Thyroid gland surgery is the traditional focus of the Martha-Maria Hospital in Munich. The typical complications of thyroid surgery, such as vocal cord nerve injury resulting in a voice disorder or parathyroid injury resulting in a calcium deficiency in the blood, are reduced to a minimum using the latest techniques. To avoid vocal cord nerve injury, we have always depicted the vocal cord nerve during surgery. In addition, since 1998 we have regularly performed so-called neuromonitoring of the vocal cord nerve during all thyroid and parathyroid operations. We have the greatest experience with this method worldwide.

Thyroid surgery is the traditional focus of the Martha-Maria Hospital in Munich. The typical complications of thyroid surgery, such as vocal cord nerve injury resulting in a voice disorder or parathyroid injury resulting in a calcium deficiency in the blood, are reduced to a minimum using the latest techniques. To avoid vocal cord nerve injury, we have always depicted the vocal cord nerve during surgery. In addition, since 1998 we have regularly performed so-called neuromonitoring of the vocal cord nerve during all thyroid and parathyroid operations. We have the greatest experience with this method worldwide.

With the so-called neuromonitoring of the vocal cord nerve, we are now able not only to visualize and spare the nerve in its course, but also to assess its function with a high degree of probability, which was previously not possible in thyroid surgery. Neuromonitoring-oriented we have developed special surgical strategies, especially for problem cases. In order to avoid injury to the parathyroid glands, these are also made visible during the operation to protect them. If the blood circulation is damaged, individual parathyroid glands are immediately removed and then reimplanted into the cervical musculature, thus ensuring that their function is maintained. In order to assess whether the removed thyroid tissue is benign or malignant, we have the option of performing a fine-tissue frozen section examination. The pathologist can then communicate directly with the surgical team by telephone within 30 minutes. This enables us to obtain precise information about the tissue removed. In addition to the safety of the patient and the functional surgery, we are also interested in cosmetically favorable scar formation in our patients. For this reason, very small skin incisions are made - if possible - or the operation is performed in a minimally invasive way.

The parathyroid glands are small organs that fit more or less tightly to the thyroid gland and regulate the body's calcium metabolism. The regulation takes place via the hormone of the parathyroid gland, the so-called parathyroid hormone.

Surgery of the parathyroid glands is usually necessary if there is an overproduction of the parathyroid hormone. If this overproduction is caused by enlargement of the parathyroid glands for reasons that are not obvious, the resulting disease is called primary hyperparathyroidism. In this case, either only one gland (about 80 percent) or two glands (about two percent) or all four glands (17 percent) may be affected. The disease is almost always benign, in rare cases there is an inherited disorder. Depending on the number of diseased glands, different surgical procedures are chosen.

It is important to leave enough healthy parathyroid tissue to ensure that calcium metabolism continues to function and to remove all diseased tissue. The possible positional variations of the parathyroid glands and the recognition of diseased tissue require a very experienced surgeon, especially for this type of surgery. At Martha-Maria Hospital Munich, this experience is given to a high degree by the large number of operations we perform.

In addition to the experience, some special devices are indispensable in parathyroid surgery, for example the possibility of cold preservation of parathyroid tissue. This tissue can be preserved for years and, if necessary, after thawing, can be implanted into the human musculature to resume normal function.

A further newer procedure in parathyroid surgery, which we have also been using since 1998, is the measurement of parathyroid hormone during surgery, the so-called Quick Parathyroid Hormone Test. This parathormone measurement can be used to measure the success of the operation at an early stage during the operation.

If the appropriate conditions are met, minimally invasive parathyroid operations are also possible.

If the overproduction of parathyroid hormone is due to reactive reasons (such as chronic kidney failure or if calcium cannot be absorbed into the body through the intestine), we speak of reactive hyperparathyroidism. In this case all four parathyroid glands are always diseased and enlarged. They are either removed except for a small, normal-sized residue (subtotal parathyroidectomy) or all parathyroid glands in the neck area are removed and part of the tissue is implanted into the muscles of the forearm in the same session (total parathyroidectomy plus autologous transplantation). During these operations, cryopreservation of the parathyroid tissue is then of great importance to the patient.

Paralysis of the vocal cord nerves (recurrent paresis) is one of the dreaded complications in thyroid and parathyroid surgery. A unilateral recurrent paresis leads to a standstill of one vocal cord. In most cases, the voice is then hoarse. The frequencies given in the literature vary from less than one percent to more than 20 percent in second and multiple operations (recurrent surgery). Paralysis of both vocal cord nerves often results in respiratory distress, which may require a tracheotomy.

However, the majority of vocal cord paralyses that occur during surgery on the thyroid or parathyroid gland regress. To keep the risk of recurrent paresis as low as possible, we monitor the vocal cord nerve by means of neuromonitoring. For this purpose, the vocal cord nerve (nervus recurrens) is electrically stimulated by a probe during the operation. The stimulation causes the muscle supplied by the nerve - here the vocalis muscle - to contract. This muscle is located in the larynx and moves the vocal cord. An electrode placed in this muscle derives corresponding signals and displays them acoustically. In this way it is possible to localize the vocal cord nerve and to check its integrity during the operation.

Protrusions of the esophagus in the neck area, the so-called Zenker's diverticula, almost always require surgical treatment, as they usually cause complaints such as obstruction of the passage when swallowing (dysphagia), return of undigested chyme into the mouth (regurgitation), a feeling of pressure and tightness in the neck area and chronic irritable cough due to the transfer of chyme into the trachea (aspiration).

Depending on the size of the sacs, age and concomitant diseases of the patients, we offer different surgical procedures:

• open surgery (through an incision in the neck) removal of the diverticulum and simultaneous splitting of the thickened muscles of the upper esophageal sphincter, which is one of the causes of the diverticulum.
• the sole splitting of the thickened esophageal muscles in the cervical area (cervical myotomy) with leaving and / or sewing (fixation) of the diverticulum to the wall of the pharynx This procedure is considered for very small bulges of the esophagus.
• Another therapeutic option is the splitting of the diverticulum entrance from the inside with special devices that are introduced into the upper part of the esophagus via the mouth (transoral threshold splitting). This procedure must also be performed under general anesthesia.

The much rarer protrusions of the esophagus in its lower part, if they cause any discomfort to the patient at all, can be removed minimally invasively (i.e. without a large skin incision and opening of the thorax) by means of thoracoscopy. The same applies to the likewise rare benign tumors of the esophageal wall musculature (leiomyomas), if they have led to a narrowing of the esophagus or exceed a certain size, so that malignant growth must be feared.

The most common diaphragmatic hernias (axial diaphragmatic hernias) are harmless and only require surgery if they cause discomfort. These are the axial sliding hernias. Here the stomach entrance slides through the enlarged passage through the diaphragm in an axial direction upwards into the chest. This is often dependent on the position of the patient.

If at the same time the function of the stomach entrance is disturbed (cardia insufficiency) and this leads to heartburn (reflux of the gastric juice into the esophagus) and if this "reflux disease" cannot be treated sufficiently with medication, the axial diaphragmatic hernia is also removed during the operation for reflux disease.

Certain forms of diaphragmatic hernia always require surgery. This is when parts of the stomach or even almost the entire stomach ("upside-down stomach" or "thoracic stomach") slides up into the thoracic cavity next to the entrance of the esophagus into the abdominal cavity (paraesophageal hernias up to the "thoracic stomach"). Such a situation carries the risk of incarceration of parts of the stomach (life-threatening emergency) or the development of ulcers and chronic bleeding. These hernias often cause complaints such as chest pain, belching and heart pain, which are initially wrongly attributed to other causes.

We perform surgery on paraesophageal hernia, if there are no other reasons against it, minimally invasive via laparoscopy. In this procedure, as in the open surgical procedure (via abdominal incision), the stomach is completely relocated back into the abdominal cavity and attached to the diaphragm with sutures (gastrophrenicopexy). At the same time, the passage (hernia gap) at the diaphragm is narrowed with a few sutures (hiatoplasty).

Stomach surgery, as in all hospitals around the world, has fortunately decreased considerably over the last 20 years, thanks to advances in the drug treatment of stomach ulcers and the detection of the bacteria responsible for them.

Only in the case of so-called therapy-resistant ulcers, i.e. benign ulcers that do not respond to any non-operative treatment, and of course in the case of malignant tumors of the stomach, do we still regularly perform stomach surgery today. It depends entirely on the disease, whether only a small part, four-fifths, the entire stomach or the entire stomach with a small part of the lower esophagus has to be removed.

Certain forms of stomach cancer (gastric carcinoma), which have already spread over the entire stomach wall and affected neighboring lymph nodes, but have not yet spread to other organs (metastases), are treated with chemotherapy before surgery (neoadjuvant chemotherapy as a multimodal therapy concept). In the case of malignant stomach tumors, the adjacent lymph nodes must always be removed in order to detect or rule out tumor involvement. Advanced stomach carcinomas with metastases in other organs are treated exclusively with chemotherapy. However, if the tumor in the stomach leads to obstruction of the food passage (stenosis) or to life-threatening bleeding, removal is also indicated in such cases. This is not curative (for the purpose of healing the patient), but palliative (to improve the quality of life). So-called bypass operations serve the same purpose, in which stomach or intestinal sections that are affected by tumors but cannot be removed surgically are eliminated by changing the passage (bypassing the affected section), so that the patient can eat and drink again (or at least permanent vomiting due to intestinal obstruction can be prevented).
We also perform the insertion of feeding tubes into the stomach or small intestine either from the inside (endoscopically as "PEG = percutaneous endoscopic gastrostomy"), via laparoscopy (laparoscopic) or open surgery (via abdominal incision).

If a patient frequently needs infusions to support nutrition or for chemotherapy, he or she will receive a so-called port implantation. A closed chamber, which can be punctured with a needle without pain, is implanted under the skin. A catheter leads from this chamber into a large blood vessel (vein), through which nutrition or medication can then be administered without any problems. This small procedure is usually possible under local anesthesia (also outpatient). Of course, this system can be removed again under local anesthesia when it is no longer needed.

Colon operations are also part of the basic care of patients at our clinic.

In the case of benign diseases such as sigmoid diverticulitis (inflammation of intestinal wall protuberances in the scimitar) and colon polyps (benign tumours), we offer minival-invasive surgical techniques such as laparoscopic (via laparoscopy) sigmoid resection (removal of the scimitar) or the combined laparoscopic (via laparoscopy) and simultaneously endoscopically (endoscopy from within) assisted removal of benign polyps (adenomas). The latter is necessary if polyps cannot be removed from the inside of the colon (colonoscopy) due to their size and/or location and a major open surgery (by means of an abdominal incision) should be avoided.

We also perform the removal of large polyps in the rectum under general anaesthesia via the anus (transanal) with removal of the affected mucous membrane (mu-cosectomy) and special instruments (ultracision).

In the spectrum of treatment of haemorrhoidal vein disease, we offer all classic surgical methods. We will only use the stacker haemorrhoidectomy according to Longo (circular removal of the rectal mucosa with a special stapler) when more convincing long-term results substantiate the success of this procedure.

Malignant tumours of the colon and rectum are unfortunately increasing in frequency. Fortunately, early detection examinations contribute to the fact that patients with less advanced stages of the disease come to the operation more often and thus the chances of recovery are improved. Molecular genetic findings in familial colon carcinomas also allow risk groups to be defined (patients who are highly likely to develop a malignant colon tumour) and included in appropriate screening programmes.

Minimally invasive surgical methods have not yet become widely accepted in the treatment of malignant colon tumours. Due to the frequency of these tumours, the surgical methods are highly standardised and can be performed with corresponding routine. Certain parts of the colon and rectum are removed together with the tumour and the neighbouring lymph nodes. The extent of the part of the intestine to be removed depends not only on the tumour but especially on the vascular supply of the intestine. Most malignant tumours are located near the rectum and the ileum. In these cases, an artificial bowel outlet is usually not necessary. Only if the tumour affects the sphincter muscle of the anus, the entire rectum is removed and a new artificial anus must be created (anus praeter). Nowadays, the possibilities for fitting an artificial anus are so sophisticated that no one will notice it. Swimming in swimming pools is also possible.

Crohn's disease is a disease of adolescents and young adults and is related to ulcerative colitis. Both diseases are characterised by diffuse diarrhoea as the main symptom, with further problems and complications.

In principle, Crohn's disease can affect the entire gastrointestinal tract. Surgery is always necessary if complications such as fistulas, abscesses or intestinal constrictions (with or without intestinal obstruction) have occurred that cannot be improved with medication.

Ulcerative colitis is a disease of the colon only and can usually be treated with medication without surgery. Surgery is necessary if the disease has been present for a very long time and is difficult to control with medication. If the disease has been going on for several years and leads to recurrent attacks, surgery should always be considered. This usually involves removing the entire colon, which usually resolves the symptoms.

In the surgical department of the Martha-Maria Hospital in Munich, operations are regularly performed on the oesophagus, stomach, small intestine, colon and rectum. The in-house Surgical Endoscopy Unit not only ensures surgically relevant, targeted diagnostics in the run-up to such operations, but also the appropriate experience in the conservative (non-surgical) treatment of problems (complications) after the operation. In addition, it is possible to work simultaneously endoscopically during operations on the digestive tract. This makes it possible, for example, to locate sources of bleeding in the stomach or intestine or to present small mucous membrane tumours (adenomas, polyps) for minimally invasive removal by laparoscopy.

In the surgical department of the Martha-Maria Hospital in Munich, all interventions in the area of the chest and lungs are regularly performed. These include first and foremost tumor diseases, which have increased dramatically in our society over the last decades.

A major advance for patients is the introduction of minimally invasive lung surgery, which is also performed in its entirety at our hospital. On the one hand, these minimally invasive interventions serve to further clarify unclear findings in the area of the lung and the chest wall. However, resection procedures can also be performed thoracoscopically. A frequent problem is recurrent pleural effusions, which can be treated very well by minimally invasive means.

In addition, other lung diseases are also treated, such as the so-called spontaneous pneumothorax or inflammatory diseases.

Tumours of the lung are usually discovered in an X-ray. They are often circular, which is why they are also called "round foci".

Every round focus needs to be further clarified. This requires a computer tomogram of the chest, which usually helps to decide what further steps are necessary. Round foci can be both benign and malignant.

The bronchial carcinoma

Lung cancer is the most common tumour disease in men and - together with breast cancer - in women. It is crucial for patients to recognise and treat this disease as early as possible, which means that a cure can be achieved here too. Therefore all "shadows in the lungs", or "round foci", should be further clarified! In case of doubt, these round foci must be surgically removed and examined. If an adequate operation is performed in an early tumour stage, patients with lung cancer can also be cured.

Metastases in the lung

Other lung tumours that should often be treated surgically are metastases from other tumours. If these metastases, which also look like round foci on an X-ray, can be completely removed, the patient often has a good chance of being cured.

Minimally invasive lung surgery

In recent years, minimally invasive surgery has also become increasingly established in thoracic surgery (as was the case in visceral surgery before), by means of which a wide range of different diseases can be treated. In addition, minimally invasive surgery can also be performed for purely diagnostic purposes, e.g. to take a tissue sample from the lung, pleura, mediastinum or lymph nodes.

In specialist circles, this is known as "Video-Assisted Thoracic Surgery" or also known as "VATS" for short. In contrast to the open surgical method, VATS requires only three skin incisions of a few centimetres in size. The ribs are not spread. This means that the patient recovers much more quickly, as the trauma for the patient is much less severe.

Surgery with the latest technical equipment

By using modern technical equipment we guarantee a high degree of safety for the patient

• Use of the latest imaging platform with high quality HD imaging especially for minimally invasive, video-assisted surgery
• Instruments specially developed for minimally invasive lung surgery

Operating with the smallest incisions

• 2 incisions, approx. 1cm small: once at the lower end of the rib cage in a line through the front edge of the armpit, as well as at the lower edge of the rib arch in extension of the upper hip scoop
• an approx. 4 cm long incision at the lower edge of the armpit to remove diseased lung tissue. In order to prevent the spread of tumour cells, the lung tissue is always removed with a recovery bag
• the blood vessels of the lungs and bronchial tubes are cut through with small titanium clips (staplers) and sealed blood-dry and airtight
• cosmetic intradermal suture of the skin
• the thoracic drainage is usually removed after about 2-4 days VATS lobectomy

Disease of the windpipe (= trachea) is usually associated with severe limitations and suffering for those affected. Mostly this is respiratory distress, which leads to a considerable reduction in performance and also to immobilisation.
The following diseases can lead to a narrowing of the trachea:

1. Enlargement of the thyroid gland - especially when the thyroid gland moves into the chest - can lead to compression of the windpipe and thus to stridor and shortness of breath.
2. Narrowing of the windpipe due to both benign and malignant tumours.
3. Narrowing of the windpipe due to stenoses after tracheotomy.
4. Idiopathic unification of the trachea.
5. Tracheomalacia (= instability of the trachea)

The treatment of these diseases depends on the type of constriction, but also on its location. For example, a compression of the windpipe due to an enlargement of the thyroid gland can usually be eliminated and thus cured by a thyroid resection.
Several options are available for the treatment of tracheal stenosis of other causes:

1. Interventional, endoscopic ablation by the pulmonology department in our clinic. These include the insertion of stents (tubes made of silicone and/or metal) to bridge constrictions as well as the removal of foreign tissue by means of laser and/or cryogenic (= icing) technology
2. Tracheal resection. The trachea can be resected up to a length of 4-6 cm. Continuity is restored by anastomosis. This is a relatively minor operation, after which the patient remains in hospital for about 1 week. These operations are performed in the surgical clinic of our hospital.

Interventional, endoscopic ablations can be used, for example, for idiopathic and tumour-related stenoses. The interventional insertion of tracheal stents also allows the airways to be kept open. These stents also stabilise the trachea, so that this procedure can also be used for tracheomalacia.
The location of the lesion in the trachea is important for this option. If the lesion in the trachea is too close to the larynx, these stents cannot be inserted because they cannot be placed or anchored.

Tracheal resection is a very good therapeutic option for all lesions of the trachea. A classic indication is tracheal stenosis after tracheotomy, even the already mentioned idiopathic stenosis can be treated in this way.
The advantage of the operation is the fact that a permanent freedom from symptoms can be achieved.
However, the location of the stenosis or tumour is also important for tracheal resection. Lesions that lie directly under the larynx or involve the larynx represent a particular challenge (high tracheal stenosis). In this case, good preoperative diagnostics is required, which is carried out by our pulmonological, - and ENT medical department.

The decision to operate is made in an interdisciplinary consultation. Operations involving the larynx are performed in cooperation with the head physician of our ENT department.

In our hospital, a large number of minimally invasive procedures are performed.

Almost all procedures, especially in the abdominal area, are successfully performed laparoscopically and video-assisted. The main advantage for the patient is the reduction of the trauma necessary for surgical access. Smaller incisions are possible, resulting in less pain for the patient and a shorter stay in hospital.

Of course, all operations are still performed conventionally, i.e. open surgery, as certain situations and findings cannot be successfully treated with the "keyhole technique". This means that treatment is tailored to the individual patient and situation.

A basic prerequisite for the success of minimally invasive parathyroid surgery is an exact preoperative localization diagnosis of the enlarged parathyroid gland (sestamibiscintigraphy, ultrasound, CT or NMR). Furthermore, there should be no large nodular goiter and no previous surgery or radiation should have taken place in the neck area. A suspected malignant disease of the parathyroid or thyroid gland is also a contraindication for the endoscopic surgical technique. The ideal candidate for minimally invasive video-assisted parathyroid or thyroid surgery is therefore a patient with a solitary adenoma of the parathyroid or thyroid gland.

In the endoscopic surgical technique, an approximately 1.5 centimeter long skin incision is made above the jugular fossa. Under video camera assistance, fine instruments are used to bluntly open up the space between the thyroid gland and the vascular nerve sheath and to visit the enlarged parathyroid gland. The vessels are severed between ligatures or metal clips and the epithelial body is retrieved. The vocal cord nerve can be precisely identified due to the optical magnification. A struma node can be removed in a similar way using this minimal surgical approach.

The intraoperative rapid determination of parathyroid hormone levels is a basic prerequisite for the successful performance of the endoscopic operation; if successful, the parathyroid hormone level must drop to normal within ten minutes after removal of the diseased parathyroid gland.

The advantages of the minimally invasive surgical technique are certainly better cosmetic results as well as a lower postoperative pain load and a faster convalescence of the patients. It is estimated that possibly 15 to 20 percent of all parathyroid and thyroid operations can be performed minimally invasively if the above mentioned criteria are observed. However, conventional methods still retain their value for the treatment of those patients in particular, in whom an exact further localization of the parathyroid glands is not possible, in the presence of a multiple gland disease, when a second operation is necessary or in the presence of a large goiter.

Technique of laparoscopic adrenal gland surgery:

A special camera is inserted into the abdominal cavity filled with carbon dioxide gas through a small incision in the navel area. Subsequently, fine instruments are inserted into the abdominal cavity through four further incisions. The operation is performed on the adrenal gland, which is then removed.

In-patient stay: about one to two weeks

Laparoscopic gall bladder removal is the "golden standard" in the treatment of gallstone disease. It can also involve a more or less pronounced inflammation of the gall bladder.

What examinations are necessary?

• Blood sampling to determine the liver and bile duct values as well as the pancreas values
• Ultrasound examination (sonography)
• Gastroscopy

Technique of laparoscopic gall bladder surgery:

The abdominal cavity is inflated with carbon dioxide gas. The abdominal cavity is adjusted on a television monitor using a camera inserted at the navel. The instruments are inserted into the right upper abdomen through three small incisions (0.5 to 1.5 centimeters) and the gallbladder is removed in this way.

Inpatient stay: approximately two to five days

According to the latest surgical knowledge, both open surgery and laparoscopic appendectomy can be used with the same safety and a comparable result ("out-come") in cases of appendicitis.

Advantages for laparoscopic appendectomy are seen especially in the clarification of chronic lower abdominal pain in men and women and in the diagnostic clarification of lower abdominal pain in women of childbearing age and in overweight patients.

Which preliminary examinations are necessary?

• Blood test
• Ultrasound examination
• possibly gynecological examination

Inpatient stay: about four to five days

In principle, every inguinal hernia should be operated. In our clinic, all methods for the treatment of inguinal hernia, including recurrent hernia, are available and can be applied individually.

• open surgical method according to Shouldice: The hernia sac is removed through an incision in the groin area and the hernia gap is closed by special sutures which strengthen the abdominal wall by doubling it.
• open surgical method with insertion of a plastic mesh (so-called Lichtenstein operation): The abdominal wall is strengthened tension-free by inserting a body-compatible plastic net.
• Abdominal mirror method with mesh inlay: The inguinal hernia is closed by three small incisions from the abdominal cavity under camera view through a plastic mesh insert.

Which examinations are necessary?

Usual preparation for surgery
Ultrasound examination (groin and testicles)

In-patient stay: approximately two to five days

The surgical intervention in the abdominal cavity as well as in the small and large intestine requires a more or less large abdominal incision according to conventional treatment methods. For selected patients with certain diseases, laparoscopic surgical procedures can also be used.

Here, too, the advantages of laparoscopic surgery come into play. No large incisions are necessary, painfulness is reduced and patients recover more quickly and can therefore leave the hospital more quickly.