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99.51 Segmental infarction of the lesser omentum and acute abdomen I. Bohlmann, D. De Lorenzi (Grabs) Objective: Segmental infarction of the lesser omentum is an extremely rare cause of acute abdomen, and is often neglected as a differential diagnosis. The patients present with various symptoms, the localization of pain mostly suggests appendicitis or cholecystitis. Therefore, preoperative diagnosis can be difficult, although recently, extensive use of computertomogram and ultrasound examination to prevent unnecessary surgery, has been favored. Methods: We present a case of intraperitoneal fat focal infarction of the lesser omentum in a 65- year- old female. She was admitted with increasing colicky abdominal pain of the right upper quadrant, accompanied by nausea. Results: The patient was admitted with increasing colicky abdominal pain of the right upper quadrant and rebound tenderness. Ultrasound confirmed cholecystolithiasis, there were no other suspicious findings detected. Subsequently, she underwent a laparoscopic cholecystectomy, were the focal infarction of the lesser omentum was noticed. The involved omentum was resected, additionally. Postoperatively, the patient recovered well and could be discharged after four days. Conclusion: As imaging techniques advance, conservative therapy has recently gained more interest. Patients with non- complicated omentum torsion and unambiguous diagnosis, can be safely treated by conservative means. However, in the majority of the cases, surgical resection will still be the treatment of choice, especially since primary omentum infarction is even less frequent. 99.52 Volvulus of the vermiform appendix mimicking acute appendicitis G. Kocher, C. Frei-Lanter, M. Decurtins (Winterthur) Objective: Torsion of the vermiform appendix is a rare pathological entity. We present a case and discuss the relevance of this pathological entity. Methods: Case report and review of the literature. Results: A 48-year old patient who was under antibiotic treatment with Amoxicillin/Clavulanic acid since seven days because of facial impetigo presented with a 6-hour history of right lower quadrant abdominal pain of gradual onset. Examination revealed marked tenderness at the right lower quadrant with guarding and rebound tenderness, a WBC count of 11.7x10^9 /L and a CRP of 22mg/l. After an inconclusive ultrasound, CT scan showed a distended appendix consistent with acute appendicitis. At laparoscopy 12 hours after onset of symptoms, the appendix was 9cm in length, in deep purple color and rotated through 360° in clockwise direction approximately 1cm from the unremarkable appendiceal base (Figure 1). Appendectomy was done, and histology showed hemorrhagic infarction compatible with torsion and ulcerophlegmonous appendicitis. Conclusion: There are only about 25 case reports of torsion of the vermiform appendix in the literature since Payne et al. reported the first patient in 1918. Most cases are reported to be primary appendiceal torsions, about 25% of all cases are reported to be secondary in association with lipoma, mucocele, cystadenoma or fecalith impaction. Volvulus of the appendix can occur at any age. Risk factors seem to be a solid mass fixed onto a narrow base, a long shape and free lying pelvic position. It is unclear whether inflammation precedes or follows the torsion. Most often, the direction of rotation is anticlockwise. Clinically the condition is indistinguishable from acute appendicitis and diagnosis is only made at operation. If appendectomy is performed because of suspected acute appendicitis, the differentiation between torsion and acute inflammation of the appendix seems to be irrelevant. However, this becomes relevant if an antibiotic treatment is discussed as first-line treatment of suspected acute appendicitis. Such a non-operative first-line treatment was recently published to be a safe firstline therapy of acute appendicitis by Hansson et al. In case of torsion of the appendix as in our patient, a non-operative approach most certainly will be unsuccessful, risking perforation with its consequences on patient outcome. Figure 1 74 swiss knife 2010; 7: special edition 99.53 Splenic rupture after colonoscopy: a case report R. Meier, C. Toso, F. Volonte, G. Mentha (Geneva) Objective: We report a case of splenic laceration after colonoscopy. Methods: Colonoscopy is the gold standard diagnostic and therapeutic procedure for rectum and colon pathologies. Splenic injury is a rare complication of this procedure, 66 cases have been reported in the literature. Results: An outpatient colonoscopy was performed in a 68 y.o. woman by her general gastroenterologist in order to investigate chronic abdominal pain, associated to a rapid 10 kg weight loss. The procedure was uneventful until 90 cm from the anal margin, when the patient developed acute left upper quadrant pain. The colonoscopy was stopped and a non-enhanced abdominal CT scan was performed which excluded the presence of free intra-abdominal air or fluid [Fig.1]. Laboratory tests showed moderately increased pancreatic enzymes. Guided by these results, the attending physician diagnosed a mild pancreatitis, and sent the patient to her general practitioner for further investigations. The next day, the patient experienced increased level of abdominal pain, and she subsequently passed out. On admission in our emergency department, she was in shock. An enhanced CT scan revealed the presence of an active bleeding from the spleen with 2L of free intra-abdominal fluid [Fig. 2]. The CT scan brought to light a pancreatic neck mass [Fig. 3]. An emergency splenectomy was performed with lymph node sampling. The postoperative course was uneventful, the final histological result showed well-differentiated adenocarcinoma, that was managed with palliative chemotherapy. Conclusion: The main mechanisms of splenic injury are looping of the endoscope, and an excessive traction on the splenocolic ligament. Conditions associated to a decreased mobility between the spleen and the colon are considered predisposing factors. The presence of a pancreatic mass with a neighbouring inflammation could represent a possible risk factor. The clinical presentation in this patient was remarkable for acute left upper quadrant pain, which should be identified as a symptom of possible splenic injury. The imaging modality of choice should be enhanced CT scan, in order to look for intra-abdominal free air or fluid and a possible extravasation of contrast. In conclusion, colonoscopic splenic injury is a rare but potentially fatal complication that the endoscopist, the emergency physician and the surgeon should recognise in order to ensure appropriate care management. Figure 1: Non-enhanced CT scan with slightly Figure 2: CT scan with iv contrast of the enlarged spleen (11.2 cm x 4.6 cm), abdomen, demonstrating an active bleeding 3 hours after colonoscopy from the spleen (arrow) with sub-capsular hematoma, 48 hours after colonoscopy 99.54 Intestinal actinomycosis – often mistaken for malignancy F. Näf, A. Enzler-Tschudy, T. Steffen, J. Lange (St. Gallen) Figure 3: CT scan with iv contrast showing pancreatic neck mass (arrow) Objective: Intestinal actinomycosis can cause severe abdominal complaints. However, it is often misdiagnosed due to rare incidence and large imaging variety. Actinomycosis is an infectious disease caused mainly by anaerobic gram positive bacteria, Actinomyces israelii. The disease is characterized by the formation of painful abscesses in the mouth, tonsils, lung or gastrointestinal tract. Methods: A 46-year old woman presented with abdominal pain in the inferior hemiabdomen for one week, increasing abdominal girth and recurrent fever in the last three months. She lost 15 kilograms in the last six months and had night sweat. Ultrasonography and abdominal computertomography showed a tumor mass in the right inferior abdominal quadrant (71 x 51 x 55 millimeters). Fine needle aspiration of the tumor showed neutrophils without malignant cells. Results: Because of the unclarified dignity and exact origin of the tumor, a right colectomy was performed. Intraoperatively the tumor was found to infiltrate the abdominal wall. Additionally, a second tumor was found in the large omentum, mimicking peritoneal carcinomatosis. Histological workup of the resected specimen showed the diagnosis of gastrointestinal actinomycosis. Therefore the patient was further treated with antibiotics. Conclusion: Intraabdominal actinomycosis usually begins in the gastrointestinal tract and spreads to the abdominal wall. It is typically mistaken for malignancy. The treatment of choice of actinomycosis is antibiotic therapy. However, since gastrointestinal actinomycosis can cause severe abdominal complaints, operative treatment is often performed.
99.55 Complexes de von Meyenburg(hamartomes biliaires): découverte fortuite lors d‘une cholécystectomie par laparoscopie D. Douma 1 , K. Djebaili 1 , C. Becciolini 1 , A. Safret 2 , J.-C. Renggli 1 , L. Ducali 1 ( 1 La Chaux-de-Fonds, 2 Neuchâtel) Objective: Nous rapportons une observation des complexes de von Meyenburg(hamartomes biliaires) chez une jeune patiente. Methods: Il s‘agit d‘une patiente de 25 ans, en bonne santé habituelle,qui se plaignait depuis huit mois de douleurs abdominales hautes réccurentes associées à un sydrome de reflux gastro-oesophagien,sans trouble de transit. Pas de notion perte de poids. Cliniquement,elle était apyrétique,l‘abdomen était sensible dans l‘hypocondre droit et le signe de Murphy était positif. Le bilan biologique était normal. L‘échographie abdominal mettait en évidence une lithiase vésiculaire sans signe de cholécystite et sans dilatation des voies biliaires. La gastroscopie réalisée ne montrait aucune pathologie. Une cholécystectomie par laparoscopie était programmée. Lors de l‘intervention,nous avons découvert à la surface du foie de multiples lésions faisant penser à des métastases hépatiques. (Fig 1). Des biopsies ont été pratiquées et montraient plusieurs complexes de von Meyenburg sans signe de malignité (Fig 2 et 3). L‘évolution clinique était favorable et à 48 heures post-opératoires,la patiente avait regagné son domicile en bon état général. Results: Les Complexes de von Meyenburg sont décrits comme étant des lésions hamartomateuses des voies biliaires. L‘origine de ces lésions est congénitale, liée à une anomalie de la plaque ductale. Le mécanisme est probablement lié à une anomalie embriologique dans le développement des voies biliaires pendant la phase tardive du développement. Ces lésions sont asymptomatiques et le plus souvent découvertes par hasard lors d‘une échographie ou d‘un scanner abdominal. L‘IRM hépatique est importante afin de différencier ces lésions des métastases hépatiques. Le diagnostic positif répose sur l‘analyse histologique des biopsies des lésions. La transformation maligne des complexes de von Meyenburg est estimée à 7% Conclusion: Une biopsie hépatique doit être réalisée systématiquement chez tous les patients qui présentent de multiples lésions hépatiques découvertes lors d‘une chirurgie laparoscopique. Seul le résultat histologique permettra d‘éliminer le diagnostic de métastases ou de confirmer les complexes de von Meyenburg. Il est important d‘avoir à l‘esprit le risque potentiel de développer un cholangicarcinome hépatique. En l‘absence de recommandation sur le suivi de cette pathologie, nous n‘avons pas prévu de contrôle à long terme. Figure 1 Figure 2 Figure 3 99.56 The captive ascites – incisional hernia repair in the presence of cirrhosis and ascites A. Schlegel 1 , D. De Lorenzi 2 ( 1 Goldach, 2 Grabs) Objective: The prevalence of umbilical hernias in cirrhotic patients with ascites is about 20%. Factors that contribute to the development of an umbilical hernia in these patients are increased intra-abdominal pressure from ascites, weakness of the abdominal fascia and muscle wasting. Repair of umbilical hernias in cirrhotic patients is associated with an elevated morbidity and mortality. We find a tendency to reserve hernia repair until bowel-related complications develop. We present a case of an enormous incisional hernia 2 years after umbilical hernia repair in a patient with ascites. Methods: A 56-year-old male patient presented an enormous incisional hernia with a large amount of ascites. In his medical history we found a cirrhotic liver disease. A year before he underwent an urgent mesh - repair of a strangulated umbilical hernia. An ultrasound revealed a small gap between mesh and fascia without herniation of visceral organs. After medical treatment of ascites an open hernia repair was performed. Results: After opening of the hernia sac three litre ascites were evacuated. Dissection of the sac, exposition of the hernia gap seized about 4x2.5 cm and placing of 8 single, non - absorbable sutures, including fascia and mesh. Before tightening the knots, fibrin tissue adhesive was inserted into the area of hernia gap. The overrun skin was removed. Skin closure with bracket. Over the subcutaneous drainage vibravenous fluid was inserted for 3 hours post - operative. The follow - up presented no complications. Conclusion: The optimal management of umbilical hernia in patients with ascites is still undefined. If left untreated, abdominal wall defects grow to immense sizes and can be associated with complications that demand urgent surgical intervention and lead to a high mortality. Generally an elective repair is recommended after reducing ascites. In candidates for liver transplantation, herniorrhaphy can be performed at the end of the transplantation procedure. Using a mesh seemed to decrease the incidence of recurrence. Some studies did not confirm these results. The reason not to choose meshassisted repair is the assumption that ascites mesh ingrowths is impaired and there is a presumed increased risk of infection and leakage through the mesh, as shown in our case. But no comparative, randomized, prospective studies exist with regard to the type of mesh, fixation, complications or recurrence. 99.57 Clostridial bacteraemia associated with an ileal Gastrointestinal Stromal Tumor (GIST) S. Sugasi, M. Peter, J.-M. Michel, B. Egger (Fribourg) Objective: Gastrointestinal stromal tumors (GIST‘s) are the most common mesenchymal neoplasms of the gastrointestinal tract. Often discovered incidentally, GIST‘s can present with more overt symptoms of bleeding, obstruction, or perforation. Bacteraemia associated with a GIST has been very rarely described. In this report, we present an unusual clinical case that illustrates how GISTs can become infected, and demonstrate the importance of Clostridium perfringens bacteraemia as an indicator of possible underlying gastrointestinal neoplasm. Methods: A 82 years-old, male, was hospitalized for diminished state with abdominal pain accompanied by vomiting and fever at 39.5°. Endoscopy exams with gastroscopy and colonoscopy did not show any lesion. Physical examination revealed a remarkable diffuse tenderness of the abdomen. Although at admission inflammatory parameters were normal, blood cultures were taken. An abdominal computed tomography revealed a mass in the distal ileon. Due to persisting pain, surgery was performed with segmentary resection of the exophytic 5 cm ileal tumor. Blood culture confirmed a Bacteraemia with Clostridium perfringens. The postoperative recovery was uneventful. Histopathology revealed a high grade GIST (Fletcher Grade 4) resected in toto. Results: GIST‘s may ulcerate, bleed or grow large enough to cause pain or obstruction; uncommonly infection and perforation can occur. Anaerobic bacteraemia is rare, the most frequently isolated anaerobes are Bacteroides fragilis and Clostridium perfringens and the most frequent route of entry is intra-abdominal disease such as abscesses on intestinal obstruction and malignancy. Clostridium perfringens is a gram-positive rod-shaped anaerobic bacteria that is a normal saprophytic inhabitant of the human gastrointestinal tract. In general, Clostridia may find a favourable anaerobic environment for propagation in the center of hypoxic or necrotic tumour mass. Immediate antibiotic therapy and surgical intervention are necessary for a successful outcome. Conclusion: GIST‘s are more often discovered incidentally or secondary to occult bleeding. Anaerobic bacteraemia has been rarely described with GISTs. As patients with malignancy have an increased incidence of clostridial infection, Clostridium perfringens bacteraemia could be an indicator of possible underlying gastrointestinal neoplasm. 99.58 Cholecystectomy - new techniques, new instruments and related expenses J. M. Janczak, G. Linke, A. Zerz (St. Gallen) Objective: Recently, new techniques for cholecystectomy such as single port access (SPA) or transvaginal hybrid cholecystectomy (tvCCE) were evaluated and introduced in clinical practice. More and more surgeons consider to start these approaches in clinical routine, which requires new devices such as trocars, optics or flexible and curved instruments. New technologies require new expenses. Based on our experience, we report on necessary and suitable single-use equipment for CCE, SPA and tvCCE and the related expenses. Methods: Single-use surgical materials required for CCE, SPA and tvCCE performed in our hospital are listed and expenses are calculated. Results: The expenses for SPA account between 1187 SFR and 1522 SFR. Single-use material for tvCCE is calculated with 970 SFR and CCE about 705 SFR. swiss knife 2010; 7: special edition 75
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Visceral Surgery - Cholecystitis &
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(CHI=54 [6.49%]; SWI=27[4.98%]) wer
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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
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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
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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: ial colitis was excluded by stool c
Page 77 and 78: 99.64 Traumatic abdominal wall hern
Page 79 and 80: 99.75 Isolated dorso-medial disloca
Page 81 and 82: FRAGMIN ® DER ERFAHRENE WEGGEFÄHR
Page 83 and 84: Kalbermatten Daniel, PD Dr., CHUV C
Page 85 and 86: Meyer Antoine, Dr., Hôpital canton
Page 87 and 88: Covidien Switzerland Limited multip
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