Laparoscopic Sleeve Gastrectomy for Morbid Obesity with Intra-operative Endoscopy: Lessons We Learned After 100 Consecutive Patients.

BACKGROUND: Sleeve gastrectomy has become the second most common bariatric operation due to its low rates of morbidity and mortality, satisfactory treatment of patients' obesity, and resolution of associated co-morbidities. According to standard technique, calibration of the stomach is performed with varying sizes of bougies while use of intra-operative endoscopy has only sparsely been reported. METHODS: Between 2004 and 2013, 100 patients have undergone laparoscopic or robotic sleeve gastrectomy with intra-operative endoscopic guidance. Technical aspects of the operation, results concerning morbidity, progressive weight loss, and resolution of co-morbidities were retrospectively reviewed. RESULTS: Morbidity and mortality was zero. Rates of excess weight loss at 6 months and 1 and 3 years were 52.1, 67.4, and 61.3 %, respectively. Patients' highest rate of excess weight loss was achieved 18 months post-operatively. These rates were inversely related with preoperative age, body mass index, and the existence of preoperative co-morbidities. CONCLUSION: Sleeve gastrectomy with intra-operative endoscopic guidance is at least as safe and effective as with the bougie. Given the available expertise and equipment, the use of this technique can increase the intra-operative sense of safety with no compromise or even improvement of the immediate or long-term results.

A hybrid technique for recurrent incisional hernia repair.

PURPOSE: The aim of this technical report is to investigate the safety and effectiveness of a hybrid technique for recurrent incisional hernia repair, which combines the conventional and laparoscopic approaches. METHODS: Six patients suffering from recurrent and complicated incisional hernias underwent a hybrid technique for their repair. The open part of the operation ensured extensive and safe adhesiolysis, reduction of the hernia content into the peritoneal cavity, and proper placement of the bowel loops into the peritoneal cavity, minimizing the risk of bowel perforation. For the laparoscopic part of the procedure, intraperitoneal (underlay) e-PTFE mesh placement, of the appropriate size covering the actual hernia size and the scar edges for at least 3 cm, was laparoscopically fixated by transfascial stay stitches, allowing stretch of the mesh on the anterior abdominal wall, probably avoiding the mesh deformation in the future. RESULTS: The overall size of the fascial defect was calculated between 116 and 187 cm, the size of the mesh used ranged from 308 to 468 cm, the total operative time ranged from 128 to 207 minutes and within a maximum follow-up period of 12 months, all patients are asymptomatic without any evidence of hernia recurrence. CONCLUSIONS: The hybrid technique is safe in cases of recurrent or complicated or difficult incisional hernias. A longer follow-up period is required to estimating the effectiveness and the cost-effectiveness of the method.