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To estimate the value of TEP in the treatment of incarcerated and irreponible inguinal and femoral hernias more exactly we prospectively collected and evaluated the data of our clinic for the period of Oct. 1999 until Dec. 2003. In this period we performed in total 1 671 hernia repairs including 79 patients suffering from an incarcerated (n = 33) or irreponible (n = 46) inguinal or femoral hernia. Using only the TEP-technique we treated mainly the irreponible hernias (46 patients). In the combination of LAP (laparoscopy) and TEP (27 patients) the laparoscopy provided the possibility to classify as well the incarcerated tissue as the result of the reposition. With this combined technique we treated the majority of the incarcerated hernias. To confirm the recovery of the incarcerated tissue laparoscopy can be of high value at the end of the combined LAP + TEP (2 patients). Thus TEP was performed in 92 % of the cases. In 2 cases we performed a conventional hernioplasty and one operation was finished conventionally after switching from endoscopic to conventional procedure. In 2 patients we performed a laparoscopically supported resection of the incarcerated tissue without patch implantation. 1 patient acquired TAPP. The use of different operative techniques and their combinations demonstrates as well the possibility as the necessity of a differentiated and case adapted proceeding in the treatment of incarcerated hernias. Lethality with 1.2 % and early postoperative morbidity with only 5.0 % were low. The hospitalisation period was 4.7 d on average. Our results are comparable to results of literature and show that TEP-technique and combined TEP + LAP-technique are possible and reasonable for the treatment of incarcerated and irreponible hernias.

In the period 01/00-12/01 in 35 out of 199 patients the laparoscopic appendectomy was performed with mini-instruments. This paper gives the prospectively registered data as well as our standardized technique of laparoscopic appendectomy with mini-instruments. The operations were performed via a 12 mm umbilical trocar and two suprapubic mini-trocars. Preparation was done with mini-instruments guided by 10 mm/30 degrees optic. Stapling of appendix and ligature of mensenteriolum via the 12 mm umbilical trocar was guided by 30 degrees -mini-optics. There was only one change of a mini-trocar to a 10 mm trocar for better view. 33 patients were female, mean age 23.4 years, mean BMI 21.1, mean operation time 41.1 minutes, mean post-op stay 3.3 days. There were no intra- or postoperative complications. The laparoscopic appendectomy with mini-instruments can be done by experienced surgeons in slender patients with low inflammation grade of the appendix without an increased complication rate and with a very good cosmetic result.

One can no longer think about modern hernia surgery without mentioning endoscopic techniques. But due to their high technical demands the learning curve is comparatively long. And by technical mistakes and their consequences (pain, recurrence, complications) the benefits of the endoscopic techniques can easily be turned to drawbacks. The following text explains the steps of the total extraperitoneal endoscopic hernioplasty (TEP) technique in detail pointing out alternatives and risks. From preparation, indication and positioning, from trocar placement to extraperitoneal dissection and mesh placement, the principles of TEP are elucidated in respect of local anatomy and possible complications. The text as well as the accompanying video in the Mediathek are based on the authors' 20 years of experience in the TEP technique. Both of them may help in safe TEP application to minimise the complication rate as well as recurrences. Then patients can benefit from the advantages of this technique.

BACKGROUND: Since January 1 st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg. METHODS: The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1 st 2005 were detected as well as re-operations in patients who had been operated before. RESULTS: 629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg / m 2 in 2005 and 48.4 kg / m 2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures. CONCLUSION: A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Gastric diverticula are rare. In the literature the mentioned incidences vary between 0.01 % and 2.6 % depending on the method of detection. Until now the laparoscopic treatment of gastric diverticula is reported worldwide by eight authors (eight laparoscopic resections and one laparoscopic invagination with oversewing). Between September 2000 and November 2004 we have operated upon two patients laparoscopically for a gastric diverticulum. In two case reports we describe our operative and perioperative procedure. In both cases the gastric diverticulum was resected with a linear stapling device. In the second patient we did simultaneously a laparoscopic 360 degrees -Nissen-fundoplicatio plus dorsal hiatorrhaphy and fundopexy because of reflux disease based on a cardia insufficiency. The dates of the literature concerning incidence, localisation, classifications, symptoms, diagnostic and therapy are summarized and discussed. Our two case reports show, like the cases mentioned in the literature, that symptomatic gastric diverticula can be treated by laparoscopic resection with very good results.

To estimate the value of TEP in the treatment of incarcerated and irreponible inguinal and femoral hernias more exactly we prospectively collected and evaluated the data of our clinic for the period of Oct. 1999 until Dec. 2003. In this period we performed in total 1 671 hernia repairs including 79 patients suffering from an incarcerated (n = 33) or irreponible (n = 46) inguinal or femoral hernia. Using only the TEP-technique we treated mainly the irreponible hernias (46 patients). In the combination of LAP (laparoscopy) and TEP (27 patients) the laparoscopy provided the possibility to classify as well the incarcerated tissue as the result of the reposition. With this combined technique we treated the majority of the incarcerated hernias. To confirm the recovery of the incarcerated tissue laparoscopy can be of high value at the end of the combined LAP + TEP (2 patients). Thus TEP was performed in 92 % of the cases. In 2 cases we performed a conventional hernioplasty and one operation was finished conventionally after switching from endoscopic to conventional procedure. In 2 patients we performed a laparoscopically supported resection of the incarcerated tissue without patch implantation. 1 patient acquired TAPP. The use of different operative techniques and their combinations demonstrates as well the possibility as the necessity of a differentiated and case adapted proceeding in the treatment of incarcerated hernias. Lethality with 1.2 % and early postoperative morbidity with only 5.0 % were low. The hospitalisation period was 4.7 d on average. Our results are comparable to results of literature and show that TEP-technique and combined TEP + LAP-technique are possible and reasonable for the treatment of incarcerated and irreponible hernias.

In the period 01/00-12/01 in 35 out of 199 patients the laparoscopic appendectomy was performed with mini-instruments. This paper gives the prospectively registered data as well as our standardized technique of laparoscopic appendectomy with mini-instruments. The operations were performed via a 12 mm umbilical trocar and two suprapubic mini-trocars. Preparation was done with mini-instruments guided by 10 mm/30 degrees optic. Stapling of appendix and ligature of mensenteriolum via the 12 mm umbilical trocar was guided by 30 degrees -mini-optics. There was only one change of a mini-trocar to a 10 mm trocar for better view. 33 patients were female, mean age 23.4 years, mean BMI 21.1, mean operation time 41.1 minutes, mean post-op stay 3.3 days. There were no intra- or postoperative complications. The laparoscopic appendectomy with mini-instruments can be done by experienced surgeons in slender patients with low inflammation grade of the appendix without an increased complication rate and with a very good cosmetic result.

Since January 1st 2005, the situation of bariatric surgery in Germany has been examined. The data are registered in cooperation with the Institute of Quality Assurance in Surgery at the Otto-von-Guericke-University Magdeburg.The data registration took place prospectively in an internet online data base. All primary bariatric procedures performed since January 1st 2005 were detected as well as re-operations in patients who had been operated before.629 patients underwent bariatric surgery in 21 hospitals in 2005 and 828 patients were operated in 32 hospitals in 2006. The mostly performed operation was gastric banding with 46.8 %, followed by Roux-Y gastric bypass with 38.5 %. 74.4 % of the patients were female. The medium BMI of all patients was 48.5 kg/m2 in 2005 and 48.4 kg/m2 in 2006. Follow-up data were available for 71.2 % of the patients operated in 2005. These data show a higher reduction of BMI after malabsorptive than after restrictive bariatric procedures.A trend from restrictive bariatric procedures to a malabsorptive approach could be observed. In Germany the BMI of patients undergoing bariatric surgery is higher than in most countries world-wide. No differences could be detected in intraoperative and short-term complications as well in the complication rate in the first year of follow-up in comparison with the literature.

Gastric diverticula are rare. In the literature the mentioned incidences vary between 0.01 % and 2.6 % depending on the method of detection. Until now the laparoscopic treatment of gastric diverticula is reported worldwide by eight authors (eight laparoscopic resections and one laparoscopic invagination with oversewing). Between September 2000 and November 2004 we have operated upon two patients laparoscopically for a gastric diverticulum. In two case reports we describe our operative and perioperative procedure. In both cases the gastric diverticulum was resected with a linear stapling device. In the second patient we did simultaneously a laparoscopic 360 degrees -Nissen-fundoplicatio plus dorsal hiatorrhaphy and fundopexy because of reflux disease based on a cardia insufficiency. The dates of the literature concerning incidence, localisation, classifications, symptoms, diagnostic and therapy are summarized and discussed. Our two case reports show, like the cases mentioned in the literature, that symptomatic gastric diverticula can be treated by laparoscopic resection with very good results.

The aim of the present paper is to describe the development of a standardized technique of laparoscopic cholecystectomy using mini-instruments in order to demonstrate its feasibility with no increase in the risk of the patient. For this purpose, the prospective data of the first 60 patients that appeared suitable to undergo laparoscopic cholecystectomy with mini-instruments were recorded initially, 45 patients were operated on using a 10 mm, 30 degrees standard laparoscope inserted via the umbilicus, together with two mini-instruments and a standard instrument inserted under the right costal arch. The subsequent 15 interventions were performed using, in addition to a 10 mm standard trocar placed in the umbilicus to accommodate the 10 mm laparoscope, three subcostal employed mini-trocars. For the special surgical steps involved in intraoperative cholangiography, and the clipping of the cystic duct and cystic artery, a minilaparoscope was introduced through the epigastric port. Fifty-five of the patients were women, their average age was 47.6 years and the mean BMI 23.5. The sole intraoperative complication seen was bleeding from the liver that made necessary conversion to a 5 mm port to aspirate the coagulum. Conversion to a standard 5 mm instrument was also required in two cases of broken forceps and in one case with a thick-walled gallbladder in which the mini grasping forceps proved too weak. The mean operating time was 62.4 min, and no postoperative complications occurred. For elective laparoscopic cholecystectomy including intraoperative cholangiography in slim patients, the use of mini-instruments is not associated with any increased risk of complications, and the operating time is acceptable. However, the general use of mini-instruments cannot as yet be recommended because of the less-than-optimal properties of the mini-instruments and the reduced optical quality of the mini-laparoscopes.

The current end stage in the development of endoscopic treatment of inguinal hernia involves the introduction of a patch into the extraperitoneal space. This may be done via a transabdominal approach (TAPP) or via a total extraperitoneal approach (TEP). The present article describes the TEP technique in detail. In addition to dealing with the ideal case, the authors also discuss the procedure in relation to all know forms of hernia. Furthermore, they provide the reader with suggestions on how to deal with intraoperative technical problems and how to avoid recurrences.