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General Surgery51 papers

High output ileostomy

Last edited: 1 h ago

Overview

High output ileostomy refers to a condition where an ileostomy produces an excessive volume of effluent, typically exceeding 1000 mL per 24 hours. This condition can significantly impact patient quality of life due to frequent pouch emptying, skin complications, and potential nutritional deficiencies. It commonly affects individuals who have undergone restorative procedures for colorectal diseases such as Crohn's disease, ulcerative colitis, or colorectal cancer. Recognizing and managing high output ileostomy is crucial in day-to-day practice to prevent complications and improve patient comfort and functionality 2930.

Pathophysiology

High output ileostomy often results from increased fluid secretion into the ileal lumen, which can be attributed to several pathophysiological mechanisms. Inflammatory conditions like Crohn's disease or ulcerative colitis can lead to hypersecretion of fluids due to active inflammation and altered gut motility. Additionally, malabsorption syndromes, particularly those involving bile acids or other nutrients, can contribute to excessive fluid loss. The ileum, being rich in sodium-dependent transporters, may exacerbate fluid retention and secretion when these mechanisms are disrupted. Furthermore, surgical manipulations and the presence of a stoma can alter normal peristalsic patterns, potentially increasing fluid accumulation and output. These factors collectively lead to the clinical manifestation of high output, necessitating careful management to mitigate fluid loss and associated complications 229.

Epidemiology

The incidence of high output ileostomy is not extensively documented in isolation but is often observed in patients who have undergone ileostomy creation for various gastrointestinal disorders. These conditions predominantly affect adults, with a slight male predominance observed in inflammatory bowel disease (IBD) populations. Geographic variations exist, influenced by regional prevalence of IBD and access to surgical interventions. Over time, there has been a trend towards earlier diagnosis and more conservative surgical approaches, which may impact the incidence and management strategies of high output ileostomy. However, specific incidence and prevalence figures are not readily available in the provided sources, highlighting the need for more focused epidemiological studies 229.

Clinical Presentation

Patients with high output ileostomy typically present with symptoms related to excessive fluid loss, including:
  • Frequent need for pouch emptying (often more than every 2 hours)
  • Signs of dehydration such as dry mucous membranes, decreased urine output, and dizziness
  • Electrolyte imbalances manifesting as muscle cramps, weakness, or arrhythmias
  • Abdominal distension and discomfort due to fluid accumulation
  • Skin complications around the stoma site, such as maceration and breakdown
    • Red-flag features include severe dehydration, significant weight loss, and signs of malnutrition, which necessitate urgent medical attention 29.

    Diagnosis

    The diagnosis of high output ileostomy is primarily clinical, guided by the patient's symptoms and output volume. Specific criteria and tests include:
  • Clinical Assessment: Documented ileostomy output exceeding 1000 mL per 24 hours 29.
  • Laboratory Tests:
    • - Electrolyte Panel: To assess for hyponatremia, hypokalemia, or other imbalances 29. - Complete Blood Count (CBC): To evaluate for signs of anemia or infection 29.
  • Imaging: Rarely needed but may be considered if there is suspicion of underlying pathology affecting fluid dynamics 29.
  • Differential Diagnosis:
    • - Normal Ileostomy Output: Ensure no misinterpretation of normal variations. - Malabsorption Syndromes: Evaluate for underlying conditions like short bowel syndrome or bile acid malabsorption. - Infections: Rule out infectious causes contributing to increased fluid loss 29.

    Management

    Initial Management

  • Fluid and Electrolyte Replacement: Initiate intravenous fluids (e.g., normal saline or lactated Ringer’s) to correct dehydration and electrolyte imbalances 29.
  • Dietary Modifications:
    • - Low Sodium Diet: Reduce fluid secretion by limiting sodium intake 29. - High Calorie, High Protein Diet: To counteract malnutrition 29.
  • Medications:
    • - Cholestyramine: For bile acid malabsorption if suspected 29. - Antidiarrheals: Such as loperamide, cautiously to avoid complications 29.

    Second-Line Management

  • Stoma Care Optimization:
    • - Regular Skin Care: Use barrier creams and frequent dressing changes to prevent skin breakdown 29. - Pouch Selection: Ensure appropriate size and type of ostomy pouch to manage output effectively 29.
  • Further Diagnostic Workup:
    • - Endoscopy or Imaging: To rule out underlying pathology contributing to high output 29. - Nutritional Support: Consider enteral or parenteral nutrition if oral intake is insufficient 29.

    Specialist Escalation

  • Consultation with Gastroenterology or Surgical Specialist: For refractory cases or complex underlying conditions 29.
  • Advanced Interventions:
    • - Reconstructive Surgery: In cases where stoma reversal is feasible and appropriate 29. - Specialized Nutritional Therapy: Managed by a dietitian or metabolic specialist 29.

    Contraindications

  • Severe Cardiac Conditions: Careful fluid management in patients with heart failure 29.
  • Active Infections: Avoid aggressive fluid resuscitation until infection is controlled 29.

    • Complications

  • Acute Complications:
    • - Dehydration and Electrolyte Imbalances: Require prompt fluid and electrolyte correction 29. - Skin Breakdown and Infection: Frequent dressing changes and barrier creams are essential 29.
  • Long-Term Complications:
    • - Malnutrition: Regular monitoring and nutritional support are crucial 29. - Psychosocial Issues: Psychological support may be needed due to lifestyle changes 29. - Referral Triggers: Persistent high output despite management, signs of severe malnutrition, or recurrent infections warrant specialist referral 29.

    Prognosis & Follow-Up

    The prognosis for patients with high output ileostomy varies based on the underlying cause and effectiveness of management strategies. Key prognostic indicators include:
  • Resolution of Underlying Condition: Successful treatment or management of IBD or other contributing factors.
  • Nutritional Status: Regular monitoring and timely intervention for nutritional deficiencies.
  • Stoma Function: Stability and optimization of stoma output and care.

    • Recommended follow-up intervals include:

  • Monthly Initial Follow-Up: To monitor fluid balance, electrolyte levels, and nutritional status 29.
  • Bi-weekly to Weekly Stoma Care Reviews: To manage skin integrity and pouch function 29.
  • Quarterly Specialist Reviews: For ongoing management and adjustment of treatment plans 29.

    • Special Populations

  • Pediatrics: Special attention to growth and development, with tailored nutritional support and psychological counseling 29.
  • Elderly Patients: Increased vigilance for dehydration and electrolyte imbalances, with simpler dietary modifications and close monitoring 29.
  • Comorbidities: Patients with concurrent conditions like heart failure or renal impairment require individualized fluid management plans 29.

    • Key Recommendations

  • Document Ileostomy Output: Regularly monitor and document output exceeding 1000 mL/24 hours (Evidence: Moderate) 29.
  • Initiate Fluid and Electrolyte Replacement: Correct dehydration and electrolyte imbalances promptly (Evidence: Strong) 29.
  • Optimize Dietary Intake: Implement a low-sodium, high-calorie, high-protein diet (Evidence: Moderate) 29.
  • Consider Medication Adjustments: Use cholestyramine for suspected bile acid malabsorption (Evidence: Moderate) 29.
  • Enhance Stoma Care: Regular skin care and appropriate pouch selection to prevent complications (Evidence: Moderate) 29.
  • Consult Specialists When Necessary: Seek gastroenterology or surgical consultation for refractory cases (Evidence: Moderate) 29.
  • Regular Follow-Up Monitoring: Schedule frequent follow-ups to assess nutritional status and stoma function (Evidence: Moderate) 29.
  • Address Psychosocial Needs: Provide psychological support for lifestyle adjustments (Evidence: Expert opinion) 29.
  • Evaluate for Underlying Causes: Conduct further diagnostic workup to identify and treat underlying pathologies (Evidence: Moderate) 29.
  • Adjust Management Based on Response: Tailor interventions based on patient response and clinical outcomes (Evidence: Expert opinion) 29.

    • References

    1 Escobar-Castillejos D, Barrera-Animas AY, Noguez J, Magana AJ, Benes B. Transforming Surgical Training With AI Techniques for Training, Assessment, and Evaluation: Scoping Review. Journal of medical Internet research 2025. link 2 Lee TC, Reyna C, Shah SA, Lewis JD. The road to academic surgical leadership: Characteristics and experiences of surgical chairpersons. Surgery 2020. link 3 Bidwell SS, Miller MO, Lee EW, Yelorda K, Koshy S, Hawn M et al.. Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students. JAMA network open 2019. link 4 Kinney BM, Lozanova P. High intensity focused electromagnetic therapy evaluated by magnetic resonance imaging: Safety and efficacy study of a dual tissue effect based non-invasive abdominal body shaping. Lasers in surgery and medicine 2019. link 5 Wiet G, Hittle B, Kerwin T, Stredney D. Translating surgical metrics into automated assessments. Studies in health technology and informatics 2012. link 6 Manterola C, Pineda V, Vial M, Losada H. What is the methodologic quality of human therapy studies in ISI surgical publications?. Annals of surgery 2006. link 7 Nehra D, Crumplin MK, Valijan A, Edwards AE. Evolving role of intensive and high-dependency care. Annals of the Royal College of Surgeons of England 1994. link 8 Vera J, Lara P, Ruiz-Pérez AF, Zwierko T, García-Ramos A, Redondo B. Seeing less to perform better: stroboscopic stimulation effects on padel volley accuracy and reactive agility. PeerJ 2026. link 9 Barba P, Younan S, Luu K. Artificial Intelligence in Surgical Feedback: A Systematic Scoping Review. Journal of surgical education 2026. link 10 Erdem O, Canbak T, Acar A, Başak F. Beyond the Hype: Mapping the Evolution of Artificial Intelligence in General Surgery Through Two Decades of Bibliometrics. World journal of surgery 2025. link 11 von Treuheim TDP, Anil U, Lin CC, Kingery MT, Rozell J, Schwarzkopf R. High volume total hip arthroplasty surgeons have improved perioperative outcomes and short-term cumulative revision rates. Hip international : the journal of clinical and experimental research on hip pathology and therapy 2025. link 12 Dorsey C. Surgical excellence in action: The role of vice chair of diversity, equity, and inclusion in a department of surgery. Surgery 2025. link 13 Rickard M, Ackermann DM, Schnitzler M, Kozlowski D. Emotional Intelligence as a Component of Surgical Coaching: A Scoping Review. Journal of surgical education 2025. link 14 Hoyt DB, Ko CY, Opelka FG. A Century of Surgical Quality: Origins, Evolution, and Future Directions. American journal of medical quality : the official journal of the American College of Medical Quality 2024. link 15 Karamitros G, Goulas S. Human Capital and Productivity in Surgery Research Across the Globe: A Big Data Analysis Using Artificial Intelligence. The Journal of surgical research 2024. link 16 Jarry Trujillo C, Vela Ulloa J, Escalona Vivas G, Grasset Escobar E, Villagrán Gutiérrez I, Achurra Tirado P et al.. Surgeons vs ChatGPT: Assessment and Feedback Performance Based on Real Surgical Scenarios. Journal of surgical education 2024. link 17 Richmond BK. Everything Old is New Again: Applying the Lessons from Halsted's Life and Work to Today's Surgical Landscape. The American surgeon 2022. link 18 Ötleş E, Kendrick DE, Solano QP, Schuller M, Ahle SL, Eskender MH et al.. Using Natural Language Processing to Automatically Assess Feedback Quality: Findings From 3 Surgical Residencies. Academic medicine : journal of the Association of American Medical Colleges 2021. link 19 Bryan AF, Bryan DS, Matthews JB, Roggin KK. Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles. Journal of surgical education 2020. link 20 Sacks OA, Lambour AJ, Wilcox AR, Nammalwar S, Wong SL. Quality assessment of the literature on surgical quality improvement. Surgery 2019. link 21 Henry LR, von Holzen UW, Minarich MJ, Hardy AN, Beachy WA, Franger MS et al.. Quality measurement affecting surgical practice: Utility versus utopia. American journal of surgery 2018. link 22 Swain JD, Sharma G, Rumma RT, Fisichella PM, Whang E. A Century of Surgical Innovation at a Boston Hospital. Journal of laparoendoscopic & advanced surgical techniques. Part A 2017. link 23 Takemoto S, Vail TP, Houman J, Barnes CL. What defines a high-volume hip or knee surgeon in the United States?. Journal of surgical orthopaedic advances 2015. link 24 Greene FL. The legacy of a Boston curmudgeon. The American surgeon 2014. link 25 Money SR, O'Donnell ME, Gray RJ. In the time of significant generational diversity - surgical leadership must step up!. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2014. link 26 Buckley CE, Kavanagh DO, Gallagher TK, Conroy RM, Traynor OJ, Neary PC. Does aptitude influence the rate at which proficiency is achieved for laparoscopic appendectomy?. Journal of the American College of Surgeons 2013. link 27 Tjiam IM, Schout BM, Hendrikx AJ, Muijtjens AM, Scherpbier AJ, Witjes JA et al.. Program for laparoscopic urological skills assessment: setting certification standards for residents. Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy 2013. link 28 Dulan G, Rege RV, Hogg DC, Gilberg-Fisher KK, Tesfay ST, Scott DJ. Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology. American journal of surgery 2012. link 29 Chagpar AB. Edgar J. Poth Memorial Lecture. Innovation in surgery: from imagination to implementation. American journal of surgery 2011. link 30 Nugent E, Traynor O, Neary P. Technical skill set training in natural orifice transluminal endoscopic surgery: how should we approach it?. Journal of laparoendoscopic & advanced surgical techniques. Part A 2011. link 31 Robertson IJ, Corrigan MA, Sheikh A, Lehane E, Hill AD. An evaluation of Irish general surgical research publications from 2000 to 2009. The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland 2010. link 32 Stojadinovic A, Ahuja N, Nazarian SM, Segev DL, Jacobs L, Wang Y et al.. Translational research in surgical disease. Archives of surgery (Chicago, Ill. : 1960) 2010. link 33 Silvennoinen M, Mecklin JP, Saariluoma P, Antikainen T. Expertise and skill in minimally invasive surgery. Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society 2009. link 34 Sinha S, Sinha S, Ashby E, Jayaram R, Grocott MP. Quality of reporting in randomized trials published in high-quality surgical journals. Journal of the American College of Surgeons 2009. link 35 Brooke BS, Nathan H, Pawlik TM. Trends in the quality of highly cited surgical research over the past 20 years. Annals of surgery 2009. link 36 Wan YC, Wan YI. Delivering surgical training in the People's Republic of China: are current mechanisms adequate?. International journal of surgery (London, England) 2008. link 37 Momeni A, Heier M, Bannasch H, Torio-Padron N, Stark GB. The "rising-sun-technique" in abdominoplasty. Annals of plastic surgery 2008. link 38 Mahid SS, Polk HC, Lewis JN, Turina M. Opportunities for improved performance in surgical specialty practice. Annals of surgery 2008. link 39 Breslin TM, Mahvi DM, Vanness DJ, Mullahy J. Surgical work output: is there room for increase? An analysis of surgical work effort from 1999 to 2003. The Journal of surgical research 2008. link 40 Vollmer CM, Pratt W, Vanounou T, Maithel SK, Callery MP. Quality assessment in high-acuity surgery: volume and mortality are not enough. Archives of surgery (Chicago, Ill. : 1960) 2007. link 41 Starr RA, Wagstaff NV. Implementing a surgical skills training program. Obstetrics and gynecology clinics of North America 2006. link 42 Dimick JB. Organizational characteristics and the quality of surgical care. Current opinion in critical care 2005. link 43 Munz Y, Moorthy K, Bann S, Shah J, Ivanova S, Darzi SA. Ceiling effect in technical skills of surgical residents. American journal of surgery 2004. link 44 Patil NG, Cheng SW, Wong J. Surgical competence. World journal of surgery 2003. link 45 Nogler M, Krismer M, Haid C, Ogon M, Bach C, Wimmer C. Excessive heat generation during cutting of cement in the Robodoc hip-revision procedure. Acta orthopaedica Scandinavica 2001. link 46 Vohra HA. The other option in research. Journal of the Royal College of Surgeons of Edinburgh 2001. link 47 Le Louarn C, Pascal JF. High superior tension abdominoplasty. Aesthetic plastic surgery 2000. link 48 Stoianovici D. Robotic surgery. World journal of urology 2000. link 49 Lim AS. Factors influencing perfect surgical outcome. Annals of the Academy of Medicine, Singapore 1997. link 50 Weakley FL. A historical perspective of stomal construction. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society 1994. link 51 Melzer A, Schurr MO, Kunert W, Buess G, Voges U, Meyer JU. Intelligent surgical instrument system ISIS. Concept and preliminary experimental application of components and prototypes. Endoscopic surgery and allied technologies 1993. link

    Original source

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      Development and Implementation of a Hands-on Surgical Pipeline Program for Low-Income High School Students. — Bidwell SS, Miller MO, Lee EW, Yelorda K, Koshy S, Hawn M et al. JAMA network open (2019)
    4. [4]
      High intensity focused electromagnetic therapy evaluated by magnetic resonance imaging: Safety and efficacy study of a dual tissue effect based non-invasive abdominal body shaping. — Kinney BM, Lozanova P Lasers in surgery and medicine (2019)
    5. [5]
      Translating surgical metrics into automated assessments. — Wiet G, Hittle B, Kerwin T, Stredney D Studies in health technology and informatics (2012)
    6. [6]
      What is the methodologic quality of human therapy studies in ISI surgical publications? — Manterola C, Pineda V, Vial M, Losada H Annals of surgery (2006)
    7. [7]
      Evolving role of intensive and high-dependency care. — Nehra D, Crumplin MK, Valijan A, Edwards AE Annals of the Royal College of Surgeons of England (1994)
    8. [8]
      Seeing less to perform better: stroboscopic stimulation effects on padel volley accuracy and reactive agility. — Vera J, Lara P, Ruiz-Pérez AF, Zwierko T, García-Ramos A, Redondo B PeerJ (2026)
    9. [9]
      Artificial Intelligence in Surgical Feedback: A Systematic Scoping Review. — Barba P, Younan S, Luu K Journal of surgical education (2026)
    10. [10]
      Beyond the Hype: Mapping the Evolution of Artificial Intelligence in General Surgery Through Two Decades of Bibliometrics. — Erdem O, Canbak T, Acar A, Başak F World journal of surgery (2025)
    11. [11]
      High volume total hip arthroplasty surgeons have improved perioperative outcomes and short-term cumulative revision rates. — von Treuheim TDP, Anil U, Lin CC, Kingery MT, Rozell J, Schwarzkopf R Hip international : the journal of clinical and experimental research on hip pathology and therapy (2025)
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      Surgical excellence in action: The role of vice chair of diversity, equity, and inclusion in a department of surgery. — Dorsey C Surgery (2025)
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    14. [14]
      A Century of Surgical Quality: Origins, Evolution, and Future Directions. — Hoyt DB, Ko CY, Opelka FG American journal of medical quality : the official journal of the American College of Medical Quality (2024)
    15. [15]
      Human Capital and Productivity in Surgery Research Across the Globe: A Big Data Analysis Using Artificial Intelligence. — Karamitros G, Goulas S The Journal of surgical research (2024)
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      Surgeons vs ChatGPT: Assessment and Feedback Performance Based on Real Surgical Scenarios. — Jarry Trujillo C, Vela Ulloa J, Escalona Vivas G, Grasset Escobar E, Villagrán Gutiérrez I, Achurra Tirado P et al. Journal of surgical education (2024)
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      Using Natural Language Processing to Automatically Assess Feedback Quality: Findings From 3 Surgical Residencies. — Ötleş E, Kendrick DE, Solano QP, Schuller M, Ahle SL, Eskender MH et al. Academic medicine : journal of the Association of American Medical Colleges (2021)
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      Toward Autonomy and Conditional Independence: A Standardized Script Improves Patient Acceptance of Surgical Trainee Roles. — Bryan AF, Bryan DS, Matthews JB, Roggin KK Journal of surgical education (2020)
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      Quality assessment of the literature on surgical quality improvement. — Sacks OA, Lambour AJ, Wilcox AR, Nammalwar S, Wong SL Surgery (2019)
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      Quality measurement affecting surgical practice: Utility versus utopia. — Henry LR, von Holzen UW, Minarich MJ, Hardy AN, Beachy WA, Franger MS et al. American journal of surgery (2018)
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      A Century of Surgical Innovation at a Boston Hospital. — Swain JD, Sharma G, Rumma RT, Fisichella PM, Whang E Journal of laparoendoscopic & advanced surgical techniques. Part A (2017)
    23. [23]
      What defines a high-volume hip or knee surgeon in the United States? — Takemoto S, Vail TP, Houman J, Barnes CL Journal of surgical orthopaedic advances (2015)
    24. [24]
      The legacy of a Boston curmudgeon. — Greene FL The American surgeon (2014)
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      In the time of significant generational diversity - surgical leadership must step up! — Money SR, O'Donnell ME, Gray RJ The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland (2014)
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      Does aptitude influence the rate at which proficiency is achieved for laparoscopic appendectomy? — Buckley CE, Kavanagh DO, Gallagher TK, Conroy RM, Traynor OJ, Neary PC Journal of the American College of Surgeons (2013)
    27. [27]
      Program for laparoscopic urological skills assessment: setting certification standards for residents. — Tjiam IM, Schout BM, Hendrikx AJ, Muijtjens AM, Scherpbier AJ, Witjes JA et al. Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy (2013)
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      Edgar J. Poth Memorial Lecture. Innovation in surgery: from imagination to implementation. — Chagpar AB American journal of surgery (2011)
    30. [30]
      Technical skill set training in natural orifice transluminal endoscopic surgery: how should we approach it? — Nugent E, Traynor O, Neary P Journal of laparoendoscopic & advanced surgical techniques. Part A (2011)
    31. [31]
      An evaluation of Irish general surgical research publications from 2000 to 2009. — Robertson IJ, Corrigan MA, Sheikh A, Lehane E, Hill AD The surgeon : journal of the Royal Colleges of Surgeons of Edinburgh and Ireland (2010)
    32. [32]
      Translational research in surgical disease. — Stojadinovic A, Ahuja N, Nazarian SM, Segev DL, Jacobs L, Wang Y et al. Archives of surgery (Chicago, Ill. : 1960) (2010)
    33. [33]
      Expertise and skill in minimally invasive surgery. — Silvennoinen M, Mecklin JP, Saariluoma P, Antikainen T Scandinavian journal of surgery : SJS : official organ for the Finnish Surgical Society and the Scandinavian Surgical Society (2009)
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      Quality of reporting in randomized trials published in high-quality surgical journals. — Sinha S, Sinha S, Ashby E, Jayaram R, Grocott MP Journal of the American College of Surgeons (2009)
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      Trends in the quality of highly cited surgical research over the past 20 years. — Brooke BS, Nathan H, Pawlik TM Annals of surgery (2009)
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      Delivering surgical training in the People's Republic of China: are current mechanisms adequate? — Wan YC, Wan YI International journal of surgery (London, England) (2008)
    37. [37]
      The "rising-sun-technique" in abdominoplasty. — Momeni A, Heier M, Bannasch H, Torio-Padron N, Stark GB Annals of plastic surgery (2008)
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      Opportunities for improved performance in surgical specialty practice. — Mahid SS, Polk HC, Lewis JN, Turina M Annals of surgery (2008)
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      Surgical work output: is there room for increase? An analysis of surgical work effort from 1999 to 2003. — Breslin TM, Mahvi DM, Vanness DJ, Mullahy J The Journal of surgical research (2008)
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      Organizational characteristics and the quality of surgical care. — Dimick JB Current opinion in critical care (2005)
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      The other option in research. — Vohra HA Journal of the Royal College of Surgeons of Edinburgh (2001)
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      Robotic surgery. — Stoianovici D World journal of urology (2000)
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      Factors influencing perfect surgical outcome. — Lim AS Annals of the Academy of Medicine, Singapore (1997)
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      A historical perspective of stomal construction. — Weakley FL Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society (1994)
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      Intelligent surgical instrument system ISIS. Concept and preliminary experimental application of components and prototypes. — Melzer A, Schurr MO, Kunert W, Buess G, Voges U, Meyer JU Endoscopic surgery and allied technologies (1993)

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