[Hernia repair--which technique? Help in making the decision]. / Hernienrepair--welche Technik? Hilfen zur Entscheidungsfindung.

Operation of the inguinal hernia is the most common operation in general surgery. Many criteria influence the kind of operation the surgeon will perform. Detailed anatomic knowledge of the inguinal region, standardised tactical and technical performance of the operation team, careful preparation and a minimum of blood loss reduce complications to low levels. These items are the same for all operation methods. The Shouldice procedure has been the golden standard for many years, nowadays (1998) in America in more than 80% of operations a mesh is implanted in the abdominal wall. A Cochran review of EBM showed advantages for mesh repair compared to nonmesh repair. Patient oriented decision making in choosing a method for inguinal hernia repair should be the new standard of modern general surgery.

Evaluation of the effects of a pneumoperitoneum with carbon dioxide or helium in a porcine model of endotoxemia.

BACKGROUND: The expansion of the laparoscopic techniques to the critically ill patient is currently under debate. In order to evaluate the potential risks of performing laparoscopy in a body with signs of sepsis, the effects of the pneumoperitoneum were studied in a porcine model of mild endotoxemia. METHODS: Twenty-eight pigs were separated into four groups of seven animals: untreated control (C), 2 microg/kg/h endotoxin (E), endotoxin and a pneumoperitoneum (3 h, 15 mmHg) with CO2 (EC) or with helium (EH). Hemodynamic and homeostatic variables were studied for a period of 5.5 h. Primary endpoints were arterial and mucosal pH and the ATP content of the bowel wall. Statistical evaluation was performed using analysis of variance and the Bonferroni test. RESULTS: Endotoxin infusion induced characteristic symptoms of early sepsis: increase of arterial CO2, pulmonary arterial, portal venous, and pulmonary artery wedge pressure, and decrease of arterial pressure, cardiac output, arterial and mucosal pH. An additional pneumoperitoneum led to aggravation of all criteria with significant alterations in arterial and mucosal pH, arterial CO2, wedge and portal venous pressure. The most striking derangement of mean values was observed for mucosal pH (EC: 7.40, EH: 7.54) and arterial pH (EC: 7.15, EH: 7.18). In group EC, two animals died in septic shock. CONCLUSION: Applying a pneumoperitoneum during an ongoing sepsis significantly deteriorates hemodynamic and homeostatic variables, thus enhancing the risk of severe complications.

CO(2) pneumoperitoneum: what we know and what we need to know.

The development of the laparoscopic technique in surgery was so overwhelming that scientific evaluation could not keep in step. While investigators were still discussing the effects of the pneumoperitoneum on the healthy organism, laparoscopy was already performed in patients with an acute abdomen due to trauma or disease. Therefore, there is an urgent need of further experimental and clinical studies with relevant endpoints to gain external evidence concerning the benefits of diagnostic or therapeutic laparoscopy for critically ill patients. In experiments with pigs we have shown that even in a healthy organism perfusion and energy metabolism of the small bowel is impaired by a pneumoperitoneum with carbon dioxide. Under the conditions of a systemic inflammatory response syndrome induced by infusion of endotoxin, the negative effects of the pneumoperitoneum were significantly amplified. Furthermore, we found that the increased intracranial pressure as caused by a head injury was further enhanced during a pneumoperitoneum but not by the alternative method of mechanical wall retraction. The current literature dealing with the effects of a pneumoperitoneum in critically ill patients is still controversial. Our data support the results of those authors who hold the opinion that creating a pneumoperitoneum in patients with acute abdominal problems means an additional serious burden that in single cases may lead to a disaster. As evidence is lacking, the current extension of laparoscopy into the field of intensive care medicine is still a human experiment that must be performed with high responsibility, extensive monitoring, and according to the rules of a clinical study.

Pregnancy: A contraindication?

According to David L. Sackett evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence when making decisions about the care of individual patients. It means integrating individual clinical expertise with the best available external evidence from systematic research. On the basis of this idea in medicine the following communication summarizes and evaluates current statements and literature on laparoscopic surgery during pregnancy. The topic is an example for excellent individual clinical performance on one hand, as gynecologists have perform laparoscopic procedures during pregnancy for decades. On the other hand, pregnancy is considered to be a contraindication for laparoscopic surgery by clinicians, because no excellent external evidence from systematic research is available. To find an answer to the question of whether pregnancy is a contraindication for laparoscopic surgery we performed a literature search and gained information by conducting interviews with several experts in gynecology and endoscopic operations. We concluded that there are almost no "scientific" data about endoscopic surgery during pregnancy, but gynecologists representing the "real world" seem to have no fear of the procedure for their patients. Between the two extremes, performing laparoscopic operations during pregnancy might be advantageous for maximal patient-friendly surgery, but considering pregnancy as a contraindication for the laparoscopic approach might be the safer treatment. The reader may decide that the subject on endoscopic surgery in pregnancy is still open.

Laparoscopic vs conventional appendectomy--a meta-analysis of randomised controlled trials.

AIM: To compare the effectiveness and safety of laparoscopic and conventional "open" appendectomy in the treatment of acute appendicitis. METHODS: Meta-analysis of randomised controlled trials available by May 1998 that compared both techniques. Within each trial and for each outcome an effect size was calculated; the effect sizes were then pooled by a random-effects model. RESULTS: We summarised outcome data of 2877 patients included in 28 trials. Operating time was +16 min (95% confidence interval +12-20 min) longer for laparoscopic appendectomy. Overall complication rates were comparable, but wound infections were definitely reduced after laparoscopy [rate difference -4.2%, (-2.3% to -6.1%)]. Intra-abdominal abscesses, however, occurred slightly more frequently [+0.9%, (-0.4% to +2.3%)]. Hospital stay after laparoscopic appendectomy was 15 h (8-23 h) shorter, and patients returned to full fitness or work 7 days (5-9 days) earlier. Pain intensity on day 1 was slightly less. Heterogeneity was present for some outcome measures due to methodological differences among the primary studies. CONCLUSION: Laparoscopic appendectomy reduces wound infections and eases postoperative recovery. Nevertheless, the various differences among the primary studies and their partly flawed methodology make it difficult to generalise from these findings.

[Effect of pneumoperitoneum on plasminogen activator activity in the abdomen]. / Einfluss des Pneumoperitoneums auf die Plasminogen Aktivator-Aktivität im Abdomen.

In a study in pigs it was examined whether peritoneal plasminogen activator activity (PAA) is impaired by creation of a pneumoperitoneum (PP) with CO2 or with helium. The animals were anesthetised and laparotomised, and peritoneal biopsies were taken from the cecum, the ileum and the wound site. Then a PP of 15 mmHg was created with CO2 (Grp. 1, n = 6) or helium (Grp. 2, n = 6). Group 0 (n = 7) was left without gas insufflation. After a PP of 3 hrs and an additional observation period of 2 hrs further tissue samples were collected. In the biopsies specific PAA was determined. In all groups a decrease of specific PAA occurred. However, at the end of the experiment PAA was significantly lower in the cecum of the CO2-group (24.3 U/mg, 32.4%) when compared to the controls without gas (75.1 U/mg, 100%) or the helium group (65.1 U/mg 86.7%). Our data raise suspicion that insufflation of CO2 for laparoscopic intervention may enhance the risk of peritoneal adhesions by a suppression of PAA.

[Effect of pneumoperitoneum on hemodynamics and intestinal integrity in endotoxinemia: CO2 versus helium]. / Einfluss eines Pneumoperitoneums auf Hämodynamik und intestinale Integrität bei Endotoxinämie: CO2 versus Helium.

In a study in pigs pathophysiological effects of a pneumoperitoneum (PP) established during endotoxemia (2 micrograms/kg b.w./hr) were investigated. In this situation a PP with carbon dioxide (CO2) or helium induces a deterioration of systemic hemodynamics or acid-base-stability. Some of these effects threaten vital stability. PP with either gas causes a mucosal acidosis of the small bowel within the meaning of an impairment of intestinal oxygen supply. A CO2-PP adversely affects the intestinal energy metabolism and leads to significantly increased endotoxin levels in contrast to helium after desufflation of the abdominal cavity. Data of this study at least demand for a careful monitoring, if laparoscopy is performed in septic and critically ill patients.

[Laparoscopic colorectal surgery--attempt at evaluating a new technology]. / Laparoskopische colorectale Chirurgie--Versuch der Bewertung einer neuen Technologie.

The aim of this study was to access the importance of the laparoscopic colorectal resection. Of 131 patients 80 were operated on laparoscopically. The conversion rate was 14% (13/93). A total of 47 patients suffered from cancer. Curative resection was performed in 41 patients (87%). For comparison, 48 patients who underwent open resection were used. The complication rate was lower after laparoscopy and no reoperation was performed. Patients recovered quicker and their first oral food intake and bowel movement were earlier. Hospital stay was shorter (15.3 vs. 8.1 days), and pain at rest and in motion was significantly reduced. Equal numbers of mesenteric lymph nodes were retrieved; adequate margins of resection could be obtained and the length of resected bowel did not differ. No port metastases were observed. Reduced morbidity, reduced hospital stay, reduced abdominal pain, quicker reconvalescence, and reduced overall health care costs are strong arguments in favor of laparoscopic colectomy.

[Mayo duplication in treatment of incisional hernia of the abdominal wall after conventional laparotomy. Results of a retrospective analysis and comparison with the literature]. / Die Mayo-Dopplung zur Behandlung des Narbenbruchs der Bauchdecken nach konventioneller Laparotomie. Ergebnisse einer retrospektiven Analyse und ein Literaturvergleich.

About 10% of patients undergoing conventional laparotomy will develop incisional hernias. Traditionally these hernias are in this country most often repaired by a Mayo-duplication. In this retrospective analysis we investigated a consecutive series of 114 patients (mean age: 53 (11-87) years, gender ratio m:f 1.2:1.97% electively operated) with 135 hernias, operated between 1/1985 and 12/1992 by a standard Mayo-procedure. Recurrence-rates and quality of life were evaluated by clinical examination. The mean follow-up time was 5.7 (2.5-10.2) years with a follow-up rate of 84.4%. The overall recurrence rate was 53.5%. Further uni- and multi-variate analysis was unable to find any clinically relevant risk factors for hernia development. Health related quality of life was evaluated with a validated index at the time of their follow-up visit. There were no differences in patients without a hernia recurrence (n = 52) when compared to those with an actually present recurrence (n = 36). However, physical function of all patients was significantly impaired when compared to healthy individuals. According to our results and those reported by others the Mayo-duplication when applied to all patients leads to non-acceptable results and implantation of auto- or alloplastic material should be considered more frequently.

[Postoperative pain therapy in inpatient treatment]. / Postoperative Schmerztherapie in der stationären Behandlung.

Pain therapy is a central medical task and a legal duty. Not the anaesthetist but the pain-causing surgeon is responsible for therapy of pain. Pain as a negative sensation is subjective and individual. Postoperative pain is an essential aspect of the topic "pain in surgery". Therapy starts with the awareness of the problem. Effective pain therapy requires clinical competence and application of available therapeutic options. Initial steps of successful pain treatment include: an informative dialogue with the patient, conveying of confidence, and skillful choice of diagnostic and/or therapeutic options. Application of drugs presupposes detailed knowledge of their specific effects. For convincing therapeutic results, one has to analyse different causes of pain. Acute surgical pain is classified and treated according to a three-step scheme: intense pain with strong opioids, intermediate pain with weaker opioids or non-opioids, and slight pain with non-steroidal anti-inflammatory drugs. Opioids are used with caution in abdominal surgery because of their negative effects (obstipation), the same is the case with Novalgin in trauma patients because of its effect on temperature and leukopenia. Patient-controlled analgesia with appropriate devices means further progress for suitable patients. Effective pain therapy within the framework of successful surgery is feasible and influences patients' comfort and possibly even their morbidity and mortality.

[Laparoscopic colon resection in carcinoma--beneficial or not?]. / Laparoskopische Colonresektion beim Carcinom--sinnvoll oder nicht?

It was the aim of our study to investigate the role of laparoscopic colorectal cancer resection for cure. Postoperative morbidity, pain and hospital stay (n = 21) was reduced and patients' recovery accelerated compared to conventionally operated patients (n = 54). The number of resected lymph nodes and tumor distances were comparable; however, portal recurrences remain the main problem.

[Conservative surgery--choice of procedure and strategy: invasive versus minimally invasive surgery]. / Schonendes Operieren--Verfahrenswahl und Strategie: Invasives versus minimal invasives Operieren.

From the patient's view conservative surgery means less stress and strain through therapeutic interventions. Important criteria for assessment are freedom of pain, preservation of health or quick recovery from bodily impairments as well as reestablishment of integrity and fitness. The surgeon meets the patient's expectations through a careful interview, an operation with a minimally traumatizing access, a rather reliable technique and a careful follow-up. Endoscopic surgery most likely complies with this conception. This is shown in a prospective observational study on laparoscopic cholecystectomies in 500 patients and can also be expected for future indications.