The historical impact of minimally invasive surgery.

At first there is an idea which asks for more comfort for the patient and equal results compared to conventional procedures. This means less pain and fatigue, quicker convalescence and shorter hospital stay. The new procedures requests an entirely new operative skill and a new technique with new instruments. Those were early developed in Germany. The roads on which this was performed will be described. In another chapter the history of this development is shown, especially the German, French and US inventors with a special view on their personal experiences and disappointments like in the German surgeon M_he and the gynecologist Semm from Kiel, Germany. But they all remained enthusiastic as a common personal quality. The new technique (MIC) was translated "Mickey-Mouse-Surgery" and medicolegal consequences like in M_he were usual events. Another example of misunderstanding of the impact of the new technique: the first publication of Semm about the laoaroscopically removed appendix has been withheld so long in Germany until it was published in the USA in the Journal "Obstetrics and Gynecology". Besides this it is reported about the life cycle of this innovation pointing out to the final promising report, the professional adoption and public acceptance and the randomized controlled trials. The last stage is characterized by "jumping on another train". Pictures are shown of those pioneers who had the idea, who understood what they were doing and who took the responsibility. The final chapter will deal with the consequences for the future generation of surgeons and their training and the unanswered questions as to further fields. Doubtlessly, the pioneer period did not come to an end yet. A glance into the future may be allowed.

[Experience and intuition in surgery]. / Erfahrung und Intuition in der Chirurgie.

The article deals with the definition, the positive and negative assessment of intuition. Only in combination with experience and knowledge intuition many be as helpful as scores. Without these prerequisites intuition may tend to become a risk factor.

[Position of the German Society of Surgery in the community of scientific specialty societies]. / Die Stellung der Deutschen Gesellschaft für Chirurgie in der Gemeinschaft der wissenschaftlichen Fachgesellschaften.

The role of the German Surgical Society among the other scientific societies is considered as well as its relationship to the BAK and its scientific activities and publications compared with internal medicine. Its most important current issues are described and explained. It can be shown that it holds a prominent position, but is scientifically less productive than internal medicine.

[Systemic release of prostanoids after surgically-induced injury of lung tissue]. / Systemische Freisetzung von Prostanoiden nach chirurgisch induzierter Verletzung des Lungengewebes.

In a prospective study, the systemic inflammatory consequences of surgery-induced lung tissue injury were evaluated using biochemical markers. The aim was to examine whether this type of injury produces a specific pattern of prostanoid plasma levels (prostacyclin, thromboxane, PGE2, PGF2 alpha, and PGM). We, therefore, compared 18 patients (group 1) who underwent thoracotomy without injury to the lung with 26 patients (group 2) that had a resection of pulmonary tissue due to benign diseases. Group 2 patients clearly revealed increased plasma levels of C-reactive protein as well as of the granulocyte-specific PMN-elastase. In particular, there was a pronounced release of prostacyclin and its antagonist thromboxane A2 following lung tissue resection. In contrast to group 1 patients, lung tissue damage resulted in immediately elevated plasma levels of PGF2 alpha and PGE2. When, however, taking into account the time course of PGM, the stable cleavage product of PGF2 alpha, there was no hint of an altered pulmonary metabolic capacity. Presumably, this pattern of elevated prostanoid levels in group 2 is the result of the surgical damage to the lung tissue. Therefore, it can be suggested to be specific for that type of injury. Thus, the release of prostanoids following surgery-induced lung tissue damage may indicate the importance of these mediators, particularly in thoracic injuries associated with lung damage since those may lead to post-traumatic pulmonary dysfunction. These substances may also be useful in evaluating both the severity and the extent of lung tissue damage following major trauma.

[Functional outcome of Eden-Hybinette-Lange operation in post-traumatic recurrent shoulder dislocation]. / Funktionelle Ergebnisse nach Eden-Hybinette-Lange-Operation bei posttraumatisch rezidivierender Schulterluxation.

OBJECTIVE: Post-traumatic recurrent dislocation is a major problem in the operative treatment of shoulder dysfunction in young athletes. This prospectively designed study evaluates the long-term results of a modified Eden-Hybinette procedure in young male athletes. The criteria were: capacity in sports, functional limit, and persistent pain. Genuine disorders of the glenoid or muscular imbalance of the shoulder joint were criteria for exclusion. PATIENTS AND METHODS: From 1982 to 1990, 143 patients underwent surgery. Seventy percent were reevaluated within a minimum period of 18 months after the operation. The functional results were calculated using the ROWE score as well as a visual analog scale (VAS). X-rays were done after the patient had given informed consent. RESULTS: VAS and ROWE score showed excellent/good results in 61%, fair results in 18%, and poor results in 21% of the documented cases. The rate of arthrosis was 25%. Redislocation occurred in 7%, mainly without any relevant trauma. The X-rays showed complete resorption of the bone graft in 30% of the cases. Best functional results and no redislocation were found in the patients who underwent surgery with fewer than 3 dislocations compared to those with more than 4 dislocation episodes. CONCLUSIONS: In cases of post-traumatic recurrent dislocation of the shoulder in young athletes, the modified Eden-Hybinette procedure is a good method of reestablishing sufficient stability of the shoulder. The operation should be performed prior to the 3rd dislocation episode. Four or more dislocation episodes show an increased tendency to redislocate and poor functional results.

[Position of the German Society of Surgery on quality assurance]. / Stellungnahme der Deutschen Gesellschaft für Chirurgie zur Qualitätssicherung.

Internal quality control like regular rounds, conferences, assisted operations, congresses, papers and analyses of the outcomes are established since the days of Billroth. External quality control was added by law. The scientific society has to accept the new commitment and offers a list of new items to back the efforts in external quality control.

[Blood coagulation parameters as prognostic factors in multiple trauma: can clinical values be an early diagnostic aid?]. / Gerinnungsparameter als prognostische Faktoren beim Polytrauma: Können klinische Kenngrössen frühzeitig eine diagnostische Hilfestellung geben?

INTRODUCTION: Polytraumatized patients develop complex changes in blood coagulation and fibrinolysis even before their arrival at the emergency room (ER). Hemostaseological parameters (i.e. antithrombine 3, alpha-2-antiplasmine, D-dimers) obtained upon admission however, permit advance differentiation of later mortality vs. survival and of possible future secondary organ failure with varying specification. OBJECTIVES: Which clinical findings enable to identify such patients early in the ER even when no specialized hemostaseological laboratory is available? MATERIAL AND METHODS: a) Prospective study of 40 polytraumatized adults upon arrival at the hospital; b) Blood sampling at the earliest possible time during takeover in the ER; c) Injury Severity Score (ISS) for descriptive purposes; d) Evaluation of the prehospital emergency physician's records in regard to respiratory therapy, fluid resuscitation, and arterial blood pressure; e) Statistics; Wilcoxon test, Spearman correlation coefficient. RESULTS: All 40 patients (m:f = 28:12; mean age: 36 (SD: 16.6) years; mean ISS: 34.7 (SD: 11.4)) displayed advanced disseminated intravascular coagulation with secondary hyperfibrinolysis upon arrival in the ER. The amount of deviation from the hemostaseological norm could not be derived from either the correlation of the typical activated parameters of coagulation of fibrinolysis with the ISS or the analysis of the separate injuries. On the other hand the subgroup of patients displaying a systolic blood pressure of less than 100 mmHg at the site of the accident or upon arrival at the ER all had significantly lower antithrombine 3, protein C, and alpha-2-antiplasmine activities as well as increased concentrations of specific reaction products resulting from activated coagulation (thrombine-antithrombine 3-complex) and of fibrinolysis (D-dimers). CONCLUSION: In our study patients with multiple injuries displaying a systolic blood pressure of less than 100 mmHg either at the scene of the accident or upon arrival in the ER showed coagulation values which by other investigators were regarded as a sign of potential secondary organ failure or death.

Peripheral blood immune responses to surgically induced lung tissue injury.

Surgically induced lung tissue trauma reveals an immune response in peripheral blood, the degree of which could depend on extent and severity of the organ trauma and the presence of lung malignancies. The study included 34 patients who underwent elective thoracic surgery because of benign and malignant lung tissue diseases. Flow-cytometric phenotyping of lymphocyte subsets shows a clear shift to reduced immunocompetent cells after lung tissue injury. Patients with lung tumors reveal a postoperative activation of the macrophage system as indicated by increased plasma levels of neopterin. Increased levels of soluble interleukin-2 receptor in the plasma of these patients may be the result of cellular shedding of the receptor. Lung tissue trauma is also followed by reduced immunoglobulin levels which are most pronounced in the presence of lung malignancies. These results suggest that lung tissue injury leads to postoperative immunosuppression especially in tumor patients.

[Bilateral ureteroiliac fistula coincident with radiotherapy and ureteral splint]. / Bilaterale ureteroiliakale Fisteln in Zusammenhang mit Radiatio und ureteraler Splintung.

Fistulas between the iliac artery and the ureter are uncommon. Overall, fewer than 20 cases have been described in the literature. We report the first bilateral case, in which there was an association with indwelling bilateral ureteral stents and a history of radiation therapy following hysterectomy performed because of malignancy. The patient presented with massive gross haematuria.

[Humerus reconstruction after gunshot fracture]. / Humerusrekonstruktion nach Schussbruch.

High-velocity bullits can cause severe blast injuries with shattering and defects of the large bones. Initial external fixation is followed by rebuilding of the bone, which is difficult due to concomitant infection, poor revascularization and lack of a suitable bone bed. A case report of an injured African soldier shows the follow-up and difficulties of reconstruction of the shattered humerus by repeated spongious bone grafting. After successful remodeling of the bone, external fixation is followed by ASIF dynamic compression-plate osteosynthesis.

[Disorders of hemostasis after polytrauma. On the extent of intrinsic fibrinolytic activity in the preclinical phase]. / Hämostasestörungen nach Polytrauma. Zum Ausmass der körpereigenen fibrinolytischen Aktivität während der präklinischen Phase.

Coagulation disorders are of utmost importance in emergency surgery as well as for secondary organ failure of polytraumatized patients. In order to get hold of the early onset of these disorders, blood samples were harvested from 20 randomly selected patients (Injury Severity Score mean = 36.7 +/- 10.5) on the scene of emergency (mean = 18 [10-29] min after trauma) and at the time of hospital admission (mean = 78 [58-98] min after trauma). In addition to the activation of intravascular coagulation and the consumption of physiological inhibitors, high amounts (10- to 50-fold above normal) of degradation products (FgDP, FbDP, TDP, D-dimers) are present on the scene, already. The influence of hemodilution due to high-volume resuscitation is discussed.

Postgraduate education and role of surgical research in Germany.

In Germany at the very moment we have general surgery and 5 specialties, they are: traumatic, plastic and reconstructive, cardiac and central vessels as well as pediatric surgery. For qualification as a general surgeon one needs at least 6 years of straight training; two more years are necessary to qualify in one of the mentioned specialties. In some specialties one year of training can be taken into account for general surgery. The postgraduate education in each field requires a precisely defined kind and number of operations as well as an examination. There are some considerations in discussion, which should be outlined: Generally speaking this means, that the basis of 6 years of general surgery may be reduced to 4 years. Thus specialization could be started 2 years earlier. This special point is in strong discussion due to the fact that the surgical skillfulness of the young surgeons may be decreased. In university hospitals and in academic teaching hospitals surgical research is realized within the surgical department as well as in special departments for experimental surgery. The ideal would be that both institutions stimulate each other.