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Notes: Abstract. 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 perfomed 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 hepaticocholedocho-stomy 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.

Notes: Summary. We report on our experience with a new ultrasonically activated scalpel that has been developed for laparoscopic surgery. It works by means of a longitudinally vibrating blade or scissors and can be used for tissue dissection, coagulation and preparation. The high-frequency vibration causes denaturation of protein and thus allows coagulation of small vessels up to 2–3 mm. The most important advantages compared to electrocautery are very limited heat generation, no production of smoke and the lack of current flow through the patient. Because of this, the ultrasonically activated scalpell is an excellent instrument for different types of laparoscopic surgery, as well as for open liver resection.

Notes: Summary. Incisional hernia repair with conventional techniques (simple closure, Mayo-technique) is associated with unacceptable recurrence rates of 30–50 %. Therefore, surgical repair using different prosthetic biomaterials is becoming increasingly popular. Further to favourable results by French hernia surgeons, we studied the results of underlay prosthetic mesh repair using polypropylene mesh in complicated and recurrent incisional hernias. Method: After preparation and excision of the entire hernia sac, the posterior rectus sheath is freed from the muscle bellies on both sides. The peritoneum and posterior rectus sheaths are closed with a continuous looped polyglyconate suture. The prosthesis used for midline hernias is positioned on the posterior rectus sheath and extends far beyond the borders of the myoaponeurotic defect. The anterior rectus sheath is closed with a continuous suture. 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. Results: Between January 1996 and August 1997 we performed a total of 33 incisional hernia repairs (14 primary hernias, 19 recurrent hernias) using this technique (16 women, 17 men, mean age 56.19 ± 12.92 years). Local complications occurred in four patients (12 %): superficial wound infection (n = 2), postoperative bleeding, requiring reoperation (n = 1), minor hemato-seroma (n = 1). One patient suddenly died on the 3rd post-operative day from severe pulmonary embolism (mortality 3 %). Twenty-two patients with a minimum follow up to 6 months were re-examined clinically. The average follow-up time for this group was 9 months (range 6–17 months). To date no recurrent hernias have 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 = 6). Conclusions: The use of prosthetic mesh should be considered for repair of large or recurrent incisional hernias, especially in high-risk patients (obesity, obstructive lung disease) and complicated hernias. The aforementioned technique of underlay prosthetic repair using polypropylene mesh fixed onto the posterior rectus sheath allows for anatomical and consolidated reconstruction of the damaged abdominal wall with excellent results and low complication rates.

Notes: Problem: The vascularity of the articular fragment is of key importance for the final outcome in three- and four-part fractures of the humeral head. Displacement of the articular segment may compromise the arterial blood supply to the humeral head and result in avascular necrosis. There is still controversy as to whether three- and four-part fracture dislocations (articular fragment outside the glenoid) have an even worse prognosis than displaced three- and four-part fractures. Patients and methods: Between January 1985 and May 1993, 102 patients with three- and four-part fractures of the humeral head were treated by ORIF (mostly tension band wiring) at our institution. In a retrospective study we analysed the functional (Constant 100 point score) and radiological outcome of 67 (66%) of these patients. There were 21 patients with fracture dislocations (FD), n = 5 type B2X, n = 5 type B3X, n = 3 type C2X, n = 8 type C3X, according to the classification of Habermeyer [7]. The ,,X`` represents the dislocation of the articular fragment, whereas the classification to each type is done after reduction of the head. The remaining 46 patients presented with displaced, but not dislocated, three- and four-part fractures (DF), n = 24 type B2, n = 7 type B3, n = 3 type C2, n = 12 type C3. Average follow-up was 25 months (7–72 months). Patients with FD were significantly younger (average age 50 years) than patients with DF (average age 63 years, P 〈 0.05) and showed a significantly higher incidence of traumatic nerve or plexus lesions (FD 19%, DF 2%, P 〈 0.05). Results: Concerning the functional results, there was no statistically significant difference between the two groups. The FD patients even showed a slight tendency to better results than patients with DF. This was true for the three-part fractures (average Constant score 78 versus 67 points), as well as for the four-part fractures (average Constant score 62 versus 55 points). The significantly younger age of the FD patients may explain their better results. The entire group of patients with three-part fractures showed a significantly better functional outcome (average Constant score 68 points) than patients with four-part fractures (average Constant score 55 points, P 〈 0.05). The rate of partial and total avascular necrosis of the humeral head was strongly correlated to the fracture type (number of fragments, fracture of the anatomical or surgical neck, according to the classification of Habermeyer), but again there was no difference between the FD and DF group (B2X: 20%, B3X: 20%, C2X: 33%, C3X: 63%; B2: 25%, B3: 29%, C2: 33%, C3: 67%). Astonishingly, the FD were not associated with an increased rate of avascular necrosis of the humeral head. Three (axillary nerve) out of the five observed primary nerve and plexus lesions had a full neurological recovery after 6–12 months; the two patients with alterations of the brachial plexus showed a slow tendency of improvement at follow-up (12 and 18 months), but still had gross muscular atrophy and impaired sensory function. Conclusion: In displaced three- and four-part fractures of the humeral head the dislocation of the articular segment does not seem to increase the risk of avascular necrosis, if treated by timely and careful ORIF with respect to the vascularity. Even with the increased risk of primary nerve and plexus lesions in fracture dislocations, good functional results can be achieved by early operative nerve decompression and fracture stabilization in this middle-aged patient group. However, older patients with displaced or dislocated four-fragment fractures through the anatomical neck (type C3) have a poor chance of a favourable outcome, and therefore primary prosthetic replacement should be considered.

Notes: Problemstellung: In einer prospektiven Studie sollte untersucht werden, ob bei polytraumatisierten Patienten durch die initiale Computertomographie des Thorax (CTT) die diagnostische Genauigkeit für ein begleitendes Thoraxtrauma erhöht werden kann und ob aus evtl. gewonnenen Mehrinformationen wesentliche klinische Konsequenzen für das frühe Polytraumamanagement gezogen werden können. Patienten und Methodik: In einer prospektiven Untersuchung wurde bei 103 Patienten mit Verdacht auf Thoraxtrauma (94 Polytraumatisierte mit Thoraxtrauma, 9 Patienten mit isoliertem Thoraxtrauma) mit einem mittleren ISS von 30 (12 – 66), sowie einem mittleren AIS-Thorax von 3 (1 – 5), im Rahmen der primären Schockraumdiagnostik eine CTT angefertigt und mit der initialen routinemäßig im Liegen angefertigten Röntgenaufnahme des Thorax (RT) verglichen. Ergebnisse: Bei 65% der Patienten (n = 67) wurden durch die CTT wesentliche zusätzliche Informationen gewonnen (Lungenkontusionsherde (n = 33), ventraler oder nicht vollständig entlasteter Pneumothorax (n = 34), Hämatothorax (n = 21), Thoraxdrainagenfehlplazierung (n = 5), u. a. (z. B. Zwerchfell – bzw. Myokardruptur); bei weiteren 11 Patienten wurden geringfügige zusätzliche Informationen (z. B. Dystelektase, kleiner nicht drainagepflichtiger Pleuraerguß) in der CTT erzielt, bei 14 Patienten waren pathologische Befunde in RT und CTT identisch, bei 11 Patienten waren beide Untersuchungen ohne pathologischen Befund. Insgesamt erwies sich die CTT in der Diagnostik der Lungenkontusion (p〈0.001), sowie des Pneumo- (p〈0.005) und des Hämatothorax (p〈0.05) der RT signifikant überlegen. Aufgrund der Zusatzinformationen der CTT wurden bei 42 Patienten (41%) z. T. wesentliche therapeutische Konsequenzen gezogen: Thoraxdrainageanlagen bzw. -korrekturen (n = 31), druckkontrollierte Beatmung bzw. Drehbettbehandlung bei Lungenkontusion (n = 14), Einfluß auf den Operationszeitpunkt bzw. die primäre Verfahrenswahl begleitender Verletzungen des Bewegungsapparats (z. B. Femur) (n = 12), Intubation (n = 1), Bronchoskopie (n = 2), Operationsindikation bei Zwerchfellruptur (n = 2), Ausschluß einer Aortenruptur (n = 2), Perikardpunktion bei Myokardruptur (n = 1). Schlußfolgerung: Die CTT in der Primärdiagnostik des polytraumatisierten Patienten erlaubt eine wesentlich genauere Diagnostik thorakaler Verletzungen (insbesondere Pneumothorax, Hämatothorax und Lungenkontusionen) mit z. T. wesentlichen therapeutischen Konsequenzen für das weitere Management. Möglicherweise kann dadurch die bekanntermaßen hohe Komplikationsrate nach Thoraxtrauma gesenkt und die durch das Thoraxtrauma negativ beeinflußte Prognose des Polytraumatisierten verbessert werden.

Notes: Summary Blunt chest trauma is the leading cause of thoracic injuries in Germany, penetrating chest injuries are rare. Hereby, single or multiple rib fractures, hemato-pneumothorax and pulmonary contusion represent the most common injuries. The early managment of thoracic injuries consists of detection and sufficient therapy of acute life threatening situations like tension pneumothorax, acute respiratory insufficiency or severe intrathoracic bleeding. Most of the isolated thoracic injuries are adequately treated by conservative means, sufficient analgesia, drainage of intrapleural air or blood, physiotherapy and clearance of bronchial secretions provided; operative intervention is rarely indicated. In multiple injured patients however, severe blunt chest trauma and especially pulmonary contusion negatively affects outcome with a significant increase of morbidity and mortality. Hence, patients with this combination of pulmonary injuries, such as lung contusion and associated severe injuries, carry a particular high risk of respiratory failure, ARDS and MOF with a considerable mortality. Therefore, early exact diagnosis of all thoracic injuries is essential and can be achieved by thoracic computed tomography, which becomes more and more popular in this setting. Early intubation and PEEP-ventilation, alternate prone and supine positioning of multiple injured patients with lung contusion and differentiated concepts of volume- and catecholamine therapy represent the basic therapeutic principles. Additionally, the entire early trauma management of multiple injured patients must focus on the presence of pulmonary contusion. Every additional burden on their pulmonary microvascular system like microembolisation during femoral nailing, the trauma burden of extended surgery or mediator release in septic states may cause rapid decompensation and organ failure and therefore, has to be avoided.

Notes: Summary While a great part of the Anglo-American medical literature addresses the topic of penetrating trauma the German spreaking countries rather publish on blunt abdominal injury. The presented paper discusses the strategic principles of acute clinical management of abdominal trauma on the combined basis of own research results and a comprehensive review of the literature. Blunt abdominal injuries in most cases from a part in the pattern of multiple trauma. The early, first-hours mortality is most often caused by severe traumatic brain injury or abdominal trauma with massive hemorrhage. The prehospital management of penetrating injuries is characterized rather by the concept of ’load and go', whereas the on-scene stabilization of the patient with blunt abdominal injury should precede transport to the adequate hospital. On arrival in the accident and emergency room an immediate blood transfusion is recommended for hemodynamically unstable patients. If then a stabilization is not achieved, an emergency laparotomy should follow. Abdominal stab injuries should be explored by laparoscopy if an intraperitoneal lesion is suspected. If then the possibility of an intestinal lesion is present a laparotomy should be performed directly thereafter. Firearm injuries require open revision in almost all cases. The standard diagnostic technique in blunt abdominal trauma is sonography, assisted by computed tomography and, if indicated, angiography in hemodynamically stable patients. Isolated abdominal injuries without hemodynamic or coagulation disorders allow conservative treatment in the intensive care setting. In severe multiple trauma as well as in manifest shock even the smallest fluid detection should lead to laparotomy. The surgical treatment of splenic rupture is still a matter of discussion. Splenectomy is indicated in patients with severe concomitating injuries or shock whereas in the remainder of cases the total or partial preservation of the spleen should be pursued. Hepatic injuries offer a broad spectrum of operative interventions, ranging from superficial hemostatic measures over compression techniques like ’packing' and ’mesh-wrapping' to atypical and anatomical resections and to liver transplantation in exceptional cases. Lesions of tubular organs and the pancreas pose especially difficult diagnostical problems but regularly allow a rather easy operative treatment.

Notes: Abstract. The blind insertion of the Veress needle and the first trocar may cause serious complications. Therefore, many surgeons perform a minilaparotomy to safely position the first trocar. However, especially in obese patients, the dissection may be difficult and time consuming. As an alternative, optical trocars can be safely positioned under direct visualization. We report on our experience with the Optiview trocar in 200 patients and describe our preferred insertion technique. In our opinion, optical trocars are safe and easy to handle, offering several advantages over the use of the Veress needle and the minilaparotomy.

Notes: Abstract Background: Management strategies for abdominal stab wounds (ASW) in initially asymptomatic patients range from mandatory explorative laparotomy (EL) to conservative approaches with observation alone. Emergency diagnostic laparoscopy (DL) may play a potential role between these two extremes—hence lowering the rate of unnecessary laparotomies and keeping the rate of missed injuries to a minimum. Patients and Methods: At our institution mandatory EL was carried out in every patient with ASW until 1992. In a retrospective study the charts of 43 patients with ASW were reviewed in terms of initial diagnostic procedures, intraabdominal injuries, and course and length of hospital stay. Between 5/1993 and 4/1995 DL was performed in a prospective study in 15 patients with suspected peritoneal penetration (PP) after ASW according to a standardized diagnostic and therapeutic algorithm. Results: In 17 patients (40%) EL showed no PP; 15 (35%) had significant intraabdominal injuries, while 11 patients with PP didn't have lacerations of intraabdominal organs, resulting in an overall rate of nontherapeutic laparotomy of 65%. Mortality was 6% (n= 3), average hospital stay 8 days. Primary DL could exclude PP in 10 out of 15 patients (66%). The remaining five patients (33%) showed PP: In two patients with ASW to the right upper quadrant, intraabdominal injuries could be excluded by DL, and in one patient a low-grade liver injury was treated laparoscopically, thus avoiding laparotomy in a total of 87% (n= 13). In two patients with PP laparoscopy was converted to laparotomy: no pathological finding in one case, splenectomy for spleen laceration in the second patient, resulting in a rate of nontherapeutic laparotomies of 7%. All patients in this series had an uneventful course; average hospital stay was 2.4 days. Conclusions: DL offers an important diagnostic tool in excluding peritoneal penetration in ASW, hence lowering the rate of unnecessary laparotomies. Given experience and skills, laparoscopy may be used therapeutically in selected cases of ASW.