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erative complications. Overall morbidity was 2.5%. With a median follow up of 14 months, 1 Clavien grade I (hemoptysis), 2 grade II (1 pneumonia and 1 ombilical seroma) and 2 grade III (1 bowel anastomosis leak and 1 umbilical incisional hernia) complications occurred. All patients were recommending this approach and extremely satisfied with cosmetic results after LESS procedure. Conclusion: LESS visceral surgery is feasible for advanced laparoscopic surgeons but remain difficult in relation to its specificities. Technical developments are especially needed to improve feasibility and thus safety of advanced visceral LESS procedures. It offers improved cosmesis, and may offer decreased pain and shorter complete recovery. Complications are consistent with the published data for laparoscopic visceral surgery. Whether LESS surgery represents a progress in minimally invasive surgery remain to be demonstrated formally in formal randomized trials. 33.5 Transanale Tumorabtragung mittels Single-Port-Video-Rektoskopie – eine neue Anwendungsmöglichkeit für den “SILS“-Port B. Boldog, M. Weber (Schaffhausen) Objective: Transanale Tumorabtragungen bei hoch gelegenen Pathologien im Rektosigmoid sind eine chirurgisch technische Herausforderung. Die transanale endoskopische Mikrochirurgie (TME) ist zudem mit einem hohen Geräteaufwand und einer erheblichen Sphinkterdehnung verbunden. Transabdominelle Verfahren sind mit der Morbidität der tiefen Rektumchirurgie assoziert. Methods and Results: Anamnese und klinischer Befund: Ein 67 Jahre alter Patient wird wegen rezidivierenden unteren gastrointestinalen Blutungen zugewiesen. Kolonoskopisch zeigt sich ein grosses breitbasiges Adenom (Histologie) 20 cm ab ano mit der Indikation zur chirurgischen transanalen Tumorexzision Methode: Patient in SSL in Intubationsnarkose. Unter anoskopischer Kontrolle platzieren eines 20 french Foleykatheter oral von Tumor im Sigma. Füllen des Ballons unter Sicht mit 12 ml NaCl. Transanales Einsetzen des „SILS“ Port-s (Covidien). Herstellen eines Pneumo-Rectums mit CO 2 (10 mmHg). Nach oral, neben dem Ballon ins Sigma durchtretendes CO 2 wird fortlaufend durch den offenen Foleykatheter nach transanal dekomprimiert. Unter Kamera-Kontrolle (5mm Optik) exakte Lokalisation des 20 mm grossen Tumors. Mittels „laparoskopischer“ 5 mm Fasszange und 10 mm Endo-GIA (Covidien) kann der Tumor tangential an der Basis im Gesunden abgetragen werden. Conclusion: SILS und NOTES ergeben unerwartete neue „spinn-off“ Möglichkeiten in anderen Bereichen. Der Fallbericht zeigt eine neue attraktive Anwendungsmöglichkeit des SILS-Ports. Die Single- Port-Video-Rektoskopie nach Boldog ist eine neue schonende Operationstechnik. 33.6 Totally robotic right hemicolectomy: preliminary results F. Pugin, P. Bucher, N. Buchs, A. Carecchio, Ph. Morel (Genève) Objective: The aim of this study is to evaluate the feasibility of lapaparoscopic right hemicolectomy using a robotic surgical system, with intracorporeal “hand sewn” anastomosis. Methods: Patient with endoscopically non-resecable polyp and/or in situ carcinoma of the right colon were selected for this robotic approach, after giving informed consent. Patient was placed in supine position, both arms alongside the body, legs abducted, with the DaVinci surgical system at the right side. The optical port was inserted at the umbilicus, the two robotic ports in the left flank and right iliac fossa, and the assistant port above the umbilicus. After a primary ileocolic and right colic vessels division, the ileocolon was dissected and transsected. A side-to-side “hand-sewn” anastomosis was performed and the specimen removed through the enlarged right iliac port at the end of the procedure. Results: Three female patients were selected for this approach between October 2009 and January 2010. Two cases were completed fully robotically. The anastomosis was hand-sewn intracorporally in all cases. Median operative time was 230 min. The mean number of lymph nodes harvested was 16. No anastomotic insufficiency was noted. One patient developed a postoperative pulmonary infection. No other complication was recorded. Mortality was zero. Conclusion: Totally robotic right hemicolectomy is feasible and safe for premalignant disease and should be evaluate for cancerous lesion as it respects the oncologic principles of the standard laparoscopic colon resection for malignant disease. 33.7 Cholécystectomie laparoscopique, par incision ombilicale unique S. Dominguez, V. Sarbach, P. Bucher, Ph. Morel (Genève) Objective: La chirurgie laparoscopique élabore des techniques de moins en moins invasives. L’objectif du travail, la conception d‘un protocole qui examine de façon prospective notre expérience aux HUG avec une nouvelle technique de chirurgie de la vésicule biliaire par laparoscopie, par une incision unique. Methods: Il a été mené une étude prospective, descriptive, analytique et observationnelle chez des patients subissant une chirurgie avec la technique de la cholécystectomie laparoscopique avec un 26 swiss knife 2010; 7: special edition port visible seulement de 5 mm durant les 3 dernières années. Échantillonnage probabiliste non intentionnel, l‘obtention de l‘échantillon, sélectionner les cas en fonction des critères préalablement établis, y compris les patients ayant des calculs biliaires symptomatiques simples et excluant les patients atteints de cholécystite choledocholithiasis aiguë et le cancer. Les procédures sont effectuées par un chirurgien connaissant la technique laparoscopique, avant le consentement éclairé des patients. Nous avons analysé les variables suivantes: l‘âge, le sexe, la durée de la chirurgie, le temps d‘hospitalisation, de l‘indice technique de conversion et d‘effets esthétiques. Results: Tous les patients opérés avec une incision, âge moyen 39 ans, l‘indice de masse a varié de 20 à 34 (moyenne, 25.2). Aucun cas de conversion par laparoscopie standard n’a été effectué. Le temps de fonctionnement en cette première série était de 80 à 160 minutes avec une durée opératoire de 79 (extrêmes: 35-160) min. La perte de sang a été minimale dans tous les cas. Aucune complication postopératoire n’a été observée. La douleur postopératoire était semblable à la chirurgie laparoscopique traditionnelle. Le séjour postopératoire variait de 12 à 36 heures et la durée moyenne d‘hospitalisation était de 1,6 (extrêmes: 1,0-2,5) jours. L‘anatomie montre une cholécystite non spécifique. La satisfaction des patients est élevée, surtout dans les résultats cosmétiques chez les jeunes femmes, sans aucune cicatrice visible. Conclusion: La chirurgie laparoscopique est en pleine évolution vers des résultats toujours plus exigeants. Les résultats de notre expérience initiale de patients atteints de lithiase biliaire sont encourageants. Toutes les procédures ont été achevées avec succès dans un délai raisonnable. Aucune incision extra-ombilicale n’a été utilisée et pratiquement pas de cicatrice demeure. Une incision pour cholécystectomie laparoscopique, pourrait être une méthode alternative prometteuse pour le traitement de certains patients présentant une lithiase biliaire symptomatique, et bien que les résultats ne sont pas significatifs à la chirurgie laparoscopique traditionnelle sur la douleur postopératoire et le séjour hospitalier, cependant ils fournissent des résultats optimaux en esthétique. Vascular Surgery 34 34.1 Inter-hospital vascular surgical collaboration: our experience A. Lombardo 1 , L. Giovannacci 1 , J. C. Van den Berg 1 , C. Staedler 1 , L. Gürke 2 , R. Rosso 1 ( 1 Lugano, 2 Basel) Objective: In order to facilitate the centralization of vascular surgery (in specific carotid artery surgery) for our Canton and a concurrent change of the head of the surgical department as of 2005 a collaboration with an academic vascular centre was initiated. The support of the academic vascular centre allowed for assurance of quality of care, and strengthened the position of the vascular surgical unit in the regional hospital towards angiologists, neurologists, general practitioners and other hospitals. In addition the support from academic vascular surgeons was used to train the local vascular surgical team in carotid surgery. The results of this collaboration are used to demonstrate the development and outcome of carotid surgery in our regional hospital. Methods: From February 2005 to December 2009, 193 consecutive patients underwent carotid endarterectomy (CEA) under local anaesthesia. Mean age 68 (53 - 88); female n=52 (27%), male n=141 (73%); asymptomatic n=87 (45%); symptomatic n=106 (55%). Preoperative neurological assessment, duplex sonography and CT- or MR-angiography was performed in all cases. Intraoperative data were recorded. Postoperative neurological deficits, cranial nerve lesions, infections, secondary haemorrhage and general complications were analysed. Postoperative neurological examination and duplex sonography was performed at regular intervals. Results: N=193 CEA, Severe adverse events: Death: 0; Myocardial infarction: 1 (0.5%); Minor stroke: 1 (0.5%), Minor adverse events: TIA: 1 (0.5%); Neck hematoma: 17 (8%) (2 surgical revision); Infection: 2 (1%) (2 surgical revision); Cranial nerve lesions: 7 (3.6%) (Recurrens n=3, 1 permanent, Hypoglossus n=4, all transient), Follow-up (until December 2008) n=140, mean 24 months (1 - 44) , 1 occlusion (0.7%); 4 Restenoses (50% - 65%); 1 retrograde dissection of the common carotid artery, treated with stent Conclusion: The outcome of CEA in our hospital demonstrates that centralization of carotid surgery and collaboration with an academic centre allows for an academic level of vascular surgical care in a regional unit. On the other hand the collaboration allowed the academic centre to augment their catchment area and their importance as centre of excellence. 34.2 Comparative analysis of post-interventional cerebral MRI after carotid stenting or endarterectomy A. E. Pasch 1 , R. Marti 1 , L. Remonda 1 , L. Gürke 2 , P. Stierli 1,2 ( 1 Aarau, 2 Basel) Objective: Carotid artery stenting (CAS) has been invented into clinical practice with the aim to provide a less invasive alternative to surgical endarterectomy (CEA). Here we compare pre- and postinterventional cerebral MRI before and after CAS or CEA with regard to new postinterventional ischemic cerebral lesions. Methods: Retrospective, non randomized, single center analysis of cerebral MRI performed before and after carotid interventions (CAS and CEA) at the Kantonsspital Aarau between June 2007 and December 2009. MRI were compared and evaluated with regard to the occurence of new post-interventional ischemic lesions. Results: Of a total of n = 138 interventions, 18 were excluded from analysis because of missing MRI (CEA n = 12, CAS n = 6). The remaining n = 120 interventions (CEA n = 103, CAS n = 17) were included in the analysis. Mean age of patients was 71 +/- 8 years, n = 84 (70%) were male, n = 36 (30%) were female. Fresh postinterventional lesions were identified by MRI significantly more often in patients after CAS (n = 7; 41%) than in patients after CEA (n = 18; 18%; Fisher’s exact test p = 0.047; Chi square test p = 0.026).
Conclusion: In our patient cohort, CAS was significantly more often associated with the postinterventional MRI finding of fresh – and therefore likely intervention-associated - cerebral ischemias than CEA. This result warrants further investigations with regard to its clinical relevance and a possible association with patient symptoms. 34.3 Novel biodegradable vascular prosthesis: short-term results after carotid artery replacement in the pig D. Mugnai, W. Mrowczynski, S. de Valence, J.-C. Tille, E. Khabiri, R. Gurny, A. Kalangos, M. Moeller, B. H. Walpoth (Geneva) Objective: There is a continuous search for shelf-ready small-caliber vascular prostheses. Biodegradable scaffolds, repopulated by recipient’s cells regenerating a neo-vessel, can be a suitable option for both adult and pediatric, urgent and elective cardiovascular procedures. We assessed a new biodegradable vascular prosthesis for arterial replacement in the pig. Methods: Ten anesthetized pigs underwent bilateral carotid artery replacement with biodegradable electrospun Poly(e-caprolactone) (PCL) nanofibre prostheses (4mm-ID; 5cm-long); or expandedpolytetrafluoroethylene (ePTFE) prostheses serving as control. Peri-operative anticoagulation was achieved with intravenous heparin (double baseline ACT). Post-operatively, until conclusion of the study at 1-month, animals received aspirin daily. Transit Time Flow (TTF) was measured intra-operatively and at sacrifice. Doppler ultrasound follow-up was performed at 1 and 4 weeks when a selective carotid angiography assessed patency. Graft examination consisted of histology with special stainings, planimetry and SEM. Results: Surgical handling and haemostasis of the new prostheses were excellent. Patency rate was 78% (7/9) for PCL grafts, compared to 70% (7/10) for ePTFE grafts. TTF and Doppler ultrasound showed no significant changes in flow and velocity or diameter over time in both groups. Both prostheses showed minimal in vivo compliance as compared to native carotid artery. Neoendothelialisation was 79% for PCL and 80% for ePTFE grafts. Neointima formation was limited in both grafts. The PCL graft was partially infiltrated from the adventitia by macrophages, myofibroblasts and capilleries with a mild foreign-body reaction and focal thrombus formation. Conclusion: Biodegradable, electrospun PCL grafts showed good surgical properties, no aneurysm formation and similar short-term patency compared to ePTFE grafts. Rapid, good endothelialisation and cell ingrowth confirms the hypothesis of in vivo vascular tissue engineering. Despite good early results long-term follow-up is required before clinical application. 34.4 Treatment of iliofemoral venous thrombosis (IFVT) is a surgical entity – review of 13 surgical thrombectomies and catheter-directed thrombolysis C. Geppert 1,2 , R. Marti 1 , P. Hess 3 , L. Gürke 2 , P. Stierli 1,2 ( 1 Aarau, 2 Basel, 3 Luzern) Objective: The incidence of IFVT in Middle Europe is 0,1-0,3% per year. Those affected are often treated by physicians & are only referred to surgeons when severe pain &/or swelling of the limb persist. Postthrombotic syndrome & chronic venous insufficiency (CVI) are early & late sequelae of IFVTs which need to be avoided at all cost. Surgical thrombectomy combined with catheter-directed thrombolysis are the most efficient methods to desobliterate the affected veins. To aid patency & improve blood flow there are recommendations to create a temporary arteriovenous fistula (AVF). Methods: The study reviewed all surgical thrombectomies performed for IFVT in the past 6 years (electronical data). End points were postoperative patency & venous competence, complications, mortality & efficacy of AVF. Results: There were 11 patients with 7:4 female:male ratio of median age of 38 (range 19-69) years. All but 1 patient had left-sided IFVT. In total 13 limbs were operated on (1 patient bilateral IFVTs & 1 patient with re-thrombectomy due to early rethrombosis). 4 women were on oral contraceptive therapy, 1 woman developed a IFVT post partum, 1 woman with a hip ganglion & 1 woman with a large metastasis causing iliac compression. 1 man with prolonged immobilization after pelvic fracture without prophylactic antithrombotic therapy developed bilateral IFVTs & 1 man was diagnosed with aplasia of the common iliac vein. All patients underwent surgical thrombectomy & catheter-directed thrombolysis. In 3 cases a cavotomy due to the extent of the thrombosis was performed. All but 2 patients had AVF, of which 3 closed spontaneously, 2 thrombosed & 5 were closed surgically after a median of 8 (range 2-14) months. All patients were followed up for a median of 15 (range 2-27) months. In 9 limbs there was normal venous competence & no CVI. In 2 cases (1 had no AVF; 1 rethrombosed AVF) a thrombosed external iliac vein remained with good collateral circulation & symptomatic swelling of the affected limb. 1-yr mortality was 0%, there was 30% complication rate (4 of 13: 1 central venous catheter-sepsis, 1 seroma, 1 lymphocoele, 1 remaining stenosis due to overriding right iliac artery). Conclusion: Surgical thrombectomy & catheter-directed thrombolysis prevent early & late sequelae of IFVT. Controversy remains whether the formation of an AVF is beneficial. The results of our review support the creation of a temporary AVF. 34.5 Complex surgical treatment of aortic arch complications after stenting of the descending aorta F. Rüter, B. Winkler, P. Matt, M. T. Grapow, O. Reuthebuch, F. Eckstein (Basel) Objective: Stenting has become the method of choice in treatment of uncomplicated chronic or acute dissections and traumatic lesions of the descending aorta. However the advantage of avoiding open surgery is adherent to possible serious complications. A New Entity of ascending or aortic arch lesions after stenting of the descending aorta is described on the basis of two clinical cases. Methods: Report of two serious complications and their complex surgical management. Results: Case 1: Due to endoleak after primary stenting in acute Type B dissection in a 60 year old patient, a 2 nd stent with overstenting of the left sublavian artery was implanted succesfully. Routine CT- scan 3 month later showed retrograde Type A dissection with a large haematoma at the inner curvature of the aortic arch beginning at the proximal end of the covered stent. Supracoronary replacement of the ascending aorta and the aortic arch with replantation of brachiocephalic trunk and left carotid artery with distal anastomosis in “elephant trunk technique” under deep hypothermic circulatory arrest (DHCA) was performed. Postoperative subclavian steal syndrome was treated with left carotid to left subclavian artery bypass. Case 2: A 37-year-old patient received urgent stenting of traumatic descending aortic rupture in the context of multiple trauma after high speed motorcycle accident. CT scan after rehabilitation showed proximal stent fracture with partial occlusion of the aortic arch due to inversion into lumen documented by transesophageal echocardiography. Open stent explantation was performed under DHCA without any complications. Conclusion: Stenting of descending aortic lesions is associated with possible complications in ascending and aortic arch. Diagnosis is difficult due to variable occurrence, surgical treatment is complex. Frequent observation of these patients is mandatory. 34.6 A rare cardiac complication of vascular access steal syndrome A. Lakomski, S. Mantziari, O. De Rougemont, P. Meier, C. Sierro, C. Haller (Sion) Objective: The vascular access steal syndrome is a complication occuring after the creation of vascular access for hemodialysis. We report the case of a man known for terminal renal failure who presented a myocardial infarction with cardiorespiratory arrest, one year after the creation of a vascular access. Methods: A 63-years-old man known for ischemic heart disease with CABG in January 2008, and a terminal renal failure with a brachio-cephalic native arterio-venous fistula of the left arm created in April 2008, presented a ventricular fibrillation and cardio-respiratory arrest on December 2009. ECG and cardiac enzymes showed a NSTEMI in the infero-lateral territory. The coronarography two weeks later showed permeable internal mammary bypass and no significant stenosis, but a fall of pressure in the left subclavian artery, which led us to suspect a steal syndrome due to the arterio-venous fistula. Left internal mammary artery is the choice of vascular structure for myocardial revascularizations. An inversion on this artery’s flow, secondary to pressure drop in proximal subclavian artery is rare, but more and more often diagnosed. This phenomenon is known as «coronaro-subclavian steal syndrome». This pathology is more frequent in patients with a subclavian artery stenosis. Results: In our patient, the pressure drop in the left subclavian artery, due to the arterio-venous fistula on the same side with a coronary perfusion only due to the left internal mammary artery, could lead to the myocardial infarction (type 2 by hypoperfusion of the left internal mammary artery). This could explain the ventricular fibrillation and successive cardiorespiratory arrest with infarction of the inferolateral territory. A closer of the arterio-venous fistula was made, with recovery of the angina pectoralis immediately after the procedure. The patient is now dialysed by a left jugular catheter and a new fistula is scheduled on the right arm. Conclusion: Heart implication of steal syndrome has not been reported so far. The physiopathology of this condition is still poorly known. An adequate patient selection for surgery and early management are both essential to avoid the potentially fatal consequences of this condition. 34.7 Remote external iliac artery endarterectomy – how to pimp an old technique T. Lattmann, I. Schwegler (Zürich) Objective: Treatment of chronic external iliac artery (EIA) occlusive disease often requires a considerable surgical effort by lumbotomy or blind ring stripper endarterectomy. We describe step-by-step a minimally invasive technique, using fluorosopy, a guide-wire, and an over-the wire fogarthy catheter to desobliterate the EIA with a classical ring stripper. Methods: Supine position on the carbon fibre table. Preparation of the femoral vessels through a longitudinal groin incision. After inspection of the grade of calcification, the CFA is punctured and a 0.35 mm guide wire is inserted under fluoroscopic guidance followed by placement of an 8 french sheath. Control of the position under fluoroscopy using a pigtail catheter. The guide wire is changed to a 0.25mm wire and an arteriotomy of the CFA directly over the sheath is performed. Open endarterctomy is started in the CFA and a LeMaitre ® over-the-wire fogarthy-catheter (LeMaitre Vascular GmbH, Sulzbach, Germany) as well as a ring stripper according to the vessel‘s diameter is inserted. The fogarthy catheter is blocked in the unaffected part of the CIA. The ring stripper is advanced under rotating movements under fluoroscopic control up to the balloon of the fogarthy catheter. The catheter and the entire intima core are carefully retracted while the guidewire is left in position until the result is documented by fluoroscopy. If nessessary the distal intima in the SFA and the profound femoral artery are anchored with tacking sutures. The arteriotomy is closed with a patch. Results: Fourteen patients with iliac artery occlusive disease were treated by the two authors using this technique. Median age was 62.5 (50-86) years, (m:f 6:1 ). Postoperative ankle-brachial index at discharge significantly improved when compared with the preoperative situation. The intervention was successful in all cases. Two patients needed conversion to open surgery by a lumbotomy with open endarterectomy due to an unretractable intima core. Conclusion: Remote endarterectomy under fluoroscopic guidance using a guide wire and an overthe-wire fogarthy catheter is a minimaly invasive, elegant and safe technique to desobliterate chronic external iliac artery occlusions. Using this technique, the risk of vessel peforation is minimized, transsection of the intima core is controled and a residual stenosis can be treated using a stent in the same session if nessessary. swiss knife 2010; 7: special edition 27
Page 1 and 2: Abstracts 97. Jahreskongress der Sc
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 and 16: time-efficient all-in-one 3D visual
Page 17 and 18: (CHI=54 [6.49%]; SWI=27[4.98%]) wer
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 6/2009 and were prospectively f
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
Page 67 and 68: 99.16 3-D endo-stomal ultrasound (
Page 69 and 70: tional recanalization. Conclusion:
Page 71 and 72: 99.37 Extended Clavien-Dindo classi
Page 73 and 74: ial colitis was excluded by stool c
Page 75 and 76: 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
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Covidien Switzerland Limited multip
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