Status quo of plastic-reconstructive surgery from the perspective of a general and visceral surgeon

The Art of Surgery has a very long tradition and is one of the earliest treatments for serious injuries of diverse causes. Due to achievements in anesthesia and intensive care medicine in the second half of the nineteenth century, postoperative morbidity and mortality have been appreciably reduced. Operative techniques could be expanded and new operative therapies could be introduced. Although the last two-hundred years have brought about increasing specialization in medicine and operative specialties have developed in multiple areas, the operative spectrum of the visceral surgeon has remained rather broad and diverse. Numerous operative procedures are carried out in the entire gastrointestinal tract as well as the body surface. Many of these are to treat diseases, while others are of help in the plastic reconstruction of organs and the body surface. Thanks to specialization, among the positive developments are shortened operation time and length of hospital stay, as well as reduced postoperative morbidity and mortality. The advances in minimal-invasive surgery and the progress in surgical instruments and suturing techniques are some origins of these positive developments. This article cannot cover all possible resections and reconstructions of the visceral surgeon, but will instead concentrate on two major sites. The operative treatment of inguinal hernias is one of the oldest operations known to humanity. Because hernias are one of the most common operations of all visceral surgical procedures, their surgical therapy shall be particularly highlighted here. But the plastic and reconstructive possibilities of the visceral surgeon are by no means limited to hernia repair. So this manuscript will further provide insight into the resection and reconstruction possibilities of the esophagus, one of the most challenging procedures in this field

Differenzierte chirurgische Therapie von rectovaginalen Fisteln

Objective: Rectovaginal fistulae (RVF) are a serious and debilitating problem for patients and a challenge for the treating surgeons. We present our experiences in the surgical treatment of these patients. Methods: Study population consisted of 22 consecutive patients (range 26-70 years) with RVF treated in our department between 2003 and 2009. 13 RVF were observed after colorectal or gynaecological surgery, 3 occurred after radiotherapy, 2 due to tumour infiltration, 4 because of local inflammation (3x diverticultis, 1x ulcus simplex recti). The RVF was classified in all patients before treatment as either 'low' or 'high'. Results: Local procedures (transvaginal excision, preanal repair) as initial treatment were performed in 9 patients with low fistula. In 13 cases with high fistula an abdominal approach was performed to close the fistula. A recurrence was observed in 8/22 cases (36%), which were treated by a gracilis flap (n=2), a bulbospongiosus composite (n=1), a second abdominal approach (n=4), and a re-local excision (n=1). Ultimatively, in 19 cases the defect healed but in 3 patients the RVF persisted. Conclusions: Most important predictor of healing/failure is etiology followed by localization and recurrence of the RVF. Local (preanal, transvaginal) procedures are suitable for low RVF, whereas abdominal surgery is necessary in high RVF. In recurrent RVF, muscle flaps are promising procedures.Hintergrund: Rektovaginale Fisteln (RVF) stellen für betroffene Patientinnen ein schwerwiegendes psychosoziales Problem dar und bedeuten für den Chirurgen eine komplexe therapeutische Herausforderung. Wir berichten über unsere Erfahrung in der chirurgischen Therapie dieser Patientinnen.Methoden: Wir berichten über 22 Patientinnen (26-70 Jahre) mit RVF, die zwischen 2003 und 2009 in unserer Klinik behandelt wurden. 13 RVF wurden nach colorektaler oder gynäkologischer Operation festgestellt. 3 als postaktinische Folgeschäden, 2 durch Karzinominfiltrationen und 4 durch entzündliche Veränderung aufgetreten (3x Divertikulitis, 1x ulcus simplex recti). Die RVF wurden in tiefe und hohe Fistel unterteilt.Ergebnisse: Initiale Therapie zum Fistelverschluss war bei 9 Pat. durch lokale Exzision/preanal repair, bei 13 Pat. durch einen transabdominellen Zugang. Eine Rezidivfistel war in 8/22 (36%) Fällen nachweisbar. Dann wurde definitiver Fistelverschluss erreicht: 1x lokale Exzision, 4x transabdominell, 2x Gracilis-Plastik, 1x M. bulbospongiosus composite. In 19 Fällen kam es zur Ausheilung des Defektes, bei drei Patientinnen besteht eine Persistenz der RVF.Schlussfolgerungen: Die Ätiologie einer RVF hat den größten Einfluss auf die Heilungsrate gefolgt von der Lokalisation und dem Rezidiv. Bei tief liegenden Fisteln empfehlen wir zunächst ein lokales Vorgehen wie beispielsweise preanal repair und Fistelexzision. Transabdominelles Vorgehen bietet sich bei hoch liegenden Fisteln an. Bei RVF-Rezidiven ist an die Interposition eines Muskelschwenklappens (z.B. Gracilis-Plastik) zu denken