For more information please see: www.baxter.ch C: Two-component biological adhesive consisting of a Tissucol-aprotinin solution (fibrinogen, aprotinin, plasminogen, factor XIII, human albumin and plasma fibrinogen) and a solution of thrombin-calcium chloride.I: Stypsis (including parenchymal tears with diffuse bleeding), as a sealant (including vessel prosthesis, closure of torn membranes), tissue adhesion (reduces the need for stitches in regions where there is little mechanical load) and to support wound healing. D: The volume of Tissucol solution depends on the size of the areas to be stuck together or covered, or on the size of the tear to be filled. It also depends on the technique of application involved. CI: Known hypersensitivity to bovine protein or any other substance present. Do not inject into the nasal mucosa. P: Injection of the Tissucol and/or Thrombin solution bears the risk of an anaphylactic reaction. Intravasal (i.e. hemangioma) or intraventricular application bears the additional risk of a thromboembolic complication. AE: In very rare cases, existing hypersensitivity to bovine protein (aprotinin) or repeated use can result in allergic or anaphylactic reactions. If the symptoms require treatment, then standard measures should be taken e.g. administration of antihistamines, corticosteroids or adrenaline. IA: None known. Tissucol can be used in patients who are fully heparinised e.g. undergoing extracorporeal circulation. Sales Category B. Last updated Nov. 2006. Distribution: Baxter AG, 8604 Volketswil Further information are available in the current issue of the “Arzneimittel-Kompendium der Schweiz”. Please note: in Switzerland Tisseel is distributed under the tradename Tissucol Kit / Tissucol Duo S Baxter AG Müllerenstrasse Müllerenstraße 3 In some countries TISSEEL Fibrin Sealant is licensed under the trademark TISSUCOL Fibrin Sealant. BAXTER, TISSEEL, TISSUCOL and ADVANCING SURGERY, ENHANCING LIFE are trademarks of Baxter International Inc. 03.001.4.01.0108 January 2008 8604 Volketswil Volketsvil Tel 044 908 50 50 Fax 044 908 50 40 b
5.6 What is the best transperitoneal surgical technique for living kidney donor surgery? M. Matter, J.-P. Venetz, M. Pascual, N. Demartines (Lausanne) Objective: Minimal invasive nephrectomy (MIN) has been proven to be as safe as the open technique without influencing significantly the graft function. MIN can be classified either by the route (transperitoneal or retroperitoneal) or the technique (hand assisted or totally minimally invasive). We compare our experience with the latter two through a transperitoneal approach. Methods: Between 1997 (start of MIN) and 2008, 105 MIN were performed using successively total laparoscopy (MINT) in 45 (1997-2004) and hand assistance (MINH) in 60 (2005-2008), mainly by using GelPortÒ. Results: The table shows that for comparative groups of patients, the main influence of surgical technique is the significant decrease of time for nephrectomy time and total operative time. We observed no case of delayed graft function and no renal vein thrombosis. Overall postoperative morbidity was 6,7% : 2/45 MINT patients and 5/60 MINH patients (NS). Conclusion: In this comparative but not randomized study MIN (either MINT or MINH) was safe and associated with excellent results. The introduction of Hand-assistance (MINH) in our program increased safety by controlling hemostasis (less conversions), facilitated dissection, (presenting vessels for stapling) and facilitated kidney extraction. It translanted into a significantly reduced surgery time. We currently only use MINH in our living kidney donation program. 5.7 In situ split liver transplantation: results of right lobe grafts in adults P. Majno, E. Giostra, P. Morel, L. Buhler, O. Huber, M. Bednarkiewicz, T. Berney, G. Mentha (Geneva) Objective: despite technical refinements in liver surgery, the use of right lobe grafts issued of a split procedure is to some extent controversial in the opinion of adult transplant centers. Methods: retrospective analysis on a prospective database of 519 liver transplants performed in our centre. Since November 1999, 11 right grafts issued from in situ splits performed by our team have been used in adult patients, representing the study population. For the first period, concerning 5 patients, Child C status was considered as a contraindication, a restriction not implemented thereafter. Results: Donor age ranged from 18 to 78 years. Recipients were between 33 and 66 years old (median 50 years). Cold ischemia times ranged from 4 to 9 hours (median 6h). There were no vascular complications. Biliary complications occurred in two patients and were solved by surgical revision of the anastomoses. Reoperation was needed in a further case, for peritoneal lavage in a patient with indolent peritoneal infection (total reoperation rate 27%). After median follow up of 3.1 years, overall survival in the series was 91% (one patient died at 23 months from progressive atypical amyloid disease). One patient had persistent neurological damage after status epilepticus associated with Imipenem and Cyclosporine. Conclusion: in the current era of organ shortage, in situ SLT appears justified despite the increased work burden inherent to the procedure, as it generates grafts of superior quality, resulting in excellent patient and graft survival. Technical problems of the procedure concern the biliary anastomosis and the procedure may be ill advised in patients who could not stand a re-operation. Visceral Surgery – General & Bariatrics 06 6.1 Surgical glove perforation and the risk of surgical site infection H. Misteli 1 , W. Weber 1 , S. Reck 1 , R. Rosenthal 1 , M. Zwahlen 2 , P. Fueglistaler 1 , D. Oertli 1 , A. Widmer 1 , W. Marti 1 ( 1 Basel, 2 Bern) Objective: While surgical glove leakage is a known risk factor in the transfer of pathogens during surgery, the implications in asepsis for the development of surgical site infections (SSI) has not been investigated. The present study was conducted to test the hypothesis that clinically visible surgical glove perforation is associated with an increased SSI risk. Methods: The data for this prospective observational cohort study of 4147 surgical procedures were collected between January 1, 2000 and December 31, 2001 at Basel University Hospital. All procedures performed in the Vascular, Visceral and Traumatology Divisions were enrolled. Outcome of interest was the incidence of SSI which was assessed pursuant to Centers for Disease Control and Prevention standards. Eighty two variables were recorded for each surgical procedure. The main predictor variable was compromised asepsis due to visible glove perforation. The use of single gloves was standard practice. Prophylactic antibiotic administration was standardized to the Centers for Disease Control and Prevention guidelines. Patients received prophylactic antibiotics if they underwent surgery classified as wound class 1-3. Wound class 4 was excluded because of peri- and postoperative antibiotic therapy. Results: The overall SSI rate was 4.5% (188/4147). Univariate logistic regression analysis showed a higher likelihood of SSI in procedures in which gloves were perforated compared to interventions with maintained asepsis (odds ratio = 1.98; 95% confidence interval, 1.4 to 2.8; p < 0.001). However, multivariate logistic regression analyses showed that the increase of SSI risk with perforation of gloves was different for procedures with compared to procedures without surgical antimicrobial prophylaxis (test for effect modification: p=0.005). Without antibiotic prophylaxis, glove perforation entailed significantly higher odds of SSI compared to the reference group with no breach of asepsis (adjusted odds ratio = 4.24; 95% confidence interval, 1.7 to 10.8; p=0.003). On the contrary, when surgical antimicrobial prophylaxis was applied, the likelihood of SSI was not significantly higher for operations in which gloves were punctured (adjusted odds ratio = 1.25; 95% confidence interval, 0.85 to 1.85; p=0.263). Conclusion: Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI. 6.2 Optimisation de la gestion d’un centre hospitalo-universitaire grâce à l’introduction d’un référentiel procédural informatisé - résultats d’une évaluation prospective Y. Beckius, S. Richter, M. Bolli, P. Jacob, M. K. Schilling (Homburg/Saar/DE) Objective: Un référentiel procédural et clinique informatisé représente un outil de gestion permettant d’optimiser les démarches dans le management hospitalier au quotidien. Une mise en ligne d’un tel référentiel sur le réseau interne d’information et de renseignement d’un hôpital permet une analyse et optimisation des démarches. Jusque-là aucune évaluation d’un tel système n’a vu le jour. Methods: Nous avons analysé dans une étude prospective à 2 temps 67 cas avant et 62 cas après introduction d’un référentiel informatisé «evidence based». A chaque patient fut attribué son référentiel respectif avec une faible complexité de cas (éventration, artériopathie oblitérante des members inférieurs), complexité moyenne (cancer colo-rectal, anévrysme de l’aorte abdominale) ou complexité élevée (métastases hépatiques, cancer de la tête du pancréas). Les paramètres relevés étaient: la durée de l’hospitalisation; le nombre d’avis demandés, d’examens complémentaires (biologiques et d’imagerie) et l’évaluation de la satisfaction des patients. Results: Grâce à l’introduction d’un référentiel procédural et clinique informatisé la durée moyenne d’hospitalisation a pu être réduite de 14% surtout pour les cas de complexité moindre (10,4±0,8 contre 6,7±0,3) et moyenne (14,5±1,0 contre 12,4±0,7). La durée du séjour pré-opératoire a pu être réduite de façon significative de 2,6±0,5 à 1,4±0,1 jours. A également pu être observée une réduction significative du nombre d’analyses sanguines (paramètres d’urgence 6,9±0,6 contre 2,6±0,4, numération formule sanguine 7,9±0,7 contre 3,2±0,4, crase 7,9±0,7 contre 3,2±0,4, autres 4,5±0,6 contre 1,2±0,2), de demandes d’avis et d’examens d’imagerie (radiographies standard). Le délai d’envoi du courrier et des rapport médicaux s’est raccourci significativement de 15,5±2,4 à 10,5±1,2 jours. On observait en outre une amélioration de la satisfaction des patients. Conclusion: L’introduction d’un référentiel procédural et clinique informatisé permet de raccourcir la durée d’hospitalisation et de réduire le nombre d’examens complémentaires désuets et par ce biais une réduction et une meilleure maîtrise des dépenses. Par ailleurs peut être réalisée une meilleure satisfaction des patients. Ceci peut être rendu possible par l’intégration du référentiel informatisé dans le réseau d’information et renseignement interne. 6.3 Brauchen wir spezielle Weiterbildner in der <strong>Chirurgie</strong>? U. Neff, B. Muff (Bülach) Objective: Eine effiziente Weiterbildung steht in der Medizin, besonders in der <strong>Chirurgie</strong> unter zunehmendem, massiven Druck. Hauptursache der unbefriedigenden Weiterbildung sind einerseits die Erhöhung der Forderungen an die Weiterbildung durch die Standesorganisation FMH und das Bundesamt für Gesundheit (BAG), andererseits der steigende Druck an die Wirtschaftlichkeit des Kaders in unseren Spitälern. Zusätzlich kommen Veränderungen des Berufsbildes und seiner Rahmenbedingungen. Die Schere zwischen dem Möglichen und den Forderungen öffnet sich zusehends. Das Kader sieht sich daher ausserstande, die nötige effiziente Weiterbildung alleine zu erbringen. Methods: Als Versuch diese Missstände zu verbessern, wurde an unserer Klinik ein Pilotprojekt mit einer Teilzeitstelle eines Leitenden Arztes für Weiterbildung der Assistenten gestartet. Das Pflichtenheft dieses Weiterbildners besteht aus persönlichem, praktischen Teaching des ärztlichen Berufes wie z.B. Begleitung auf der Stationsvisite mit strukturiertem Feedback, individuelles Instruieren von Untersuchungstechniken, sowie bei Problemen im Umgang mit Patienten und Vorgesetzten. Zusätzlich steht er für Fragen des beruflichen Alltages und der Karriere zur Verfügung. Ausgenommen in seinem Pflichtenheft sind die Assistenz im Operationssaal , welche vom regulären Kader erbracht wird, und reine Theorievorträge. Das Gruppenteaching erfolgt am Patienten oder Demonstrationsmodell über Themen wie Untersuchungen von Hernien, Einlage einer Bülau-Drainage, Weiterschulung in Patientengesprächen, Vorbereiten von Rapporten und Betreuung des Journal-Clubs. Eine „Down-to-Top-Umfrage“ gibt Anregungen an das Kader. Results: Diese spezielle Weiterbildung hat sich in einer internen halbjährlichen Umfrage bewährt. Erstaunlicherweise hat sie keinen Niederschlag in der Beurteilung der Weiterbildungsstätten (FMH) gefunden. Ein Umstand der Fragen über die Wertigkeit dieser Umfrage aufwerfen könnte. Als Voraussetzung muss der Weiterbildner sowohl ein guter Kliniker, als auch über pädagogische Kompetenz verfügen. Dank dieser Weiterbildung finden sich die jungen, unerfahrenen Assistenten rascher im Arbeitsprozess zurecht und vermögen besser und effizienter ihre Aufgaben zu erfüllen. Conclusion: Strukturierte Weiterbildung ist ein wesentliches Mittel, Interesse an der <strong>Chirurgie</strong> zu wecken und die Motivation zu steigern, dieses Fach zu wählen. 6.4 3D vision enhances task performance independent of the surgical method O. J. Wagner 1,2 , M. E. Hagen 1 , S. Horgan 1 , G. Jacobsen 1 , M. Talamini 1 , A. Kurmann 2 , D. Candinas 2 , S. A. Vorburger 2 ( 1 San Diego/USA, 2 Bern) Objective: Despite obvious advantages of minimally invasive surgery (MIS), laparoscopy (LAP) lacks natural stereoscopic depth perception and spatial orientation. Therefore, these 2 parameters appear to represent mayor downsides of MIS. Still, the importance and overall negative effect of this lack of natural stereoscopic depth perception and spatial orientation has not been clearly demonstrated. The aim of this study was to evaluate if three-dimensional (3D) visualization improves surgical skills and task performance when compared to two-dimensional (2D) vision. Methods: 34 individuals with different surgical knowledge were evaluated. Each individual performed swiss knife 2009; special edition 9
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