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Surgery offers several options in prevention of chronic venous insufficiency and its sequelae. Both the operation on veins with valve dysfunction to reduce reflux and the elimination of obstruction in thrombosed veins aim for the reduction of venous hypertension. Elevated venous pressure, impairment of cutaneous capillaries and a chronic inflammatory process result in sclerosis of skin and subcutaneous tissue and might proceed to the fascia resulting in a chronic compartment syndrome. Non- healing chronic venous ulcers under conservative therapy for more than three months may be treated by vein-surgery, local wound care therapy like shaving and negative pressure treatment and if necessary by lowering of elevated intracompartimental pressure by fasciotomy or even fasciectomy.

Since the first use of vacuum-assisted therapy (V.A.C.) in wound care, the indications of this therapy have rapidly expanded. Vascular surgery presents many types of problematic wounds. In the current cost conscious atmosphere, there is a great demand for simple and effective therapies. The V.A.C. system has a lot of potential in the management of vascular wounds. In this article we present indications for vacuum-assisted therapy in vascular surgery: chronic leg ulcers, mesh skin graft, wound care after fasciotomy for compartment syndrome, problematic inguinal wound, false aneurysms, diabetic foot gangrene and amputations with marginal circulations.

In patients with varicose vein a duplex ultrasound is absolutely necessary prior to surgery in order to check the deep and the superficial vein systems. A standard classification is recommended to describe the type of venous insufficiency. Teleangiectasis and small varicose veins can be treated by sclerotherapy, but laser-therapy gets more and more popular. The inverting (partial)stripping of the greater and/or lesser saphenous vein avoiding nerve damage has gained popularity as did the miniphlebectomy. Newer methods using heat by radiofrequency order cryosurgery should generate less complications and have to show similar long term results than the classical procedures. Subfascial endoscopic perforator vein surgery (SEPS) is effective. Local or extended fascioctomy followed by skin transplantation in patients with recurrent ulcerations is considered as an option of therapy.

The compartment syndrome is an extremely rare complication after varicose vein surgery. If the early symptoms are not recognized and a treatment is not performed immediately most patients lose sensomotory function. Three cases with compartment syndrome after varicose vein stripping were the reason to point out the anatomy and pathophysiology of this complication and to explain the surgical technique.

Introduction: Thoracoscopic treatment of pleural empyema is still a controversial method, especially in the chronic stage of the disease. The issue is raised whether the thoracoscopic approach to the empyema-possibly combined with a small additional thoracotomy in advanced stages-is successful and of low risk., Patients and Methods: Between January 1993 and May 1995 we treated 13 patients in advanced stages of pleural empyema. The patients were all seriously ill and had severe underlying disease. The procedures were performed under general anesthesia involving intubation with a double-lumen endotracheal tube. The steps of our standard operative procedure are outlined., Results: In 5 patients with a pleural empyema in stage III thoracoscopy was facilitated by a small additional thoracotomy. A complete resolution of the disease was obtained in 12 cases and a secondary intervention was necessary in 1 patient. There was no peri- or postoperative mortality, and apart from a prolonged drainage of the pleural cavity in 3 patients no morbidity was registered. In the long-term follow up, 3 patients had died. There was no correlation between the deaths and the intervention or the empyema disease., Discussion: We discuss the advantages of a limited additional thoracotomy in case of intraoperative difficulties encountered with late stages of empyema. This treatment can still be considered minimally invasive. All patients tolerated the procedure well, and the overall results were favourable in 92% of our collective. However, thoracoscopic treatment should preferably take place at an earlier stage., Conclusion: We recommend the thoracoscopic approach-possibly combined with a limited thoracotomy-as primary treatment in late stages of pleural empyema.

We describe a rare variant of carcinoma of the ampulla of Vater. A 70-year-old man with several illnesses and a newly appeared jaundice was investigated and a signet-ring cell carcinoma of the ampulla of Vater diagnosed. We performed a local transduodenal excision. One year after operation the patient is asymptomatic. This is the second case report in the literature.

Especially in obese or severely ill patients, forming of an ileostomy or colostomy can be very difficult and laparotomy itself can lead to many complications. The intraabdominal part of this operations can easily be performed laparoscopically. The method is quick and simple and many complications can be avoided.

In a prospective study 50 patients undergoing a hernia repair were asked their opinion about an information sheet which was given to them preoperatively. For 94% this paper is of help; for 82% the written information has to be clarified by an additional personal talk with the doctor. Another possibility, especially good for visualisation, is the video. At the hospital of Davos there are at the moment 7 clips available to explain the treatment and the aftercare after an operation or conservative therapy in traumatology.