Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE
Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE
Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE
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swissknife spezial 06 12.06.2006 13:39 Uhr Seite 30<br />
15.09<br />
T.S. Vetter 1 , L. Labler 2 , O. Trentz 2<br />
1 Division of Traumasurgery, Universityhospital Zürich, 8091 Zürich/CH, 2 Chirurgie, Klinik für<br />
Unfallchirurgie, 8091 Zürich/CH<br />
Cervical spine fractures in the el<strong>der</strong>ly<br />
Objective: Cervical spine fractures in the el<strong>der</strong>ly patient are relatively common. The management<br />
of such injuries may be complicated due comorbidities and osteopenia. The aims of this<br />
study were to evaluate clinical outcome in el<strong>der</strong>ly patients with cervical spine fracture and to<br />
analyse different treatment-strategies.<br />
Methods: The records of patients with acute cervical spine fractures were reviewed from 1997<br />
to 2003. Patients ol<strong>der</strong> than 60 were analysed separately from younger patients to determine<br />
differences in ethiology, fracture location, neurologic findings, associated injuries,<br />
management and mortality.<br />
Results: We treated 180 patients with cervical fractures in this period. The mean age was<br />
52±1 years and 57%(n=128) were male. Seventy-one (39%) were ≥ 60 years old. The leading<br />
injury mechanism was fall from standing at home or outside. Fractures were mostly diagnosed<br />
on levels C1(18%) and C2(48%) compared to C6/C7 (42%) in young patients<br />
(p=0.000001). Neurological deficits occurred in 28%(n=20) with Frankle score A 1.5%(n=1),<br />
B 13%(n=9) and C 3%(n=2) and were more common than in younger patients (p=0.001).<br />
The mean ISS in the el<strong>der</strong>ly was 14±1. Most common associated injuries were to the head<br />
(52%) and upper extremities (20%). Surgical stabilisation was performed in 31 (44%) el<strong>der</strong>ly<br />
and 61 (56%) younger patients (p=0.0001). The hospital stay and the postoperative ICU<br />
surveillance showed no significant difference between the both groups. The overall mortality<br />
rate of the el<strong>der</strong>ly patients was 12% and 38% in the group with neurological deficits.<br />
Conclusion: Falls among the el<strong>der</strong>ly, including same level falls, are a common source of mostly<br />
upper cervical spine fractures. About 34% had neurological deficits with a high mortality<br />
rate.<br />
15.10<br />
R.F. Stärkle 1 , H.B. Fahrner 1 , M. Furrer 2<br />
1 Departement Chirurgie, Kantonsspital Chur, 7000 Chur/CH, 2 Chirurgie, Kantonsspital Graubünden,<br />
7000 Chur/CH<br />
Intra-operative neuromonitoring of the laryngeal nerve in thyroid surgery: mandatory or nice<br />
to have?<br />
Objective: A major complication in thyroid surgery is recurrent laryngeal nerve (RLN) palsy.<br />
We performed a prospective systemic evaluation of the intraoperative neuromonitoring after<br />
having introduced this method in our routine surgical practice.<br />
Methods: 64 nerves at risk in 52 thyroid procedures were evaluated in 47 patients (15 male,<br />
32 females, mean age 49.7 years) between I/2005 and II/2006. The pathologies were 31<br />
benign goiter, 16 thyroid cancer and 5 Graves’ disease. There were 41 primary operations, 8<br />
contralateral completion thyreoidectomies and three recurrent procedures. In one case of<br />
extensive cancer infiltration a resection of the RLN had to be performed on one side for oncological<br />
reasons (this nerve at risk was excluded). All patients were examined before and after<br />
operation by an experienced ENT specialist. Postoperatively all surgeons judged the value of<br />
the method in a standard questionnaire.<br />
Results: Mean time for the intraoperative neuromonitoring was 5.42 min. 59 nerves could be<br />
identified and correctly stimulated. None of the five nerves without satisfied signals during<br />
monitoring showed postoperative nerve palsy. Intraoperative monitoring by the surgeons was<br />
judged to be „not useful” in two, „no opinion” in 7 and „reasonable method” in 38 cases (positive<br />
feedback in 86%). In 5 procedures (9.6%) the dissection was directly influenced due to<br />
the intraoperative results of monitoring. At the immediate postoperative ENT control 4 cases<br />
(6.2%) (two cancer, one Greaves’ disease, one benign goiter) had signs of an at least temporary<br />
laryngeal nerve palsy, while only two (3.1%) had clinical signs (both cancer cases). In all<br />
four cases with postoperatively reduced movement of the vocal cord the intraoperative neuromonitoring<br />
was consi<strong>der</strong>ed to be normal. ENT follow-up of these patients is planned but not<br />
completed so far.<br />
Conclusion: The neuromonitoring was judged to be a useful tool almost for unexperienced<br />
surgeons during their surgical training. Intraoperative monitoring of the RLN may contribute to<br />
a more precise and save dissection of the nerve mainly in difficult recurrent or cancer cases.<br />
15.11<br />
M. Naef 1 , W.G. Mouton 2 , H. Wagner 2<br />
1 Surgical Department, Spital Thun-Simmental AG, 3600 Thun/CH, 2 Surgery, Spital Thun-<br />
Simmental AG, 3600 Thun/CH<br />
Fournier's gangrene: A rare complication after hemorrhoidectomy<br />
Objective: Fournier's gangrene is a necrotizing fasciitis involving the genital, perianal or perineal<br />
regions. The source of infection is anorectal in 33%, of whom a condition after hemorrhoidectomy<br />
is very rare. A mortality rate of up to 45% is described.<br />
Methods: We present a case report of a female patient with a Fournier's gangrene after<br />
hemorrhoidectomy for acute hemorrhoidal thrombosis.<br />
Results: A 41-years old female patient was operated for acute hemorrhoidal thrombosis; one<br />
nodule was excised only and the wound left open. Single shot antibiotics were given. The<br />
patient was discharged the following day after uneventful course. Four days after the operation<br />
the patient had to be readmitted due to crampy pain in the lower abdomen and difficulties<br />
to urinate. The local investigation showed a swollen perineum without any signs of skin necrosis;<br />
the rectal examination was painful. The C-reactive protein at admission was 388 mg/l.<br />
The patient had to be treated for a septic shock including intubation and antibiotics. CT scan<br />
showed pelvic inflammatory changes in the retroperitoneum, beginning at the anal canal.<br />
With the working diagnosis of a Fournier's gangrene the patient was immediately taken to the<br />
operating room. Rectoscopy showed dorsally necrotic mucosa of the anal canal. Bilateral<br />
perianal broad incisions and necrosectomy with drainage was performed. At laparotomy<br />
retroperitoneal necrosis was found from the hilus of the liver along the great vessels to the pelvis.<br />
The small and large bowel were both vital. A double loop colostomy was carried out. The<br />
postoperative course was prolonged due to a multiple organ system failure with sepsis, ARDS<br />
and disseminated intravasal coagulation. Microbiology revealed E. coli and streptococci. The<br />
patient had to be kept for 20 days in the ICU; after another 10 days in the surgical ward the<br />
30 swiss knife 2006; special edition<br />
patient could be discharged. A follow-up after 3 and 6 weeks showed no sequelae and the<br />
colostomy could be closed after 3 months.<br />
Conclusion: The major complications of Fournier's gangrene, such as ARDS, heart failure,<br />
renal failure, bleeding due to DIC and hypocalcemia, are related to the degree of sepsis at presentation<br />
and require appropriate supportive management. Known poor prognostic factors<br />
are age, female gen<strong>der</strong>, anorectal causes, number of organ failures at admission, diabetes<br />
and HIV. Prompt clinical recognition, polymicrobial treatment and early surgical debridement<br />
are the cornerstones of successful treatment.<br />
15.12<br />
A. Scheiwiller 1 , F. Holzinger 2 , D. Giachino 3 , S.M. Birrer 4<br />
1 Allgemeine- Viszerale- Und Thoraxchirurgie, Spital Bern Tiefenau, 3004 Bern/CH, 2 Klinik für<br />
Allgemeine-, Viszerale- Und Thoraxchirurgie, Spital Bern Tiefenau, 3004 Bern/CH, 3 Chirurgische<br />
Klinik, Spital Bern Tiefenau, 3004 Bern/CH, 4 Chirurgische Klinik, Spital Bern-Tiefenau,<br />
3004 Bern/CH<br />
Unerwartetes, grosses Leiomyom des distalen Oesophagus bei laparoskopischer<br />
Versorgung einer Hiatushernie Typ III: Wie weiter?<br />
Objective: Bei einer 56-jährigen Patientin wird bei schwerer Anämie (Hb 40 g/l) eine<br />
Hiatushernie Typ III diagnostiziert. Die Indikation zur laparoskopischen Operation wird gestellt.<br />
Intraoperativ tritt überraschend eine knotige Tumormasse im Bereiche des distalen<br />
Oesophagus auf. Wie weiter?<br />
Methods: Fallbericht mit Literaturreview<br />
Results: Nach Reposition des transhiatalen Bruchsackes kommt unerwartet eine knotige,<br />
hemizirkuläre Tumormasse im Bereich des distalen Oesophagus zum Vorschein<br />
(6,5x3,5x2,5cm). Bei V.a. Leiomyom des Oesophagus wird <strong>der</strong> Tumor aus <strong>der</strong><br />
Oesophaguswand enukleiert. Die Schnellschnittuntersuchung bestätigt die<br />
Verdachtsdiagnose. Die Operation wird laparoskopisch fortgesetzt mit Verschluss <strong>der</strong><br />
Myotomie und Deckung mittels Fundoplikatio nach Nissen.<br />
Conclusion: Das Leiomyom macht 5-10% aller Oesophagustumore aus. Die Coexistenz mit<br />
einer Hiatushernie liegt bei 20%. Das Leiomyom tritt vor allem im distalen und mittleren Drittel<br />
des Oesophagus auf. Die Mehrheit (50-85%) <strong>der</strong> Tumore sind asymptomatisch bzw. verursachen<br />
unspezifische Symptome, welche von <strong>der</strong> Tumorgrösse abhängig sind (>5cm oft symptomatisch).<br />
Sie werden präoperativ, wie in unserem Fall, nicht selten verpasst und manifestieren<br />
sich erst intraoperativ nach Reposition des Bruchsackes. Die laparoskopische (unteres<br />
Drittel) bzw. thorakoskopische (mittleres Drittel) Resektion gilt heute als Methode <strong>der</strong><br />
Wahl. Die Leiomyome sind wie in unserem Fall meist exzentrisch wachsend und gut abgekapselt,<br />
so dass sie sich relativ leicht enukleieren lassen. Die Myotomie wird nach Einstülpen<br />
<strong>der</strong> Mukosa mit EKN verschlossen und bei distaler Lokalisation mittels Nissen-Fundoplikatio<br />
gedeckt. Bei Tumoren >8cm kann die Myotomie oft nicht spannungsfrei verschlossen werden,<br />
so dass ein gestielter Omentum-Flap eingenäht werden muss. Gründe für eine<br />
Oesophagusresektion können sein: giant Leiomyoma (>10cm, 5% aller Leiomyome), ausgedehnte<br />
Mukosadefekte nach Tumorentfernung, ein distales Uebergreifen auf die Kardia sowie<br />
V.a. Leiomyosarkom. Häufigste postoperative Komplikation ist die Entwicklung eines<br />
Pseudodivertikels bei ungenügendem Myotomieverschluss. Wie unser Beispiel zeigt, lässt<br />
sich bei ausreichen<strong>der</strong> Erfahrung das Auftreten eines unerwarteten Leiomyomes bei <strong>der</strong><br />
Hiatushernienoperation auf laparoskopischem Wege lösen.<br />
15.13<br />
T.S. Müller 1 , A. Zwetkow 2 , P. Nussbaumer 2<br />
1 Chirurgie, Kantonsspital Chur, Chur/CH, 2 Chirurgie, Kantonsspital Chur, 7000 Chur/CH<br />
Patient comfort after TEP hernia repair – does the mesh matter?<br />
Objective: Polypropylene, the most commonly used material for mesh repair in laparoscopic<br />
hernia surgery, may be responsible for some of the postoperative morbidity. Introduction lightweight<br />
meshes showed an increased patient comfort, but the persisting frequency of local<br />
complications remained a concern. The objective of this prospective study is to examine whether<br />
the use of an ultra light titanium-coated polypropylene mesh (TiMesh TC â extralight)<br />
improves the outcome regarding local complications and patient comfort compared to a<br />
heavy weight mesh without compromising intraoperative handling and recurrence rate.<br />
Methods: From 12/00 to 6/04 two consecutive a series of TEP procedures were performed<br />
for bilateral or recurrent inguinal hernias. Intraoperative handling was judged by measuring<br />
time for surgery and mesh placement. Clinical outcomes were evaluated 6 weeks, 6 and 12<br />
months postoperatively by scoring inguinal pain, stiffness, inguinal tearing (VAS scale 1 to<br />
10), local complications and recurrences.<br />
Results: In 71 patients (62 male) with a mean age of 54 (20-84) years 133 meshes were<br />
implanted. Hernia classification (Nyhus): 14x II; 57x IIIA; 37x IIIB; 2 x IIIC and 23x IV. The mean<br />
operating time (65 vs. 55 min.) and time for mesh placement (5.7 vs. 5.2 min.) were similar<br />
in the two groups. Follow up was 93% after 6 weeks, 83% after 6 and 87% after 12 months<br />
respectively. After 6 weeks 35%(PR) vs. 91%(TiM) had a VAS score 0-1; 47%(PR) vs. 4%(TiM)<br />
VAS 2-3 and 18% vs. 5%(TiM) VAS ≥<strong>4.</strong> At 6 months the corresponding numbers were 61<br />
%(PR) vs. 92 % (TiM), 24%(PR) vs. 5%(TiM) and15 %(PR) vs. 3 %(TiM); after 12 months 84<br />
%(PR) vs. 93 %(TiM), 14%(PR) vs. 3%(TiM) and 2%(PR) vs. 4%(TiM). There was 1 recurrence<br />
in the TiM group after 3 months. Concerning local complications after 6 weeks, 6 and 12<br />
months postoperatively there were 13/12/3(PR) and 6/1/1(TiM) irritations of the spermatic<br />
cord and hydroceles respectively.<br />
Conclusion: Although the new mesh is very light the intraoperative handling is not compromised.<br />
Patient satisfaction seems higher with the new titanium-coatad mesh although the difference<br />
declines over time, and the same applies for local complications. Large hernias however<br />
may have an increased risk of recurrence, therefore we recommend the use of the stronger<br />
TiMesh TC ® light. Recapitulating the overall positive experience has led to the routine use<br />
of the titanium-coated mesh for TEP hernia repair in our institution.<br />
15.14<br />
M. Naef 1 , W.G. Mouton 2 , H. Buess 3 , H. Wagner 2<br />
1 Surgical Department, Spital Thun-Simmental AG, 3600 Thun/CH, 2 Surgery, Spital Thun-<br />
Simmental AG, 3600 Thun/CH, 3 Gynecology&obstetrics, Spital Thun-Simmental AG, 3600<br />
Thun/CH