[Assessment of quality of life and gynaecological follow-up after transvaginal cholecystectomy]. / Untersuchungen zur Lebensqualität und gynäkologisches Follow-up nach transvaginaler Cholezystektomie.

BACKGROUND: It has been reported recently that transvaginal cholecystectomy (TV­ChE) has advantages over 'classic' laparoscopic cholecystectomy (LAP­ChE) because of its minimal invasiveness. TV­ChE seems to be associated with a lesser need for analgesics and faster reconvalescence of patients. However, substantial doubts about the transvaginal access and possibly associated complaints and complications of the procedure have been raised. PATIENT/MATERIAL AND METHODS: In this prospective case-control study 30 female patients undergoing transvaginal cholecystectomy (TV­ChE group) have been compared with 30 women undergoing conventional laparoscopic cholecystectomy (LAP­ChE group). Female patients were evaluated with special regard to health-related quality of life, outcome data such as surgical complications and gynaecological complaints and changes in sexual behaviour after surgery. Additional attention was given to the extent of postoperative pain, the analgesic consumption and the rate of postoperative nausea and vomiting (PONV). RESULTS: The demographic data of both groups were comparable to a great extent. Compared to the LAP­ChE group women of the TV­ChE group reported less postoperative pain, less PONV and a lower analgesic consumption (p < 0.001). There were no serious complications in the LAP­ChE group and also none in the TV­ChE group. In comparison with the preoperative status, the results regarding health-related quality of life and feeling of well-being were significantly better for both groups after a follow-up of 12 months (p < 0.01). However, this effect was especially pronounced in the TV­ChE group (p < 0.05). No infections of the surgical wound, wound healing problems or other complications were seen in the gynaecological follow-up examination 3 weeks after the TV­ChE. Two women reported slight and temporary colpotomy-related complaints without any consequences for their sexual behaviour. CONCLUSIONS: The transvaginal cholecystectomy is a safe and less invasive surgical technique providing for an excellent patient comfort and a fast reconvalescence. TV­ChE has a positive longterm effect on health-related quality of life. Doubts about transvaginal approach of this surgical technique with regard to an increased risk of infection or late gynaecological complications appear to be unfounded.

[Comparison between transvaginal and laparoscopic cholecystectomy - a retrospective case-control study]. / Vergleich zwischen transvaginaler und laparoskopischer Cholezystektomie - eine retrospektive Fall-Kontroll-Studie.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) appears to be established in specialised surgical centres. Potential advantages of these operating techniques include surgery without scars as well as faster and more comfortable recovery. However, to date there are no controlled studies evaluating the assumed advantages of NOTES compared with both minimally invasive and open surgery. PATIENT / MATERIAL AND METHODS: In this retrospective case-controlled study 47  women undergoing transvaginal cholecystectomy (TV-ChE) have been compared with 46 women undergoing conventional laparoscopic cholecystectomy (LAP-ChE). Both groups were evaluated with regard to intraoperative respiratory and oxygenation parameters, pain intensity and need for analgesics postoperatively, rate of postoperative nausea and vomiting (PONV), duration of stay in recovery room as well as hospital stay. RESULTS: Demographic data of both groups were comparable to a great extent. However, in comparison with the women of TV-ChE group those of the LAP-ChE group were 5  years older on average (49 ±â€Š15 vs. 54 ±â€Š16  years). Even so, there were no differences in preoperative risk assessment (ASA classification) as well as intraoperative respiratory and haemodynamic parameters. Compared to the LAP-ChE group, women of TV-ChE group reported less postoperative pain (p < 0.001), less nausea or vomiting (p < 0.001) and a lower analgesic consumption in both opiates (p < 0.001) and non-opiates (p < 0.001). Furthermore, the duration of stay in recovery room was shorter in the TV-ChE group (40  minutes vs. 60  minutes, p < 0.001). Hospital stay in the TV-ChE group was 3  days on average compared to 4  days for the LAP-ChE group. The rate of general and surgical complications was lower in TV-ChE group (1 / 47) compared to the LAP-ChE group (4 / 46). In 9  women undergoing transvaginal cholecystectomy negligible vaginal bleeding was seen which stopped spontaneously in each case. CONCLUSION: The transvaginal cholecystectomy is a safe and less invasive surgical technique. Compared to laparoscopic cholecystectomy, there seem to be some advantages such as better cosmetic results, lower need for analgesics, faster mobilisation, more comfortable recovery and shorter hospital stay. These effects should be confirmed in prospective controled studies.

Shouldice standard 2020: review of the current literature and results of an international consensus meeting.

INTRODUCTION: For many years the Shouldice technique was the gold standard for inguinal hernia repair. Nowadays mesh repair has been proven to entail better results in randomized trials. Since the first publication 1953 the Repair has been described in detail in many textbooks, articles and You Tube videos. It appears that the original technique is used almost exclusively in the Shouldice Hospital in Thornhill/ Canada and despite the success of the Shouldice Hospital many surgeons inexplicably modify this original technique in their daily practice. In the last couple of years there appears to be an increasing interest in pure tissue repairs for various reasons, often fear of mesh-related pain. The aim of the study was to review the current evidence and to define an updated standard with key principles of the Shouldice repair. METHODS: Because of unpublished evidence regarding many operative details the organizing group decided to create a technical update via a consensus meeting with 13 international designated hernia surgeons from six countries. In preparation of the meeting a review of the current literature regarding Shouldice repair was done by the organizing group. A questionnaire was prepared and sent to all participants before the meeting to get an independent answer on all critical aspects. RESULTS: All questions regarding a detailed standard of the operation technique could be outlined. As result of the consensus meeting the participants have formulated all key-points of preparation/dissection and repair of the Shouldice technique. For 5 of 6 critical technical surgical steps a strong consensus could be defined in the group. There was no consensus among the group regarding the cremaster resection and the ideal indication for Shouldice repair. CONCLUSION: After a 75-year history of the Shouldice repair the technique should continue to merit consideration by all hernia surgeons. After this consensus meeting a clear binding standard of the Shouldice technique for all interested surgeons is proposed.

[Ultrasound during follow-up of carcinoma]. / Ultraschall in der Tumornachsorge.

According to the guidelines, ultrasonography (US) is now established as the cross-sectional imaging technique of choice in postoperative care of colorectal carcinoma. Although conventional percutaneous US is inferior to computed tomography (CT) and magnetic resonance imaging (MRI) for detecting hepatic metastases, the application of specific contrast media has significantly increased sensitivity and specificity to 87% and 88%, respectively. The combination of US and CT/MRI achieves the highest detection rates. During follow-up of rectal carcinoma, in up to 20% of locoregional recurrences are diagnosed solely by endorectal sonography and result in repeat resection with curative intention. In noncolorectal carcinoma, US is recommended in the guidelines for following up hepatocellular carcinoma and malignant thyroid disease, but the available data are insufficient to support those recommendations.

[Natural orifice transluminal endoscopic surgery in Germany: Data from the German NOTES registry]. / "Natural orifice transluminal endoscopic surgery" in Deutschland : Daten aus dem deutschen NOTES-Register.

BACKGROUND: The German NOTES registry (GNR) was initiated by the German Society for General and Visceral Surgery (DGAV) as a treatment and outcome database for natural orifice transluminal endoscopic surgery (NOTES). AIM: The aim of this study was the descriptive analysis of all GNR data collected over a 5-year period since its start in 2008 with more than 3000 interventions. MATERIAL AND METHODS: The GNR is an online database with voluntary participation available to all German-speaking clinics. Demographic data, therapy details, complications and data on the postoperative course of patients are recorded. All cases in the GNR between March 2008 and November 2013 were included in the analysis. RESULTS: From a total of 3150 data sets 2992 (95 %) were valid and suited for the analysis. Hybrid transvaginal cholecystectomy was the most frequently used procedure (88.7 %), followed by hybrid transvaginal/transgastric appendectomy (6.1 %) and hybrid transvaginal/transrectal colon procedures (5.1 %). Intraoperative complications occurred in 1.6 %, postoperative complications in 3.7 % and conversions were reported in 1.5 %. Intraoperative bladder injuries and postoperative urinary tract infections were identified as method-specific complications of transvaginal procedures. Bowel injuries occurred as a rare (0.2 %) but potentially serious complication of transvaginal operations. CONCLUSION: The German surgical community ensures a safe and responsible introduction of the new NOTES operation techniques with its active participation in the GNR. Despite an overall low complication rate, the high number of procedures in the GNR permitted the identification of method-specific complications. This knowledge can be used to further increase the safety of NOTES in practice.

Diaphragmatic paralysis without bulbar or limb paralysis in multiple sclerosis.

A patient is presented in whom disabling pulmonary symptoms in the absence of other significant disability complicated a long-standing course of MS. Clinical presentation and fluoroscopy confirmed the diagnosis of bilateral diaphragmatic paralysis. Magnetic resonance imaging revealed atrophy and extensive white matter changes within the cervical cord. This case is unique in that significant respiratory compromise due to cervical spinal cord involvement by MS was dissociated from bulbar dysfunction or profound limb paresis.

Endoscopic therapy and early elective operation as a therapeutic regimen in ulcer bleeding.

In a prospective protocol we treated 63 consecutive patients admitted to our surgical department with bleeding gastroduodenal ulcers between January 1986 and December 1987. The therapeutic regimen included emergency endoscopy in all cases. Active Forrest Ia or II hemorrhage was treated endoscopically with submucosal injection. Endoscopic control of hemorrhage was achieved in all but one case. Low-risk ulcers, e.g. Forrest II without visible vessel and III or ulcers caused by antirheumatic drug medication were treated definitively by therapeutic endoscopy (31 patients). Ulcers with high risk of rebleeding even after endoscopic therapy underwent additional early elective operation. Thirty patients were treated surgically by this means. Two patients required emergency operation because of failure to control the bleeding (Ia and second rebleeding) endoscopically. The overall mortality of the surgically treated patients was 6% (2/32). The mortality of the therapeutic endoscopy was 0%. Thus, the mortality of the overall group was 3%. The major advantages of this concept were: low mortality rates, elimination of rebleeding in the follow-up period, optimal conditions for the surgical therapy resulting in low death-rates and a reduced need for transfusions.

Strong ultrasonic microwaves in ferroelectric ceramics.

It is well known that ferroelectric materials have piezoelectric properties which allow the transformation of electrical signals into mechanical signals and vice versa. The transducer action normally is restricted to frequencies up to the mechanical resonance frequency of the sample. There are, however, two mechanisms which allow transducer action in ferroelectric ceramics at much higher frequencies: one is the normal piezoelectric effect in a ferroelectric ceramic in which the crystallites have periodic domain structures, the other is a domain wall effect in which ferroelastic domain walls in a periodic domain structure are powerful shear wave emitters. Both mechanisms give rise to extensive dielectric losses in ceramics at microwave frequencies.

[Anastomotic ulcers after duodenopancreatectomy for carcinoma of the head of the pancreas]. / Anastomosenulzera nach Duodenopankreatektomie wegen Pankreaskopfkarzinoms.

Anastomotic ulceration following partial pancreatoduodenectomy carries a substantial risk of complications. More than 50% of patients have episodes of bleeding and up to 20% die as a direct consequence of peptic complications. In a retrospective study of 88 patients, frequency of ulcer was analysed comparing Whipple-Child reconstruction and partial pancreatoduodenectomy with a Roux-Y gastrojejunostomy. Indication was ductal carcinoma of the pancreas in 80 cases and periampullary carcinoma in eight patients. Roux-Y gastrojejunostomy was performed in 53 cases, Billroth-II anastomosis with enteroanastomosis in 35 patients. Perioperative mortality was 7% (n = 6). Nine cases of anastomotic ulceration were verified after Roux-Y gastrojejunostomy (18%). Three out of five Roux patients with a periampullary carcinoma developed ulcers. After Billroth-II reconstruction anastomotic ulceration was found in only one out of 33 cases (3%). Six ulcers presented with bleeding, anastomotic stenosis occurred in two cases. Three ulcer patients with curatively resected periampullary carcinoma were reoperated. After resection of the Roux limb and truncal vagotomy no recurrence was seen during a follow-up period of 19 to 46 months. Roux-Y gastrojejunostomy carries an increased risk of anastomotic ulceration. The lack of inactivation of pepsin by bile acids has to be discussed as an underlying mechanism.

[Transinguinal preperitoneal mesh-plasty (TIPP) in management of recurrent inguinal hernia]. / Die transinguinale präperitoneale Netzplastik (TIPP) in der Versorgung der Rezidivleistenhernie.

From 3 years' experience with nearly 100 transinguinal preperitoneal mesh prosthesis (TIPP) repairs for recurrent inguinal hernia the indication, anesthesia, modification of the technique, and results are reported. After intraoperative classification of the hernia, the TIPP repair is indicated especially in large defects of the posterior wall (L/M III). The procedure is easily performed under local anesthesia. During 52 local TIPP repairs, conversion of anesthesia was never necessary. Important technical details include the requirement for a sufficient size of mesh (10 cm x 15 cm) and a certain caudal and cranial fixation of the prosthesis using at least three interrupted stitches for each. Apart from an increased number of seromas (12%) in the early postoperative period, the results of the TIPP are comparable with those obtained after Shouldice repair for recurrent hernia. The rate of hematomas, infections, and testicular complications range between 1% and 3%. Considering the negative case selection of only large recurrent hernias, the TIPP repair reveals a favourably low 1-year recurrence rate of 1%.

[Transinguinal preperitoneal mesh-plasty in inguinal hernia using local anesthesia]. / Transinguinale präperitoneale Netzplastik (TIPP) beim Leistenbruch in Lokalanaesthesie.

Between January 1994 and December 1995 inguinal and femoral hernias were repaired in 689 adults. In 58 patients (4 primary hernias, 54 recurrent hernias, 1st-7th recurrence) a mesh prosthesis (Marlex) was implanted in the preperitoneal space using an open inguinal approach (TIPP). After intraoperative classification of the hernia, the indications for TIPP were L/M/Mc and F III type hernias and a weak or destroyed transverse fascia. The operative technique of TIPP is described in detail. Half of the procedures were done with the patient under local anesthesia. There were no intraoperative complications. Besides an increased number of seromas the postoperative course following TIPP was comparable with that after Shouldice procedures performed in the same period. During a follow-up period of 3-24 months to date, no recurrence has been observed. If intraoperative hernia classification is performed, TIPP is an appropriate technique for recurrence-prone inguinal and femoral hernias.

[Classification of inguinal hernias]. / Klassifikation von Inguinalhernien.

Classification of inguinal hernia is a necessary prerequisite for a reliable analysis of different methods of repair. The underlying categorization is done intraoperatively based on the localization ('M' medial, 'L' lateral, 'F' femoral) and transverse diameter (I = < 1.5 cm, II = 1.5-3.0 cm, III = > 3.0 cm) of the hernial orifice. In cases of combined hernias the diameters of both fascial defects is added up, the hernia is classified according to the part of major importance for the development of recurrences, the medial defect, with the index 'c'. The classification can be applied to open as well as laparoscopic approaches. The diameters of the tip of the index finger or the length of branch of endoscopic scissors (1.5 cm), respectively, serve as standards for measurement.

[Importance of sonography in diagnosis of ileus. A retrospective study of 459 patients]. / Die Bedeutung der Sonographie in der Ileusdiagnostik. Eine retrospektive Studie an 459 Patienten.

In a retrospective trial we investigated the significance of ultrasound in the diagnosis of intestinal obstruction in 459 patients. The overall sensitivity was 93.7%. In paralysis the correct diagnosis was obtained in 98% of all. Mechanical obstruction was identified in 91%. In cases of incomplete mechanical obstruction sensitivity was 89%. The corresponding value for complete obstruction was 95%. In all patients with negative findings on abdominal x-ray (10%) the correct diagnosis was established by ultrasound. Only in 71% of cases ultrasound was successful differentiating small bowel from large bowel obstruction. The underlying cause of ileus was yielded by ultrasound in 45% of the cases. On the basis of our experience ultrasound is proven to be of significant importance in the diagnosis and differentiation of ileus.

[Chronic inguinal pain after transperitoneal mesh implantation. Case report of net shrinkage]. / Chronischer Leistenschmerz nach transperitonealer Netzimplantation (TAPP). Kasuistik einer Netzchrumpfung.

The implantation of a mesh is an essential step in laparoscopic inguinal hernia surgery. We present the case of a 22-year-old man who developed an unspecific and refractory syndrome of inguinal pain after a TAPP procedure for a primary inguinal hernia. Repeated reoperation for removement of clips and nerve transection were unsuccessful. By a transinguinal approach, 18 months after the first operation we removed a preperitoneal Prolene mesh which had shrunk and folded to 30% of its original size. The problem of biocompatibility of meshes currently used in inguinal hernia surgery is discussed.

The ulcer risk in reflux preventive gastric operations. An experimental study.

The ulcer risk of duodenogastric antireflux operations following gastric resection was analyzed experimentally in 162 rats. After gastric resection a Roux-Y gastrojejunostomy or jejunal transposition of various length were done. 10 month postoperatively a follow-up was performed consisting of endoscopy, analysis of gastrin and gastric secretion, gastric emptying tests and histamine stimulation. A high incidence of stomal ulceration was found, which was directly related to the length of the interposed jejunal segment. The reflux free stomachs within 10 month developed stomal ulcerations in 72.7%, after additional 2 mg/kg histamine stimulation in 100%. The aetiology of these ulcers seems to be acid related, because all reflux-free stomachs showed a very low pH. Reflux preventive operations are demonstrated to be a modification of the Mann-Williamson experiment. They should be used carefully or avoided.

[Laparoscopy for suspected appendicitis. Should an appendix that appears normal be removed?]. / Laparoskopie bei Verdacht auf akute Appendizitis. Soll die makroskopisch unauffällige Appendix entfernt werden?

The question whether an appendix found to be macroscopically normal at laparoscopy for suspected appendicitis should be removed remains open to debate. Potential advantages of appendicectomy in all cases include early diagnosis of neoplastic lesions that cannot be detected macroscopically, diagnosis and cure of neurogenic appendicectomy, avoidance of diagnostic confusion in later episodes of abdominal pain, and prevention of appendicitis developing later in life. Therefore, adopting a strategy of always removing the appendix even if it is found to be uninflamed at laparoscopy seems justified as long as it does not imply an increase in postoperative morbidity. We retrospectively studied all patients undergoing laparoscopic appendicectomy in which a "normal appendix" was found and all patients undergoing diagnostic laparoscopy in our hospital during a 7-year period. Our data as well as a critical review of the literature show that removal of the appendix does not increase morbidity compared to simple diagnostic laparoscopy and should always be done when performing laparoscopy for suspected acute appendicitis.