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99.64
Traumatic abdominal wall hernia following blunt trauma: a case report and review of the literature
V. Pioch 1 , M. Turina 2 , H.-P. Simmen 2 ( 1 St. Gallen, 2 Zürich)
Objective: A TAWH (traumatic abdominal wall hernia) is defined as defect of the abdominal wall musculature
and fascia with or without primary skin injury, resulting in a hernia. We describe the case of a
patient admitted with TAWH following blunt trauma.
Methods: Retrospective review of a single case.
Results: A 51-year old patient was admitted after falling down 9 meters from a silo and landing on his
right side. He immediately felt pain and tenderness in the right lower quadrant. Clinically, a superficial
skin lesion with an underlying palpable tumor was found. Following primary survey, a CT- scan was
performed revealing multiple craniofacial fractures, a contusion of the right lung as well as free intraabdominal
fluid and a herniation of a small bowel loop with a fist-sized defect of the entire abdominal
wall in the right lower quadrant. Immediate laparotomy was performed. Intraoperatively a traumatic
rupture of the meso of the terminal ileum was found. Adjacent, the lateral abdominal wall was ruptured
to the subcutaneous tissue. Resection of the harmed Ileum of 20cm length followed by direct anastomosis
and closure of the meso defect ensued. Then, continuous closure of the peritoneal perforation
on the lateral abdominal wall was performed using vicryl-0. Following exploration of the hernia from
the outside, débridement and closure layer-by-layer with Maxon-0 was performed. The postoperative
course was uneventful.
Conclusion: A TAWH after blunt trauma is a rare entity. The reported incidence of acute hernia ranges
from 02,%-3,6%. In our case the TAWH was already diagnosed in the trauma room. Mahajna et al.
reported the case of herniation of the right colon with vessel strangulation, which wasn`t seen in the
primary survey. A right hemicolectomy had to be performed on the 2nd posttraumatic day. In our case
we decided intraoperatively to perform a primary reconstruction of the abdominal wall without mesh
repair. The potential advantage of a mesh implantation lies in the augmentation of the abdominal wall,
thereby potentially lowering the risk of incisional hernia. However, the benefits of such augmentation
should be cautiously weighed against the risk of foreign body contamination when resecting bowel
during the same operation.
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Laparoscopic treatment of rare right diaphragmatic rupture with small bowell herniation after blunt
thoracic trauma
H. Hoffmann, D. Oertli, O. Heizmann (Basel)
Objective: Blunt traumatic diaphragmatic rupture (BTDR) is a life-threatening condition with an incidence
of 0,8-1,6% in blunt trauma. The closure of the diaphragm-rupture should be performed immediatly.
The diagnosis is often delayed because of absent typical symptoms or other major injuries, which
dominate the clinical aspect. An isolated BTDR is a rarity and can be followed by a period of weeks
or months without any symptoms. Most BTDR are located on the left side in the musculotendineal
intersection. Right BTDR are rarely described and less frequent. Herniation of colon, small bowell or
liver may occure and can result in ileus, necrosis and perforation.
Methods: We present a rare case of a 68 year female, hospitalized in the neurological departement
due to parkinson disease. She felt with her right hemithorax onto a chair. Initially subjective symptoms
were missing. The examination showed a slightly reduced breath without any signs of pneumothorax,
a decent pressure pain and a bruise. 4 days after trauma she developed a progrediend pulmonal decompensation
with a saturation of 89%, attendantly she showed signs of ileus. The chest x-rays offered
a herniation of small bowell into the right hemithorax with consecutive ileus-signs.
Results: We performed a laparoscopic approach and found a 4x5cm rupture of the right diaphragma
with herniation of small bowell. The small bowell appeared vital after reposition. The transdiaphragmatical
thoracoscopy showed a collapsed lung and a dislocated ripfracture, which supposably caused
the BTDR. After irrigation of the thoracic cavity we performed a direct laparoscopic tensionfree runningsuture
with non-absorbable tie (0/0 Ethibond). A drain was positioned in the right hemithorax. Afterwards
the patient showed an uneventful course.
Conclusion: The delay of the diagnosis was 4 days, which shows the variety of the clinical appearance
of the BTDR. The missing typical symptoms can mask the severity of the injury. Although large prospective
long-term-studies regarding outcome after laparoscopic approach are still missing, laparoscopy
was the method of choice in our case and could be performed savely. Compared to the thoracoscopic
approach, which is prefered by some authors, we performed the laparoscopy. It mostly allows easy
reposition of herniated organs, sufficient inspection of the thoracic and abdominal cavity and immediate
laparotomy if necessary.
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Introduction of contemporary surgery for varicosis veins in mongolia
C. Twerenbold 1 , A. Rotzer 2 , P. Nussbaumer 3 , Swiss Surgical Team ( 1 Winterthur, 2 Glarus, 3 Lachen)
Objective: After the collapse of the Soviet Union the Mongolian health system fell into a deep crisis
with a lack of consumable supplies and technical equipment. Educational and training opportunities
for physicians became very limited. Founded in 1998, the Swiss Surgical Team aims to improve the
local health system by conducting periodic educational missions to Mongolian hospitals. In Europe,
saphenous vein ligation and stripping is the gold standard for varicose vein surgery. In Mongolia however,
treatment still consists of local phlebectomies through long incisions. We aimed to investigate
the feasibility of introducing a contemporary procedure utilizing available local resources and using
varicose vein surgery as an example.
Methods: From the 22nd May to the 14th June 2009 our team performed 50 surgical procedures,
including eight interventions for varicose veins at the General Hospital of Darchan. Preoperatively every
patient was examinated using a trendelenburg test in order to identify insufficient perforans veins and
the valvular competence. After saphenous vein ligation a sterilized monofilament fishing line was used
for vein stripping. Miniphlebectomy was performed using stab incisions and a locally available crochet
hook.
Results: Saphenous vein ligation and stripping could be easily performed using the described local
materials. The intra- and postoperative course was uneventful in all cases. Our experience confirmed
that the local surgical community could easily learn the new procedure.
Conclusion: Our Mongolian experience suggests that in developing countries simple contemporary
procedures may be readily introduced using locally available inexpensive materials and instruments.
This trial establishes an approach for the introduction of new contemporary surgical techniques which
can contribute to the improvement of the local health system, otherwise unlikely to be achieved due to
prohibitively expensive conventional materials.
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Arthroscopic elevation of a reversed Hill-Sachs lesion and simultaneous ORIF of an ispilateral acromion
fracture in a patient with locked posterior shoulder dislocation combined with a displaced
acromion fracture: a case report
P. Grueninger, C. Meier (Zürich)
Objective: Traumatic posterior shoulder dislocations are frequently associated with anterior impression
fractures of the humeral head (reversed Hill-Sachs lesion). Whereas non-operative treatment is
the treatment of choice for most cases, an operative intervention may be considered for large and
engaging osseous defects.
Methods: Presentation of a minimally-invasive arthroscopic technique to elevate a large reversed Hill-
Sachs lesion in a patient with a locked posterior shoulder dislocation in combination with a displaced
fracture of the acromion.
Results: A 34-year old man sustained an isolated trauma to his left shoulder consisting of a posterior
shoulder dislocation in combination with a displaced fracture of the acromion. A CT scan which was
performed due to recurrent dislocation after closed reduction and immobilisation in internal rotation
(Gilchrist bandage) showed a locked posterior shoulder dislocation with a large reversed Hill-Sachs
lesion, a reversed double chondral Bankart lesion and an intact rotator cuff. In the following, closed
reduction was successfully performed and retained in a handshake brace. Arthroscopic surgery to
elevate the osseous defect was performed in combination with plate osteosynthesis of the acromion
5 days after trauma. The reversed Hill-Sachs lesion was arthroscopically visualized and a tibial ACL
target device was placed in the centre of the lesion with the K-wire entering the bone in the distal greater
tuberosity through a short incision. The cortex was opened and a cannula was inserted over the K-wire
into the humeral head. After removal of the K-wire the impression was elevated and the defect filled with
cancellous bone harvested from the anterior iliac crest. Postoperatively, the shoulder was immobilized
in a handshake brace for 3 weeks and no internal rotation >0° was allowed for 6 weeks. Three months
postoperatively the patient presented with a stable shoulder, full ROM and bony consolidation of the
humeral head.
Conclusion: While non-operative treatment with immobilisation in a handshake brace after closed reduction
may be successful in most cases, surgery should be considered for large engaging reversed
Hill-Sachs lesions. Osseous defects may be elevated using our technique via a minimally-invasive arthroscopic
approach.
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Leiomyosarcome de la veine petite saphène: un diagnostic rare
M. L. Matthey, E. Pezzetta, O. Martinet (Montreux)
Objective: Les léiomyosarcomes vasculaires sont des tumeurs rares et le plus souvent localisées dans
la veine cave inférieure; peu de cas touchant le système veineux périphérique des membres inférieurs
ont été rapportés dans la littérature. Dans cette situation les symptômes sont généralement tardifs et
aspécifiques avec un pronostic globalement défavorable.
Methods: nous présentons un cas de léiomyosarcome touchant un branche de la veine petite saphène
traité chirurgicalement avec succès.
Results: une patiente de 88 ans connue pour une insuffisance veineuse superficielle, qui a présenté
quelques mois après le traitement d’une varicophlébite du membre inférieur gauche des douleurs
dans le mollet ipsilatéral évoquant la présence d’une récidive. La persistance des symptômes malgré
le traitement anticoagulant instauré a conduit à une réévalutation angiologique. L examen échodoppler
a montré une image compatible avec un thrombus intraluminal de 4cm au sein d’une varice
accessoire provenant de la veine petite saphène. Cette même image est retrouvée 5 mois plus tard
lors d’un contrôle, une intervention chirurgicale est ainsi planifiée avec une crossectomie et stripping
des veines petites saphènes bilatérales avec phlébectomies étagées. Au cours d’un paquet pseudo-
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