R. K. J. Simmermacher

The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures

Currently available intramedullary devices for the treatment of unstable pertrochanteric femoral fractures are technically demanding and show a considerable failure rate due to their massiveness and the persistent rotational instability of the head-neck fragment. The Arbeitsgemeinschaft für Osteosynthesefragen (AO/ASIF) therefore designed a new intramedullary device, the proximal femoral nail (PFN), which during a handling study was tested in 4 European clinics. Within one year 191 proximal femoral fractures were treated with the PFN. After a follow up period of at least 4 months technical failures (poor reduction, malrotation or wrong choice of screws) were seen in just 4.6% of the cases. One patient showed a cut-out of the implant but there were no mechanical failures (bending, breaking of the implant) or ipsilateral fractures of the femoral shaft at the tip of the implant. It is therefore concluded that the results of this new implant compare favourably to the currently available implants for the treatment of the unstable pertrochanteric femoral fracture.

The new proximal femoral nail antirotation (PFNA®) in daily practice: Results of a multicentre clinical study

The treatment of unstable trochanteric femoral fractures is still challenging. The ideal implant should be easy to handle, allow for immediate full weight-bearing postoperatively and should have sufficient purchase in the femoral head/neck-fragment to limit cut-outs due to varus-deviation and rotation. The proximal femoral nail antirotation (PFNA), designed by AO, is an intramedullary device with a helical blade rather than a screw for better purchase in the femoral head and was tested in a clinical study. Consecutive patients with unstable trochanteric fractures (AO-classification 31.A.2 and A.3 only) were included and followed for 1 year. Primary objectives were assessment of operative and postoperative complications, whereas secondary objectives included surgical details, general complications and final outcome measurements. In 11 European clinics, 315 patients were included and treated with a PFNA. Almost all fractures healed within 6 months. Fifty-six percent of the patients regained the pre-trauma mobility and 18% died within the follow-up period. Forty-six implant-related complications--leading to 28 unplanned re-operations--were recorded, with four acetabular penetrations (three of which were after a new fall on that hip) and seven ipsilateral femoral shaft fractures as the most serious ones. As the joint-penetrations did not resemble the cut-out seen with other implants it is concluded that the PFNA--due to its helical blade--possibly limits the effects of early rotation of the head/neck-fragment in unstable trochanteric fractures and therefore seems currently to be the optimal implant for the treatment of these fractures especially in osteoporotic bone.

Robot-Assisted Endoscopic Surgery: A Four-Year Single-Center Experience

Background: Robotic systems were introduced in the late 1990s with the objective to overcome the technical limitations of endoscopic surgery. In this prospective cohort study the potential safety, feasibility, pitfalls and challenges of robotic systems in gastrointestinal endoscopic surgery are assessed and our vision on future perspectives is presented. Methods:Between August 2000 and December 2004, 208 procedures were performed with support of the Intuitive Surgical da Vinci™ robotic system. We started with cholecystectomies (40) and Nissen fundoplications (41) to gain experience with robot-assisted surgery. In the following years more complex procedures were carried out, i.e. colorectal procedures (7), type III/IV paraesophageal hernia repair (32), redo Nissen fundoplications (9), Heller myotomies (24), esophageal resections (22), rectopexies (16) and aortobifemoral bypasses (3). Results:The median robotic set-up time was 13 min, and 7 min in the last 50 procedures. The median operating time for the total of procedures was 120 min (45–420) and the median blood loss was 30 ml (0–800). Fourteen procedures were converted to open surgery (6.7%). Equipment-related problems, such as start-up failures and positioning difficulties of the robotic arms, were encountered in 11 cases (5.3%). Postoperative complications were seen in 11 patients (11/176, 6.3%) after robot-assisted laparoscopic procedures. Pulmonary complications occurred in 11 patients, cardiac in 3, anastomic leakage in 3, chylous leakage in 3 and vocal cord paralysis in 3 after thoracoscopic esophagolymphadenectomy for esophageal cancer. One patient died 12 days after esophageal resection (0.5%). Conclusion:During the implementation of this robotic system, we experienced an obvious learning curve, particularly with regard to the positioning of the robot cart and communication between the surgeon and operating team. After 4 years, we have experienced that the merits of the current generation of this technology probably is preserved to complex endoscopic procedures with delicate dissection and suturing. In the nearby future we will focus on the treatment of motility disorders and malignancies of the esophagus and stomach. The position of the robot in the endoscopic operating room will have to be clarified by the outcome of prospective research. Furthermore, priorities have to be acclaimed on technical sophistication and cost reduction of these systems.

Regional trauma system reduces mortality and changes admission rates: a before and after study.

Objective:To evaluate the effect of the introduction of a regionalized trauma system. Background:Trauma systems have proven to be efficacious in reducing mortality in trauma patients in the United States. To date, this was not proven for inclusive trauma systems outside the United States. The current study evaluates the effect of the introduction of an inclusive trauma system in the Netherlands in 1999. Methods:Retrospective pre- and post analyses of a trauma care system on hospital discharge data regarding trauma patients admitted to hospitals in the central region of The Netherlands. Patients treated during 1996 to 1998 (control group), before implementation of the inclusive trauma system were compared with patients treated during 2003 to 2005 (index group) after the trauma system was installed. Risk adjusted odds-ratios of death and admission to a trauma center were determined. Results:A total of 33,201 patients were included in the control group and compared with 34,840 patients in the index group. After implementation of the trauma system, in-hospital mortality for all injured patients decreased from 2.6% to 2.3% (OR: 0.89 with 95% CI: 0.80–0.98). After adjustment for differences in gender, age, injury severity, comorbidity, injured body region, mechanism and intent of injury between both groups, the odds-ratio was 0.84 with 95% CI (0.76–0.94). Multitrauma patients were the subgroup admitted more frequently to a trauma center (OR: 1.19 with 95% CI: 1.01–1.39). Conclusions:Implementation of an inclusive trauma system in The Netherlands results in a more efficient triage system of trauma patients among hospitals and is associated with a substantial and statistically significant risk reduction (16%) of death.

Long-term symptomatic outcome and radiologic assessment of laparoscopic hiatal hernia repair

BACKGROUND The long-term durability of laparoscopic repair of paraesophageal hiatal herniation is uncertain. This study focuses on the long-term symptomatic and radiologic outcome of laparoscopic paraesophageal herniation repair. METHODS Between 2000 and 2007, 70 patients (49 females, mean age +/- standard deviation 60.6 +/- 10.9 years) undergoing laparoscopic repair of paraesophageal herniation were studied prospectively. After a mean follow-up of 45.6 +/- 23.8 months, symptomatic (65 patients, 93%) and radiologic follow-up (60 patients, 86%) was performed by standardized questionnaires and esophagograms. RESULTS The symptomatic outcome was successful in 58 patients (89%), and gastroesophageal anatomy was intact in 42 patients (70%). The addition of a fundoplication was the only significant predictor of an unfavorable radiologic outcome in the univariate analysis (odds ratio .413; 95% confidence interval, .130 to 1.308; P = .125). CONCLUSIONS The long-term symptomatic outcome of laparoscopic repair of paraesophageal hiatal herniation was favorable in 89% of patients, and 70% had successful anatomic repair. The addition of a fundoplication did not prevent anatomic herniation.

Long-term Results of a Randomized Double-blinded Prospective Trial of a Lightweight (Ultrapro) Versus a Heavyweight Mesh (Prolene) in Laparoscopic Total Extraperitoneal Inguinal Hernia Repair (TULP-trial).

Objective:The aim of the randomized clinical trial was to compare the 2 years of clinical outcomes of a lightweight (Ultrapro) vs a heavyweight (Prolene) mesh for laparoscopic total extraperitoneal (TEP) inguinal hernia repair. Background:Lightweight meshes reduce postoperative pain and stiffness in open anterior inguinal hernia repair. The discussion about a similar benefit for laparoscopic repair is ongoing, but concerns exist about higher recurrence rates. Methods:Between March 2010 and October 2012, male patients who presented with a primary, reducible unilateral inguinal hernia who underwent day-case TEP repair were eligible. Outcome parameters included chronic pain, recurrence, foreign body feeling, and quality of life scores. Results:During the study period, 950 patients were included. One year postoperatively the presence of relevant pain (Numeric Rating Score 4–10) was significantly higher in the lightweight mesh group (2.9%) compared with the heavyweight mesh group (0.7%) (P = 0.01), and after 2 years this difference remained significant (P = 0.03). There were 4 (0.8%) recurrent hernias in the heavyweight mesh group and 13 (2.7%) in the lightweight group (P = 0.03). No differences in foreign body feeling or quality of life scores were detected. Conclusions:In TEP hernia surgery, there was no benefit of lightweight over heavyweight meshes observed 2 years postoperatively.

Preperitoneal mesh in groin hernia surgery. A randomized clinical trial emphasizing the surgical aspects of preperitoneal placement via a laparoscopic (TEP) or Grid-iron (Ugahary) approach

SummaryThe totally extraperitoneal placement (TEP) of a preperitoneal mesh for the repair of primary groin hernia is a well-accepted treatment. Recently a different way to place the preperitoneal mesh has been described, the grid-iron (Ugahary) approach. So far there has been no information about the surgical aspects of this operation and therefore this technique was compared to the TEP procedure in a randomized clinical trial. 162 patients were randomly allocated to have their unilateral primary groin hernia repaired by either a TEP or a grid-iron procedure. Complications during the operations and in the early postoperative period were investigated. The grid-iron approach appeared to be significantly shorter (27 minutes versus 39 minutes). Perioperative complications like bleeding from the epigastric vessels or peritoneal tears in the grid-iron group could be handled through the same incision, while in the TEP group conversion to an open anterior approach was necessary in six cases. It is concluded that the grid-iron approach for the repair of primary unilateral groin hernias is significantly faster, and that perioperative complications are easier too handle via the same incision.

Feasibility of Laparoscopic Surgery Assisted by a Robotic Telemanipulation System

Robotic telemanipulation systems have recently been introduced to enhance the surgeons dexterity and visualisation in laparoscopic surgery. Technical feasibility of robot-assisted surgery was evaluated in 30 laparoscopic cholecystectomies.

Severely injured patients benefit from in-house attending trauma surgeons

INTRODUCTION There is continuous drive to optimize healthcare for the most severely injured patients. Although still under debate, a possible measure is to provide 24/7 in-house (IH) coverage by trauma surgeons. The aim of this study was to compare process-related outcomes for severely injured patients before and after transition of attendance policy from an out-of-hospital (OH) on-call attending trauma surgeon to an in-house attending trauma surgeon. METHODS Retrospective before-and-after study using prospectively gathered data in a Level 1 Trauma Center in the Netherlands. All trauma patients with an Injury Severity Score (ISS) >24 presenting to the emergency department for trauma before (2011-2012) and after (2014-2016) introduction of IH attendings were included. Primary outcome measures were the process-related outcomes Emergency Department length of stay (ED-LOS) and time to first intervention. RESULTS After implementation of IH trauma surgeons, ED-LOS decreased (p =  0.009). Time from the ED to the intensive care unit (ICU) for patients directly transferred to the ICU was significantly shorter with more than doubling of the percentage of patients that reached the ICU within an hour. The percentage of patients undergoing emergency surgery within 30 min nearly doubled as well, with a larger amount of patients undergoing CT imaging before emergency surgery. CONCLUSIONS Introduction of a 24/7 in-house attending trauma surgeon led to improved process-related outcomes for the most severely injured patients. There is clear benefit of continuous presence of physicians with sufficient experience in trauma care in hospitals treating large numbers of severely injured patients.