[Artificial intelligence, robotics and digitalization in the concept of military surgery of the German medical service]. / Künstliche Intelligenz, Robotik und Digitalisierung im Konzept der Einsatzchirurgie des deutschen Sanitätsdienstes.

BACKGROUND: As in other areas, military surgery is being transformed by developments in artificial intelligence, robotics and digitalization. Although the prospect of operating with a robot-assisted surgery system in the country of deployment while the responsible surgeon is in Germany is still a long way off, the training of military surgeons and the treatment of injured soldiers on deployment would nowadays be unimaginable without the digitalization of surgery in the armed forces. The structure of the medical environment in German clinics places restrictions on training that is close to operational reality. In the daily routine it is not possible to carry out the necessary numbers of deployment-relevant emergency surgical procedures under the expected conditions. Such procedures thus require the use of appropriate simulators or simulated scenarios that are as close to reality as possible. Although military surgeons are qualified in at least two specialist areas, the availability of telemedicine on deployment is helping to noticeably improve the treatment of injured soldiers. Telemedical consultation with colleagues in Germany makes it possible, for example, to reach joint decisions across different branches and disciplines. CONCLUSION: Until now it has not been possible to substitute the attending surgeon in the country of deployment with robot-assisted surgery systems or even robots for carrying out life-saving and stabilizing procedures; however, in order to provide surgeons with the necessary tools to successfully operate in situations where there is a shortage of personnel and materials in an inhospitable environment, use is made of the means that are currently available in the German medical services and constant efforts are made to explore the future possibilities of digital simulation. This article shows the reader the current status of digitalization in surgical training and deployments in the German armed forces.

[Hemostyptics for treatment of junctional vascular injuries : Management of traumatic vascular injuries at the transition from trunk to extremities]. / Hämostyptika zur Behandlung der "junctional vascular injuries" : Versorgung traumatischer Gefäßverletzungen am Übergang vom Körperstamm zur Extremität.

BACKGROUND: Uncontrolled post-traumatic bleeding is still the leading cause of death among trauma patients. In situations of mass casualty incidents (MASCAL) and military conflicts the treatment of uncontrolled critical bleeding is a challenge and associated with a worse outcome due to the austere environment; however, even under optimal treatment circumstances in situations of individual medicine the severity of vascular trauma is underestimated. As a consequence, this leads to a poorer prognosis for patients with (vascular) injuries. From this perspective it was reasonable to intensify the training of physicians, paramedics (Advanced Trauma Life Support©) and first responders (Hartford consensus) for handling of critical bleeding in traumatized patients. Furthermore, the main emphasis of the revised S3 clinical guidelines on polytrauma/severely injured treatment from 2016 of the German Society for Trauma Surgery is on the preclinical treatment. Despite a renaissance and increasing use of tourniquets, the treatment of bleeding in the transition from the trunk to the extremities (junctional vascular injuries), which are inaccessible to placing a tourniquet, remains a problem. CONCLUSION: It was the military that in addition to the development of special tourniquets, intensified research programs and the implementation of hemostatic devices and dressings in this anatomical region. This article deals with junctional vascular injuries at the transition between the trunk and the extremities. In addition to the anatomical situation, this article gives the reader an overview of the currently available hemostyptics and their mode of action.

[Treatment strategies for mass casualty incidents and terrorist attacks in trauma and vascular surgery : Presentation of a treatment concept]. / Versorgungsstrategien beim MANV/TerrorMANV in der Unfall- und Gefäßchirurgie : Darstellung eines Versorgungskonzeptes.

The treatment of patients in the context of mass casualty incidents (MCI) represents a great challenge for the participating rescue workers and clinics. Due to the increase in terrorist activities it is necessary to become familiar with this new kind of threat to civilization with respect to the medical treatment of victims of terrorist attacks. There are substantial differences between a "normal" MCI and a terrorist MCI with respect to injury patterns (blunt trauma vs. penetrating/perforating trauma), the type and form of the incident (MCI=static situation vs. terrorist attack MCI= dynamic situation) and the different security positions (rescue services vs. police services). This article is concerned with question of which changes in the surgical treatment of patients are made necessary by these new challenges. In this case it is necessary that physicians are familiar with the different injury patterns, whereby priority must be given to gunshot and explosion (blast) injuries. Furthermore, altered strategic and tactical approaches (damage control surgery vs. tactical abbreviated surgical care) are necessary to ensure survival for as many victims of terrorist attacks as possible and also to achieve the best possible functional results. It is only possible to successfully counter these new challenges by changing the mindset in the treatment of terrorist MCI compared to MCI incidents. An essential component of this mindset is the acquisition of a maximum of flexibility. This article would like to make a contribution to this problem.

[Evaluation of interest in research among surgically active medical officers in the German Armed Forces]. / Evaluation des Forschungsinteresses unter chirurgisch tätigen Sanitätsoffizieren der Bundeswehr.

BACKGROUND: Research in military medicine and in particular combat surgery is a broad field that has gained international importance during the last decade. In the context of increased NATO missions, this also holds true for the Bundeswehr (German Armed Forces); however, medical officers in surgery must balance research between their clinical work load, missions, civilian and family obligation. MATERIAL AND METHODS: To evaluate engagement with and interest in research, a questionnaire was distributed among the doctors of the surgical departments of the Bundeswehr hospitals by the newly founded working group Chirurgische Forschung der Bundeswehr (surgical research of the Bundeswehr). Returned data were recorded from October 2013 to January 2014 and descriptive statistics were performed. RESULTS: Answers were received from 87 out of 193 military surgeons (45 %). Of these 81 % announced a general interest in research with a predominance on clinical research in preference to experimental settings. At the time of the evaluation 32 % of the participants were actively involved in research and 53 % regarded it as difficult to invest time in research activities parallel to clinical work. Potential keys to increase the interest and engagement in research were seen in the implementation of research coordinators and also in a higher amount of free time, for example by research rotation. CONCLUSION: Research can be regarded as having a firm place in the daily work of medical officers in the surgical departments of the Bundeswehr; however, the engagement is limited by time and structural factors. At the departmental level and in the command structures of the military medical service, more efforts are recommended in the future in order to enhance the engagement with surgical research. This evaluation should be repeated in the coming years as a measuring instrument and data should be compared in an international context.

[Vacuum-assisted fascial closure in the management of diffuse peritonitis]. / Die V.A.C.-Therapie im Behandlungskonzept der diffusen Peritonitis.

The surgical treatment of patients suffering from peritonitis with an open abdomen is commonplace. However scheduled as well as required dressing changes and peritoneal lavages mean a time- and costs-intensive challenge for the nursing and medical personnel. Since the introduction of the abdominal dressing-kit (KCI, Walluf, Germany) in the management of diffuse peritonitis one expects to influence the patients' recovery in a positive way due to the continuous evacuation of intraabdominal infectious fluids, augmentation of tissue's granulation, prevention of fascial retraction and prevention of an abdominal compartment syndrome. First on trial we established 2004 in our surgical department the use of the abdominal dressing-kit as a routine procedure in the management of diffuse peritonitis.

[Urinary retention with ruptured fornix caused by a maggot. An autoerotic accident]. / Harnstauung mit Fornixruptur durch Schmeissfliegenlarve Ein autoerotischer Unfall.

Foreign bodies in the urinary tract represent a possible cause for genitourinary disease. A huge variety of objects are inserted into the urinary tract for therapeutic, autoerotic, or psychiatric reasons and the symptoms for foreign bodies can be rather unspecific. Dysuria, hematuria, and urinary tract infection can suggest the presence of intravesical foreign bodies. Symptomatic urinary retention is more seldom and the causal foreign bodies are mostly iatrogenically applied. We present a unique case of maggots self-inserted into the urinary tract for autoerotic reasons causing symptomatic urinary retention with fornix rupture.

Repair of intercostal pulmonary herniation.

Intercostal pulmonary herniation occurring years after blunt thoracic trauma is a rare phenomenon. We report on the case of a 66-year-old patient who developed a pulmonary herniation 2 years after a seat-belt injury. Thoracotomy was performed, and the thoracic wall defect was closed with approximating periostal absorbable sutures. The postoperative course was uneventful. Different surgical approaches and the use of prosthetic patches are discussed. Periostal fixation of the adjacent ribs with absorbable sutures is usually sufficient for herniation repair. In cases in which prosthetic meshes are needed, the application of PTFE might produce the best results with the least complications.

Gallamine triethiodide selectively blocks voltage-gated potassium channels in Ranvier nodes.

The effects of gallamine on ionic currents in single intact Ranvier nodes of the toad Xenopus were investigated. The following fully reversible effects were observed: 1. With a test concentration of 1 mmol/l the current-voltage relation of steady-state potassium currents, IK ss exhibited a complete block of IK ss up to about V = 110 mV; with stronger depolarisations the block was incomplete. The peak sodium currents, in contrast, were not affected. 2. At the same test concentration the potassium permeability constant PK was reduced by 92% from its normal value, while the sodium permeability constant PNa decreased by only 8%. 3. Concentration-response relations of the block of PK yielded an apparent dissociation constant of 30 micromol/l and a steepness parameter of unity. Patch-clamp experiments on cloned Kv1.1, Kv1.2, Kv1.3 and Kv3.1 channels yielded apparent dissociation constants of 86, 19, >>100 and 121 micromol/l, respectively. Our findings show that gallamine is particularly well suited for separating potassium and sodium currents in axonal current ensembles. They also strongly suggest that potassium currents in Ranvier nodes of Xenopus are mainly carried by an ensemble of Kv1.1 and 1.2 channels.

Tolperisone--a novel modulator of ionic currents in myelinated axons.

The actions of tolperisone on single intact Ranvier nodes of the toad Xenopus were investigated by means of the Hodgkin-Huxley formalism. Adding tolperisone to the bathing medium (100 micromol/l) caused the following fully reversible effects: 1. The sodium permeability P'Na was decreased by about 50% in a nearly potential-independent manner while the so-called sodium inactivation curve was shifted in the negative direction by about 3 mV. 2. The remaining parameters of the sodium system, i.e. m, taum and tauh, did not change. 3. The potassium permeability P'K decreased at strong depolarizing potentials (V > 60 mV); hence the permeability constant P(K) decreased by about 8%. However, weak depolarizations (V < 60 mV) caused P'K to increase by about 7%. 4. The potassium activation curve was shifted in the positive direction by about 9 mV and the exponent of n, b, was reduced from about 3.5 to about 1.5. Concentration-response relations for reduction of the sodium permeability constant PNa and of the potassium permeability constant P(K) yielded apparent dissociation constants of about 0.06 mmol/l and 0.32 mmol/l, respectively. The increase of P'K at V = 40 mV, however, was largely concentration-independent. Our findings show that, in contrast to the prevailing view, tolperisone cannot be said to have a so-called lidocaine-like activity, because its effect on potassium permeability in the threshold region is fundamentally different from that of other known local anaesthetics. We infer that this effect, in combination with the decrease in sodium permeability, is responsible for the tendency of tolperisone to reduce excitability and hence for the antispastic action of tolperisone documented by clinical observations.