Researcher and surgeon with specialization in minimally invasive and upper GI surgery having special interest in emergency and visceral trauma surgery.
Background: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the ... more Background: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the introduction of minimally invasive techniques; these offer great advantages for the patient but pose problems for surgeons. Disadvantages due to the limited movement radius of the endoscopic instruments and the rigidity of the instrument tips can be reduced or eliminated by the use of computer-assisted telemanipulators. Methods: We report our experience with eight abdominal and seven heart operations performed between 16 March and 31 July 2001 with a Zeus TM surgical robotic system. There were four cholecystectomies, four Nissen fundoplications, five atraumatic dissections of the left internal mammary artery (ITA), and two pericardotomies. Results: All but one operation were completed successfully with the Zeus TM device. No patient suffered any peri-or postoperative complications. Due to an electronic defect in one of the manipulators, the final cholecystectomy had to be completed as a conventional laparoscopic procedure. The duration of surgery was about 40 % longer than with conventional laparoscopic technique. The specific costs related to the robotic system were EUR 910 per operation. Conclusions: Computer-assisted manipulators are at a developmental stage that allows their successful use in clinical applications. Routine use is, however, at present only possible with a limited number of procedures.
Background: The greatest challenge in traumatized patients is the diagnosis of injuries to hollow... more Background: The greatest challenge in traumatized patients is the diagnosis of injuries to hollow visceral organs. Methods: The diagnostic and therapeutic work-up of patients with bowel lacerations is reviewed. Results: In most cases small bowel lacerations can be treated by suturing the defect, or by segmental resection. Treatment of large bowel injuries depends on the part of the colon involved and on concomitant peritonitis. Conclusions: The last decade has seen a trend toward primary repair of bowel injuries. However, the final decision in the individual case depends on the extent of the peritonitis and the surgeon's experience.
Summary Background: Intraabdominal organ injuries are sustained by 40 to 50% of polytraumatized... more Summary Background: Intraabdominal organ injuries are sustained by 40 to 50% of polytraumatized patients. The spleen is most commonly affected. While 95% of pediatric cases will not require surgery, this is the case with only 5 to 10% of adults. Methods: Organ preservation is desirable, even in emergency cases with splenic rupture. Of the techniques available for this purpose, tissue
Background: According to the basic idea of minimally invasive surgery, reduction of surgical trau... more Background: According to the basic idea of minimally invasive surgery, reduction of surgical trauma, the caliber of instruments in needlescopic surgery is reduced to a few millimeters. The reduction in caliber can reduce power transmission to the instruments and impair view and light of the optic, which can cause limitations in its application. This study aimed to analyze the technique and results of needlescopic laparoscopy using the example of cholecystectomy. Methods: From 2007 to 2010, 124 patients underwent needlescopic and 130 conventional laparoscopic cholecystectomy. The trocar sites were always the same as for conventional laparoscopic cholecystectomy; a 10 mm trocar was introduced transumbilically in open technique and a total of three 2 mm trocars were used on the epigastrium and the right subcostal space. Intraoperative cholangiography was routine as in conventional laparoscopy. Results: All procedures were completed laparoscopically. Three cases (2.4%) required conversion to conventional laparoscopy. In 11 cases (9%), intraoperative cholangiography could not be performed. In 6 patients (5%), there were intraoperative complications such as opening of the gallbladder with spilling of the stones. The bile duct was never injured and there were no reoperations; hemoglobin never fell below 11 g/dl. There was significantly less need for analgesics in the first 3 days than with conventional laparoscopic cholecystectomy. Patient satisfaction was scored as 10 (very good) on a scale from 1-10 by 117 patients (94%). Conclusions: In contrast to NOTES and single port surgery, minilaparoscopy adheres to the basic principles of laparoscopy. With selected patients, needlescopic technique reduces postoperative pain, and has a better cosmetic result with higher patient satisfaction.
European Journal of Surgical Oncology (EJSO), 1995
Neuroendocrine cells are present in various organ systems. These widely distributed cells as well... more Neuroendocrine cells are present in various organ systems. These widely distributed cells as well as their histogenetically related tumours can produce various peptides and peptide hormones. From 1984 to 1993, 349 neuroendocrine tumours were found among 511,382 histological diagnoses at the Institute of Pathology of the Medical School of the Karl Franzens University in Graz. In 30% carcinoid of the appendix was diagnosed, in 16% carcinoid of the colorectum, in 9% carcinoid of the small intestine and in 2% duodenal carcinoid. Carcinoid of the stomach was detected in 14%. Seven of these cases showed microcarcinoidosis and five of them were combined with an adenocarcinoma. Carcinoid of the oesophagus was present in 1%, neuroendocrine pancreatic tumours in 6%. Neuroendocrine tumours of the bronchial system were found in 12%, medullary thyroid cancer in 5%. In 1% a Merkel-cell tumour was diagnosed. Other more rare localizations of neuroendocrine tumours were the uterus, ovary, breast, testes, epididymis, anal region and the upper respiratory tract.
ABSTRACT In an experimental animal study (Sus scrofa domesticus) we investigated the effects of t... more ABSTRACT In an experimental animal study (Sus scrofa domesticus) we investigated the effects of the new technique of laser needle stimulation (wavelength: 685 nm; energy density: 4.6 kJ/cm2 per point; application duration: 20 min). The results revealed changes in microcirculatory parameters of the skin resulting in an increase in blood flow. However, the quality and intensity of the laser light did not induce micromorphological alterations in the skin.
European Journal of Trauma and Emergency Surgery, 2011
Background Fistulas are abnormal communications between two epithelial surfaces, either between t... more Background Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas. Methods On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital. Conclusion Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.
Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World... more Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.
Purpose of Review Exploratory laparotomy is the traditional therapeutic approach in patients with... more Purpose of Review Exploratory laparotomy is the traditional therapeutic approach in patients with abdominal trauma. However, due to potential associated morbidity and mortality, avoiding unnecessary laparotomies is an important issue. Recent Findings While selective nonoperative management has shown good results, certain clinical situations in hemodynamically stable patients, where the need for surgery could be in doubt, call for proactive diagnosis. In these cases, laparoscopy can be used to exclude or diagnose potential injuries requiring surgery. When the surgeon has the necessary expertise, some of these injuries can be treated laparoscopically. Summary Over the last decades, diagnostic and therapeutic applications of laparoscopy have increased, with reported reduction in nontherapeutic laparotomies. Furthermore, shorter duration of hospital stay, faster recovery, and reduced costs have been reported. However, as seen in other minimally access interventions, safe implementation of laparoscopy in trauma care requires adequate surgical training and skills as well as appropriate staffing and equipment.
A spleen-preserving program was implemented at the author's institution during the mid-19... more A spleen-preserving program was implemented at the author's institution during the mid-1980s using a five-part injury-grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl-Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.
Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out o... more Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively. After the gallbladder was removed, three patients underwent open common duct exploration. In another five cases, anatomical anomalies were discovered. Cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication--common duct injury. Cholangiography should be attempted on all patients undergoing LC.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 1998
Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallblad... more Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.
Background: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the ... more Background: In the past 15 years, abdominal and thoracic surgery has been greatly changed by the introduction of minimally invasive techniques; these offer great advantages for the patient but pose problems for surgeons. Disadvantages due to the limited movement radius of the endoscopic instruments and the rigidity of the instrument tips can be reduced or eliminated by the use of computer-assisted telemanipulators. Methods: We report our experience with eight abdominal and seven heart operations performed between 16 March and 31 July 2001 with a Zeus TM surgical robotic system. There were four cholecystectomies, four Nissen fundoplications, five atraumatic dissections of the left internal mammary artery (ITA), and two pericardotomies. Results: All but one operation were completed successfully with the Zeus TM device. No patient suffered any peri-or postoperative complications. Due to an electronic defect in one of the manipulators, the final cholecystectomy had to be completed as a conventional laparoscopic procedure. The duration of surgery was about 40 % longer than with conventional laparoscopic technique. The specific costs related to the robotic system were EUR 910 per operation. Conclusions: Computer-assisted manipulators are at a developmental stage that allows their successful use in clinical applications. Routine use is, however, at present only possible with a limited number of procedures.
Background: The greatest challenge in traumatized patients is the diagnosis of injuries to hollow... more Background: The greatest challenge in traumatized patients is the diagnosis of injuries to hollow visceral organs. Methods: The diagnostic and therapeutic work-up of patients with bowel lacerations is reviewed. Results: In most cases small bowel lacerations can be treated by suturing the defect, or by segmental resection. Treatment of large bowel injuries depends on the part of the colon involved and on concomitant peritonitis. Conclusions: The last decade has seen a trend toward primary repair of bowel injuries. However, the final decision in the individual case depends on the extent of the peritonitis and the surgeon's experience.
Summary Background: Intraabdominal organ injuries are sustained by 40 to 50% of polytraumatized... more Summary Background: Intraabdominal organ injuries are sustained by 40 to 50% of polytraumatized patients. The spleen is most commonly affected. While 95% of pediatric cases will not require surgery, this is the case with only 5 to 10% of adults. Methods: Organ preservation is desirable, even in emergency cases with splenic rupture. Of the techniques available for this purpose, tissue
Background: According to the basic idea of minimally invasive surgery, reduction of surgical trau... more Background: According to the basic idea of minimally invasive surgery, reduction of surgical trauma, the caliber of instruments in needlescopic surgery is reduced to a few millimeters. The reduction in caliber can reduce power transmission to the instruments and impair view and light of the optic, which can cause limitations in its application. This study aimed to analyze the technique and results of needlescopic laparoscopy using the example of cholecystectomy. Methods: From 2007 to 2010, 124 patients underwent needlescopic and 130 conventional laparoscopic cholecystectomy. The trocar sites were always the same as for conventional laparoscopic cholecystectomy; a 10 mm trocar was introduced transumbilically in open technique and a total of three 2 mm trocars were used on the epigastrium and the right subcostal space. Intraoperative cholangiography was routine as in conventional laparoscopy. Results: All procedures were completed laparoscopically. Three cases (2.4%) required conversion to conventional laparoscopy. In 11 cases (9%), intraoperative cholangiography could not be performed. In 6 patients (5%), there were intraoperative complications such as opening of the gallbladder with spilling of the stones. The bile duct was never injured and there were no reoperations; hemoglobin never fell below 11 g/dl. There was significantly less need for analgesics in the first 3 days than with conventional laparoscopic cholecystectomy. Patient satisfaction was scored as 10 (very good) on a scale from 1-10 by 117 patients (94%). Conclusions: In contrast to NOTES and single port surgery, minilaparoscopy adheres to the basic principles of laparoscopy. With selected patients, needlescopic technique reduces postoperative pain, and has a better cosmetic result with higher patient satisfaction.
European Journal of Surgical Oncology (EJSO), 1995
Neuroendocrine cells are present in various organ systems. These widely distributed cells as well... more Neuroendocrine cells are present in various organ systems. These widely distributed cells as well as their histogenetically related tumours can produce various peptides and peptide hormones. From 1984 to 1993, 349 neuroendocrine tumours were found among 511,382 histological diagnoses at the Institute of Pathology of the Medical School of the Karl Franzens University in Graz. In 30% carcinoid of the appendix was diagnosed, in 16% carcinoid of the colorectum, in 9% carcinoid of the small intestine and in 2% duodenal carcinoid. Carcinoid of the stomach was detected in 14%. Seven of these cases showed microcarcinoidosis and five of them were combined with an adenocarcinoma. Carcinoid of the oesophagus was present in 1%, neuroendocrine pancreatic tumours in 6%. Neuroendocrine tumours of the bronchial system were found in 12%, medullary thyroid cancer in 5%. In 1% a Merkel-cell tumour was diagnosed. Other more rare localizations of neuroendocrine tumours were the uterus, ovary, breast, testes, epididymis, anal region and the upper respiratory tract.
ABSTRACT In an experimental animal study (Sus scrofa domesticus) we investigated the effects of t... more ABSTRACT In an experimental animal study (Sus scrofa domesticus) we investigated the effects of the new technique of laser needle stimulation (wavelength: 685 nm; energy density: 4.6 kJ/cm2 per point; application duration: 20 min). The results revealed changes in microcirculatory parameters of the skin resulting in an increase in blood flow. However, the quality and intensity of the laser light did not induce micromorphological alterations in the skin.
European Journal of Trauma and Emergency Surgery, 2011
Background Fistulas are abnormal communications between two epithelial surfaces, either between t... more Background Fistulas are abnormal communications between two epithelial surfaces, either between two portions of the intestine, between the intestine and some other hollow viscus, or between the intestine and the skin of the abdominal wall. The etiology of intestinal fistulas is in most cases a result of multiple contributing factors. Despite significant advances in their management over the past decades, intestinal fistulas remain a major clinical problem, with a high overall mortality rate of up to 30% due to the high rate of complications. This paper aims to describe classification systems based on the anatomy, physiology and etiology that may be helpful in the clinical management of intestinal fistulas. Methods On the basis of anatomical differences, fistulas can be classified based by the site of origin, by site of their openings, or as simple or complex. Physiologic classification as low, moderate or high output fistulas is most useful for the non-surgical approach. Concerning the etiology, we classified the possible causes as (postoperative) trauma, inflammation, infection, malignancy, radiation injury or congenital. Conclusion Fistula formation can cause a number of serious or debilitating complications ranging from disturbance of fluid and electrolyte balance to sepsis and even death. They still remain an important complication following gastrointestinal surgery.
Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World... more Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.
Purpose of Review Exploratory laparotomy is the traditional therapeutic approach in patients with... more Purpose of Review Exploratory laparotomy is the traditional therapeutic approach in patients with abdominal trauma. However, due to potential associated morbidity and mortality, avoiding unnecessary laparotomies is an important issue. Recent Findings While selective nonoperative management has shown good results, certain clinical situations in hemodynamically stable patients, where the need for surgery could be in doubt, call for proactive diagnosis. In these cases, laparoscopy can be used to exclude or diagnose potential injuries requiring surgery. When the surgeon has the necessary expertise, some of these injuries can be treated laparoscopically. Summary Over the last decades, diagnostic and therapeutic applications of laparoscopy have increased, with reported reduction in nontherapeutic laparotomies. Furthermore, shorter duration of hospital stay, faster recovery, and reduced costs have been reported. However, as seen in other minimally access interventions, safe implementation of laparoscopy in trauma care requires adequate surgical training and skills as well as appropriate staffing and equipment.
A spleen-preserving program was implemented at the author's institution during the mid-19... more A spleen-preserving program was implemented at the author's institution during the mid-1980s using a five-part injury-grading scale that is similar and comparable to the AAST classification. Since that time, all patients with splenic injuries admitted to the Department of Surgery at the Karl-Franzens University Hospital in Graz, a level I trauma center, have been prospectively evaluated with respect to splenic preservation. Analysis of the relation of the severity of organ injury to the use of nonoperative management showed that degree I or II injuries were treated nonoperatively, whereas degree III and IV injuries were usually treated with adhesives, partial resection, or mesh splenorrhaphy; only degree V injuries almost always required splenectomy. With increasing experience in nonoperative management of splenic injuries the initial criteria have become less rigid, and there is now a tendency to attempt it in patients who formerly would have undergone surgery.
Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out o... more Laparoscopic cholecystectomy (LC) using electrocoagulation was successfully performed in 56 out of 58 selected patients. Cholangiography was performed in 53 patients. Six patients had common duct stones; five were unsuspected preoperatively. After the gallbladder was removed, three patients underwent open common duct exploration. In another five cases, anatomical anomalies were discovered. Cholangiography performed via the cystic duct before any structures are divided can prevent the most serious complication--common duct injury. Cholangiography should be attempted on all patients undergoing LC.
Journal of Laparoendoscopic & Advanced Surgical Techniques, 1998
Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallblad... more Today, laparoscopic cholecystectomy is the method of choice for treatment of symptomatic gallbladder disorders. It minimizes effects of the operation that are independent of the gallbladder, such as trauma to the abdominal wall and other soft tissue. The surgical wounds were even smaller when 2-mm trocars were used. Laparoscopic cholecystectomy using 2-mm instruments was performed in a consecutive series of 14 patients with symptomatic gallstones. The procedure was completed in 12 cases, with conversion to open surgery in two cases. Intraoperative cholangiography was always performed. The postoperative course was always uneventful. The cosmetic effect was highly satisfactory. The procedure using 2-mm instruments could be indicated in selected patients with uncomplicated gallstone disease.
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