Mdm jeddah 1

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Mdm jeddah 1

  1. 1. Haemostasis, sealing and adhesion prevention in Gynecology and Obstetrics Prof. Dr. med. Michael D Mueller Universitätsklinik für Frauenheilkunde
  2. 2. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 2
  3. 3. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 3  Are sometimes difficult in surgery  Life threatening bleeding is not seldom in OBGYN  Insufficient haemostasis  may contribute to postoperative morbidity and mortality  adhesion formation Haemostasis and vessel sealing
  4. 4. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 4 Adhesions  Adhesions may cause: • Re-hospitalisation • Dyspareunia • Chronic pelvic pain • Intestinal obstruction • Chronic fatigue • Infertility  Prevention of adhesions (de novo or by re-formation)  challenging surgical problem  TachoSil® is an efficacious and safe local haemostatic and helps to prevent adhesions
  5. 5. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 5 What is TachoSil®? Coatet with human • Fibrinogen 5.5 mg / cm2 • Thrombin 2.0 IU / cm2 • Riboflavin (yellow to mark the active side) Sponge • Equine collagen
  6. 6. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 6 Fibrin- Monomer Fibrin-Polymer Principles of Action Tissue Vlies Thrombin Faktor IIa Fibrinogen Faktor I Strong TachoSil®- Tissue connection
  7. 7. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 7 Animal model: TachoSil® applied on a liver Cryofixation and SEM-photo after 15 minutes Liver parenchyma Fibrin clot Closer view after 15 min.  stringy structure of the fibrin clot
  8. 8. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 8 Characteristics – tissue integration Progressive biologic tissue integration  Endogenous Fibrin  metabolic elimination  Collagen  granulation tissue (few cells, rich in collagen fibers)  after 24 weeks nearly no remnants 4 W postop. 12 W postop. TachoSil® remnants
  9. 9. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 9 General indications Hämostase • Parenchymatöse Organe • Sämtliche Weichteile, Hals, Extremitäten • Thorakal und abdominal • Nach Lymphadenektomie • Lungen, Darm, parenchymatöse Organe • Induratio Penis Plastica Adhesion prevention • Microsurgery • Myoma Haemostasis •Parenchymatous organs •Soft tissues in general, neck, extremities •Thoracic surgery and abdominal surgery in general Sealing • After lymphadenectomy • Lungs, bowel, parenchymatous organs • Bladder
  10. 10. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 10 Collagen fleecebound fibrin sealant is not associated with an increased risk of thromboembolic events or major bleeding after its use for haemostasis in surgery: a prospective multicentre surveillance study. Birth M et al. (2009) Prospective multicenter study (12 European countries) Study focused on the occurrence of thromboembolic events, major bleeding & immunologic events (hypersensitivity incl anaphylaxis) during first 6 months after surgery 124 adverse events in 3098 patients receiving TachoSil® : 46 (1.5%) thromboembolic events 62 (2.0%) major bleeding events 8 (0.3%) immunologic events Group of gynecologic surgery: no thromboembolic or immunologic events 1 major bleeding event
  11. 11. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 11 TachoSil® – established & well documented Number of studies / surgical specialisation Visceral surgery 11 Vascular surgery 14 Gynecol incl. Breast 5 Neurosurgery 4 Thoracic 11 Urology 7 Others 4 Basic science 27 Review 25 Number of studies / country Japan 22 Germany 20 Austria 12 USA 11 England 8 Others 30 Multicenter 5 Total 108 Study design Review 27 Basic science 27 Cohort 19 Case Reports 17 RCT 10 Comparative 8 Total 108
  12. 12. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 12 Osada H. et al (1999) Diagnosis n Patients Myoma 12 Cervical cancer 1 Endometrium cancer 1 Adenomyosis and benigne ovarian tumor 1 Tubal infertility 1 Durchgeführte Prozeduren Anzahl Patienten Myomectomy 10 Radical hysterectomy 2 Simple hysterectomy 2 Microsurgery of the tubes 1 Ovarial cystectomy 1 Retrospective case series from Japan, 4 centres
  13. 13. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 13 TachoSil® in Obstetrics and Gynecology Santulli P. et al (2011)
  14. 14. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 14 C-section and diffuse Bleeding of the uterine scar
  15. 15. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 15 Postpartum Hemorrhage (PPH) Anticipate the danger !!!!
  16. 16. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 16 Risk factor Odds Ratio (95% CI) retained placenta 3.5 (2.1 - 5.8) failure to progress during the second stage of labor 3.4 (2.4 - 4.7) placenta accreta 3.3 (1.7 - 6.4) lacerations 2.4 (2.0 - 2.8) instrumental delivery 2.3 (1.6 - 3.4) large for gestational age (LGA) newborn 1.9 (1.6 - 2.4) hypertensive disorders 1.7 (1.2 - 2.1) induction of labor 1.4 (1.1 - 1.7) augmentation of labor with oxytocin 1.4 (1.2 - 1.7) Obesity Risks for Postpartum Hemorrhage (PPH) “4 T’ s” as a mnemonic: tone, tissue, trauma, and thrombosis Sheiner E et al. (2005)
  17. 17. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 17 Vaginal- or cervical tears 1:8 Atony of the uterus 1:100 Retained placenta 1:2300 Placenta accreta etc. 1:2500 Inversio uteri 1:6400 Stanco et al. 1993; AJOG  Hysterectomy 20% 45% Reasons for PPH
  18. 18. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 18 Abu Dhabi 1997 Bristol 1988 Dublin 1990 Hinchingbrooke 1998 Total 1 100.1 Prendiville W et al. BJOG 1988 Cochrane Database 2003 Reduction > 40% Transfusions Anaemia PPH Prophylaxis Active management of the third stage of labor:  intramuscular administration of 10 IU of oxytocin  controlled cord traction  fundal massage after delivery of the placenta substantially reduces the risk of PPH
  19. 19. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 19  Initial general management administration of oxytocin, emptying the urinary bladder, fluid replacement, examination of birth canal and placenta   Specific management for uterine atony uterotonic drugs, uterine massage, bimanual compression of the uterus (external or internal),  Specific management for genital lacerations repair of genital lacerations, hemostatics, compression  Specific management for retained placenta manual removal  Continued management until the woman reaches the appropriate facility or the appropriate provider: anti-shock garment, IV perfusion, “walking” blood bank First line treatment of PPH
  20. 20. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 20 500-1000ml 10-15% 1000-1500ml 15-25% 1500-2000ml 25-35% none Palpitations Tachycardia BP change Symptoms Slight fall (80-100mmHg) Weakness Sweating Tachycardia Marked fall (70-80mmHg) Restlessness Pallor oliguria Clinical findings in postpartum haemorrhage Degree of shock 2000-3000ml 35-45% moderatecompensate mild severe Profound fall (50-70mmHg) Collapse Air hunger anuria Blood loss Go to the OR
  21. 21. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 21 Second line Surgery Embolisation rFactor VIIa (NovoSeven®) Tamponade
  22. 22. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 22 Second line Tamponade „Tamponade Test“ Condous et al. Obstet Gynecol 2003 Sengstaken-Blakemore-Catheter Linton-Catheter Foley-Catheter (several!) Gaze-Tamponade „Kondome“-Catheter Bakri-Catheter 70-300ml "When blood is flowing in rivers, it will make packers out of non-packers in a hell of a hurry!„ Horger E. AJOG 1993 Vaginal delivery
  23. 23. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 23 Atony 4 weeks after delivery !! No retained placental material
  24. 24. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 24 B-Lynch C. BJOG 1997 Ferguson JE. Obstet Gynecol 2000 Hayman RG Obstet Gynecol 2002 Manidip P. el al J Obstet Gynaecol Res 2003 Atony (when the bleeding is reduced after compression of the uterus) B-Lynch-Suture
  25. 25. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 25
  26. 26. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 26 Allam MS et al. Int J Gynaecol Obstet 2005 Ghezzi et al. Hum Reprod 2007 Multiple compression sutures
  27. 27. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 27 TachoSil® in obstetrics for  Oozing hemorrhages  Bleeding from the stitches
  28. 28. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 28 Perreira-Technique
  29. 29. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 29
  30. 30. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 30 92917 238 (0.3%) 12 (5%) Pl accreta (n,% praevia) 0 Prior CS Total women Pl praevia (n,%) 3820 850 29 1 2 >3 3 183 125 (0.65%) 15 (1.8%) 3 (10%) 5 (3%) 6 (24%) 7 (47%) 2 (67%) 2 (40%) Clark O et al. Obstet Gynecol 1985 Placenta accreta, in- or percreta
  31. 31. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 31  Bleeding from the lower part of the uterus  Risk of hysterectomy preop discussed with the patient  Prepared team with experienced surgeons Placenta praevia
  32. 32. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 32 „low“ compression sutures Placenta previa (bleeding from the lower part of the uterus!) Cave: occlusion of the cervical canal
  33. 33. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 33 1 2 3 4 Blader
  34. 34. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 34 Placenta percreta
  35. 35. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 35 Placenta percreta
  36. 36. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 36
  37. 37. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 37
  38. 38. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 38 Successful continuation of pregnancy after repair of a midgestational uterine rupture with the use of a fibrincoated collagen fleece (TachoComb®) in a primigravid woman with no known risk factors. Shirata I et al. (2007)  30-year-old Japanese primigravid woman presented at 24 2/7 gw  Past medical history noncontributory & antenatal care uneventful  No uterine contractions or history of recent abdominal trauma  Emergency laparotomy  partial uterine rupture of ~ 3 cm in the right posterior wall of the uterine fundus  Uterine rupture sutured  sufficient hemostasis could not be obtained  TachoComb®  Cesarean section at 35 2/7 gw
  39. 39. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 39 TachoSil® can be used in laparoscopic surgery Preparation • Compress the TachoSil® • Roll the piece, yellow side outside Introduction • Open the trocar • Go through the upper part of the trocar and grab the TachoSil® • The trocar has to be dry!
  40. 40. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 40 Myomas  surgical challenge for adhesions & bleeding
  41. 41. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 41 Adhesions after myomectomy Dubuisson JB 1998 155 41 % 19 % 81 98 % 82 %
  42. 42. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 42 Adhesions after myomectomy More frequent in posterior myomas Usually located at the site of the suture More frequent with simultaneous surgery (e.g. ovary) The size of the myoma does not play a role!
  43. 43. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 43
  44. 44. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 44
  45. 45. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 45 TachoSil® as bleeding and adhesion prevention
  46. 46. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 46
  47. 47. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 47
  48. 48. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 48 Endometrioma: strategies for adhesion prevention 1) Careful surgical procedure ( better no surgery than bad surgery !) 2) Application of barier agents 3) Pharmacologic interventions 4) Adjuvant therapy to avoid recurrence
  49. 49. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 49 Surgical strategies for adhesion prevention • Cutting • Surgical denudation • Ischemia • Dessication & abrasion peritoneal trauma healing process = mesothelial regeneration and fibrosis adhesions between the damaged serosal surfaces TachoSil® dissolves gradually and might be used to prevent adhesions
  50. 50. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 50 Surgical strategies for adhesion prevention a. Carefully handle tissue with field enhancement (magnification) techniques b. Focus on planned surgery and, if any secondary pathology is identified, question the risk: benefit ratio of surgical treatment before proceeding c. Perform diligent haemostasis and ensure diligent use of cautery d. Reduce cautery time and frequency and aspirate aerosolised tissue following cautery e. Excise tissue—reduce fulguration f. Reduce duration of surgery, risk of infection, drying of tissues g. Use frequent irrigation and aspiration in laparoscopic and laparotomic surgery when needed h. Limit use of sutures and choose fine non-reactive sutures Good surgical technique is fundamental to any adhesion reduction strategy: De Wilde RL et al. (2012)
  51. 51. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 51 i. Avoid foreign bodies when possible—such as materials with loose fibres j. Avoid non-peritonised implants and meshes k. Minimal use of dry towels or sponges in laparotomy l. Use starch- and latex-free gloves in laparotomy m. Reduce pressure and duration of pneumoperitoneum in laparoscopic surgery De Wilde RL et al. (2012) Surgical strategies for adhesion prevention
  52. 52. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 52 Stripping and TachoSil®
  53. 53. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 53 TachoSil® in acute bleeding
  54. 54. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 54
  55. 55. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 55
  56. 56. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 56 Deep conization, pelvic Lymphonodectomy
  57. 57. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 57
  58. 58. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 58 TachoSil® as lymphocyst prevention?
  59. 59. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 59 Prevention of Lymphocele in Female Pelvic Lymphadenectomy by a Collagen Patch Coated With the Human Coagulation Factors: A Pilot Study. Tinelli A. et al. (2011) Randomized in 2 groups: 1 = standard technique plus TachoSil® (n = 30) 2 = standard technique only (n = 28) Intraoperative application of TachoSil® : - reduced rate of postoperative lymphocysts after PL - seems to provide a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL
  60. 60. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 60 The Use of a Surgical Patch in the Prevention of Lymphoceles After Extraperitoneal Pelvic Lymphadenectomy for Prostate Cancer: A Randomized Prospective Pilot Study. Simonato A et al. (2009) Femoralkanal (T1, 1x1cm) EIV, external iliac vein Fossa obturatoria (T2, 2.5x1cm) EIA, external iliac artery ON, obturator nerve. * Clips & cautery 60 Patients with prostatectomy Standard technique + TachoSil® (n=30) Standard technique * (n=30)
  61. 61. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 61 Simonato A et al. (2009)
  62. 62. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 62 TachoSil® reduced the risk of lymphocele Significantly less lymphocysts 5 vs 19 (P=0.009) Less symptomatic lymphocysts 2 vs 11 (P = 0.001) Less surgery necessary 1 vs 4 Kontroll TachoSil 3 0 3 0 5 1 9 2 11 Simonato A et al. (2009)
  63. 63. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 63 Laparoscopic transvesical repair of recurrent vesicovaginal Fistula using with Fleece-bound sealing system Erdogru T. et al. (2008) • 37 year old woman with recurrent VVF • 5 yr after initial operation • TachoSil used as tissue barrier between Bladder and Vagina
  64. 64. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 64 Summary: Clinical benefits and possibilities with TachoSil®  can be applied in areas of difficult accessibility. Also suitable for MIS procedures  can be applied in sensitive areas (e.g. close to nerves)  can be used to cover large areas (overlapping patches)  is highly flexible after sealing the wound and withstands extreme stretching and compression  Haemostasis secured even under demanding conditions can be used immediately since no preparation is needed By combining the adhesive properties of fibrin clotting with the mechanical support of a collagen sponge, TachoSil® achieves  haemostasis within 3-5 minutes
  65. 65. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 65 Thank you very much!
  66. 66. michel.mueller@insel.ch Universitätsklinik für Frauenheilkunde, Inselspital Bern Bleeding and vessel sealing in Obstetrics and Gynecology, Jeddah 9.12.12 66

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