[TULC - total umbilical laparoscopic cholecystectomy]. / TULC - Total Umbilikale Laparoskopische Cholezystektomie.

BACKGROUND: Except for some few cases only symptomatic cholecystolithiasis constitutes an indication for operative treatment. The gold standard meanwhile has been the laparoscopic cholecystectomy, because the method shows good results with short hospital stay. Recently there has been an intensive discussion about combination of laparoscopic techniques with natural body orifice using surgery (NOTES). These techniques permit further reduction of surgical trauma and enhancing of cosmetic results. However, the technical effort is significant and most of the times a combination (hybrid procedure) of NOTES with standard laparoscopic procedure is performed, so that we concentrated on performing a laparoscopic cholecystectomy using a single incision through the umbilicus. METHODS: A 5-mm incision left deep in the umbilicus and a 10-mm incision directly below were used for creating a pneumoperitoneum and for inserting the ports for the optic and the dissector. Exposition of the gallbladder was carried out by sutures, that were penetrated from outside through the abdominal wall into the abdominal cavity and transfixed through the gallbladder in order to hang up the gallbladder like a puppet by penetrating the abdominal wall again to the outside. Removal occurred through the umbilical incision. RESULTS: We successfully operated on 90  patients in a 12-month period. Mean operating time was 48 (39-71) min whereby no conversion to open surgery was necessary. No intra- or postoperative complications occurred in any patient. Average hospital stay was 2.5 (2-4) days, postoperative examination showed no differences to the usual laparoscopic cholecystectomy with a good cosmetic result and no visible scars. CONCLUSION: The purpose of our study was to further improve the cosmetic results of minimally invasive surgery of the gallbladder by operating totally through the umbilicus, using 2  ports deep in the umbilicus. We thereby avoid further surgical trauma due to creating an access through another organ as is done in the NOTES technique. For this operation no special equipment like flexible endoscopes was needed as common laparoscopic instruments were used.

[Ascending varicose vein phlebitis--classification and therapy]. / Aszendierende Varikophlebitis--Klassifikation und Therapie.

Ascending varicophlebitis can cause pulmonary embolism by entering the deep venous system. Classification into four stages permits a differentiated therapeutic strategy: if the thrombus reaches or enters the deep venous system, immediate surgery consisting of crossectomy, resection of the saphenous vein, radical excision of all varicosed veins and ligature of insufficient perforating veins are indicated.

[Simultaneous vascular and endovascular surgery of complex vascular diseases]. / Simultane vaskuläre und endovaskuläre Chirurgie der komplexen Gefässerkrankungen.

Complex vascular disease requires combined, intraoperative endovascular and reconstructive therapy. Hereby, transprosthetic, transluminal angioplasty is particularly well suited for this purpose. The 5-year patency rate after combined inguinal patch plasty and femoral balloon dilation (n = 58) was 70%. The 5-year patency rates following transgraft angioplasty, with subsequent stent implantation and cross-over bypass (n = 46) and after transprosthetic, popliteal-crural dilation was 83% and 63%, respectively. Three patients with a type IIb (after Allenberg) aneurysm were treated with an aortoiliac stent prosthesis, combined with a cross-over bypass. The follow-up examinations at 2, 16 and 36 months were uneventful.

[Combined interventions in transfemoral stent implantation in infra-renal abdominal aortic aneurysm]. / Kombinierte Eingriffe der transfemoralen Stentprothesenimplantation beim infrarenalen Bauchaortenaneurysma.

The transluminally placed endovascular graft (TPEG) is a novel method for the treatment of abdominal aortic aneurysms (AAA). Aortobiiliacal application requires three anchor sites and can often not be performed in cases of aneurysm, occlusion, or elongation of the iliac arteries. Here the aorto-uniiliacal stent implantation combined with crossover bypass provides an alternative procedure, and thus broadens the therapeutic endovascular spectrum.

[Severe craniocerebral trauma]. / Das schwere Schädel-Hirn-Trauma.

In medical services where acute accident patients are encountered, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the Department of Surgery at the University Hospital in Munich, we have been performing neurotraumatological treatment since 1983. We had 162 patients with severe head and brain injuries, 95 intracerebral contusional bleeding, 8 depression fractures, and 3 hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 68 patients and osteoclastic trepanation in 65. Further interventions were elevation of the 8 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurosurgical surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1 cured; 2 slightly; 3 severely handicapped; 4 vegetative state; 5 expired). The Traumatic Coma Data Bank (1991) recorded the outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.

[The contribution of the general and trauma surgeon in neurotraumatology: experiences and results of 10 years]. / Die Stellung des Allgemein- und Unfallchirurgen in der Neurotraumatologie: Erfahrungen und Ergebnisse aus 10 Jahren.

In acute medical service, general and traumatic surgeons are faced with the problem of treating severe head and brain injuries. In the department of surgery of the University Hospital in Munich, we have been performing neurotraumatological treatment since 1982. Within 10 years we saw 138 patients with severe head and brain injury. We had 48 cases of epidural hematoma. 81 of acute subdural hematoma. 84 of intracerebral contusional bleeding, 5 of depression fractures and 3 of hygromas. All these patients underwent surgical treatment. Osteoplastic trepanation was performed in 49 patients and osteoclastic trepanation in 60. Further interventions were elevation of the 5 depression fractures and evacuation of the 3 hygromas. Comparison with other investigations in departments of neurological surgery in the United States suggest that our results reflect a similar outcome (according to Jennet and Bond's outcome scale: 1, cured; 2, slightly handicapped; 3 severely handicapped; 4, vegetative state; 5, expired). The Traumatic Coma Data Bank (1991) recorded outcome of severe head and brain injuries as follows: 1, 27%; 2, 16%; 3, 16%; 4, 5%; 5, 36%; and our own results were: 1, 24%; 2, 17%; 3, 15%; 4, 5%; 5, 39%. Organization procedures and treatment strategies are suggested.