Conditions and treatment methods

Symptoms

Oesophageal cancer usually arises in the lower, middle or upper section of the oesophagus. Typical signs are increasing difficulty swallowing – initially with solid food, later also with liquids. Many patients lose weight unintentionally, feel pressure behind the breastbone or suffer from heartburn. In advanced stages, hoarseness and a cough reflex when swallowing may occur.

Treatment

The operation is today usually performed minimally invasively (through small incisions) and includes:

• Laparoscopy to rule out metastases (diagnostic laparoscopy)
• Removal of the lower section of the oesophagus together with surrounding tissue
• Reshaping of the remaining stomach into a tube (gastric tube formation)
• Pulling the gastric tube up into the chest and suturing it to the remaining oesophagus (anastomosis)
• Preventive placement of a vacuum sponge to reduce complications (Endo-Vac placement)

For tumours located higher up, the entire oesophagus must occasionally be removed. The connection is then sutured by hand at the neck.

Operative technique: Today usually minimally invasive (laparoscopically in the abdomen, thoracoscopically in the chest). Robotically assisted or open is also possible.

Life after surgery

The greatest risk after the operation is a leaking suture line, which has, however, become significantly rarer thanks to modern methods such as the vacuum sponge. Recovery takes several weeks. Patients must permanently eat smaller meals and chew slowly, since the gastric tube is smaller than the original stomach. Heartburn may occur because the natural closure mechanism is missing. Regular oncological follow-up with endoscopies and imaging is required.

Symptoms

Gastric cancer initially often causes no or only non-specific symptoms: a feeling of fullness, loss of appetite, nausea and a feeling of pressure in the upper abdomen. As the disease progresses, weight loss, anaemia (due to occult bleeding) and pain after eating may occur. Stomach ulcers (ulcers) today only rarely require surgery.

Treatment

Depending on the location and size of the tumour:

• Partial removal of the stomach if the tumour lies in the lower third (subtotal gastrectomy)
• Complete removal of the stomach with connection of the small bowel to the oesophagus (gastrectomy with Roux-en-Y reconstruction)
• In both cases the surrounding lymph nodes are removed as well

Operative technique: Open, laparoscopic or robotic possible. For partial resections, the minimally invasive or robotic technique is increasingly used.

Life after surgery

After gastrectomy a weight loss of several kilograms is to be expected. Patients must permanently eat more frequent and smaller meals (5–6 instead of 3 per day), since the capacity is severely limited. Vitamin B12 must be supplemented for life as an injection or tablet, since it can no longer be absorbed without a stomach. After partial resection the restrictions are smaller. Regular follow-up with blood checks and imaging is necessary.

Symptoms

Benign or semi-malignant tumours of the gastric wall are often discovered incidentally during a gastroscopy. Some cause a feeling of pressure in the upper abdomen, occasionally mild bleeding or a feeling of fullness. Many patients have no symptoms.

Treatment

• Stomach-preserving procedures: only the tumour is shelled out of the gastric wall, the stomach itself is preserved
• The operation can often be performed minimally invasively (using keyhole technique)

Operative technique: Laparoscopic (standard) or open. Robotic possible, but rarely necessary.

Life after surgery

As the stomach is preserved, there are usually no permanent dietary restrictions. Recovery usually takes 1–2 weeks. With GIST tumours, regular follow-up is important, since these tumours can recur in rare cases.

Symptoms

Liver tumours and liver metastases (secondaries from other cancers, often from the colon) often initially cause no symptoms. As the disease progresses, a feeling of pressure in the upper right abdomen, fatigue, loss of appetite and unintentional weight loss may occur. Yellowing of the skin (jaundice) only occurs when bile flow is obstructed.

Treatment

• Removal of liver tissue together with the tumour (liver resection)
• Removal of metastases, also bilaterally and in several steps (one- or two-stage metastasis resection)
• Destruction of tumours by electrical pulses if removal is not possible (irreversible electroporation)

Treatment is carried out in close cooperation between surgery, oncology, radiology and pathology.

Operative technique: Open (standard for larger procedures), laparoscopic for smaller resections or robotic possible.

Life after surgery

The liver has an extraordinary capacity for self-healing: even after removal of up to 70% of the tissue, it grows back to its original size within a few weeks. During the recovery phase (2–4 weeks) alcohol should be avoided and high-fat food should be avoided. In the long term, most patients can lead a normal life. Regular follow-up with ultrasound and blood values is necessary.

Symptoms

Lung metastases are secondaries from tumours of other organs (often colon, kidney or soft tissues) that have settled in the lung. They are often discovered during follow-up examinations on a computed tomography (CT) scan without any symptoms being present. With larger or numerous lesions, cough, shortness of breath or occasionally bloody sputum may occur.

Treatment

• Removal of small sections of lung around the metastases (lung metastasis resection)
• For multiple lesions in one lung lobe: removal of the entire lobe (lobectomy)

Before the operation, lung function is checked and imaging is used to rule out metastases at other sites (bones, brain).

Operative technique: Minimally invasive via a camera in the chest (thoracoscopic / VATS), open via a chest incision (thoracotomy) or robotic possible.

Life after surgery

After the operation, drainage tubes are inserted for a few days to drain wound secretions and escaping air. The hospital stay is usually only 3–4 days. Lung function usually recovers well, provided enough healthy tissue is preserved. Mild shortness of breath on exertion may persist temporarily. Regular CT follow-ups are necessary for early detection of new lesions.

Symptoms

Pancreatic cancer is often discovered late, since it initially causes few symptoms. Possible signs are dull upper abdominal pain radiating into the back, jaundice (due to obstruction of bile flow), unintentional weight loss, newly developed diabetes and a general deterioration of well-being.

Treatment

Depending on the location of the tumour:

• Removal of the head of the pancreas together with the duodenum, surrounding lymph nodes and gallbladder, followed by reconnection of the small bowel (Kausch-Whipple procedure)
• Removal of the tail of the pancreas, often together with the spleen, possible by keyhole technique (distal pancreatectomy)
• Removal of the middle section while preserving the tail, which reduces the risk of diabetes (central pancreatectomy)

Operative technique: Head surgery (Whipple) is usually performed open, increasingly also robotically. Distal resection is often performed laparoscopically or robotically.

Life after surgery

The hospital stay is 10–14 days after head surgery and 7–8 days after tail removal. Since insulin-producing cells are removed during the operation, there is an increased risk of diabetes, which then has to be treated with medication or insulin. Digestive enzymes must be taken as capsules with meals. The diet should be low in fat and spread over several smaller meals. Regular oncological follow-up is mandatory.

Symptoms

Gallbladder cancer is rare and is often discovered incidentally during a gallbladder removal for gallstones. Possible symptoms are persistent pain in the upper right abdomen, jaundice, loss of appetite and weight loss. With advanced tumours a palpable lump in the upper abdomen may be present.

Treatment

• Open gallbladder removal with removal of an adjacent piece of liver and the surrounding lymph nodes (extended cholecystectomy with partial liver resection and lymph node dissection)
• For an incidental finding after keyhole surgery, re-operation is usually required

Operative technique: Always open, since partial liver resection and lymph node removal are necessary.

Life after surgery

Without a gallbladder one can live normally – bile flows directly from the liver into the bowel. In the first weeks, soft stools and mild digestive problems after high-fat meals may occur, which usually resolve spontaneously. With cancer, close oncological follow-up with imaging is necessary.

Symptoms

Colon cancer usually develops slowly from intestinal polyps. Typical signs are blood in the stool (often invisible), changed bowel habits (alternation of constipation and diarrhoea), unexplained anaemia, abdominal pain and unintentional weight loss. In the early stages there are often no symptoms – which is why screening colonoscopy from the age of 50 is important.

Treatment

Depending on the location of the tumour, the affected bowel section is removed together with the surrounding lymph nodes:

• Removal of the S-shaped section of bowel (sigmoid resection)
• Removal of the right half of the colon (right hemicolectomy)
• Removal of the transverse colon (transverse colectomy)
• Removal of the left half of the colon (left hemicolectomy)

The healthy bowel ends are then sutured back together.

Operative technique: Laparoscopic (standard today), open or robotic. The robotic technique offers advantages particularly with complex resections.

Life after surgery

Bowel movements are more frequent and softer in the first weeks after surgery, but usually normalise within 2–3 months. The greatest complication is a leaking suture line (anastomotic leak, in 3–4% of cases). A high-fibre diet and adequate fluid intake support recovery. Follow-up includes regular colonoscopies, blood tests (tumour markers) and imaging over 5 years.

Symptoms

Rectal cancer often causes blood on or in the stool, mucus discharge, the feeling of incomplete bowel emptying, painful urge to defecate (tenesmus) and changed bowel habits. Since these symptoms resemble those of haemorrhoids, they sometimes go unexamined for a long time.

Treatment

• Complete removal of the rectum together with the entire surrounding fatty and lymphatic tissue (total mesorectal excision), usually using keyhole technique
• Temporary artificial small-bowel outlet for 8–12 weeks to protect the suture line (protective ileostomy)
• Subsequent reversal of the artificial outlet

For very low-lying tumours, a permanent artificial bowel outlet must occasionally be created.

Operative technique: Laparoscopic (often), open or robotic. The robotic technique offers particular advantages in the narrow pelvis through more precise instruments and better vision.

Life after surgery

In the first months after the operation, bowel movements are more frequent (up to 5–6 times daily), which improves over time. Temporarily, mild uncontrolled stool loss can occur. The suture line is leaky in 5–8% of cases, which is usually well manageable with a protective stoma. Pelvic floor training supports recovery. Oncological follow-up with endoscopies, imaging and blood tests extends over 5 years.

Symptoms

Anal cancer is a rare tumour disease that is often associated with infection by human papillomaviruses (HPV). The first signs are bleeding from the anus and pain on defecation. Itching, palpable lumps at the anus and changes in bowel habits may also occur.

Treatment

• In contrast to most other cancers, anal cancer is usually not primarily operated on
• Most patients are successfully treated with combined radiotherapy and chemotherapy (chemoradiotherapy)
• Surgery is only considered if this therapy fails
• Treatment is planned within the framework of a tumour conference (interdisciplinary tumour board)

Life after surgery

During and after chemoradiotherapy, skin irritation in the anal area, diarrhoea and fatigue can occur. Most side effects subside within weeks. Sphincter function may be temporarily impaired. Regular follow-ups with clinical examination and imaging are necessary over several years to detect recurrence at an early stage.

Symptoms

Thyroid cancer usually presents as a palpable, painless lump in the neck that is noticed on ultrasound examination. In advanced stages, hoarseness (due to pressure on the voice nerve), difficulty swallowing, shortness of breath and swollen cervical lymph nodes may occur. Many thyroid nodules are benign – a tissue sample (puncture) clarifies the situation.

Treatment

• Complete removal of the thyroid (total thyroidectomy), usually with clearance of the cervical lymph nodes
• For small tumours confined to one side: removal of only one half of the thyroid (hemithyroidectomy)
• Subsequently often radioiodine therapy to eliminate residual tissue

Operative technique: Open through a small neck incision (standard). Robotic via an axillary approach (scar-free neck) is possible.

Life after surgery

After complete removal of the thyroid, thyroid hormones must be taken as a tablet for life (usually one tablet in the morning). Calcium levels must be closely monitored initially, since the parathyroid glands can be temporarily impaired. The risk of injuring the voice nerve is around 2%. Regular follow-up with blood tests, ultrasound and possibly whole-body scintigraphy is necessary.

Symptoms

Small-bowel tumours are rare. Carcinoids (slow-growing hormone-producing tumours) can cause abdominal cramps, diarrhoea and episodic facial flushing. GIST tumours (connective-tissue tumours of the bowel wall) occasionally lead to bleeding, abdominal pain or bowel obstruction. Both types of tumour are sometimes discovered incidentally during examinations.

Treatment

• Removal of the affected section of small bowel with adequate safety margin (small-bowel resection)
• For carcinoids and GIST: extended removal with the associated lymph nodes and the supplying mesentery
• Suturing together of the healthy bowel ends (anastomosis)

Operative technique: Open or laparoscopic. For extensive tumours, usually open.

Life after surgery

As long as at least 2 metres of small bowel remain, nutrient deficiencies usually do not occur. With larger removals, diarrhoea and deficiency symptoms (vitamins, minerals) can occur, which are compensated by dietary supplementation. Leaking sutures occur rarely (1–2%). Follow-up includes regular imaging and, for carcinoids, monitoring of special tumour markers (chromogranin A, 5-HIAA in urine).

Symptoms

Adrenal tumours can produce hormones and thereby cause a wide variety of symptoms: high blood pressure and palpitations (with adrenaline-producing tumours, so-called phaeochromocytomas), weight gain with moon face and central obesity (with cortisol-producing tumours), or changes in sexual characteristics. Some tumours produce no hormones and are discovered incidentally on imaging. Adrenal tumours can also occur as part of syndromes in which several glands are affected.

Treatment

• Adrenal removal by keyhole technique for smaller tumours (laparoscopic adrenalectomy)
• Open adrenal removal for larger tumours (open adrenalectomy)
• For adrenaline-producing tumours, medical pretreatment must be carried out before the operation in order to prevent dangerous blood-pressure crises during the procedure

Operative technique: Laparoscopic (standard for smaller tumours), open for large tumours, robotic possible.

Life after surgery

The removal of an adrenal gland is usually not noticed, since the other side fully takes over the function. With hormone-producing tumours, the hormone-related symptoms usually disappear within weeks to months after the operation. In rare cases the remaining adrenal function must be supported with medication. Regular hormone checks are necessary.

Symptoms

The gallbladder stores the bile produced by the liver and releases it into the small bowel for fat digestion. Gallstones can trigger cramp-like pain in the right or middle upper abdomen (biliary colic), which often occurs after high-fat meals and radiates into the right shoulder or back. Other symptoms are nausea, vomiting, bloating, itching, yellowing of the eyes and skin (jaundice), pale stool and dark urine. Inflammation of the gallbladder (cholecystitis) additionally causes fever and persistent pain. Rarely, perforation with peritonitis occurs.

Treatment

• Gallbladder removal by keyhole technique (laparoscopic cholecystectomy) – today’s standard
• Open gallbladder removal in case of very severe inflammation or suspicion of tumour (open cholecystectomy)

Operative technique: Laparoscopic (standard), open in case of severe inflammation, robotic possible.

Life after surgery

The colicky pain that often persisted for years disappears abruptly after the operation. The absence of the gallbladder has no negative consequences – bile simply flows directly from the liver into the bowel. In the first weeks, soft stools after high-fat meals may occur, which usually resolves quickly. Complications are very rare. Specific follow-up is not necessary in uncomplicated cases.

Symptoms

Chronic inflammation of the pancreas causes severe, recurrent upper abdominal pain that radiates belt-like into the back. The inflammation leads to calcifications and stone formation in the duct of the gland. Over time, digestive function may decline (fatty, foul-smelling stool) and diabetes may develop. The most common cause is excessive alcohol consumption.

Treatment

Depending on the extent and location of the changes:

• Removal of the head of the pancreas (Kausch-Whipple procedure)
• Removal of the tail of the pancreas (distal pancreatectomy)
• Removal of the middle section while preserving the tail (central pancreatectomy)

Operative technique: Open (often for head surgery), laparoscopic or robotic for tail resections.

Life after surgery

Hospital stay: 10–14 days after head surgery, 7–8 days after tail removal. Pain relief after the operation is often markedly better. Digestive enzymes must be taken as capsules with meals. The risk of diabetes is increased, particularly after tail removal, since most insulin-producing cells are located there. Abstinence from alcohol is mandatory. Regular monitoring of blood sugar, weight and nutrient status is necessary.

Symptoms

Diverticula are out-pouchings of the bowel wall that occur primarily in the S-shaped colon (sigmoid). They are common and often cause no symptoms. With inflammation (diverticulitis), pain in the lower left abdomen, fever, constipation or diarrhoea and a general feeling of illness occur. In severe cases, bowel perforation with peritonitis, abscess formation or bowel narrowing may occur.

Treatment

• Removal of the affected S-shaped bowel section with reconnection of the healthy ends (sigmoid resection)
• In emergency situations (bowel perforation), a temporary artificial bowel outlet may be necessary

Operative technique: Laparoscopic (standard), open in emergencies or with complications, robotic possible.

Life after surgery

Most patients are symptom-free after the operation. Bowel movements normalise within a few weeks. A high-fibre diet with adequate fluid intake prevents new diverticular problems. The risk of a leaking suture line is 3–4%. A regular follow-up colonoscopy is recommended.

Symptoms

Ulcerative colitis is a chronic inflammation of the lining of the colon and rectum. Typical are bloody-mucus-containing diarrhoea (up to 20 times a day), cramp-like abdominal pain, urge to defecate and a general feeling of illness with fatigue and weight loss. The disease progresses in flare-ups and increases the long-term risk of bowel cancer.

Treatment

Surgery becomes necessary when medications cannot adequately control the inflammation, precancerous changes occur or complications develop:

• Complete removal of the colon (colectomy)
• Formation of a replacement reservoir from small bowel (ileoanal J-pouch), which is connected to the anus
• Temporary artificial small-bowel outlet to protect the reservoir

Operative technique: Laparoscopic, open or robotic. The operation is often carried out in several stages.

Life after surgery

The J-pouch enables stool emptying via the natural route, although with more frequent bowel movements (4–8 times daily). Ulcerative colitis is usually cured by the operation. In the first months the body has to adjust to the new reservoir. Occasional inflammation of the pouch (pouchitis) can occur and is treated with antibiotics. In the long term most patients lead a normal life.

Symptoms

A bowel obstruction is an emergency. Typical signs are violent, cramp-like abdominal pain that occurs in waves, vomiting (initially stomach contents, later bilious to faecal), a distended abdomen and complete cessation of bowel movements and passage of wind. The most common causes are adhesions following previous operations, kinking or, rarely, tumours.

Treatment

• Removal of the diseased or dead bowel section (small-bowel resection)
• Suturing together of the healthy bowel ends (anastomosis)
• Release of adhesions (adhesiolysis)
• In case of circulatory disturbances: removal of the dead tissue as an emergency procedure

Operative technique: Open (often in emergencies), laparoscopic possible for adhesiolysis.

Life after surgery

As long as at least 2 metres of small bowel remain, no significant digestive problems occur. Leaking sutures are rare (1–2%), but somewhat more common with pre-existing circulatory disturbances. In severe cases with major bowel loss, long-term feeding via the bloodstream (parenteral nutrition) may become necessary, which, however, is very rare. New adhesions can cause renewed problems. Specific follow-up is not necessary in uncomplicated cases.

Symptoms

The thyroid controls numerous metabolic processes. With overactivity (hyperthyroidism) the metabolism works too fast: palpitations, sweating, weight loss despite a good appetite, nervousness, tremor and diarrhoea are typical. In Graves’ disease the eyes may additionally protrude. Thyroid nodules (nodular goitre) often cause a feeling of tightness in the neck, difficulty swallowing or visible swellings. Some nodules produce hormones uncontrollably (hot nodules).

Treatment

• Complete removal of the thyroid in Graves’ disease or with multiple nodules (total thyroidectomy)
• Removal of one half of the thyroid for one-sided nodules (hemithyroidectomy)
• Shelling out of a single nodule if the rest of the gland is unremarkable (enucleation)

Operative technique: Open through a small neck incision (standard). Robotic via axillary approach possible (scar-free neck).

Life after surgery

After complete removal, a thyroid tablet must be taken for life – with correct dosing there are no restrictions. After removal of one half, hormone replacement therapy is often not necessary, since the remaining half is sufficient. The risk of voice-nerve injury is around 2% in primary operations. Calcium levels are monitored in the first days. Regular blood tests (thyroid values) are necessary in the long term.

Symptoms

The four parathyroid glands regulate the calcium level in the blood. With overactivity, too much calcium is released from the bones:

• Primary hyperparathyroidism: A single parathyroid gland is enlarged. Symptoms are kidney stones, bone pain, fatigue, constipation, nausea and depressive mood. Often the diagnosis is made through an incidentally elevated calcium value.
• Secondary hyperparathyroidism: Due to kidney problems, too little calcium is absorbed, in response to which all four parathyroid glands enlarge. This results in bone softening, gastric ulcers and kidney stones.

Treatment

• For primary hyperparathyroidism: removal of the single enlarged parathyroid gland (targeted parathyroidectomy)
• For secondary hyperparathyroidism: removal of all four parathyroid glands or at least three and a half (subtotal parathyroidectomy)

Operative technique: Open through a small targeted neck incision (standard). Robotic possible.

Life after surgery

The operation usually cures the symptoms of overactivity – in particular bone pain, kidney stones and fatigue. After removal of all parathyroid glands, calcium must be supplemented. Calcium levels are closely monitored in the first days and weeks. In the long term, regular blood tests (calcium, parathyroid hormone) are required.

Symptoms

The spleen lies in the upper left abdomen beneath the diaphragm and is an important organ of immune defence. It also breaks down old red blood cells and platelets. Splenic injuries usually result from accidents (blunt abdominal trauma) and cause severe pain in the upper left abdomen that may radiate into the left shoulder, as well as signs of internal blood loss (pallor, dizziness, circulatory weakness). Splenic tumours are often removed at the same time during operations on neighbouring organs (pancreas, stomach).

Treatment

• Complete removal of the spleen (splenectomy) – for severe injuries or large tumours
• Partial removal of the spleen if only one area is affected (partial splenectomy)
• Removal of the tail of the pancreas with preservation of the spleen, where possible (spleen-preserving distal pancreatectomy)

Operative technique: Laparoscopic, open or robotic. In emergencies (splenic rupture) usually open.

Life after surgery

The platelet count rises after splenectomy, which increases the risk of blood clots – some patients need blood-thinning medication temporarily. Since the spleen plays an important role in defence against certain bacteria (pneumococci, Haemophilus influenzae, meningococci), patients must be vaccinated. These vaccinations must be regularly refreshed. Fever after splenectomy must always be taken seriously and clarified medically promptly (risk of severe blood poisoning, OPSI syndrome). In daily life, the loss of the spleen is not noticeably perceived by most people.

Symptoms

Severe obesity (adipositas) is a chronic disease with strong genetic predisposition. With a BMI over 35 kg/m² life expectancy is significantly reduced. Associated conditions include diabetes (type 2), elevated blood lipids, high blood pressure, cardiovascular diseases, joint damage, gallstones and an increased risk of cancer. Many patients additionally suffer from shortness of breath, sleep apnoea, restricted mobility and psychological strain.

Treatment

The prerequisite is a BMI over 35 (or over 30 with poorly controlled diabetes) and a conservative therapy lasting at least two years that has not been successful:

• Sleeve gastrectomy: reduction of the stomach by removing a large part (sleeve gastrectomy)
• Gastric bypass: rerouting of food past most of the stomach and the upper small bowel (Roux-en-Y gastric bypass)
• Rerouting of digestive juices to reduce nutrient absorption (biliopancreatic diversion)

The procedures work via three mechanisms: reduction of stomach volume, reduced nutrient absorption and changes in hunger and satiety hormones.

Operative technique: Laparoscopic (standard for all bariatric procedures) or robotic. Open operations are rare.

Life after surgery

Diet must be permanently adjusted: in the first months 6 small, balanced meals per day, initially only about 6 tablespoons per meal. Eating and drinking must be separated (30-minute interval). Multivitamins and minerals must be taken for life. Regular follow-up with blood tests, dietary advice and psychological support is required for life. Most associated conditions (diabetes, high blood pressure) markedly improve or disappear completely.

Symptoms

Haemorrhoids are vascular cushions at the transition from the rectum to the anus that contribute to normal closure. When they enlarge and slip downwards, they cause bleeding (bright red blood on the toilet paper or in the bowl), itching, mucus discharge, weeping and, in advanced stages, pain and palpable lumps at the anus. Symptoms occur particularly during defecation.

Treatment

Depending on the severity:

• Sclerosing of the haemorrhoids with laser (laser haemorrhoidoplasty)
• Lifting and pulling up with stapler (stapler haemorrhoidopexy according to Longo)
• Ultrasound-guided ligation of the supplying arteries (Doppler-guided haemorrhoidal artery ligation / HAL)
• Removal with a tissue-sealing scalpel (haemorrhoidectomy)

For mild symptoms, sclerosing injections or rubber-band ligations are initially used.

Operative technique: Specialised proctological procedures performed via the anus (transanally). No classic open, laparoscopic or robotic technique.

Life after surgery

Wound healing in the anal area takes 2–4 weeks and can be painful, particularly during defecation. Warm sitz baths, painkillers and soft stool (through a high-fibre diet and adequate fluid intake) make healing easier. Excessive straining during defecation should be permanently avoided. Recurrences are possible, but can be reduced through healthy bowel habits.

Symptoms

An anal abscess is a cavity filled with pus that arises through acute inflammation of small glands in the anal canal. It causes severe, throbbing pain at the anus, swelling, redness and frequently fever. Without treatment the inflammation can spread into the surrounding tissue. An anal fistula is an unnatural, tunnel-like duct between the anal canal and the skin, which arises as a consequence of an abscess. It causes persistent discharge, weeping and recurrent inflammation.

Treatment

• Excision of the fistula tract (fistulectomy)
• Cutting open the fistula tract for simple, superficial fistulas (fistulotomy)
• Coverage with a tissue flap for complex fistulas (flap procedures)
• Reconstruction of the sphincter muscle if it has been damaged by the fistula (sphincter reconstruction)

In the case of an acute abscess, the pus is initially urgently drained; definitive fistula treatment takes place in the inflammation-free interval.

Operative technique: Specialised proctological procedures via the anus (transanal/perianal). No classic open, laparoscopic or robotic technique.

Life after surgery

Healing takes 2–6 weeks depending on the procedure. With open wound treatment, regular wound flushing and dressing changes are necessary. Sitz baths and a high-fibre diet for soft stool support healing. Recurrences are not unusual with complex fistulas and may require further surgery. Sphincter function is preserved as well as possible with modern procedures.

Symptoms

An anal fissure is a painful tear in the lining of the anus and is one of the most common causes of acute anal pain. Typical are stabbing pain during and after defecation (which can last for hours), bright red blood on the toilet paper and spasm of the sphincter muscle. Out of fear of pain, defecation is delayed, which worsens constipation and triggers a vicious circle. Men and women are equally affected, younger adults more frequently than older ones.

Treatment

Initially conservative (in the first 6–8 weeks):

• Increased fluid and fibre intake for soft stool
• Application of ointments to relax the muscle (nitroglycerine, calcium antagonists)
• Injection of botulinum toxin to relax the sphincter muscle

For chronic fissure (longer than 6 weeks):

• Excision of the tear with the scarred tissue (fissurectomy)
• Coverage with a skin flap (flap repair / V-Y anoplasty)

Operative technique: Specialised proctological procedures via the anus (transanal/perianal).

Life after surgery

After conservative therapy, most fissures heal within 6–8 weeks. After surgery, healing takes 3–6 weeks. Warm sitz baths, painkillers and especially soft stool (high in fibre, plenty of fluids) are decisive. Constipation should be permanently avoided to prevent recurrences.

Symptoms

A pilonidal sinus arises through ingrown hairs in the buttock crease. Broken hairs are pushed root-first through friction into the skin, trigger an inflammation with foreign-body reaction in the subcutaneous fatty tissue and form fistula tracts. Mainly young men with strong hair growth are affected. There are three forms: symptom-free pits (without treatment), acute pus collections (abscess with pain, swelling, redness) and chronically weeping fistula openings with purulent or bloody discharge.

Treatment

• Excision with open wound healing (excision) – safe, but long healing time and recurrence rate up to 30%
• Minimally invasive procedure through small puncture openings as the first choice in uncomplicated cases (pit-picking)
• Coverage with a sliding skin flap (advancement flap)
• Diamond-shaped flap repair with a very low recurrence rate below 3% (Limberg flap repair)

For an acute abscess, the pus is initially drained; definitive surgery takes place after the inflammation has subsided.

Operative technique: Local surgical procedure in the coccygeal region (perianal/gluteal). No classic open, laparoscopic or robotic technique.

Life after surgery

The healing time depends greatly on the procedure: with open wound healing 4–12 weeks with regular dressing changes, with flap repairs 2–3 weeks. Sitting may be painful in the first days. Hair removal of the buttock crease (laser, shaving) can prevent recurrences. Physical activity is fully unrestricted again after complete healing.

Symptoms

The pelvic floor is a muscular plate that supports the pelvic organs and ensures closure of the bladder and bowel. Weakness primarily affects women and can lead to descent of the perineum, prolapse of pelvic organs (vagina, bladder, rectum) and stool and urine emptying disorders. With rectal prolapse the rectum prolapses through the anus – a rare but severely impairing disorder with mucus discharge and stool soiling. In advanced cases the prolapse must be pushed back by hand.

Treatment

• Reconstruction via the anus or vagina (transanal/transvaginal reconstruction)
• Lifting of the descended organs by keyhole technique (minimally invasive colpo-rectosacropexy)
• Placement of a supporting mesh on the rectum – the European standard (ventral mesh rectopexy)

The choice of procedure depends on which structures are affected. A precise assessment with history, examination and magnetic resonance imaging (MRI) is necessary.

Operative technique: Laparoscopic or robotic (for mesh rectopexy and colpo-rectosacropexy), transanal/transvaginal for local reconstructions.

Life after surgery

Recovery takes 2–6 weeks depending on the procedure. Heavy lifting should be avoided for several weeks. Pelvic floor training (physiotherapy) is an important part of follow-up treatment and should be continued long term. Results are usually good, with marked improvement of symptoms. With mesh placement it is checked in the long term whether the mesh has grown in correctly.

Symptoms

Faecal incontinence describes the inability to control bowel movements, which leads to involuntary loss of solid or liquid stool. About 2% of the population is affected, with frequency increasing with age: up to 11% of men and 26% of women over 50. In nursing homes the rate is around 40%. The causes are varied: injuries to the sphincter muscle (e.g. after childbirth or surgery), nerve damage or unknown causes.

Treatment

Initially conservative: dietary adjustment, medication (loperamide), pelvic floor training and biofeedback therapy.

Operative procedures in case of inadequate response:

• Suturing of the sphincter muscle (anal sphincteroplasty)
• Replacement of the sphincter muscle with a thigh muscle (dynamic graciloplasty)
• Nerve pacemaker at the sacrum (sacral nerve stimulation)
• Nerve stimulation at the shin (posterior tibial nerve stimulation)
• Injection of fillers into the sphincter region (bulking agents)
• Bowel irrigation from above (antegrade bowel irrigation)
• Creation of an artificial bowel outlet as a last option (stoma)

Operative technique: Specialised proctological procedures (transanal/perianal). The nerve pacemaker is inserted through a small incision at the sacrum. Graciloplasty is an open procedure.

Life after surgery

The combination of conservative and operative treatment leads to marked improvement in most patients. The nerve pacemaker (sacral nerve stimulation) shows good long-term results in many studies. Pelvic floor training should be continued permanently. Incontinence pads provide additional security in everyday life. Open conversation with the treating physician is important, as many patients wait too long out of shame.

Symptoms

Chronic constipation is one of the most common diseases of the digestive tract and affects 2–35% of the population. Typical are infrequent bowel movements (less than 3 times a week), hard stools, severe straining, the feeling of incomplete emptying and abdominal pain. A distinction is made between:

• Transit disorder: The colon transports the stool too slowly (too few contraction waves)
• Emptying disorder: Problems in the pelvic floor prevent normal bowel emptying
• Secondary causes: Other diseases (hypothyroidism, Parkinson’s, medications) or narrowings (tumour, diverticula)

Treatment

Initially conservative: high-fibre diet, adequate fluid intake, exercise and laxatives.

Operative procedures in case of treatment failure:

For transit disorder:

• Nerve pacemaker at the sacrum (sacral nerve stimulation / SNS)
• Partial or total removal of the colon (segmental or total colectomy)
• Creation of an artificial small-bowel outlet (ileostomy)

For emptying disorder:

• Plication of the rectal wall (rectal plication / Sullivan-Khubchandani technique)
• Partial removal of the rectum with stapler (STARR / Transtar)
• Pelvic floor tightening from the perineum (transperineal levatorplasty)
• Lifting of descended organs by keyhole technique (laparoscopic colpo-rectosacropexy)

Operative technique: Laparoscopic or robotic (for colectomy and colpo-rectosacropexy), transanal/transperineal for local pelvic floor procedures. The nerve pacemaker is inserted through a small incision at the sacrum.

Life after surgery

Surgery is only considered for severe, treatment-resistant constipation and is only carried out after comprehensive assessment. After colectomy, bowel movements are more frequent and softer. A high-fibre diet, adequate fluid intake and regular exercise remain important for life. Pelvic floor training (biofeedback) supports recovery in emptying disorders. Regular follow-ups monitor treatment success.

Symptoms

An inguinal hernia arises when tissue (usually loops of bowel or fatty tissue) protrudes through a weak spot in the abdominal wall in the groin area. Typical signs are a visible or palpable bulge in the groin that becomes more pronounced with coughing, straining or physical exertion. Many patients feel a pulling or dull pain in the groin, particularly when lifting heavy objects or standing for long periods. At rest or when lying down, the bulge can often be pushed back. Men are significantly more frequently affected than women.

Treatment

• Placement of a synthetic mesh to reinforce the abdominal wall (mesh repair)
• Keyhole technique from the abdominal side (laparoscopic transabdominal preperitoneal repair, TAPP)
• Keyhole technique in the space of the abdominal wall (totally extraperitoneal repair, TEP)
• Open mesh placement according to Lichtenstein for large hernias or after previous surgery

Operative technique: Preferably laparoscopic (TAPP or TEP) or robotically assisted. For large or complicated hernias open according to Lichtenstein.

Life after surgery

After inguinal hernia surgery, physical rest is recommended for 2–3 weeks. Light everyday activities are quickly possible again. Heavy lifting (over 10 kg) should be avoided for 4–6 weeks. Sport can usually be resumed gradually after 3–4 weeks. The inserted mesh grows into the tissue and reinforces the abdominal wall permanently. The recurrence risk is below 2%. Numbness in the groin area can occur temporarily and usually subsides within a few months.

Symptoms

In an umbilical hernia, tissue protrudes through a weak spot in the navel area. A bulge appears at or next to the navel, which becomes larger with exertion. Many umbilical hernias cause no or only minor symptoms such as a feeling of pressure. With larger hernias, pain, nausea and digestive problems may occur. Overweight, pregnancies and heavy physical work promote development.

Treatment

• Direct suture for small hernias (under 2 cm)
• Placement of a synthetic mesh for larger hernias (mesh repair)
• Minimally invasive treatment for larger defects

Operative technique: Small umbilical hernias are treated open with direct suture or mesh. Larger hernias can be operated on laparoscopically or robotically.

Life after surgery

Recovery after an umbilical hernia procedure is usually rapid. Light activities are possible after a few days. Heavy lifting should be avoided for 3–4 weeks. With mesh placement the recurrence rate is very low. Overweight patients benefit from weight reduction in order to avoid recurrence.

Symptoms

A femoral hernia occurs below the inguinal ligament in the area of the thigh vessels. It is rarer than an inguinal hernia and more frequently affects women. The bulge is often small and difficult to detect. Femoral hernias cause pain in the groin or thigh area and have an increased risk of incarceration, which is why they should be operated on promptly.

Treatment

• Closure of the hernia gap with mesh placement
• Keyhole technique through the abdominal cavity (laparoscopic mesh repair)
• Open surgery for incarcerated hernias (emergency)

Operative technique: Preferably laparoscopic (TAPP), since any inguinal hernia can be treated at the same time. For incarceration, open emergency surgery.

Life after surgery

Recovery is similar to that for inguinal hernia. Physical rest for 2–3 weeks, no heavy lifting for 4–6 weeks. Because of the higher risk of incarceration, prompt operative treatment is particularly important. The recurrence rate after mesh placement is very low.

Symptoms

An incisional hernia arises in the area of a previous operation scar when the abdominal wall has not fully healed at the suture site. It appears as a bulge along the scar, which becomes larger with exertion. Symptoms range from a feeling of pressure through pulling pain to digestive problems with large hernias. Incisional hernias occur in about 10–15% of all abdominal operations and are more common after open procedures than after keyhole operations.

Treatment

• Placement of a synthetic mesh to reinforce the abdominal wall (mesh repair)
• Separation of the lateral abdominal muscles for tension-free closure expansion (component separation according to Ramirez or TAR technique) for large hernias
• Keyhole technique for suitable hernias

Operative technique: Laparoscopic or robotic for small to medium-sized hernias. For large incisional hernias, open reconstruction with extended abdominal wall plasty (TAR or component separation).

Life after surgery

Recovery takes 3–6 weeks depending on the size of the hernia. With large incisional hernias and abdominal wall reconstruction, longer rest of 6–8 weeks is necessary. Wearing an abdominal belt can be supportive in the first weeks. Heavy lifting should be avoided for at least 6 weeks. Weight reduction in cases of overweight, smoking cessation and good blood-sugar control in cases of diabetes significantly reduce the risk of recurrence.

In open surgery, a larger incision (depending on the procedure 10–30 cm) is made in the skin and abdominal wall in order to give the surgeon direct access to the operating area. The surgeon works with their hands and instruments directly inside the body and has a good overview of the entire operating field.

Advantages:

• Direct access and good overview, particularly with large tumours or adhered tissue
• Quickly performed in emergencies
• No special technical equipment required

Disadvantages:

• Larger incision and therefore more pain after the operation
• Longer recovery time and hospital stay
• Larger scar
• Higher risk of incisional hernias

In laparoscopic surgery, 3–5 small incisions (each 5–12 mm) are made in the abdominal wall. Through these openings a camera and thin instruments are introduced. The abdomen is inflated with gas (CO₂) so that the surgeon has space and vision. The surgeon operates by looking into the body via a screen and controlling the instruments from outside.

Advantages:

• Significantly smaller incisions and less pain
• Faster recovery and shorter hospital stay
• Smaller scars
• Lower risk of wound infections and incisional hernias

Disadvantages:

• Restricted mobility of the instruments (straight rods that can only tilt and rotate)
• Two-dimensional camera image (no spatial vision)
• Technically demanding, particularly in narrow body regions (e.g. pelvis)
• Not possible in all patients or diseases

In robotic surgery, the surgeon sits at a control console and controls a surgical robot (e.g. Da Vinci) which moves the instruments inside the patient’s body. The instruments are introduced through small incisions (as in keyhole technique), but have articulating joints that allow movements in all directions. The surgeon sees a magnified, three-dimensional image.

Advantages:

• Highest precision through articulating instruments (similar to a human wrist)
• Three-dimensional, magnified image for better vision
• Particularly advantageous in narrow, hard-to-reach body regions (e.g. pelvis in rectal cancer, thyroid via axilla)
• Tremor filter: small hand movements of the surgeon are smoothed out
• Small incisions as in keyhole technique

Disadvantages:

• High costs for the device and maintenance
• Longer preparation time (set-up of the robot)