Internal Hernia and Roux-en-Y Gastric Bypass: Should the Routine Closure of Defects Still Be a Matter of Debate?

Safety and Efficiency of an Articulating Needle Driver in Advanced Laparoscopic Abdominal Surgery

Objective: Robotic platforms offer articulating needle drivers but are associated with high costs and lack tactile feedback. The recently developed mechanical Laparoscopic Articulating Needle Driver (LAND) (Flexdex^®) for conventional laparoscopy offers enhanced dexterity without these limitations. The goal of this study was to assess safety and efficiency during the implementation of the LAND, and describe its learning curve, in an expert center for laparoscopic surgery. Methods: All LAND-assisted procedures after clinical implementation for a period of 16 months were included into this study. Primary outcome domains were safety (intra- and postoperative complications within 30 days) and efficiency (operative time, suturing, and knot tying time of staple defects of enteroenterostomy). CUmulative SUM (CUSUM) analysis was utilized to describe the enteroenterostomy suturing time learning curve across consecutive cases by plotting the deviation from the series mean. Results: Forty-five procedures (34 Roux-en-Y gastric bypass [of which 7 including diaphragmatic hernia repair], 2 diaphragmatic hernia repair with Nissen fundoplication, and 2 right-sided hemicolectomy) were included into this study. Median (range) operative time and enteroenterostomy suturing time were 68 (46-177) minutes and 161 (112-241) seconds, respectively, comparable with conventional needle driver standards. One procedure was converted to the conventional needle driver due to device malfunctioning and one patients' postoperative course was complicated by a Clavien-Dindo grade 3a complication (intraluminal bleeding requiring gastroscopy). CUSUM chart displays a progression toward the mean from case 22 onward, indicating a limited learning curve. Conclusion: The LAND can be implemented safely and efficiently at a center of excellence for laparoscopic surgery and is associated with a limited learning curve.

Multiple concurrent complications of Roux-en-Y gastric bypass with MiniMizer gastric ring-alimentary limb intussusception through slipped ring into pouch, with remnant stomach internal herniation

Roux-en-Y gastric bypass (RYGB) is the second most common bariatric procedure performed in Australia, second to sleeve gastrectomy. Banding of pouches and anastomoses, via silastic bands or MiniMizer rings, have been used to assist in improving restriction. Though banded gastric bypasses are effective in weight loss, band migration, whether it be slippage or erosion, occurs in up to 7% of banded bariatric procedures. Jejunal intussusception and internal herniation are both individually known complications of RYGB. It is, however, rare to have all three phenomenon occur in a single patient. In this study, the authors present a report of a middle-aged lady, 2 years post-primary RYGB with MiniMizer gastric ring insertion presenting with all three complications.