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Microlaparotomy cholecystectomy (MLC) is an alternative for minimal invasive surgical interventions of the biliary tract. In Hungary over 7000 operations were performed in 21 surgical departments as at December 31. 1998 and numerous additional departments have indicated their demand for the initiation of the method. Every new surgical procedure requires a "learning curve" during the application of MLC, difficulties encountered with the surgical solution occurred in a 14-15% range. We studied difficulties noticed during micro-, minilaparotomy cholecystectomy in 2400 unselected cases from the adoption of the surgical method in our department until December 31, 1998. We grouped our findings into avoidable, and unavoidable difficulties. Circumstances that can present unavoidable difficulties include: the patient's abnormal change in build, surgical interventions that have to be performed on patients 8-10 days after obstructive cholecystitis, abnormal gallbladder not indicated during preoperative examination, as well as biliary tract variations. A considerable part of the difficulties can be avoided by MLC-desirable positioning of the patient on the operating table, appropriate choice of surgical incision site and method, satisfactory anaesthesia, the use of necessary instruments suitable for exposure and unobjectionable illumination of the surgical area, as well as the performance of cholecystectomy with required modifications per given circumstances. The concomitant 2.5-16% alternating conversion rate after minicholecystectomy is indicative of the importance of the use of instruments assuring adequate exposure and excellent illumination of the surgical area. During the practice in our department this occurrence was recorded in 0.29% with the use of the ROMICRO R-set.

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Gallstone disease is a major health problem, 10-15% of the adult population of Hungary are afflicted, and each year about 20,000 cholecystectomies are undertaken. There are two essential and widely accepted methods for the removal of gallbladder: conventional open cholecystectomy and laparoscopic cholecystectomy. Since 1988 the authors worked on a new surgical technique and equipment (ROMICRO R-set) for cholecystectomy using a single 2-4 cm microlaparotomy inside the infrasternal triangle. They demonstrate the innovation's phases of this new technique and ROMICRO R-set. Till 1999 more than 7000 microlaparotomy cholecystectomy were undertaken in Hungary. The benefits of laparoscopic cholecystectomy can be achieved with less expense and risk by microlaparotomy cholecystectomy. Most patients are often not willing to accept conventional open cholecystectomy, but the microlaparotomy cholecystectomy alternative is unknown to the public and to most physicians. All countries have experienced a fast growth in their health care expenses over the last decades which will continue in the future. But spending an ever larger share of our nation's resources on health care cannot be afforded. As a consequence, making choices will became more and more unavoidable, also in galltree surgery. Therefore economic evaluation compares the different techniques of cholecystectomy necessary not only in terms on surgical and on patients aspect, but also in term of costs.

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The solutions for graft infection and its complications in vascular surgery are well known. However, publications dealing with this topic do not, or just occasionally mention muscular flap plast, which is already quite widely used in other fields of surgery. The authors first used pedicled muscular flap plasty in 1996, to cover grafts that had been exposed as a result of infection. Later, this method was also applied in covering subinguinal suturelines and anastomoses respectively, to ward off impending haemorrhage. Between 1996 and 1999, 32 patients presenting with septic complications after vascular surgery were treated. Muscular flap plasty was performed in 12 of these cases. In 7 patients the exposed graftsere covered, while in 5 patients the subinguinal suture-lines and anastomoses were covered respectively with muscle flaps, 5 of the graft covering procedures were successful. In two cases of superinfection and septic progression respectively the graft had to be removed without amputation of the extremity. 3 successful operations were recorded in the cases where the covering of the subinguinal suturelines and anastomoses were the aim. 2 patients presented with erosive haemorrhage, which led to ligation of the femoral artery and consequent amputation, in view of the absence of further possibilities for reconstruction.

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In the past few years, two massive eel (Anguilla anguilla L.) devastations occurred in Lake Balaton, Hungary. In 1991, 300 tons of eel perished in the western basin of the lake, while in the summer of 1995 30 tons of eel died in the eastern part of the lake. Investigations carried out to find the causes of these ecocatastrophes included measurements of certain biochemical parameters: the blood sugar level, and the acetylcholinesterase (AChE, EC 3.1.1.7), lactate dehydrogenase (LDH, EC 1.1.2.3), glutamic-oxaloacetic transaminase (GOT, EC 2.6.1.1) and glutamic-pyruvic transaminase (GPT, EC 2.6.1.2) activities in the blood serum of the collected eels. In both 1991 and 1995, deltamethrin (DM), the active ingredient of the insecticide K-OTHRIN 1 ULV used against mosquitoes, was detected in the eels; in 1995 it was demonstrated in several other animal species, i.e., bream (Abramis brama L.), pike perch (Stizostedion lucioperca L.), and the common gull (Larus canus), and in sediment samples from the lake. Additionally, laboratory experiments were carried out to study the effects of DM on eels. In 1991, eels were collected from the western (the site of the devastation) and eastern basins of the lake. The eels from the eastern basin were used as controls. At that time, the AChE activity in the blood serum of the eels from the western basin was significantly inhibited compared to that in animals from the eastern basin (P < 0.05, Student t test). Eels from the western part of the lake had GOT and GPT levels 20 and 100%, respectively, higher than those of eels from the eastern part of the lake. The blood glucose level was much higher in the eels from the affected area of the lake as compared to those from the eastern part. The brain and liver of the eels contained DM residues at 20 micrograms/kg wet tissue (Gönczy, 1992). Gönczy suspected that one of the causes of the massive eel loss in 1991 was the presence of DM in the fish. In 1995, when the eel devastation occurred in the eastern basin, moribund and surviving eels were collected from this part of the lake. The AChE activity was significantly inhibited in the blood serum of the dying eels as compared to that in surviving animals (P < 0.05, Student t test). The blood glucose content exhibited a difference too: it was 2.5 times higher in the dying eels than in the surviving ones. A huge increase in the LDH level was measured in the dying eels, indicating damage to different muscle tissues to an extent never observed previously. The GOT activities of the serum were twice as high in the dying eels as in the living fish. The GPT was not significantly changed in the serum of dying eels as compared to the surviving animals. DM was detected in different tissue samples of the dying eels: 2.7-18.5 micrograms/kg in the liver, 9.0-31.1 micrograms/kg in the gill, and 3.0 micrograms/kg wet tissue in the muscle. DM residues were found in tissue samples from other animals, in the following concentrations: 0.4 micrograms/kg in bream, 2.1 micrograms/kg in pike perch, 1.1 micrograms/kg wet tissue in dead gulls. The sediment samples collected from different places and at different times contained DM in a concentration of 5.5-30.0 micrograms/kg wet sediment at the time of the eel deaths, while the sediment samples collected from the same places a month later still contained DM at 7.0-8.8 micrograms/kg wet sediment. Laboratory experiments with the insecticide K-OTHRIN 1 ULV revealed that 1.0 microgram/liter of its active ingredient, DM, caused the death of 50% of the eels after an incubation time of 96 hr. In the liver of the dead eels, DM was detected at 2.9-20.0 micrograms/kg wet tissue. All the above-mentioned changes and the DM residue detected in the eels appear to demonstrate the contribution of DM in the severe eel devastation. This finding on the ecological risk of such types of insecticides might be useful in their further application.

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There is no data on the special complications of micro (less than 4 cm incision) and modern mini laparotomy cholecystectomies (4.1-6 cm incision). Out of 710 non selected patients, 643 micro laparotomy cholecystectomies were performed and 61 modern mini laparotomies due to choledocholithiasis. On three occasions, conventional mini (6.1-10 cm) laparotomy was performed and in another three, conventional laparotomy (over 10 cm incision) was executed. Intraoperative bleeding was encountered in 15 cases (2.1%) while accidental hepatic duct clipping occurred in one case (0.1%). Damage to the bile duct did not occur in any case reported. Postoperative bleeding was reported in 8 cases (1.1%) and delayed bile leakage was reported in 10 cases (1.4%). Special complications reported as a result of pathological alteration in the bile tract as follows: Intraoperative bleeding encountered during simple cholecystectomy-1% but cholecystectomy due to obstructive cholecystitis 3.8%, also caused by intraoperative bleeding. Delayed bile leakage in simple cholecystectomy was not observed, but after cholecystectomy for obstructive cholecystitis it encountered in 3.4%. Special complications resulted in four early reoperations (0.5%). Two other patients were re-operated within three weeks, independent of special complications. The percentage of both intra and postoperative complication was significantly higher in obstructive cholecystitis with an operative delay of 11 or more days.

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The conventional and laparoscopic cholecystectomy is as already every day utilized method, the operation procedure is well developed and the instruments used allow a reliable operation. The cholecystectomy performed by minilaparotomy is not yet a widespread procedure, since there is no established method and the instruments needed are not readily available, as well as the fact that special complications' rates is not yet well known. In order to further elaborate on the procedure and to demonstrate it's true value, 710 micro- and modern minilaparotomies, without exclusion or selection, were analyzed and the operation procedures were then summarized. The operations were completed with microlaparotomy (smaller than 4 cm incisions) in 643 cases (90.6%) with modern minilaparotomies (4.1-6 cm) in 61 cases (8.6%), with conventional mini (6.1-10 cm), and the incisions longer than 10 cm with conventional laparotomies in 3-3 instances (0.4-0.4%). We performed a complete cholecystectomy in 97.2%, a longer cystic stumps was left in 1.7%, subtotal and partial cholecystectomies in 0.7% and 0.3% respectively. In 69 of the cases (9.7%) simultaneous choledocholithiasis was discovered and resolved. 21.2% of the operations were termed as difficult. 2/3 of the intra and postoperative complications as well as early reoperations occured in cases where they followed a delayed operation of obstructive cholecystitis. One patient was lost (0.14%) due to non-surgical complication. These experiences show that cholecystectomy performed by micro and modern minilaparotomy is a realistic alternatives to the conventional and laparoscopic cholecystectomies.

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The authors report cases of complex bilateral autologous breast reconstruction performed at one sitting after bilateral ablation as a result of non-malignant disease. During planning, as well as execution of the operations, up-to-date pre- and intraoperative examinations were employed in order to enhance to safety of the procedures.

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The authors review the results of the use of antibiotic prophylaxis (AP) during 412 cases of micro (MLC) and modern mini-laparotomy cholecystectomy (MMLC). 2 gr of Mandokef (M) or 1.5 gr of Zinacef (Z) were the employed antibiotics, administered intravenously 30 minutes before the commencement of the operations. In the case of patients above the age of 50 AP was given on routine basis. Apart from cases of obstructive cholecystitis (OC), a single shot of Mandokef or Zinacef proved effective; there was no occurrence of suppuration. Out of 94 under fifty patients--where in accordance with the accepted standpoint applied to traditional cholecystectomy AP would not have been necessary--AP was administered in 43 cases: no suppuration occurred. 51 patients did not receive AP; here 2 cases of suppuration occurred (4%). In 99 patients suffering from obstructive cholecystitis (OC), the single-shot AP was supplemented and continued with cover therapy where necessary. On the basis of the time elapsed between the presentation of the OC and the operation, the cases were classified in the following groups: 1.27 patients operated on within 10 days: no cases of suppuration or other complications II. 34 patients operated on between 10 days and 6 weeks: 2 cases (5.9%) III. 38 patients operated on after 6 weeks: 3 cases (7.9%) of suppuration or other complications were encountered. After MLC and MMLC the patients are emitted form hospital within 24-72 hours. However, 80% of the bacteria resoiling in the gallbladder can cause wound suppuration 4-10 days post-operatively.(ABSTRACT TRUNCATED AT 250 WORDS)

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