[Strategy for avoidance of negative appendectomies]. / Strategien zur Vermeidung negativer Appendektomien.

Appendectomy is the most commonly performed emergency surgical procedure. Even in the era of laparoscopic surgery and modern computed tomography, the rate of negative appendectomies, defined as the removal of a non-inflamed appendix, remains high (10-15%). The general problem and incidence, as well as the influence of modern diagnostic modalities on the rate of negative appendectomies are of particular clinical relevance. Several clinical scoring systems have been developed, but they did not find their way into the daily clinical routine. A proposed diagnostic algorithm could support further efforts to reduce the rate of negative appendectomies. The risk of overtreatment in the reduction of the negative appendectomy rate might potentially lead to acceptance of a higher perforation rate.

[Risk management in the operation room. Results of a pilot project of interdisciplinary "incident reporting"]. / Risikomanagement im Operationsbereich. Ergebnisse eines pilotprojektes zum interdisziplinären "incident-reporting".

BACKGROUND: Methods for error analysis are suitable to increase patients' safety as well as staff satisfaction and may avoid, in a sense of process control, financial damage to the hospital. The aim of the presented pilot study was to establish and evaluate an incident reporting system as a first step towards a new safety culture. METHODS: In June 2003 an incident reporting system was introduced in the central surgical suite, in which the surgical and anaesthesiologic departments took part as well medical and nursing staff. Besides conceiving a report form, a "board of confidence" was elected, kick-off meetings were held and a baseline study on the basis of industrial psychological knowledge was initialised. RESULTS: The process of creating confidence is arduous and depends elementarily on sincere cooperation of management staff, especially of the heads of the departments. The exclusive participation of only two medical departments led to conflicts. Therefore, after finishing the pilot study, the system was expanded to the whole surgical suite including all operating departments. In order to increase the motivation for the strictly voluntarily participation, the frequency of regular echoes to the staff was optimised. To achieve high acceptance in the whole staff, the board of confidence needs a clearly defined position within the system of quality management. CONCLUSIONS: For the first time in Germany an incident reporting system under participation of several medical departments has been installed. After finishing the pilot project, in future we will be able to evaluate changes caused by this system. Simultaneously an electronic database for reported adverse events and strategies to avoid them are being developed based on similar systems in aviation industry. In near future, the system will be of increasing importance likewise for inpatient units and non-operative departments.

[Laparoscopic hernioplasty by total extraperitoneal approach]. / Die laparoskopische Hernioplastik nach dem TEP-Verfahren -- Eine Analyse und Nachbeobachtung von 195 Fällen.

INTRODUCTION: Despite the increasing acceptance of the TEP-procedure by patients and general practitioners this method has to be further examined. In addition to the classic surgical criteria of examination, subjective aspects of patient comfort must be taken into consideration as they are getting more and more significant for the evaluation of different methods. METHODS: According to this targets patients were clinically examined and questioned about specific topics regarding their quality of life after TEP-surgery and evaluated prospectively. RESULTS: Between 1995 and 2000 endoscopic total extraperitoneal hernioplasty (TEP) was used for 200 inguinal hernia repairs in 195 patients. 195 patients could be interviewed about the operation's outcome and examined physically and sonographically after 3 months, 188 patients after 6 months and 184 patients after 12 months post-op. The recurrence rate was 1.7 %, the rate of major complications was < 1 %. Sensitivity disorders were found in 7.3 % of all cases at the final examination prior to discharging but none at the 3 months check-up. The median postoperative period until the resumption of sexual intimacy was approximately two weeks, but one male patient reported about long-lasting pain in copulation (0.51 %). DISCUSSION: With regard to the aspects mentioned above, the TEP-procedure provided excellent results in the examined patient cohort and therefore turned out to be at least comparable with competitive endoscopic methods. A remarkable new finding was that patients could go back to work on average 2 weeks earlier than regaining their everyday fitness.

[Laparoscopic hernioplasty by transabdominal preperitoneal approach]. / Die laparoskopische Hernioplastik nach dem TAPP-Verfahren -- Eine Analyse und Nachbeobachtung von 267 Fällen.

INTRODUCTION: Despite the increasing acceptance of the TAPP-procedure by patients and general practitioners this method has to be further examined. In addition to the classic surgical criteria of examination, subjective aspects of patient comfort must be taken into consideration as they are getting more and more significant for the evaluation of different methods. METHODS: According to this objective patients were clinically examined and questioned about specific topics of quality of life after TAPP-operations. Furthermore, the patients documentation (medical report/OP-report) was evaluated retrospectively. RESULTS: Between1995 and 1998 endoscopic transabdominal preperitoneal hernioplasty was used for 267 inguinal hernia repairs in 204 patients. 155 patients could be interviewed about the operative outcome and 199 operated inguinal hernias could be examined physically and sonographically. The recurrence rate was 2.5 %, the rate of major complications was 4.4 %. Postoperative pain-syndrome were found as a major complication in only two cases (1.3 %), postoperative nervous disorders could be diagnosed in 3.5 % of the patients. Further subjective complaints were seen in 19 % of the patients. The median postoperative period until the resumption of sexual intimacy was approximately two weeks, but six male patients reported about long-lasting pain in copulation (3.9 %). DISCUSSION: With regard to the aspects mentioned above, the TAPP-procedure provided exellent results in the examined patient cohort and therefore turned out to be at least comparable with competitive methods. Nevertheless, the postoperative pain in sexual activity that a few male patients complained of represents a new aspect which has to be further investigated.

[Surgeons learn how to learn. Study of 76,499 herniorrhaphies performed between 1993 and 1997 registered by the chamber of physicians in Westfalia-Lippe]. / Chirurgen lernen Lernen Eine. Untersuchung von 76.499 Leistenhernienreparationen der Jahre 1993-1997 der Arztekammer Westfalen-Lippe.

INTRODUCTION: New techniques require "new" surgeons who are able to apply them safely. The bushfire-like employment of laparoscopic cholecystectomy confronted a community of surgeons totally inexperienced in that technique. Thus, the collective learning curve was paralleled by a temporary increase of postoperative complications. The aim of the following study was to analyze the learning curve for laparoscopic herniorrhaphy with regard to the complication rates during that period. METHODS: A total of 76,499 questionnaires from the external quality assurance of the Westfalia-Lippe physicians board registered between 1993 and 1997 were analyzed retrospectively. The parameters (duration of the operation and hospitalization, ASA classification, rate of obese patients, intra- and postoperative complications) were analyzed and plotted as a synchronized learning curve of the whole group of surgeons. RESULTS: As for laparoscopic cholecystectomy, a learning curve was found for laparoscopic herniorrhaphy, which could be attributed to a decreasing duration of the procedures and increasing ASA classification and rate of morbid obese patients while complication rates were kept constantly low. After 9 months of application laparoscopic hernia repair seemed to have been introduced to a new collective of surgeons while learning parameters showed inverse trends for a short period of time. The complication rate of laparoscopic hernia repair was constantly lower than in routine open inguinal hernia repair. CONCLUSION: Since laparoscopic inguinal hernia repair is a demanding method, surgeons apparently did not forget the lessons learned from the introduction of laparoscopic cholecystectomy as they were able to avoid increasing intra- and postoperative complication rates during their learning curve. Surgeons are learning to learn.

[Results of surgical quality assurance in Westphalia-Lippe--recurrence data in inguinal hernia operation. A coomparison of literature and reality]. / Ergebnisse der Chirurgischen Qualitätssicherung in Westfalen-Lippe--Rezidivquoten der Leistenhernienoperationen. Ein Vergleich von Literatur und Realität.

The data of 90,289 patients of the quality-control program of the Arztekammer Westfalen-Lippe have been analyzed in regard of the patients age at the time of the primary operation and in case of operation because of recurrent inguinal hernia. In both groups of patients distribution of age was identical in principle but transferred to higher age in recurrent hernia by about 3.4 years thus indicating that recurrent hernia mostly occur early after primary operation. Shouldice method showed decreasing acceptance due to increasing numbers of repair operations by laparoscopy and Lichtenstein's method. This tendency was even more pronounced in case of recurrent inguinal hernia. Obviously the surgeons' selection of methods in inguinal hernia repair is not only influenced by evidence based data since Shouldice repair is reported to be superior in each regard.

[Regional changes in surgical technique of inguinal hernia in Westphalia-Lippe. Results of surgical quality assurance in Westphalia-Lippe 1993 to 1997 with special reference to laparoscopic techniques]. / Regionale Veränderungen der Operationstechnik der Leistenhernie in Westfalen-Lippe. Ergebnisse der Chirurgischen Qualitätssicherung in Westfalen-Lippe in den Jahren 1993 bis 1997 unter besonderer Berücksichtigung der laparoskopischen Technik.

Based on the data of the external quality assurance of the Chamber of Physicians of Westphalia-Lippe in 1993-1997, the regional changes of the surgical procedures used for inguinal hernia repair were analysed. An extensive spatial distribution of the laparoscopic repair, overall increasing from 1.9% in 1993 to 22.0% in 1997, was observed. This is visualised in geographic maps. The rapid introduction of a new surgical technique without available long-term results should be considered critically.

[Clinical anatomy in the operating room. A model of integrated medical education]. / Klinische Anatomie im Operationssaal. Ein Modell der integrierten Mediziner-Ausbildung.

Clinical relevance of theoretical knowledge is advantageous to be demonstrated early during preclinical education in medical schools. We describe a new way for anatomists and surgeons of teaching anatomy together during surgical procedures in the operating theatre, thus demonstrating successfully the need of keen insight in the field of gross anatomy. The students reported to be motivated to learn anatomy. A questionnaire was completely answered by 24 students after having finished the 96/97 course of anatomy in the operating theatre. The students reported that they have learned a lot as well as to be highly motivated to continue their efforts of gaining knowledge on the field of gross anatomy because of its clinical relevance.

[Learning and optimising minimally invasive techniques by operating on embalmed human corpses]. / Das Erlernen und Optimieren minimal-invasiver Operationsverfahren am menschlichen Leichnam.

The expansion of minimally invasive surgery worldwide provokes an intensive interest of all surgical disciplines in gaining possibilities for research, learning and teaching by operating on human corpses. Despite the fact that German anatomical institutes in general have the infrastructure to realise such clinical cooperations, at present they may offer such opportunities only to a restricted degree, since the concentration on student teaching and anatomic research limits the capacity of the staff for a commitment in this field of applied science. To provide a basis for future estimations of the efforts necessary to perform solo surgery on the human cadaver, especially with emphasis on research, quality control and teaching, this article reports on practical experiences with such a project named "ANAtoMIC", identifying minimal conditions which have to be realised.

Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement.

A knowledge of the parietal structures of the abdominal wall is necessary to minimize risks of operative procedures like laparoscopy. For means to prevent intraoperative bleeding and the occurrence of abdominal wall hematoma, we studied the course of the inferior epigastric arteries and the ascending branch of the deep circumflex iliac artery in 21 human cadavers. The abdominal wall structures were dissected and the distances of the arteries in relation to anatomic structures such as the umbilicus, pubic symphysis, superior ischial spine and lower edge of the rib-cage were measured. Comparison of the morphometric results obtained with the location of 36 trocar incision sites recommended in the common literature yields the information that about half of these incision sites incur the risk of injuring the arteries.

[Kidney donation by the elderly--an emergency solution?]. / Nierenspende im Alter--eine Notlösung?

In 1994 the number of kidney donors once again decreased in Germany. On the other hand, more and more old people are being considered for renal transplantation; thus the shortage of transplants is becoming more severe. The kidneys of elderly donors might improve this situation. The results available are inconsistent. There is no doubt that kidney function declines with age, but the individual aging process depends mainly on concomitant disease, especially arterial hypertension. Transplantation of kidney from an elderly person requires appropriate selection of donors as well as good perioperative management. Doctors in medical intensive care units should contact transplant centres more often to evaluate potential elderly kidney donors. More open-minded assessment of certain situations is necessary in conservative medical disciplines.

Laparoscopic marsupialization of lymphocele after combined pancreas-kidney transplantation.

Early definitive treatment of symptomatic posttransplant lymphoceles offers good results with fewer graft losses and reduced morbidity. If interventional therapy fails, laparoscopic internal marsupialization to the peritoneal cavity may be performed with excellent results and at low cost. In combined pancreas-kidney transplantation the transperitoneal laparoscopic access may be difficult due to adhesions caused by the intraabdominal positioning of the pancreatic graft and posttransplantation pancreatitis. Both posttransplantation lavage of the abdominal cavity as well as immunosuppression reduce formation of intraabdominal adhesions subsequent to combined pancreas-kidney transplantation. Thus, posttransplant lymphoceles may be treated safely even after combined kidney-pancreas transplantation.

[Transplantation of the kidney of an 80-year-old donor after complex revascularization with good transplant function]. / Transplantation der Niere einer 80 jährigen Spenderin nach komplexer Revascularisierung mit guter Transplantatfunktion.

There is no age limit in kidney donation. Kidney function has to be evaluated on an individual basis even in elderly donors. We report the transplantation of the kidney of an 80-year-old donor with good organ function postoperatively. Complex revascularization had to be performed because of arteriosclerosis in two of three renal arteries.

A comparison of long term results of the standard Whipple procedure and the pylorus preserving pancreatoduodenectomy.

The standard Whipple procedure involves intestinal disturbances, such as dumping, diarrhea, dyspeptic complaints and the occurrence of ulcers of the anastomoses. A postoperative weight loss was observed ranging between 10 and 40 kilograms. Only a few patients were able to compensate after several months. It was thought that preservation of the intact stomach would prevent the complications arising from a loss of gastric reservoir function and thus the malnutrition could be improved postoperatively. Between 1985 and March 1992, we performed the pylorus-preserving Whipple procedure and treated a group of 43 patients with this method. In the same period, 15 patients were operated upon with the standard Whipple procedure. The present evaluation of the accumulated patient data, including extensive functional studies, led to the following results comparing the pylorus preserving Whipple procedure with the standard Whipple procedure. First, the capacity for food uptake and the development of body weight postoperatively is significantly better. Second, gastric or jejunal ulcers were not observed. Third, there were no clinical signs of digestive disorders, such as different forms of dumping. Nutrition and digestion were not impeded by the preserved opening mechanism of the pylorus. Fourth, the postoperative exocrine function was only slightly decreased. Fifth, glucose metabolism postoperatively was influenced only slightly by preservation of the pylorus. In taking the results of all the examinations into consideration, it can be said that the restricted organ loss in the Whipple procedure with pylorus preservation leaves the secretory and functional capacity of the upper part of the gastrointestinal tract almost unchanged.

[Temperature range in bipolar high frequency coagulation of the appendiceal stump]. / Temperaturentwicklung bei bipolarer Hochfrequenzcoagulation am Appendixstumpf.

Since laparoscopic appendectomy is performed more frequently disturbances of cecal motility have been found postoperatively in many cases. The etiology of this "syndrome of the fifth day" has not been cleared yet. To assess whether high-frequency bipolar electrocautery could be one of the etiologic factors, measurements of temperature were performed in lamb bowel, cadaver appendices and in vivo during laparoscopic appendicectomy. Next to the appendix stump ligation at the cecum wall the mean maximal temperature was as high as 53.2 degrees C. We believe that high frequency electrocoagulation is one of the etiologic factors of disturbances of the cecal motility especially if safety distances are not followed.

[C-reactive protein in the early diagnosis of postoperative infection following bone surgery]. / Das C-reaktive Protein zur Früherkennung postoperativer Infektionen nach Knochenoperationen.

Of a prospective 101 patient study group after different operative osteosynthetic procedures 94 patients without postoperative infection showed a uniform acute phase response which was characterized by determination of C-reactive protein levels, ESR, WBC and body temperature. 7 patients suffering from infection in the postoperative period but no patient with non-inflammatory complications showed distinct CRP value patterns. In 4 wound infections CRP increased from day 2 to 4 and thus was the earliest sign of developing infection. Latency to the clinical diagnosis based on clinical signs, ultrasound, WBC in blood and wound drainage was up to 14 days. There was no patient with CRP increasing after day 2 but no infection. CRP is a very sensitive, non-expensive tool for early diagnosis of bacterial infection. It is superior to ESR, WBC in blood and drainage, ultrasound and diagnosis based on clinical signs.