Gastrointestinal Liver Surgery
All diseases of the gastrointestinal tract that require surgery are treated in the Surgical Clinic.
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.
Planned interventions in the small intestine are relatively rare and mainly concern inflammatory diseases. The Meckel's diverticulum, a bulge in the wall of the small intestine two to 15 centimeters long about 40 to 120 centimeters before the thin intestine meets the large intestine, can lead to complaints such as "appendicitis" and should always be removed, even if it is only discovered by chance.
Benign and malignant tumors of the small intestine are very rare and are treated by removing the tumor-bearing part of the small intestine with an appropriate healthy part (safety distance).
After open abdominal operations (laparotomies) but also after minimally invasive laparoscopies (laparoscopies), adhesions can develop in the abdominal cavity, which can lead to recurrent pain, vomiting and even intestinal obstruction (ileus). Only when all other possible causes of the complaints have been excluded and the patient is suffering considerably, a so-called adhesiolysis (loosening of the adhesions) is carried out in order to eliminate the complaints as far as possible. Unfortunately, adhesions can reappear after this operation and cause the same complaints as before the operation.
Colon surgery is 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 ileum) and colon polyps (benign tumors), we offer minival-invasive surgical techniques such as laparoscopic (via laparoscopy) sigmoid resection (removal of the ileum) or the combined laparoscopic (via laparoscopy) and simultaneously endoscopic (endoscopy from within) assisted removal of benign polyps (adenomas). The latter is necessary if polyps cannot be removed from the inside of the colon during colonoscopy due to their size and/or location and a large open surgery (by means of an abdominal incision) is to be avoided.
We also perform the removal of large polyps in the rectum under general anesthesia via the anus (transanal) with removal of the affected mucosa (mu-cosectomy) and special instruments (ultracision).
In the spectrum of hemorrhoidal vein treatment we offer all classical surgical methods. We will only use the stacker hemorrhoidectomy 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 tumors 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 tumor) and introduced into appropriate early detection programs.
Minimally invasive surgical methods have not yet become established in the treatment of malignant colon tumors. Due to the frequency of these tumors, surgical methods are highly standardized and can be performed with correspondingly high levels of routine. Certain parts of the colon and rectum are removed together with the tumor and the adjacent lymph nodes. The extent of the intestinal part to be removed is not only determined by the tumor, but especially by the vascular supply of the intestine. Most malignant tumors are located near the rectum and the ileum. In these cases, an artificial anus is usually not necessary. Only if the tumor affects the anal sphincter, the entire rectum is removed and a new artificial anus must be created (anus praeter). Nowadays, the possibilities of an artificial anus are so mature that nobody will notice it. Even swimming in swimming pools is possible.
Crohn's disease is a disease of adolescents and young adults and is related to ulcerative colitis. Both diseases are characterized by diffuse diarrhea as a leading 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, which cannot be improved with drug treatment.
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 persists for several years and leads to recurrent attacks, surgery should always be considered. Usually the entire colon has to be removed, which usually eliminates the symptoms.
In the surgical department of the Martha-Maria Hospital in Munich, procedures are regularly performed on the oesophagus, stomach, small intestine, colon and rectum. The in-house Surgical Endoscopy Unit ensures not only a surgically relevant, targeted diagnosis in the run-up to such operations, but also appropriate experience in the conservative (non-surgical) treatment of problems (complications) after surgery. In addition, it is possible to work simultaneously endoscopically during operations on the digestive tract. This allows, for example, to locate sources of bleeding in the stomach or intestine or to present small mucosal tumors (adenomas, polyps) for the then possible minimally invasive removal by laparoscopy.