Abstracts - Chirurgie Kongress

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lower pulmonary vein. Staging showed no other tumor manifestations. After an unsuccesfull CT-guided biopsy, a thoracotomy with lobectomy of the lower lobe and mediastinal lymphadenectomy was performed. Postoperatively, the patient developed a left sided hemiplegia of arm and leg. A CT scan of the brain showed ischemic areas, likely due to tumor emboli. Meanwhile, a new CT-Scan reveiled tumor progression along the left lung vein into the left atrium. The patient was transferred to a tertiary center for subsequent surgery with extirpation of the residuary tumor. The patient recovered very well and went on to receive additive chemotherapy for 6 months. Currently there is no evidence of disease recurrence and the patient continues regular follow-up. Conclusion: The patient has recovered completely from the cerebral embolism, the surgery and the chemotherapy. The further outcome remains uncertain. According to the literature, outcome is poor in patients with metastatic disease. However, in cases of successful local resection, longterm survival has been reported. 83.4 Oral anticoagulation in aortic dissection: Effect on secondary dilatation and malperfusion syndrome E. Krähenbühl, S. Prader, F. Immer, E. Krähenbühl, L. Englberger, D. Reineke, T. Carrel, J. Schmidli (Bern) Introduction: Late complications are frequently encountered in patients treated because of acute type A dissection (AADA). Secondary dilatation and immediate or delayed malperfusion syndrome (MPS) are the most common complications. The effect of oral anticoagulation (OA) following AADA repair is discussed controversially. No guidelines are available in the literature. Methods: 108 patients who underwent AADA repair were analyzed. 59 patients (54.6%) were under antiplatelets (AP) and 32 (29.6%) under cumadine (OA). The remaining patients had no medication or a combination of both treatments. Follow-up data were analyzed, focusing on patency of the false lumen, the occurrence of delayed MPS and late dilatation. Results were compared between the two groups. Results: Patients characteristics were similar in both groups. Average follow-up was 31.1±14.2 months. Secondary dilatation was more pronounced in the AP-group with an overall average increase per patient of 0.4mm/y compared to 0.02mm/y in the OA-group (p
Visceral Surgery – Nouvel Technologies 84 84.1 “No visible scar” laparoscopic cholecystectomy - first experiences with transvaginal hybrid-NOTES cholecystectomy R. Fahrner, E. Grossen, R. Müller, O. Schöb (Schlieren) Objective: Laparoscopic cholecystectomy has become standard procedure during the last two decades. Natural orifice transluminal endoscopic surgery (NOTES) will further decrease the operative trauma to the abdominal wall and reduce postoperative pain, wound infection, risk of hernia and hospital stay. We report the first results of transvaginal Hybrid-NOTES cholecystectomy. Methods: From July 2008 to December 2008, 5 women were treated by transvaginal Hybrid-NOTES cholecystectomy. Pneumoperitoneum was created through a 5 mm incision in the umbilicus. Two rigid trocars (12 mm and 5 mm) were inserted in the posterior fornix of the vagina. Patient data, operative time, complications and postoperative course were recorded prospectively in each patient. Results: The average age of the 5 patients was 34.6 years (19 to 44 years) and the mean body mass index was 24.8 kg/m 2 . One patient had in advance a cesarean section and two patients a conization. In all patients operation was performed without intraoperative complications and no further procedure was done simultaneously. The mean operative time was 79 minutes (65 to 88 minutes). The mean hospital stay was 2.6 days (2 to 3 days). Non steroidal anti-inflammatory drugs and paracetamol or metamizol were administered for postoperative analgesia. The postoperative course was except for little vaginal bleeding in the first 3 to 7 days uneventful. The further postoperative follow-up after 4 weeks was without complications. Conclusion: The transvaginal Hybrid-NOTES cholecystectomy is a feasible and probably safe procedure. Operative time was despite of any expected learning courve effects not significantly longer than in laparoscopic cholecystectomy. The posterior colpotomy is a simple approach to the abdominal cavity and wound healing is very rapid. Using rigid instruments and techniques wellknown for laparoscopic techniques transvaginal cholecystectomy seems feasible with low operative risk. 84.2 Vergleich der intraoperativen Leberverformung mit der präoperativen durch 3D-Bildgebung unterstützten Operationsplanung: Prospektive klinische Studie O. Heizmann 1 , S. Zidowitz 2 , H. Bourquain 2 , S. Potthast 1 , D. Oertli 1 , C. Kettelhack 1 ( 1 Basel, 2 Bremen/DE) Objective: Der Einsatz der 3-D-Planung und der Navigationssysteme in der Leberchirurgie wird aktuell von den klinischen Anwendern auf Grund eines hohen technischen Aufwands im Transfer der Anwendungen von starren anatomischen Strukturen auf atembewegliche und verformbare Organe kontrovers diskutiert. Mit den Segmentierungssystemen kann die Darstellung der Lebersegmente, der Tumorlage bezüglich der Gefäßsysteme, wie auch die Volumenbestimmung des Restvolumens berechnet und dargestellt werden. Basis der Datenakquisition ist in der Regel die Computertomographie(CT). Das Ziel unserer Studie war es die Parenchymverformung durch den Vergleich der prä- vs. intraoperativer Bildgebung nach der Lebermobilisation zu dokumentieren. Methods: Bei 12 konsekutiven Patienten mit einem resektionsbedürftigen Lebertumor wurde die Leberresektion nach präoperativer Planung mit Hilfe der 3D-Bildgebung in einem Multifunktionsraum für Bildgebung und Interventionen (MBI) durchgeführt. Nach Mobilisation der Leber, der Darstellung und Sicherung der zu- und abführenden Lebergefäße wurde unter Wahrung strenger chirurgischer Sterilität ein kontrastmittelunterstütztes intraoperatives CT durchgeführt. Anschließend wurde die Leberresektion in üblicher Weise vollendet. Results: Alle Eingriffen wurden im MBI mit intraoperativem CT durchgeführt. In zwei Fällen war der Vergleich auf Grund mangelnder Gefäßkontrastierung nicht möglich. Die Dauer des CT betrug 30±7min. Es zeigte sich eine signifikante Parenchymverformung mit Änderung der Gefässtopographie, welche zur Organperipherie hin zunahm. Weiterhin zeigte sich eine Aufspreizung der dorsalen und eine Kompression der vertralen Parenchymanteile. Conclusion: Die operationsbedingte Organverformung und ihr Ausmass wurden erstmalig mittels intraoperativer CT dokumentiert. Eine Verformungstendenz bezüglich der Referenzpunkte (Gefässverzweigungen 1. und 2. Ordnung) war zu erkennen. Eine Gesetzmässigkeit kann trotzdem nicht postuliert werden, so dass die Berechnung der Vektoren mit Hilfe einer Software nicht möglich ist. Deswegen kann die präoperative 3D-Segmentierung alleine nicht die Grundlage eines Navigationsprotokolls bilden. Unsere Ergebnisse zeigen eindrücklich wie stark die Leberanatomie durch die chirurgische Mobilisation verändert wird und unterstreichen die Notwendigkeit einer echten 3D-basierten intraoperativen Navigation. 84.3 Robotic single incision surgery with the da Vinci© Surgical System: initial experience with transabdominal and transvaginal access M. Hagen 1 , O. Wagner 1 , P. Morel 2 , K. Thompson 1 , A. Spivak 1 , M. Talamini 1 , G. Jacobsen 1 , S. Horgan 1 ( 1 San Diego/USA, 2 Geneva) Objective: Despite cosmetic advantages of single incision surgery and NOTES, technical challenges using a single access make techniques non-intuitive and widespread acceptance is limited. Robotic surgery might have the potential to overcome such hurdles due to the option computer technology allowing unusual arm configurations. We report our initial experience with robotic single incision surgery using intersecting robotic arms through the abdominal wall and the vagina in human cadavers and pigs. Methods: The da Vinci© Surgical System (Intuitive, Sunnyvale, CA, USA) was used to perform single incision surgery in human cadavers transabdominally and transvaginally and transabdominally in pigs. For the transabdominal access, a robotic 10-mm scope stabilized with a 12 mm port and two 5-mm robotic instruments were introduced through a multichannel single port (TriPort, ACS, Wicklow, Ireland). The camera was placed centrally and both robotic arms were crossed at the level of the abdominal wall, inverting both instruments` tips for triangulation. Control of robotic arms was switched from right to left and vice versa to achieve intuitive manipulation. The same robotic setup was used transvaginally, but camera and working arms were introduced through separate trocars. Results: With the transabdominal setup, it was possible to work with the robotic system in the typical, intuitive fashion even though working arms were intersected. Tissue manipulation, suturing and a cholecystectomy were performed. A slight loss of range of motion was discovered due to the unusual setup of the working arms, but set-up allowed the usual range within the operative field. Transvaginal setup including docking of the system and introduction of instruments into the abdominal cavity was possible, put no useful manipulation could be performed due to space restriction of the vagina and between the thighs. Conclusion: Transvaginal robotic surgery with the da Vinci© Surgical System does not appear to be feasible using the above setup. Though, transabdominal robotic single port surgery is feasible by using intersected robotic working arms crossed at the level of the abdominal wall and reversed robotic arm control. This approach seems to offer all advantages of single incision surgery while maintaining the intuitive control of robotic surgery. Clinical application appears justified. 84.4 Soft tissue navigation: an ex-vivo porcine liver model for multimodality imaging and simulation of deformations to validate techniques for image-guided liver surgery A. vom Berg 1 , M. Peterhans 1 , B. Dagon 2 , L. Nolte 1 , C. Baur 2 , S. Weber 1 , D. Inderbitzin 1 , D. Candinas 1 ( 1 Bern, 2 Lausanne) Objective: Our investigations on a porcin liver model adress the integration of a clinically applicable navigation system for enhancing spatial orientation during complex hepatic resections. Methods: The system being developed consists of an interface to preoperative planning (MeVis Distant Services) and contains an integrated ultrasound transducer (Terasion 8IOA) and an optical tracking system (NDI Vicra/Atracsys InfiniTrack) for spatial referencing of transducers and surgical instruments. The navigated ultrasound is used for acquiring 3D-information on organ motion during surgery for updating the planning data. The actualised planning datasets are then visualised together with navigated surgical tools. This enables tool guidance and provision of information on the location of critical structures. For data aquisition controlled deformations were induced on three porcine livers with simulated blood flow during image aquisition by CT scanner. Ultrasound images were acquired using a calibrated and optically tracked ultrasound probe (Philips Sonos 5500). From the resulting CT datasets, portal and hepatic veins where segmented semi-automatically using a 2D region-growing algorithm. Surface models were created and vessel centerlines were calculated using a skeletonization algorithm. The ultrasound images were segmented using our automatic vessel segmentation algorithm which provides a parametric vessel representation. The differences between vessel trees reconstructed from CT and segmented vessel from ultrasound were quantified by calculating the Euclidean distances between the centerlines obtained from CT and the vessel center points from the ultrasound. Results: In our ex-vivo model the information from ultrasound and CT represent exactly the same anatomical situation (no breathing motion). The deformation predicted from ultrasound imaging can be validated quantitatively using the corresponding CT dataset to develop an integrated hardware/software framework for navigation, interactive display and ultrasound. Conclusion: Computer assisted surgery is the future of liver surgery by combining CT scans with real time ultrasound images allowing the surgeon to identify the exact position of surgical instruments in liver parenchyma. Our software system is ready to be used in clinical trials. 84.5 A randomized clinical trial comparing cost and effectiveness of bipolar vessel sealer to clips and vascular staplers in straight laparoscopic colectomy M. Adamina 1,2 , B. J. Champagne 1 , B. N. Bae 1 , Y. G. Joh 1 , M. Lauginghouse 1 , C. P. Delaney 1 ( 1 Cleveland/ USA, 2 Basel) Objective: This study compares the costs and effectiveness of two standard techniques for vascular control in straight laparoscopic colectomy. Methods: Patients scheduled for laparoscopic colectomy were randomized to bipolar vessel sealer (Ligasure Atlas, Covidien) or laparoscopic clips (Endo Clip, Covidien) and vascular staplers (Endo GIA linear stapler, Covidien). Time and ability to control the main vascular pedicles were recorded. Costs of disposable instruments were evaluated. Diagnosis, type and duration of procedure, body mass index (BMI), presence of adhesions, abscess or phlegmon, as well as estimated blood loss (EBL) were used to adjust multivariate regression models and evaluate effectiveness and costs. Results: Of 59 randomized patients, there were 32 bipolar vessel sealer and 27 laparoscopic clips and vascular staplers cases. Diagnosis, occurrence and severity of adhesions and abscess, median BMI (27kg/m 2 ), operative time (170min), EBL (50ml), and length of stay (3 days) were similar between groups. Twenty right colectomies, 31 left colectomies and 8 total colectomies were performed for diverticulitis (16), neoplasia (33), and colitis (10). There were no conversions. Both diagnosis and procedure were significant predictors of the duration of surgery, while randomization to either group was not. An average of 2.4 laparoscopic clips and 1.6 vascular staplers were used per procedure in the laparoscopic clips and vascular staplers group. Overall, there was no significant difference in costs of disposable instruments. Two instruments failures occurred in the laparoscopic clips and vascular staplers arm, while one bipolar vessel sealer had to be replaced (p=ns). Bipolar vessel sealer decreased operative time by 106 minutes (p=0.04) for total colectomies and by 33 minutes (p=0.04) for right colectomies. Moreover, the bipolar vessel sealer reduced instrument costs by $446.9 in total colectomies and by $85.9 (p=0.07) in right colectomies. There were no significant differences in operative time and cost for left colectomies. swiss knife 2009; special edition 61
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Abstracts 96. Jahreskongress der Sc
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Der Jahreskongress der Chirurgische
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High Definition - Wenn das Detail e
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Visceral Surgery - Transplantation
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Page 45 and 46: Results: Fifty-seven patients (34.3
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Page 51 and 52: 2-34.3 weeks), respectively. Use of
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Abstracts - Chirurgie Kongress

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