Das Verständnis der GIST (Gastrointestinalen Stromatumoren) hat sich im vergangenen Jahrzehnt grundlegend gewandelt. Ursprünglich zwischen unbedeutendem Leiomyom und hoffnungslosem Sarkom eingeschätzt, besteht inzwischen ein differenziertes Wissen um variierende diagnostische Befunde sowie interdisziplinäre Therapiekonzepte in denen eine lebensqualitätsorientierte Chirurgie einen festen Stellenwert hat.

Einleitung: Spezifität und Sensitivität der klinischen Perfusionsbeurteilung des Darmes betragen 29 respektive 35%. Ausdruck dieser inadäquaten und zu wenig bewussten Beurteilungswertigkeit sind Gesamtkomplikationsraten bei der Chirurgie des Linkscolons und Rektums bis 20%. Mit der Laser-Fluoreszenz-Angiographie [LFA] steht jetzt ein einfach zu handhabendes mobiles System zur direkten intraoperativen Anwendung und sofortigen quantitativen digitalen Auswertung der Perfusion als Risikofaktor zur Verfügung, dessen Wertigkeit für die Linkscolon- und Rektumchirurgie in einer Beobachtungsstudie untersucht wurde. Exemplarisch eindrucksvolle Fallbeispiele verdeutlichen die Bedeutung eines im klinischen Alltag tatsächlich handhabbaren einfachen Objektivierungssystems.

Einleitung: Die Chirurgie des Linkscolons und Rektums gerade des älteren Menschen weist mit Anastomoseninsuffizienzen und Spätstenosen weiterhin eine Gesamtkomplikationsrate bis 20% auf. Mit der Laser-Fluoreszenz-Angiographie [LFA] steht jetzt ein einfach zu handhabendes mobiles System zur direkten intraoperativen Anwendung und sofortigen quantitativen digitalen Auswertung der Perfusion als Risikofaktor zur Verfügung, dessen Wertigkeit für die Linkscolon- und Rektumchirurgie in einer Beobachtungsstudie untersucht werden sollte.

Introduction: Inadequate suture tension has been recognized as a relevant factor for the failure of laparotomy closure. Due to the lack of adequate sensor devices, the experimental measurement of suture tension dynamics could not be achieved. A miniaturized sensor and data logger were developed and applied experimentally. Material and Methods: Specially designed, bridge shaped metall microsensors were fitted with strain gauges under the microscope. An implantable, programmable data logger (multi-layer technique, 256 kByte RAM) was also built. During experimental use, two microsensors positioned on the thread measured suture tension each second [N]. After 26 hours, the data logger was read out via an external connectboard. During the animal experiment in 14 pigs, initial suture tension was adjusted at 0.8 [N] in all animals. In half of the animals, intraabdominal pressure (IAP) was elevated to 20 mm of mercury using a pneumoperitoneum (PP) for two periods of 8 hours. Results: In animals without PP, the mean reduction of suture tension after 26 hours reached 60%. The mean loss in the first hour after laparotomy closure was found to be 50%. In animals with PP a direct and linear apposition of IAP on suture tension was found. After reduction of the PP, a steep loss of suture tension to mean levels 50% below initial tension was seen. After the second period of IAP, the mean suture tension then reduced to 0.1

BACKGROUND:The purpose of the study was to examine hemodynamic parameters and intravascular volume in a porcine model in the presence of intra-abdominal hypertension (IAH) lasting for 24 hours. METHODS:Twelve pigs (52.5 +/- 4.9 kg) were studied over a period of 24 hours. In six animals, the intra-abdominal pressure was increased to 30 mm Hg via carbon dioxide-pneumoperitoneum. The others served as controls. Using the double-indicator dilution technique, intrathoracic blood volume (ITBV), total circulating blood volume, and cardiac output (CO) were measured. Standard parameters (e.g., central venous pressure [CVP]), were also recorded. RESULTS:In the presence of IAH, ITBV and total circulating blood volume were significantly reduced to 55% and 67% of control values. CO decreased to 27% and CVP increased fourfold. CONCLUSION:IAH leads to significant intravascular volume depletion that is not reflected by the CVP. Assessment of CO and ITBV in the presence of a critically increased intra-abdominal pressure is therefore recommended.

Objective: Intravesical bladder pressure (IVP) measurement is considered to be the gold standard for the assessment of intra-abdominal pressure (IAP). However, this method is indirect, discontinuous, and potentially infectious and relies on a physiological bladder function. This study evaluated two novel methods for direct, continuous IAP measurement. Design and setting: Experimental study in an animal research laboratory. Subjects: 18 male domestic pigs. Interventions: CO2 was insufflated to increase the IAP to 30 mmHg for 18 and 24 h in six animals each. Another six animals served as controls. A piezoresistive (PRM) and an air-capsule (ACM) pressure measurement probe were placed intra-abdominally and of IAP was measured every 1 h (PRM/ACM) or every 2 h (IVP). The mean difference between insufflator readings and IAP values and limits of agreement (mean difference +/-2 SD) were calculated. Measurements and results: In the presence of applied pressure IVP and PRM remained significantly below insufflator readings while ACM values showed no difference. Mean difference (and limits of agreement) were 4.5 (-2.1 to 11.1 mmHg), 1.6 (-8.0 to 11.2 mmHg), and 0.5 (-4.5 to 5.4 mmHg) for IVP, PRM, and ACM. The mean measurement-to-measurement drift of the ACM values was 9.0+/-10.2 mmHg. Conclusions: In this model agreement of PRM and ACM with insufflator readings was comparable to IVP. As both methods may be advantageous regarding continuous straightforward measurement of IAP, the employment in further experimental and clinical investigations is suggested.

Background. Laparostomy is frequently performed in the surgical therapy of mechanical obstruction, peritonitis, or trauma to prevent abdominal compartment syndrome (ACS). Extended incisional hernia is inevitable when fascial closure is missed (up to 90% of cases). Intra-abdominal pressure (IAP) has not yet been evaluated as a criterion for the feasibility of fascial closure.

Laparotomy closure relies on the incisional edges as anchor for the suture material. The results of these techniques are not satisfying, with failure rates of up to 20%. To investigate the effect of different conventional closure techniques and a novel "bridging technique" on abdominal wall perfusion an animal study was performed in rabbits. Abdominal wall perfusion was measured using the method of dynamic laser-fluorescence videography in the first 72 h of incisional wound healing in 25 animals. Suture tension was controlled with a water-filled polyurethane balloon connected to a pressure detector. The effect of laparotomy closure on abdominal wall tissue perfusion depends significantly on the applied technique and suture tension. Avoiding direct sutures in the incisional edges during laparotomy closure leads to a better tissue perfusion of the incisional region than conventional suture techniques. Suture tension can be controlled and adjusted using a water-filled polyurethane balloon as a pressure sensor.

Durch einen erhöhten intraabdominellen Druck (IAD) wie beim abdominellen Kompartmentsyndrom wird sowohl die Organdurchblutung als auch die kardiale Funktion signifikant eingeschränkt. Unter diesen Bedingungen konnte eine Reduktion des Herzzeitvolumen (HZV) und manifeste Schädigungen der intraabdominellen Organe gezeigt werden. Es ist jedoch unbekannt, zu welchem Umfang diese Organschäden Folge der lokalen oder der systemischen Durchblutungsminderung ist. Ziel der vorliegenden Studie war es zu klären, ob eine ausgedehnte Volumengabe das HZV erhalten und Organschäden verhindern kann. Material und Methoden: Wir untersuchten 18 intubierte und analgosedierte Schweine (DL, 50 kg). Mittels CO2 Pneumoperitoneum wurde der IAP in 2 Gruppen (VL and ST, je n = 6) auf 30 mmHg angehoben. In der Kontrolle blieb der IAD unverändert. Alle Tiere erhielten eine körpergewichtsadaptierte Standardinfusion. In der VL-Gruppe wurde zusätzlich eine definierte Menge Ringerlösung gegeben wenn das HZV unter den Wert der Kontrollgruppe fiel (> 70 ml/min × kg). Das HZV wurde mittels Doppelindikator Dilutionstechnik unter der Verwendung von eisgekühlten Indocyaningrün gemessen. Weitere Parameter waren Stun-dendiurese sowie Serumkreatinin, -harnstoff, -Alanine-Aminotransferase (ALT), -laktat, — bilirubin, -lipase and Alkalische Phosphatase (AP). Die statistische Analyse erfolgte mittels einer Varianzanalyse für Meßwiederholungen und einem post-hoc Test nach Bonferoni. Zusätzlich wurden gepaarte und ungepaarte t-Tests durchgeführt. Ein p < 0.05 wurde als signifikant erachtet. Bei wiederholtem t-Test erfolgte eine Anhebung des Signifikanzniveau. Ergebnisse: In der ST-Gruppe war das HZV signifikant auf 25% der Kontrollwerte verringert. Alle Tiere dieser Gruppe wurden anurisch. Weiterhin stiegen Serumkreatinin, -harnstoff, -laktat, -bilirubin, -lipase sowie ALT and AP signifikant an. In der VL-Gruppe blieben HZV, Stundendiurese und Serumparameter im Vergleich zur Kontrollgruppe unverändert. Dazu war jedoch die Infusionsmenge in dieser Gruppe im Vergleich zu den anderen beiden Gruppen massiv erhöht: 10570 ± 1928 (VL) gegen 3700 ± 928 (ST) and 3918 ± 1042 ml (Kontrolle, p < 0,01). Zusammenfassungg:In diesem Modell des Abdominellen Kompartment Syndroms konnte eine massive Gabe von Fliissigkeit das Herzzeitvolumen über einen Zeitraum von 24 h auf dem Niveau der Kontrollgruppe halten. Darunter blieb die Stundendiurese erhalten und die Serumparameter unverändert, was im Gegensatz zur bekannten Literatur steht. Weitergehende histologische Untersuchungen sind notwendig, um eine Organschädigung auszuschließen. Diese Ergebnisse legen nahe, daß HZV unter einem erhohtem IAD engmaschig zu überwachen.

Primäre Leiomyosarkome der großen Gefäße stellen eine Rarität dar. Die häufigste Lokalisation ist die V. cava inferior. Bei einer klinisch unspezifischen Symptomatik erfolgt die Diagnosestellung meist erst intraoperativ oder autoptisch. Die Therapie der Wahl des vaskulären Leiomyosarkoms besteht in einer radikalen Tumorresektion. Wir berichten über eine 49-jährige Patientin mit seit 10 Jahren bestehenden Abdominalbeschwerden bei einem niedrig malignen Leiomyosarkom der V. cava inferior. Es wurde eine radikale Tumorresektion mit Gefäßersatz durchgeführt. Diagnostik, Therapie und Prognose werden diskutiert.

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.

. A suture length to wound length ratio (SLWL ratio) of 4:1 for laparotomy closure has proven in clinical studies to reduce incisional hernia incidence. The effect of different SLWL ratios on the mechanical qualities of the healing incision has not been examined experimentally. In 50 rats, the musculo-fascial layer of median laparotomies was closed with polypropylene sutures using SLWL ratios of 8:1, 4:1, 2:1 and 1.7:1. Single and running sutures, different tissue bites and different suture tensions were applied. Five rats served as controls. After 14 days, the horizontal strength of the incision was tested in a digitised tensiometer. The SLWL ratio, suture tension and suture technique proved to have significant influences on the mechanical strength of the incision. Running sutures and especially closures with a ratio of between 4:1 and 8:1 proved significantly stronger than wounds closed with single sutures. When small tissue bites were applied, the positive influence of running sutures was equalised in the early phase of wound healing. High suture tension led to significantly weaker scars independent of the applied suture technique. In accordance with clinical data, it could be proven experimentally that running closure of midline laparotomies with a SLWL ratio above 4:1 avoiding high suture tension exerts a significantly positive effect on the mechanical strength of the incision. Further studies are needed to allow measurement and better control of suture tension.

INTRODUCTION:Preservation of sexual function and voiding capacity after rectal cancer surgery has increased after adopting the technique of nerve-sparing dissection and total mesorectal excision. Still the rate of sexual and urinary dysfunction ranges between 25 and 67%. The precise locations where nerve damage occurs have not been looked at systematically. MATERIAL AND METHODS:In ten human corpses and two formalin-fixed human pelvises the autonomous pelvic nerves were isolated. Their relation according to surgical mobilization of the rectum were photodocumented. RESULTS:Pelvic autonomous nerves are clearly defined structures with only minor interindividual variability. The inferior mesenteric plexus forms a dense network around the inferior mesenteric artery (AMI) to a distance of 5 cm from the aorta. The distance between the lateral rectum and the pelvic plexus is only 2-3 mm. The anterior rectum is almost directly adherent to the neurovascular bundle, separated only by Denonvillier's fascia. The parasympathetic branches of the sacral segments S2-S5 cannot be isolated using the standard surgical approach. CONCLUSION:(1) The nomenclature of fascias and the course of the autonomous pelvic nerves is not clearly defined in the literature; (2) a high tie of the AMI leads to damage of the sympathetic nerves; (3) the narrow space between the anterior and lateral rectum makes sharp dissection under direct vision necessary; (4) fascias and nerves can be used as guiding structures during mobilization; (5) a preservation of selected parasympathetic roots in the small pelvis is not feasible using the standard surgical approach.

UNLABELLED Abdominal compartment syndrome is defined by increased intraabdominal pressure above 20 mmHg with increased pulmonary peak pressure and oliguria. In primary abdominal compartment syndrome the increased intraabdominal pressure is caused directly by peritonitis, ileus or abdominal and pelvic trauma. Secondary compartment syndrome is a result of forced closure of the abdominal wall after abdominal surgery. The effects are decreased cardiac output, pulmonary atelectasis, oliguria to anuria and hepatic as well as intestinal reduction of perfusion. Effective monitoring is done by standardised measuring of urinary bladder pressure. Normal values are between 0 and 7 cm H2O, after elective laparotomies 5-12 cm H(2)0. Above 25 cm H(2)0 they are definitely pathological. For the prevention and therapy of manifested abdominal compartment syndrome the application of a laparostomy using a resorbable mesh is recommended. Between 1988 and 1999 we applied a laparostomy to lower the intraabdominal pressure in 377 patients. In 16% of the cases it was indicated by primary abdominal compartment syndrome with a bladder pressure of 31 +/- 4 cm H(2)0 preoperatively, which could be lowered to 17 +/- 4 cm H(2)0 by laparostomy. An early reconstruction of the abdominal wall could be performed in 18% of the cases. CONCLUSIONS The abdominal compartment syndrome is an often underestimated problem in abdominal surgery involving multiple organ systems. The temporary laparostomy lowering intraabdominal pressure rather than a forced closure of the abdominal wall should be used in all circumstances.

Background: Although laparotomy closure is associated with a cumulative 15% failure rate, the effect of different suture techniques and materials on the ultrastructural composition of the healing incision has not been investigated. Method: in 40 Wistar rats the collagen fibril diameters and the regenerative tissue were compared using electron microscopy 14 and 28 days after midline laparotomy. Wounds were closed with single and running sutures using either polypropylene or polyglactin 910. Results: Closure with polypropylene led to significantly larger mean fibril diameters than closure with polyglactin. Regardless of time and suture material, running closure resulted in significantly smaller mean collagen fibril diameters than single sutures. Four weeks after laparotomy, inflammatory reactions, disorganization of collagen and irregularities of the vascular architecture were found after closure with absorbable suture material but not after closure with nonabsorbable material. Conclusion: Suture material and suture method significantly influence the ultrastructural composition of the healing incision. Persisting mechanical irritation around the suture threads after single sutures and severe persisting inflammatory reactions after the use of absorbable suture material are important influencing factors.