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and 6/2009 and were prospectively followed. Only patients with a hernia diameter of ≥ 5cm were
included in this study. We compared 56 patients who underwent open incisional hernia repair with 69
patients who underwent laparoscopic repair. Rives technique using a prosthetic mesh was performed
in the open group, whereas an intraperitoneal dual layered onlay mesh repair was implanted in the
laparoscopic group. Clinical long-term follow-up investigations were performed at our institution.
Results: The demographic parameters including gender, age, BMI, and operative time were not significantly
different between the two groups. Conversion rate to open implantation of an intraperitoneal
mesh in the laparoscopic group was 10%. Median hospital stay was significant shorter in the laparoscopic
group (6 days, range 1-23 vs. 7 days, range 1-67; p=0.014). Incidence of surgical site infections
was reduced in the laparoscopic group compared to the open group (5.8% vs. 26.8%; p=0.0011). One
fistula was found in the open group, none in the laparoscopic group (p=n.s.). Bulging of the implanted
mesh was observed in 17.4% in the laparoscopic group and in 7.1% in the open group (p=n.s). Chronic
pain occurred in 19% in the laparoscopic group and in 10% in the open group (p=n.s.). Incapacity
for work was 3 weeks after laparoscopic and 6 weeks after open surgery (p=n.s). After a median
follow-up of 65 months (1-80) in the open group and 33 months (1-62) in the laparoscopic group
a recurrence rate of 18% in the open group and 16% in the laparoscopic group was found (p=n.s).
Conclusion: Laparoscopic repair of large incisional hernia repair is associated with a significant shorter
hospital stay and fewer surgical site infections. At long-term follow-up recurrence rate is comparable
to open surgery. Abdominal bulging is a specific problem associated with laparoscopic repair of large
incisional hernia.
28.9
Prophylactic intraperitoneal onlay mesh (IPOM) to prevent incisional hernia is feasible and safe - preliminary
results of a randomized controlled trial
P. Glauser 1 , P. Kissling 1 , E. Kuhnt 2 , D. Strub 1 , S. Käser 1 , C. A. Maurer 1 ( 1 Liestal, 2 Leipzig/DE)
Objective: Incisional hernias occur in up to 20% of all open abdominal surgeries. This study examines
the use of a prophylactic intraperitoneal onlay mesh (IPOM) to prevent incisional hernia following midline
laparotomy.
Methods: This prospective, randomized and controlled trial was started in August 2008. Patients
undergoing median laparotomy are randomly allocated either to abdominal wall closure according
to Everett alone with a PDS-loop running suture (group A) or to the same procedure with additional
IPOM (group B). The primary endpoint is the incidence of incisional hernias at 2 and 5 years following
midline laparotomy. Secondary endpoints are the feasibility and safety of the mesh implantation even
in contaminated situations (Altemeier grade I – III), and the identification of risk factors for incisional
hernias. Patients with contaminated situation grade IV were excluded from this study. The postoperative
pain is recorded by visual analogue scale (VAS). This study is registered on www.clinicaltrial.gov.
Results: Up to date, 74 patients were included in this study, 36 patients in group A and 38 patients
in group B. Separated to the different grade of wound contamination the allocation in group A is n=
17 grade I; n= 2 grade II, n= 17 grade III, and in group B: n= 12 grad I; n= 8 grad II; n= 18 grad III,
respectively. In all of these patients, no wound infection was encountered and no mesh had to be
removed. No mesh penetration and no bowel obstruction with the need for surgical reintervention did
occur. One burst abdomen occurred in group A, none in group B. Up to date, no incisional hernia was
detected. There is no difference in postoperative pain.
Conclusion: The preliminary short-term results indicate that the placement of an IPOM with prophylactic
intention is a feasible and safe procedure, even in contaminated situations like colorectal surgery.
Visceral Surgery – Novel Technologies 33
33.1
Integration of computer assisted surgery and intraoperative navigation in complex liver surgery and
tumorablation: first results after treatment of 10 patients
A. vom Berg, D. Inderbitzin, M. Peterhans, L. Nolte, S. Weber, D. Candinas (Berne)
Objective: Intraoperative tissue deformation in liver surgery complicates the integration of preoperative
planning datasets. Furthermore detection of lesions by intraoperative sonography in cirrotic liver tissue
or after effective neoadjuvant chemotherapy can be difficult and impede tissue sparing surgery. The
integration of computer navigated tool guidance improves surgical orientation. We report our experience
in navigated hepatic surgery in 10 patients.
Methods: Ten patients with primary or secondary liver cancer were scheduled for computer assisted
hepatic surgery over a time period of 5 month; eight patients with colorectal liver metastasis, and two
with primary liver cancer. Parenchyma dissection and ablation was guided by the optical tracking
system and navigated ultrasound for updating the preoperative planning data (MeVis Distant Services).
Postoperative data was analysed for assessment of feasability and simplification of surgical
procedures.
Results: Navigated liver surgery was successful in 8 patients. Preoperative planning was realised
in all patients. Mean error of projection of preoperative data in the operative situs was 5mm (range
0-15mm). Mean operation time was prolonged by a mean set up time for the system of 15 min (5-
25 min). R0 resection was achieved in 7 out of 8 patients. In one case intraoperative detection of
lesions by sonography was not possible after neoadjuvant therapy but the projection of preoperative
tomography-based planning data on the operative situs allowed R0 resection.
Conclusion: Parenchyma preserving oncological resection and ablation for primary or secondary liver
tumor is faciliated by computer assisted surgery. In addition, navigated hepatic surgery has the potential
to expand the surgical spectrum of resectability on currently non resectable patients.
33.2
Female population perception of transvaginal versus transumbilical single access and standard laparoscopy
P. Bucher, S. Ostermann, F. Pugin, Ph. Morel (Geneva)
Objective: Laparoendoscopic single-site (LESS) and natural orifice translumenal endoscopic (NOTES)
surgery may be the future of minimally invasive surgery. Aim was to evaluate concerns of female population
regarding transvaginal NOTES and transumbilical LESS.
Methods: Anonymous survey (describing laparoscopic, transumbilical LESS, and transvaginal NOTES
cholecystectomy without regards to potential risk or advantages) were given to 300 females: paramedical
staff n=100, patients n=100 and population n=100. They (median age 35, 16-79 years)
were queried about preferred techniques, marital status, sexuality, children, formattion, and worries
regarding transvaginal and transumbilical access. Among them, 54% had children, 79% had a stable
relationship, and 96% were sexually active (vaginal intercourse).
Results: With similar operative risk, 87% preferred LESS, 4% preferred NOTES and 8% laparoscopy.
LESS and NOTES choice were influenced by a desire of improved cosmesis (82%) and pain (44%).
For single access, 96% choose transumbilical and 4% transvaginal. 96% had worries regarding transvaginal
access. Worries were fear of vaginal pain during intercourse (68%), fear of decrease sensibility
during intercourse (43%), refuse of short term sexual abstinence (40%), fears of infertility (23%) or
sterility (6%), and others (14%). 62% reported that they fears the use of a too intimate body part for
surgical access, while only 9% reported it for transumbilical route. LESS evocated worries in 35% of
participants. 19% reported fear of umbilical pain, 15% about post-op umbilical sensibility, and 11%
about incisional hernia. Post-op intercourse abstinence after NOTES worried 76% (defined as 3 weeks
in survey). Worries were: feel less attractive (40%), less feminine (32%), fear of tension with intimate
(35%), though their lover wouldn’t accept it (20%), possibility of abortion of new relationship (26%),
feel less comfortable in social relationship (16%), and 14% others.
Conclusion: The high acceptation rate for transumbilical LESS approach compare to transvaginal
NOTES may be related to fears regarding post-operative sexuality and fertility. The importance of temporary
post-operative sexual abstinence (vaginal intercourse) is important and may be difficult to influence.
However, these issues may be related to cultural factors and may explain the difference in
acceptation rates of transvaginal NOTES among different regions.
33.3
Transvaginal rigid-hybrid NOTES cholecystectomy: evaluation of 150 patients in routine clinical
practice
G. R. Linke, I. Tarantino, J. Janczak, R. Hoetzel, R. Warschkow, I. Siercks, J. Lange, A. Zerz (St. Gallen)
Objective: Transvaginal rigid-hybrid NOTES cholecystectomy (tvCCE) reduces abdominal wall incisions
and might decrease surgical trauma by combining endoluminal access and laparoscopic techniques.
We assessed the feasibility and safety of tvCCE in routine practice for symptomatic cholecystolithiasis
and acute cholecystitis in low-selected patients.
Methods: From September 2008 to December 2009, 150 of 211 (71%) consecutive symptomatic
cholecystolithiasis (n=108) or cholecystitis (n=42) patients were scheduled for tvCCE with 9 different
surgeons. Patients were not excluded because of age, obesity, previous surgery, or degree of gallbladder
inflammation. A pre- and two-week postoperative gynaecological examination was performed.
Sexual function was assessed pre-, 6 weeks and 12 months postoperatively.
Results: Patients` mean age was 52.3 ± 17.5 (range 18-87) years and mean body mass index was
27.2 ± 6.1 (range 17.6-43.8) kg/m 2 . Four patients had conversion to conventional laparoscopic
cholecystectomy. There were no intraoperative complications. Three major complications occurred:
one stroke, one herniation within the transumbilical access, and one infected douglas haematoma,
which was laparoscopically evacuated. Minor complications were reported in 16 (11%) patients. Apart
from the douglas hametoma, there were no serious postoperative gynaecological findings. Six weeks
(n=146) and 12 months (n=26) postoperatively, dyspareunia symptoms did not differ compared to
the preoperative state.
Conclusion: TvCCE is feasible and safe in routine practice for symptomatic cholecystolithiasis and
acute cholecystitis.
33.4
Laparoendoscopic single-site visceral surgery: single-center experience and lesson learned with the
first 200 cases
P. Bucher, F. Pugin, Ph. Morel (Genève)
Objective: Single port access (SPA), or laparoendoscopic single-site (LESS) surgery has rapidly entered
clinical practice and undergone various mutations in its instrumentation since two years. To
present operative and peri-operative outcomes in an observational cohort of patients who underwent
LESS surgery at a single academic center.
Methods: Prospective study evaluating patient outcomes after LESS visceral surgery from July 2007 to
September 2009. Demographic data including age, body mass index, operative time, operative indications,
complications, hospital stay, and postoperative Subjective post-operative results were evaluated
using validated body image scales and QoL scale (SF12). Visual Analog Pain Scale scores were accrued.
Data were prospectively collected in an institutional database.
Results: 200 patients have undergone a visceral LESS procedure. Majority of cases were: cholecystectomies
(64 cases), appendectomies (37), 3 Inguinal hernias (TEP), primary and incisional hernias
(TIPP) (39), followed by colectomies with anastomosis, emergency procedures (including perforated
gastroduodenal ulcer repair, bowel strangulation, hartmann), pancreatic necrosectomies (including
tail resection), gastrojejunostomy, splenectomy, cancer staging LESS laparoscopy with biopsy. Median
patient age was 45 (18-94) years. Median patients BMI was 25 (19-42). Overall conversion rate was
3.5% (5 cases with additional ports and 2 conversion for open surgery), but none of them for intraop-
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