Reestablishing bowel continuity subsequent to sigma resection with terminal descendostomy and blind closure of the rectum (Hartmann procedure) by a descendo-rectostomy (DR) is well suited for a laparoscopic approach. One part of the operation is performed extracorporally, and with the laparoscopic operation there is no need to consider radical tumor surgery or staging rules. We demonstrate our techniques for laparoscopic DR. - Operational steps. - A. conventionally: complete dissection of the descendo-stoma, insertion of a 29 or 31 mm circular stapler head secured by a purse string suture and repositioning of the colon into the abdomen; blunt dissection of reachable intra-abdominal adhesions with a finger, and placement of a 10-mm umbilical trocar using palpation; air tight closure of the abdominal wall at the original stoma site. B. laparoscopically: upon creation of a CO2 pneumoperitoneum, placement of two additional 10 mm trocars; adhesiolysis of the pelvis; preparation of the blind rectal stump; transanal insertion of the circular stapler and perforation of the rectal stump; bringing down the proximal colon into the pelvis (possible need to mobilise the splenic flexure); reconnecting the stapler head with the instrument and firing the stapled anastomosis. - The postoperative period was uneventful. Using a laparascopic approach for a DR following Hartmann's procedure is an attractive and viable method to reestablish bowel continuity.

We can report our experience of this operative method by internal rush pin fixation of shaft fractures in childhood. Our results are very convincing and we can say that this method is successful and a good alternative in future by the possibility of a functional treatment.

We describe a rare variant of carcinoma of the ampulla of Vater. A 70-year-old man with several illnesses and a newly appeared jaundice was investigated and a signet-ring cell carcinoma of the ampulla of Vater diagnosed. We performed a local transduodenal excision. One year after operation the patient is asymptomatic. This is the second case report in the literature.

Tension-free repair, a prerequisite for long-term stability, cannot always be achieved with conventional techniques established for groin reconstruction. Lichtenstein gathered substantial experience simply by closing the hernia in a tension-free fashion using prosthetic material. However, most surgeons fearing graft infection are reluctant to further evaluate this technique. In a feasibility study we entered 70 patients (29 patients with recurrent hernia) receiving a polypropylene mesh (Marlex) to bridge the defect from the inguinal ligament to the internal oblique muscle. Only 1 wound infection and 1 local hematoma requiring reoperation were observed. Nearly 2 years follow-up data revealed no case of recurrence. The Lichtenstein procedure deserves more attention from surgical community and might be a reliable technique esp. in large hernias and redos.

Herniation through the foramen of Winslow (HFW) is exceedingly rare, the ileum, coecum or ascending colon is involved mostly. One new case is presented here to illustrate the clinical findings, which are often discreet, and the characteristical radiographic features, which can lead to definitive preoperative diagnosis. Treatment is by surgical reduction of the hernia, resection of non-viable bowel or fixation of coecum and ascending colon. Closure of the foramen is generally considered unnecessary. Without delay in diagnosis and treatment, the former high letality rate of the condition is now nearly zero.

The charts of all the patients operated upon for paraesophageal hernia (HPO) were reviewed. 24 patients could be found between 1976 and 1992. The mean age was 64 years, with 15 men and 9 women. 15 patients had a pure HPO, whereas 9 had a mixed hernia (HPO and laxial hiatal hernia). 3 patients presented with acute symptoms, and 2 of them were operated on emergently. The remaining patients had elective surgery, consisting of reduction of the stomach (all cases), excision of the hernia sac (12), closure of the diaphragm (17) and gastropexy (8). There was no mortality. Due to the fact that acute complications occur in as much as 30-40% of the cases, elective surgery should be proposed to any patient with a known paraesophageal hernia if the operative risks are not prohibitive. A careful preoperative assessment including endoscopy and pH-manometry of the esophagus will provide arguments to add a antireflux procedure to the standard operation, which should include reduction of the stomach, resection of the sac, closure of the hiatal defect and gastropexy.

Especially in obese or severely ill patients, forming of an ileostomy or colostomy can be very difficult and laparotomy itself can lead to many complications. The intraabdominal part of this operations can easily be performed laparoscopically. The method is quick and simple and many complications can be avoided.

To control heat damage in the liver after cholecystectomy caused by electrosurgery or Laser, gallbladders were resected at autopsy partly by the Holmium:YAG-Laser and Nd:YAG-Laser and partly by electrosurgery. Heat damage was documented by histological examinations of the liver-bed of the gallbladder. Microscopical evaluation showed that electrocautery tends to produce deeper heat damage in the liver-tissue than the Holmium:YAG-Laser.

Panniculitis mesenterialis is an illness of the mesenterium of the small intestine and is not familiar to all clinical physicians. The rare reports in the literature mostly describe a good outcome with a few cases ending lethal. Pathologists paying attention to detect panniculitis during postmortem examination report about an incidence of about 1%. This discrepancy may be based on the fact that only extended changes of the mesenterial fat tissue cause symptoms. The pathological base consists in extensive necrosis of fat tissue with fibrosis of the mesenterium. Aetiology is unknown, diagnosis is usually made during laparotomy. There is no specific treatment, prognosis is generally good.

Mesenteric venous thrombosis is an infrequent but distinct form of intestinal ischemia. We report 2 cases of acute mesenteric venous thrombosis, treated successfully by carrying out intestinal resection and postoperative anti-coagulation (Heparin, Sintrom). Both patients were diagnosed in the operating room. Improvements in computed tomography may identify patients earlier in their clinical course, heparin has both a primary therapeutic role in early disease and a postoperative adjunctive role in advanced disease. With such care, these patients can expect an acceptable prognosis.

We present a case of a 74-year-old-woman who developed 3 episodes of intestinal pneumatosis, 2 times complicated by pneumoperitoneum, with consequent lethal outcome after 4 months. Intestinal pneumatosis, according to the literature, is a difficult and rare problem, associated with a large number of current diseases, can be complicated by pneumoperitoneum, mostly without clear etiology, whose treatment remains empirical (antibiotics, O2-therapy), not excluded laparotomy, if the clinical situation requires it.

As a cause of small intestine occlusion, volvulus is often a consequence of a band or adhesions. Except in infants, it is rarely the primary cause of symptomatology. Between January 1976 and December 1992, 13 patients (7 women and 6 men, mean age of 56.8 years) were admitted in our department for an acute abdomen due to a spontaneous primary volvulus of the small bowel. Clinical examination and laboratory tests did not help in preoperative diagnosis. All patients underwent an explorative laparotomy. Six patients had had prior abdominal surgery but none of them presented adhesion or band. In 8 patients (62%), detorsion was sufficient. Resection of a segment of small bowel was necessary in 4 patients. Gangrenous of the entire bowel was observed in one patient who rapidly died. Two patients presented minor complications. One patient with Down syndrome died of bronchoaspiration. One patient has been reoperated on one year later for recurrence of the volvulus, and underwent a Noble procedure. We conclude that volvulus of the small bowel is a rare cause of acute abdomen that must be remembered. Early surgery is mandatory to reduce the risk of gangrene, which is known to double the mortality. Laparoscopy will be helpful in early diagnosis and therapy.

Appendix carcinoid in children is a rare condition which is found by accident at the histological examination of the appendix. We report on a rare case in which a covered perforation of a diverticulum had occurred. First of all the patient was treated conservatively with antibiotics and 2 months later the appendectomy à froid was performed. The annual follow-up of these patients is certainly indicated.

Since 1990 the Surgical Department of the Kantonsspital Schaffhausen has been taking part in a quality assurance program organized by the "Bundesland Baden-Württemberg". The traceroperation "appendectomy" will be used to demonstrate the principle of quality assurance and our results for the years 1991 and 1992 will be presented.