Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

swissknife spezial 06 12.06.2006 13:39 Uhr Seite 10
pic colectomy in uncomplicated, recurrent diverticulitis. However, early laparoscopic management
has the advantage of one hospitalisation in opposite to primary medical treatment of
acute diverticulitis and secondary hospitalisation for elective procedure.
1.06
D. Wondberg 1 , U. Zingg 2 , U. Metzger 3 , A. Platz 4
1 Surgery, Triemli Hospital, 8063 Zürich/CH, 2 Departement of Surgery, Triemli Hospital Zürich,
8063 Zürich/CH, 3 Chirurgie, Stadtspital Triemli Zürich, Zürich/CH, 4 Chirurgie, Stadtspital
Triemli, Zürich/CH
V.A.C. ® Abdominal Dressing System in left open abdomen in patients with secondary peritonitis
Objective: In the management of secondary peritonitis, it may be necessary to leave the abdomen
open. The V.A.C. ® Abdominal Dressing System (ADS), KCI, San Antonio, Texas, was especially
designed for temporary closure of left open abdomen. Delayed primary facial closure or
planned ventral hernias with secondary elective repair are the underlying concepts.
Methods: All patients with secondary peritonitis and consecutively left open abdomen treated
with the V.A.C. ® ADS between 2002 and 2006 were analysed.
Results: 17 patients were treated with the V.A.C. ® ADS. Median age was 63 years (31-85).
Hospital lethality was 35%. Indications for initial operations were: bowel perforation 8
(47.2%), bowel obstruction 3 (17.6%), sepsis with unclear localisation 3 (17.6%), other 3
(17.6%). 15 out of 17 (88.2%) were performed as emergencies. Indications for the V.A.C. ®
ADS were: persistent abdominal sepsis 8 (47.1%), dehiscence of abdominal facia 7 (41.2%),
ischemia 1 (5.9%), abdominal compartment 1 (5.9%). The median of V.A.C. changes per
patient was 9 (3-18). Specific complications of the V.A.C. ® ADS were: enterocutaneous fistulas
2 (11.8%), localized facial necrosis 4 (23.5%), tension skin blisters 1 (5.9%). The interval
to normalized intraabdominal condition was median 10 days (0-30). Primary facial closure
was feasible in 3 patients (17.6%). 10 patients (58.8%) were treated with inlay resorbable
mesh and consecutive skin mesh grafting, resulting in a giant ventral hernia. 4 patients
(23.5%) died before abdominal closure was possible. Out of 10 patients with giant ventral
hernia, 6 were readmitted for closure of the hernia. Median interval was 5 months (4 – 12).
Conclusion: In patients with left open abdomen in secondary peritonitis, the V.A.C. ® ADS offers
an effective temporary closure. Each change allows a thorough abdominal lavage. Serious
complications are rare and may not be caused by the system itself. However, in patients with
secondary peritonitis, delayed primary facial closure was not always possible. Almost 60%
had to be treated with inlay resorbable mesh and skin grafting, followed by secondary closure
months later. The visceral edema as well as the massive adhesions between small bowel
loops does not always allow a primary closure. Instead of forcing a primary closure with the
potential risk of a compartment syndrome, we favoured the mentioned two step procedure.
1.07
I. Frésard1 , P. Morand2 , J.M. Michel2 , M. Bergmann3 , L. Krähenbühl4 1 2 Chirurgie Générale, Hopital cantonal Fribourg, 1700 Fribourg/CH, Chirurgie Générale,
Hôpital Cantonal Fribourg, Fribourg/CH, 3Institut Anatomie, Université Fribourg, Fribourg/CH,
4Chirurgie, Hopital cantonal de Fribourg, 1700 Fribourg/CH
Enseignement de procédures complexes en chirurgie laparoscopique: apport de l'enseignement
sur cadavres conservés selon la méthode de Thiel
Objective: Avec l’essor de la laparoscopie depuis le début des années 90, des interventions
de plus en plus complexes sont réalisées par cette voie d’abord. Ces procédures requièrent
l’acquisition de compétences particulières. De nombreux programmes pour l’entrainement
des bases psychomotrices en laparoscopie ont vu le jour notamment sur pelvi-trainers et
simulateurs. En ce qui concerne les procédures plus complexes, des cours sur animaux
notamment sur des cochons ont été mis en place, qui ont le désavantage d’une anatomie qui
peut différer de celle rencontrée lors d’interventionen sur des patients. Les simulateurs quant
à eux n’offrent pas encore la possibilité d’exercer les interventions complexes, ce que permettent
les cours sur cadavres conservés selon la méthode de Thiel.
Methods: Les données ont été récoltées au moyen de questionnaires remplis par les participants
aux divers cours organisés par le Swissendos à Fribourg durant les années 2003-
2005 (cours de chirurgie bariatrique, colo-rectale, vasculaire, hernies). Les cadavres ont été
préparé selon la méthode de Thiel (Ann Anat 1992, 174 :185-195), qui permet de conserver
aux tissus leur élasticité et un aspect proche de celui rencontré lors d’interventions réelles.
Results: Le nombre total de questionnaire est de 327 pour des cours comprenant chirurgie
bariatrique, colo-rectale, hernies et 1 cours de chirurgie vasculaire (n=10). Les chiffres sont
donnés sous forme de moyenne, sur une échelle de 1-6, 6 étant la meilleure note : aspect des
tissus 5.7, consistance 5.5, repères anatomiques bien identifiables 5.7, apport pour la pratique
5.7, satisfaction globale 5.7 et 94% des participants recommanderaient le cours. Bien
que non statistiquement significatif, des résultats moins bons ont été obtenus pour cours de
chirurgie aortique avec note de satisfaction de 4.6.
Conclusion: Devant la complexité croissante des interventions réalisées par voie laparoscopique,
l’entrainement sur cadavres conservés selon la méthode de Thiel offre la possibilité de
pratiquer diverses procédures très différentes (chirurgie viscérale, thoracique, vasculaire,
gynécologie) répondant ainsi à la demande croissante d’aquérir des compétences spécifiques
hors du bloc opératoire. Bien que cette méthode s’applique mieux à certains types de
procédures et qu’un savoir faire spécifique joue un rôle important dans la conservation des
tissus, il s’agit de la méthode qui offre les conditions les plus réalistes, que ce soit en ce qui
concerne les repères anatomiques, la consistance des tissus ou la sensation tactile et qui surpasse
à l’heure actuelle les exercices sur animaux ou simulateurs.
1.08
R. Ipaktchi 1 , G. Beldi 2 , N. Haupt 3 , M.M. Wagner 4 , M. Peter 5 , D. Candinas 6
1 DMLL, Klinik und Poliklinik für Viszerale und Transplantationschirurgie, 3010 Bern/CH, 2 Clinic
of Visceral and Transplantation Surgery, Inselspital Bern, 3010 Bern/CH, 3 University of Bern,
University of Bern, Bern/CH, 4 Vchk, Inselspital, 3011 Bern/CH, 5 DMLL, Klinik und Poliklinik für
Viszerale und Transplantationschirurgie, Bern/CH, 6 Vchk, Inselspital, Bern/CH
Tissue adhesive versus stapler for mesh fixation in laparoscopic inguinal hernia repair: a prospective,
randomised observer blinded study
Objective: The laparoscopic approach is widely accepted for inguinal hernia repair but requires
mesh placement. There is an ongoing debate on the ideal mesh fixation technique as this
might relate to postoperative pain and hyperalgesia. Aim of this randomised study was to
10 swiss knife 2006; special edition
compare mesh fixation with tissue adhesive (N-butyl-2 Cyanoacrylat, Glubran ® ) versus stapler
(Protak ® ) fixation.
Methods: At this interims analysis a total of 39 hernia operations were included. In group A the
mesh was fixed using staplers (n=18) and in group B tissue adhesive was used (n=21). Both,
patients and physicians performing the postoperative follow-up at 6 wks and 6 mts were blinded.
In all patients localisation, and intensity of pain and numbness in the groin was assessed
using „von Frey hairs” which is a means that allows a quantitative and qualitative sensitivity
assessment. Visual analogue scale was used to assess postoperative pain. Values are
indicated as mean ± SD.
Results: No intra- and postoperative complication occurred. Mean length of stay in group A
was 4.5 d (± 0.7) and in group B 4.5 d (± 0.7) without statistical significant difference. There
was no recurrence in either group at 6 months. At 6 weeks the intensity of pain (VAS) in group
A was 1,7 ± 0,7, in group B 0,4 ± 0,2 (p=0,03). After 6 months the intensity of pain (VAS) in
group A was 1,5 ± 0,6 and in group B 0,8 ± 0,4 (p=0,3).
Conclusion: The use of tissue adhesive instead of stapler for mesh fixation significantly lowers
the incidence of postoperative pain following laparoscopic groin hernia repair without increasing
recurrence rate.
1.09
J. Renggli1 , F. Chèvre2 , L. Regusci3 , E.X. Delgadillo2 , C. Becciolini4 , M. Merlini5 1 2 Surgery, EHM, La Chaux-de-Fonds, 2300 La Chaux-de-Fonds/CH, Surgery, La Chaux-de-
Fonds, 2300 La Chaux-de-Fonds/CH, 3Service De Chirurgie, Hôpital de La Chaux-de-Fonds,
2300 La Chaux-de-Fonds/CH, 4Surgery, La Chaux-de-Fonds, La Chaux-de-Fonds/CH,
5Surgery, Hôpital de La Chaux-de-Fonds, 2300 La Chaux-de-Fonds/CH
Laparoscopic treatment of evisceratioin: preliminary results of a prospective non-randomized
study
Objective: Laparoscopic treatment of an abdominal evisceration, first described in 1993, is a
safe and recognized technique. It allows a lower postoperative morbidity and a shorter hospital
stay.
Methods: The aim of our prospective non-randomized study was analyse the results of laparoscopic
evisceration treatment with implantatioin of composite mesh (Parietex Composite ® )
Results: From October 2003 to December 2005 (26 months), 59 patients (32 men, 27
women; mean age 60.3 (25-82)) were operated at the Department of Surgery, General
Hospital EHM, La Chaux-de-Fonds, Switzerland. The mean Body Mass Index was 28.79 (18.3
– 43). The ASA score of the studied population was: ASA 1: 5 patients; ASA 2: 34 patients; ASA
3: 20 patients. The size of the evisceration extended between 3 to 20 cm (mean 12.6 cm). The
mean duration of the procedure was 113 minutes and the mean duration of the hospital stay
was 5.8 days (3-16). The main postoperative complications were an early recurrence necessitating
a reintervention, a small suprapubic recurrence (not operated), 7 cases of postoperative
pain facing the deep fixation of the mesh and 5 minor complications (1 subileus, 1 lower
urinary tract infection, 3 seromas).
Conclusion: The preliminary result of this study show that a laparoscopic treatment is feasible
for a large number of postoperative eviscerations with a short hospital stay and a low morbidity
rate.
02
2.01
I. Tarantino 1 , B.P. Müller-Stich 2 , M. Zünd 1 , J. Lange 3 , A. Zerz 1
1 Departement of Surgery, Kantonsspital St.Gallen, 9007 St.Gallen/CH, 2 Surgery,
Kantonsspital St.Gallen, 9000 St.Gallen/CH, 3 Surgery, Kantonsspital St.Gallen, St.Gallen/CH
Endoscopic posterior mesorectal resection: a new approach to treatment of T1-carcinomas
of the lower third of the rectum.
Objective: Transanal excision (TE) of T1 carcinomas of the lower third of the rectum (T1-clr)
has become an established procedure although a not negligible risk of loco-regional recurrence
has been reported. This potentially increased risk is tolerated due to the known high morbidity
and mortality rates after transabdominal rectal resection. Dorsoposterior extraperitoneal
pelviscopy makes it possible to remove the relevant lymphatic field of the lower third of the
rectum from perineal, in the sense of a rectum-sparing endoscopic posterior mesorectal
resection (EPMR).
Methods: A TE was performed in patients with a tumour of the lower third of the rectum endosonographically
confined to the mucosa or submucosa and no evidence of malignant lymph
nodes. After completion of the usual staging we offered patients with histological confirmation
of a T1-clr, as an alternative to simple clinical controls every three month, an EPMR. This
second intervention was performed four to six weeks after the TE.
Results: We operated on thirteen patients with T1-clr by TE in combination with EPMR as a two
stage procedure. It was possible to perform a complete excision of the primary and to resect
the posterior part of the mesorectum in all cases. There was no intraoperative bleeding and
the operating time ranged from 45 to 125 minutes. In two cases an intraoperative rectal perforation
occurred with no prostoperative relevance. Postoperative morbidity consisted of two
transient neurological complications and a pulmonary embolism. There was no perioperative
mortality. Histological analysis revealed a median of 8 (range, 4-20) lymph nodes within
the resected part of the mesorectum. Two patients diagnosed with lymph node metastases
received an adjuvant radiochemotherapy. After a median follow-up of 48 (range, 4-78)
months there was no evidence for loco-regional recurrence. In one patient with negative
lymph nodes but vessel infiltration liver metastasis was detected 8 month postoperatively.
Conclusion: In conclusion the EPMR is a safe and effective option in treatment of T1-clr after
TE. It has to be considered whether EPMR in combination with TE allows for local radicality
and an adequate tumor staging in T1-clr, in terms of a better directed therapy planning compared
to TE alone.
2.02
M. Arigoni 1 , S. Breitenstein 2 , A. Heigl 3 , S. Arma 4 , F. Fasolini 4 , C. Meier 5 , M. Decurtins 6
1 Chirurgia, Ospedale Regionale di Lugano, 6903 Lugano/CH, 2 Department of Visceral and
Transplantation Surgery, University Hospital Zurich, 8091 Zurich/CH, 3 Chirurgie, Kantonsspital
Winterthur, 8400 Winterthur/CH, 4 Chirurgia, Ospedale Beata Vergine, 6850 Mendrisio/CH,
5 Chirurgie, Stadtspital Triemli, Zürich/CH, 6 Chirurgische Klinik, Kantonsspital, 8401
Winterthur/CH