in the upper gastrointestinal tract (author's transl)]. / Komplikationen der schweren Säureverätzung im oberen Gastrointestinaltrakt.

Case reports of 3 patients are given with severe corrosive lesions of the esophagus and stomach due to acid ingestion. All of them survived the initial phase and seemed to be expecting a favourable clinical course. In all of these cases however massive upper gastrointestinal bleeding, perforation, and death occurred in a later phase after an interval free of symptoms. Treatment of severe corrosions of the upper gastrointestinal tract differs significantly from treatment of less serious cases. In less severe cases care has to be taken to avoid later complications in the first place. If there are serious corrosions however vital indications are predominant in determining the course of treatment during the initial phase. An interval with no or rather few clinical symptoms of 3 weeks duration after severe corrosive lesions should not be considered to exclude the danger of later lethal complications, especially bleeding and perforation. In order to avoid such complications endoscopic and eventually surgical exploration after the acute initial phase is recommended.

Atraumatic method of renal blood flow estimation by 133Xenoninhalation and its application to transplanted kidneys.

Non-invasive measurement of organ blood flow can be achieved by tracing the elimination patterns of 133Xe administered by inhalation. An adaption of the method for the estimation of renal blood flow was developed. The 133Xe is accumulated in the tissue by re-breathing for 1 min and the time course of its washout from the kidney is followed for 14 min thereafter. Normal values were determined in ten dogs and forty-five healthy human volunteers. In man they were similar to results obtained with 131I-hippuran clearance. When flow rates were between 250 and 600 ml/100 g/min the correlation coefficient was 0.84. Only in cases with high cortex flow rates (greater than 600 ml/100 g/min) did the inhalation method give values higher than those determined by the 131I-hippuran clearance. In dogs the results closely correlated with results obtained by direct intra arterial xenon injection (r = 0.96). The value of the inhalation method in routine examination of patients with kidney transplants and its suitability for the early detection of ongoing rejection is demonstrated.

[Metabolic activities in isolated hepatocytes as a vitality parameter in the hypothermically preserved liver]. / Stoffwechselaktivitäten isolierter Hepatocyten als Vitalitätsparameter in der hypotherm konservierten Leber.

Vital hepatocytes have been isolated from an adult human liver for the first time. Vitality of the parenchymal cells was examined by trypanblue staining, morphological sppearance and energy-requiring metabolic functions such as gluconeogenesis and glycogen synthesis. Following a cold ischemic time of 6 hours metabolic activity had decreased considerably.

[Causes and risks in a interruption of systemic immunosuppressive therapy following kidney transplantation]. / Ursachen und Risiko einer Unterbrechung der systemischen immunsuppressiven Therapie nach Nierentransplantation.

The immunosuppressive therapy of 22 transplant recipients was temporarily suspended 25 times resulting in rejection reactions in 7 cases with the eventual loss of five transplants. One patient succumbed to fungal infection following the loss of kidney function. No connection between the risk of rejection and the previous number of rejection treatments or the histocompatibility could be established. Acute rejection reactions mostly occurred immediately after the interruption of therapy. There was no increased risk associated with a longer break in treatment. Interruption of therapy during the first period of immunosuppressive treatment, that is approximately 3 months after transplantation, was associated with the lowest risk of rejection. As a result of our experience in 25 cases it appears that the temporary suspension of immunosuppressive therapy is associated with little risk and avoids a drug intoxication as well as reduces the mortality due to infection.

[Clinical hemodilution]. / Klinische Hämodilution Vergleichsstudie bei 112 abdominalchirurgischen Patienten speziell zu Fragen der Verträglichkeit

UNLABELLED: Acute hemodilution has been performed in 46 patients immediately before major gastrointestinal surgery. Clinical, hemodynamic, respiratory and metabolic parameters have been studied and compared with results in 66 patients, submitted to similar operations under equal conditions without hemodilution. Two kinds of hemodilution have been used: normovolamic hemodilution by bloodexchange with 5% human albumin and moderate hypervolamic hemodilution by bloodexchange with equal parts of Dextran 60 and PPL. RESULTS: 1. The first mentioned kind of hemodilution and method of blood-exchange was superior in regard to stability of cardiovascular behavior. 2. The general tolerance of anesthesia and surgical trauma was superior in the nonhemodiluted group, but was good or tolerable also in the hemodiluted group in 82,6%. Side effects, more frequently and more pronounced in the hemodiluted group concerned to hypo- and hypertensive reactions, vasoconstriction, hypokaliemie and cardial arrhythmics. Exclusively in the hemodiluted group ST-lowering in the EKG has been stated in some patients. These reactions have been estimated as a sign of marginal compensatory capacity in the individual cardial situation and were reversibel by blood transfusion. These observations strengthen the necessity for accurate monitoring in hemodiluted patients. Moreover it is recommended to restrict hemodilution in the level of Hk 27-28%. Under these conditions acute normovolamic hemodilution is recommended further for a wider clinical use.

[Hypertonic circulatory response to clinical haemodilution (author's transl)]. / Kreislaufreaktionen bei Håmodilution

Preoperative haemodilution was performed in 46 patients. By exchange of 1785 ml of patient's blood with plasma substitutes, haematocrit was lowered to 24.8% mean. Cardiac output rose, the other circulatry parameters remained constant on average. 8 patients experienced, however, a circulatory reaction with acute systemic and pulmonary hypertension, peripheral vasoconstriction, and ST-depression in ECG. These cases showed a decrease in oxygen uptake. In further 42 patients haemodilution was limited to haematocrit 27%, and only three weak hypertonic reactions were observed. Therefore we recommend haemodilution to be limited to this hematocrit. Saving homologous blood transfusions is the major goal of haemodilution. In comparable surgical procedures 60-70% of patients without haemodilution are given homologous blood. In our two patient groups with haemodilution blood transfusions were necessary in 15 and 21%, respectively. Thus, haemodilution is a valuable mean of hepatitis prophylaxis by saving homologous blood transfusions. This advantage outweighs the possible risks of circulatory reactions.

[Special problems in anaesthesia of haemodiluted patients (author's transl)]. / Spezielle Gesichtspunkte zur Narkoseführung bei akut hämodiluierten Patienten

In a series of 46 patients acute haemodilution was deliberately performed to test the validity of experimental data in clinical practice. Several metabolic and haemodynamic parameters as well as continuous registration of ECG were followed. The withdrawn blood has been exchanged by Dextran 60/PPL in equal quantities resp. by 5% human albumin. Using Dextran 60/PPL a light degree of hypervolemia (700 ml) was applied. Results confirmed that haemodilution is practicable in patients in principe. Exchange of blood by human albumin was followed by less severe side effect of haemodilution than was exchange by Dextran 60/PPL. in mild hypervolaemia. The course of haemodiluted and non haemodiluted patients during comparable surgical procedures (gastrointestinal operations) has been analysed: although measured parameters did not differ significantly between both series--except of Hb and Hk--side effects of the cardiovascular type were more frequently observed in the hemodilutiongroup. Provided there is knowledge of the dangers and side effects and special care (control monitoring) of the patients by the anesthesiologist, acute hemodilution is further recommended.

[Clinical experiences with the acute normovalemic hemodilution (author's transl)]. / Klinische Erfahrungen mit der akuten normovolämischen Hämodilution

Acute normavolemic hemodilution is a mean of autotransfusion and allow hepatitis prophylaxis in major surgical procedures which general require homologous blood transfusions. The dilutional drop in blood viscosity is followed by an increased cardiac output, while blood pressure and heart rate remain stable. The CO incerase compensates for the reduced oxygen capacity of the diluted blood. Hemodilution was applied in a total of 88 patients. In 46 cases thorough circulatory and laboratory investigations were performed. While an average of 1785 ml blood was withdrawn and replaced synchronically by plasma substitutes, hematocrit was lowered to 24.8% mean and CO rose from 4.4 to 6.01 l/min. In one half of the patients side reactions were observed that occurred in combination as a syndrome in 8 patients: rise in systemic blood pressure and pulmonary artery pressure, disproportional CO increase, peripheral vasoconstriction, and ST-depression in ECG. The possible pathomechanisms of these side reactions are discussed. A sympathetic adrenergic reaction could be excluded by catecholamine estimation. Hyposia may be assumed to be the more probable reason. Since severe side reactions only occured at hematocrit levels below 26%, the dilution waslimited lately to hct 27%. Patients with coronary heart disease, age greater than 70 years, and anemia less than 12 g% hgb were excepted. In 70% of major surgical procedures, e.g. colonic surgery, homologous blood becomes necessary, in 50% in the amount of 2-4 units. The corresponding blood loss of 1000-2000 ml may be compensated by acute normovolemic hemodilution and autotransfusion. In fact, only 15% of our patients required homologous blood transfusions.

[Haemodilution and cerebral blood flow (author's transl)]. / Hämodilution und Gehirndurchblutung

Cerebral blood flow has been estimated in 10 patients during acute haemodilution and during the consecutive operation. Cerebral blood flow showed a lasting increase during the time of haemodilution, but this increase did not parallel the decrease of haematocrit value. The increase of cerebral blood flow became pronounced only, when the haematocrit become lower than 30%. Assumably the elevation of cerebral flow is mainly due to autoregulative mechanisms of cerebral blood flow to sustain oxygenation. It is concluded, that haemodilution below values of 30% hc might be dangerous in patients suffering from cerebral sclerosis.