Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Acute mesenteric ischemia (AMI) is a rare cause of acute abdomen. Coupled with a high patient age, non-specific clinical symptoms and a significant co-morbidity the disease is still associated with a significant mortality of 60-85%. With a combination of preexisting cardiac arrhythmia and sudden abdominal pain AMI should always first be ruled out. ⋯ There should be a wide indication for second-look surgery. The most important prognostic factor and the only factor that can be influenced by the surgeon is the time interval between onset of symptoms and surgery. Therefore angiography or laparotomy should be performed as early as possible in cases of suspected AMI.
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Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. ⋯ In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.
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The coagulation system is a complex network of interacting proteins and cells with extensive sensitivity, amplification and control pathways. The system represents a delicate balance between procoagulant and anticoagulant as well as profibrinolytic and antifibrinolytic activities. Clinically relevant phenotypes, e.g. bleeding and thrombosis, occur immediately when this balance is no longer in equilibrium. ⋯ In a bleeding patient, patient's history, clinical findings, routine and advanced laboratory coagulation testing as well as point-of-care coagulation monitoring help to reliably and readily identify the underlying coagulation disorder. Modern coagulation management is proactive, individualized, balanced and follows clearly defined algorithms. Coagulopathic bleeding can be successfully controlled with specific interventions in the coagulation system.
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Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. ⋯ Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel.
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With an incidence of 200,000 new cases per year in Germany, inguinal hernia has a significant socioeconomic impact. The 2009 guidelines from the European Hernia Society established treatment recommendations. ⋯ Lightweight mesh reduces recurrence rates and is the treatment of choice even in primary hernias. Laparoscopic hernia repair is associated with specific risks but is superior in postoperative pain and earlier return to work.