Pourquoi le patient obèse morbide est-il un patient à risque anesthésique élevé ?

A fully stapled technique for gastrojejunal anastomosis creation in robotic Roux-en-Y gastric bypass

PURPOSE

The purpose of this paper is to showcase a fully stapled approach to creating a gastrojejunostomy during a robot-assisted Roux-en-Y gastric bypass.

METHODS

We utilize two robotic 12-mm ports, two robotic 8-mm ports, and one 8-mm assistant port. The tools used are a fenestrated bipolar forceps, vessel sealer, cadiere grasper, needle driver, and a robotic stapler. After the partial gastrectomy, the roux limb is brought up to the gastric pouch where monopolar scissors are used to create a gastrotomy and enterotomy. The gastrotomy is made just above the staple line of the gastric pouch. The enterotomy is created 2 cm distal to the roux limb's staple line. The stapler is inserted into both the gastrotomy and enterotomy to create the common channel. A 2-0 vicryl suture is used to place four interrupted sutures across the remaining enterotomy in full thickness bites. An endoscope or Visigi bougie is advanced across the anastomosis into the roux limb before the final suture. The tails of the most lateral and medial sutures are grasped and lifted towards the abdominal wall. The stapler is advanced over the approximated enterostomy while holding tension with the suture tails. The stapler is fired transversely across the suture line to seal the gastrojejunostomy. The staple line may be oversewn with silk sutures. A leak test is performed prior to completing the reconstruction with the jejunojejunostomy.

CONCLUSIONS

A fully stapled technique of anastomosis creation may reduce operative time, standardizes the process for reproducibility, and increases consistency across operators and patients.

Assessment of the Effect of Perioperative Venous Lidocaine on the Intensity of Pain and IL-6 Concentration After Laparoscopic Gastroplasty

BACKGROUND AND OBJECTIVES

Opioids are associated with sedation and respiratory depression. The primary objective of this study was to assess pain intensity after gastric bypass with lidocaine. The secondary objective was to assess the IL-6 concentration, consumption of morphine, time to morphine request, time to extubation, and side effects.

METHODS

Sixty patients aged 18 to 60 years, with ASA (American Society of Anesthesiologists) scores of 2 or 3, who underwent bariatric surgery were allocated to two groups. Patients in group 1 were administered lidocaine (1.5 mg/kg) 5 min before the induction of anesthesia, and group 2 was administered 0.9% saline solution in an equal volume. Subsequently, lidocaine (2 mg/kg/h) or 0.9% saline was infused during the entire surgical procedure. Anesthesia was performed with fentanyl (5 μg/kg), propofol, rocuronium, and sevoflurane. Postoperative patient-controlled analgesia was provided with morphine. The following were evaluated: pain intensity, IL-6, 24-h consumption of morphine, time to the morphine request, time to extubation, and adverse effects.

RESULTS

The lidocaine group had a lower pain intensity than the saline group for up to 1 h, with no differences between groups in IL-6 and time to extubation. The lidocaine group consumed less morphine within 24 h, had a longer time until the first supplemental morphine request, and had a lower incidence of nausea.

CONCLUSIONS

Lidocaine reduced the intensity of early postoperative pain, incidence of nausea, and consumption of morphine within 24 h and increased time to the first morphine request, without reducing the plasma concentrations of IL-6.

Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery

To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature.

METHODS

We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance.

CONCLUSION

Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.