Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen
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Review Comparative Study
[Ex situ resection and resection of the in situ perfused liver: are there still indications?].
Most liver tumors can be removed with conventional resection techniques employing partial or total vascular occlusion when needed. Duration of tolerable warm ischemia has not yet been defined, but it seems to be well tolerated up to 60 min. In a few cases with extended vascular resection and reconstruction liver protection by hypothermic perfusion is advantageous. ⋯ Major reconstruction of hepatic vessels with good technical access should be performed under in situ hypothermic protection using veno-venous bypass. Tumors involving the hepatic venous confluence and/or retrohepatic vena cava should be approached by either the in situ, or preferentially, the ante situm resection technique. The indication for an ex situ liver resection resulting in autotransplantation of the remnant liver exists only in rare cases for oncological reasons.
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Interfragmentary movement and size of the fracture gap influence fracture healing. Limited movements promote callus formation and may result in increased mechanical stability. Although larger movements still promote callus formation, the bony consolidation of the fracture is hampered. ⋯ Therefore, having in mind a minimally invasive surgical approach, one should strive for good reduction of the fracture ends and flexible yet stable osteosynthesis. Dynamization of the fracture by enabling axial movement will close the fracture gap, stimulate tissue differentiation and possibly accelerate the healing process. External mechanical stimulation, however, has not been shown to effectively enhance the healing process under flexible fixation or in load-bearing patients.
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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. ⋯ 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.
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Injuries precede the vast majority of all odontoid pseudarthroses. Because of specific anatomic conditions type II injuries lead more often than other types to non unions. For its development insufficient internal or external fixation and a persisting fracture gap are crucial. ⋯ Therapeutical recommendations need to be differentiated. Unstable non unions are most often responsible for persistent pain, may result in acute or chronic myelopathy++ and therefore - as well as ossa odontoidea - need operative fixation. In considerably displaced non unions a closed reduction manoeuver with long term traction should be tried. The operative treatment of choice is the posterior transarticular screw fixation C1/C2 desirably in a percutaneous technique. Tight, "stable" pseudarthroses in the sense of a persisting fracture gap in painfree patients should first be controlled radiologically. If the odontoid position remains unchanged, non operative treatment may be continued.