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tional recanalization.
Conclusion: Major liver resections without Pringle’s maneuver are feasible, safe and accompanied by
only moderate blood loss. Performing liver resections without Pringle’s maneuver might help to avoid
liver failure in the postoperative course.
99.27
Is the conservative treatment for acute cholecystitis in the elderly patients a good option? Retrospective
study
S. Dominguez, B. Bédat, T. Berney, Ph. Morel (Geneva)
Objective: Laparoscopic cholecystectomy is nowadays recognized as the standard treatment for
acute cholecystitis. A few alternatives have been described in the case of high risk patients for surgery
(cholecystostomy, partial cholecystectomy) but there is no literature about the outcome of conservative
treatment in high risk patients.
Methods: Retrospective analysis of 97 patients over 75 years old, hospitalized from January 2003 to
November 2008 with a diagnosis of acute cholecystitis. Inclusion criteria were: clinical status in line
with a diagnosis of acute cholecystitis (right upper quadrant pain), blood tests showing an inflammatory
state and radiologic study showing a gallbladder inflammation. All patients were treated with an
intravenous antibiotherapy during 10 days. Cases for which a cholecystectomy has been performed
were excluded. 34 patients (35%; 23 women, 12 men; mean age: 86 years old) remained in the study,
6 of them refused the surgery and 29 were considered at high risk for surgery (ASA III-IV). The selected
patients and/or their consulting physician were contacted to know their outcome.
Results: Among the 34 selected patients, 15 presented a pain recidive (44.1%), 5 (14.7%) suffered a
second acute cholecystitis, 3 (8.8%) have been operated for a cholecystectomy, 10 (28.6%) died (of
other causes than gallbladder, biliary or post cholecystectomy complications).
Conclusion: The rate of acute cholecystitis recidive in our group of elderly patients is about 15% in the 3
years following the first episode, no major complications were described in the follow-up. This support
the idea that conservative treatment in high risk patients is an acceptable alternative.
99.28
Die akute myeloische Leukämie als chirurgische Erkrankung
G. Lindemann, R. Gischig, G. Szöllösy, S. Wildi (Zürich)
Objective: Die akute myeloische Leukämie (AML) ist eine hämatologische Erkrankung, die sich nur
selten primär extramedullär manifestiert. Im Gastrointestinaltrakt kann es sekundär zu einem Befall
von Oesophagus, Magen, Dünndarm oder Kolon kommen. In ungefähr 5% der Patienten mit akuten
Leukämien treten abdominale Komplikationen auf (Neutropene Enterocolitis, spontane Milzruptur,
Milzabzess).
Methods and Results: Eine 43jährige, bis anhin gesunde Patientin wird wegen einer symptomatischen
Choledocholithiasis zur ERCP zugewiesen. Überraschenderweise zeigt sich in der Untersuchung eine
röhrenförmige Stenose des Ductus choledochus mit nur geringer Stauung und ohne Konkremente in
den Gallengängen. Deswegen Durchführung einer Papillotomie und Einlage eines Katheters zur Drainage
bei Verdacht auf eine entzündliche Stenose. Endosonographisch kann ein Tumorwachstum, serologisch
eine Pankreatitis oder eine Echinokokkus-Infektion ausgeschlossen werden. Bei nachgewiesenen
Gallenblasensteinen erfolgt im Verlauf die laparoskopische Cholecystektomie, wo sich in der
Histologie eine ausgedehnte transmurale Infiltration durch myeloische Vorläuferzellen zeigt, welche
hinweisend auf eine extramedulläre Manifestation einer akuten myeloischen Leukämie ist. Die Bestätigung
der Diagnose wird immunhistologisch und im Differenzialblutbild mit 7,4 G/L Blasten erreicht.
Conclusion: Der extramedulläre Befall von Gallenblase oder Gallengängen als Erstmanifestation einer
Leukämie stellt eine ausgesprochene Rarität dar. Bei unserer Patientin wurde die Verdachtsdiagnose
einer AML aufgrund der Gallenblasen-Histologie gestellt, und dann immunhistologisch und mittels Differentialblutbild
bestätigt.
99.29
Mono-Umbilical Cholecystectomy (MUC), simple and safe
W. Schweizer 1,2,3 , H. Marlovits 1 ( 1 Schaffhausen, 2 Zürich, 3 Winterthur)
Objective: The so called NOTES techniques are by far not minimally invasive, perforating internal
organs like stomach, rectum or vagina with the respective possible complications. The instruments
needed are complicated and the technical skill of the surgeon needs an enormous training effort that
is by far not affordable for most surgeons.
Methods: Looking for a simple and safe method for less trauma in minimal invasiv surgery we developped
a method, using only the umbilicus as a natural orifice for the surgical approach, introducing up
to three instruments through this one same access using conventional laparoscopic instruments and
trocars. This technique can probably be performed by most minimally invasive experienced surgeons
and needs only a slight modification of the usual „conventional“ minimally invasive methods. It is by
far not as time consuming as the NOTES techniques and does not need sophisticated and expensive
instruments.
Results: We present the technique and the first 50 patients with MUC procedures for gallstones. All
operations (january till december 2009) were performed with only one complication (postoperative
bleeding in a patient with von Willebrand coagulopathy). A successful Cholangiogramm was performed
in 47 patients, revealing a small bile leak near the cystic duct in one patient, which was sewn
immediately through the umbilicus only. All patients had uneventful postoperative courses.
Conclusion: With a simple and safe monoincisional technique for an umbilical access in minimally
invasive surgery, the possibly harmful and exclusive NOTES techniques with transgastric, transrectal
or transvaginal approach, very time consuming procedures and expensive instruments can possibly
be avoided. Considering the umbilicus as a natural orifice and using it exclusively as a monoincisional
approach for up to three slightly modified instruments, many minimally invasive operations can easily,
safely and time sparingly be performed by experienced laparoscopic surgeons as an operation with
a very short learning curve.
99.30
Successful redo laparoscopic antireflux surgery in gastroesophageal reflux disease
R. Fahrner 1,2 , V. Neuhaus 2,3 , O. Schöb 2 ( 1 Berne, 2 Schlieren, 3 Zurich)
Objective: Laparoscopic antireflux surgery is a well established treatment of gastroesophageal reflux
disease (GERD). Recurrent reflux, gas-bloat syndrome or dysphagia may result in a reoperation which
is at higher risk of perioperative morbidity and mortality.
Methods: From March 1st 1999 to December 31st 2009, 170 antireflux procedures were performed.
27 of these (16%) were redo procedures, whereof 8 patients were first treated in an external hospital.
Time period between first operation and revision was 692 days (18-3688). Postoperative course, perioperative
morbidity and mortality after redo-fundoplication were analysed retrospectively.
Results: Initial fundoplication was performed because of up-side-down stomach (n=3), GERD with
(n=20) or without hiatal hernia (n=4). The indications for redo procedures were recurrent reflux or
herniation of the wrap (n=24) or scarred adhesions and dysphagia (n=3). During revision additional
procedures were performed such as reposition of small bowel out of the hiatal space (n=4), myotomy
of the esophageal sphincter (n=1), cholecystectomy (n=1), laparoscopic inguinal hernia repair (n=1).
All procedures were completed laparoscopically. The mean operation time was 144 minutes (range:
65-285). Five lesions of the wrap and one lesion of the pleura were stated intraoperatively and were
treated during the operation. No postoperative deaths occurred. The median hospital stay was about
7 days (3-19).
Conclusion: Redo-fundoplication is technically challenging because of scarred tissue and the risk of
esophageal perforation. Reoperation is associated with higher morbidity and mortality. Our results
were comparable to the current literature and feasible with low incidence of perioperative morbidity
and no mortality.
99.31
Abdominal wall rupture following a fit of coughing
S. Feichter 1 , P. Kirchhoff 2 , D. Oertli 2 , O. Heizmann 2 ( 1 Luzern, 2 Basel)
Objective: Thiersch skin graft is a widely accepted and utilized procedure for closing an open abdomen.
Other possibilities are suture, mesh inlay, only skin closure, negative pressure wound dressing,
Bogota bag, fascia graft or towel clips.
Methods: We present a case report of a 72 year old female that came to our emergency department
with abdominal Thiersch rupture and exposed small intestine after coughing. 18 months before, she
was operated for an incarcerated epigastric hernia with a four-quadrant peritonitis, necrosis and perforation
of the incarcerated transverse colon. A right hemicolectomy with primary anastomosis was
done. Direct closure of abdominal wall showed no difficulty. Two weeks later a second laparotomy and
ileo-transversostomy was necessary due to suspected anastomotic insufficiency. Another two weeks
later, stool appeared in the V.A.C. dressing, a third laparotomy was necessary. The terminal ileum and
proximal transverse colon were resected, a terminal ileostomy and colonic mucous fistula were installed.
Direct abdominal wall closure was not possible, so a Vicryl mesh inlay was used, covered by
V.A.C. Later, the wound was closed by Thiersch. After 18 month, a star-shaped rupture of the Thiersch
and adherent small bowel loops happened. At laparotomy, two ruptures of intestine were sewed, 10cm
of ileum was resected and an end-to-end anastomosis was done, also the intestinal continuity was
rebuilt. The abdominal wall was reconstructed by a vicryl mesh inlay. At follow-up 3 months later, the
patient presented in good condition, the abdominal wall was closed.
Results: Many options are available for abdominal wound closure. In our case sepsis, peritonitis and
bowel swelling made primary closure not possible, so a Thiersch skin graft was used. For our elderly
patient in poor clinical condition, it was the safest, fastest and less invasive solution. Problems associated
with skin graft are known: constant mechanical irritation can lead to herniation or ulcers, also
hypaesthesy and reduced tissue flexibility occur.
Conclusion: An abdominal wall reconstruction should be performed with a tension free closure technique
or with mesh. For patients in poor clinical condition, a Thiersch skin graft is still a useful option. It
is less invasive and quick to perform. If the patient’s condition improves, an elective secondary abdominal
wall reconstruction should be done.
99.32
Proceed ventral patch: a new procedure in the treatment of umbilical hernia
B. Muggli, G. Frey, W. Mouton, M. Naef, H. Wagner (Thun)
Objective: A variety of newly developed mesh products have recently become available to use inside
the peritonealcavity. This analysis reports our earliest results in the new procedure of umbilical hernia
repair with the use of Proceed Ventral Mesh. The PVP Mesh is the first and only umbilical hernia device
featuring lighter-weight mesh and exclusive absorbable depolyment technology. The recurrence rate
with mesh repair are significantly lower compared with suture repair. And the PVP mesh is strong
enough to withstand more than 2 times the maximum abdominal wall pressure.
Methods: During a 8-month period between 04/09 and 12/09, 41 adult patients underwent a umbilical
hernia repair using an intra-abdominal placement of a Proceed mesh. All patients undergoing
umbilical hernia repair by the authors were studied with the evaluation of intraoperative and postoperative
results. Hospital and office chart reviews were used to evaluate the short- and mid-term outcome
in this study.
Results: Between April 2009 and December 2009 41 patients underwent a open umbilical hernia repair
with PVP mesh. The mean age of the patients was 54 years (range 19-84 years). The ASA-Score
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