Use of mesh for hiatal hernia repair: a survey of SAGES members.

BACKGROUND: Mesh use during hiatal hernia repair (HHR) has been suggested to be safe and effective. Concern has been raised about the risk of mesh-related complications, and the higher risk of complications if revisional hiatal surgery is undertaken after mesh has been used. Available data have not established a clear role for mesh in HHR. To assess surgeons' adoption of the use of mesh for HHR, SAGES members were surveyed regarding their practice related to mesh use for HHR. METHODS: Between April and September 2010, an internet-based survey tool was used to survey SAGES members. Potential participants were contacted via e-mail and invited to complete the survey. Of the 5,323 attempted contacts, 5,024 reached active e-mail accounts. From these, 2,518 members responded (50% response rate). RESULTS: The majority of respondents currently perform HHR (69%), but only 18% perform more than 20 per year. Of those who perform HHR, 94% use a laparoscopic approach for the majority of repairs. Whereas 25% of surgeons use mesh for the majority of repairs, 23% of surgeons never use mesh. When mesh is used, an absorbable mesh is most commonly used (67%). An onlay technique is used by 93% of respondents. Only 7% of surgeons who have been in practice more than 20 years use mesh compared with 59% of surgeons in practice less than 10 years. Fifty-seven percent of surgeons have never performed revisional foregut surgery on a patient with prior mesh. CONCLUSIONS: Although the majority of surgeons have used mesh for HHR, it is the minority who use it routinely, with younger surgeons more likely to use mesh than older surgeons. Absorbable mesh is most commonly used. When mesh is used, an onlay technique is most commonly used. There is no clear accepted use of mesh in hiatal hernia repair.

Quality of life after sleeve gastrectomy and adjustable gastric banding.

BACKGROUND: With the addition of laparoscopic vertical sleeve gastrectomy (SG) to the bariatric surgery procedural toolkit, patients desiring a restrictive bariatric procedure often choose between adjustable gastric banding (LAGB) and SG. One study compared quality of life after these 2 procedures and found no difference. The purpose of our study was to re-evaluate the postoperative quality of life in LAGB and SG patients at a military teaching hospital in the United States. METHODS: A retrospective review of 108 consecutive laparoscopic restrictive bariatric procedures performed within 15 months at a Department of Defense hospital was conducted. Of these 108 patients, 69 had undergone laparoscopic vertical SG and 39 LAGB. A validated quality of life questionnaire (Bariatric Quality of Life) was conducted a mean of 9.3 ± 3.2 months (range 5-16) postoperatively. The weight loss and standard laboratory parameters were measured at 0, 1, 3, 6, and 12 months. RESULTS: The quality of life assessment revealed significantly better scores after SG than after LAGB (66.5 versus 57.9, P = .0002). The excess weight loss and excess body mass index loss at 3, 6, and 12 months postoperatively were significantly greater in the laparoscopic SG group. The patients demonstrated a clear preference over time for SG once it was offered. CONCLUSION: Early postoperative quality of life was superior after SG than after LAGB. SG also resulted in superior early excess weight loss. In a practice not constrained by reimbursement, these findings were associated with increased patient choice of SG after it began to be offered.

Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese.

BACKGROUND: This study aimed to determine the incidence, etiology, and management options for symptomatic stenosis (SS) after laparoscopic sleeve gastrectomy (LSG). METHODS: A retrospective study reviewed morbidly obese patients who underwent LSG between October 2008 and December 2010 to identify patients treated for SS. RESULTS: In this study, 230 patients (83% female) with a mean age of 49.5 years and a mean body mass index (BMI) of 43 kg/m(2) underwent LSG. In 3.5% of these patients (100% female; mean age, 42 years; mean BMI, 42.6 kg/m(2)), SS developed. The LSG procedure was performed using a 36-Fr. bougie and tissue-reinforced staplers. Four patients had segmental staple-line imbrication, and seven patients underwent contrast study, with 71.4% demonstrating a fixed narrowing. Endoscopy confirmed short-segment stenoses: seven located at mid-body and one located near the gastroesophageal junction. Endoscopic management was 100% successful. The mean number of dilations was 1.6, and the median balloon size was 15 mm. The mean time from surgery to initial endoscopic intervention was 48.8 days, and the mean time from the first dilation to toleration of a solid diet was 49.6 days. Two patients were referred to our institution after undergoing LSG at another facility. The mean time to the transfer was 28.5 days. The two patients had a mean age of 35 years and a mean BMI of 42.3 kg/m(2). Both patients experienced immediate SS after perioperative complications comprising one staple-line hematoma and one leak. Contrast studies demonstrated minimal passage of contrast through a long-segment stenosis. Both patients underwent multiple endoscopic dilation procedures and endoluminal stenting, ultimately requiring laparoscopic conversion to Roux-en-Y gastric bypass. The mean time from the initial surgery to the surgical revision was 77 days, and the mean time after the first intervention to tolerance of a solid diet was 82 days. CONCLUSION: Symptomatic short-segment stenoses after LSG may be treated successfully with endoscopic balloon dilation. Long-segment stenoses that do not respond to endoscopic techniques may ultimately require conversion to Roux-en-Y gastric bypass.

Transcervical videoscopic esophageal dissection during two-field minimally invasive esophagectomy: early patient experience.

BACKGROUND: Transhiatal (two-field) esophagectomy reduces cardiopulmonary complications by avoiding thoracic access, but requires blind mediastinal dissection. The authors developed a minimally invasive esophagectomy (MIE) technique applying single-incision laparoscopy technology to better visualize the thoracic esophageal dissection. This is performed using laparoscopy and simultaneous transcervical videoscopic esophageal dissection (TVED). Our aim is to demonstrate feasibility of two-field MIE with TVED and improve recovery in high-risk patients. METHODS: We performed a retrospective cohort study of eight patients who underwent two-field MIE with TVED over 10 months. The majority were male (N = 6) with mean age of 63 ± 12 years. Mean body mass index (BMI) was 30.2 ± 5.1 kg/m(2). Indications for operation were: high-grade dysplasia (N = 2), adenocarcinoma (N = 6) with one receiving neoadjuvant chemoradiation. Using the Charlson comorbidity index, three patients were low risk and five were high risk. TVED was performed with a modified single-incision access device across the left neck. The mediastinal esophagus was dissected distally and circumferentially with simultaneous transabdominal laparoscopy for gastric conduit creation and distal esophageal dissection. RESULTS: Mean operative time was 292 min (range 194-375 min). Three obese patients required temporary abdominal desufflation to avoid extrinsic mediastinal compression. Mean estimated blood loss was 119 mL (range 25-400 mL). A median of 23 lymph nodes (range 13-29) was harvested. Median intensive care unit (ICU) stay was 1 day (range 1-5 days), and median overall stay was 7 days (range 5-16 days). The three low-risk patients had no major complications. Three of five high-risk patients had major complications, including two cervical anastomotic leaks. Major complications were seen in three of four obese patients (BMI >30 kg/m(2)). There were no mortalities. CONCLUSIONS: The TVED approach may avoid the morbidity of transthoracic esophageal dissection by improving esophageal visualization. Complications with TVED appear to correlate with obesity and comorbidities. Although TVED appears feasible, a larger experience is required.

Laparoscopic intraoperative biliary ultrasonography: findings during laparoscopic cholecystectomy for acute disease.

Laparoscopic cholecystectomy (LC) is one of the most commonly performed operations, yet the frequency of bile duct injury remains unacceptably high, and up to 25% of urgent LCs are converted to the open approach. Intraoperative laparoscopic biliary ultrasonography (IOUS) allows identification of portal structures before division of any structure, but the impact of IOUS on LC for acute biliary disease has not been clearly reported. A retrospective review was conducted of all patients who underwent cholecystectomy over a 29-month period. IOUS was performed after release of the medial and lateral peritoneal attachments of the gallbladder. Of the 65 patients, 43 (66%) had an urgent operation. Mean operative time was 89.6 minutes (range 45 to 196 minutes). IOUS was used routinely, when available, in 50 patients (77%). The biliary anatomy was completely observed in 48 patients (96%). IOUS identified significant biliary abnormalities in 20 patients (40%) including presence of a foreshortened cystic duct (CD) (<1 cm) in 7 patients (14%), common bile duct stones in 4 patients (8%), abnormal CD anatomy in 4 patients (8%), and abnormal vascular anatomy in 8 patients (16%). No patient was converted to open operation, no bile duct injury occurred, and no patient required subsequent biliary intervention. IOUS is effective at observing biliary anatomy in the setting of acute disease, and may be a useful tool during these difficult cases.

Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair.

BACKGROUND: Component separation technique (CST) enables rectus abdominus medialization, but may cause wound complications. Few published outcomes exist involving laparoscopic CST. Our aim was to examine feasibility and outcomes involving open and laparoscopic (lap) CST during ventral incisional hernia repair (VIHR) and present an algorithm for ventral herniorrhaphy. STUDY DESIGN: Our design was a retrospective cohort study. Over 22 months, 28 patients underwent one of the following: (i) unilateral (U-) lap CST with open VIHR [n = 5], (ii) bilateral (B-) lap CST with open VIHR [n = 7], (iii) B-lap CST with lap VIHR [n = 8], or (iv) B-open CST with open VIHR [n = 8]. Indications for open VIHR included mesh removal, concomitant visceral procedure, wound revision, thin/ulcerated skin, abdominal wall tumor, frozen abdomen, and/or off-midline hernia. During open VIHR, CST was performed in the Ramirez fashion. Lap CST was performed before intraperitoneal access in lap VIHR and after retrorectus dissection in open VIHR. Patient surveillance consisted of clinical encounters and telephone interviews. RESULTS: Groups were similar regarding age, body mass index, American Society of Anesthesiologists classification, hernia width, operative time, and hospital stay. Six of the 20 patients who underwent open VIHR developed wound complications, and two required early reoperation. Four of the six with concomitant visceral procedures had wound complications. No laparoscopic VIHR patients had a wound complication. Based on 11 months' follow-up, one open VIHR patient has concern for recurrence. CONCLUSIONS: Laparoscopic CST is feasible during open and laparoscopic VIHR, but it appears most beneficial for wound healing after laparoscopic VIHR. During open VIHR, laparoscopic CST may not substantially reduce wound complications.

Video: transcervical videoscopic esophageal dissection in minimally invasive esophagectomy.

BACKGROUND: Minimally invasive esophagectomy (MIE) may involve video-assisted thoracoscopic surgery (VATS) for mediastinal esophageal dissection. Usually, VATS requires single-lung ventilation and has associated cardiopulmonary morbidity [1-3]. Alternatively, transhiatal dissection can be performed, although its complications include vocal cord palsy [4], cardiac arrythmias [5], and increased bleeding [5, 6], the latter associated with mortality after esophagectomy [2]. Therefore, the feasibility of MIE using transcervical videoscopic esophageal dissection (TVED) in swine was investigated. A simultaneous laparoscopic and TVED approach may decrease operative time and blood loss while improving visualization and avoiding single-lung ventilation. METHODS: Two pigs (Sus domesticus) underwent two similar procedures. The methods were approved by the authors' Institutional Animal Care and Use Committee (no. A24209) under United States Department of Agriculture guidelines. Steps included a cervical incision to accommodate a modified hand-assist access device. The cervical esophagus was dissected. Trocars were placed through the modified access device, and pneumomediastinum was established. The tracheoesophageal plane was dissected into the thorax and beyond the mid esophagus, on which the pleura of the separate mediastinal compartment inserts itself. Vagal nerves were identified and divided distal to recurrent branches. Standard laparoscopic techniques were used for esophagogastric dissection. After specimen extraction, the animals were euthanized. RESULTS: A full circumferential dissection of the mediastinal esophagus was successfully accomplished in two animals using a single-incision TVED for MIE. CONCLUSIONS: A novel technique for mediastinal esophageal dissection using a TVED approach performed with instruments designed for single-port surgery is described. Fortunately, the human lacks the swine's separate mediastinal compartment, and this unique difference should facilitate the human version of this dissection. This approach may avoid the potential morbidity of VATS while providing better visualization and facilitating dissection of the upper mediastinal esophagus compared with either the transhiatal approach or the previously attempted rigid mediastinoscopic approaches [7-9].

Hiatal mesh is associated with major resection at revisional operation.

BACKGROUND: Mesh-assisted hiatal closure during foregut surgery is increasing. Our aim was to evaluate the complications that follow revisional foregut surgery. Specifically, we compared surgical indications and perioperative outcomes between patients with and without prior hiatal mesh (PHM). METHODS: We conducted an institutional review board (IRB)-approved retrospective cohort study from a single tertiary-care referral center. Over 37 months, 91 patients underwent revisional foregut surgery. We excluded 13 cases including operations performed primarily for obesity or achalasia. Of the remaining 78 patients, 10 had PHM and 68 were nonmesh patients (NM). RESULTS: The groups were similar in terms of age, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, and rates and types of anatomic failure. Compared with NM patients, PHM patients had increased estimated blood loss (410 vs. 127 ml, p < 0.01) and operative time (4.07 vs. 2.89 h, p < 0.01). The groups had no difference in perioperative blood transfusion or length of stay. Complete fundoplication was more commonly created in NM patients (2/10 vs. 42/68, p = 0.03). Three of the 10 PHM patients and 3 of the 68 NM patients required major resection. Therefore, PHM patients had 6.8-fold increased risk of major resection compared with NM patients [95% confidence interval (CI) = 1.585, 29.17; p = 0.05]. The NM patients with multiple prior hiatal operations had 4.6-fold increased risk of major resection compared with those with one prior operation (95% CI = 2.919, 7.384; p = 0.03). In PHM patients, however, the number of prior hiatal operations was not associated with major resection. CONCLUSIONS: PHM is associated with increased risk of major resection at revision. The pattern of failure was not different in patients with hiatal mesh, suggesting that hiatal mesh does not eliminate the potential for revision. When performing hiatal herniorrhaphy, the increased risk of recurrence without mesh must be weighed against the potential risk for subsequent major resection when using mesh.