[Individualized or standard approach to the abdomen : Currently available data]. / Individualisierter oder Standardzugangsweg zum Abdomen : Aktuelle Datenlage.

BACKGROUND: Every abdominal incision can lead to early (e. g. abdominal infection) and late complications (e. g. hernia). The correct incision is often important to have optimal access to the surgical area and to keep complications low. OBJECTIVE: An analysis of the recent literature was carried out to clarify which access routes have advantages over other types of incision. MATERIAL AND METHODS: A literature search was carried out in the following databases: Cochrane database of systematic reviews (CDSR), Cochrane library, Medline and PubMed. Systematic reviews and studies with large numbers of cases were used for the evaluation, whereas studies with small numbers of cases and case reports were not taken into account. RESULTS: Midline incisions are the first choice for acute and elective abdominal surgery because of a good view into and rapid access to the abdominal cavity. For large upper abdominal operations transverse incisions can be considered of equal value due to excellent exploration possibilities, e.g. of the liver and pancreas. 25 years after the introduction of laparoscopy, this technique has become established for cholecystectomy, fundoplication and bariatric surgery. For appendix and colon surgery laparoscopy has the advantage of being less traumatic, whereby postoperative pain and hospitalization are reduced but under circumstances longer operating times must be expected. The single incision laparoscopic surgery (SILS) technique is beneficial in cosmetic outcome; however, incisional hernias, prolonged operating times and higher complication rates are limiting factors for this technique. Natural orifice transluminal endoscopic surgery (NOTES) and atypical incisions are rarely used.

Impact of two extubation techniques on the intra-abdominal pressure: a preliminary study.

PURPOSE: High pressure peaks might be a risk factor for the development of abdominal hernia. The course of abdominal pressure during extubation remains unclear. This preliminary study assessed the impact of two established extubation techniques. METHODS: Twenty-four consecutive patients suffering from abdominal wall hernia with the indication for surgical treatment were included. Twelve patients were extubated directly after the intravenous anaesthesia was stopped, before they had spontaneous breathing (deep extubation). The other 12 were extubated after they had spontaneous breathing (awake extubation). Intra-abdominal pressure (IAP) was measured via bladder catheter continuously. RESULTS: The highest value during extubation as well as the main increase in IAP was significantly lower in patients who underwent deep extubation (p < 0.001). CONCLUSIONS: Therefore, this extubation technique might improve the outcome of hernia repair.

Recurrence and complications after laparoscopic versus open inguinal hernia repair: results of a prospective randomized multicenter trial.

BACKGROUND: The aim of this prospective randomized multicenter trial was to evaluate the recurrence rates and complications of open versus laparoscopic repairs of inguinal hernias. METHODS: Patients with primary unilateral inguinal hernias were randomized to Shouldice repair, Bassini operation, tension-free hernioplasty (Lichtenstein repair), laparoscopic transabdominal extraperitoneal hernioplasty (TEP), or laparoscopic transabdominal preperitoneal hernioplasty (TAPP). The primary outcome parameter was the rate of recurrence at 3 years. The secondary outcome was the rate of intraoperative, perioperative, and long-term complications. Follow-up comprised of clinical examination after 1, 2, and 3 years. RESULTS: Three hundred and sixty-five patients were randomly assigned to one of the five procedures. The intention-to-treat analysis showed that the cumulative 3-year recurrence rate was 3.4% in the Bassini group, 4.7% in the Shouldice group, 0% in the Lichtenstein group, 4.7% in the TAPP group, and 5.9% in the TEP group (p = 0.48). Comparing open (Bassini, Shouldice, Lichtenstein) versus laparoscopic (TAPP, TEP) techniques (p = 0.29) and comparing the use of mesh prostheses (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) (p = 0.74) showed no significance in the rate of recurrence. The rates of intraoperative (p = 0.15), perioperative (p = 0.09), and long-term complications (p = 0.13) were without significance between the five groups. Comparing mesh techniques (Lichtenstein, TAPP, TEP) versus suturing techniques (Bassini, Shouldice) showed no significance in the rate of complications. The per-protocol analysis for the comparison of mesh (Lichtenstein, TAPP, TEP) versus suturing (Bassini, Shouldice) techniques revealed that recurrences (p = 0.74), intraoperative (p = 0.64), perioperative (p = 0.27), and long-term complications (p = 0.91) were evenly distributed. CONCLUSIONS: In this multicenter study, no significant difference in the recurrence rate and complications between laparoscopic and open methods of hernia repair was revealed.

Measurement of the tensile strength of the ventral abdominal wall in comparison with scar tissue.

BACKGROUND: Paramedian laparotomies lead to incisional hernias in approximately 30% of cases. In contrast, incisional hernias occur very rarely in the linea alba or the ventral abdominal wall. In this setting we investigated the difference between scar tissue and the non-incised abdominal wall tissue. METHODS: At the post mortem examination of 66 recently deceased individuals, accurately measured pieces of resected tissue from the linea alba, the anterior and the posterior rectus sheath, and scar tissue following median laparotomy, were exposed to tensile loads. FINDINGS: In the epigastric region the tissue ruptured at a mean horizontal load of 10.0 (SD 3.4) N/mm(2) in the linea alba and 6.9 (SD 2.5) N/mm(2) in scar tissue (P<0.001), and at a mean vertical load of 4.5 (SD 2.0) N/mm(2) in the linea alba and 3.3 (SD 1.6) N/mm(2) in scar tissue (P<0.05). In the hypogastric region as well, scar tissue was significantly less resistant in the main direction of load. INTERPRETATION: Scar tissue has a significantly lesser loading capacity than the intact ventral abdominal wall and therefore poses a permanent risk for herniation. For this reason, closure of the abdominal wall should be given due consideration and subjected to further investigation. Specifically, sustained reinforcement of scar tissue by means of suture techniques or non-absorbable sutures warrants further study. When constructing meshes for reinforcement of incisional hernias, the two-fold tensile load on the midline in horizontal direction as opposed to the craniocaudal direction must be taken into account.

Selection of patients for laparoscopic antireflux surgery.

Since the first laparoscopic fundoplication was performed, the frequency of antireflux surgery has increased rapidly with some centers now having an experience of about 1,000 procedures. The question arises whether this increase is due to a change in indications for the surgical treatment of gastrointestinal reflux disease (GERD) despite the simultaneous appearance of powerful antisecretory medications. Adequate knowledge of the pathophysiology of GERD is necessary in order to establish selection criteria for patients suitable for laparoscopic antireflux surgery. In this article, we review the epidemiology and pathophysiology, and provide a rationale for medical and surgical treatment. We also offer an approach to patient selection for antireflux surgery.

Bursting strength evaluation after different types of mesh fixation in laparoscopic herniorrhaphy.

BACKGROUND: In laparoscopic inguinal herniorrhaphy, meshes commonly have been fixed with a stapler. Recently, a new mode of fixation using a helical fastener has been introduced. The purpose of this experimental study was to compare the stability achieved by various types of mesh fixation. METHODS: In 20 human cadavers, polypropylene meshes 10 x 15 cm in size were fixed in both groins by using either a helical fastener or a hernia stapler (4.8 mm). The mesh was fixed with 2, 4, and 8 elements and stressed with a dynamometer until the prosthesis ruptured. A paired and two-sided Student's t-test was used for statistical evaluation. RESULTS: With the helical fastener, the mesh could be fixed always at the desired site. However, with the stapler, it was not possible to fix the mesh in the pubic bone or, at times, in the Cooper's ligament. When two fixation elements were used, the mesh fixed by the helical fastener was able to withstand a median load of 34 N (range 23-53 N), and that fixed by the stapler 7.5 N (range 3-12 N; p < 0.001). When four fixation elements were used, the mesh fixed by the helical fastener was able to withstand 70.5 N (range 53-80 N) and that fixed by the stapler 17. 5 N (range 4-25 N; p < 0.001). With the use of eight elements, the mesh fixed by the helical fastener withstood 127 N (range 84-156 N) and that fixed by the stapler 32.5 N (range 15-59 N; p < 0.001). Thus, in all cases the helical fastener was significantly more stress resistant. The main reason for detachment of the mesh was tissue disruption or deformation of the fixation elements. Only when a stress of more than 130 N was applied did the mesh tear in two cases. CONCLUSIONS: The stress-bearing capacity (shear force resistance) of a mesh fixed by a helical fastener is up to four times that of a mesh fixed by a stapler. Therefore, the helical fastener provides significantly more stable fixation and will be able to protect the patient better from recurrent hernias caused by mesh migration.

Mesh fixation with the helical fastener in laparoscopic herniorrhaphy: initial results.

In laparoscopic herniorrhaphy, an alternative to mesh fixation with a stapler is now offered by the helical fastener. The helical fastener was used in 46 patients (39 men and 7 women) with 30 unilateral and 15 bilateral inguinal hernias and 1 femoral hernia. We also used a 5-mm optical system, with which we were able to reduce the size of the trocar incisions. Two 5-mm incisions and one 7-mm incision were used. The fixation elements could easily penetrate bone; therefore, the mesh was easily fixed in the public bone. Laterally, the mesh was fixed in the iliopubic tract. The peritoneum was closed by continuous, extracorporeal knotted sutures. Complications included a wound hematoma in two cases and a small bowel obstruction secondary to inadequate closure of the peritoneum in another case. This was treated by the laparoscopic technique, and the peritoneum was closed with staples. All patients were available for follow-up after 6 to 12 months and were free of recurrence at that time. Patients started to stress the groin after 2 weeks (range 1 to 3). In view of the 40% reduction in incision size and the greater stability of mesh fixation, we prefer the helical fastener over stapler fixation.

Static calculations for mesh fixation by intraabdominal pressure in laparoscopic extraperitoneal herniorrhaphy.

In laparoscopic extraperitoneal herniorrhaphy, there have been no static calculations for nonfixed prostheses with regard to the ideal size of the prosthesis, mesh overlap on the hernial orifice, friction coefficient, and shear forces. The aim of the present study was to perform these static analyses. The friction coefficient of a polypropylene mesh was measured in an experimental setting. Based on the distribution of adhesive force and load on the mesh, we calculated the required mesh overlap over the hernial opening. The friction coefficient was determined as mu0 = 0.3. The friction surface required to immobilize the prosthesis is 4.16 times the stress surface. Assuming a safety factor of 2.5, the minimum distance between the margin of the prosthesis and that of the hernial opening should be equal to the diameter of the hernial opening. For smaller lesions we recommend a minimum mesh overlap of 2 cm over the hernial orifice. From a hernia size 2 cm and larger, the distance between the margin of the prosthesis and the hernial opening should be equal to the diameter of the orifice. From 4 cm and larger, the prosthesis should be secured with a stapler (or a similar mode of fixation) to prevent recurrence.

[Malignant lymphomas of the thyroid gland]. / Maligne Lymphome der Schilddrüse.

In the period from 1957-1989 43 malignant lymphomas of the thyroid gland were treated in the surgical department of Kaiser Elisabeth hospital. 42 were classified as non-Hodgkin lymphomas and one as a Hodgkin lymphoma. The sex distribution was 32 women (mean age 70) to 11 men (mean age 72). The patients were divided into two groups according to postoperative management. First group (1957-1978): conventional irradiation. N = 24 patients, mean survival time 5 months (0-37 months). Second group (1979-1989): high voltage irradiation and/or chemotherapy. N = 19 patients, mean survival time 39 months (1-128 months). All patients in the first group died, whilst in the second group only 9 have died to date. Moreover, 9 of the 10 patients who are still alive are in full remission. Over the past 10 years we have achieved a clear improvement in survival time; this is a result of extended radicality of the surgical procedures, haematological staging and an improvement in the chemotherapy and irradiation regimens.

[Prognostic factors in highly malignant thyroid tumors]. / Prognostische Faktoren bei hochmalignen Schilddrüsentumoren.

Patients diagnosed as suffering from highly malignant thyroid tumours die within a few months due to rapid tumour progression. Survival depends on some valuable prognostic factors, namely tumour size, lymph node involvement, metastatic status, fast tumour growth and preoperative N. recurrens paresis. Life expectation and life quality are dependent on the feasibility of radical surgical treatment. It is necessary to remove the whole tumour to improve the survival rate and to reduce the incidence of local recurrence. Some highly malignant thyroid tumours show a high chemosensitivity.

[Reinterventions in anaplastic cancers and sarcomas of the thyroid gland]. / Reeingriffe bei anaplastischen Karzinomen und Sarkomen der Schilddrüse.

In the years 1979-1988, operations were performed on 41 anaplastic carcinomas and 11 sarcomas of the thyroid gland. Out of these cases reoperation was indicated in 18 patients (34.6%): in 11 cases only a palliative tracheotomy could be done (group I), whilst in the remaining 7 patients surgical removal of the recurrent tumour was possible (group II). Analysis of group II patients revealed that the initial surgical intervention had been a macroscopically radical operation. The difference between the survival rates of both groups was highly significant (group I 64 days, group II 412 days mean survival). Despite the fatal prognosis of these highly malignant tumours, we conclude that reoperation for the removal of a recurrent tumour is advisable in those patients in whom the initial operation was a radical excision. Longer survival rates and improved quality of life were achieved. If the initial operation was merely palliative, then only a tracheotomy is the likely procedure in case of recurrence.