[Case report: emergency surgery of a giant scrotal hernia]. / Notfallmässige Versorgung einer monströsen Skrotalhernie.

We present the case of a 61-year-old patient, who had developed a giant scrotal hernia during the course of 30 years. The patient was transferred to our service after stabilization of hemorrhagic shock due to bleeding from varicosis of the giant scrotal sack. The urgent operation was performed by resection of parts of small intestine, colon ascendens, transversum, and the left testis. After 9 days on our intensive care unit and 18 days on our ward the patient was discharged to further ambulatory care. At one year follow up the patient complained about only discrete abdominal problems which could be successfully treated by diet. The operative treatment modalities of so called "giant hernias" as well as possible complication management are discussed.

Self-guided robotic camera control for laparoscopic surgery compared with human camera control.

BACKGROUND: In laparoscopic surgery, the surgeon no longer has direct visual control of the operation area, and a camera assistant who maneuvers the laparoscope is essential. Problems of cooperation between the two naturally arise, and a robotic assistant that automatically controls the laparoscope can offer a highly desirable alternative to this situation. METHODS: A self-guided robotic camera control system (SGRCCS) based upon a color tracking method has been developed and its use evaluated in 20 cases of laparoscopic cholecystectomy and compared with using human camera control. RESULTS: In 83% of the patients the procedures were successfully completed with the SGRCCS. Set-up time for the robot averaged 21 minutes; and the surgical time with and without the robot averaged 54 and 60 minutes, respectively. Using the robot instead of a human camera assistant significantly reduced both the frequency of the camera correction, 2.2 per hour compared with 15.3 per hour, and frequency of the lens cleaning, 1.0 per hour compared with 6.8 per hour. Subjective assessment by the surgeon revealed that the robot performed better than the human assistant in 71 % of the cases. CONCLUSIONS: In laparoscopic surgery, the SGRCCS offered optimal camera guidance and helped to maintain the surgeon's concentration during the operation.

Endoscopic stapling diverticulostomy for Zenker's diverticulum.

Endoscopic stapling diverticulostomy (ESD) using an endostapler is a modification of the standard endoscopic treatment of Zenker's diverticulum (ZD). It is characterized by complete myotomy of the upper esophageal sphincter, with division of the common wall between diverticulum and esophagus, followed by immediate simultaneous closure of the divided edges with the staples. ESD was performed on 21 patients with ZD between January 1996 and October 1997. The results were then evaluated. Operation time averaged 22 min. Wide opening of the diverticulum and excellent hemostasis were achieved. All of the patients but one, who died postoperatively of myocardial infarction, resumed oral intake without any evidence of cervical sepsis or mediastinitis. Complete relief of dysphagia was achieved in all 20 patients. Hospital stay averaged 4.7 days (range, 2-7 days). The patients were followed up after ESD for a median time period of 12 months. No relapses were recorded. ESD is an effective endoscopic treatment for ZD that entails a low risk of complications and requires only a short period of hospitalization.

Long-term follow-up of endoscopic therapy in patients with post-surgical biliary leakage.

BACKGROUND/AIMS: Leakage is a rare complication of biliary surgery which is thought to follow a benign course after appropriate treatment. However there is a paucity of long-term follow-up data. PATIENTS AND METHODS: In this retrospective analysis, we present our experience with 21 patients in whom a biliary leakage was diagnosed following conventional and laparoscopic cholecystectomy (n = 14) or other types of biliary surgeries such as liver transplantation or segmental liver resection. Long-term follow-up (mean: 15.5 months) was obtained by telephone contact with patients, families or referring physicians. RESULTS: Endoscopic therapy was primarily successful in 20 of 21 patients and failed in 1 case with complete common bile duct dissection. Closure of the leakage was achieved by placement of nasobiliary tubes or endoprostheses with (n = 16) or without (n = 4) endoscopic papillotomy. Despite successful endoscopic therapy 3 patients died, 1 unrelated to the intervention, and 2 due to prolonged biliary sepsis (mortality: 9.5%; 30 day: 4.8%). Long-term follow-up in the surviving 18 patients showed them to be free of biliary complaints. CONCLUSION: ERCP is the primary modality to diagnose and treat post-operative biliary leakages. Despite rapid healing of the leakage in all 20 successfully treated cases, complications-related mortality was higher than previously suspected.

[Possibilities of telecommunications in surgery]. / Möglichkeiten der Telekommunikation in der Chirurgie.

In contrast to telesurgery, telepresence involves only the audiovisual dialogue between the local surgeon and a remote expert; the latter, however, is able to actively monitor the operation by giving his judgement and recommendations. Under clinical conditions, telepresence may have the potential to facilitate intraoperative consultation of remote experts or even tele-assistance. Technical requirements consist of a suitable telemanipulation device (remotely controlled camera and indicator) and a high-duty communication system for real-time transmission of the operating site and the control signal. A minimum of 2 Mbyte/s of transmission capacity is recommended.

[Technical requirements and possibilities of teleconsultation in laparoscopic interventions]. / Technische Erfordernisse und Möglichkeiten der Telekonsultation bei laparoskopischen Eingriffen.

Recent developments in robot technology and communication media have opened the way for their use in various medical techniques. Automated camera guidance as well as new telecommunication systems make it possible to carry out extensive laparoscopic operations precisely and to provide teaching assistance from great distances (so-called telepreceptorship). Long-term cost reduction, reduction of surgical complications and the improvement of quality standards are some of the benefits which could be realized by use of such systems.

[Bile duct lesions in laparoscopic cholecystectomy]. / Gallenwegsläsionen bei laparoskopischer Cholecystektomie.

Laparoscopic cholecystectomy is both resulting in a slightly higher incidence of biliary lesions and a change of prevalence of the type of lesions. Damage to the biliary system occurs in 4 different types: The most severe case is the lesion with a structural defect of the hepatic or common bile duct with (IVa) or without (IVb) vascular injury. Tangential lesions without structural loss of the duct should be denominated as type III (IIIa with additional lesion to the vessels, type IIIb without). Type II comprehends late strictures without obvious intraoperative trauma to the duct. Type I includes immediate biliary fistulae of usually good prognosis. The increasing prevalence of structural defects of the bile ducts appears to be a peculiarity of laparoscopic cholecystectomy necessitating highly demanding operative repair. In the majority of cases, hepatico-jejunostomy or even intraparenchymatous anastomoses are required. Adaptation of well proven principles of open surgery is the best prevention of biliary lesions in laparoscopic cholecystectomy as well as the readiness to convert early to the open procedure.

[Role of i.v. cholangiography and ultrasonography in preoperative diagnosis before laparoscopic cholecystectomy]. / Die Rolle der i.v. Cholangiographie und der Sonographie in der präoperativen Diagnostik vor laparoskopischer Cholezystektomie.

In a prospective clinical study the relevance of i.v. cholangiography and ultrasonography for preoperative diagnosis before laparoscopic cholecystectomy was assessed. Imaging of the common bile duct was realized successfully via i.v. cholangiography in 96.3% of all patients. Compared with ERCP, i.v. cholangiography diagnosis proved correct in 91.6% of all cases with pathological depiction of the common bile duct. Ultrasonography offered a sensitivity of 97.8% for assessing the common bile duct diameter. However, the distinction between intraductal concrements and artifacts caused by air superposition may be difficult. I.v. cholangiography is the most sensitive and easy to realize diagnostic technique to identify concrements in the common bile duct. The results of this study indicate that a combined strategy of i.v. cholangiography and ultrasonography may replace ERCP for preoperative diagnosis before laparoscopic cholecystectomy, if there is a sufficient depiction of the common bile duct and without concrements in it.

[Laparoscopic cholecystectomy: ERCP as standard preoperative diagnostic technique]. / Laparoskopische Cholezystektomie: ERCP als präoperative Standarddiagnostik?

In a prospective study 250 patients with proven cholelithiasis and clinical, biochemical and ultrasound indications for laparoscopic cholecystectomy (LC) underwent endoscopic retrograde cholangiography (ERCP) and (if bile-duct stones had been shown) endoscopic papillotomy (EPT). The biliary system was demonstrated in 229 patients (91.6%). Biliary tract stones were confirmed in 18 of 68 patients in whom they had been suspected clinically. In addition, ERCP revealed small stones in the bile-duct in eight of 154 patients with normal biochemical results and unremarkable ultrasound imaging, and in seven patients bile-duct anomalies which required EPT or open cholecystectomy. However, in retrospect five of the patients with cystic duct anomalies could have been treated by LC. The complication rate of ERCP/EPT was 3.2%. It is concluded from these results that, in view of the cost and potential risk to the patient, ERCP before LC can be limited to patients suspected of having bile-duct stones, even though small stones may be missed.

Prospective evaluation of the use of endoscopic retrograde cholangiography prior to laparoscopic cholecystectomy.

Preoperative cholangiography and subsequent removal of bile duct stones may increase the efficacy of laparoscopic cholecystectomy and reduce the rate of conversion to open cholecystectomy. Since there is little data on the incidence of choledocholithiasis in this group of patients, we undertook a prospective study on the routine performance of ERC in 288 patients selected for laparoscopic cholecystectomy. ERC succeeded in 264 of the 288 patients (91.7%) and showed a normal bile duct system in 227 (86.0%). Atypical bile duct anatomy was seen in eight patients. Open cholecystectomy was performed in seven of them but was judged to be absolutely necessary in only two cases (one patient each with Caroli syndrome and Mirizzi syndrome). ERC also revealed bile duct stones in 29 of 264 patients (11.0%) which had not been suspected on the basis of clinical, laboratory and ultrasonographic findings in nine cases (3.4%). EPT succeeded in all of the 29 patients with choledocholithiasis but open cholecystectomy was subsequently performed in four patients due to incomplete bile duct clearance (n = 3) or temporary bleeding after EPT (n = 1). The rate of ERC/EPT-related morbidity was 2.8%. It is concluded from a risk-benefit analysis in these patients that ERC should be restricted to patients with suspected bile duct stones. Following this strategy, small ductal concrements and bile duct abnormalities will be missed in 6.4% of cases but the clinical relevance of these findings is still unclear. In patients with combined gallbladder and common bile duct stones, preoperative EPT plus subsequent laparoscopic cholecystectomy appears to be an effective and time-saving therapeutic regimen which should be compared with open cholecystectomy plus common bile duct exploration in future studies.

[Technique of laparoscopic cholecystectomy]. / Technik der laparoskopischen Cholezystektomie.

A new technique for laparoscopic cholecystectomy is described which regards as far as possible the conventional approach to cholecystectomy. Positioning of the operating team is identical to normal cholecystectomy, and the surgeon is able to use both hands to operate since the camera is handled by the assistant. Dissection of the infundibulum is performed in the socalled "tease-and-tear" technique. The peritoneal layer is opened by coagulation. The cystic duct and artery are bluntly dissected by a commercially available dissector. Fat and connective tissue are gently torn off from both structures. After closure of cystic duct and artery by clips, the gallbladder is cut out by thermocoagulation. 178 operations were performed by 8 surgeons; mean duration of the operation was 60 min. A change to open cholecystectomy was necessary in 2.5%. Three complications occurred, requiring reoperation in one case of insufficiency of the cystic duct and another one with intestinal perforation. In the third case, bile leakage from an aberrant bile-duct occurred but dried up spontaneously after a few days. No death occurred nor were there any lesions of the common bile-duct. Conclusively, this new technique seems to be safe and simple to teach due to its approximity to the conventional technique and is recommended as a standard procedure.

[An anatomic study of the pancreatic lymphatics. Review of the summary and an abridged version of the original text]. / Eine anatomische Studie der peripankreatischen Lymphabflusswege. Review der Zusammenfassung und Kürzungen des Originaltextes.

A detailed study of the lymphatics around the pancreas was carried out in order to provide a theoretic basis for ideal lymph-node resection in radical cancer operations. The following results were obtained as a result of minute macroscopic dissection of the lymphatics. Three major pathways are identified on the anterior surface of the head of the pancreas. The upper pathway belongs to the common hepatic group. The middle and lower routes are associated with the superior mesenteric nodal group. All these pathways terminate in the node situated to the right of the origins of the celiac trunk and the superior mesenteric artery. The lymphatics arising from the neck of the pancreas also converge at the same node. Behind this node, there is a terminal node for the lymphatics which arise from the posterior surface of the head. Both nodes are firmly adherent, with only the nerve plexus of the head of the pancreas intervening. In this study, we have named these lymph-nodes Lnn celiacomesenterici dextri superficialis et profundi. Two distinct pathways are identified in the left half of the pancreas. One follows the splenic blood vessels and the other accompanies the inferior pancreatic artery. By way of these routes, lymphatics from the left half of the pancreas terminate in the node situated to the left of the origins of the celiac trunk and superior mesenteric artery. We have applied the term Ln celiacomesentericus sinister to this node.(ABSTRACT TRUNCATED AT 250 WORDS)