[Learning curve in laparoscopic rectum surgery]. / Lernkurve in der laparoskopischen Rektumchirurgie.

Laparoscopic colorectal surgery has become increasingly more common since first being described in a publication in 1990. Despite a multitude of studies about the learning curve in laparoscopic colon surgery, there are almost no such studies with regard to laparoscopic rectum surgery. This paper aims to describe a surgeon's learning curve with regard to laparoscopic rectum surgery. Based on data collected in a prospective observational study of 180  patients, it can be established that a surgeon experienced in open colorectal surgery, with basic experience in laparoscopic surgery, after suitable preparation and having a personal interest in minimally invasive surgery, needs to perform about 35  laparoscopic rectum resections within 200  laparoscopic colon resections until selection rate, operating time and rates of general and surgical complications reach a plateau. A selection of cases suited to a surgeon's personal level of operating experience, is a prerequisite for a low rate of conversions and complications and for oncological long-term results comparable to those achieved through open surgery. However, the learning curve is dependent on a multitude of factors that are partly unknown at this point. Its duration most certainly varies between individual surgeons. Every surgeon is required to critically evaluate his or her own laparoscopic experience and select cases accordingly. Supervision by surgeons more experienced in laparoscopic colorectal surgery prevents disadvantages for patients in the early phases of the surgeon's learning curve. Training in laparoscopic colorectal surgery should take place only in institutions with a sufficient number of cases treated and a continuity in experienced teachers. CAMIC's efforts in establishing centres of competence and reference are therefore to be commended and supported.

Modifiable surgical and anesthesiologic risk factors for the development of cardiac and pulmonary complications after laparoscopic colorectal surgery.

BACKGROUND: In contrast to patient-related risk factors, which are difficult to influence, factors relating to surgery and anesthesia that can be influenced have hardly been investigated. This study aimed to identify such risk factors. METHODS: Pre- and intraoperative surgical and anesthesiologic factors of 388 colonic and 112 rectal procedures performed by a single surgeon within 50 months were recorded and analyzed for correlations with postoperative complications requiring treatment. RESULTS: Higher American Society of Anesthesiology (ASA) emergency interventions and intraoperative factors (bleeding, long operating time) had an elevated risk for general complications. Furthermore, patients benefited from the clinical experience of the anesthesiologist, especially in terms of emergency procedures, hemorrhagic complications, and a longer operating time. CONCLUSIONS: Standardization of the surgical technique, "bloodless" surgery, standardization of intraoperative monitoring, and the use of board-certified anesthesiologists for high-risk cases, emergency procedures, and patients with high ASA stages are able to reduce postoperative morbidity.

[Intrathoracic thoracoscopic anastomosis in minimally invasive oesophageal resection - technical tips]. / Intrathorakale thorakoskopische Anastomose nach minimalinvasiver Osophagusresektion - ein operationstechnischer Hinweis.

INTRODUCTION: Minimally invasive oesophageal resections are being increasingly propagated. However, a leakage of the cervical anastomosis, occurring in up to 30 % of the cases, remains a severe disadvantage. By means of a case report, a new alternative technique of intrathoracic thoracoscopic anastomosis is described. PATIENT AND METHOD: After the customary laparoscopic abdominal performance of lymph-node dissection, a gastric conduit was performed in a 73-year-old patient with an adenocarcinoma of the gastro-oesophageal junction. After that the oesophagus had been resected thoracoscopically and an intrathoracic side-to-side/functional end-to-end anastomosis between the gastric conduit and oesophagus was performed with linear staplers. RESULTS: There were no postoperative complications. CONCLUSION: The intrathoracic thoracoscopic oesophagogastrostomy seems to be an oncologically adequate procedure that has less complications than the other laparoscopic-thoracoscopic techniques described so far. However, further studies are necessary to prove this conclusively.

[Sense or nonsense of a prophylactic drainage after laparoscopic colorectal surgery - a prospective study]. / Sinn oder Unsinn einer prophylaktischen Drainage nach laparoskopischer Kolonresektion - eine prospektive Untersuchung.

INTRODUCTION: A growing number of studies do not show an advantage of prophylactic drainage in intraabdominal surgery any more. Especially against the background of "fast-track" surgery, this study aimed at an analysis of the influence of drainage on the patient's outcome in elective laparoscopic colorectal surgery. METHOD: Within a 50-month period, 569 laparoscopic colorectal operations were carried out at the Klinikum Bremerhaven Reinkenheide, a centre for minimally invasive surgery. Of these, 505 patients were operated by one surgeon. For this prospective study, the data of 299 elective colon resections because of carcinoma or diverticulitis of the sigmoid colon in Hinchey stages 0-II, out of these 505 patients, have been analysed. RESULTS: Before May 2006, a drainage was always used (n = 163, group A). Since May 2006, no drainage was used in 103 patients (group B). In another 33 patients (group C), drainage was used in complicated cases. The operation time was significantly reduced in patients with no drainage (99 min in group B vs. 120 min in group A) and there was a significantly reduced postoperative stay (6 days in group B vs. 11 days in group A). Furthermore, patients without drainage suffered less surgical and general complications than patients with drainage (6 vs. 10 % surgical complications; 1 vs. 6 % general complications). Infections of the wound occurred in 8.6 vs. 4.9 % of the cases when a drainage was used. CONCLUSION: According to our experience, prophylactic drainage does not seem to be necessary in elective colon surgery. Overall, drainage was accompanied by a higher rate of surgical and general complications. Therefore it does not fit into the concept of "fast-track" surgery.

[Influenceable surgical and anesthesiological risk factors for the development of cardiac and pulmonary complications in laparoscopic surgery of the colon]. / Beeinflussbare chirurgische und anästhesiologische risikofaktoren für die entwicklung kardialer und pulmonaler komplikationen nach laparoskopischer kolonchirurgie.

INTRODUCTION: Due to the demographic shift in the age structure of the population, increasingly older, multimorbid patients are operated who have a substantially higher risk for the occurrence of intra- and postoperative complications. Apart from the identification of patient-referred, hardly influenceable risk factors, influenceable intraoperative surgical and anesthesiological risk factors have hardly ever been examined. The aim of this investigation was therefore to identify influenceable risk factors for the development of post-operative morbidity. METHODS: In a period of 44 months, we performed a laparoscopic colon resection in 157 men and 209 women with a mean age of 63 years. The ASA classification, POSSUM score, status of the anesthesiologist, change of the anesthesiologist, intraoperative monitoring, kind of anaesthesia, fluctuations of blood pressure and pulse during the operation, shock-index > 1, substitution of erythrocyte concentrates and FFPs as well as intraoperative surgical complications were documented prospectively. Postoperative general complications requiring therapy, in particular, cardiac and pulmonal problems as well as surgical complications, in particular, infections and hemorrhages, were documented. The data analysis was performed using the program package SPSS. RESULTS: Intraoperative monitoring was more frequently used in higher ASA stages, whereas for ASA stage IV no central venous line was used in 17 % and no arterial catheter was placed in 33 %. a similar tendency concerning the POSSUM score could not be determined. Patients cared for by junior surgeons exhibited cardiac complications in 6.7 % and 13.1 % had to be mechanically ventilated postoperatively versus 2 % of cardiac complications and 9 % mechanical ventilation among those managed by specialists. An increase in postoperative complications could also be found when a change in anesthesia took place. During treatment by an assistant in case of emergencies, in cases where intraoperative substitution of erythrocytes or an operation lasting more than two hours, more cardiac complications and a higher rate of mechanical respiration was observed than during treatment by a specialist. A mechanical respiration was significantly more necessary in higher ASA stages (p < 0.01), in an operation lasting more than 2 hours (p < 0.01), in cases with the occurrence of intraoperative bleeding complications (p < 0.01), procedures with a lower status of the anesthesiologist (p < 0.01) and in procedures with a change of the anesthesiologist (p < 0.05). CONCLUSION: Factors such as overweight, ASA classification or urgency cannot be changed. Surgical factors such as a standardisation of the operation technique with reduction of the operating time and careful staunching of bleeding can help to reduce postoperative complications. Anesthesiologists can also help by avoiding a change of the anesthesiologist as well as by preference of specialists in patients with higher ASA stages and in emergency cases.

Minimally invasive transhiatal and transthoracic esophagectomy.

BACKGROUND: Standard esophagectomy requires either a laparotomy with transhiatal removal of the esophagus or a combination of laparotomy and thoracotomy. Currently, it still is associated with a high rate of morbidity and mortality. Complications leading to greater morbidity and mortality are rarely seen after minimally invasive surgery. The authors present their experience with 25 minimally invasive esophageal resections. METHODS: Between August 1st, 2003 and November 30th, 2005, the authors performed 25 minimally invasive esophageal resections for 4 woman and 21 men. Data were acquired prospectively. RESULTS: In this series, a laparoscopic transhiatal approach was performed in 9 cases, a combined laparoscopic-thoracoscopic procedure in 12 cases, and laparoscopic creation of a gastric tube combined with thoracotomy in 4 cases. No conversion became necessary. The mean operation time was 165 min (range, 150-180 min) for the laparoscopic transhiatal approach and 300 min (range, 240-360 min) for both combination approaches. Using the combined laparoscopic-thoracoscopic procedure, 23 lymph nodes (range, 19-26 lymph nodes) were removed, and using the laparoscopic transhiatal approach, 14 lymph nodes (range, 12-17 lymph nodes) were removed. The median stay in the intensive care unit was 1.5 days (range, 1-22 days), and the overall postoperative stay was 10 days (range, 7-153 days). Two intraoperative complications and two cervical anastomotic leakages were observed. The 30-day mortality rate was 0%. CONCLUSION: The findings demonstrate that laparoscopic transhiatal and combined laparoscopic/thoracoscopic esophagectomy are feasible and can be performed with low rates of morbidity and mortality. Due to an equal extent of lymph node dissection, there should be no difference in long-term survival between minimally invasive surgery and open surgery.

[Laparoscopic resection with primary anastomosis in Hinchey stages I and II without previous abscess drainage]. / Laparoskopische Resektion mit primärer Anastomose im Hinchey-Stadium I und II ohne vorherige Abszessdrainage. Eine prospektive Untersuchung.

INTRODUCTION: Intra-abdominal abscesses in diverticulitis so far have been drained percutaneously until the acute inflammation subsides and colon resection can be carried out for restoration of continence. However this method is successful in only about half of patients and lavage lasts for 2 to 3 weeks. Therefore it has to be decided whether an early operation without prior interventional drainage can attain results similar to those of the elective operation. METHODS: We performed primary laparoscopic surgery without prior interventional drainage or colon lavage in 72 patients in Hinchey stages I and II within 12 h of hospital admission. The peri- and postoperative processes were analyzed prospectively using 115 parameters. RESULTS: There was no difference in the postoperative course of patients receiving elective surgery for recurrent diverticular disease and those undergoing surgery for acute diverticulitis (Hinchey stages I and II). The rates of surgical and general complications were identical (7.7% vs 9.6% and 9% vs 3.6%, respectively). Wound infections were noted in 7.7% and 7.2%, respectively. No case of anastomotic leakage was observed. CONSEQUENCE: Based on our prospective data (grade of evidence II), we consider laparoscopic sigmoid resection with primary anastomosis (in continuity) in Hinchey stages I and II without prior interventional drainage and colon preparation to be justified.

[Laparoscopic appendectomy as training procedure for all stages of appendicitis]. / Die laparoskopische Appendektomie als Ausbildungs- und Regeloperation.

Appendectomy is one of the most common procedures in general surgery. Appendectomy is routinely performed in our department laparoscopically and as a training procedure for all stages of appendicitis. Between 1.1.2003 till 31.7.2005 642 patients underwent appendectomy. 613 of them were performed laparoscopically with a conversion rate of 0,6% in uncomplicated findings and 8,1% in complicated findings (perforated, abscess and gangrenous appendicitis). The postoperative recovery after laparoscopic appendectomy was without any significant complication in 98.2% of the patients with acute appendicitis and 89% of the patients with complicated findings. The overall morbidity rate in both situations (uncomplicated and complicated findings) did not differ from that described in literature. This supports impressively our thesis that laparoscopic appendectomy is feasible in all situations, with a high value for training young surgeons.