[Laparoscopic appendectomy--a lot of effort for a minor operation?]. / Entzündeter Blinddarm? Bahn frei für das Laparoskop!

In the hands of an experienced surgeon, laparoscopic appendectomy is by no means a time-consuming procedure that might put the patient at risk. In particular it enables an all round inspection of the abdominal cavity, thus enabling both the detection of diverticular disease and tumors or processes within the true pelvis. The complication-free operation leaves behind only tiny scars, so that, in the event of abdominal complaints at some later date, a mistaken diagnosis of appendicitis might easily be established elsewhere. To help prevent this, the patient must be given the relevant information about the procedure. In addition, provision of the patient with a medical ID card is proposed.

[Laparoscopic resection of the colon]. / Schnell wieder auf den Beinen--aber um welchen Preis?

In terms of achievable outcome, laparoscopic resection of the colon is equally as good as the conventional open procedure. The sole contraindications are patients with severe cardiopulmonary disease, massive adhesions, and peritonitis following a perforation (relative contraindication). The question as to whether the minimally invasive approach is justifiable from the oncological point of view remains to be clarified in further studies.

[Procedural options for laparoscopic inguinal hernial repair--what should the general physician recommend?]. / Serie Schlüssellochchirurgie, Teil 1: Leistenhernien. Bruch-OP mit oder ohne Netz--was können Sie empfehlen?

For the repair of inguinal hernias the conventional Bassini, Shouldice and Lichtenstein procedures, plug repair and laparoscopic procedures are available. The latter may be a totally endoscopic preperitoneal repair (TEP) or a transabdominal preperitoneal meshplasty (TAPP), usually applying polypropylene meshes. In general, alloplastic material should not be used in patients younger than 45, so as to prevent possible groin or testicular complaints, or avoid difficulties with a scar plate in the event of subsequent surgery. Exceptions are, for example, large recurrences or an expressed preference on the part of the patient.

[Fundoplication reborn--thanks to laparoscopic surgical techniques]. / Serie Schlüssellochchirurgie, Teil 2: Fundoplicatio. Reflux-Stopp ohne Risiken und Nebenwirkungen?

Irrespective of the exact procedure employed, laparoscopic fundoplication--in the hands of the expert--is a rapidly performed operation with a low complication rate. Over the long-term, young patients with severe reflux complaints (GERD) in particular should benefit from this operation.

[The value of sonography in the differential diagnosis of pseudotumours of the kidney (author's transl)]. / Bedeutung der Sonographie für die Differentialdiagnostik von Pseudotumoren der Niere.

Two hundred and three patients with urographic appearances suspicious of a space-occupying lesion were examined by sonography. Seventy-nine showed normal results; there were 65 cysts, 20 malignant lesions, 20 pseudo-tumours and 19 with other abnormalities such as hydronephrosis, urolithiasis and inflammatory lesions. Pseudotumours are due to varients of the structure of the kidney, which resemble space-occupying lesions in the excretory urogram. The sonogram shows them as low echo, centrally protruding structures arising from the edge of the parenchyma. Angiographically they are islands of parenchyma with normal vessels. Sonography has proved to be a necessary complement to excretion urography and provides a more certain indication for renal arteriography. Angiography can be limited to changes in the parenchyma, since sonography is able to define cystic processes.

[Sonographic diagnosis of enlarged parathyroid glands in hyperparathyroidism (author's transl)]. / Sonographische Diagnostik vergrösserter Nebenschilddrüsen beim Hyperparathyreoidismus.

Fifty-nine patients suspected clinically of having primary or tertiary hyperparathyroidism have been examined since 1978 in order to localize enlarged parathyroid glands. With glands larger than 5 mm. this proved successful in about 90% of those situated in the neck. The sonographic features of enlarged parathyroid glands are poor echoes, smooth margins and the typical position on the medial and posterior surface of the thyroid gland. A requirement for diagnostic success is the use of modern compound apparatus with digital convertors and focussed high resolution probes.

[Laparoscopic management of a Spigelian hernia]. / Die laparoskopische Versorgung einer Spieghel'schen Hernie.

The Spigelian hernia occurs where the vertical linea semilunaris, along the lateral border of the rectus muscle, joins the linea semicircularis. The hernia lies in the soft tissue under the aponeurosis of the oblique abdominis muscle; incision of that layer can be avoided by laparoscopic techniques. In this case the hernial canal was closed, firstly with single titanium staples, and secondly with a continuous laparoscopic suture using resorbable material. In suspicious cases laparoscopy should be performed to confirm the diagnosis of a Spigelian hernia. Laparoscopic hernial repair should be evaluated by further usage of this technique.

[Modification of the infrared light coagulator LC 250. Development of probes for endoscopic use]. / Weiterentwicklung des Infrarotlicht-Coagulators LC 250. Entwicklung von Sonden für den endoskopischen Gebrauch.

With regard to prior positive results using the infrared-light-coagulator LC 250 for hemostasis of bleeding parenchymal organs and inoperable tumors, new tubes with 5 and 10 mm diameter were developed for laparoscopic purposes. The first clinical experiences showed the secure and rapid hemostasis after bleedings of the liver following a cholecystectomy, smaller resections and biopsies also resulted after lesions of the abdominal wall. The newly developed applicator consisting of a metal or teflon grip, improved the performance of these probes.

[Preoperative ultrasonic diagnosis and localization of enlarged parathyroid glands in suspected hyperparathyroidism]. / Präoperative sonographische Lokalisationsdiagnostik vergrösserter Nebenschilddrüsen bei Verdacht auf Hyperparathyreoidismus.

Since August 1978, the neck of 68 patients with the clinical diagnosis of hyperparathyroidism was examined by ultrasound. The accuracy of the method increased from 61% during the first period of investigation to 82% using a newly-developed ultrasound scanner. These results are comparable with those obtained by invasive methods like angiography or selective venous blood sampling for the assay of parathyroid hormone. Positive preoperative localization of enlarged parathyroid glands confirmed the diagnosis of HPT. Cases involving acute HPT preoperative localization of enlarged parathyroid glands requires prompt surgical management. Preoperative localization of an adenoma allows direct removal of the enlarged gland and exploration of the others within the immediate section from microscopic examination under surgery.

[Incidence of stab injuries of the heart in the clinic and forensic autopsy practice. Experiences with 6 surgical procedures]. / Häufigkeit von Herstichen in Klinik und rechtsmedizinischem Sektionsgut.

During a period when 6 patients were operated following a cardiac stab wound 4 patients survived the procedure. In 45 persons forensic autopsies were performed. The analysis of both groups elucidate that successful treatment is possible if pericardial tamponade inhibits free bleeding into the cavity of the thorax. But this situation must be treated very quickly avoiding cardiac arrest due to cardial blockage. In contrast to the autopsies in the clinical group no atrial wounds or incisions of coronary arteries were observed.

[The Hickman catheter in bone marrow transplantation, long-term cytostatic and infusion therapy. Experience of 102 catheters in children]. / Der Hickman-Katheter bei Knochenmarktransplantation, langfristiger Cytostatica- und Infusionstherapie. Erfahrungen mit 102 Kathetern bei Kindern.

Right atrial Hickman catheters are used for long-term venous access in children suffering from leukemia and malignoma. Parenteral alimentation, blood withdrawal and bone marrow transplantation can be performed safely without high incidence of cutaneous infections and sepsis due to a long subcutaneous tunnel. Aseptic dressing changes and catheter care are the most important prerequisites for a low complication rate in the use of these catheters. Septicemia and technical complications observed following the use of 102 Hickman catheters in 81 children are reported and discussed.

[Infrared coagulation of the lung. Initial experimental and clinical results]. / Infrarotcoagulation an der Lunge. Erste tierexperimentelle und klinische Ergebnisse.

With regard to the good results which were found using the infrared coagulator (IRC) in hemostasis of liver and spleen experimental and clinical investigations of the lung were performed. Animal experiments elucidated the necessity of ligation of greater vessels as well as bronchi. Secure plugging of lung tissue was also possible following increased positive pressure respiration. A mean maximal extend of necrosis of 3 mm was measured. Clinical use in 11 patients proved secure plugging of tissue due to IRC application. Drainages could be removed within 4 days without appearance of broncho-pleural fistulas.

[Arterial compression syndrome. First the fingers tingle, then thrombosis of the brachial artery]. / Arterielles Kompressionssyndrom. Erst kribbeln die Finger, dann thrombosiert die Arteria brachialis.

The thoracic outlet syndrome and the entrapment syndrome involving the popliteal artery are two major examples of arterial compression syndrome. Since not only the arteries, but also the entire neurovascular bundle is compressed, the initial symptoms are often neurological: paresthesias, tingling, numbness, etc., in particular when certain movements are carried out. In such a case, bilateral blood pressure measurements, provocative tests and Doppler (duplex) examination are indicated. A point that is, perhaps, less well-known is the fact that compression can lead to serious vascular lesions ranging from post-stenotic aneurysms to complete thrombotic occlusion and peripheral emboli. When the diagnosis has been confirmed, early surgery is indicated.

[With the right shut. Well prepared for dialysis]. / Mit dem richtigen Shunt. Gut gerüstet zur Dialyse.

To accomplish hemodialysis in the patient requiring regular dialysis, a well-made shunt establishing a permanent access to the vascular system is essential. This involves making a connection between a vein and an artery, either directly or via a plastic prosthesis. A classic example is the Cimino shunt, a subcutaneous shunt between the cephalic vein and the radial artery, which today can usually be carried out under plexus anesthesia. It is important to establish the indication for a shunt in good time and to optimally prepare the patient, e.g. by vein training. In cooperation with the nephrologist, the vascular status of the patient, and prior diseases such as peripheral occlusive arterial disease or diabetes mellitus, must be established. A fully functional shunt is essential for the patient with terminal kidney failure to be able to lead a civilized life of the long-term.

[Cerebrovascular insufficiency--2. When is surgery indicated?]. / Zerebrovaskuläre Insuffizienz--Teil 2. Wann lohnt die Operation?

For the vascular-surgical treatment of cerebrovascular insufficiency, prior staging is essential. In stage I only the 80-89% asymptomatic stenosis should be operated on. Using this approach, the stroke risk decreases significantly in comparison with conservative treatment. Stage II disease is the domain of vascular surgery. In stage II a and b, an operation makes sense only exceptionally in the noncomatose patient and within the first 6 hours following the event. Prior to disobliteration of stage IV stenoses, CT and MRI findings need to be considered. In the presence of a contralateral high-grade stenosis of the internal carotid, surgery is recommended here too. The classical method is carotid disobliteration with patchplasty. Possible alternativeas are eversion endarterectomy and carotid bifurcation-plasty.

[Acute ischemia of the extremities. As critical as a myocardial infarct]. / Akute Extremitätenischämie. Bedrohlich wie ein Myokardinfarkt.

Acute limb ischemia is a vascular-surgical emergency requiring immediate referral to a hospital provided with all the necessary therapeutic facilities. Essential initial measures are protection of the limb against continued cooling, management of pain, and bolus administration of heparin. For the physician providing further care, not only an accurate history, but, ideally, also the results of earlier investigations such as ECG, abdominal US or Doppler studies, provide useful information. In patients who have not undergone prior surgery vascular-surgical management, that is, embolectomy with a balloon catheter, is the treatment of choice. Furthermore, the patient requires continuing care after discharge; here, wound management and the supervision of anticoagulation measures that might be needed are important tasks for the general practitioner.

[Peripheral arterial occlusive disease. Symptoms, basic diagnosis and staged therapy]. / Periphere arterielle Verschlusskrankheit (pAVK). Symptomatik, Basisdiagnostik und Stufentherapie.

Intermittent claudication or rest pain are typical symptoms of peripheral arterial occlusive disease (PAOD) affecting the lower limbs. The pain is localized one level below that of the occlusion. Initial investigations should determine skin temperature and color, pulse status, stenotic sounds and Doppler occlusive pressures. If intermittent claudication is present, angiography of the pelvis and legs then follows. Treatment is stage-dependent: while in stages I and IIa conservative treatment such as cessation of smoking, administration of acetylsalicylic acid and walking training suffices, stages IIb and higher require invasive measures extending from PTA to amputation of gangrenous parts of the limb.

[Aortic stent versus open prosthesis implantation. How can the aneurysm be excluded?]. / Aortenstent versus offene Prothesenimplantation. Wie wird das Aneurysma ausgeschaltet?

The diagnosis of an infrarenal aortic aneurysm mandates not only regular ultrasonographic monitoring, but also careful instruction of the patient about an emergency, that is, symptoms associated with rupture, and how to react. If ultrasound reveals a clear increase in the size of the aneurysm, or if a diameter of 5 cm is reached, the indication for surgery is established. Two options are then available: implantation of an aortic stent, which has the advantage of being a minimally invasive procedure, or open prosthesis implantation. However, the benefits and risks of both options must be carefully weighed up, since the patients are often elderly and have cardiopulmonary problems. Postoperative surveillance of the patient comprises three- to six-monthly follow-up with ultrasound or CT scan.

[Crossectomy--exhairesis--stripping--laser therapy. How even refractory varicose veins respond to treatment]. / Krossektomie-Exhairese-Stripping-Lasertherapie. Wie selbst hartnäckige Varizen verschwinden.

Chronic venous insufficiency affects more than 50% of the German population. Major factors involved in its development are age, family disposition, female sex and an occupation involving much standing. Together with the clinical presentation, Doppler and duplex ultrasonography in particular enable a reliable pre-operative diagnosis, and deep venous thrombosis can also be definitively excluded. Indications for surgical treatment are in particular varicosis of the greater and lesser saphenous vein and perforating vein insufficiency. Commonly used procedures are crossectomy, restrictive stripping of pathological vein segments, resection of varicose side branches, and the endoscopic discission of perforating veins. Recent developments are deep-freezing and extraction of the vein and endovenous laser treatment (EVLT), requiring only tiny incisions. In most cases, these interventions can be performed on an outpatient basis.