[Transanal total mesorectal excision-a critical appraisal]. / Transanale totale mesorektale Exzision ­ eine kritische Standortbestimmung.

INTRODUCTION: Total mesorectal excision (TME) is the international standard for rectal cancer surgery. In addition to laparoscopic TME (lapTME), transanal TME (taTME) was developed in recent years to reduce the rate of incomplete TME, conversion to open surgery and postoperative functional impairment. Despite limited evidence, this technique is becoming increasingly more popular and is already routinely used by many hospitals for rectal cancer in varying tumor level locations. The aim of this review was to evaluate the taTME compared to anterior rectal resection with lapTME as the standard of care in rectal cancer surgery based on currently available evidence. METHOD: The databases PubMed and Medline were systematically searched for publications on transanal total mesorectal excision (taTME) and transanal minimally invasive surgery (TAMIS). Relevant studies were selected and further research based on the reference lists was undertaken. RESULTS: A total of 16 studies analyzing 3782 patients were identified. The taTME does not lead to a higher rate of complete TME-resected specimens compared to the standard procedure. So far, superiority could not be demonstrated for complication rates or for functional or oncological results. Serious complications secondary to dissection in incorrect planes were observed. The anastomotic level generally seems to be closer to the sphincter after taTME versus anterior lapTME. CONCLUSION: Considering current evidence, taTME failed to show superiority compared to conventional anterior lapTME. Although taTME has some potential advantages, it carries substantial risks. If performed outside of clinical trials, it should therefore only be used in carefully selected patients with a high possibility of conversion, following adequate patient informed consent and after intense and systematic training of the surgeon.

Transvaginal Hybrid NOTES Cholecystectomy: A Single-Centre Long-Term Experience on Sexual Function.

INTRODUCTION: Transvaginal hybrid NOTES cholecystectomy is an alternative approach to the traditional laparoscopic technique. Despite increasing data regarding clinical outcomes following transvaginal hybrid NOTES cholecystectomy, there is still a lack of long-term results, particularly with regard to sexual function. Therefore, the aim of this study was to evaluate long-term outcome of a series of transvaginal hybrid cholecystectomy. PATIENTS AND METHODS: Female patients with symptomatic cholecystolithiasis who underwent transvaginal hybrid NOTES cholecystectomy were retrospectively analysed regarding clinical and surgical outcome parameters. Furthermore, all patients received a 17-question survey postoperative with questions about sexual intercourse, the domains satisfaction and pain of the German Female Sexual Function Index. RESULTS: Overall, 47 of 80 patients were included in the study with a completed survey responses (return rate 58.6%), with a mean age of 48 years, mean body mass index of 29 and mean operative time of 47 min. The median follow-up was 40 months. There were no intra- or postoperative complications and no conversion to a laparoscopic or open approach. No significant differences were found for postoperative sexual function (painful intercourse, inability to achieve orgasm), although sexual intercourse was less frequent postoperatively (p = 0.022). Forty-four patients (93.7%) were satisfied with the aesthetic and the overall postoperative result, and 40 patients (85.1%) would recommend the applied surgical technique to friends and family. CONCLUSION: The findings show that transvaginal hybrid NOTES cholecystectomy is a safe procedure for female patients, particularly with regard to sexual function.

[Are there too many conferences for general and visceral surgery in Germany? : A survey of DGAV members]. / Gibt es in Deutschland zu viele Kongresse in der Allgemein- und Viszeralchirurgie? : Eine Befragung der DGAV-Mitglieder.

BACKGROUND: Human and financial resources are increasingly bound due to economic pressure and the working hours Act whereby the already restricted further training times are further limited. The industry also has less funding available for sponsorship of conferences and workshops. Against this background the question arises whether a reduction or focusing of the conferences is necessary; therefore, the aim of this survey was to obtain an opinion from members of the German Society of General and Visceral Surgery (DGAV) and possibly to derive a need for action to submit to the board members. METHODS: From 7 February to 18 March 2015 an online survey was conducted by the DGAV with their members regarding the number of necessary congress events in Germany. RESULTS: A total of 670 responses were received (return rate 16 %). In total, 56 % of participants felt that there are too many conferences. A differentiation according to the position of the respondent and the level of the associated hospital resulted in the following: 69.3 % of the participating head physicians (HP) shared this opinion, compared to 48.6 % of senior physicians (SP) and 34.4 % of residents (RP). Of the participants from basic and standard care hospitals (B/SC) 50 % shared this opinion, compared to 59.2 % from maximum care hospitals (MC) and 63.6 % from university hospitals (UH). In addition, a total of 75 % of the participants (HP 82.9 %, SP 78.4 %, RP 70.5 %) were in favor of keeping the congress of the DGAV (annual meeting of the German Society for Digestive and Metabolic Diseases in conjunction with the Autumn meeting of the DGAV) in its previous form, regardless of the underlying level of care of the associated hospital (B/SC 77 %, MC 79 %, UC 68 %). CONCLUSION: More experienced surgeons in particular tended to favor a reduction of events with a focus on the major conferences; however, younger colleagues preferred a wider spectrum of meetings. In order to comply with both positions a wide range of events should be continued to be provided in the future so that surgeons can choose which to attend according to the individual preferences.

[Diverticular disease - choice of surgical procedure]. / Divertikelkrankheit - operative Verfahrenswahl.

The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. The tenets of surgical treatment of diverticulitis are resection of the entire sigmoid and creation of a tension-free anastomosis in the upper rectum. With respect to the required extent of resection according to current data it is not necessary to remove the entire colonic segment bearing diverticula because such a strategy does not reduce the recurrence rate. In the emergency situation due to free perforation a primary anastomosis with defunctioning ileostomy should be favored because the stoma reversal rate after primary anastomosis is higher than after Hartmann's procedure. The Hartmann procedure should be reserved for perforated diverticulitis with severe septic complications; however, the final treatment decision for primary anastomosis or Hartmann's procedure should be dependent on the individual patient. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis as an alternative to resection surgery. In cases of diverticular bleeding a subtotal colectomy should be performed if the diverticular bleeding site cannot be localized.

[Stump closure in laparoscopic appendectomy. Influence of endoloop or linear stapler on patient outcome]. / Stumpfverschluss bei der laparoskopischen Appendektomie. Einfluss der endoskopischen Schlinge oder des Linearstaplers auf das Patientenoutcome.

BACKGROUND: Even though laparoscopic appendectomy is one of the most frequent procedures in abdominal surgery, the technique of appendiceal stump closure is still not standardized. The aim of this retrospective study was to analyze the effect of the use of endoloops or linear staplers for appendiceal stump closure concerning surgical site infections (SSI) and intra-abdominal abscesses (IAA). PATIENTS AND METHODS: All laparoscopic appendectomies between January 1st 2007 and May 31st 2010 were split into an endoloop group (ELG) and a linear stapler group (LSG). The groups were compared with respect to the outcome parameters SSI and IAA. RESULTS: A total of 430 appendectomies were performed in the study period of which 105 operations were conducted laparoscopically. In this study 47.6 % (n = 50) were alloted to the LSG and 52.4 % (n = 55) to ELG. In LSG 3.1 % (n = 1) developed an SSI versus 10.0 % (n = 4, p = 0.254) in ELG. No IAAs occurred in LSG compared to 2 (5.1 %, p = 0.499) in ELG. CONCLUSION: The use of EL for appendiceal stump closure is safe and cost effective for low-grade appendicitis but high-grade appendicitis should be treated with LS.

[What is the actual benefit of sigmoid resection for acute diverticulitis? : Functional outcome after surgical and conservative treatment]. / Welchen Erfolg bringt die Sigmaresektion bei der akuten Sigmadivertikulitis tatsächlich? : Funktionelle Ergebnisse nach operativer und konservativer Therapie.

INTRODUCTION: The correct therapeutic management of acute sigmoid diverticulitis (SD) is still controversially discussed. Essential to the success of therapy is primarily the long-term resolution of Patient symptoms after surgical or conservative therapy. The aim of this study was to compare the long-term outcome after conservative and surgical treatment of Patients with acute SD. PATIENTS AND METHODS: Consecutive admissions of all Patients with acute SD were prospectively recruited from January 2005 to June 2008 with the exception of a free perforation. The following data were recorded: age, sex, first or recurrent episode of SD, computed tomography (CT) stage, white blood cell count, C-reactive protein, persistent symptoms and recurrence after conservative and surgical therapy. Furthermore, information on the rates of postoperative sexual and bladder dysfunction was collected. The long-term outcome was evaluated by a standardized questionnaire. In June 2008 all Patients were contacted using a standardized questionnaire. RESULTS: A total of 153 Patients were included in the study of whom 70 (45.8  %) presented with the first episode, 83 (54.2  %) had a prior history of SD and 40 Patients were treated conservatively whereas 113 Patients were surgically treated by sigmoid resection. Uncomplicated SD was seen in 16 Patients (conservative 4, surgical 12, p = 0.961), phlegmonous SD was seen in 88 cases (conservative 29, surgical 59, p = 0.026) and covered perforated SD in 49 cases (conservative 7, surgical 42, p = 0.022). The median follow-up was 32 months (range 12-52 months). At follow-up 25  % of conservative and 8.8  % of Patients treated surgically complained about persistent symptoms (p = 0.009). The following symptoms occurred (conservative vs. surgery): painful defecation (22.5  % versus 8.8  %, p = 0.024.), constipation (25  % versus 8.8  %, p = 0.009), abdominal cramp (22.5 % versus 4.4  %, p = 0.001) and painful flatulence (25  % versus 8.8  %, p = 0.009). Sexual or bladder dysfunction occurred postoperatively in 7  % and 9  %, respectively. Of the conservatively treated Patients 32.5  % had a recurrence of SD during follow-up compared to 3.5 % of surgically treated Patients (p < 0.001). CONCLUSIONS: Surgical treatment of acute SD is more effective than conservative therapy for the prophylaxis of recurrent SD and avoidance of persistent symptoms.

Suitability of a virtual reality simulator for laparoscopic skills assessment in a surgical training course.

BACKGROUND: Virtual reality simulators (VRS) can acquire specific performance parameters for laparoscopic surgery. The aim of this study was to evaluate the suitability of a VRS for the assessment in a surgical skills course. MATERIALS AND METHODS: One hundred five attendees of a 7-day surgical skills course were tested with a VRS at the beginning (T1) and at the end (T2) of the course. Two standard VRS tasks (lifting and grasping (LG) and fine dissection (FD)) with two scores and 21 individual parameters were used. VRS performance was correlated to laparoscopic experience and experience in playing video games in order to assess the influence of preexisting skills. RESULTS: The participants improved significantly in both scores and in 19/21 VRS parameters between T1 and T2. Laparoscopic experts were significantly better than novices only for the parameter tissue damage on T1 in LG (41.4 %, P < 0.001). Gamers were significantly better than non-gamers in all manual parameters on T1 in LG. Both groups of laparoscopic experience as well as non-gamers improved between T1 and T2 in LG for most parameters, while gamers only improved for tissue damage. CONCLUSIONS: The VRS was able to assess the gain in surgical performance during the course in general. However, laparoscopic experience and video game experience strongly influenced the results. Laparoscopic experience was correlated to the parameter tissue damage, whereas video game experience was correlated to manual parameters. This knowledge can be used to build adequate scoring systems for VRS and to design tasks that target specific course skills.

[Simulation training in surgical education - application of virtual reality laparoscopic simulators in a surgical skills course]. / Simulationstraining in der Weiterbildung - Einsatz von virtuellen laparoskopischen Operationssimulatoren in einem chirurgischen Trainingskurs.

BACKGROUND: Training and simulation are gaining importance in surgical education. Today, virtual reality surgery simulators provide sophisticated laparoscopic training scenarios and offer detailed assessment methods. This also makes simulators interesting for the application in surgical skills courses. The aim of the current study was to assess the suitability of a virtual surgery simulator for training and assessment in an established surgical training course. MATERIALS AND METHODS: The study was conducted during the annual "Practical Course for Visceral Surgery" (Warnemuende, Germany). 36 of 108 course participants were assigned at random for the study. Training was conducted in 15 sessions over 5 days with 4 identical virtual surgery simulators (LapSim) and 2 standardised training tasks. The simulator measured 16 individual parameters and calculated 2 scores. Questionnaires were used to assess the test persons' laparoscopic experience, their training situation and the acceptance of the simulator training. Data were analysed with non-parametric tests. A subgroup analysis for laparoscopic experience was conducted in order to assess the simulator's construct validity and assessment capabilities. RESULTS: Median age was 32 (27 - 41) years; median professional experience was 3 (1 - 11) years. Typical laparoscopic learning curves with initial significant improvements and a subsequent plateau phase were measured over 5 days. The individual training sessions exhibited a rhythmic variability in the training results. A shorter night's sleep led to a marked drop in performance. The participants' different experience levels could clearly be discriminated ( ≤ 20 vs. > 20 laparoscopic operations; p ≤ 0.001). The questionnaire showed that the majority of the participants had limited training opportunities in their hospitals. The simulator training was very well accepted. However, the participants severely misjudged the real costs of the simulators that were used. CONCLUSIONS: The learning curve on the simulator was successfully mastered during the course. Construct validity could be demonstrated within the course setting. The simulator's assessment system can be of value for the assessment of laparoscopic training performance within surgical skills courses. Acceptance of the simulator training is high. However, simulators are currently too expensive to be used within a large training course.