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tectomy and hysterectomy, and this is briefly shown. An oncologic laparoscopic proctectomy down to the pelvic floor was performed. Key steps and potential pitfalls are demonstrated, including protection of the ureter and pelvic nerves, principles of a good intestinal anastomosis, and mesentery lengthening technique. Specimen extraction was through a 5 cm muscle splitting incision in the right lower abdomen. Total operative time was 290 minutes, including 55 minutes of adhesiolysis and creation of a loop ileostomy. Blood loss was minimal. The patient underwent an enhanced recovery pathway, including a liquid diet on postoperative day 1. She was advanced to solid diet and oral analgesia on postoperative day 3, and she was discharged home on postoperative day 5 without requiring homecare. The diverting ileostomy was closed at 8 weeks. The patient remained without complication or cancer recurrence at one year follow-up. Conclusion: Laparoscopic proctectomy is a safe and efficient procedure. Patient selection and advanced laparoscopic skills are paramount. It is hoped that this video will contribute to a wider and safer practice of laparoscopic proctectomy. 15.3 Laparoscopic perineal hernia repair with Ti-MESH technique and peritoneal technique after laparoscopic abdominoperineal rectumamputation (TME) M. Nägeli, O. Schöb (Schlieren) Objective: Perineal hernia is a seldom complication following abdominoperineal rectumaputation (0.6-7% after abdominoperineal resection). It is seen more often after radiochemotherapy and abdominoperineal operations without omentoplasty. Methods: Demonstration of a laparoskopic pelvic floor closure technique with supralevatory T-iMESH onlay and retrovesical peritonealplasty of the pelvic entry. 50y old male with rectumcarcinoma pT3 N1. Preoperativ radio- and chemotherapy. Surgically an abdominoperineal rectumamputation (TME) was performed without complications. Postoperativ cheomotherapy. The patient is disturbed by an intermittent perineal hernia 6 month postoperativ. Results: An overlapping Ti-MESH polyester net 10x7cm is placed above an approximately 2cm big perineal hernia in the pelvic outlet. The net is fixated with Protack clips. Closure of the pelvic entry is performed with a peritoneoplasty from the dorsal peritoneum of the bladder. The peritoneal flap is still fixated at the bladder and sawn to the promontory and laterally with lapraty suture. The patient could leave the hospital on the 3 rd postperative day. Conclusion: A laparoscopic combination of synthetic mesh repair and a peritoneal bladder flap is an appropriate solution for symptomatic perineal hernia. The shown technique is applying the criterias of the tension free closure of hernias analog the TEEP (Total Endoscopic Extraperitoneal Patchplasty). 15.4 Roboterassistierte laparoskopische Oesophagokardiomyotomie nach Heller und anteriore Fundoplikatio nach Dor - die Therapie der Wahl bei primärer Achalasie A. Scheiwiller, J. Metzger (Luzern) Objective: Bei Patienten mit primärer Achalasie hat sich in den letzten Jahren vor allem beim jungen Patienten die minimalinvasive Myotomie mit partieller Fundoplikatio als first-line-Therapie etabliert. In unseren Augen stellt dieser Eingriff eine der wenigen Operationen dar, bei denen die roboterassistierte Methode Vorteile gegenüber dem konventionell laparoskopischen Vorgehen aufweist. Methods: Wir präsentieren ein Video unserer Technik der roboterassistiert laparoskopischen Oesophagokardiomyotomie und anterioren Fundoplikatio. Der Patient wird in Rückenlage und 40 Grad Antitrendelenburgposition operiert. Einführen des ersten Trokars und Installation des Pneumoperitoneums erfolgen über einen offenen Zugang. Unter laparoskopischer Kontrolle werden Arbeitstrokare eingeführt, der Leberretraktor platziert und die Roboterarme des daVinci-Roboters angedockt. Unter Schonung des anterioren Vagusastes wird am oesophago-kardialen Uebergang die Muskulatur des Oesophagus über 6 cm nach cranial gespalten und die Myotomie anschliessend 2 cm nach caudal auf die Kardia erweitert. Nach endoskopischer Kontrolle folgt die Durchtrennung der Vasa gastricae breves und Deckung des Muskeldefektes mit anteriorer Fundoplikation. Results: Mit Hilfe des in allen Ebenen beweglichen Roboterinstrumentes lässt sich auch im Bereich der Kardia das Risiko der Mukosaperforation auf ein Minimum reduzieren. Conclusion: Die roboterassistiert laparoskopische Oesophagokardiomyotomie und anteriore Fundoplikatio stellt in unseren Augen die Therapie der Wahl bei Patienten mit primärer Achalasie dar. 15.5 Arthroscopic repair of a massive traumatic rotator cuff tear after traumatic glenohumeral dislocation: an instructional step-by-step video P. Grueninger, C. Meier (Zürich) Objective: Traumatic anterior glenohumeral dislocations are frequently associated with lesions of the rotator cuff in elderly patients. The video demonstrates the arthroscopic repair of a massive rotator cuff tear and long head of biceps tenodesis (LHBT) following traumatic anterior shoulder dislocation. The goal is to show a systematic analysis of the cuff lesion, the surgical exposition of the subscapularis (SSC) tear with its subsequent reattachment and infra (ISP) - and supraspinatus (SSP) tendon reconstruction. Furthermore, treatment of the LHB dislocation by anchor tenodesis is demonstrated. Different suturing techniques are shown. Methods: Instructional step-by-step video. Results: A 74-year old active man complained about persistent severe pain (VAS 7), weakness and loss of function 3 months after traumatic shoulder dislocation. Initial treatment consisted of closed reduction and short-term immobilisation in a Gilchrist bandage. Based on the physical examination a significant cuff tear was suspected. Further evaluation by Arthro-MRI revealed a massive cuff tear consisting of a non-retracted complete SSC tear and an ISP+SSP rupture (Patte II). Fatty muscular infil- 16 swiss knife 2010; 7: special edition tration (grade I-II) of ISP+SSP and dislocation of the LHB tendon were evident. We operated in beachchair position with 2.5 kg traction, interscalene-catheter and general anaesthesia. After diagnostic arthroscopy the rotator interval was opened. Debridement and mobilisation of the rotator cuff was performed. An anchor LHBT was done in Lasso-Loop technique. SSC-repair was performed in single row mattress- and Lasso-Loop technique. ISP+SSP were reattached by a double row technique: The medial row was done with mattress stitches and the lateral in tension band technique. Postoperatively, an abduction pillow was applied for 6 weeks and pain free passive range of motion was encouraged. No external rotation >0° to protect the SSC repair was allowed. Conclusion: The presented case emphasizes the importance of a high index of suspicion, meticulous physical examinations, and further evaluation by Arthro-MRI to detect rotator cuff lesions which are commonly seen in elderly patients with traumatic shoulder dislocation. Arthroscopic repair of massive cuff lesions is a safe and feasible option to treat pain, weakness, loss of range of motion and recurrent dislocation. 15.6 Failure of weight loss after roux-y gastric bypass (RYGB): 0ptions for redo-surgery Y. Borbély 1,2 , M. von Flüe 1 , R. Peterli 1 ( 1 Basel, 2 Berne) Objective: In the last decades, RYGB was established as gold standard in bariatric surgery. Long-term weight loss of about 75% excessive body weight can be expected. A weight regain of 20% over 10 years is thereby considered as normal. However, failure rates of up to 30% are reported in the literature. Usual causes of weight regain at follow-up are low energy expenditure, binge eating or errors of technique. In RYGB, the foremost technical error causing weight regain is creation of too large a gastric pouch. Methods, Results and Conclusion: In this video, we address surgical options such as conversion to biliopancreatic diversion, sleeve resection of an enlarged pouch, shortening of the common channel or administration of added restriction using a scilastic ring. Visceral Surgery – Aspects of Nutrition and Infections 18 18.1 Systematic review of immune-enhancing nutrition in abdominal surgery Y. Cerantola, M. Hübner, F. Grass, N. Demartines, M. Schäfer (Lausanne) Objective: Patients undergoing major gastro-intestinal (GI) surgery are still at increased risk to develop complications. The role of immune-enhancing enteral nutrition (IN) in those patients has not yet been fully elucidated since interpretation of available studies remains difficult due to methodological heterogeneity. We aimed to assess the impact of IN on postoperative complications, in particular infectious complications, length of hospital stay (LOS), and mortality in patients undergoing major GI surgery. Methods: A systematic review using a standardized methodology for meta-analysis was performed. Randomized controlled trials (RCTs) published from 1985 to 2009 and assessing the clinical impact of perioperative enteral IN for abdominal elective surgery were included. IN was defined as containing at least two of the three main components amino acids (arginine and/or glutamine), omega-3 fatty acids and ribonucleic acids. Statistical analysis was performed using Review Manager Software for Windows ® (RevMan 5.0.23; The Nordic Cochrane Centre, Copenhagen, Denmark) and Prism 5.2 (GraphPad ® Software, CA, USA). Results: Overall, 21 RCTs enrolling a total of 2695 patients met the inclusion criteria and were therefore included in the final meta-analysis. Twelve of those were considered as high quality studies (Jadad score >3). Significant heterogeneity concerning patients, control groups, timing, and duration of IN administration was found. IN, given either pre-, peri- or postoperatively, significantly reduces overall complications (odds ratio [95% confidence interval]: 0.48 [0.34, 0.69]; 0.39 [0.28, 0.54]; 0.54 [0.39, 0.75]), infectious complications (0.36 [0.24, 0.56]; 0.41 [0.28, 0.58]; 0.53 [0.40, 0.71]) and LOS (mean difference [95% confidence interval]: -2.42 [-3.21, -1.63]; -1.59 [-2.27, -0.92]; -2.81 [-3.29, -2.32]). Beneficial effects of IN could be confirmed by analysis of pooled data, and by excluding low quality trials. Perioperative IN has no influence on mortality (0.90 [0.46, 1.76]). Conclusion: There is good evidence that perioperative enteral IN decreases morbidity and LOS after major GI surgery. Thus, the routine use of IN can be strongly recommended. 18.2 Epidemiological survey of methicillin-resistant staphylococcus aureus (MRSA) in swiss and US patients undergoing colorectal surgery P. Gervaz 1 , S. Harbarth 1 , B. Huttner 1 , Ph. Morel 1 , A. Robicsek 2 ( 1 Geneva, 2 Chicago/USA) Objective: Organisms isolated from surgical site infections (SSI) after colorectal surgery are usually bacteria commensal to the colon, but methicillin-resistant staphylococcus aureus (MRSA) might be responsible for additional SSI-related morbidity. The aim of the study was to compare the modes of acquisition and the incidence of MRSA infection in patients who underwent colorectal resection in Switzerland and in the United States. Methods: Over a 50-month period from July 2004 to September 2008, detections of MRSA were prospectively studied in two hospitals, one in Switzerland (SWI) and one in Chicago, USA (CHI). Patients admitted for an elective procedure were screened for MRSA colonization, and standard infection control measures were implemented for MRSA carriers. Results: Overall, 1,373 patients (CHI=831, SWI=542) were screened. Eighty-one patients (5.89%)
(CHI=54 [6.49%]; SWI=27[4.98%]) were preoperatively known MRSA carriers. Swiss patients (N=13) were more likely than US patients (N=4) to develop MRSA SSIs (2.39% vs. 0.48%, p=0.002). However, in the Swiss hospital, there were more emergency procedures (42% vs. 20%); the class of contamination was higher (3.1 vs. 22); cancer was more prevalent (60% vs. 34%); and the postoperative hospital stay was longer (15.9 ±16.3 vs. 8.3±7.1, p>0.001). Conclusion: The incidence of MRSA infection after colorectal surgery is low (1.2%) and the majority (69%) of infected patients were MRSA-free on admission and were colonized during hospitalization. Altogether, these data suggest that the prevention of MRSA infection after colorectal surgery should rely more on the application of basic surgical basic principles than on vancomycin use for prophylaxis. 18.3 Perioperative nutrition is still a surgical orphan F. Grass, M. Hübner, Y. Cerantola, S. Müller, M. Schäfer, N. Demartines (Lausanne) Objective: To assess if screening programs and treatment of preoperative malnutrition have been implemented into surgical practice to decrease morbidity. There is strong evidence that postoperative morbidity can be minimized by early identifying and treating patients at nutritional risk before major surgery. The validated nutritional risk score (NRS) is recommended by the European Society of Parenteral and Enteral Nutrition for nutritional screening. It remains unclear whether routine preoperative nutritional assessment and perioperative nutrition is widely implemented. Methods: A survey was conducted in 173 Swiss and Austrian surgical departments. Implementation of nutritional screening, perioperative nutrition, and estimated impact on clinical outcome were assessed. Non-responders were repeatedly contacted by the authors. Results: The overall response rate was 55%, whereby 69% (54 / 78) of Swiss and 44% (42 / 95) of Austrian centers responded. Despite 80% and 59% of the responding centers are aware of a reduced complication rate and shortened hospital stay, respectively, only 20% of them implemented routine nutritional screening. Financial (49%) and logistic restrictions (33%) are the predominant reasons against the routine clinical use. Screening is mainly performed either in the outpatient’s clinic (52%) or during admission (54%). The NRS is only used by 14%. Instead, various clinical (78%), e.g. BMI and laboratory findings (56%), e.g. albumine, are used. Indication for perioperative nutrition is based on preoperative screening in 49%. While 23% use preoperative nutrition, 68% apply nutritional support pre- and postoperatively. Preoperative nutritional treatment ranged from three days (33%), to five days (31%) and even seven days (20%). Conclusion: Despite malnutrition is well recognized as major risk factor for increased postoperative morbidity, the majority of surgeons are reluctant to implement routine screening and nutritional support. If nutritional assessment is performed, local institutional screening parameters are still preferred. It remains difficult to overcome traditions, and to change surgeon’s mind. 18.4 Association of noise volume in the operating room with surgical site infections A. Kurmann 1 , M. Peter 1 , F. Tschan-Semmer 2 , D. Candinas 1 , G. Beldi 1 ( 1 Berne, 2 Neuchâtel) Objective: In a previous study we showed that the subjective perception of noise in the operating room was associated with surgical site infections. In the present study we hypothesized that noise volume in the operating room represents a surrogate marker of incidence on surgical site infections (SSI). Methods: Noise volume was measured during 35 elective open abdominal procedures. All involved personnel was previously informed. The microphone of the noise measuring device (PCE 353 ® , PCE GmbH & Co.KG, Germany) digitally registered every second the volume in decibel (dB) just below the surgical lamps above the patient. Elevations of noise volume above baseline were assessed. A standardized questionnaire was filled out to evaluate discipline of the operating room team. Main outcome measure was the incidence of SSI 30 days after surgery. Results: Overall rate of SSI was 17% (6/35). Demographic parameters including gender, age, BMI, and operative time were not significantly different between patients with or without SSI. Median noise volume above baseline was significant higher in patients with surgical site infections (43.5 dB, range 26-60 dB vs. 25 dB, range 25-60 dB; p=0.04). Peaks ≥ 4dB over the baseline values were found in 22.45% with SSI versus 10.7% in patients without SSI (p=0.02). The discipline score showed that talking about non operative specific topics was associated with a significant higher sound level (p=0.02). Whereas changing of surgical team members or talking about operative specific topics are not associated with a higher sound levels. Conclusion: In this study we show an association between intraoperative noise volume and SSI. We propose that intraoperative noise may represent a surrogate parameter of various factors such as a difficult operation, lack of discipline, lack of concentration or a stressful environment in general that in turn might elevate the incidence of SSI. 18.5 Surgical site infection – a 10 year results‘ analylsis and strategy in a peripheral Swiss hospital M. Giuliani, S. Schlunke, J. Al-Muaid, D. Brasola, P. Biegger (Locarno) Objective: Surgical site infections (SSI) are well known, being the second most frequent nosocomial infection worldwide. Highly resistant pathogen germs, an aging population and the economic pressure on our healthcare system require a clear statement. According to the reviewed literature, there is a positive correlation between the hospital size and SSI. Unlike other well demonstrated factors, the careful surgical handling of tissues seems to have a crucial, yet not well documentable importance. Methods: We present our data, collected over a period of 7 years by a hospital independent source (Institut Central Service des Maladies Infectieuses Canton du Valais), setting benchmarks with over 14‘000 similar operations from 18 different hospitals (appendectomy, cholecystectomy and colon resections). Results: 196 appendectomies, 320 cholecystectomies and 293 colon resections are reviewed in detail. Despite having a more severe NNIS score (wound contamination score, ASA classification), our infection rates have constantly remained remarkably low over the years and our RR and OR (CI 95%) are significantly lower than the benchmark. We comment the results of the study and explain our strategy in surgical practice. Conclusion: Apart from common measures like oxygenation, warming up during surgical interventions and prophylactic antibiotic administration, what also counts equally in our opinion ist the standardization of procedures, cautious dissection and meticulous tissue handling, as the key to these constant satisfying results - offering at the same time an optimal basis for teaching specific surgical knowledge to younger colleagues. In a world becoming more and more technology-dependent, the importance of surgical knowhow and tissue handling should not be missed. 18.6 Risk factor analysis for surgical site infection after excision and primary closure of pilonidal sinus S.-G. Popeskou, D. Christoforidis, C. Ruffieux, N. Demartines (Lausanne) Objective: Excision and primary closure for pilonidal sinus disease is associated with a high rate of surgical site infection (SSI). The aim of our present study was to assess the risk factors for SSI in this context. Methods: All consecutive patients undergoing excision and primary closure of pilonidal sinus between 2002 and 2008 were analyzed retrospectively. SSI was defined according to the Center for Disease Control criteria. We performed uni- and multivariate analysis of risk factors including sex, age, smoking, BMI, type of pilonidal sinus, use of perioperative antibiotic prophylaxis, methylene blue or surgical drain. Results: Out of 157 consecutive patients 131 (83%) had complete charts and were included in the study (men, 74.1%, age 24 (15-66)). SSI was observed in 41(31%) patients. Median time to healing was 20 days (12-76) in patients without SSI vs. 62 days (20-170) in patients with SSI (p
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Page 3 and 4: Der Jahreskongress der Chirurgische
Page 5 and 6: Abstracts Session Topic Page 02 Vis
Page 7 and 8: Visceral Surgery - Cholecystitis &
Page 9 and 10: performed were recorded. Descriptiv
Page 11 and 12: avec délai dans le diagnostic, ang
Page 13 and 14: group (conventional: n=13, RS=1.8 +
Page 15: time-efficient all-in-one 3D visual
Page 19 and 20: Conclusion: Both procedures markedl
Page 21 and 22: 22.7 Transplantation of kidneys fro
Page 23 and 24: of the remaining 40 patients with a
Page 25 and 26: and 6/2009 and were prospectively f
Page 27 and 28: Conclusion: In our patient cohort,
Page 29 and 30: plantation. With the introduction o
Page 31 and 32: Results: SLN negative patients were
Page 33 and 34: Conclusion: This is the first study
Page 35 and 36: were grouped into four age groups a
Page 37 and 38: gain up to the 20 th procedure (Fig
Page 39 and 40: ��
Page 41 and 42: normal angiogenesis induced by cell
Page 43 and 44: 52.4 Sham-feeding of patients with
Page 45 and 46: Methods: Erfasst wurden Aggressions
Page 47 and 48: Conclusion: Pharmacological inhibit
Page 49 and 50: 54.19 Gene chip analysis of A20 exp
Page 51 and 52: 55.10 Optimized intrapleural cispla
Page 53 and 54: 62.7 Posttraumatic symptomatic cyst
Page 55 and 56: Conclusion: Only patients older 75
Page 57 and 58: no sign of occlusion. No further th
Page 59 and 60: packing as part of damage control s
Page 61 and 62: sonalführung und werden auch in de
Page 63 and 64: Figure 3 Figure 2 Figure 4 71.2 Tec
Page 65 and 66: formed 5 months later, again with a
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99.16 3-D endo-stomal ultrasound (
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tional recanalization. Conclusion:
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99.37 Extended Clavien-Dindo classi
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ial colitis was excluded by stool c
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99.55 Complexes de von Meyenburg(ha
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99.64 Traumatic abdominal wall hern
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99.75 Isolated dorso-medial disloca
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FRAGMIN ® DER ERFAHRENE WEGGEFÄHR
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Kalbermatten Daniel, PD Dr., CHUV C
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Meyer Antoine, Dr., Hôpital canton
Page 87 and 88:
Covidien Switzerland Limited multip
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