[Surgical infections: the role of laparoscopic surgery]. / Chirurgische Infektionen - Stellenwert der laparoskopischen Chirurgie.

Surgical diagnostic and therapy in intraabdominal infections should be fast and definite. Infectious diseases of the abdomen are appendicitis, cholecystitis, peptic ulcer perforations, colonic perforations (mostly diverticulitis), gynaecologic infections and other rare indications. The role of laparoscopy especially in the treatment of intraabdominal infections is presented for different diagnoses. Besides its therapeutic options, laparoscopy plays a crucial role as diagnostic tool in intraabdominal infections. The decision for a laparoscopic or open access to the abdomen should be made individually under consideration of the diagnoses and the laparoscopic training of the operating team.

[Typical and avoidable doctor's errors in surgical gastroenterology]. / Arztliche Erfahrung, Kenntnis der Leitlinien, interdisziplinäres Gespräch. Wie man Kunstfehler in der Gastroenterologie vermeidet.

Everyone makes mistakes, and even the greatest efforts may fail to eliminate them completely. In contrast, typical errors and miscalculations--which by the very fact of being typical are predictable--can and must be avoided. The reasons for such mistakes may be lack of experience, inadequate interdisciplinary cooperation, and ignorance of the current state of the art. This applies equally, and in particular, to the field of surgical gastroenterology. Intensive interdisciplinary discussions, a healthy surgical hierarchy, a knowledge of pertinent guidelines and the latest literature and, last, but not least--against the present background of discussions about working hour and diagnosis-related groups--a rested and motivated physician, are the pillars of error-free patient management.

Intraoperative suspicion of gallbladder carcinoma in laparoscopic surgery: what to do?

The frequency of gallbladder cancer in Europe is less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, patients with gallstones have gallbladder removal much earlier in their gallstone history. So the percentage of gallbladder carcinomas will decrease in the future. We report on our surgical procedures in patients with suspicious gallbladders having laparoscopic gallbladder removal, and how to proceed after the diagnosis of gallbladder carcinoma. From June 1990 to December 2001, we have performed 7,130 cholecystectomies in a single department. 47 of these patients (0.66%) were identified as having carcinoma. There were 40 females and 7 males, with a mean age of 70.6 years. In 17 cases (36%) there was a preoperative suspicion of malignancy. Most commonly, in 30 cases (64%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathological examination of the resected gallbladder. We recommend removal with a bag for all gallbladders with a suspected wall or scleroatrophic calcified gallbladder area. In stage Tis or T1 laparoscopy + cholecystectomy is sufficient. For T2 and T3 we perform reoperation with liver bed resection and lymphadenectomy.

[Laparoscopic cholecystectomy--surgical standard in cholelithiasis]. / Laparoskopische Cholecystektomie--Chirurgischer Standard bei Cholelithiasis.

Laparoscopic surgery showed a dramatic development in the last years of the 20th century. From the beginning laparoscopic cholecystectomy (LCCE) has been the pacemaker of this development. Today laparoscopic cholecystectomy is the first choice for treatment of cholecystolithiasis in nearly all surgical clinics. Therefore laparoscopic cholecystectomy is the most common part of minimal invasive technique. LCCE is the golden standard in therapy of gallstones, more than 90% of cholecystectomies in specialized clinics are done laparoscopically. It is an established, evidence based operation today. Open cholecystectomy is left for special indications only. A problem of LCCE is the occult carcinoma of the gallbladder. In histological proven carcinoma of the gallbladder LCCE is the adequate operation only for Tis and T1 carcinoma. In T2 and T3 carcinoma a radical oncologic resection with lymph node dissection should be performed. Due to the poor prognosis T4 tumors should be left with laparoscopic biopsy only.

[Surgery of the gallbladder and bile ducts by minimally invasive surgery]. / Chirurgie der Gallenblase und Gallenwege durch MIC.

The laparoscopic cholecystectomy is the most used minimally invasive surgical technique. Seventy-five percent of all gallstone diseases are actually treated by this procedure, as proved by an impressive comparison of Swiss, Austrian and German data. More than 265,000 cholecystectomies are analyzed. Twelve percent of all operations are performed in an acute situation, intraoperative complications are found in 1%; the postoperative complications is 5%. The lethality in all countries is between 0.1 and 0.2%.

[Reuse of instruments for minimal invasive surgery--status and prospects]. / Aufbereitung von Instrumenten der minimal-invasiven Chirurgie--Stand und Perspektiven.

The development of instruments for minimal invasive surgery (MIS) is moving in the direction of the miniaturization of mechanical components, a combination of multiple functions in a single instrument, and the introduction of new techniques, in particular those reducing bleeding and thermal damage when cutting blood vessels. These tendencies have consequences for the reprocessability of the instruments, usually making reprocessing more difficult. In particular cleaning--the removal of contaminations from tiny lumina, joints, etc., is highly demanding. In addition, proof of successful cleaning is difficult, and no standardised method of doing this in practice is currently available. An overview of the problems associated with the reprocessing of instruments for minimal invasive surgery is given, and a numbers of possible solutions are discussed.

The clinical suitability of laparoscopic instrumentation. A prospective clinical study of function and hygiene.

On the basis of experience gained from 6,000 laparoscopies (73% cholecystectomies) at the Moabit Hospital in Berlin, we carried out a cohort study to analyze the failure rate and decontamination of labeled "tracer" instruments processed in three test trays that were each subjected to 100 cycles. The majority of repairs focused on the functional parts of separable scissors and damaged or lost components. At 4%, the repair index after laparascopic use was less than that of a previously documented investigation period covering 1990 to 1996. A comparison of the costs of disposable and reusable instruments showed that reusable instruments were more cost-effective by a factor of > or =10, indicating that the price gap reported in our previous calculation for 1992 and 1994 has closed only slightly. After 100 cycles, we found traces of proteinaceous material in the eluate on every fourth instrument inspected (eight of 32); half of them (four) gave a positive reading when tested with a hemoglobin pseudoperoxidase test stick. It must be said, however, that similar residual contamination has been found on instruments used in conventional open surgery, with no indication of clinical relevance. This study was designed to examine the clinical suitability of laparoscopic instruments in terms of function and hygiene. Improvements in instrument design and cleanability must focus in particular on the reproducibility of cleaning results, because cleaning is the most important step in processing sterile supplies. As the number of minimally invasive operations has risen considerably, a mere visual check no longer meets the requirements prescribed by modern quality assurance. A multicenter study of residual proteins found on tracer instruments in all surgical fields is now in progress.

How to proceed in patients with carcinoma detected after laparoscopic cholecystectomy.

Carcinoma of the gallbladder is a rare disease. Gallbladder carcinoma is detected in less than 1% of all gallstone operations. With the introduction of laparoscopic surgery and the higher acceptance of this technique, gallbladders are now removed much earlier than they used to be. With the increase of cholecystectomies, the diagnosis of unexpected gallbladder carcinoma became more frequent. We report on how to proceed in patients with a diagnosis of gallbladder carcinoma and discuss the additional problems that have arisen since laparoscopic cholecystectomy became established. From June 1990 to December 1999, we performed 6230 cholecystectomies in the surgical department of Moabit Hospital in Berlin. Of these, 42 (0.6%) were identified as carcinoma. There were 37 women and five men, and the mean age was 69 years. In 16 patients (39%), there was a preoperative suspicion of malignancy. In 26 patients (61%), malignancy was suspected intraoperatively or diagnosed postoperatively after pathologic examination of the resected gallbladder. In these patients, an open repeat operation was necessary in seven cases to achieve an adequate curative resection and staging. This involved additional liver bed resection and lymph node dissection of the hepatoduodenal ligament. Abdominal wall (port site) recurrence in the absence of distant metastasis was present only in two patients. We recommend removal using a bag in all gallbladders with wall thickening, irregularities, or scleroatrophic calcified gallbladder area. In stage Tis or T1, laparoscopic cholecystectomy is sufficient. In stage T2 and T3, we perform a repeat operation with liver bed resection and lymphadenectomy.

Sterile and economic instrumentation in laparoscopic surgery. Experiences with 6,000 surgical laparoscopies, 1990-1996.

BACKGROUND: Because so many common surgical problems can now be addressed by the laparoscopic approach, the issue of sterile processing has to be reconsidered. METHODS: Selected laparoscopic instrumentation was analyzed regarding wear and tear and decontamination after sterile processing following 6,000 surgical laparoscopies carried out between 1990 and 1996 at the Academic Hospital Moabit, Berlin. RESULTS: Fewer than 7.9 (parts of) instruments failed per 100 laparoscopies. Most of the repairs involved scissors. The main problems were blunting, burnt or disconnected electromechanical components, defective insulation, and damaged or lost parts of dismantable instruments. Residues of human blood proteins were detected on a few instruments. The effect of intraluminal rinsing was documented by measuring the iron content (as an indicator for blood contamination). A comparison of costs showed that it was >10 times cheaper to use instrumentation with reusable components. CONCLUSIONS: The sterile processing of economic reusable instrumentation for laparoscopies needs staff well trained in sterile supply. Instrument design should allow easy dismantling and rinsing of internal parts. Insulating compounds present a problem for decontamination. Disinfection with aldehydes before cleaning the lumina of instruments must be avoided because protein coagulation will occur. A tube-in-tube concept for tubular instruments offering compatibility should be favored.

[Laparoscopic instruments in practical clinical tests--prospective study of functional aspects and residual contamination]. / Laparoskopie-Instrumente im praktischen Kliniktest--Prospektive Studie zu Funktionalität und Restkontamination.

Wear, tear, and possible contamination after 100 clinical cycles of three test trays were investigated on laparoscopic "tracer" instruments in a prospective clinical study. Failure was below 4 per 100 laparoscopies, and remaining contamination was detected after passing 100 cycles in 20%, which happened to control instruments from open surgery as well. Further clinical data of contamination levels for apparently clean instruments must be collected to evaluate and correlate to microbiological testing.

[Sequential therapy concept in choledocholithiasis]. / Zweizeitiges Therapiekonzept bei Choledocholithiasis.

Of 4023 Patients with gallstone disease, 124 were treated for common bile duct stones by endoscopy (ERC/EPT). Stone clearance was completed in 81% of the patients. Due to a morbidity of 5.9% and a mortality of 0.6%, the concept of preoperative ERC followed by laparoscopic cholecystectomy seems to reduce risk for the patients.

Cardiovascular and metabolic responses to anesthetic-induced malignant hyperthermia in swine.

BACKGROUND: Several cardiovascular disturbances, such as tachycardia and hypotension, are observed during human and porcine malignant hyperthermic (MH) crises. However, the pathophysiologic mechanisms responsible for the deterioration of cardiovascular function during MH are not completely known. The purpose of this study was to elucidate the changes in left ventricular (LV) function and metabolism and the systemic and regional hemodynamics during anesthetic-induced MH in swine. METHODS: The study was carried out in 12 open-chest MH-susceptible pigs and in 8 healthy control (non-MH-susceptible) pigs under the same conditions. The cardiovascular and metabolic responses to halothane (1% inspired) and succinylcholine (3 mg.kg-1 intravenously 15 min after the start of halothane administration) were studied. Global hemodynamic and LV variables (expressed as means +/- SEM) were determined over a period of 90 min after the beginning of halothane exposure. Simultaneous investigations were performed on hindleg and cardiac muscle to compare the regional functional and metabolic changes in these tissues. RESULTS: MH was triggered in all MH-susceptible pigs. Early (10-30 min) cardiovascular changes during the development of MH consisted of a rapid increase in heart rate (from 86 +/- 4 to 204 +/- 8 beats.min-1), cardiac index (+84%), and peak rate of change in LV pressure (+150%); stroke volume index (-24%) and mean aortic pressure (-13%) decreased progressively even in the early stage of MH. These alterations were accompanied by an early and persistent reduction in systemic vascular resistance (maximally -57%) with an increase in aortic pressure amplitude. Early changes in coronary and peripheral hemodynamics during the development of MH consisted of a three-fold increase in coronary blood flow in conjunction with a marked decrease (-77%) in coronary vascular resistance. The early circulatory changes were associated with a fourfold increase in myocardial and a 2.5-fold increase in peripheral O2 consumption. The ratio of the LV stroke work index (LVWI) to myocardial O2 consumption (MVO2) was significantly decreased, by a factor of 5. Increased catecholamine concentrations and myocardial lactate and H+ production could be demonstrated throughout the MH crisis. In the late stage of MH (> 30 min), pronounced hypotension and a subsequent decrease in cardiac index were noted. These changes were associated with a significant reduction in LV end-diastolic pressure, from 9 +/- 1 to 6 +/- 1 mmHg (P < 0.05), and in the rate of change in LV pressure, by a maximum of -25%. Coronary vascular resistance remained reduced while coronary blood flow decreased. Peripheral (hind-leg) blood flow initially increased by 48% while peripheral vascular resistance decreased by 42%, followed by a fivefold increase in peripheral vascular resistance with a marked decrease in peripheral blood flow (-88%) in the late phase of MH. CONCLUSIONS: The current findings indicate that metabolic status during MH is characterized by a demand ischemia of the heart and of the skeletal muscle. Insufficient coronary blood flow and increased metabolism as a result of tachycardia and increased concentrations of catecholamines are the dominant factors contributing to the dramatic alteration in cardiac performance during porcine MH. Acidosis, hypovolemia, and hyperkalemia, especially in the late phase of MH, are additional essential factors responsible for the progressive cardiovascular deterioration and cardiac death.

[Indications for laparoscopic surgery of the large intestine]. / Indikation zur laparoskopischen Dickdarmchirurgie.

Laparoscopic colon resection is feasible but not standardized regarding indication and surgical procedure. Indications are mainly benign diseases (diverticulitis, Crohn's disease, ulcerative colitis and sessile dysplastic polyps or adenomas). Rare indications are benign tumors, angiodysplasia of the colon and dolichocolon. Laparoscopic rectopexy and sutural closure of iatrogenic colon perforation have minimal invasive indication, too. Indication for laparoscopic colon resection for malign tumors in T1-stage is still unclear. Use of minimal invasive procedures for palliative reasons (construction of colostomy or bypass anastomoses in malign tumors) is appropriate. In 32 laparoscopic bowel operations we found no lethality. In 5 cases early conversions to laparotomy were necessary. Postoperatively following complications occurred: 1 intraabdominal bleeding, 1 stenosis of anastomosis and 1 wound infection.

[Experiences with 2,200 laparoscopic cholecystectomies as the treatment concept in gallstone disease]. / Erfahrungen nach 2200 laparoskopischen Cholezystektomien als Behandlungskonzept des Gallensteinleidens.

The laparoscopic cholecystectomy is fully integrated into the therapy concept of gallstone disease. The laparoscopic procedure was successfully performed in 97.5% of 2200 patients. In 2.5% of the patients the operation had to be converted to open surgery. Complications occurred in 3.6%, containing infections of the umbilicus (2.2%), postoperative bleedings (0.4%) and lesions of the d.hepatocholedochus (0.4%). Mortality rate was 0.1%. During the last 2 years the indication for the laparoscopic approach has been rapidly expanded while the indication for primary open surgery was reduced to 2% of the patients. Laparoscopic cholecystectomy proved to be a rapid and safe procedure for treating gallbladder stones.

[Ligation of the cystic duct--experience in 1,750 laparoscopic cholecystectomies]. / Verschluss des Ductus cysticus--Erfahrungen bei 1750 laparoskopischen Cholecystektomien.

Between 3/1990-3/1993 laparoscopic cholecystectomy was performed in 1750 patients in the mean age of 49.8 (7-83). In 48 patients (2.7%) the procedure had to be shifted to open surgery. The overall complication rate was 3.9%, the mortality 0.11%. The PDS-clip Absolok 300 was regularly used for occluding the cystic duct and the cystic artery. Clip-associated complications were never observed. The induced duct occlusion proved save even against operative manipulation. But special characteristics of the clip and its application had to be considered.

[Use of laparoscopic surgical methods in mechanical ileus of the small intestine and in stomach perforation]. / Der Einsatz laparoskopischer Operationsmethoden beim mechanischen Dünndarmileus und bei der Magenperforation.

We report on the application of laparoscopic operative methods in ten patients with mechanical bowel obstruction and in seven patients with gastric perforation. From these experiences conclusions were drawn concerning the principles of trocar positioning as well as tactical and strategical considerations in acute abdominal surgery with known and unknown target regions.

Complement activated granulocytes can cause autologous tissue destruction in man.

Activation of polymorphonuclear granulocytes (PMNs) by C5a is thought to be important in the pathogenesis of multiple organ failure during sepsis and after trauma. In our experiment exposure of human PMNs to autologous zymosan activated plasma (ZAP) leads to a rapid increase in chemiluminescence. Heating the ZAP at 56( degrees )C for 30 min did not alter the changes, while untreated plasma induced only baseline activity. The respiratory burst could be completely abolished by decomplementation and preincubation with rabbit antihuman C5a antibodies. Observation of human omentum using electron microscopy showed intravascular aggregation of PMNs, with capillary thrombosis and diapedesis of the cells through endothelial junctions 90 s after exposure to ZAP. PMNs caused disruption of connections between the mesothelial cells. After 4 min the mesothelium was completely destroyed, and connective tissue and fat cells exposed. Native plasma and minimum essential medium did not induce any morphological changes. These data support the concept that C5a activated PMNs can cause endothelial and mesothelial damage in man. Even though a causal relationship between anaphylatoxins and organ failure cannot be proved by these experiments C5a seems to be an important mediator in the pathogenesis of changes induced by severe sepsis and trauma in man.

[Comparative analysis of mezlocillin/metronidazole and amoxicillin/clavulanic acid as "one shot" preventive antibiotic administration in colorectal interventions]. / Vergleichsanalyse von Mezlozillin/Metronidazol und Amoxicillin/Clavulansäure als "one shot"-Antibiotikaprophylaxe bei kolorektalen Eingriffen.

The prophylactic effect of intraoperative "one shot" antibiotic application in colorectal surgery was investigated. Patients were randomised and the antibiotic combination Mezlocillin/Metronidazole (group A) or Amoxicillin/Clavulamid acid (group B) was applicated in 160 patients. 111 patients were selected for the study (group A: 59; group B: 52 patients). In the postoperative course 53% (group A) and 67% (group B) of the patients developed bacterial infections. Abdominal wound healing was complicated by infection in 15% (A) and 12% (B) of the patients. A significant difference between the two groups could not be proven, 24% of all patients with documented intraoperative bacterial contamination and 10% of the patients with negative findings developed wound infections. In colorectal surgery patients are still at high risk for infectious complications. Applicated antibiotics should basically cover aerobic and anaerobic germs.