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Figure 3
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71.2
Technique of transabdominal triple neurectomy for recurrent inguinodynia
F. Pugin, P. Bucher, I. Inan, Ph. Morel (Geneva)
Objective: Triple neurectomy is proposed treatment for persistant chronic neuropathy after mesh
inguinal hernia repair. Open neurectomy with an anterior inguinal approach and/or a posterior lumbotomy
can be used. A minimally invasive endoscopic retroperitoneal technique has been described
and presents the advantage of a single stage procedure. We describe here (with video) a minimally
invasive transabdominal approach for simultaneous triple neurectomy.
Methods: This transabdominal approach was proposed to a fifty year’s old patient for persistent
chronic pain after unsuccessful anterior neurectomy and mesh revision 18 month after a laparoscopic
inguinal hernia repair.
Results: The optical port was introduced at the umbilicus. Two 5mm port were used as working trocars.
The peritoneum was incised horizontally and the retroperitoneal space dissected. The genito-femoral,
ilioinguinal and ilio-hypogastric nerves were identified and resected. The peritoneum was closed
with absorbable tackers. The preoperative described pain disappeared completely one month after the
operation and the patient returned to normal activity.
Conclusion: A transabdominal retroperitoneal approach can be proposed for minimally invasive triple
neurectomy for chronic inguinodynia after mesh hernia repair.
71.3
Effectiveness and implementation of the surgical Time Out - WHO International Patient Safety Goals
S. Schlunke, A. Greco, J. Al-Muaid, M. Giuliani, D. Brasola, P. Biegger (Locarno)
Objective: since 2008 our hospital is the first Swiss hospital certified by the Joint Commission International
(http://www.jointcommissioninternational.org). One of the over 1200 measurable standards
is also one of the WHO recommended international patients safety goals: a surgical time out prior to
every invasive procedure.
Methods: to obtain complete adhesion of all involved clinicians we produced a tutorial video about
communication in the OP theatre, about disruptive behaviour of surgeons and the execution of the
surgical time out.
Results: monitoring of documented time out execution in our records rose from 45% to a constant
97-100%.
Conclusion: in our opinion, disruptive behaviour is an important but largely ignored source of error. The
surgical time out is a possibility to involve the whole operating team in a pro-active and positive way of
thinking, increasing at the same time the patient’s safety. The video is a good tool to open a discussion
among colleagues about patient safety issues.
71.4
Laparoscopic repair of an internal herniation of the caecum and colon ascendens through the foramen
of Winslow
M. Cardell, M. K. Jung, E. Grossen, T. Delko, O. Schöb (Schlieren)
Objective: Herniation through the foramen of Winslow (HFW) is an extremly rare occurrence. Internal
hernias represent less than 1% of all hernias and of these only about 8% occur through the foramen
of Winslow. Since Blandin reported the first case of HFW in 1834 there have been only a few cases
reported in the literature. Therapy is immediate surgical reduction of the hernia which has been performed
by laparotomy so far.
Methods: A 63-year-old woman presenting with a short history of progressive, colicky pain in the upper
abdomen. The pain was from a sudden onset combined with a missing stool passage and absence
of flatus. She underwent surgery for adnexectomy three years ago and for appendectomy many years
ago. On physical examination she had a distended abdomen and muscular defence localized across
the epigastrium. All laboratory investigations were normal. The plain abdominal x-rays showed a di-
lated colon transversum, a compressed stomach and signs of coprostasis and meteorism. CT-scan of
the abdomen suggested a volvulus of the colon transversum with signs of obstruction. Worsening of
the symptoms led to decision for immediate diagnostic laparoscopy.
Results: Intraoperative findings showed a complete displacement of the stomach to the left and anteriorly
by a big mass. Further surgical exploration revealed a herniation of the terminal ileum, caecum
and colon ascendens through the foramen of Winslow into the lesser sack. Reduction was feasible
laparoscopically by constant traction. After reposition the herniated bowels showed no signs of necrosis
and were viable. Therefore no resection was performed. The dilated foramen of Winslow was partially
closed with a running LapraTy-suture (PDS 4-0). The further postoperative course was uneventfull
and the patient could be discharged after four days.
Conclusion: A herniation through the foramen of Winslow is very rare and preoperative diagnosis is
scarcly to achieve. An inconclusive diagnostic workup should not delay an operative exploration because
the rapid surgical reduction of the internal hernia is the only factor that decreases its morbidity
and mortality. The laparoscopic repair is a feasible, effective and save procedure.
71.5
Der laparoskopische Narbenhernienrepair
V. Pioch, T. Steffen, M. Thurnheer, J. Lange (St. Gallen)
Objective: Die laparoskopische Versorgung von Bauchwandhernien hat sich in den letzten Jahren
immer mehr etabliert. Patienten scheinen postoperativ weniger Beschwerden zu haben, und die Hospitalisationszeit
ist kürzer. Neuerdings wurde das Indikationsspektrum auch auf die Versorgung von
Narbenhernien erweitert.
Methods: Narbenhernien und Rezidivnarbenhernien werden mittels IPOM Technik laparoskopisch
versorgt. Um gegenüber dem offenen Vorgehen keine Kompromisse einzugehen, wird mit unserer
Methode der Bruchsack konsequent reseziert, und die Bruchlücke unter Reduktion der Bruchhöhle
verschlossen. Hierzu müssen die Nähte extrakorporal geknotet werden. Ggf. kann der Bruchsack auch
offen reseziert werden, da damit die Vorteile der IPOM Technik nicht geschmälert werden.
Results: Als Video präsentieren wir anhand von zahlreichen Beispielen die Prinzipien der laparoskopischen
Versorgung von Narbenhernien in chronologischer Abfolge. Das Prinzip des Vorgehens wird im
Detail aufgezeigt, wobei entscheidende Punkte besonders hervorgehoben werden.
Conclusion: Die Versorgung von Narbenhernien mittels intraperitonealer Netzimplantation (IPOM) ist
ein adäquates Vorgehen, auch bei grossen ventralen Hernien. Voraussetzung sind fortgeschrittene
laparoskopische Fertigkeiten und die Einhaltung von Grundprinzipen der Hernienversorgung. Konsequenterweise
wird somit der Bruchsack immer reseziert, die Bruchlücke verschlossen und die Bruchhöhle
in der Grösse reduziert.
Visceral Surgery – Posters 99
99.1
Duodenal ileus as primary manifestation of Crohn‘s disease: a case report
G. Kocher, F. Grieder, M. Decurtins (Winterthur)
Objective: Duodenal Crohn‘s disease is a rare condition. Almost all patients have associated involvement
of distal small or large intestine. We report the rarity of a patient with mechanical ileus as the
initial manifestation of an isolated, stenosing duodenal Crohn‘s disease.
Methods: Case report and review of literature.
Results: We report the case of a 21-year old female patient presenting with a 5 weeks history of epigastric
pain, weight loss, nausea and vomiting. Upper gastrointestinal contrast study showed duodenal
filiform stenosis over a length of 4cm (Figure 1). Gastroduodenoscopy revealed ulcerations in Pars
I duodeni followed by a non passable stenosis. Biopsies showed non-specific acute and chronic inflammatory
changes. Elevated faecal calprotectin and elevated blood ASCA IgA /IgG levels confirmed
the diagnosis of Crohn‘s disease. Extraduodenal involvement was ruled out by colonoscopy and MR-
Sellink. Management included successfull repeated endoscopic ballon dilation of the stenosis to a diameter
of 16mm, accompanied by medical treatment with a proton pump inhibitor and temporary administration
of corticosteroids. Two months after the patient was discharged on standard dose proton
pump inhibitor and normal nutrition she was asymptomatic but control-gastroduodenoscopy revealed
restenosis which was dilatated again successfully with one single intervention from 10 to 16mm.
Conclusion: Clinically significant gastroduodenal disease occurs in 0.5% to 4% of all patients with
Crohn‘s. Diagnosis of primary duodenal disease can be very difficult, especially in the absence of
known disease more distally in the bowel. Symptoms are often non-specific as are endoscopic and
bioptic findings. As in our case analysis of faecal calprotectin and blood ASCA levels can be of diagnostic
value. Medical management involves the use of a proton pump inhibitor plus corticosteroids.
Endoscopic dilatation proved to be effective in short stenotic lesions (≤ 4cm). With intractable disease
surgery (stricturoplasty or laparoscopic/open bypass) is a viable and safe option.
swiss knife 2010; 7: special edition 63