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

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