[Medicolegal aspects of primary and renal hyperparathyroidism]. / Medikolegale Aspekte der Chirurgie des primären und renalen Hyperparathyreoidismus.

BACKGROUND: Compared with malpractice claims in thyroid surgery, expert medico-legal reviews of surgery performed for hyperparathyroidism (HPT) that aim to prove or rebut surgical malpractice are rare. The aim of this analysis was to describe typical risk patterns for possible treatment errors and to generate recommendations for avoiding these treatment errors. MATERIAL AND METHODS: A total of 12 surgical expert medico-legal reviews, which were carried out by order of 9 arbitration boards and 3 courts between 1997 and 2020 were evaluated. RESULTS: If the indications for surgical treatment of hyperparathyroidism were present, the failure to identify a parathyroid adenoma or hyperplastic parathyroid glands was in the majority of cases not rated as a surgical treatment error, especially in atypical localizations. Unilateral recurrent laryngeal nerve palsy and postoperative bleeding cannot always be prevented, despite maximum diligence. In contrast, bilateral recurrent laryngeal nerve palsy can be prevented when intraoperative neuromonitoring is correctly applied. A lack of patient information regarding postoperatively persistent HPT, postoperative hypoparathyroidism following the removal of inconspicuous parathyroid glands and nonindicated lobectomy or total thyroidectomy, mostly performed under the assumption of an intrathyroid parathyroid adenoma, represented avoidable malpractice issues. CONCLUSION: Advanced knowledge of the pathophysiology of the disease and the anatomy of the parathyroid glands as well as the establishment of intraoperative and perioperative standards can prospectively greatly reduce avoidable errors in the surgical treatment and postoperative care of HPT.

Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS: Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS: During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION: Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.

[EUROCRINE®: adrenal surgery 2015-2019- surprising initial results]. / EUROCRINE®: Nebennierenoperationen 2015 bis 2019 ­ überraschende erste Ergebnisse.

BACKGROUND: Since 2015 operations performed in the field of endocrine surgery have been entered into the European registry EUROCRINE®. The aim of this analysis was a description of the current healthcare situation for adrenal surgery in a homogeneous healthcare environment corresponding to the German-speaking countries-or to the presence of the working group on surgical endocrinology (CAEK) of the German society for general and visceral surgery (DGAV)-and to assess the adherence to current international treatment guidelines. METHODS: An analysis of the preoperative diagnostics, the applied operative techniques and the underlying histological entities was carried out for all operations on adrenal glands in Germany, Switzerland and Austria, which were registered in EUROCRINE® from 2015 to 2019. RESULTS: In the total of 21 participating hospitals from the German-speaking EUROCRINE® countries, 658 operations on adrenal glands were performed. In 90% of cases unilateral adrenalectomy was performed, in 3% bilateral adrenalectomy and in 7% other resection procedures. In 41% the main histological diagnosis was an adrenocortical adenoma. In 15% malignant entities were detected on final histology, including 6% adrenocortical carcinoma (ACC) and 8% metastases to the adrenal glands. 23% of the operations were performed for pheochromocytoma. This entity was primarily resected using minimally invasive approaches (82%), whereas minimally invasive techniques were applied in 28% for ACC and in 66% for metastases to the adrenal glands. CONCLUSION: Surprisingly, following adrenocortical adenoma and pheochromocytoma, the third most common histological entity was metastasis of different extra-adrenal primary tumors to the adrenal gland. Of the operations for ACC 28% were scheduled for minimally invasive techniques, but conversion to open surgery was necessary in 20%. The analysis revealed discrepancies between treatment reality and international guideline recommendations that raise questions, which will be addressed by an updated version of the EUROCRINE® module for the documentation of adrenal surgery.

Surgical therapy of adrenal tumors: guidelines from the German Association of Endocrine Surgeons (CAEK).

BACKGROUND AND AIMS: Previous guidelines addressing surgery of adrenal tumors required actualization in adaption of developments in the area. The present guideline aims to provide practical and qualified recommendations on an evidence-based level reviewing the prevalent literature for the surgical therapy of adrenal tumors referring to patients of all age groups in operative medicine who require adrenal surgery. It primarily addresses general and visceral surgeons but offers information for all medical doctors related to conservative, ambulatory or inpatient care, rehabilitation, and general practice as well as pediatrics. It extends to interested patients to improve the knowledge and participation in the decision-making process regarding indications and methods of management of adrenal tumors. Furthermore, it provides effective medical options for the surgical treatment of adrenal lesions and balances positive and negative effects. Specific clinical questions addressed refer to indication, diagnostic procedures, effective therapeutic alternatives to surgery, type and extent of surgery, and postoperative management and follow-up regime. METHODS: A PubMed research using specific key words identified literature to be considered and was evaluated for evidence previous to a formal Delphi decision process that finalized consented recommendations in a multidisciplinary setting. RESULTS: Overall, 12 general and 52 specific recommendations regarding surgery for adrenal tumors were generated and complementary comments provided. CONCLUSION: Effective and balanced medical options for the surgical treatment of adrenal tumors are provided on evidence-base. Specific clinical questions regarding indication, diagnostic procedures, alternatives to and type as well as extent of surgery for adrenal tumors including postoperative management are addressed.

[Update of the S2k guidelines : Surgical treatment of benign thyroid diseases]. / Aktualisierung der S2k-Leitlinie : Operative Therapie benigner Schilddrüsenerkrankungen.

Thyroid resections represent one of the most common operations with 76,140 interventions in the year 2016 in Germany (source Destatis). These are predominantly benign thyroid gland diseases. Recommendations for the operative treatment of benign thyroid diseases were last published by the CAEK in 2010 as S2k guidelines (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. [AWMF] 003/002) against the background of increasingly more radical resection procedures. Hemithyroidectomy and thyroidectomy are routinely performed for benign thyroid disease in practice. The operation-specific risks show a clear increase with the extent of the resection. Therefore, weighing-up of the risk-indications ratio between unilateral lobectomy or thyroidectomy necessitates an independent evaluation of the indications for both sides. This principle in particular has been used to update the guidelines. In addition, the previously published recommendations of the CAEK for correct execution and consequences of intraoperative neuromonitoring were included into the guidelines, which in particular serve the aim to avoid bilateral recurrent laryngeal nerve paralysis. Moreover, the recommendations for the treatment of postoperative complications, such as hypoparathyroidism and postoperative infections were revised. The updated guidelines therefore represent the current state of the science as well as the resulting surgical practice.

[Adrenal adenomatoid tumor. A rare clinicopathological entity]. / Adenomatoider Tumor der Nebenniere. Eine seltene Differenzialdiagnose des Nebennierentumors.

Adenomatoid tumors are uncommon, benign tumors of the genital tract which have also been reported to occur extragenitally. Case reports on adenomatoid tumors of the adrenal gland exist. Most of these are incidentally discovered at autopsy or after the resection of incidentalomas. We report on the case of a young man with epigastic pain and with the finding of a 4 cm heterogeneous right adrenal mass on abdominal CT scan. After endocrine activity had been ruled out, an inactive, benign adrenal tumor was suspected and laparoscopic right adrenalectomy performed. The specimen was found to be an adenomatoid tumor. We discuss the differential diagnosis and the possible embryological origin of these tumors. The feature of 'local invasive ability' does not imply malignancy. All cases discovered surgically and at autopsy have been benign. Local resection seems to be the appropriate therapy.

Laparoscopic lateral adrenalectomy versus open posterior adrenalectomy for the treatment of benign adrenal tumors.

BACKGROUND: Minimally invasive techniques play an important role in adrenal gland surgery. The objective of this study was to compare laparoscopic transabdominal adrenalectomy in the lateral position to the open posterior adrenalectomy with respect to the intraoperative and the short-term postoperative course. METHODS: Forty laparoscopic adrenalectomies (LA) carried out between July 1998 and August 2001 were compared to 30 open posterior operations (PA) performed between July 1994 and June 1998. In all cases the indications for surgery was a benign lesion smaller than 8 cm. RESULTS: Age, gender, tumor size, and distribution of the tumor histology were comparable in both groups (LA vs PA). In favor of LA, statistically significant differences (p <0.05) were observed regarding the intraoperative blood loss (260 vs 380 mL), the postoperative narcotic equivalents (2.9 vs 6.4 mg), the morbidity rate (13 vs 27%), and the length of hospital stay (7 vs 10 days). Average operating time was significantly longer for LA (135 vs 106 min). There were two conversions to open adrenalectomy due to diffuse bleeding. Following LA, we observed one major complication (postoperative bleeding from the spleen making a laparotomy necessary) and four minor complications (one small retroperitoneal hematoma, two subcostal nerve irritations, one pleural effusion). PA resulted in one major (wound infection) and seven minor complications (two subcutaneous hematomas, two nerve irritations, two pleural effusions, one dystelectasis). CONCLUSIONS: Laparoscopic adrenalectomy proved as a safe and reliable procedure, displaying all advantages of minimal access surgery. In our institution, it has become the standard technique employed for benign adrenal disease. However, the operation is technically demanding, and as adrenal surgery is rare, it should be restricted to centers with special interest in laparoscopic and endocrine surgery.

[Laparoscopic colostomy: experience in patients with ovarian or ano-rectal cancer, non-operable or with rectovaginal fistula]. / Colostomia per via laparoscopica: esperienze con pazienti affetti da carcinoma ovarico o ano-rettale inoperabile o con fistole retto-vaginali.

Between August 1995 and May 2001 laparoscopic colostomy was successfully carried out in 23 patients with advanced ovarian cancer, inoperable carcinoma of the anorectum or rectovaginal fistulas. There were no intraoperative or postoperative complications and postoperative recovery was rapid with all patients having function of the colostomy within 24 hrs and regaining their preoperative state of mobility on the second postoperative day. The laparoscopic approach allows the careful selection of the colostomy site, easy mobilisation of the colon, causing only little disruption to the intestinal function hence improving postoperative recovery. From Authors' experience, laparoscopic colostomy is a simple and safe operation in most cases and can be used as the preferred technique of intestinal diversion.

Minimally invasive video-assisted parathyroidectomy and intraoperative parathyroid hormone monitoring. The first 36 cases and some pitfalls.

BACKGROUND: The success of parathyroid surgery depends on the identification and removal of all hyperactive parathyroid tissue. At this writing, bilateral cervical exploration and identification of all parathyroid glands represent the operative standard for primary hyperparathyroidism (pHPT). However, improved preoperative localization techniques and the availability of intraoperative parathyroid hormone monitoring prepare the way for minimally invasive procedures. METHODS: Patients with pHPT and one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, a rapid chemiluminescense immunoassay was used to measure intact parathyroid hormone (iPTH) levels shortly before and then 5, 10, and 15 min after excision of the adenoma. The operation was considered successful when more than a 50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between October 1999 and November 2001, 36 of 82 patients with pHPT were eligible for a minimally invasive approach. A conversion to open surgery became necessary in five patients because of technical problems. In three cases, intraoperative iPTH monitoring showed no sufficient decrease in iPTH values. In these cases, subsequent cervical exploration showed one double adenoma and two hyperplasias, respectively. In two patients we had difficulty interpreting intraoperative iPTH values, resulting in persistent pHPT. CONCLUSIONS: Despite the use of high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy, the presence of multiple glandular disease cannot be ruled out completely. Intraoperative iPTH monitoring to ensure operative success is indispensible for a minimally invasive approach. Despite our problems with iPTH monitoring in two patients, we believe that in selected cases, minimally invasive parathyroidectomy represents an attractive alternative to conventional surgery.

[Autotransplantation of at least one parathyroid gland during thyroidectomy in benign thyroid disease minimizes the risk of permanent hypoparathyroidism]. / Simultane Autotransplantation von Nebenschilddrüsengewebe im Rahmen der totalen Thyreoidektomie wegen M. Basedow oder benigner Knotenstruma.

OBJECTIVE: Permanent hypoparathyroidism is a distressing complication of thyroid surgery. The reported incidence varies between 0.4 and 13.8 % and is directly correlated to the extent of thyroidectomy. The aim of this retrospective study was to analyze whether simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease could reduce the risk of permanent hypoparathyroidism. METHODS: Since 01/1999 all thyroid operations are prospectively recorded. Beside daily postoperative measurement of serum calcium level, iPTH is routinely determined on the third post op day. Patients with complications are followed closely. Postoperative hypoparathyroidism persisting for more than 6 months is defined permanent. RESULTS: Between 01/1999 and 02/2001 146 total thyroidectomies for benign thyroid disease have been performed (81 pat. with Graves disease, 62 with nodular goiter, 3 with thyroiditis de Quervain/Hashimoto). In 37 pat. (25 %) at least one parathyroid gland was simultaneously autotransplanted into the ipsilateral sternocleidomastoid muscle. Group I (no parathyroid autotransplantation, n = 109) and group II (parathyroid autotransplantation, n = 37) were comparable concerning patient age, thyroid disease and lowest post op calcium level (2.07 versus 2.05 mmol/l). The incidence of postoperative symptomatic hypocalcemia (14.7 % versus 21.6 %) and temporary hypoparathyroidism (15.6 % versus 18.9 %) was higher in group II patients (n. s.). Conversely, permanent hypoparathyroidism occurred exclusively in group I patients (2.75 %), patients with parathyroid autotransplantation (group II) did not develop this complication. CONCLUSIONS: Simultaneous autotransplantation of at least one parathyroid gland during total thyroidectomy for benign thyroid disease seems to minimize the risk of permanent hypoparathyroidism. The potential of routine autotransplantation in this setting has to be evaluated. The incidence of postoperative temporary hypocalcemia may be elevated with this policy.

[Intraoperative monitoring of intact parathyroid hormone during surgery for primary hyperparathyroidism]. / Intraoperative Bestimmung des intakten Parathormons (iPTH) in der Chirurgie des primären Hyperparathyreoidismus.

The aim of the present study was to evaluate a new immunometric assay for intraoperative parathyroid hormone monitoring. The test was applied in 70 patients who underwent surgery for primary hyperthyroidism (pHPT) between 6/1999 and 6/2001. Among these patients, 61 showed a solitary adenoma, eight a hyperplasia and one a double adenoma. Intraoperative iPTH samples were taken at the beginning of the operation and 5, 10 and 15 min after removal of the parathyroid gland. Criterion for a successful operation were a decrease of iPTH levels of more than 50 % within 5 min and of more than 60 % within 15 min after parathyroidectomy. Following the removal of a solitary adenoma, iPTH levels decreased by 63 % (+/- 13 %) after 5 min and by 76 % (+/- 10 %) after 15 min respectively. In case of hyperplasia, a significant decrease of iPTH levels was not observed until a subtotal parathyroidectomy had been carried out. In the present study there were 2 false negative and one false positive results corresponding with a sensitivity of 97 % and a specificity of 89 % for prediction of a solitary adenoma. In our opinion, intraoperative iPTH monitoring using this new assay allows the safe distinction between adenoma and multiglandular disease. It represents a valuable adjunct to surgical skill as it permits minimally invasive operations for solitary adenomas, and in case of recurrent surgery helps to detect the region of interest by selective venous sampling for parathyroid hormone.

[The value of magnetic resonance cholangiography for the expedient diagnosis of choledocholithiasis]. / Stellenwert der Magnetresonanz-Cholangiographie in der rationellen Diagnostik der Choledocholithiasis.

INTRODUCTION: Management of symptomatic cholecystolithiasis is vitally influenced by dilated biliary tract and choledocholithiasis. The objectives of this prospective pilot study were to evaluate the diagnostic value of preoperative magnetic resonance cholangiography (MRC) compared to diagnostic endoscopic retrograde cholangiography (ERC) and to establish an efficient algorithm for diagnostics and treatment of choledocholithiasis. METHODS: All consecutive patients with cholecystolithiasis and dilated biliary tract proven by sonography as well as elevated liver function tests were enrolled within 12 months. Patients without evidence of bile duct calculi underwent preoperative MRC, whereas patients with choledocholithiasis immediate ERC. RESULTS: 58 patients (30 male, 28 female) with a median age of 59.4 years underwent preoperative MRC. In 18 patients (10 male, 8 female; median age 63.5 years) with evidence of choledocholithiasis we subsequently performed ERC and papillotomy. Bile duct stones were detected and removed after papillotomy in 10 patients, whereas calculi could not be found anymore in 8 patients. The remaining 40 patients without calculi evident on MRC were transferred to magnetic resonance tomography and ERC in case of suspected malignancy or to cholecystectomy and intraoperative cholangiography (IOC), which could definitely exclude choledocholithiasis. In comparison to ERC respectively IOC, MRC was able to detect bile duct stones with a sensitivity of 100% and a specificity of 83.3%. CONCLUSIONS: Non-invasive MRC seems to replace diagnostic ERC concerning the presence of choledocholithiasis in case of cholecystolithiasis and dilated biliary tract with a high sensitivity. The preoperative ERC with stone extraction is still the therapy of choice in case of radiologically confirmed choledocholithiasis.

[Surgical and adjuvant therapy of neuroendocrine tumors of the gastrointestinal tract and their metastases. A retrospective analysis of personal patient group]. / Die operative und adjuvante Therapie neuroendokriner Tumoren des Gastrointestinaltrakts und ihrer Metastasen. Eine retrospektive Analyse des eigenen Patientenguts.

INTRODUCTION: Carcinoid tumors are the most common neuroendocrine tumors of the gastrointestinal tract. Surgical treatment and prognosis depend on the location of the tumor. METHOD: Between 01.01.1985 and 31.12.1999 25 patients with neuroendocrine tumors of the gastrointestinal tract or their metastases were treated in our institution. The records of these patients were reviewed retrospectively. Patients still alive were reexamined clinically. RESULTS AND CONCLUSIONS: The most frequent primary sites were the ileum and jejunum (36%), appendix (36%), stomach (12%), pancreas (8%), colon (4%) and bronchus with hepatic metastasis (4%). A malignant carcinoid syndrome was present in 8 patients. In patients with neuroendocrine tumors, curative, radical tumor removal should be attempted. Some patients with advanced disease needed some surgery for tumor debulking and resection of metastases. In non-resectable liver metastases hepatic arterial chemotherapy and chemoembolization after implantation of port catheters seem to be very beneficial therapeutic options. A fixed part of the therapeutic regime in progressive disease is adjuvant chemotherapy with 5-fluorouracil and streptozotocin and symptomatic therapy with octreotide.

Minimally invasive video-assisted parathyroidectomy.

BACKGROUND: The standard surgical procedure for parathyroidectomy consists of bilateral cervical exploration and the visualization of all four parathyroid glands. However, improved preoperative localization techniques and the availability of intraoperative intact parathyroid hormone (iPTH) monitoring now allow single adenomas to be treated with minimally invasive techniques. METHODS: Patients with primary hyperthyroidism (pHPT), who were found to have one unequivocally enlarged parathyroid gland on preoperative ultrasound and 99mTc-SestaMIBI scintigraphy underwent minimally invasive video-assisted parathyroidectomy by an anterior approach. Intraoperatively, rapid electrochemiluminescense immunoassay was used to measure iPTH levels shortly before and 5, 10, and 15 mins after excision of the adenoma. The operation was considered successful when a >50% decrease in preexcision iPTH levels was observed after 5 min. RESULTS: Between November 1999 and May 2000, 10 of 22 patients with pHPT were deemed eligible for the minimally invasive approach. In all cases, the adenoma was removed successfully. However, in two cases, intraoperative iPTH monitoring did not show a sufficient decrease in iPTH values. Subsequent cervical exploration revealed a double adenoma in one case and hyperplasia in the other. CONCLUSIONS: Even when high-resolution ultrasound and 99mTc-SestaMIBI scintigraphy are used, the presence of multiple glandular desease cannot be ruled out entirely. When the minimally invasive approach is contemplated, intraoperative iPTH monitoring is indispensible to ensure operative success. However, in selected cases, minimally invasive parathyroidectomy represents an excellent alternative to the conventional technique.

[Intraoperative monitoring of intact parathyroid hormone (iPTH) in surgery of primary hyperparathyroidism with a new rapid test]. / Intraoperatives Monitoring des intakten parathormons (iPTH) in der Chirurgie des primären Hyperparathyreoidismus mit einem neuen Schnelltest.

OBJECTIVES: Intraoperative differentiation between adenoma and hyperplasia during surgery for primary hyperparathyroidism (pHPT) is sometimes difficult, but essential for good results. The aim of our study was to evaluate a new highly sensitive electrochemiluminescence immunoassay (ECLIA) for intraoperative monitoring of intact parathyroid hormone (iPTH) following parathyroidectomy as an adjunct for identification of solitary adenoma in patients with pHPT. METHODS: Thirty consecutive patients with pHPT (2 with recurrent pHPT) were examined following a standardized protocol: Immediately before and 5, 10 and 15 min following parathyroidectomy of the enlarged gland, iPTH was measured with a new ECLIA (Roche-Diagnostics, Mannheim, Germany). The results were available within 15-20 min. Besides 20 conventional bilateral neck explorations, parathyroidectomy was carried out in a minimally invasive video-assisted technique (MI-VAP) in 10 patients. RESULTS: Among the 30 patients we found 24 with solitary adenoma (80%), 5 with hyperplasia (17%) and one with a double adenoma (3%). Five minutes after removal of a solitary adenoma the level of iPTH had decreased by 65 (12)% [mean (+/- SD)], after 10 min by 76 (8)% and after 15 min by 81 (8)%. All patients with multiple gland disease could be clearly identified, as iPTH after 15 min did not fall below 50% of basal value. Only after removal of all hyperplastic glands did iPTH decrease to the normal range. Sensitivity and specificity for prediction of a solitary adenoma were 92% and 100% (decline of iPTH more than 50% from baseline value 5 min after parathyroidectomy). In one patient with recurrent pHPT intraoperative sampling from different sites in both internal jugular veins could predict the quadrant of the enlarged gland. Correlation (r) between the results of the quick and the conventional assay, which requires 24 h of incubation, was 0.955. All patients had normal or low calcium levels postoperatively. CONCLUSIONS: (1) Intraoperative monitoring of iPTH with this new quick assay allows safe identification of patients with solitary adenoma during surgery for pHPT. (2) It represents a valuable adjunct to surgical skill not only in primary operations for pHPT but especially in cases of recurrent surgery for pHPT. (3) With this test available minimally invasive techniques for parathyroidectomy may be employed in cases of preoperatively localized adenoma (ultrasound, sesta-mibi scan), avoiding bilateral neck exploration with its higher potential for complications.

[The use of an underlay polypropylene mesh in complicated incisional hernias: sucessful French surgical technique]. / Il trattamento dei laparoceli complicati con rete di poliprolilene nella tecnica "underlay": metodo provato della chirurgia francese.

BACKGROUND: Incisional hernia repair with conventional techniques is associated with high recurrence rates of 30-50%. Surgical repair using different prosthetic biomaterials is becoming increasingly popular. On the basis of the favourable results by French surgeons, the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias have been studied. METHODS: After preparation and excision of the entire hernia sac, the peritoneum and posterior rectus sheath are closed with a continuous looped polyglyconate suture. The prosthesis used for the midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The prosthesis for lumbar and subcostal hernias is placed in a prepared space between the transverse and oblique muscles. Intraperitoneal placement of the mesh must be avoided. Between January 1997 and September 1998 a total of 57 incisional hernia repair (25 primary hernias, 32 recurrent hernias) have been performed using this technique (28 women, 29 men, mean age 56+/-13 years). RESULTS: Local complications occurred in 6 patients (11%). One patient suddenly died on the 3rd postoperative day from severe pulmonary embolism (mortality 1,7%). Thirthy-seven patients with a minimum follow-up of 6 months were reexamined clinically (follow up time 6-33 months). Till now one recurrent hernia has been observed. There were only minor complaints like a feeling of tension in the abdominal wall (n = 3) and slight pain under physical stress (n = 9). CONCLUSIONS: The aforementioned technique of underlay prosthetic repair allows an anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates especially in high risk patients and complicated hernias.

[Laparoscopic adrenalectomy with lateral approach--a comparison with the conventional dorsal technique]. / Laparoskopische Adrenalektomie in Seitenlage--ein Vergleich mit der konventionellen dorsalen Technik.

OBJECTIVES: Minimal invasive techniques are gaining more and more acceptance in adrenal gland surgery. In a matched case control study laparoscopic transabdominal adrenalectomy in the lateral position (LA) was compared to the conventional open dorsal technique (DA) with resection of the 11th or 12th rib. METHODS: Between July 1998 and March 2000, 26 LA in 24 patients (two bilateral) were prospectively documented and compared to 25 DA in 23 matched patients (two bilateral), who had been operated on between January 1995 and June 1998. Indications for adrenalectomy in all patients were benign adrenal lesions < 6 cm. RESULTS: Age, gender, average tumor size (3.5 cm/3.6 cm) and tumor types (Conn adenoma: 10/7; Cushing: 8/7, including 2 bilateral in each group; pheochromocytoma: 3/6, incidentaloma: 2/2; others: 3/3) were distributed in both groups (LA/DA) without statistical differences. However, statistically significant differences (P < 0.05) were present (LA vs DA) comparing intraoperative blood loss (200 vs 360 ml), postoperative narcotic equivalents (1.1 vs 6.2), morbidity (8 vs 30%), and length of hospital stay (5.5 vs 9 days). Average operating time was significantly longer in LA (130 vs 105 min), but decreased during the last LA cases to the DA level. One LA had to be converted to open surgery due to diffuse bleeding. Following LA we observed two minor complications (small retroperitoneal hematoma, nerve irritation below the 12th rib); following DA there were 6 minor (2 dorsal subcutaneous hematomas, 2 nerve irritations, dystelectasis, pleural effusion) and one major complication (wound infection). CONCLUSION: LA represents a safe procedure with all the common advantages of minimal access surgery. Based on our experience and that of others, laparoscopic adrenalectomy has become the gold standard for adrenalectomy in most cases of benign adrenal disease. As adrenal surgery is rare, at present LA should be restricted to centers with a special interest in endocrine and laparoscopic surgery.

[Timely management of bile duct complications after laparoscopic cholecystectomy]. / Zeitgerechtes Management von Gallengangkomplikationen nach laparoskopischer Cholecystektomie.

INTRODUCTION: Bile duct complications after laparoscopic cholecystectomy occur twice to three times more frequently than after an open procedure. Four different types of lesions may be differentiated by the Siewert classification: postoperative bile fistulas (type I), late strictures (type II), tangential injuries of the bile duct (type III) and defect lesions (type IV). The diagnostic and therapeutic management is demonstrated in relation to our own experience and the literature. METHODS: Eleven patients (median age 43.8 +/- 17.2) with bile duct complications after laparoscopic cholecystectomy were operatively treated between November 1993 and December 1998. Nine patients (four type-II lesions, five type-IV lesions) were referred from another hospital; 2 defect lesions out of 410 laparoscopic cholecystectomies (0.5%) were documented in our own patient group. RESULTS: Four patients with late strictures were operatively treated with a hepaticocholedochostomy (n = 2) or hepaticojejunostomy (n = 2) after 14.3 +/- 8.4 months and were discharged from hospital after 10.6 +/- 3.8 days. In both cases with type-IV lesion and a short defect, an end-to-end anastomosis was successful (hospital stay 11.6 +/- 1.0 days). However, a retrocolic Roux-Y end-to-side hepaticojejunostomy was performed in all cases with a larger defect (n = 5; hospital stay 14.8 +/- 2.0 days). The two defect lesions in our own group were detected by intraoperative cholangiography and immediately treated after conversion either with hepaticocholedochostomy or hepaticojejunostomy (hospital stay 11.2 +/- 0.6 days). CONCLUSIONS: The incidence of bile duct complications after laparoscopic cholecystectomy might be kept down by anatomic preparation, selective intraoperative cholangiography and early consideration of conversion to open procedure. The clinical course after biliary tract injury can be positively influenced only by a standard diagnostic and operative procedure and by an early transfer to a specialized center.