Zentralblatt fur Chirurgie最新文献

The management of anorectal carcinomas necessitates a multimodal therapeutic approach. Advances in modern medicine have reduced the incidence of complete rectal extirpations and permanent colostomies to below 10%. Despite these improvements, the reconstruction of anorectal defects, particularly following abdominoperineal extirpation (APE) or pelvic exenteration, remains a significant challenge. Deep tissue defects, the impact of neo- or adjuvant radiotherapy, and bacterial contamination contribute to compromised wound healing, with reported complication rates reaching up to 60%.This retrospective study analysed all patients presenting with anorectal defects following oncological surgery in 2024 at a university-based plastic surgery clinic providing maximum-care services. The study assessed various influencing factors, including radiochemotherapy, cachexia, diabetes mellitus, nicotine consumption, vascular diseases, and corticosteroid therapies. Additionally, the evaluation covered the effect of surgical defect coverage using pedicled gracilis flap reconstruction on the number of required interventions and the time to complete wound healing and patient mobilisation.Prolonged intensive care treatment and prior radiochemotherapy were identified as primary contributors to disorders in postoperative wound healing. Moreover, factors such as cachexia, diabetes mellitus, and nicotine consumption had a detrimental impact on wound healing. Plastic-surgical defect reconstruction utilising a pedicled gracilis flap significantly reduced the number of required interventions and expedited recovery time.The interdisciplinary management of patients with anorectal defects post-oncological surgery can be optimised through targeted reconstructive plastic surgery. Pedicled gracilis flap reconstruction has proven to be an effective technique for defect coverage and should be integrated into treatment protocols at an early stage. Further studies are warranted to standardise guidelines, particularly regarding the optimal timing of reconstructive interventions.

The management of trunk wall defects can be a challenge in surgical practice, especially when conventional methods such as primary wound closure or skin grafts are insufficient due to the size and depth of the defect, its location, location, or lack of adequate skin and soft tissue coverage. In recent years, perforator-based local flaps have emerged as a modern, muscle-sparing alternative to traditional local myocutaneous or free microsurgical flaps. Particularly in the back region, suitable recipient vessels for free flaps are often unavailable due to vascular anatomy. At the same time, compared to conventional random-pattern flaps, perforator-based flaps offer increased reliability, as they are based on targeted vascular perforators. This allows them to be designed beyond the classic 2:1 length-to-width ratio and enables greater reach with improved perfusion. By utilising perforating vessels, functionally important musculature can largely be preserved, which may lead to reduced postoperative morbidity and faster rehabilitation.This article is aimed at surgically active colleagues without specialised training in plastic-reconstructive surgery who are nonetheless regularly confronted with complex wound situations-for example, following tumour resections, chronic infections, pressure ulcers, or postoperative wound healing disorders. The goal is to provide a practical overview of the principles, indications, and limitations of perforator-based local flaps. In addition to an introduction to the underlying vascular anatomy (angiosome and perforasome theory), preoperative diagnostic procedures, various flap techniques, and typical clinical courses-including potential surgical complications-are presented.A particular focus is placed on the selection of appropriate flap types based on defect location and the presence of local perforators, with the goal of achieving the simplest, safest, and most sustainable soft tissue coverage possible. Clinical case examples illustrate operative approaches in different regions of the trunk wall.

Lymphoedema is a chronic, progressive condition that may occur as a primary disorder or secondarily following lymphatic damage, such as after lymphadenectomy or radiotherapy. Conservative therapies often provide only limited relief, so that surgical approaches like vascularised omental lymph node transfer (VOLT) are increasingly relevant.We present two cases of advanced secondary lower-limb lymphoedema following lymphadenectomy. Both patients demonstrated severe lymphatic transport dysfunction on lymphoscintigraphy and MRI. A double microsurgical lymph node transfer using VOLT was performed in each case. The omentum, selected for its high lymph node density and lymphangiogenic potential, was divided intraoperatively to reconstruct both the groin and lower leg regions. In addition, a systematic literature review on omental lymph node transfer for lymphoedema was conducted using PubMed.In both cases, postoperative assessment confirmed adequate perfusion of the grafts and clinical improvement of lymphoedema symptoms. The literature review revealed consistent evidence of significant limb volume reduction, improved lymphatic drainage, and a marked decrease in the incidence of cellulitis following VOLT.VOLT is an effective surgical option for therapy-refractory lymphoedema and may substantially improve patient quality of life. Despite promising results, further standardised prospective long-term studies are required to validate its efficacy and safety.

Surgery can be considered to be one of the major medical disciplines in the study of human medicine. In this context, surgical education is a great challenge, in particular, due to the necessary training of technical skills. The aim of the manuscript was based on i) selective references out of the medical scientific literature and ii) own teaching-associated experiences to reflect an innovative systematic and structured use of diverse teaching modi and coordinated teaching contents as conceptual idea for the surgical practice as part of the study of human medicine.Surgical practice has been i) established as obligatory practice-oriented part of surgical teaching during the study of human medicine and ii) approved as indispensable teaching tool. Successive implementation of the SkillsLab was a milestone in the study of human medicine medical education, in particular, with regard to the practical focus and issues. Since 2009, facultative teaching sessions have been available for the medical students at the Otto-von-Guericke University Medical School of Magdeburg (Germany) - in other words, University Medicine at Magdeburg [UMMD]), which are designed and provided by the various surgical disciplines. Since 2011, parts of curricular surgical teaching have been specified: Within 9 modules, medical students are taught theoretical basics using oral presentations and exercises as well as practical surgical activities during the 1st part of the obligatory surgical practice time-period of 2 weeks, corresponding to 56 hours overall. During the 2nd more bed-side-oriented (and, thus, conventional) surgical practice, the skills acquired during the 1st part of surgical practice can be further trained and solidified and further systematisised, with structured teaching contents using innovative teaching approaches. The "Logbook - Surgical Practice" which needs to be conducted by the students themselves, summarises the teaching contents, gives instructions and allows the semiquantitative acquisition of teaching results/effects ("Observed - Under Instructions Performed - Independently Executed").Teaching in the SkillsLab allows far better integration of the medical students in surgical activities during surgical practice and sustainably increases the practically focused and, thus, desirable teaching effect.

Oncologic chest wall resection and reconstruction present significant surgical challenges due to the complex interplay of anatomical and physiological factors. Ensuring adequate oncologic margins while preserving structural integrity and function is essential for optimal oncological and physiological patient outcomes. Advanced visualization technologies such as virtual reality (VR) are being increasingly investigated for surgical use cases because of their ability to provide a comprehensive and immersive representation of anatomical structures, thereby enhancing preoperative planning and, potentially, intraoperative guidance. The goal of this study is to establish a streamlined workflow using state-of-the-art technology to optimize surgical planning and potentially improve patient outcomes in the complex field of chest wall reconstruction.Eight cases of complex chest wall resection were retrospectively analyzed using the "Medical Imaging XR" VR platform with AI-driven anatomical auto segmentation. An interdisciplinary team of surgeons collaboratively planned the surgical procedures in VR, and predicted parameters such as resection extent, defect dimensions, and reconstruction strategies. These were then quantitatively compared with actual intraoperative findings. User experience was assessed with the User Experience Questionnaire (UEQ), workspace perception ratings, and Simulator Sickness Questionnaire (SSQ).In 3 cases (37.5%), the actual resection exceeded the VR-predicted extent due to underestimated tumor infiltration. Planning exceeded resection in 50% of cases by up to 24% and one case (12.5%) showed a large overestimation in VR. UEQ scores showed high hedonic quality (Stimulation = 2.19, Novelty = 2.69) and positive pragmatic usability (Efficiency = 1.13, Dependability = 1.63). Workspace perception was favorable (mean 4.9/6), and cybersickness remained low.AI-enhanced VR planning enables interdisciplinary collaboration and can improve spatial understanding in complex chest wall surgery. Although it facilitates structured preoperative planning and communication, it should be viewed as a complementary tool to select the surgical strategy rather than as a definitive predictor of the extent of resection. Limitations in imaging resolution and segmentation accuracy can lead to under- or overestimation of tumor boundaries. Further development and clinical validation are necessary to determine its full impact on surgical planning quality and outcomes.

Large trunk defects occur after extensive oncological resections, trauma, infections or adjuvant radiotherapy and often require complex reconstructions. In the case of multi-layered skin soft tissue defects without the possibility of primary closure, defect coverage using free flaps is necessary if local flap options are exhausted. AV loops can bridge to recipient vessels if local options are limited and are used in combination with free flaps. A plethora of free flaps is available in the armamentarium for defect coverage, which are selected according to the reconstruction required. Common flaps for reconstruction are the perforator-based anterolateral thigh flap (ALT flap), but also muscle-bearing flaps with and without a skin island, such as the latissimus dorsi flap or the vastus lateralis flap. Early interdisciplinary collaboration between different specialist disciplines - with the involvement of plastic-reconstructive surgeons - can enable the closure of critically large defects.

Complex abdominal wall defects lead to significant morbidity and require interdisciplinary therapeutic approaches. Plastic surgical techniques and the evolvement of microsurgery can provide a reliable means of reconstruction. For large defects involving the M. rectus abdominis, the free functional M. latissimus dorsi flap serves as a workhorse. Through microsurgical tissue transplantation, the abdominal wall can be functionally reinforced and reinnervated, while also covering the associated soft tissue defect.This study presents an interdisciplinary approach to complex abdominal wall reconstruction using a case example.Particularly as a chimeric flap, in combination with the scapular/parascapular flap, even exceptionally large defects can be reconstructed safely. By utilising a common vascular pedicle, these flaps can be transferred together via the subscapular vessel axis. The coaptation of the thoracodorsal nerve, which innervates the latissimus dorsi muscle, with a motor nerve branch leading to the rectus abdominis muscle enables functional muscular stabilisation of the abdominal wall following reinnervation.To achieve the best possible outcome and reduce hospitalisation, the early integration of plastic surgery into interdisciplinary treatment concept is essential.