[Comparative studies of total extraperitoneal hernioplasty in combined spinal epidural anesthesia versus balanced general anesthesia]. / Vergleichende Untersuchungen zur Durchführung der totalen extraperitonealen Hernioplastik in kombinierter Spinal-Epidural-Anästhesie versus balancierter Allgemeinanästhesie.

To appraise the clinical impact of combined spinal-epidural anaesthesia (CSE) in patients undergoing total extraperitoneal laparoscopic hernia repair (TEPP), we performed a prospective study in 40 patients. These patients were randomized to receive either CSE (n = 20) or a balanced general anaesthesia (BGA) with controlled ventilation (n = 20). The aim of the study was to determine the impact of the intraoperative gas insufflation on compensatory respiratory reactions during regional anaesthesia. Therefore, blood gas samples were drawn and additional parameters were assessed as follows: noninvasive haemodynamic, lactate and glucose levels, differential blood count, and the patients' level of comfort during the perioperative setting, which was determined by a questionnaire. In our study it was clarified that the respiratory compensation of extraperitoneal gas insufflation is not decreased by regional anaesthesia. The haemodynamic state of the patients was stabilized by early interventions. In addition--there was no evidence that the anaesthesia regime used had any influence on the so called stress-parameters. Most of the patients with regional anaesthesia showed severe agitation often accompanied by chest pain. Hence, regional anaesthesia is not recommended in this setting.

[Laparoscopy assisted radical vaginal hysterectomy (LAVRH) for cervical carcinoma--perioperative parameters and complications]. / Die laparoskopisch assistierte vaginale Radikaloperation LAVRO des Zervixkarzinoms--Perioperative Parameter und Komplikationsraten.

OBJECTIVE: Presently we note a standardization of techniques for laparoscopy assisted radical vaginal hysterectomy (LARVH). Altgassen et al. pointed to this fact with their evaluation of 108 operations for cervical cancer. They considered the necessity to perform 100 such operations before standardizing this method. In our survey we compare a similar number of operations performed in our department in order to prove whether Altgassen's thesis is correct, taking peri- and postoperative parameters as well as complications into consideration. For this purpose we analyzed the number of operations necessary to develop and standardize laparoscopic pelvic lymphadenectomy combined with radical vaginal hysterectomy in women treated for cervical cancer. PATIENTS AND METHODS: Between 1st August 1993 and 31st January 1999, 80 patients with cervical cancer FIGO stage Ia2-IIb were selected for laparoscopy assisted radical vaginal hysterectomy. We were able to perform this operation in 71 patients. The operation reports and records of the postoperative period were evaluated retrospectively. RESULTS: The average duration of the operation increased from 380 minutes in cervix carcinoma Ia2 to 530 minutes in cervix carcinoma IIb. The average blood loss remained the same at 1,000 ml for each operation. Correspondingly the average decrease of hemoglobin was 3.5% for all operations. The number of pelvic lymph nodes removed unilaterally varied between 6 and 13. If the group of 37 patients with cervical cancer FIGO stage Ib--particularly homogenous as far as the spread of the tumor and the course of the operation are concerned--is divided up into one group up to the 50th operation and another group after the 50th operation, the regression analysis after the 50th operation shows a statistically significantly higher number of lymphnodes (11 compared to 25; Mann-Whitney-U-Test, p = 0.00014). However no differences were found for mean blood loss (800 ml compared to 700 ml) or duration of operation (400 minutes compared to 420) (Mann-Whitney-U-Test, p > 0.05). 5% of serious complications were associated with the laparoscopic part of the procedure--a blood vessel lesion, a ureter lesion, two postoperative intraperitoneal secondary hemorrhages. 7.5% serious complications in the area of the bladder and the ureter were associated with the vaginal part of the procedure. In 6% of our procedures we observed lymphedema in the lower extremities. Deep Compartment Syndrome was observed in 5% of our patients and associated with the duration of the procedure. CONCLUSION: To implement and standardize our technique of laparoscopic pelvic lymphadenectomy and radical vaginal hysterectomy a learning phase of 50 procedures was necessary.

[Improved prognosis in breast carcinoma by excision of non-palpable carcinoma-suspected lesions. Analysis of 319 ambulatory surgery operations]. / Prognoseverbesserung beim Mammakarzinom durch Exstirpation nichttastbarer karzinomverdächtiger Läsionen. Analyse von 319 ambulantchirurgischen Operationen.

A retrospective study is described according to which 319 outpatients had been operated on for suspected carcinoma because of breast lesion, in the course of three years in this hospital. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. In the non-palpable cases, mammography was indicated in 98 patients (47.6%) undergoing controls for mastopathy, in 41 patients (19.9%) undergoing a first mammography in the course of preventive check-ups, and in 33 patients (16.0%) undergoing a check-up after operative therapy of breast cancer. Prior to operation, 84.0% (n = 173) of the non-palpable lesions were marked by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnet resonance imaging (MRI). Intraoperative specimen mammography was made in every case marked by mammography. In 19.4% (n = 40) out of the 206 cases of marked though non-palpable focuses a tumour was found. 25% (n = 10) of all marked tumours were diagnosed and treated as in-situ stage tumours, 65% (n = 26) were diagnosed and treated as tumours in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumours were diagnosed and treated as being pN0 tumours, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and non-palpable findings should be reserved for departments with marking and quick-freezing facilities.

[The radiological and surgical management of nonpalpable breast lesions]. / Radiologisches und chirurgisches Management der nichtpalpablen Mammaläsion.

In this retrospective study the results of surgical biopsy of suspected breast cancer in 319 outpatients are reported. In 113 cases (35.4%) the lesion was palpable, in 206 cases (64.6%) it was not. Concerning the nonpalpable lesions, mammography was performed in 98 patients (47.6%) for work-up of fibrocystic changes, in 41 patients (19.9%) for initial participation in a breast cancer prevention program, and in 33 patients (16.0%) for surveillance after breast conservation therapy. Prior to operation, 84.0% (n = 173) of the nonpalpable lesions were detected by mammography, 11.2% (n = 23) by sonography, and 4.8% (n = 10) by magnetic resonance imaging. Intra-operative specimen mammography was carried out in every case detected by mammography. In 19.4% (n = 40) of 206 nonpalpable lesions a malignant tumor was found. Twenty-five percent (n = 10) of all marked tumors were diagnosed and treated as in-situ stage tumors, while 65% (n = 26) were diagnosed and treated as tumors in the pT1 stage. As regards the nodal stage, 85% (n = 34) of the tumors were diagnosed and treated as pNO tumors, and 100% (n = 40) were found to be free from any distant metastases. Consequently, for improving prognosis and, at the same time, for reducing the rate of breast amputations as a means of curative therapy of breast cancer, regular screening in defined risk groups is necessary. Surgical treatment of patients with small and nonpalpable findings should be reserved for departments with marking and quick-freezing facilities.

[Renaissance of vaginal hysterectomy for cervical carcinoma. 100th anniversary of the first abdominal radical surgery of cervical carcinoma by Ernst Wertheim on November 16, 1898]. / Zur Renaissance der vaginalen Radikaloperation des Collumkarzinoms. Zum 100. Jahrestag der ersten abdominalen Radikaloperation eines Collumkarzinoms durch Ernst Wertheim am 16. November 1898.

In the 100 year long history of the abdominal radical operation of collum carcinoma, due to the continued clinical surgical and scientific work of several generations of physicians, abdominal radical operation with standardized pelvic lymphonodectomy has become the method of choice for surgical treatment of collum carcinoma since 1970. Vaginal radical operation in its various forms has since played only a very restricted role in surgical treatment of collum carcinoma. According to the opinion of the majority of cancer surgeons vaginal radical operation had to be abandoned in view of discontinuous spreading of carcinoma into the regional pelvic lymph nodes. Because of its simplicity vaginal radical operation would still be useful today for very old high-risk patients and very young women with early invasive collum carcinoma detected in cancer screening. In view of our knowledge of the lymph node problem in collum carcinoma, however, this can no longer be the vaginal radical operation of past generations. In order to prevent critical objections to vaginal radical operation, the early attempts of Stoeckel, Suboth Mitra, Bastiaanse, Navratil, Inguilla, and Akashi were resumed. Since 1989 attempts have been made to combine vaginal radical operation of collum carcinoma with laparoscopic pelvic or para-aortic lymphonodectomy. The development has passed the following stages: the development of laparoscopic pelvic and para-aortic lymphonodectomy based on staging criteria the combination of laparoscopic lymphonodectomy with vaginal radical operation of collum carcinoma the combination of laparoscopic lymphonodectomy with complete laparoscopic radical hysterectomy and only subsequent vaginal removal of organs.

[Quality assurance in excision of suspected malignant, preoperatively marked and unmarked, breast lesions. A one-year analysis]. / Qualitätssicherung der Exstirpation malignitätsverdächtiger präoperativ markierter und unmarkierter Mammaläsionen. Eine Einjahresanalyse.

The breast cancer incidence is increasing for all industrial countries in the last years. Therefore the relevance of screening methods especially of mammography for early registration of suspected lesions becomes more and more important. One result of using screening methods is an increased rate of patients with lesions which are suspected for cancer but non palpable. For the background of that fact we are describing our one year experience with the therapy of cancer suspected breast lesions in 136 female patients. In 47 cases (34.6%) there was a palpable and in 89 cases (65.4%) a non-palpable lesion. The need for mammography was assured in 43 patients (48.3%) through mastopathic controls, in 23 patients (25.8%) within the frame work of a preventive first mammography and in 15 patients (16.8%) through controls after operative therapy for breast cancer. All non-palpable lesions were marked preoperatively through mammography 88.8% (n = 79), sonography 6.7% (n = 6), or through magnet resonance imaging MRI 4.7% (n = 4). Every mammographic marked case was followed by an intraoperative specimen mammography. In 16.8% (n = 15 from 89) of the non-palpable marked areas, a carcinoma was found. 16.7% (n = 3) of the detected cancers were diagnosed in an in-situ-stage, all others in an early stage (pT1-, pN0-, M0-stage) and treated. Besides the early diagnosis of breast cancer and the resulted improvement of prognosis also the rate of breast saving therapies can be increased. Reflecting our datas it should be demanded a regular screening for defined risk groups. In conclusion to improve the prognosis of breast cancer patients and reduce the risk of ablative therapies it is necessary to release a consequent marking of non-palpable cancer suspected breast lesions, a consequent aseptic handling before operation, an intraoperative mammography of the resected area and a frozen section.

[Endoscopic appendectomy in gynecology]. / Die endoskopische Appendektomie in der Gynäkologie.

From 1987 to 1997 we treated 406 patients with appendicitis. 392 patients were treated by endoscopic appendectomy, 14 patients underwent laparotomy for appendectomy. Among these 406 patients we found 4 patients with primary pelvic inflammatory disease, 18 patients with endometriosis, 15 pregnant patients and 13 patients older than 60 year's. The difficulties during the laparoscopic operation were unimportant and we could keep them under control by laparoscopic. 13 patients developed severe complications during the postoperative period. For this reason we do not perform a prophylactic appendectomy during gynaecological laparoscopies. We present in this paper our results and indications for the endoscopic appendectomy.

[Effect of surgical laparoscopy on prognosis of early and limited ovarian malignancies]. / Der Einfluss der operativen Laparoskopie auf die Prognose früher und begrenzter Ovarialmalignome.

9375 laparoscopies were performed at our clinic between 1987 and 1993. In this patient group the incidence of early or localised stages of ovarial malignomas FIGO I and II is 0.9 per cent. 81 laparoscopies were performed on patients suffering from localised stages of ovarial malignomas. 32% (n = 26) of these laparoscopised patients suffering from ovarial malignomas were subjected to extended diagnostic-surgical laparoscopy. These 26 localised stages of ovarial malignomas on which tumour-aggressive laparoscopy had been performed, were followed up and the relevant literature studied and processed. In 23 of the patients thus subjected to tumour-aggressive laparoscopic surgery we did not observe any deterioration of the prognosis during the treatment period (1-8 years). Problematic postoperative courses were seen in 3 patients; the reasons for this are discussed in the present paper. Measures resulting in opening of the tumours during diagnostic-surgical laparoscopy are neither accidental nor unforeseen incidents, but are rather part of an overall surgical strategy. If safety techniques are adopted-as described in this paper-diagnostic-surgical laparoscopy can be performed even during localised stages of ovarial malignomas without any presently recognisable adverse effect on patient prognosis.

[The clinical picture of endoscopically treated extrauterine pregnancy. Postoperative follow-up of 677 endoscopically operated extrauterine pregnancies 1983-1993]. / Das klinische Bild der endoskopisch behandelten Extrauteringravidität. Postoperative Beobachtungen an 677 endoskopisch operierten Extrauteringraviditäten 1983-1993.

677 ectopic pregnancies were treated by laparoscopy from 1983-1993. Complications in 26 cases led to a second laparoscopic intervention; these complications are analysed to access the advantages and risks of this new procedure. The postoperative HCG blood levels were observed and salpingectomy vs. organ-preserving techniques compared. 30 cases of postoperative HCG-increases and 19 cases with operative treatment of residual trophoblast are also analysed. Endoscopic salpingectomy of tubal pregnancies is a safe procedure with a very low complication rate. Organ-preserving treatment of tubal pregnancies via laparoscopy has a critical complication range of 7-9%. This should be considered for the choice of the operating procedure and the patient should be informed of the risks and their frequency.

[Risk of recurrence and rate of intrauterine pregnancy after endoscopic therapy of extrauterine pregnancies. 10 years experiences with the treatment of 709 extrauterine pregnancies]. / Rezidivrisiko und intrauterine Schwangerschaftsrate nach endoskopischer Therapie von Extrauteringraviditäten. 10jährige Erfahrungen mit der Behandlung von 709 Extrauteringraviditäten 1983-1992.

709 ectopic pregnancies were observed from 1983-1992 in the Department of Gynaecology of the Neukölln Hospital, Berlin, Germany, 585 out of which underwent laparoscopic treatment. 169 of 372 patients treated from 1986-1991 still wished to conceive, and we found intrauterine pregnancies in 60% (102 patients) and recurrent ectopic pregnancies in 27% (46 patients). In 9% (11 patients) of these the recurrence occurred following a delivery. A long term follow-up of patients from 1986-1988 was carried out in 1989 and 1993. Compared to 1989, the data of 1993 show a remarkable increase in recurrences and a merely slight increase in intrauterine pregnancies. For representative results the duration of follow-up should be 5 years or longer. 37 cases were operated on while preserving the organ, on a solitary tube or on both tubes. This group with an intrauterine pregnancy rate of 33-47% and a recurrence rate of 49% is discussed later. The risk of recurrence is increased after organ-preserving treatment of a second tubal pregnancy and after severe pelvic inflammatory disease. The process of deciding between maintaining the organ versus salpingectomy, is also discussed.

[Endoscopic appendectomy in gynecology and obstetrics]. / Die endoskopische Appendektomie in Gynäkologie und Geburtshilfe.

From 1987 to 1990, 99 patients were treated for appendicitis. 67 patients were treated by endoscopic appendectomy, 32 patients underwent laparotomy for appendectomy. Among these 67 patients we found 4 patients with endometriosis, 6 with pelvic inflammatory disease, and 4 pregnant patients. In no case did we have difficulties during the laparoscopic operation; only 4 patients developed severe inflammatory complications during the postoperative period. For this reason, we do not perform a prophylactic appendectomy during gynaecological laparoscopies. We recommend careful postoperative treatment after laparoscopic appendectomy.

[Change in tubal pregnancy 1983-1989. 7-years experiences with surgical laparoscopy]. / Die Tubargravidität im Wandel der Jahre 1983-1989. 7jährige Erfahrungen mit der operativen Laparoskopie.

The authors report on the changing aspects in diagnostics and surgical treatment of tubal pregnancy during a period of 7 years (1983-89). In that period, 432 cases of tubal pregnancy were diagnosed and treated, 311 of which were treated by endoscopic abdominal surgery. Diagnosis of tubal pregnancy now depends on radioimmunology for identifying the presence of beta-HCG in the serum as well as on sonographic diagnosis. This may supply proof of tubal pregnancy in many cases as early as 3-4 weeks after conception. Surgery should not be initiated too early, but should also not be too late. We found that the 4th to 5th week after conception yields the best results. During 1986-88, 156 patients were surgically treated by laparoscopy because of tubal pregnancy. These operations and the subsequent fate of the patients are analysed. 66 patients continued to actively wish for a child. In 15% of these there was a recurrence of tubal pregnancy. 62% of these patients became again pregnant in utero.

[Microscopic DNA cytophotometry of axillary lymph node metastasis in mammary carcinomas]. / Mikroskopische DNS-Zytophotometrie axillärer Lymphknoten-Metastasen beim Mamma-Carcinom.

65 primary mammary carcinomas and their corresponding axillary lymphnode metastases were studied. DNA-histograms were measured in imprints using microscopical Feulgen-cytophotometry (CAS 100). Comparison between DNA histograms according to AUER-typing showed a close consent in all except five cases; with a shifting from euploidy to aneuploidy (one case), and from aneuploidy to euploidy (four cases). The clinical value of these findings should be proved.

[Organ-saving therapy of small ovarian cystomas and dermoids by surgical laparoscopy--a trial 1985-1987]. / Organerhaltende Therapie kleiner Ovarialkystome und Dermoide durch operative Laparoskopie--ein Versuch 1985-1987.

The article reports on the results of the removal of small benign ovarian tumors (teratoma, cystic adenoma) without oophorectomy. 10 patients were treated by laparotomy and 23 patients with operative laparoscopy. The laparoscopy procedure is limited to tumors not larger than 5 cm. In this procedure it is especially difficult to recognize the difference between a luteal cyst and a cystic tumor which is a already malignant. Careful preoperative and intra-operative attention must be paid to the differential diagnosis. So far, follow up of the 14 patients with cystic adenoma and the 19 patients with teratoma, has shown no recurrence of tumor in the remaining ovary.

[Clinical effectiveness and systemic toxicity of various mixtures of prilocaine and bupivacaine in axillary plexus block]. / Klinische Wirksamkeit und Systemtoxizität verschiedener Mischungen von Prilocain und Bupivacain zur axillären Plexusblockade.

The presently existing local anesthetics (LA) do not guarantee a rapid onset and simultaneously a long duration of action. The combination of a medium-long acting LA with bupivacaine, a long-acting LA with slow onset, could be means to achieve these aims. Prilocaine was chosen as the medium-long acting LA because it has the lowest toxicity of this group and for pharmacological reasons. METHODS. In a prospective, controlled double-blind study 100 patients scheduled for axillary block for elective surgical procedures of the hand or wrist were randomly assigned to five groups. Twenty patients in each group received either 40 ml prilocaine 1.5%; 40 ml bupivacaine 0.375%; 20 ml prilocaine 1% + 20 ml bupivacaine 0.5%; 20 ml prilocaine 2% + 20 ml bupivacaine 0.5%; or 20 ml prilocaine 2% + 20 ml bupivacaine 0.375%. The LA mixtures were freshly mixed 15 min prior to the axillary block. The blocks were performed using an immobile, short-beveled needle by anesthesiologists who were familiar with this technique. Analgesia was classified using the pin-prick method with 0 = no analgesia, 1 = analgesia, 2 = anesthesia. Motor blockade was classified with 0 = no motor block, 1 = paresis, 2 = paralysis. The following nerves were analyzed: ulnar, radial, median, musculocutaneous, and medial antebrachial. In 6 patients of each group plasma levels of the LA were measured by gas chromatography and methemoglobinemia was determined. Statistical analysis of the data was performed using the Student t-test and chi-square test on a level of significance of P less than 0.05. Results. All surgical procedures could be performed as planned in regional anesthesia. Twenty minutes after injection of the LA only 15% of the blocks were sufficient in the bupivacaine group, while in the other four groups 40%-50% of the blocks were complete (P less than 0.05). The degree of analgesia was deeper in the groups with 2% prilocaine and prilocaine alone than in the group with 1% prilocaine. Forty minutes after injection there were no significant differences between the groups. Motor blockade after 20 min was significantly lower in the bupivacaine group than in the prilocaine group (P less than 0.05). After 4 h all three prilocaine-bupivacaine mixtures showed a significantly more pronounced analgesia of the median nerve than the prilocaine group (P less than 0.02-0.001).(ABSTRACT TRUNCATED AT 400 WORDS)

[Hepatic coma - experimental study with swine (part 1)]. / Das Coma hepaticum - experimentelle Studie am Schwein (1. Mitteilung).

An acute coma hepaticum was produced in 8 pigs by means of one intraperitoneal dose of thioacetamide. Distinct changes in the behaviour of the animals, changes of the biochemical parameters inclusively the enzyme pattern with a typical lesion pattern of the liver parenchyma and a displacement of the plasma amino acids were shown. All pathological changes in comparison with the normal animal characterize the liver insufficiency after 24 hours as a comatose state. This acute toxic model serves as the base for investigations within the physiology of nutrition about parenteral feeding of L-amino acid mixtures in coma hepaticum. The nearly exclusive hepatotropic lesion degree of thioacetamide is suitable as an experimental model for this purpose.