Liver injuries may occur alone as well as within the broader context of polytrauma. Immediate surgical intervention is indicated in hemodynamically instable patients with detection of free intra-abdominal fluid as demonstrated by imaging studies. For these patients, a damage control concept has been devised in order to decrease early mortality after trauma. With this strategy complex reconstructive interventions are avoided during the initial phase. Stabilization of the patient by treatment of the lethal triad consisting of hypothermia, coagulopathy and metabolic acidosis is at the core of this therapeutic concept. Should there be a need for reconstructions or other major surgical interventions these will be performed with delay after stabilization of the patient. Packing for the temporary treatment of liver injuries is part of the damage control concept.

Einleitung: Material/Methode: Ergebnisse: Diskussion: Introduction: Material/Methods: Results: Discussion:

Background: Operative treatment of high-grade carotid stenosis is an established procedure. The question whether a temporary either selective or routine-shunt is needed, is a matter of controversy, and the decision is based on a number of available monitoring procedures. Within the framework of quality assurance based on the regular collection of our own patient data, carotid thromboendarterectomy (TEA) with recording of somatosensory evoked potentials (SEP) was analysed for its effectiveness.Patients and Methods: Two non-randomised groups of patients were analysed retrospectively: Group 1: 99 carotid TEAs with no recording of SEP (1.1.99-31.12.99); Group 11: 139 carotid TEAs with SEP recording (1.1.01-31.12.01). These two groups were unselected in terms of procedure, as also with regard to age, sex, stage or degree of carotid stenosis or surgeon, and were homogeneously distributed. A comparison was made of anaesthesia and operating times, shunt rate and the outcome of the two groups. Additionally, the two subgroups surgery with no shunt, and surgery with shunt, and the subgroups thromboendarterectomy with patchplasty (TEA) and eversion endarterectomy (EEA), were analysed.Results: A temporary shunt was employed in 41 (41.4%) of the patients in Group I (no SEP recording) and in 16 (11.5%) of those in Group 11 (SEP recording). The average operating time in Group 11 was 11.4 min shorter (p < 0.001) than in Group 1. The average carotid clamping time in Group 11 was significantly reduced (by 4.2 min; p < 0.001), while the duration of anaesthesia prior to skin incision was increased by an average of 18.3 min (p < 0.001), and the overall duration of anaesthesia by an average of 15.8 min (p < 0.001). A comparison of the subgroups surgery with no shunt and surgery with shunt revealed - both in Group I and Group II-a significant prolongation of the anaesthesia time and operating time (p < 0.001). In both Groups I and 11, the subgroup TEA revealed a significant prolongation of both the anaesthesia and operating times vis-A-vis EEA. The major stroke rate was 2.0% in Group I and 1.4% in Group 11, and the minor stroke rate 3.0 in Group I and 3.6% in Group 11; no deaths were observed.Conclusions: A reduction in the shunt rate to 11% (by means of SEP) significantly decreased the average operating time (incision - suture) and the clamping time, with identical outcome in Groups I and 11. Despite a reduction in the average incision-suture time in Group 11 (with SEP recording), the average overall operating time (anaesthesia time) was significantly increased due to the greater technical effort required. Carotid TEA with a selective shunt as determined by SEP is a high-cost procedure with no demonstrable benefit. At a stroke rate < 5% and a need for stratification into several groups in accordance with the AHA classification, it is not possible to achieve adequate patient recruitment for a randomised analysis of outcome of the individual monitoring procedures. Alternative procedures are the routine use of a shunt and operation under regional anaesthesia.

Today, spleen-preserving or splenic-tissue-conserving surgery is both an accepted and desirable principle in the surgical treatment of injuries to the spleen as well as nontraumatic benign splenic lesions. In the rare case of benign tumorous lesions of the spleen, the question whether splenectomy or resection is the preferred successful therapeutic option is still being discussed. We present a case in which a high-pressure water jet dissector (Helix Hydro-Jet, A. Pein Medizintechnik, Schwerin, Germany) was used to perform an elective resection in a 13-year-old boy with a hamartoma of the spleen. The postoperative course was free of complications. The case illustrates the excellent features of water jet dissection in terms of transection of the parenchymal tissue and safe and selective hemostasis, which has also made the Hydro-Jet our preferred instrument for surgery on the splenic parenchyma.

Epidemiologische Daten zeigen einen Rückgang der Inzidenz einer akuten Appendizitis. Derzeit ist von einer Inzidenz von 110 - 200/100 000 Einwohner auszugehen. In der Diagnostik haben die Sonographie und die Computertomographie, insbesondere bei unklaren abdominellen Befunden, einen differenzialdiagnostischen Stellenwert. Die Laparoskopie stellt ein diagnostisches Verfahren mit therapeutischer Option dar und konnte ihren Stellenwert seit Anfang der 90er-Jahre zunehmend festigen. Im Falle einer nicht perforierten Appendizitis besteht die Therapie der Wahl in der laparoskopischen Appendektomie. Vorteile werden hierbei insbesondere hinsichtlich postoperativer Wundinfektionen und der Rekonvaleszenz gesehen. Bei perforierter Appendizitis und Peritonitis finden sich nach laparoskopischer Appendektomie höhere Raten postoperativer intraabdomineller Abszesse. In diesen Fällen sollte die Indikation zur offenen Appendektomie großzügig gestellt werden.

Ziel der Untersuchung war es, den Stellenwert der Laparoskopie im Versorgungsablauf des Bauchverletzten und beim akuten Abdomen zu bestimmen. Für die Beurteilung des Stellenwertes der Laparoskopie beim Abdominaltrauma wurde das Krankengut der Chirurgischen Klinik des Carl-Thiem-Klinikums Cottbus aus den Jahren 1998 bis 2002 retrospektiv analysiert. In diesem Zeitraum wurden 104 Patienten wegen eines Bauchtraumas operativ versorgt, davon 33 (31,7 %) primär laparoskopiert. In 18 Fällen wurde der abdominelle Eingriff ohne Konversion laparoskopisch beendet, bei 10 Patienten dabei intraabdominelle Verletzungen laparoskopisch versorgt. Die Rate der so genannten „negativen” Laparotomien lag bei 7,7 %. Beim akuten Abdomen besteht die wichtigste Indikation zur diagnostischen Laparoskopie in der Abklärung unklarer rechtsseitiger Unterbauchbeschwerden. Aber auch in Einzelindikationen (mesenteriale Durchblutungsstörungen, Perforationen, Meckelsches Divertikel, gynäkologische Erkrankungen, Peritonitis unklarer Genese, Dünndarmileus) stellt die diagnostische Laparoskopie ein wichtiges diagnostisches Instrument mit therapeutischer Option dar. Anhand der Daten einer Multizenterstudie mit 1703 diagnostischen Laparoskopien bei Verdacht auf Appendizitis wird der Stellenwert der diagnostischen Laparoskopie im Rahmen der Appendizitisbehandlung dargestellt. Gute Einzelindikationen werden in Falldarstellungen und Literaturanalysen erörtert. Damit sollte die Laparoskopie unserer Meinung nach einen festen Platz im diagnostischen und gegebenenfalls therapeutischen Prozedere beim Bauchtrauma und akuten Abdomen einnehmen.