The historical impact of minimally invasive surgery

At first there is an idea which asks for more comfort for the patient and equal results compared to conventional procedures. This means less pain and fatigue, quicker convalescence and shorter hospital stay. The new procedures requests an entirely new operative skill and a new technique with new instruments. Those were early developed in Germany. The roads on which this was performed will be described. In another chapter the history of this development is shown, especially the German, French and US inventors with a special view on their personal experiences and disappointments like in the German surgeon M_he and the gynecologist Semm from Kiel, Germany. But they all remained enthusiastic as a common personal quality. The new technique (MIC) was translated "Mickey-Mouse-Surgery" and medicolegal consequences like in M_he were usual events. Another example of misunderstanding of the impact of the new technique: the first publication of Semm about the laoaroscopically removed appendix has been withheld so long in Germany until it was published in the USA in the Journal "Obstetrics and Gynecology". Besides this it is reported about the life cycle of this innovation pointing out to the final promising report, the professional adoption and public acceptance and the randomized controlled trials. The last stage is characterized by "jumping on another train". Pictures are shown of those pioneers who had the idea, who understood what they were doing and who took the responsibility. The final chapter will deal with the consequences for the future generation of surgeons and their training and the unanswered questions as to further fields. Doubtlessly, the pioneer period did not come to an end yet. A glance into the future may be allowed.

[Experience and intuition in surgery]

The article deals with the definition, the positive and negative assessment of intuition. Only in combination with experience and knowledge intuition many be as helpful as scores. Without these prerequisites intuition may tend to become a risk factor.

[Position of the German Society of Surgery in the community of scientific specialty societies]

The role of the German Surgical Society among the other scientific societies is considered as well as its relationship to the BAK and its scientific activities and publications compared with internal medicine. Its most important current issues are described and explained. It can be shown that it holds a prominent position, but is scientifically less productive than internal medicine.

[Systemic release of prostanoids after surgically-induced injury of lung tissue]

In a prospective study, the systemic inflammatory consequences of surgery-induced lung tissue injury were evaluated using biochemical markers. The aim was to examine whether this type of injury produces a specific pattern of prostanoid plasma levels (prostacyclin, thromboxane, PGE2, PGF2 alpha, and PGM). We, therefore, compared 18 patients (group 1) who underwent thoracotomy without injury to the lung with 26 patients (group 2) that had a resection of pulmonary tissue due to benign diseases. Group 2 patients clearly revealed increased plasma levels of C-reactive protein as well as of the granulocyte-specific PMN-elastase. In particular, there was a pronounced release of prostacyclin and its antagonist thromboxane A2 following lung tissue resection. In contrast to group 1 patients, lung tissue damage resulted in immediately elevated plasma levels of PGF2 alpha and PGE2. When, however, taking into account the time course of PGM, the stable cleavage product of PGF2 alpha, there was no hint of an altered pulmonary metabolic capacity. Presumably, this pattern of elevated prostanoid levels in group 2 is the result of the surgical damage to the lung tissue. Therefore, it can be suggested to be specific for that type of injury. Thus, the release of prostanoids following surgery-induced lung tissue damage may indicate the importance of these mediators, particularly in thoracic injuries associated with lung damage since those may lead to post-traumatic pulmonary dysfunction. These substances may also be useful in evaluating both the severity and the extent of lung tissue damage following major trauma.

[Functional outcome of Eden-Hybinette-Lange operation in post-traumatic recurrent shoulder dislocation]

OBJECTIVE

Post-traumatic recurrent dislocation is a major problem in the operative treatment of shoulder dysfunction in young athletes. This prospectively designed study evaluates the long-term results of a modified Eden-Hybinette procedure in young male athletes. The criteria were: capacity in sports, functional limit, and persistent pain. Genuine disorders of the glenoid or muscular imbalance of the shoulder joint were criteria for exclusion.

PATIENTS AND METHODS

From 1982 to 1990, 143 patients underwent surgery. Seventy percent were reevaluated within a minimum period of 18 months after the operation. The functional results were calculated using the ROWE score as well as a visual analog scale (VAS). X-rays were done after the patient had given informed consent.

RESULTS

VAS and ROWE score showed excellent/good results in 61%, fair results in 18%, and poor results in 21% of the documented cases. The rate of arthrosis was 25%. Redislocation occurred in 7%, mainly without any relevant trauma. The X-rays showed complete resorption of the bone graft in 30% of the cases. Best functional results and no redislocation were found in the patients who underwent surgery with fewer than 3 dislocations compared to those with more than 4 dislocation episodes.

CONCLUSIONS

In cases of post-traumatic recurrent dislocation of the shoulder in young athletes, the modified Eden-Hybinette procedure is a good method of reestablishing sufficient stability of the shoulder. The operation should be performed prior to the 3rd dislocation episode. Four or more dislocation episodes show an increased tendency to redislocate and poor functional results.

[Position of the German Society of Surgery on quality assurance]

Internal quality control like regular rounds, conferences, assisted operations, congresses, papers and analyses of the outcomes are established since the days of Billroth. External quality control was added by law. The scientific society has to accept the new commitment and offers a list of new items to back the efforts in external quality control.

Peripheral blood immune responses to surgically induced lung tissue injury

Surgically induced lung tissue trauma reveals an immune response in peripheral blood, the degree of which could depend on extent and severity of the organ trauma and the presence of lung malignancies. The study included 34 patients who underwent elective thoracic surgery because of benign and malignant lung tissue diseases. Flow-cytometric phenotyping of lymphocyte subsets shows a clear shift to reduced immunocompetent cells after lung tissue injury. Patients with lung tumors reveal a postoperative activation of the macrophage system as indicated by increased plasma levels of neopterin. Increased levels of soluble interleukin-2 receptor in the plasma of these patients may be the result of cellular shedding of the receptor. Lung tissue trauma is also followed by reduced immunoglobulin levels which are most pronounced in the presence of lung malignancies. These results suggest that lung tissue injury leads to postoperative immunosuppression especially in tumor patients.

[Bilateral ureteroiliac fistula coincident with radiotherapy and ureteral splint]

Fistulas between the iliac artery and the ureter are uncommon. Overall, fewer than 20 cases have been described in the literature. We report the first bilateral case, in which there was an association with indwelling bilateral ureteral stents and a history of radiation therapy following hysterectomy performed because of malignancy. The patient presented with massive gross haematuria.

[Humerus reconstruction after gunshot fracture]

High-velocity bullits can cause severe blast injuries with shattering and defects of the large bones. Initial external fixation is followed by rebuilding of the bone, which is difficult due to concomitant infection, poor revascularization and lack of a suitable bone bed. A case report of an injured African soldier shows the follow-up and difficulties of reconstruction of the shattered humerus by repeated spongious bone grafting. After successful remodeling of the bone, external fixation is followed by ASIF dynamic compression-plate osteosynthesis.

[Disorders of hemostasis after polytrauma. On the extent of intrinsic fibrinolytic activity in the preclinical phase]

Coagulation disorders are of utmost importance in emergency surgery as well as for secondary organ failure of polytraumatized patients. In order to get hold of the early onset of these disorders, blood samples were harvested from 20 randomly selected patients (Injury Severity Score mean = 36.7 +/- 10.5) on the scene of emergency (mean = 18 [10-29] min after trauma) and at the time of hospital admission (mean = 78 [58-98] min after trauma). In addition to the activation of intravascular coagulation and the consumption of physiological inhibitors, high amounts (10- to 50-fold above normal) of degradation products (FgDP, FbDP, TDP, D-dimers) are present on the scene, already. The influence of hemodilution due to high-volume resuscitation is discussed.

Postgraduate education and role of surgical research in Germany

In Germany at the very moment we have general surgery and 5 specialties, they are: traumatic, plastic and reconstructive, cardiac and central vessels as well as pediatric surgery. For qualification as a general surgeon one needs at least 6 years of straight training; two more years are necessary to qualify in one of the mentioned specialties. In some specialties one year of training can be taken into account for general surgery. The postgraduate education in each field requires a precisely defined kind and number of operations as well as an examination. There are some considerations in discussion, which should be outlined: Generally speaking this means, that the basis of 6 years of general surgery may be reduced to 4 years. Thus specialization could be started 2 years earlier. This special point is in strong discussion due to the fact that the surgical skillfulness of the young surgeons may be decreased. In university hospitals and in academic teaching hospitals surgical research is realized within the surgical department as well as in special departments for experimental surgery. The ideal would be that both institutions stimulate each other.

[Light and scanning electron microscopy studies of the pleura. A contribution to the pathogenesis of spontaneous pneumothorax in young patients]

In a prospective study of 10 patients (7 men, 3 women, mean age 26.2 years), who underwent thoracotomy because of recurrent spontaneous pneumothorax, we performed light and scanning electron microscopic investigations of the resected pleura. The purpose of our work was to explain pleural changes which allowed the penetration of air through the intact wall of the blebs. In 8 of 10 cases we found small bullae at the top of the upper lobe, the remaining 2 showed up with massive pleural scar. The morphological and ultrastructural findings indicated that the presence of air induced a reactive process at the visceral pleura which led to degeneration and scarification. The changes consisted of simple membrane formation up to complete destruction of the pleural layer. The development of blebs is due to an air fistula coming out of the lung parenchyma. Penetration of air through the bleb's wall is explained with the increasing pressure inside and the dehiscence of degenerated pleural structure. In our opinion spontaneous pneumothorax in young people is caused by a localized disease of the upper lobe. The pleural changes are the visible effects of a degenerative process induced by air fistula from lung parenchyma. Therefore wedge-resection of that region is a rational therapy in patients with spontaneous pneumothorax.

[Recurrence of non-small cell bronchial cancer: indications and results of surgical treatment]

Bronchoscopic laser application and radiotherapy are very effective in treating the recurrence of bronchogenic carcinoma. Reoperation is rarely possible. During the period from January 1981 to June 1989, 242 patients underwent lung resection at the Bundeswehrhospital Ulm because of malignant airway disease. In ten of these patients reoperation was performed in case of tumour recurrence. The median survival time was 17 months (2 to 60 months). Comparing the literature with our own experience we conclude that operative treatment of bronchogenic recurrences is possible in few selected cases. The indication for reoperation depends on the stage of the primary tumour, the spread of the recurrence and the physiological status of the patient.

[The use of bioresorbable implants (Biofix) in surgery. The indications, technic and initial clinical results]

Carrying out osteosyntheses with absorbable implants is a dream cherished by traumatologists for a long time. The absorbable rods available on the medical market comply within narrow ranges with the necessary conditions with regard to stability, absorption time and biocompatibility. In our clinical department 38 osteosyntheses with Biofix rods were performed. The complication rate amounted to 13%-5 abacterial disturbances of wound healing and secretions. The indications assured so far are limited to refixation of chondral and osteochondral fragments as well as the fixation of cortical-cancellous bone grafts.

[Pleural porosity in idiopathic spontaneous pneumothorax]

Intraoperative investigations after axillary thoracotomy in 28 patients with spontaneous pneumothorax shows true ruptures of subpleural bullae in 25% of the cases. In 75% structural pleural changes in the top of the lung are responsible for porosity and air leakage of the wall of the bullae. Pleural porosity causes a prolonged treatment of this illness. Appreciation of the phenomenon of "pleural porosity" is the key for understanding several questions regarding the diagnosis and treatment of spontaneous pneumothorax that had remained unanswered to date.

[Measuring compartment pressure of the lower leg with a microtip probe]

In the acute compartment syndrome it is difficult to decide on the basis of clinical criteria alone whether or not fasciotomy is indicated. Reliable and objective parameters are required before a treatment schedule can be devised. Measurement of the pressure inside the acute compartment can facilitate the decision as to whether operative treatment is appropriate in the case of the muscular compartment involved. We performed compartment pressure measurements in the tibialis anterior compartment in 27 healthy volunteers using a microtip probe. Clinically relevant results were obtained. It was demonstrated that this method could be used either in acute cases or for long-time measurements. We think that using a microtip probe for intracompartmental pressure measurement provides reliable data and makes the decision on fasciotomy much easier.

[Pathophysiology and methods of treatment in renal hypertension in renal artery aneurysms]

Aneurysms of the renal artery occur infrequently and remain mostly asymptomatic. A review of the pertinant literature reveals approximately 300 reports. Hypertension is the predominant sign and affects two thirds of all patients, particularly in aneurysms complicated by stenosis or thromboembolism of renal artery, which is caused by the renin-angiotensin-mechanism. A solitary renal aneurysm causes no renal hypertension; 66% of all diagnosed renal artery aneurysms require no treatment. Resection of the aneurysm and direct suture was done in half of all operated patients. Only in 27 cases operative treatment consisted of extirpation and patch-plastic (autologic or alloplastic). Two additional cases in our own hospital with resection and patch-plastic are described. By using those techniques it is possible to normalize renal artery blood flow as well as blood pressure. Other well-known surgical procedures are nephrectomy, aorto-renalbypass and several others.

Closure of lung leaks by fibrin gluing. Experimental investigations and clinical experience

In 28 male Wistar rats a standardized lung incision was closed by running suture and in half of the animals by additional application of fibrin adhesive. The animals were sacrificed 30 minutes and 5 days postoperatively. A significantly higher tolerance to increased inflation pressure was found in the fibrin-treated group. Ten patients undergoing pulmonary resection had conventional closure of parenchymatous lesions with additional fibrin gluing. Under positive air way pressure ventilation the sealing effect proved to be better after application of fibrin adhesive to the sutured area.

[Thyroid hormone levels after surgical stress reaction (author's transl)]

In a larger collective of surgical patients the behaviour of the individual thyroid parameters (T4, T3, rT3, TBG and thyroxine-binding capacity) were studied before, during and after operation and set in relation to each other. There are significant shifts in T4 metabolism towards the formation of rT3. In spite of its greatly reduced metabolic activity compared with T3, an important regulatory effect is attributed to rT3, in thyroid metabolism in stress situations.

[Problems after surgery of acute abdomen]

Many problems may persist after operation of an acute abdomen. Most important are peritonitis, hemorrhage, vascular occlusion and reduced general condition. Pathophysiology, clinical symptoms and therapeutic principles are discussed.

[Pathophysiology of lung resections (author's transl)]

Changes of adaptation and complications which may appear after extended lung operations must be known both to the surgeon and to the doctor responsible for the after-treatment. They are divided into pulmonary, cardiac, and intestinal early and late sequelae. Pathophysiology, clinical aspects and therapy of the most frequent changes are briefly demonstrated in this paper, sometimes with the aid of our own illustrations and experimental results.

[Acute ischemic gastric mucosal and duodenal lesions in dogs: "stress ulcer" after experimental disseminated intravascular coagulation]

Experimental disseminated intravascular coagulation (DIC) without considerable effect on blood pressure is shown to produce within 80 min acute mucosal bleeding in stomach and duodenum. A documented high degree of tissue hypoxia caused by mucosal microthrombosis is necessary for the genesis of mucosal lesions. These results stress the necessity to look for DIC in patients with upper gastrointestinal "stress ulcers".

[Concentration of antibiotics in the human lung. Clinical studies of Reverin distribution in various pulmonary lobes]

On 12 patients with bronchial carcinoma serum and lung-tissue concentration levels of tetracyclin were measured. The concentration levels of the antibiotic were twice as high in the lung tissue as in the serum. In the lower lobe of the lung significantly higher values were measured than in the upper lobe. The demonstrated tissue levels of Pyrrolidino-methyltetracyclin (Reverin) in human lung are high enough to be effective in pulmonary bacterial infection.