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Eosinophilic oesophagitis (EO), primarily a gastro-enterological disease, should be known to the surgeon and endoscopist as a differential diagnosis of dysphagia. We present a chronic and recurrent case of EO. As frequently seen, macroscopic findings are indicative of the causal illness. The diagnosis is finally made by the histological findings of a macroscopically inconspicuous mucosa of the esophagus, which is found in 10% of cases with EO. Random biopsies are necessary for the diagnosis. A short overview of therapy and course and a review of the literature are given.

Background: Assessment of scientific performance is critical for selection committees and research funding. The present work evaluated the standing of German surgical research within the international community., Methods: A database analysis was performed in December 2009 using the ISI Web of Science., Results: The highest impact factor of surgical journals is currently 8.460 with a median impact of all journals of 1.369. Leading academic surgeons have an h-index of more than 60. German surgeons are within the top five leading researchers in the fields of surgery for esophageal and pancreatic cancer, thyroid, hernia, and liver/kidney transplantation. Among the 50 institutions with most publications on a particular topic, 4-5 German centers are mostly represented. The top positions are in total decisively occupied by leading universities in the USA., Conclusion: On the basis of scientific parameters German surgical research can compete with leading international centers in certain fields, but should aim to increase the overall impact of research by publishing more in journals with above average impact factors.

The surgeon is the key "prognosis factor" for colorectal cancer. For this reason quality criteria were recently established (including minimum numbers) in order to treat patients who are entitled to the best quality of care and to improve the prognosis. The aim of this study was to critically discuss the existing demands on the surgeon based on the current literature and our own results and to formulate evidence-based quality criteria for surgical clinics. After reviewing the current literature criteria were compiled, discussed and finally presented in a summarized form. These are based on current developments on the diagnostic and therapy of large intestine and colorectal carcinoma. New developments of the German Cancer Society for planning of organ centers are incorporated. The quintessence of our study is that the number of cases alone is not decisive for the success of therapy. Important are the application of the correct surgical-oncology operation procedure, adherence to standards and the training of surgeons. Following the S3 guidelines stage-oriented therapy should additionally be carried out in a structured sequence. This includes an interdisciplinary decision making on the diagnostic and therapy strategy (tumor board). The organization structure of the hospital (teams, tumor board, emergency care with intensive care unit, emergency diagnostic and options for interventional measures) can be more important than the hospital case numbers alone. These demands which have been evaluated from published data and own results are designed to raise the therapy of colorectal cancer to the best possible level of quality and to effect a further improvement in the prognosis.

Various techniques for repair of an incisional hernia are available for the surgeon. Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of recurrence and therefore should only be used in exceptional cases. An underlying systemic disturbance of collagen metabolism is assumed to exist in patients with an incisional hernia. In such patients the mechanisms of wound healing and remodeling of the abdominal wall following laparotomy are insufficient, which necessitates reinforcement of the abdominal wall with a non-resorbable alloplastic mesh prosthesis to enable a long-term cure. The implantation of such meshes can be carried out laparoscopically or by an open approach. The gold standard of open repair techniques is the retromuscular placement of a mesh prosthesis. The retromuscular mesh placement as a reinforcement of the abdominal wall (augmentation) must be categorically differentiated into the abdominal wall replacement by mesh bridging. In this technique the mesh is likewise placed in the retromuscular space, however a complete closure of the ventral fascia is not necessary. Retromuscular augmentation enables an extra-peritoneal placement of the prosthesis, an optimization of tissue integration by plane coverage of the prosthesis by well vascularized muscular tissue and a sufficient overlap in cranio-caudal and lateral directions. Mesh fixation is best made with absorbable suture material but is better suited for technical simplification. The use of a prophylactic drainage should be decided depending on the individual patient's risk factors, because sufficient evidence-based data are currently not available. If augmentation is not possible bridging is necessary and then the mesh has to be fixed without underlying support. Current data reveal that the recurrence rate following incisional hernia repair by retromuscular mesh augmentation has decreased promisingly in comparison to simple suture techniques. In total the recurrence rate following retromuscular mesh placement ranges between 2 and 12%. Current results of prospective randomized multicentre trials are not available. However, it is to be expected that further development of mesh materials as well as improvement of surgical techniques with avoidance of typical pitfalls will lead to further reduction of the recurrence rate with an improvement in patient satisfaction.

The Aachen model is a practical mode in teaching and advanced training, which is closely geared to the areas of academic acquisition and training. During medical education optional student courses with constitutive curricula offer practical points of contact to the surgical department at all times. Besides improvement of manual training the aims are enhancing interests and acquisition of talents. This guided structure will be intensified with progression into advanced education. Next to the formal guidelines of the curriculum, education logbook and progression conversations, quality, transparency and reliability are particularly emphasized. An evaluation of both the reforms and the surgical trainers is still to be made. In addition procurement of an affirmative occupational image is essential.

The discipline of general and visceral surgery will change over the next 20 years due to technical and digital developments. Of particular significance will be computer-assisted surgery, pre-operative simulation and intra-operative navigation and also the further development of the minimally invasive technique itself, which overcomes the present limitations of complex visceral surgical resection and reconstruction and will replace open surgery in more and more fields. It is extremely probable that over the next 20 years surgeons will be dealing increasingly more with old patients and the spectrum of interventions will also change. Oncologic surgery will change due to the high dynamics in the development of new anti-cancer medications. Other fields, such as obesity surgery, will become more important. An irreversible development is the economization of the discipline and quality assurance. This will accelerate the development of high-volume centers for a large proportion of visceral surgical interventions.

Acute appendicitis is one of the most common acute surgical conditions of the abdomen. Nevertheless, the indications for appendectomy are associated with a high preoperative rate of false diagnoses. Although the rate of unnecessary appendectomies is comparatively high (20-30%) it is considered acceptable because the rate of perforated appendices is 7-30%. With good availability and lack of radiation exposure, ultrasound is the slice imaging modality of first choice. The sensitivity of ultrasonic detection of appendicitis lies between 55 and 98% and the specificity between 78 and 100%. Computed tomography (CT) has a significantly higher sensitivity for detecting acute appendicitis compared to ultrasound both in infancy and adulthood but the specificity shows no significant differences. CT is, therefore, the imaging modality of choice in cases of relevant differential diagnosis that cannot be visualized adequately or inconclusively by sonography especially in obese and critically ill patients. Comparison of ultrasound and magnet resonance imaging (MRI) revealed a significant advantage for MRI regarding accuracy, sensitivity and negative predictive value. In contrast, specificity and positive predictive value showed no significant differences. Currently MRI is only an alternative imaging modality to ultrasound in cases of undetermined and inconclusive ultrasonic findings especially in childhood and pregnancy. The value of ultrasound in the diagnosis of acute appendicitis is increasing and, particularly in the hands of experienced investigators, is an important imaging modality which delivers important and decision-making findings. Nevertheless, the final decision for appendectomy depends on the findings of the physical examination.

During the last decade surgical treatment of rectal cancer has seen various improvements. Partial or total mesorectal excision (TME) became standard procedure. The surgical quality of the TME has a high effect on prognosis. Besides metastases, the circumferential resection margin receives the most attention. As recent studies established a distal resection margin of 1 cm, the rate of continence-preserving resections has grown, especially after neoadjuvant radiochemotherapy. In the hands of an expert, laparoscopic rectal resection is a technically safe procedure. Its oncological efficacy cannot yet be decided. Modern therapy for rectal cancer comprises multilateral considerations and therefore needs a multimodal orientation.

Many different causes have been described for dysphagia. An uncommon one is trichobezoars, which are mainly caused by trichotillomania. This may lead to mechanical obstruction and peritonitis due to perforation of the gut. Here we report a case of a giant trichobezoar (30x20x10 cm) in the stomach of a 20-year-old female. The patient presented unclear dysphagia and a palpable tumor in the epigastrium. Computed tomography showed an inhomogeneous tumor spreading from the upper belly to the pelvis. A B1 resection was performed and the patient recovered uneventfully.

Background: An open medical market is supposed to be a promising tool for preserving the meagre resources of the German public health care system. The competition between humane and economic practice induces conflicts which burden physicians as well as patients. To analyse this problem by scientific means, inpatients were interviewed with the help of a standardised protocol., Patients and Methods: During 10 weeks 524 inpatients were interviewed. The structured questionnaire consisted of nine closed-ended questions with multiple-choice answers. Question 3 included a free amendment. The gender ratio was balanced, and the age pattern represented the typical patient collective of our clinic., Results and Conclusion: The majority of patients expect negative changes in their medical service and the social attitude towards patients and physicians due to promoted medical competition. Besides an increasing financial load, losses in trust, self-determination, and therapeutic freedom are expected. Instead a responsible transparency will not be achieved. Patients still judge the economically dominated reforms on the German health care market with scepticism or even hostility. In their point of view future discussions must aim at a more modern attitude towards health economics in order to bridge the schism they perceive between medical competition and humanitarianism. The understanding of strong financial management as a prime condition for stable social security is the basis of synergies to deal with upcoming reforms.

Hydatid disease is a parasitic infection caused by Echinococcus granulosus, and the most frequently affected organ is the liver. Diagnosis is usually based on radiological and serological findings. Even though percutaneous drainage and medical therapies are suggested for selected cases, for the most part surgery is required. The surgical strategy consists of killing the cyst, removing its contagious elements from the liver, obliterating the cystic cavity, and preventing recurrence and complications. A large spectrum of operations - from simple drainage to liver transplantation - has been proposed for reaching these objectives. Laparoscopic surgery is used increasingly for hydatid disease. This article reviews the current status of hydatid disease surgery, with special emphasis on liver cysts.

Background: The financial resources in the German Public Health care system are running short due to reduced budgets and demographic changes. Reform plans of the state, backers, and care providers seem to neglect patients' needs. To analyse this problem by scientific means, inpatients were interviewed as to their views concerning fair allocation., Patients and Methods: During 6 weeks, 532 inpatients were interviewed. The structured questionnaire consisted of eight closed-end questions with multiple choice answers. The gender ratio was balanced, and the age pattern represented the typical patient collective of our clinic., Results and Conclusion: The majority of the patients do not support the reform plans in the German public health care system. They feel comfortable with the present medical standard and quality of health care and wish no reductions in the medical service. The required individualisation of risk and care is rejected. Thus patients reveal an almost dichotomous understanding of medical care on the one hand and its cost on the other. Modern reform and change concepts need effective professional public relations to increase public understanding and reduce objections to unpopular measures.

In the early period following surgery, it is very important to reveal any complications. In this article the role of ultrasound in recognizing postoperative complications is demonstrated. Ultrasound findings in typical complications of abdominal surgery such as bleeding, abscess formation, acute cholecystitis, pancreatitis, and postoperative ileus are described. The diagnosis of postoperative bleeding, acute cholecystitis, and ileus is very reliable by ultrasound (sensitivity and specificity >95%). Ultrasonography is inferior to computed tomography in detecting pancreatitis and abscess formation. The guiding of interventions by ultrasound offers additional therapeutic options.

Background: The structure and organisation of German hospitals currently are undergoing radical change forced by reforms in the German public health system. Operating procedures, efficiency assays, and management programs compete with the traditional philanthropic relationship between physician and patient. To analyse this problem by scientific means, inpatients were interviewed in standardised fashion on current expectations, ideals, and experience with that relationship., Patients and Methods: During 4 weeks, 507 inpatients were interviewed. The structured questionnaire used consisted of nine closed multiple-choice questions. The proband sex ratio was balanced, and their age pattern represented the typical patient collective in our clinic., Results and Conclusion: The patient perception of physicians' roles described clear priorities. Besides a skilled expert, the patients were looking for a friend and guide through their disease, diagnosis, and therapy. The paternalistic relationship between physician and patient thus is not very antiquated. In contrast, material institutional criteria, provision of services, and hotel-like atmosphere played secondary roles.

Abdominal compartment syndrome (ACS) is characterized by a persistent pathologic increase in intra-abdominal pressure (IAP) exceeding 20 mmHg with consecutive dysfunction of multiple organ systems. The main causes of ACS are abdominal trauma, obstruction, infection, and sepsis, but it may also be initiated by extra-abdominal diseases. The gold standard for diagnosis is repeated assessment of the IAP measurements of bladder pressure. The incidence of ACS is up to 15% in operative ICUs and the therapy of choice for it is decompressive laparotomy. Nevertheless, mortality is high, up to 60%.

Introduction: Since the use of prosthetic mesh for the surgical repair of inguinal hernias has become increasingly popular, mesh material introduced during a previous operation is being detected in a growing number of patients undergoing surgery for recurrent hernia. This applies to at least 10% of recurrences. Needed is a therapeutic algorithm for the surgical management of recurrent hernias after previous mesh repair., Material and Methods: A total of 672 recurrent hernia repairs performed in hospitals in the German cities Aachen and Koblenz were analysed in order to review clinical practice. In 92 patients (13.7%) who underwent surgery for recurrent hernia, mesh had been used in the previous hernia repairs. Attention was focused on the location of the recurrence in relation to the site of mesh implantation and on the advantages and disadvantages of the various surgical procedures for repairing recurrent hernias. Re-examination was performed with a mean follow-up of 3 years., Results: Surgeons mostly decided during operation which procedure to use. A transinguinal approach was preferred for patients presenting with recurrent hernia and pain, and mesh material introduced during a previous operation was then explanted. In the case of multiple recurrences, a minimal direct suture repair was used for small defects or a preperitoneal approach for inserting a new, large mesh. The majority of recurrences were medial or suprapubic, especially those occurring after a Lichtenstein repair. After re-examining 87 of 92 patients, nine recurrences (10.3%) were found. Mesh-free suturing methods were affected most frequently. Moderate complaints were reported by 39.1%, and 4.6% suffered from medical chronic pain., Conclusion: The surgical management of recurrent hernias after previous mesh repair is a particular challenge for surgeons. We introduce a therapeutic algorithm for recurrent hernia surgery after previous mesh implantation based on analysis of clinical practice.

Open resection of the colon is one of the most frequent abdominal operations, which clearly indicates the great importance of colon carcinomas. The surgical aim is resection of the affected intestinal region and the according lymph drainage region. In this respect, the techniques employed are strictly standardized: right hemicolectomy for right colon carcinoma, transverse resection for right colon carcinoma, left hemicolectomy for descendent colon carcinoma, and sigmoid resection for sigmoid carcinoma. In case of benign underlying disease, the operational method depends largely on the extent to which the intestine is affected and can include anything from simple colotomy and polyp removal to colectomy for toxic megacolon. Elective colon surgery is usually primary, but in emergencies a protective stoma might be necessary. Standardized indication and operational techniques enable low perioperative mortality and complication rates that make open colon resection usually un-problematic even in very old patients.

With a long-term incidence of 10-20%, incisional hernias remain one of the most common surgical complications. Beside technical causes, wound-healing problems are increasingly being discussed. Conventional suture repair shows disappointing results and should be used only in selected cases. By the implantation of mesh prostheses, notable improvement could be achieved, with recurrence rates of <10%. Its main principle is retromuscular mesh reinforcement of the entire scar. Particularly in the neighbourhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris.

Background: To optimise the satisfaction of patients after repair of primary inguinal hernias under local anaesthesia, we analysed the analgetic power of Ropivacain in the postoperative period., Material and Methods: One hundred consecutive patients underwent repair under local anaesthesia with the same volume of 0.75% Ropivacain or 1% Mepivacain in a randomised and blinded manner. Postoperative pain analysis was carried out in all patients., Results: Subjective pain levels at rest and under stress as well as impairment by pain were found to be significantly lower in the Ropivacain group at the day of operation. Decrease in vital capacity and peak flow showed similar results. The postoperative amount of analgesics and time of mobilisation showed a positive influence by the use of Ropivacain., Conclusion: Ropivacain reduces postoperative pain levels after hernia repair. This leads to increased comfort for patients, without elevated perioperative risk.

Introduction: Over 75% of ingested foreign bodies pass the gastrointestinal tract without any complications. Blunt foreign bodies may lead to a disruption of the intestinal passage, mainly in the area of the ileocoecal opening. The size of the reported foreign bodies varies considerably. The aim of this study was the anatomic investigation to clarify the possible causes of obstruction and its influence on the diameter of the ileocoecal opening., Material and Method: We investigate anatomically and describe the ileocoecal opening on the basis of 27 specimens., Results: We found not a flap mechanism but a valve mechanism in the ileocoecal junction. The median diameter of the formalin-fixated specimens was 10.9 mm respectively 21.8 mm according to an assumed correction factor of 2. The cause for intestinal obstruction most probably is the ingestion of blunt, angular foreign bodies in the ostium ileale., Conclusion: The intraindividual differences as well as the considerable size of foreign bodies that pass the ileoceocal opening support the hypothesis, that the complications described are more a consequence of an ingestion of blunt, cornered foreign bodies in the ostium ileale independent ofn the size of the ileocoecal opening itself.

Ambulatory surgery of inguinal hernia is gaining in popularity. While in the USA, admitting patients for inguinal hernia surgery is an exception, fewer than 10% of all such operations in Germany are performed in a day-case surgical setting. One reason for the situation observed in Germany is still a lack of acceptance by the patients. A second reason is the general nature of our health system. Surgery of the inguinal hernia can adequately be done as a standardised ambulatory procedure. We prefer conventional repair under local anaesthesia. In qualified hands, vitally dangerous complications are minimal. Careful indication, standardisation of the procedure as well as good information for and guidance of the patients provide a basis for successful day-case surgery. Indications, limitations, and risks are presented and analysed from a clinical point of view.

The solitary fibrous tumor (SFT) is a very rare and usually benign neoplasm. This tumor is mostly located in the thoracic cavity, but it has also been reported in numerous sites including liver, skin, and meninges. Due to its rarity diagnosis is often difficult. Accordingly, histopathological differentiation is of major importance. Solitary fibrous tumors consistently express CD 34 and react negatively to epithelial markers. This absence of expression of epithelial markers, especially cytokeratin, is also useful to distinguish these rare entities from sarcomatous mesotheliomas. The treatment of choice for solitary fibrous tumors is extensive surgical resection. Up to now there is no evidence that radiation and chemotherapy are effective. The local recurrence or onset of metastases depends on histologic parameters. In cases of benign classification (60-80%), the recurrence rate was only 2% after surgical excision. One-half of the patients with malignant tumors can be cured; the rest develop recurrences and metastases more often. Especially in those cases, emphasis should be placed on continual follow-up examination. We report two cases of a 65- and a 75-year-old male patient with huge intrathoracic solitary fibrous subpleural tumors, discovered incidentally on routine chest X-ray.

Sphincter preservation is a goal in the treatment of rectal cancer and should be considered in all patients with intact analsphincter. For tumors of the upper rectum, this is easily achieved by end-to-end decendorectostomy. Total mesorectal excision is obligatory for tumors of the mid and lower third of the rectum. Reconstruction of intestinal continuity can be achieved by colonal anastomosis, if the oncologic situation allows a sphincter-preserving procedure. Creation of a colonic J-pouch can improve functional results. This leads to a reduction of stool frequency and urgency without negative effects on continence and complication rate. The functional effects are maximal during the initial months, but are still significant up to 9 years postoperatively. The pouch should not exceed a length of 6 cm in order to prevent evacuation disorders. The transverse coloplasty pouch may allow pouch reconstruction in patients in whom this is currently impossible, but long-term follow-up is not yet available.

New laws for assisted patient death in The Netherlands and Belgium have resulted in animated discussion about the permissibility of the practice in Germany. Physicians here are being confronted more and more by patients and their relatives with the wish for assisted death. Polls confirm that the majority of this population supports active death assistance, whereas doctors reject it. At a symposium in October 2002 (Clinically Assisted Death and Human Dignity-A Dutch-German Dialogue), case studies illustrating this question were presented. The present study compiles viewpoints of physicians, ethicists, theologians, jurist, politicians, and journalists.

We report a case of postoperative ileocecal invagination in a 63-year-old male. Forty-six days after esophageal resection and gastric tube reconstruction with cervical anastomosis for an esophageal carcinoma, the patient suffered from colicky pain in the right abdomen. The diagnostics showed an ileocecal invagination up to the right flexure of the colon. The invagination was based on a leiomyoma of the terminal ileum. Because of necrosis of the mucous membrane, an ileocecal resection with ileoascendostomy could not be avoided. We discuss this case on the basis of the existing literature.

Introduction: The Internet offers an increasing amount of medical information, but its value for surgical patients is doubtful., Methods: Using "inguinal hernia" as catchword, an amateur search was imitated on a German-speaking metasearch machine. One hundred fifty sites, standardized regarding quality and efficiency,were evaluated., Results: In summary, more than 50% of the sites revealed poor results. Technical appearance, quality of content, and target grouping show big deficiencies. The applicable laws were mostly not respected. The ranking lists of the search machines do not reflect the quality of the sites., Conclusion: Patients need competent guides to process surgical information from the Internet. The establishment of a specialized institution to control surgical websites according to quality, content, and legality seems to be needed.

We report a case of gall bladder tuberculosis in a 64-year-old male. The gall bladder is an extremely rare localization of an infectious disease seen frequently worldwide--tuberculosis. The reason for this special resistance against the mycobacteria is not clear and is controversial. In imaging, the disease can mimic acute or chronic cholecystitis or carcinoma of the gall bladder. It is important to consider tuberculous cholecystitis in differential diagnosis and to do tuberculin skin tests in case of suspicion. This test is technically easy and cost-effective. Since 1968, isolated tuberculosis of the gall bladder has not been reported in western civilization. This case study was done because of the rareness of the disease,and we review the literature on this topic.

The long history of surgical drainages stands in contradiction to available and reliable data. As of today, closed systems made of silicone are preferable. Taking possible complications into consideration and the good results of routine operations without drainages, indication for use should be critically evaluated. Interdisciplinary research,however, offers the chance of optimizing material and surface characteristics, biostability, biocompatibility, and flow rates. New drainages with improved performance and reduced side effects may counteract the current tendency to do without.

A total of 140 patients presenting with umbilical hernia underwent Spitzy's operation and were included in a retrospective study to analyse the recurrence rate. The patients received a questionnaire and were invited for a physical examination including ultrasound. Participation included 108 patients (follow-up 77%). A total of seven patients (6.5%) developed postoperative wound infections. Prolonged postoperative impairment was mentioned by nine patients (8.3%). After a mean period of 16 days, the patients were able to continue their occupation, and after 27 days, they could manage their usual physical activity. The recurrence rate was 13.0%. The risk for a recurrence correlated with the relative bodyweight. In the group with a body-mass-index (BMI) of less than 30, the recurrence rate was 8.1 %, whereas 31.8% of the patients with a BMI of more than 30 developed a recurrent hernia. The size of the hernial orifice also had an influence on the postoperative result. In patients with a hernial gap smaller than 1 cm the recurrence rate was 6.3%, with hernia orifices from 1 to 2 cm the rate was 4.1%, from 2 to 3 cm 14.3%, from 3 to 4 cm 25.0% and in patients with hernial gaps greater than 4 cm the rate of recurrences was 54.5%. Considering these results,we recommend the use of alloplastic material for umbilical hernia repair for patients with a BMI greater than 30.0 and hernia orifice larger than 3 cm. The decision for use of a mesh in hernial gaps from 2 to 3 cm should depend on individual factors.

Tumors of the retrorectal space are rare entities. The case report of a retrorectal tailgut cyst serves to illustrate the clinical and diagnostic findings, differential diagnosis, and therapy of retrorectal tumors. Tumors in this area can be identified by palpation. The subsequent investigations include ultrasound, endosonography, endoscopy, and by choice computed tomography or magnetic resonance imaging. Usually tailgut cysts are characterized as cystic tumors, well delineated with multicystic formation. The diagnosis has to differentiate between carcinomas of the colorectum, hamartomas, lymphomas, teratomas, chordomas, abscess formation, dermoid cysts, epidermoid cysts, and enteral cysts. An elevated level of CEA may point to malignancy. Complete surgical resection is the therapy of choice.

Incisional hernia is the most frequent late complication of surgery; its incidence is constant and it has a high socio-economic impact. Possible preventive measures are analysed in this article on the basis of current clinical and experimental findings. An argument that is restricted strictly to the surgical and technical aspects does not do justice to the complexity of incisional hernia development. It has been proved that continuous mattress suturing after laparotomy is beneficial in terms of wound healing and also means significantly shorter operating times and smaller amounts of suture material are needed. Combined with a suture length-to-wound length ratio of at least 4:1, this technique is superior to single interrupted suturing as its bio-mechanical properties are better and it allows better collagen synthesis in the region of the incision. It is not possible to recommend any one particular suture material at present. The possibilities of influencing the endogenous risk factors connected with the patient and any co-morbidity is hampered by economic aspects and low efficiency, although precisely such endogenous factors have a high potential for influencing treatment in the future. Suture tension is a relevant parameter that has not yet been sufficiently fully evaluated. Better monitoring of suture tension might open up the possibility of devising new variants of laparotomy closure techniques that would reduce the incidence of incisional hernias. In view of the significance of impaired wound healing for the surgical specialties, suture tension and the search for possible ways of influencing and modulating collagen synthesis look like promising topics that would reward a more intense research effort in the future.

In order to reduce the high frequency of bowel movement after resection of the rectum in cases of rectal cancer, the creation of a colonic J-pouch was developed. Meanwhile this operation is well established. As a variation to the standard technique, von Flüe introduced in 1994 the interposition of an ileocecal segment, intended to improve the reservoir function via its own distensibility. Despite the conserved neural and vascular integrity of the ileocecal segment, major complications arise such as pouchitis with necrosis. In these cases, resection of the pouch and permanent discontinuity of stool passage is routine therapy. Patients with permanent stoma face many difficulties both physical and psychological, and often the quality of life diminishes. In the literature there is no detailed case of colonic J-pouch reconstruction following resection of an insufficient ileocecal pouch. This operation is technically highly demanding but feasible.

Parastomal herniation is a frequent complication when an artificial anus is constructed. As a tunnel through the abdominal wall is nonphysiological, there is an inherent trend to enlargement of the aperture with any artificial stoma. However, none of the technical modifications tried has proved reliable in reducing the incidence of parastomal herniation. The only clear-cut indications for repair are ileus and incarceration or serious problems with the colostomy bags. There are three basic methods of repair: fascial closure, stoma relocation and augmentation of the abdominal wall by nonabsorbable meshes, and any of the three can be combined in many ways. The first two techniques each have a recurrence rate of 40%-80%, and neither can therefore any longer be recommended for use in isolation. Only with the last technique of abdominal wall reinforcement it is possible to achieve a recurrence rate of under 20%. The best type of mesh and the optimal implantation technique are still under discussion.

Since the onset of an incisional hernia is caused by the biological problem of forming stable scar tissue, the mesh techniques are now the methods of choice for incisional hernia repair. Polypropylene is the material most widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which have been adapted to the physiological requirements of the abdominal wall and permit a reliable tissue integration. These meshes make it possible for a scar net to form rather than a stiff scar plate, thus helping to avoid the complications encountered with the use of earlier meshes. The ideal position for the mesh seems to be the retromuscular underlay position, in which the force of abdominal pressure holds the prosthesis tightly against the deep surface of the muscles. The retromuscular underlay repair technique has yielded the lowest incidence rates for recurrence: around 10% even after long-term follow up. Analysis of the failures after open mesh repair suggests that inadequate size of the mesh with insufficient overlap at the edges is the main reason for recurrence. An overlap of at least 5-6 cm all round must therefore be considered mandatory for successful reinforcement of the abdominal wall. Open mesh repair, particularly with modern low-weight polypropylene meshes applied by the retromuscular underlay technique, offers excellent results in the treatment of incision hernias, even in long-term follow-up studies.

Epidemics, caused by methicillin-resistant Staphylococcus aureus (MRSA) are an increasing problem in surgical hospitals. About 10 years ago, Germany only had sporadic cases with MRSA; currently, about 15% of all Staphylococcus aureus in Germany are methicillin-resistant. The most important measures in management and therapeutic strategies regarding MRSA are presented.

Primary vascular leiomyosarcomas of the great vessels are rare and the most common localization is the inferior vena cava. Due to nonspecific clinical signs, diagnosis is often made during operation or autopsy. At present, a radical tumor resection is the first choice of treatment. This is a case report of a 49-year-old woman who suffered from abdominal pain for 10 years because of a weakly malignant leiomyosarcoma of the inferior vena cava. A radical tumor resection and reconstruction with a prosthetic vascular graft were performed. Diagnosis, therapy, and prognosis are discussed.

Interventional techniques in treatment of complicated diverticulitis gain more and more importance. In particular abscesses and bleeding are treated successfully. In case of diverticular abscess (Hinchey classification stage I and II) percutaneous drainages are placed sonographically or CT guided. Interventional drainage offers the possibility of elective one-stage surgical treatment of diverticulitis with significant reduce of mortality and morbidity rates. Diverticular bleeding is usually diagnosed and treated endoscopically. Only if endoscopy is not able to manage bleeding, angiography or nuclear scan is demanded. In case of stenosis endoscopic treatment has not jet gained clinical relevance.

The diagnostic procedure is determined by the severity of the diverticulitis. In complicated cases of diverticulitis, it is necessary to detect those patients with obstructive ileus, perforation, and peritonitis who require instant emergency surgery. In all other cases, diagnostic procedures serve as a tool to determine the best therapeutic options. The CT scan of the abdomen seems to have the highest reliability for determining therapy. Other investigations such as barium enema and coloscopy are not indicated in emergency cases or cannot exactly describe the stage of the diverticular disease. Many surgeons still prefer an enema with water-soluble contrast medium in emergency cases to visualize a perforation. CT scans have the same ability to answer this question, but they are more expensive and are not available everywhere at any given time.

Diverticular disease of the colon ranks in prevalence equal to diabetes or coronary heart disease. Surgical treatment of colonic diverticulitis is in general very successful. Therapeutic options have broadened in recent years: while improved diagnostic modalities allow a pre-surgical containment of the disease process by percutaneous techniques, minimally-invasive surgical procedures can replace conventional surgery in many cases without a change in the risk of complications. However, there is no proof of a general superiority of the laparoscopic approach. Surgical morbidity and mortality mainly derives from perforations with diffuse peritonitis. As a rule, these cases should be treated by a Hartmann procedure. In selected cases it is also possible to perform a primary anastomosis. This decision should be guided by well-known scoring systems.

The term "quality" is a new buzzword used in connection with diagnostic and therapeutic activities. In the context of surgery, the term is usually restricted to the subdivision "quality of results." The specific circumstances surrounding a patient threatened by a malignant tumor justify separate consideration of oncologic surgery. Upon scrutiny, the frequency with which the term quality of results is used is in stark contrast to the lack of distinct clarification of the parameters it covers and grave uncertainty in data collection. Since medical action is not identical to technical action, attention must be called to the limitations of this popular terminology, especially with regard to oncology.

Introduction: Incisional hernia formation is one of the most frequent complications in visceral surgery requiring reoperation. Risk factors for incisional hernia formation and preventive strategies are not clearly defined., Methods: In a retrospective study including 2983 patients over a 10-year period, the influence of demographic data, pre-, intra- and postoperative risk factors for incisional hernia development were evaluated. From the subgroups medical history, medication, laboratory values, indication, surgical technique, course of operation, postoperative course and wound healing, altogether 43 parameters were analysed. Statistical evaluation was performed using the chi 2-test according to Pearson, and binary logistic regression analysis., Results: The mean incisional hernia incidence in the study was 4.3%. In the mean follow-up period of 21.1 months, the incisional hernia incidence was calculated at 9.8% using the Kaplan-Meier estimate; for a 10-year period it reached 18.7%. The study revealed that 31.5% of all incisional hernias developed in the first 6 months after the operation, 54.4% after 12 months, 74.8% after 2 years and 88.9% after 5 years. Significant demographic factors influencing incisional hernia incidence were age (> 45 years) and male gender. The preoperative factors anaemia (Hb < 100 g/l) and BMI > 25, the intraoperative factors recurrent incision and previous laparotomy, and the postoperative factors catecholamin-therapy and disturbed wound healing were of significant influence., Conclusion: The calculated incisional hernia incidence for a 10 year period of almost 20% and the manifestation of 50% of all hernias more than 12 months after the operation, underline the necessity to intensify surgical research in the field of laparotomy healing. In comparison to demographic and endogenous risk factors, the surgical technique has less influence on laparotomy healing. Measures to ameliorate tissue perfusin seem to exert a positive influence on incisional hernia incidence.

Malignant tumors associated with hernial sacs are rare entities. A review of literature offers only small groups of patients. The high incidence of inguinal hernia repair operations demands recognition of this morbidity. It should be suspected in cases of tight tissue in the hernial sac in differentiation to the unreduced inguinal and femoral hernia. Therapy of choice must be a resection in toto (R0), incomplete resection causes inguinal spreading or recurrence of the tumor. The exact evaluation of the surroundings should follow. There is no other standardized therapy besides operation. A case of leiomyosarcoma in inguinal hernia will present the entity of neoplastic disease in hernial sac.