Anterior reconstruction of the esophageal hiatus: a novel approach for the repair of large diaphragmatic hernias

Introduction: Paraesophageal hernias (PEH) often require surgical repair. The standard approach, primary posterior hiatal repair, has been associated with a high recurrence rate. Over the past few years, we have developed a new approach for repairing these hernias, which we believe restores the original anatomy and physiology of the esophageal hiatus. Our technique includes anterior crural reconstruction with routine anterior mesh reinforcement and fundoplication. Objective: To determine the safety and the clinical success of anterior crural reconstruction with routine mesh reinforcement. Material and methods: Data were collected retrospectively on 178 consecutive patients who had a laparoscopic repair of a symptomatic primary or recurrent PEH between 2011 and 2021 using the above technique. The primary outcome was clinical success, and the secondary outcome was 30 days of major complications and patient satisfaction. This was assessed by imaging tests, gastroscopies, and clinical follow-up. Results: Mean follow-up was 65 (SD 37.1) months. No intraoperative or 30 days postoperative mortality or major complications were recorded. Recurrence rate requiring a re-operation was 8.4% (15/178). Radiological and gastroenterological evidence of minor type 1 recurrence was 8.9%. Conclusion: This novel technique is safe with satisfactory long-term results. The outcome of our study will hopefully motivate future randomized control trials.

V-055 LAPAROSCOPIC FUNDOPLICATION WITH HANDXTM HOOK AND NEEDLE HOLDER

Aim

HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip.This report is to show the feasibility and safety of this technology implemented with a monopolar dissecting hook in a complex abdominal procedure.

Materials and Methods

We report the case of the laparoscopic repair of a large hiatal hernia using HandXTM instruments.

Results

The index case was a 69-year-old female with symptomatic large paraesophageal hiatal hernia. Three 5 mm trocars were used: 1 in the left midclavicular line, 1 in on the right of the midline close to the costal arch and 1 assistant on the right midclavicular line, one 11 mm umbilical. The sac was dissected with the HandXTM monopolar hook and the stomach was fully reduced into the abdomen with the hernia sac. The hiatus was closed with three separated stiches handled with the articulating needle holder. A Nissen funduplication was performed. Three separated stiches were used to secure the wrap, using the HandX needle holder. At the end of the operation a mesh was used to reinforce the hiatus. The operative time was 80 minutes, no blood loss nor intraoperative or post-operative complications were recorded

Conclusions

The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic Nissen fundoplication.

V-040 LAPAROSCOPIC TRANS-ABDOMINAL PREPERITONEAL PROCEDURE (TAPP) FOR RIGHT INGUINAL HERNIA WITH HANDXTM HOOK AND NEEDLE HOLDER

AIM HandX™ is a handheld, powered laparoscopic device with interchanging single-patient fully articulating instruments. It is electromechanically controlled, and, as the manual interface is handled by the surgeon, beside the patient's bed, the movements of the surgeon's wrist and fingers are translated to the instrument-articulating tip. This report is to show the feasibility and safety of this technology applied in inguinal hernia repair. MATERIALS AND METHODS We report the case of the laparoscopic repair of a right inguinal hernia using HandXTM instruments. RESULTS The index case was a 55-year-old, otherwise healthy male, with an inguinal right hernia. Three trocars were used: one 10 mm umbilical and two of 5 mm, approximately 4 cm laterally from the umbilicus and 1 cm under the level of the horizontal umbilical line. The dissection started with peritoneal cut, from the antero-superior iliac spine to the medial umbilical ligament, into the preperitoneal avascular plane. The anatomical landmarks (epigastric vessels, Cooper and Gimbernat ligaments, the corona mortis and external iliac vessels) were identified and well exposed. A polypropylene mesh was inserted from the optical trocar, placed in the appropriate position and fixed with three separated stiches handled with the articulating needle holder. The peritoneal flap was closed with a readsorbable running suture handled with the HandX instrumentation. No blood loss nor intraoperative or post-operative complications were recorded CONCLUSIONS The report showed how the HandX technology could be safely adopted to obtain both a safe dissection and an ergonomically advantageous suture in laparoscopic TAPP.

Laparoscopic approach in emergency for the treatment of acute incarcerated groin hernia: a systematic review and meta-analysis

PURPOSE

Minimally invasive approach for acute incarcerated groin hernia repair is still debated. To clarify this debate, a literature review was performed.

METHODS

Search was performed in PubMed, Embase, Scopus, Web of Science, and Cochrane databases, founding 28,183 articles.

RESULTS

Fifteen articles, and 433 patients were included (16 bilateral hernia, range 3-8). Three hundred and eighty-eight (75.3%) and 103 patients (22.9%) underwent transabdominal preperitoneal and totally extraperitoneal repair, respectively, and in 5 patients, the defect was buttressed with broad ligament (1.1%) (not specified in 3 patients). Herniated structures were resected in 48 cases (range 1-9). Intraoperative complications and conversion occurred in 4 (range 0-1) and 10 (range 0-3) patients, respectively. Mean operative time and hospital stay ranged between 50 and 147 min, and 2 and 7 days, respectively. Postoperative complications ranged between 1 and 19. Five studies compared laparoscopic and open approaches (163 and 235 patients). Herniated structures were resected in 19 (11.7%) and 42 cases (17.9%) for laparoscopic and open approach, respectively (p = 0.1191). Intraoperative complications and conversion occurred in one (0.6%) and 5 (2.1%) patients (p = 0.4077), and in two (1.2%) and 19 (8.1%) patients (p = 0.0023), in case of laparoscopic or open approach, respectively. Mean operative time and hospital stay were 94.4 ± 40.2 and 102.8 ± 43.7 min, and 4.8 ± 2.2 and 11 ± 3.1 days, in laparoscopic or open approach, respectively. Sixteen (9.8%) and 57 (24.3%) postoperative complications occurred.

CONCLUSION

Laparoscopy seems to be a safe and feasible approach for the treatment of acute incarcerated groin hernia. Further studies are required for definitive conclusions.

The Effects of One Anastomosis Gastric Bypass Surgery on the Gastrointestinal Tract

One anastomosis gastric bypass (OAGB) is an emerging bariatric procedure, yet data on its effect on the gastrointestinal tract are lacking. This study sought to evaluate the incidence of small-intestinal bacterial overgrowth (SIBO) following OAGB; explore its effect on nutritional, gastrointestinal, and weight outcomes; and assess post-OABG occurrence of pancreatic exocrine insufficiency (PEI) and altered gut microbiota composition. A prospective pilot cohort study of patients who underwent primary-OAGB surgery is here reported. The pre-surgical and 6-months-post-surgery measurements included anthropometrics, glucose breath-tests, biochemical tests, gastrointestinal symptoms, quality-of-life, dietary intake, and fecal sample collection. Thirty-two patients (50% females, 44.5 ± 12.3 years) participated in this study, and 29 attended the 6-month follow-up visit. The mean excess weight loss at 6 months post-OAGB was 67.8 ± 21.2%. The glucose breath-test was negative in all pre-surgery and positive in 37.0% at 6 months (p = 0.004). Positive glucose breath-test was associated with lower reported dietary intake and folate levels and higher vitamin A deficiency rates (p ≤ 0.036). Fecal elastase-1 test (FE1) was negative for all pre-surgery and positive in 26.1% at 6 months (p = 0.500). Both alpha and beta diversity decreased at 6 months post-surgery compared to pre-surgery (p ≤ 0.026). Relatively high incidences of SIBO and PEI were observed at 6 months post-OAGB, which may explain some gastrointestinal symptoms and nutritional deficiencies.

The rise of one anastomosis gastric bypass: insights from surgeons and dietitians

One anastomosis gastric bypass/Mini Gastric Bypass (OAGB/MGB) is an emerging bariatric surgery (BS) technique. We evaluated and compared attitudes of bariatric surgeons and dietitians towards the considerations for choosing BS-type ("Decision-making"), the contributing factors to the rise of OAGB/MGB in Israel ("OAGB/MGB-rise") and notions regarding the occurrence of gastrointestinal (GI) symptoms and nutritional deficiencies following OAGB/MGB. Anonymous online surveys were distributed. The participants were asked to rate by a 10-point Likert scale (0 = not at all; 100 = very much/often) their attitudes towards "Decision-making", "OAGB/MGB-rise" and occurrence of GI symptoms and nutritional deficiencies following OAGB/MGB. For "Decision-making" and "OAGB/MGB-rise", items were considered prioritized where ≥ 50% of the group considered them as 'very-important' (rating ≥ 80). Data on age, sex, years-in-practice and main workplace were also collected. A total of 106 professionals participated in the survey (42 surgeons; 64 dietitians). The respective mean age, years-in-practice and sex were 52.3 ± 8.7 vs. 42.3 ± 9.0 years, 21.0 ± 10.8 vs. 15.5 ± 9.2 years and 85.7% vs. 3.1% males. The inter-observer agreement for prioritized items related to "Decision-making" was fair (Kappa = 0.250; P = 0.257) and both groups prioritized patient's BMI, comorbidities and compliance. The inter-observer agreement for prioritized items related to "OAGB/MGB-rise" was moderate (Kappa = 0.550; P = 0.099) and both groups prioritized ease of performance, shorter operation duration and failure of former restrictive BS. Surgeons reported lower occurrence of nutritional deficiencies and GI symptoms as adverse effects of OAGB/MGB (P ≤ 0.033). The study highlights the views of bariatric surgeons and dietitians concerning factors that underpin the rise of OABG/MGB in Israel and possible rates of GI symptoms and nutritional deficiencies associated with this modality.

[FLEXIBLE ENDOSCOPY IN THE HANDS OF THE SURGEON - THE ISRAELI SURGEON'S POINT OF VIEW]

The flexible endoscope was developed over 50 years ago as a diagnostic tool for the gastrointestinal (GI) tract. Since then, many therapeutic interventions were developed using the endoscope, mostly by surgeons. In the past decade, following technological developments and improvements made in light sources and video, more advanced procedures were developed, and the flexible endoscope is slowly becoming a powerful surgical tool that enables performing advanced procedures that replace traditional surgery, such as intra-operative endoscopy for exact localization of pathologies, active guidance of the surgical acts during surgery, treatment of common diseases of the GI tract and interventions to treat post-operative complications. The use of the flexible endoscope by surgeons varies between regions. Whereas it is a mandatory part of surgical residency in North America, Australia and parts of Asia, in other parts of the world, including Israel, flexible endoscopy is not accessible to surgeons. In this review we chart the reasons for this phenomenon and define the needs for change so that flexible endoscopy will become a common surgical tool in Israel.

Nutritional status following One Anastomosis Gastric Bypass

BACKGROUND & AIMS

One Anastomosis Gastric Bypass (OAGB) has been accepted as an effective treatment for morbid obesity. However, data are scarce regarding nutritional implications of this procedure. Thus, our aim was to describe the health and nutritional status 12-20 months following OAGB surgery.

METHODS

A prospective cohort study on patients who underwent OAGB surgery from January 2016 to May 2017 in a large, multi-disciplinary, bariatric clinic. Pre-surgery data including demographic details, anthropometrics, co-morbidities, blood tests and lifestyle habits were obtained from the patients' medical records. Follow-up evaluations were performed 12-20 months post-surgery and data collected included anthropometrics, blood tests, eating and lifestyle parameters, adherence to follow-up regime and gastrointestinal (GI) related side effects. In addition, patients were asked to rate their overall state of health (OSH) from 0 to 100 using a visual analogue scale (VAS).

RESULTS

Eighty-six OAGB patients (72.1% women) were tested 14.7 ± 2.0 months post-operatively. Their mean age and BMI preoperatively were 46.1 ± 11.4 years and 42.0 ± 4.9 kg/m², respectively. The mean % excess weight loss at 12-20 months postoperatively was 88.4 ± 19.3%. Lipid and glucose profiles were significantly improved at 12-20 months postoperatively compared to baseline (P < 0.001 for all). Relatively high proportions of nutritional deficiencies were found pre-operatively and postoperatively for iron (33.9% vs. 23.7%, P = 0.238), folate (30.9% vs. 11.8%, P = 0.004), vitamin D (56.6% vs. 17.0%, P < 0.001) and hemoglobin (16.7% vs. 42.9%, P < 0.001). Postoperatively, most participants reported taking multivitamin, calcium, vitamin D and vitamin B12 supplementation (≥62.8%), having participated in at least 6 meetings with a dietitian (51.8%) and presently doing physical activity (69.4%). The mean postoperative OSH VAS score was 88.2 ± 12.3, but most participants reported on flatulence (67.4%) and some reported on diarrhea (25.6%) as GI side effects of the surgery.

CONCLUSIONS

Substantial improvements in health and anthropometric parameters are found in the short-term follow-up after OAGB, with a satisfactory reported quality of life and adherence to recommendations. However, a high prevalence of some GI side effects, nutritional deficiencies and specially anemia is a matter of concern.

European association for endoscopic surgery (EAES) consensus statement on single-incision endoscopic surgery

Background

Laparoscopic surgery changed the management of numerous surgical conditions. It was associated with many advantages over open surgery, such as decreased postoperative pain, faster recovery, shorter hospital stay and excellent cosmesis. Since two decades single-incision endoscopic surgery (SIES) was introduced to the surgical community. SIES could possibly result in even better postoperative outcomes than multi-port laparoscopic surgery, especially concerning cosmetic outcomes and pain. However, the single-incision surgical procedure is associated with quite some challenges.

Methods

An expert panel of surgeons has been selected and invited to participate in the preparation of the material for a consensus meeting on the topic SIES, which was held during the EAES congress in Frankfurt, June 16, 2017. The material presented during the consensus meeting was based on evidence identified through a systematic search of literature according to a pre-specified protocol. Three main topics with respect to SIES have been identified by the panel: (1) General, (2) Organ specific, (3) New development. Within each of these topics, subcategories have been defined. Evidence was graded according to the Oxford 2011 Levels of Evidence. Recommendations were made according to the GRADE criteria.

Results

In general, there is a lack of high level evidence and a lack of long-term follow-up in the field of single-incision endoscopic surgery. In selected patients, the single-incision approach seems to be safe and effective in terms of perioperative morbidity. Satisfaction with cosmesis has been established to be the main advantage of the single-incision approach. Less pain after single-incision approach compared to conventional laparoscopy seems to be considered an advantage, although it has not been consistently demonstrated across studies.

Conclusions

Considering the increased direct costs (devices, instruments and operating time) of the SIES procedure and the prolonged learning curve, wider acceptance of the procedure should be supported only after demonstration of clear benefits.

A preclinical animal study of a novel, simple, and secure duct and vessel occluder for laparoscopic surgery

BACKGROUND

Secure occlusion of large blood vessels and ductal structures is critical to all surgeries and remains a challenge in many minimally invasive procedures. This study compares in vivo use of the Amsel Occluder (AO) for secure laparoscopic blood vessel and duct closure, with one of the many commercially available hemoclips (Ligaclip®), in the porcine model.

METHODS

Laparoscopic closure of vessels and ducts was performed on 12 swine to compare the ease of use, safety and efficacy of the AO with a hemoclip, as well as the tissue response at > 30 days (10 swine). All vessels and ducts were occluded and then transected between the occluding clips. Any bleeding or leakage was noted. In the chronic study, confirmation of satisfactory vessel occlusion post nephrectomy was determined by laparotomy as well as by contrast angiography and venography. The tissue response and healing was evaluated by a histopathological study for the effects of any biological incompatibilities.

RESULTS

In the acute laparoscopic study, a total of 24 occlusions between 2 and 10 mm were performed with the AO (n = 19) and hemoclip (n = 5). In the chronic study, 5 nephrectomies (AO n = 3, hemoclip N = 2) and 5 cholecystectomies (AO n = 3, hemoclip n = 2) were performed with survival ranging from 42 to 72 days. One pig who sustained a splenic injury at trocar insertion and suffered a delayed ruptured spleen with massive hemorrhage on postoperative day 22. Unlike occlusion with the AO, multiple hemoclips were used for each vessel occlusion. Histopathological examination showed no difference in the tissue response and healing of the AO and hemoclip.

CONCLUSIONS

The Amsel Vessel occluder delivered laparoscopically provides an occlusion similar to a hand-sewn transfixion suture, is simple to use, and creates an occlusion which is not only more secure, but also as safe with respect to the health of the surrounding tissues, as that of the widely used hemoclip (Ligaclip®).

First experience with THE AUTOLAP™ SYSTEM: an image-based robotic camera steering device

BACKGROUND

Robotic camera holders for endoscopic surgery have been available for 20 years but market penetration is low. The current camera holders are controlled by voice, joystick, eyeball tracking, or head movements, and this type of steering has proven to be successful but excessive disturbance of surgical workflow has blocked widespread introduction. The Autolap™ system (MST, Israel) uses a radically different steering concept based on image analysis. This may improve acceptance by smooth, interactive, and fast steering. These two studies were conducted to prove safe and efficient performance of the core technology.

METHODS

A total of 66 various laparoscopic procedures were performed with the AutoLap™ by nine experienced surgeons, in two multi-center studies; 41 cholecystectomies, 13 fundoplications including hiatal hernia repair, 4 endometriosis surgeries, 2 inguinal hernia repairs, and 6 (bilateral) salpingo-oophorectomies. The use of the AutoLap™ system was evaluated in terms of safety, image stability, setup and procedural time, accuracy of imaged-based movements, and user satisfaction.

RESULTS

Surgical procedures were completed with the AutoLap™ system in 64 cases (97%). The mean overall setup time of the AutoLap™ system was 4 min (04:08 ± 0.10). Procedure times were not prolonged due to the use of the system when compared to literature average. The reported user satisfaction was 3.85 and 3.96 on a scale of 1 to 5 in two studies. More than 90% of the image-based movements were accurate. No system-related adverse events were recorded while using the system.

CONCLUSION

Safe and efficient use of the core technology of the AutoLap™ system was demonstrated with high image stability and good surgeon satisfaction. The results support further clinical studies that will focus on usability, improved ergonomics and additional image-based features.

Evaluating the role of simulation in healthcare innovation: recommendations of the Simnovate Medical Technologies Domain Group

Background

Innovation in healthcare is the practical application of new concepts, ideas, processes or technologies into clinical practice. Despite its necessity and potential to improve care in measurable ways, there are several issues related to patient safety, high costs, high failure rates and limited adoption by end-users. This mixed-method study aims to explore the role of simulation as a potential testbed for diminishing the risks, pitfalls and resources associated with development and implementation of medical innovations.

Methods

Subject-matter experts consisting of physicians, engineers, scientists and industry leaders participated in four semistructured teleconferences each lasting up to 2 hours each. Verbal data were transcribed verbatim, coded and categorised according to themes using grounded theory, and subsequently synthesised into a conceptual framework. Panelists were then invited to complete an online survey, ranking the (1) current use and (2) potential effectiveness of simulation-based technologies and techniques for evaluating and facilitating the product life cycle pathway. This was performed for each theme of the previously generated conceptual framework using a Likert scale of 1 (no effectiveness) to 9 (highest possible effectiveness) and then segregated according to various forms of simulation.

Results

Over 100 hours of data were collected and analysed. After 7 rounds of inductive data analysis, a conceptual framework of the product life cycle was developed. This framework helped to define and characterise the product development pathway. Agreement between reviewers for inclusion of items after the final round of analysis was 100%. A total of 7 themes were synthesised and categorised into 3 phases of the pathway: ‘design and development’, ‘implementation and value creation’ and ‘product launch’. Strong discrepancies were identified between the current and potential roles of simulation in each phase. Simulation was felt to have the strongest potential role for early prototyping, testing for safety and product quality and testing for product effectiveness and ergonomics.

Conclusions

Simulation has great potential to fulfil several unmet needs in healthcare innovation. This framework can be used to help guide innovators and channel resources appropriately. The ultimate goal is a structured, well-defined process that will result in a product development outcome that has the greatest potential to succeed.

Adenocarcinoma of the Gallbladder: Incidental Finding in Patients following Laparoscopic Sleeve Gastrectomy and Cholecystectomy

BACKGROUND

Gallbladder (GB) cancer is rare. Most cases are incidentally found in specimens after a cholecystectomy. Cholelithiasis is almost always present when this diagnosis is made. Obesity is a known risk factor for gallstone formation and thus may be related to GB cancer.

OBJECTIVES

To highlight the importance of evaluating the gallbladder before surgery, resecting the gallbladder whenever required, and screening the resected tissue for malignancy.

METHODS

We retrospectively searched a prospectively maintained database of all bariatric procedures during the last 8 years for cases of concomitant laparoscopic sleeve gastrectomy (LSG) and laparoscopic cholecystectomy (LC). Pathologic reports of the gallbladders were reviewed. Demographic data and perioperative parameters were documented.

RESULTS

Of 2708 patients reviewed, 1721 (63.55%) were females and 987 (36.45%) males. Excluded were 145 (5.35%) who had a previous cholecystectomy. Of the remaining 2563, 180 (7.02%) had symptomatic gallbladder disease and underwent LSG with LC. Of these, two females (BMI 53 kg/m2 and 47 kg/m2, both age 60) were found by histological examination to have adenocarcinoma in their GB specimens (1.11%). Both were reoperated, which included partial hepatectomy of the GB bed, resection of the cystic stump, lymph node dissection, and resection of the port sites. One patient is doing well, with no evidence of disease at a postoperative follow-up of 4 years. The second patient had recurrent disease with peritoneal spread and ascites 20 months post-surgery and died 18 months later.

CONCLUSIONS

GB cancer is a rare finding in cholecystectomy specimens. The incidence of this entity might be higher in obese older females owing to the higher incidence of cholelithiasis in these patients.

Assessment of perioperative complications following primary bariatric surgery according to the Clavien-Dindo classification: comparison of sleeve gastrectomy and Roux-Y gastric bypass

BACKGROUND

Laparoscopic Roux-Y gastric bypass (LRYGBP) is the gold-standard procedure for the treatment of morbid obesity. It has been reported to be somewhat more efficient and durable than laparoscopic sleeve gastrectomy (LSG). However, it is considered more invasive and, therefore, more hazardous. There is a lack of unity in complication reporting following bariatric surgery. Thus, there is a possible misconception regarding the relative safety of the two major bariatric procedures performed worldwide. This may have contributed to a shift in practice with LSG gaining momentum "at the expense" of LRYGBP. The aim of this study was to evaluate the relative safety of primary LSG and LRYGBP according to the Clavien-Dindo complication grading system.

METHODS

A total of 2651 and 554 patients underwent primary LSG and LRYGBP, respectively at three high-volume centers. Thirty-day perioperative complications were recorded and graded. Length of hospital stays (LOS) and readmission rates were collected as well.

RESULTS

Complications occurred in 110 (3.7%) and 24 (4.3%) patients following LSG and LRYGBP, respectively (p = 0.9). No significant difference was found between the groups regarding overall and complication-grade-specific rates. Individual complication types were unevenly distributed, but not significantly so. Patients with complications were older than those without (47 and 43 years, respectively; p = 0.01). Gender was not a risk factor for complication. Median LOS and readmission rates were not significantly different.

CONCLUSIONS

LSG and LRYGBP are equally safe, at least in the perioperative period. Acknowledging and conveying this finding to surgeons and patients alike is important and might cause a pendulum shift in the distribution of bariatric procedures performed.

European Association of Endoscopic Surgeons (EAES) consensus statement on the use of robotics in general surgery

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Advantages of minimal incision laparoscopic cholecystectomy

BACKGROUND

Modifications to conventional laparoscopic cholecystectomy (CLC) are aimed at decreasing abdominal wall trauma and improving cosmetic outcome. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically challenging and expensive compared to the conventional laparoscopic approach.

OBJECTIVES

To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions.

METHODS

Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2-3 mm epigastric port. This technique was clubbed "minimal incision laparoscopic cholecystectomy" (MILC).

RESULTS

MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mmtrocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18-60) and the average postoperative hospital stay was 22 hours (range 6-50). There were no postoperative complications and the cosmetic results were rated excellent by the patients.

CONCLUSIONS

MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.

Mid-term follow-up after laparoscopic sleeve gastrectomy in obese adolescents

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is gaining credibility as a simple and efficient bariatric procedure with low surgical risk. Since surgical treatment for morbid obesity is relatively rare in adolescents, few results have bten accumulated so far.

OBJECTIVES

To prove the safety and efficacy of LSG turgery in an adolescent population

METHODS

Data were prospectively collected regarding adolescent patients undergoing LSG. All patients underwent pre- and postoperative medical and professional evaluation by a multidisciplinary team.

RESULTS

Between the years 2006 and 2011, 32 adolescents underwent LSG in our center (20 females and 12males). Mean age was 16.75 years (range 14-18 years), mean weight was 121.88 kg (83-178 kg), and mean body mass index 43.23 (35-54). Thirty-four comorbid conditions were identified. LSG was the primary bariatric procedure in all the patients. Mean operative time was 60 minutes (range 45-80 min). Tiere were two complications (6.25%): an early staple line leak and a late acute cholecystitis. There were no deaths. Mean percent excess weight loss at 1, 3, 6, 9,12, 24, 36, 48, and 60 months post-surgery was 27.9%, 41.1%, 62.6%, 79.2%, 81.7%, 71%, 75%, 102.9% and 101.6%, respectively. Comorbidities were completely resolved or ameliorated within 1 year folllowing surgery in 82.4% and 17.6%, respectively.

CONCLUSIONS

LSG is feasible and safe in morbidly obese adolescents, achieving efficient weight loss and impressive resolution of comorbidities. Further studies are required to evaluate the long-term results of this procedure as well as its place among other bariatric options.

Feeding jejunostomy for post-operative nutritional support

Enteral feeding by tube jejunostomy, inserted during definitive surgery, was used in 19 adult patients operated upon in a 24 month period. Jejunostomy feeding was associated with a low rate of minor complications enabling delivery of adequate caloric and protein input shortly after major abdominal operations and up to 9 months later. We feel that the insertion of a regular size jejunostomy tube during surgery is a simple, brief and safe procedure which offers efficient and inexpensive nutritional support, and thus has an important role in the post-operative management of selected patients. It is also easily used in the home setting if needed.

The hepatorenal reflex contributes to the induction of oliguria during pneumoperitoneum in the rat

BACKGROUND

Hepatic blood flow is known to decrease during pneumoperitoneum. Studies have shown that such changes affect kidney urinary output through the sympathetic pathway known as the hepatorenal reflex. This study investigated the potential role of the hepatorenal reflex in pneumoperitoneum-induced oliguria. The authors hypothesized that oliguria detectable during pneumoperitoneum is caused by activation of the hepatorenal reflex.

METHODS

Denervation of the sympathetic nervous structure was performed in 15 rats by applying 1 ml of 90 % aqueous phenol solution circumferentially to the portal vein and vena cava area at their entrance to the liver. The same was applied to only the peritoneum in 15 nondenervated rats. After 2 weeks, the rats were divided into three subgroups (5 rats per subgroup) that were exposed respectively to carbon dioxide-induced pneumoperitoneum at 0, 10, and 15 mmHg for 2 h. Statistical analysis was performed using Student's t test and analyses of variance.

RESULTS

Denervation did not affect the preinsufflation parameters. The denervated and the nondenervated 0-mmHg subgroups presented with similar parameters. The postinsufflation mean urine output was significantly lower in the nondenervated than in the denervated 10- and 15-mmHg subgroups (p = 0.0097). The denervated rats had a final creatinine clearance 29 % lower than the preinsufflation value (p = 0.83), whereas the nondenervated animals presented a 79 % drop in creatinine clearance (p = 0.02).

CONCLUSION

The study findings indicate that the hepatorenal reflex plays an important role in the pathophysiology of oliguria that occurs during pneumoperitoneum in the rat.

Endoluminal compression clip: full-thickness resection of the mesenteric bowel wall in a porcine model

BACKGROUND

Performing a full-thickness intestinal wall resection of a sessile polyp located on the mesenteric side with a compression clip may lead to compression of mesenteric vessels. The application of such a clip may therefore cause a compromised blood supply in the particular bowel segment, leading to perforation.

OBJECTIVE

To evaluate the performance of a newly developed, nitinol compression clip, called the NiTi clamp, for full-thickness resection of the bowel wall, while the clip is deliberately deployed endoluminally on the mesenteric side.

DESIGN

Prospective animal study. Multinational, multidisciplinary; gastroenterology and general surgery, research cooperation.

SETTING

Animal research laboratory.

INTERVENTION

Six pigs were operated upon and endoscopically evaluated and then killed after 3 weeks. Linear compression closure clips based on nitinol springs were used. Three longitudinal enterotomies were performed: in the cecum, spiral colon, and proximal rectum. Four clips were deployed in each animal.

MAIN OUTCOME MEASUREMENTS

A total of 23 clips were deployed. The average expulsion day was 9 days.

RESULTS

All but 3 clips were normally expelled. One pig developed bowel ischemia due to intussusception. In endoscopic procedures, no signs of significant segmental mucosal ischemia were found. The macroscopic appearance of the compression closure lines was thin and delicate, but epithelialization was significantly delayed at 5 sites.

LIMITATION

Differences between porcine and human colorectal anatomy.

CONCLUSION

Full-thickness clamping of the bowel with the NiTi clamp, including the local mesenteric vasculature, does not significantly impair local healing of the clamp site and gives hope to further development of novel full-thickness endoscopic resection technologies.

Endoscopically stapled diverticulostomy for Zenker's diverticulum: results of a multidisciplinary team approach

BACKGROUND

A variety of open and endoscopic surgical approaches for the treatment of Zenker's diverticulum have been described. In recent years, growing evidence has shown that the endoscopic techniques are superior to the open approaches in many aspects. Among the endoscopic techniques, endoscopically stapled diverticulostomy (ESD) appears to have better efficacy and safety than the other endoscopic techniques.

METHODS

This study retrospectively reviewed the medical records of all the patients with Zenker's diverticulum treated surgically by the same team, which involved an ear, nose, and throat surgeon and an endoscopic surgeon.

RESULTS

From January 2002 to March 2008, 55 consecutive patients with Zenker's diverticulum underwent 60 ESDs. The mean follow-up time was 32.6 months (range, 1-72 months). The mean operative time was 21.8 min (range, 5-45 min), and the average hospital stay was 2.24 days (range, 1-30 days). The treatment was technically feasible for 51 patients (93%), and initial symptom relief without recurrence was achieved for 46 patients (90.2%) after a single procedure. Five patients with recurrent symptoms underwent a successful revision ESD, with a 100% success rate among the patients for whom the procedure was technically feasible. Only two major postoperative complications (3.64%) occurred: one esophageal perforation and pneumomediastinum and one severe esophageal edema. Both patients had complete resolution of their complications with conservative treatment and no long-term sequela.

CONCLUSION

The findings showed endoscopic stapled diverticulostomy to be both safe and effective. Compared with the historical results of open diverticulectomy and myotomy, the reported procedure has fewer complications and better outcomes and should become the procedure of choice for the treatment of most patients with a diagnosis of Zenker's diverticulum.

New concepts for a compression anastomosis: superelastic clips and rings

Gastrointestinal anastomosis is a crucial step in many operative procedures, and responsible for a major portion of early and late post-operative complications. In order to improve on the results of current tools to perform an anastomosis, such as sutures and staplers, new concepts are being developed. One of these concepts is compression anastomosis. Compression anastomosis has been tried in the past but did not become popular mostly because of technical reasons. Recently, trials to accomplish compression anastomosis using Nitinol devices were conducted. Two devices were made and tested in the past three years: a side-to-side device and an end-to-end device. The common principle in both devices is the compression of two bowel loops through the constant pressure of a Nitinol device, thus producing a dual process of necrosis and healing until the lumens of both bowels fuse, and the device falls into the lumen and is excreted. Both devices have been tested in animals and humans, with encouraging results. In animals, the anastomoses were shown to demonstrate minimal inflammation and no foreign body reaction, with perfect healing of the mucosa. The side-to-side device was tested in over 500 human patients, and the end-to-end device is currently used in a large, multi-centric human trial.

Simulation of a colorectal polypoid lesion--a pilot porcine model

BACKGROUND

Large sessile polyps almost always contain villous tissue with appreciable premalignant potential and tend to recur locally after colonoscopic resection. Developing new endoscopic techniques for the removal of polyps requires a large animal model of colorectal polypoid lesions. So far, no appropriate large animal model of a colorectal or other GI polyp has been described in the English literature.

OBJECTIVE

Our purpose was to develop a large animal model simulating large, perfused and viable, sessile colorectal polypoid lesions, with distinct easily detectable histologic features.

SETTING

An animal laboratory.

INTERVENTIONS

Two simulated rectal polyps, using 2 different techniques, were created in each of 10 animals. The polyps were simulated by ovarian tissue that was introduced either intraluminally through the rectal wall or into a dissected submucosal space in the rectal wall. In 2 animals the created polyps were endoscopically resected.

RESULTS

All submucosal lesions were sessile-like polypoid lesions because the base of the polyp was the widest diameter of the lesion. All transmural polypoid lesions had short and thick pedicles. Resection by snaring and cutting was demonstrated to be feasible.

MAIN OUTCOME MEASUREMENTS

The mean measurements of the submucosal-simulated polyps were as follow: 1.74 cm (+/-0.32) x 2.07 cm (+/-0.42) x 1.51 cm (+/-0.27). The mean measurements of the transmural-simulated polyps were significantly larger: 2.55 cm (+/-0.52) x 3.57 cm (+/-1.1) x 2.7 cm (+/-0.64).

LIMITATION

This model does not simulate a real intestinal neoplasia.

CONCLUSION

Either method, the submucosal or the transmural, could be helpful in the research and development efforts of surgical and endoscopic treatments of intestinal polyps.

Laparoscopic splenectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES)

BACKGROUND

Although laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases, some areas still remain controversial. To date, the indications that preclude laparoscopic splenectomy are not clearly defined. In view of this, the European Association for Endoscopic Surgery (EAES) has developed clinical practice guidelines for LS.

METHODS

An international expert panel was invited to appraise the current literature and to develop evidence-based recommendations. A consensus development conference using a nominal group process convened in May 2007. Its recommendations were presented at the annual EAES congress in Athens, Greece, on 5 July 2007 for discussion and further input. After a further Delphi process between the experts, the final recommendations were agreed upon.

RESULTS

Laparoscopic splenectomy is indicated for most benign and malignant hematologic diseases independently of the patient's age and body weight. Preoperative investigation is recommended for obtaining information on spleen size and volume as well as the presence of accessory splenic tissue. Preoperative vaccination against meningococcal, pneumococcal, and Haemophilus influenzae type B infections is recommended in elective cases. Perioperative anticoagulant prophylaxis with subcutaneous heparin should be administered to all patients and prolonged anticoagulant prophylaxis to high-risk patients. The choice of approach (supine [anterior], semilateral or lateral) is left to the surgeon's preference and concomitant conditions. In cases of massive splenomegaly, the hand-assisted technique should be considered to avoid conversion to open surgery and to reduce complication rates. The expert panel still considered portal hypertension and major medical comorbidities as contraindications to LS.

CONCLUSION

Despite a lack of level 1 evidence, LS is a safe and advantageous procedure in experienced hands that has displaced open surgery for almost all indications. To support the clinical evidence, further randomized controlled trials on different issues are mandatory.

Laparoscopic versus non-laparoscopic-assisted ventriculoperitoneal shunt placement in adults. A retrospective analysis

BACKGROUND

Ventriculoperitoneal shunts and distal shunt revisions bear a high risk of distal malfunction, especially in patients with previous abdominal pathologies as well as in obese patients. We performed laparoscopy-guided distal shunt placement or revision for patients with and without a positive abdominal history. We review the indications, techniques, complications, and long-term outcomes of these cases and compare the results to those of patients operated without laparoscopic guidance.

METHODS

A total of 211 distal shunt procedures were performed in our institute between January 2001 and December 2005, 59 of which were laparoscopically guided, and 152 were not. Of the 211 procedures, 177 were placement of new shunt systems, and 34 were distal revisions. A total of 33 procedures were performed in 25 patients with a history of abdominal surgery or inflammatory bowel disease; 15 procedures were operated with laparoscopic guidance.

RESULTS

The short-term complication and outcome rates were similar between the laparoscopy group and the other patients. Among the patients with new shunts, the long-term distal malfunction rate was lower in the laparoscopy group compared with the nonlaparoscopy group (4% vs 10.3%, respectively; P = .17). No patients in the laparoscopy group and 6 patients operated by other techniques had distal malfunction. There was 1 laparoscopy-related mortality and no morbidity.

CONCLUSIONS

Laparoscopy is not routinely indicated in distal shunt placement or revision. However, a laparoscopy-guided procedure may lower the rate of distal malfunction in patients with previous abdominal surgeries.

End-to-end compression anastomosis of the rectum: a pig model

BACKGROUND

Generations of investigators have attempted to achieve compression bowel anastomosis by a sutureless device, providing temporary support to the tissue and facilitating the natural healing process. The biocompatibility of nickel-titanium alloy has made it attractive for use in medical implants and devices, and several studies have described the creation of a side-to-side compression anastomosis in colon surgery with a nickel-titanium clip. We evaluated the feasibility and safety of a newly designed gun for applying a nickel-titanium compression anastomosis ring (CAR) to create an end-to-end colorectal anastomosis in a porcine model.

MATERIALS AND METHODS

A segment of the proximal rectum was resected in 25 pigs. The bowel ends were anastomosed transanally by an end-to-end CAR device. The animals' follow-up continued for up to 8 weeks, and included general health status, weight gain, blood tests, and abdominal X-ray. They were then sacrificed. The anastomoses were studied for burst pressure, anastomotic index, and histopathology.

RESULTS

One pig died due to iatrogenic bowel injury unrelated to the CAR device. There was no other morbidity/mortality. The other animals recovered and gained weight. Burst pressure studies demonstrated a minimum pressure of 160 mmHg at time point 0 that escalated quickly to >300 mmHg. The mean anastomotic index after 8 weeks was 0.81. Histologic evaluation revealed minimal inflammation and minimal fibrosis at the anastomosis site.

CONCLUSION

The principles of compression anastomosis are better executed with the use of memory shape alloys. The promising results of this novel technique should encourage further studies of this technology.

Carbon dioxide pneumoperitoneum-related liver injury is pressure dependent: A study in an isolated-perfused organ model

BACKGROUND

Disturbed liver function tests are associated with the pneumoperitoneum applied for biliary and non-biliary laparoscopic surgical procedures. The extent, duration and reversibility of such an injury are unknown. An isolated organ model was used to assess reversibility of liver injury in a CO(2)-pneumoperitoneum-like environment.

METHODS

Rat livers (n = 63) were isolated and perfused within a chamber pressurized at 0, 3, 5, 8, 12, 15 or 18 mmHg for 60 minutes. Pressure was annulled during the ensuing 61-90 minutes in one-half of the groups and markers of liver function were measured and recorded.

RESULTS

Inflow pressure level, flow rate, effluent partial O(2) and CO(2) pressures, O(2) extraction rate, lactate dehydrogenase level, lactic to pyruvic acid ratio, and total xanthine oxidase and dehydrogenase levels became abnormal, starting at 15 minutes after a pressure >5 mmHg was applied in the chamber. Signs of injury slowly reversed towards baseline values in all groups except for the 15 mmHg and 18 mmHg-pressurized ones, even after pressure had been annulled for 30 minutes.

CONCLUSIONS

CO(2)-pneumoperitoneum-like conditions directly injured rat liver tissue to a degree which correlated with the amount of applied pressure. Damage caused by pressure >or=15 mmHg was no longer reversible if it had been applied over a 60-minute period.

Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System

BACKGROUND

This study was designed to evaluate the impact of 3-dimensional vision on the performance of resident and experienced surgeons using the da Vinci Robot System (Intuitive Surgical, Sunnyvale, CA).

METHODS

Four tasks were performed by 12 surgeons with varying experience. Performance times and errors were recorded using both 2-dimensional and 3-dimensional vision for each task.

RESULTS

Performance time and error rates for all 4 skills confirm a significant advantage using 3-dimensional vision. Performance times were reduced by 34% to 46% using 3-dimensional imaging for all participants with statistical significance. Error rates were reduced by 44% and 66%.

CONCLUSION

Independent of the biomechanical advantages of the da Vinci Robot System, 3-dimensional vision allows for significant improvement in performance times and error rates for both inexperienced residents and advanced laparoscopic surgeons.

Prosthetic mesh repair of large and recurrent diaphragmatic hernias

BACKGROUND

Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate.

METHODS

Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis.

RESULTS

Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment.

CONCLUSIONS

Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

The influence of surgically-induced weight loss on the knee joint

BACKGROUND

The causal relationship between obesity and osteoarthritis (OA) of the knee is generally accepted. Weight loss has been shown to reduce the development of OA and improve the radiological parameters of existing disease. However, inducing weight reduction is difficult, and thus the number of patients studied has been small. We wished to determine the effects of surgically-induced weight loss on objective, radiological evidence of OA in the knee joint.

METHODS

64 consecutive patients that were referred to the Bariatric Surgical Unit were enrolled in the study. The only exclusion criterion was the prior diagnosis of OA. Knee pain alone did not exclude patients from the study. The study was performed in a prospective manner as a before-after trial. Radiographic data was evaluated by an independent radiologist not involved in the patient care or follow-up. Upright film of the knee was taken prior to surgery and 3 months following surgery. Minimal medial joint space width (JSW) was measured by a digital image computer. In addition, patients were clinically assessed using the American Knee Society Score (AKSS) at these times.

RESULTS

59 of 64 patients were available for followup. BMI decreased from 43.4 to 36.9 (P<0.01). The medial joint space increased from 4.6 mm to 5.25 mm (P<0.001). The AKSS improved from 78.5 points (perfect function = 100 points) to 90.69 points (P<0.01).

CONCLUSION

Surgically-induced weight loss is an effective, rapid and dependable means of reversing the radiological signs of early changes associated with OA.

Laparoscopic surgery may be associated with severe pain and high analgesia requirements in the immediate postoperative period

OBJECTIVE

To assess the immediate (0-4 hours) postoperative pain level in patients after laparoscopy and laparotomy whose analgesic requirement in the Post-Anesthesia Care Unit (PACU) exceeds standard morphine therapy.

BACKGROUND DATA

Clinical observation has raised the suspicion that laparoscopic surgery may be associated with more intense immediate postoperative pain than expected.

METHODS

This prospective study assessed the 24-hour pain intensity and analgesia requirements in patients who underwent similar abdominal surgery via laparoscopy or laparotomy under standardized general anesthesia and whose pain in the PACU was resistant to 120 microg/kg intravenous morphine.

RESULTS

Of 145 sampled PACU patients, 67 were in pain (> or =6 of 10 VAS) within a 30-minute postoperative period. They were then given up to 4 intravenous boluses of 15 microg/kg morphine + 250 microg/kg ketamine. The pain VAS of 36 laparotomy patients was 4.14 +/- 2.14 (SD) and 1.39 +/- 0.55 at 10 and 120 minutes, respectively, after 1.33 +/- 0.59 doses of morphine + ketamine; the pain VAS of 31 laparoscopy patient was 6.06 +/- 1.75 and 2.81 +/- 1.14, respectively (P < 0.0005) following 2.0 +/- 0.53 doses (P = 0.0005). Diclofenac 75 mg intramuscular usage was similar (P = 0.43) between the groups up to 9 hours after surgery but was higher in the laparotomy group by 24 hours (P = 0.01). Pain scores at 24 hours after surgery were lower for the laparoscopy patients (3.01 +/- 0.87) compared with their laparotomy counterparts (4.45 +/- 0.98, P < 0.001).

CONCLUSIONS

Among patients after abdominal surgery with severe immediate (0-4 hours) postoperative pain, laparoscopic patients are a significant (46%) proportion, and their pain is more intense, requiring more analgesics than painful patients (54%) do after laparotomy. By 24 hours, the former are in less pain than the latter.

The role of mental rotation and memory scanning on the performance of laparoscopic skills: a study on the effect of camera rotational angle

OBJECTIVE

The rotational angle of the laparoscopic image relative to the true horizon has an unknown influence on performance in laparoscopic procedures. This study evaluates the effect of increasing rotational angle on surgical performance.

METHODS

Surgical residents (group 1) (n = 6) and attending surgeons (group 2) (n = 4) were tested on two laparoscopic skills. The tasks consisted of passing a suture through an aperture, and laparoscopic knot tying. These tasks were assessed at 15 degrees intervals between 0 degrees and 90 degrees , on three consecutive repetitions. The participant's performance was evaluated based on the time required to complete the tasks and number of errors incurred.

RESULTS

There was an increasing deterioration in suturing performance as the degree of image rotation was increased. Participants showed a statistically significant 20-120% progressive increase in time to completion of the tasks (p = 0.004), with error rates increasing from 10% to 30% (p = 0.04) as the angle increased from 0 degrees to 90 degrees. Knot-tying performance similarly showed a decrease in performance that was evident in the less experienced surgeons (p = 0.02) but with no obvious effect on the advanced laparoscopic surgeons.

CONCLUSIONS

When evaluated independently and as a group, both novice and experienced laparoscopic surgeons showed significant prolongation to completion of suturing tasks with increased errors as the rotational angle increased. The knot-tying task shows that experienced surgeons may be able to overcome rotational effects to some extent. This is consistent with results from cognitive neuroscience research evaluating the processing of directional information in spatial motor tasks. It appears that these tasks utilize the time-consuming processes of mental rotation and memory scanning. Optimal performance during laparoscopic procedures requires that the rotation of the camera, and thus the image, be kept to a minimum to maintain a stable horizon. New technology that corrects the rotational angle may benefit the surgeon, decrease operating time, and help to prevent adverse outcomes.

Prosthetic closure of the esophageal hiatus in large hiatal hernia repair and laparoscopic antireflux surgery

BACKGROUND

Laparoscopy has become the standard surgical approach to both surgery for gastroesophageal reflux disease and large/paraesophageal hiatal hernia repair with excellent long-term results and high patient satisfaction. However, several studies have shown that laparoscopic hiatal hernia repair is associated with high recurrence rates. Therefore, some authors recommend the use of prosthetic meshes for either laparoscopic large hiatal hernia repair or laparoscopic antireflux surgery. The aim of this article was to review available studies regarding the evolution, different techniques, results, and future perspectives concerning the use of prosthetic materials for closure of the esophageal hiatus.

METHODS

A search of electronic databases, including Medline and Embase, was performed to identify available articles regarding prosthetic hiatal closure for large hiatal or paraesophageal hernia repair and/or laparoscopic antireflux surgery. Techniques and results as well as recurrence rates and complications related to the use of prosthetics for hiatal closure were reviewed and compared. Additionally, recent experiences and recommendations of experienced experts in this field were collected.

RESULTS

The results of 42 studies were analyzed in this review. Some techniques of mesh hiatal closure were evaluated; however, most authors prefer posterior mesh cruroplasty. The type and shape of hiatal meshes vary from small angular meshes to A-shaped, V-shaped, or complete circular meshes. The most frequently utilized materials are polypropylene, polytetrafluoroethylene, or dual meshes. All studies show a low rate of postoperative hernia recurrence, with no mortality and low morbidity. In particular, comparative studies including two prospective randomized trials comparing simple sutured hiatal closure to prosthetic hiatal closure show a significantly lower rate of postoperative hiatal hernia recurrence and/or intrathoracic wrap migration in patients who underwent prosthetic hiatal closure.

CONCLUSIONS

Laparoscopic large hiatal/paraesophageal hernia repair with prosthetic meshes as well as laparoscopic antireflux surgery with prosthetic hiatal closure are safe and effective procedures to prevent hiatal hernia recurrence and/or postoperative intrathoracic wrap migration, with low complication rates. The type of mesh, particularly the size and shape, is still controversial and is a matter for future research in this field.

Analysis of outcome of laparoscopic splenectomy for idiopathic thrombocytopenic purpura by platelet count

Laparoscopic splenectomy (LS) is now performed routinely in patients with idiopathic thrombocytopenic purpura (ITP) refractory to the medical treatment. Low preoperative platelet count was deemed to be a contraindication for a laparoscopic approach; however, there is no data reporting the outcome in those patients. We aimed to evaluate the influence of the preoperative platelet count on the operative and postoperative course and complication rate. Retrospective cohort study that was conducted in tertiary care university-affiliated medical center and included 110 consecutive patients who underwent LS. All patients were divided into three groups by their preoperative platelet counts: <or=20 x 10(9)/L (n = 12), (20-50) x 10(9)/L (n = 18), and >50 x 10(9)/L (n = 80). The outcome and the influence of preoperative factors predictive of complications, blood transfusion, and length of stay were compared between the groups. Patients with a platelet count of <or=20 x 10(9)/L had a much longer hospital stay, received more blood transfusions, and suffered more complications than patients with platelet counts of (20-50) x 10(9)/L or higher (P < 0.05). Transfused patients had a longer hospital stay than non-transfused patients (2.08 vs. 6.4 days, P = 0.029). The strongest predictor for transfusion was the platelet count (odds ratio = 23, P = 0.008). LS in patients with very low platelet counts is feasible and reasonably safe, but the platelet count is a major determinant of morbidity. Every effort should be made to elevate platelet levels to >20 x 10(9)/L before surgery. Patients with counts >20 x 10(9)/L can safely undergo LS.

Colonic anastomosis performed with a memory-shaped device

BACKGROUND

The present study was prompted by our previous successful experience with the compression anastomosis clip (CAC) on animals followed by a study on 20 patients scheduled for colonic resection.

METHODS

Sixty patients with colonic cancer were assigned randomly to undergo an anastomosis either with the CAC or a stapler. To perform anastomosis with CAC, the 2 edges of the resected colon are aligned. Two 5-mm incisions are made close to the edges, through which (using a special applier) the CAC, after being cooled in ice water, is introduced in an open position. In response to the body temperature, the clip resumes its original (closed) position, thereby clamping the 2 bowel segments together. At the same time, a small scalpel incorporated in the applier makes a small incision through the clamped walls for the passage of gas and feces. The clip is detached from the applier to be left inside the intestine. The 2 5-mm incisions are sutured. The clip is expelled with the stool within 5 to 7 days, creating a perfect uniform compression anastomosis.

RESULTS

Neither group had anastomotic complications such as leakage or obstruction. All the other parameters were better in the study group than in the control patients.

CONCLUSIONS

The use of the CAC for colonic surgery is safe, simple, efficient, shortens operation time, and is almost what we call the "no-touch concept" in surgery and may decrease infection.

VENTILATORY AND HEMODYNAMIC CHANGES DURING RETROPERITONEAL AND TRANSPERITONEAL LAPAROSCOPIC NEPHRECTOMY: A PROSPECTIVE REAL-TIME COMPARISON

PURPOSE

Nephrectomies are currently performed via the transperitoneal or retroperitoneal laparoscopic approach. We compared the ventilatory and hemodynamic effects of these approaches.

MATERIALS AND METHODS

After institutional ethics committee approval was obtained patients requiring nephrectomy in a 9-month period were prospectively allocated to the retroperitoneal (24) or transperitoneal (15) approach. All were initially ventilated in the volume controlled mode (10 ml kg tidal volume). Intraoperative fingertip, pulse derived arterial oxygen saturation less than 97%, end tidal CO2 partial pressure greater than 40 mm Hg and peak inspiratory pressure greater than 36 cm H2O necessitated changes in ventilatory parameters, as deemed necessary by the anesthetist. If tidal volume decreased greater than 25% of baseline, pressure controlled ventilation was begun instead.

RESULTS

Peak inspiratory and plateau pressures increased for the transperitoneal approach by approximately 30% more than in the retroperitoneal group (p <0.05). Volume controlled ventilation was changed to pressure controlled ventilation in 8 transperitoneal vs zero retroperitoneal cases (p <0.05). Heart rate, and systolic and diastolic blood pressure increased by approximately 13% more in the transperitoneal than in the retroperitoneal group (p <0.05).

CONCLUSIONS

Nephrectomy via the retroperitoneal laparoscopic approach interferes with ventilatory and hemodynamic functions less than nephrectomy via the transperitoneal approach.

Port complications following laparoscopic adjustable gastric banding for morbid obesity

BACKGROUND

Laparoscopic adjustable gastric banding (LAGB) has gained widespread acceptance. However, the technique has problems intrinsic to the material wear and tear around the port and connecting tubing that can lead to failure. Port complications are considered to be minor; however, few studies have analyzed them, and the optimal technique of port implantation and management has not been elucidated.

METHODS

All patients who suffered from complications involving the tubing or access-port were included in this study. Their complaints, imaging studies, operative reports and hospitalization files were retrospectively reviewed.

RESULTS

1,272 of the patients were available for a mean follow-up period of 37 months. During this time, 91 patients (7.1%) experienced port complications that required 103 revisional operations. Of these patients, 62 had system leaks, 19 infectious problems, and 10 miscellaneous problems requiring operative correction. Overall port problems led to band removal in 6 patients, and replacement in 1 patient.

CONCLUSION

Access-port complications after the Lap-Band procedure are among the most common and annoying ones, and can render the device susceptible to failure. Careful surgical technique and routine use of radiologic guidance for band adjustments are the keys to avoiding complications.

Laparoscopic Adjustable Gastric Banding Prior to Renal Transplantation

End-stage renal failure is most commonly caused by the obesity-related diseases, diabetes mellitus and essential hypertension, and is best treated with renal transplantation. Obesity may contribute to poor patient and graft survival, and is an exclusion criterion in some renal transplant programs. Diet and exercise programs have not proven to be effective for weight loss before transplantation, and bariatric surgery in any form has not been used in this setting before. We report three morbidly obese patients who underwent laparoscopic adjustable gastric banding to meet the criteria for renal transplantation and subsequently were successfully transplanted.

Band slippage after laparoscopic adjustable gastric banding: etiology and treatment

BACKGROUND

Laparoscopic adjustable gastric banding is a safe and effective procedure for the management of morbid obesity. However, band slippage is a common complication with variable presentation that can be rectified by a second laparoscopic procedure.

METHODS

We studied case series of 125 consecutive patients who suffered from band slippage between November 1996 and May 2001 from a group of 1,480 laparoscopic adjustable gastric banding procedures performed during this time. The decision of whether to remove or replace/reposition the band was made prior to the operation, although the specific method used when replacement or repositioning was deemed suitable was determined by the operative findings. A laparoscopic approach was used in all but three patients.

RESULTS

A total of 125 patients (8.4%) suffered band slippage (posterior slippage, 82.4%; anterior slippage, 17.6%). In 70 patients (56%), the band was removed, whereas in 55 patients (44%) it was repositioned or replaced immediately. Of these 55 patients, six underwent later removal, five due to recurrent slippage and one due to erosion. Fourteen patients suffered complications, including gastric perforation (n = 8), intraoperative bleeding (n = 1), postoperative fever (n = 3), aspiration pneumonia (n = 1), upper gastrointestinal bleeding (n = 1), and pulmonary embolism (n = 1).

CONCLUSION

Band slippage is not a rare complication after laparoscopic adjustable gastric banding. The decision to remove or replace the band or convert to another bariatric procedure should be made preoperatively, taking both patient preference and etiology into consideration. Short-term results indicate that band salvage is successful when the patient population is chosen correctly.