Zentralblatt für Chirurgie
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The creation of a center for interdisciplinary operative intensive care through the fusion of several smaller intensive care units from various specialties is mainly driven by economic reasons. To specify some conditions for making such a fusion less expensive and to identify the impact of larger intensive care units on the quality of patients' treatment and on surgical training are the subjects of this study. ⋯ The concept of an interdisciplinary surgical ICU is obviously most practicable and reasonable if subunits with approximately twelve beds are concentrated in one centre for operative intensive care. This offers an advantage concerning the organisation and for the philosophy of treating special diseases by specialised medical teams. The size maintains the advantage of economies of scale as well the economies of scope and also promises effective logistics. For the management, an experienced intensive care specialist, either an anaesthesiologist or a surgeon should be assigned. All subject-specific advanced skills in intensive care have to be covered by an interdisciplinary continuing education.
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There is some controversy regarding concepts currently propagated for an optimal surgical and antibiotic therapy in patients with secondary peritonitis and organ failure. It is not known whether the recent general progress in critical care ("Surviving Sepsis Campaign") has also improved outcome of this particular patient group. ⋯ Source control is the most important determinant for acute survival and has to be placed on top of the therapeutic priority list. The number of revisions needed to obtain source control, however, does not vary with survival and cannot guide decisions on therapy withdrawal or continuation. The recent prognostic improvement indicates the efficiency of new adjuvant therapeutic measures in unselected surgical high-risk patients.
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In the light of an incisional hernia incidence of between 10 and 20 % that remains constantly high in spite of modifications of suture materials and suture techniques, intensified scientific efforts aiming at incisional hernia prevention are -required. This article reviews the scientific results dealing with incisional hernia incidence, time of manifestation, risk factors and the influence of suture material and suture technique. A lack of evidence-based data and no current consensus concerning the ideal material and technique to close laparotomies has to be mentioned. ⋯ This technique has almost no influence on abdominal wall per-fusion, leaves the architecture and dynamics of the abdominal wall intact, and results in a favour-able ultra-structural composition of collagen and a mechanically stable laparotomy healing after 15 months. Measures to prevent incisional hernia formation - which is in fact the post-operative complication in surgery most frequently leading to re-operation - require intensified research activities. Success will only be achieved if the development of -unconventional closure techniques is encouraged and the beaten path of suturing the incisional edges is discarded.