Laparoscopic transversus abdominis release for complex ventral hernia repair: technique and initial findings.

PURPOSE: The open Rives-Stoppa retrorectus and transversus abdominis release (TAR) techniques are well established in open ventral and incisional hernia repair. The principles are currently being translated into minimally invasive surgery with different concepts. In this study, we investigate our initial results of transperitoneal laparoscopic TAR for ventral incisional hernia repair (laparoscopic TAR). METHODS: Over a 20-month period, 23 consecutive patients with incisional hernias underwent surgery. Laparoscopic TAR was performed transperitoneally with adhesiolysis from the anterior abdominal wall, development of the retrorectus space and TAR, midline reconstruction and extraperitoneal mesh reinforcement. RESULTS: There were 23 incisional hernias, of which 70% were M2-M4 and 60% were W3. Median patient age was 68 years and the median BMI was 31. Median operating time was 313 min, and hospital stay was 4 days. Morbidity was 26% (Clavien-Dindo 1: n = 4 and 2 + 3b: n = 2). CONCLUSION: With the laparoscopic TAR, it was possible to treat a series of patients with ventral incisional hernias. The operating times were long. However, with a low rate of perioperative complications the hospital stay was short As feasibility is demonstrated, the clinical relevance of the method has to be further evaluated.

[Intrahepatic cholangiocarcinoma : Results after 84 resections]. / Das intrahepatische Cholangiokarzinom : Ergebnisse nach 84 Resektionen.

BACKGROUND: The incidence of intrahepatic cholangiocarcinoma (ICC) is increasing worldwide. Surgical resection is the only curative treatment option. AIM OF THE STUDY: This study analyzed the prognostic factors after resection of ICC. MATERIAL AND METHODS: A total of 84 patients were surgically treated under potentially curative intent. Perihilar and distal cholangiocarcinomas were excluded. The 5­year survival was analyzed with respect to tumor stage (TNM), number of lesions, complete surgical resection (R0), peritoneal carcinosis and postoperative complications. RESULTS: The 5­year survival was 27% and 77% of patients underwent R0 resections. In the univariate analysis a T stage >2, an N+ situation or an R+ resection as well as peritoneal and multilocular intrahepatic spread were associated with a poorer prognosis. Postoperative complications also negatively influenced survival. On multivariate analysis the absence of peritoneal spread, node-negative tumor stages, singular hepatic lesions and a low T stage as well as the absence of complications were associated with improved survival. DISCUSSION: The prognosis of ICC is poor even after successful surgical resection. Well-known tumor characteristics such as TNM are relevant prognostic factors. Surgical resection is accompanied by postoperative complications (most frequently biliary), which negatively influence survival. Adjuvant strategies are urgently needed to improve long-term survival even after complete surgical resection.

Interobserver variability in target volume delineation of hepatocellular carcinoma : An analysis of the working group "Stereotactic Radiotherapy" of the German Society for Radiation Oncology (DEGRO).

BACKGROUND: Definition of gross tumor volume (GTV) in hepatocellular carcinoma (HCC) requires dedicated imaging in multiple contrast medium phases. The aim of this study was to evaluate the interobserver agreement (IOA) in gross tumor delineation of HCC in a multicenter panel. METHODS: The analysis was performed within the "Stereotactic Radiotherapy" working group of the German Society for Radiation Oncology (DEGRO). The GTVs of three anonymized HCC cases were delineated by 16 physicians from nine centers using multiphasic CT scans. In the first case the tumor was well defined. The second patient had multifocal HCC (one conglomerate and one peripheral tumor) and was previously treated with transarterial chemoembolization (TACE). The peripheral lesion was adjacent to the previous TACE site. The last patient had an extensive HCC with a portal vein thrombosis (PVT) and an inhomogeneous liver parenchyma due to cirrhosis. The IOA was evaluated according to Landis and Koch. RESULTS: The IOA for the first case was excellent (kappa: 0.85); for the second case moderate (kappa: 0.48) for the peripheral tumor and substantial (kappa: 0.73) for the conglomerate. In the case of the peripheral tumor the inconsistency is most likely explained by the necrotic tumor cavity after TACE caudal to the viable tumor. In the last case the IOA was fair, with a kappa of 0.34, with significant heterogeneity concerning the borders of the tumor and the PVT. CONCLUSION: The IOA was very good among the cases were the tumor was well defined. In complex cases, where the tumor did not show the typical characteristics, or in cases with Lipiodol (Guerbet, Paris, France) deposits, IOA agreement was compromised.

[The surgical technique of laparoscopic right hemihepatectomy. Technical aspects and results]. / Chirurgische Technik der laparoskopischen Hemihepatektomie rechts. Machbarkeit und Ergebnisse.

INTRODUCTION: This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy. PATIENTS AND METHODS: From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler. RESULTS: Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively. CONCLUSIONS: Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.

[Monitoring a melanocytic tumor. When is excision indicated?]. / Melanozytärer Tumor im zeitlichen Verlauf. Wann ist die Exzision indiziert?

Follow-up examination with comparison of dermoscopic images was performed over 24 months on an initially unimpressive, distinctly asymmetrical melanocytic tumor in a 39-year-old woman. She did not follow the recommendation for an excision after 19 months and 5 months later she came back for the next follow-up image. At this stage she was pregnant. The dermoscopic suspicion of a melanoma in-situ was confirmed by histology. This case is instructive in the view of follow-up, self-examination, self- detection of a melanoma, asymmetric changes of melanocytic lesion and evaluation of changes during pregnancy.

Pitfalls and technical aspects during the research of intestinal anastomotic healing in rats.

BACKGROUND: Fundamental experimental research into intestinal anastomotic healing in rodent models will gain increasing interest in the future. METHODS: The aim of this study was to describe our 5-year experience with a standardized experimental setup of small and large bowel anastomoses in a rodent model and present a basic set of assessment tools investigating anastomotic healing. Anastomotic technique, perioperative complications such as anastomotic insufficiency (AI) and obstructive ileus were in the focus. RESULTS: During different studies with varying study patterns, 167 rat small bowel anastomoses and 120 colonic anastomoses were performed. Overall mortality was 3.6% in small bowel and 2.5% in colonic anastomoses, AI occurred in 2.9 and 4%, respectively. A postoperative obstructive ileus was seen in 3/167 small bowel anastomoses and none in the colonic group. CONCLUSION: When performing experimental intestinal anastomoses in a standardized operative setting and critically considering special perioperative issues, the incidence of relevant complications can be maintained at an adequately low level.