[Register of Difficult Surgical Situations]. / Register der schwierigen chirurgischen Situationen.

Every surgical problem that increases the likelihood of intraoperative and postoperative complications is considered to be a difficult surgical situation. Based on this definition, Korenkov et al. proposed to classify patients according to the following intraoperative difficulty levels (I to IV): (I) ideal situation (easy to operate, no problems), (II) fairly easy/manageable/simple (some minor difficulties may occur), (III) difficult/problematic (difficult to operate; some operative techniques are considerably more difficult than others), and (IV) very difficult (every operative step is difficult/challenging). Kaafrani et al. proposed a severity classification for intraoperative adverse events. Depending on the severity level, classes range from I (injury requiring no repair) to VI (intraoperative death). Clavien and colleagues published a globally established classification system for postoperative complications. In this classification, the severity of postoperative complications ranges from severity grade I (minimal deviation from the normal postoperative course) to severity grade V (death of patient). Based on the proposed classifications and the problems of individual surgical decision-making, we had the idea to create a Register of Difficult Intraoperative Situations (DIS register). The basic principle of such a register is the collection of an individual expert's experiences. The scientific analysis should focus on patients with apparent modifications in treatment due to difficult intraoperative situations. Registration and processing of enrolled cases will be performed anonymously based on an appropriate IT platform. The main goal of this register is to develop an accessible database for practising surgeons. This will provide an opportunity for every surgeon to find out what other surgeons did in similar situations.

Single-incision versus standard multi-incision laparoscopic colectomy in patients with malignant or benign colonic disease: a systematic review, meta-analysis and assessment of the evidence.

BACKGROUND: Single-incision laparoscopic colectomy (SILC) requires only one umbilical port site and (depending on technique) a specimen extraction site. The aim of this study was the assessment of the available evidence for the comparison of SILC to conventional multi-port laparoscopic colectomy (MLC) in adult patients, in whom elective colectomy is indicated because of malignant or benign disease. First, previous meta-analyses on this topic were assessed. Secondly, a systematic review and meta-analysis of randomised controlled trials, was performed. METHODS: Electronic literature searches (CENTRAL, MEDLINE and EMBASE; up to March 2016) were performed. Additionally, we searched clinical trials registries and abstracts from surgical society meetings. For meta-analysis, risk ratios (RR) or mean differences (MD) with 95 % confidence intervals were calculated and pooled. The quality of previous meta-analyses was evaluated against established criteria (AMSTAR) and their reported results were investigated for consistency. RESULTS: We identified 6 previous meta-analyses of mostly low methodological quality (AMSTAR total score: 2 - 5 out of 11 items). To fill the evidence gaps, all these meta-analyses had included non-randomised studies, but usually without assessing their risk of bias. In our systematic review and meta-analysis of randomised controlled trials exclusively, we included two randomised controlled trials with a total of 82 colorectal cancer patients. There was insufficient evidence to clarify whether SILC leads to less local complications (RR = 0.52, 95 % CI 0.14 - 1.94) or lower mortality (1 death per treatment group). Length of hospital stay was significantly shorter in the SILC group (MD = -1.20 days, 95 % CI -1.95 to -0.44). One of the two studies found postoperative pain intensity to be lower at the first day. We also identified 7 ongoing trials with a total sample size of over 1000 patients. CONCLUSION: The currently available study results are too sparse to detect (or rule out) relevant differences between SILC and MLC. The quality of the current evidence is low, and the additional analysis of non-randomised data attempts, but does not solve this problem. SILC should still be considered as an experimental procedure, since the evidence of well-designed randomised controlled trials is too sparse to allow any recommendation.

Right diaphragm injury: an unusual complication in single-port laparoscopic cholecystectomy.

Laparoscopic cholecystectomy (LC) is nowadays the standard method for cholecystectomy. Recently, surgeons attempt to introduce even less-invasive surgical procedures, such as single-port LC or LC through natural orifice transluminal endoscopic surgery (NOTES). The number of studies showing the feasibility of these techniques increased during the last years, but specific complications that correlated with these new techniques are still not apparent. Here, we report on a case with an unusual complication, iatrogenic right diaphragm injury in single-port LC. A 72-year-old man underwent single-port LC because of symptomatic cholecystolithiasis. During the operation, the long rigid straight forceps holding the fundus of the gallbladder slipped off toward the right diaphragm and caused a 1-cm full-thickness diaphragmatic tear. Laparoscopic suture repair was performed, and the patient recovered uneventfully. In using long forceps in single-port LC or transvaginal NOTES-LC, reticulating and bent instruments may avoid this unusual but possible complication in these operations.

Natural orifice specimen extraction for avoiding laparotomy in laparoscopic left colon resections: a new approach using the McCartney tube and the tilt top anvil technique.

BACKGROUND: Classical laparoscopic left colon resection requires a minilaparotomy. This wound can cause pain and morbidity. We describe our technique to avoid minilaparotomy by natural orifice specimen extraction. METHODS: A four-port standard laparoscopic dissection for diverticular disease and small tumors of the left colon was performed. A silicon McCartney tube was transanally inserted into the rectum to remove the specimen and to pass the anvil of the circular stapler into the abdominal cavity. The head of the anvil was mechanically pretilted to facilitate introduction into the proximal colon. Double-stapled anastomosis was performed in the usual manner. RESULTS: Eight patients with diverticular disease or small tumors were operated. There were no adverse events. Operating time ranged between 95 and 180 minutes. For malignancies, tissue margins and lymphadenectomy were oncologically adequate. Four week follow-up was uneventful. CONCLUSION: The described natural orifice specimen extraction technique has the potential to avoid incision-related morbidity of the minilaparotomy in laparoscopic left colon resections.

Benign peritoneal multicystic mesothelioma diagnosed and treated by laparoscopic surgery.

Benign cystic mesothelioma is a rare pathology predominantly encountered in females. The increased use of laparoscopy for abdominal pain, particularly in female patients, implies that surgeons are aware of the macro- and laparoscopic presentation of this tumor for adequate diagnosis and therapy. In this paper, we present the case of a young woman with benign multicystic mesothelioma in which only laparoscopy led to the appropriate diagnosis. Subsequently, the tumor was removed by laparoscopic surgery.

One year ago not business as usual: wound management, infection and psychoemotional control during tertiary medical care following the 2004 Tsunami disaster in southeast Asia.

INTRODUCTION: Following the 2004 tsunami disaster in southeast Asia severely injured tourists were repatriated via airlift to Germany. One cohort was triaged to the Cologne-Merheim Medical Center (Germany) for further medical care. We report on the tertiary medical care provided to this cohort of patients. METHODS: This study is an observational report on complex wound management, infection and psychoemotional control associated with the 2004 Tsunami disaster. The setting was an adult intensive care unit (ICU) of a level I trauma center and subjects included severely injured tsunami victims repatriated from the disaster area (19 to 68 years old; 10 females and 7 males with unknown co-morbidities). RESULTS: Multiple large flap lacerations (2 x 3 to 60 x 60 cm) at various body sites were characteristic. Lower extremities were mostly affected (88%), followed by upper extremities (29%), and head (18%). Two-thirds of patients presented with combined injuries to the thorax or fractures. Near-drowning involved the aspiration of immersion fluids, marine and soil debris into the respiratory tract and all patients displayed signs of pneumonitis and pneumonia upon arrival. Three patients presented with severe sinusitis. Microbiology identified a variety of common but also uncommon isolates that were often multi-resistant. Wound management included aggressive debridement together with vacuum-assisted closure in the interim between initial wound surgery and secondary closure. All patients received empiric anti-infective therapy using quinolones and clindamycin, later adapted to incoming results from microbiology and resistance patterns. This approach was effective in all but one patient who died due to severe fungal sepsis. All patients displayed severe signs of post-traumatic stress response. CONCLUSION: Individuals evacuated to our facility sustained traumatic injuries to head, chest, and limbs that were often contaminated with highly resistant bacteria. Transferred patients from disaster areas should be isolated until their microbial flora is identified as they may introduce new pathogens into an ICU. Successful wound management, including aggressive debridement combined with vacuum-assisted closure was effective. Initial anti-infective therapy using quinolones combined with clindamycin was a good first-line choice. Psychoemotional intervention alleviated severe post-traumatic stress response. For optimum treatment and care a multidisciplinary approach is mandatory.

[Liver transplantation with no-heatbeating donor supplied gaseous oxygen during cold preservation in pigs].

OBJECTIVE: To investigate the availability of liver transplantation with non-heart beating (60 min) donors supplied gaseous oxygen by hepatic vein in cold preservation period in pigs. METHODS: Thirty-six pigs were randomly divided into three recipient groups and three donor groups (group A-15 min of warm ischaemia, group B-60 min of warm ischaemia and group C-60 min of warm ischaemia with gaseous oxygen by hepatic vein during cold preservation period). OTL was performed after four hours cold preservation. Postoperative 5 days survival rate of the liver metabolic, function and inflammatory reaction were observed. RESULTS: All animals in group A and C survived after reperfusion for 5 days, but animals in group B died within 3 hours postreperfusion. The damage of liver construction and function were found in group A and group B. There was no significant difference of the changes between group A and C. CONCLUSIONS: Gaseous oxygen persufflation during cold preservation has important protective and resuscitative effect for liver from long-time no-heart beating donors. It was possible to become a promising method for liver transplantation with no-hearbeating donors.