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Patients with small bowel obstruction hardly ever need a stoma. Advanced peritoneal carcinomatosis (mostly due to colorectal or ovarial cancer) may require a proximal palliative fecal diversion. Likewise stomatas for colonic ileus became less frequent. The type of the stoma and its necessity depend on the patient's condition, on the duration and the cause of the obstruction, i.e. on the condition and the damage of the bowel. Terminal sigmoidostomy has its place mainly as a part of the Hartmann's procedure treating sigmoid diverticulitis with inflammatory pseudotumor, with free perforation and diffuse peritonitis. For oncological reasons Hartmann's resection should not be performed for rectal cancer--except for very old patients in bad condition. Colonic ileus due to colorectal cancer can usually be treated by resection and primary anastomosis. In case of delayed ileus it may be better to resect the proximal colon and to perform an ileocolostomy to avoid complications. Risky anastomoses due to damaged bowel or for patients in bad condition may be protected by a loop-ileostomy or a loop transverse colostomy. They are both easy to perform and to close with very few complications. Summarizing we may conclude that very few patients really need a stoma today--patients showing special risks such as diffuse peritonitis, absceding inflammation or damaged bowel as a result of delayed ileus.

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Laparoscopic resection of the colon for malignant disease is both technically and methodically possible. But at present it is not clear whether this method includes new and unknown dangers too and whether it really provides any advantages for the patient. The benefits with regard to comfort/quality of life have not been examined closely enough. It can not be assumed that patients operated on a malignant disease are able to perceive and to profit from the comfort achieved by laparoscopic operations in the same way as patients undergoing laparoscopic cholecystectomy. There is a definite need of closely controlled studies to define when the use of laparoscopic operation benefits the quality of life for the patients. By solving the technical problems we probably achieve less than we will admit if we can not prove clearly and objectively the advantages with regard to survival-rate and increase in the quality of life for the patients.

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In a review of 328 cases the combination of laparoscopic cholecystectomy with specific use of endoscopic retrograde cholangiography (pre- and postoperatively) proved to be a riskless, secure and time-saving procedure. In our opinion this is a minimal invasive method of treatment for patients with cholecysto-/choledocholithiasis.

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With the experience of 80 cases of laparoscopic cholecystectomy, we started to operate all gallbladders by the laparoscopic way, even if there was the diagnosis of an acute cholecystitis. Between May 1991 and January 1992, 20 patients with acute cholecystitis have been operated by laparoscopic surgery. The patients' ages varied from 21 to 75 years (mean 53 years). The preoperative evaluation of the biliferous ducts, especially in case of cholestasis, should give a precise diagnosis of anatomic variations or stones. Therefore the ERCP as an additional preoperative examination was necessary in 10 (50%) cases. 14 (70%) could be operated by the laparoscopic way without surgical complications. In 6 patients closed procedures had to be changed to open cholecystectomy because of the following reasons: Scars and uncertainty about the anatomy in Calot's triangle (4x), severe adhesions to the colon (1x), and perforation of a gallbladder with necrotic wall, respectively. The good results, the possibility of a direct view of the situs, and the fact that anytime during the operation a change to the open procedure is possible, are reasons to start all cholecystectomies by the laparoscopic manner.

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The sonography is very important diagnostic method for the abdominal emergency cases. This diagnostic screening method should be available in the surgical emergency station. Liquid, abscesses, organ ruptures and also many inflammations can be diagnosed with this not invasive method. It is our opinion that a training program in sonography should be available for young surgeons for the judgement of the abdominal emergency cases.

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The sonographic-radiologically guided puncture and catheter insertion enables certain palliative and curative therapeutic procedures to be performed. Liver abscesses represent the most common examples for this procedure, although interabdominal abscesses as well as pancreatic pseudocysts can also be treated successfully. In our collection of clinical cases various preformed pigtail catheters were employed using either the Seldinger-principle or, with help of a rigid needle, introduced directly into the lesion. Advantages of sonographically guided therapeutic interventions include quick implementation without radiation exposure, immediate recognition of possible complications as well as negligible expenditures. Ultrasonically guided therapeutic interventions should be undertaken only through the close collaboration between intervening radiologists and abdominal surgeons. Only so are they both low-risk and successful.

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Certain pancreas-pseudocysts can be effectively drained either transgastrically or transduodenally using endoscopic procedures. Applicable methods include repeated fine needle punctures, insertion of a drainage tube or the percutaneous pseudocyst-drainage according to Hancke. The percutaneous sonographic pancreas-pseudocyst drainage represents an alternative or an adjunct to the classical surgical cyst drainage employing a cysto-jejunostomy or cysto-gastrostomy. The indications are analog to the surgical cysto-enterostomy, whereas the optimal method for each individual patient should be decided by interdisciplinary consultation. The following report presents 21 case studies of pancreas-pseudocysts which were treated conservatively using ultrasonographical procedures.

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During the last decade the industry has developed material to improve the quality of life of patients with an enterostomy. Patients are better informed and prepared before operation. Postoperative advising by professional nurses help the patient to maintain an odorless, leak-proof and continent stoma. Most of the patients today with enterostomies are able to have a socially integrated life with minimal psychological and physical handicaps.

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Within 7 years 4 cases of prolapse of the small bowel through the vaginal vault stump were observed. These occurred between 5 and 10 years following two cases of radical abdominal hysterectomy for cancer and two cases of vaginal hysterectomy and colporrhaphy. The small bowel was replaced three to six hours following the prolapse by median laparotomy. One patient died following late sepsis after the laparotomy.

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A clinical study of the cases of acute abdomen in 1970 and in 1980 has been conducted in two surgical departments (Zoug and Olten, Switzerland). In 660 cases the question was investigated whether progress has been made with the introduction of technical aids during the last ten years. In 1980 more specialized methods such as sonography, laparoscopy etc. were employed. Preoperative diagnosis was significantly improved and the agreement between pre- and postoperative diagnosis was markedly ameliorated.

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We report on a case of renal oncocytoma (proximal tubular adenoma) with typical vascular architecture. The vascular supply of the oncocytoma showed a 'spoke-wheel'-like pattern. The typical angiographic features may help to differentiate oncocytomas from hypernephromas and thus diagnose it as such in the preoperative period. By the use of the electron microscope some typical invasions into a small vein could be traced, therefore it seems likely that renal oncocytoma is semi-malignant. Confusion of the renal oncocytoma with a large renal cyst is a classical diagnostic error which can be fatal.

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