Hiatal hernia repair with mesh: a survey of SAGES members.

BACKGROUND: Primary repair of large hiatal hernia is associated with a high recurrence rate. The use of mesh may reduce this recurrence rate. The indication for mesh use, the type of mesh to use, and the placement technique are controversial. A survey of surgeon practice was undertaken to obtain a better understanding of the controversies surrounding this clinical problem. METHODS: A questionnaire on the technique and results of mesh hiatal herniorrhaphy was sent to 1,192 members of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES). RESULTS: There were 275 responses; 261 of these were analyzed. A total of 5,486 hiatal hernia repairs with mesh were reported; 77% and 23% were performed laparoscopically vs open, respectively. The most common indication for mesh usage was an increased size hiatal defect (46% of respondents). The most common mesh types were biomaterial (28%), polytetrafluoroethylene (25%), and polypropylene (21%). Suture anchorage was the most common fixation technique (56% of respondents). The findings showed a failure rate of 3%, a stricture rate of 0.2%, and an erosion rate of 0.3%. Biomaterial tended to be associated with failure, whereas nonabsorbable mesh tended to be associated with stricture and erosion. CONCLUSIONS: The use of mesh during hiatal hernia repair resulted in a reported recurrence rate which appeared to be lower than that obtained historically without mesh. No one mesh type was clearly superior in terms of avoiding failure and complication.

Laparoscopic revision of failed fundoplication and hiatal herniorraphy.

OBJECTIVE: The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND: Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS: A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS: Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION: Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Laparoscopic peritoneal dialysis catheter insertion using a Quinton percutaneous insertion kit.

OBJECTIVE: We assessed a unique technique of laparoscopic peritoneal dialysis (PD) catheter insertion which can minimize catheter dysfunction. METHODS: We performed a retrospective review of patients undergoing laparoscopic PD catheter placement with a Quinton percutaneous insertion kit between July 2000 and December 2004. RESULTS: Thirty-one catheters were placed laparoscopically. The mean operating time was 52 minutes. Adhesiolysis was required in 9 (29%) and omentectomy or omentopexy in 3 (10%) cases. Late complications included catheter dysfunction in 2 patients (6.5%), debilitating abdominal pain requiring catheter removal in 1 patient, and 1 trocar-site hernia. The mean follow-up was 17 months. CONCLUSIONS: Laparoscopic PD catheter insertion using a Quinton percutaneous insertion kit is safe, reproducible, and effective. It facilitates placement of the catheter tip into the pelvis and allows adhesiolysis, omentectomy, or omentopexy when necessary. Utilization of this technique results in a low rate of PD catheter dysfunction.

Laparoscopic Roux-en-Y Gastric bypass utilizing the triple stapling technique.

OBJECTIVE: To evaluate the outcomes of a single surgeon's experience with laparoscopic Roux-en-Y gastric bypass (LRYGB) utilizing the triple stapling technique for creation of the jejunojejunostomy. METHODS: A retrospective review of patients who underwent LRYGB utilizing the triple stapling technique for creation of the jejunojejunostomy (JJ) between 10/01 and 12/04 was performed. RESULTS: LRYGB was performed in 435 consecutive patients. The mean age was 41 years (range, 14 to 68), and 82% were female. Mean initial body mass index was 50 (range, 35 to 91). One conversion to open (0.2%) was necessary. Mean operating time was 144+/-26 minutes. Mean length of stay was 2.3+/-1.5 days. There were 3 leaks at the gastrojejunostomy anastomosis (0.7%). No leaks occurred at the JJ anastomosis. One patient underwent revision of the JJ (0.2%) secondary to obstruction of the JJ on upper gastrointestinal study. Intraluminal bleeding occurred in 21 patients (4.8%). Patients required blood transfusion of 2.2+/-1.1 units (range, 0 to 5), but none required surgical or endoscopic intervention. Mortality occurred in 2 patients (0.5%). Mean excess body weight loss was 72% at 1 year. CONCLUSION: Construction of the jejunojejunostomy utilizing the triple stapling technique is expeditious, safe, and associated with minimal complication.

Postoperative gastrointestinal complaints after laparoscopic Nissen fundoplication.

OBJECTIVES: Approximately 80% of patients complain of various symptoms immediately after laparoscopic Nissen fundoplication. These symptoms typically are treated medically without an extensive evaluation to identify the cause. We reviewed our experience of laparoscopic Nissen fundoplication to determine the course of postoperative symptomatology in our patient population, and present a rational approach to this problem. METHODS: Over a 10-year period, 628 patients underwent primary laparoscopic Nissen fundoplication for gastroesophageal reflux disease; patients were evaluated with a standard set of questions for postoperative gastrointestinal complaints. Three- and 6-month follow-up data were compared by using the chi square test. RESULTS: One-year follow-up data were available for 615 patients (98%). All of these patients had symptoms during the first 3 postoperative months. Early satiety (88%), bloating/flatulence (64%), and dysphagia (34%) were the most common; however, 94% of patients had resolution of their symptoms by the 1-year follow-up visit, and most had resolved after 3 months. Patients with persistent reflux or dysphagia after 3 months typically had an anatomic failure of the operation. CONCLUSIONS: Most patients who have undergone laparoscopic Nissen fundoplication for gastroesophageal reflux disease will have gastrointestinal complaints during the initial 3 postoperative months. Nearly all of these patients will have resolved their symptomatology after 3 months. Those with persistent symptoms after 3 months warrant evaluation for operative failure.

Value of preoperative upper endoscopy in patients undergoing laparoscopic gastric bypass.

BACKGROUND: Preoperative evaluation of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGBP) has included esophagogastroduodenoscopy (EGD) with little data to substantiate its use. METHODS: A retrospective analysis was conducted of patients from Feb 04 to Mar 05 who underwent preoperative EGD and subsequently LRYGBP. RESULTS: 169 patients underwent EGD prior to surgery. Their mean age was 41.1 years (range 14-66), mean BMI 49.7 (range 35-78), and 82% were females. There were no complications from EGD. Significant findings in patients at EGD included gastric ulceration in 3 (2%), duodenal ulcer in 1 (0.7%), Barrett's esophagus in 2 (1.3%), and a GI stromal tumor (GIST) in 1 (0.7%). EGD revealed hiatal hernias in 56 (35.2%), esophagitis in 28 (17%), Schatzki's ring in 5 (3%), gastritis in 43 (27%), gastric polyps in 8 (5%), and duodenitis in 9 (6%). 53 patients (33.3%) had a negative EGD. Ulcer and severe gastritis, esophagitis, and duodenitis diagnosed preoperatively were treated medically before surgery. 9 hiatal hernias were repaired intraoperatively. The patient with the GIST underwent laparoscopic near-total gastrectomy and gastric bypass, while 1 patient with an antral polyp underwent laparoscopic partial gastrectomy in addition to the LRYGBP. CONCLUSION: EGD is essential for diagnosis of GI diseases including tumors, ulcers, and hiatal hernias that alter the medical and surgical management of patients undergoing gastric bypass.

L5-S1 laparoscopic anterior interbody fusion.

OBJECTIVE: We evaluated our experience with laparoscopic L5-S1 anterior lumbar interbody fusion (ALIF). METHODS: This represents a retrospective analysis of consecutive patients who underwent L5-S1 laparoscopic ALIF between February 1998 and August 2003. RESULTS: Twenty-eight patients underwent L5-S1 LAIF (15 males and 13 females). The mean age was 43 years (range, 26 to 67). Mean operative time was 225 minutes (range, 137 to 309 minutes). No conversions to an open procedure were necessary. Twenty-four (85.7%) patients underwent successful bilateral cage placement. Four patients (14.3%) in whom only a single cage could be placed underwent supplementary posterior pedicle screw placement. Mean length of stay (LOS) was 4.1 days (range, 2-to 15). Two patients underwent reoperation subacutely secondary to symptomatic lateral displacement of the cage. One patient developed radiculopathy 6 months postoperatively and required reoperation. One patient developed a small bowel obstruction secondary to adhesions to the cage requiring laparoscopic reoperation. Fusion was achieved in all patients. Visual analogue scale scores for back pain were significantly improved from 8.6+/-0.8 to 2.8+/-0.8 (P<0.0001) at 1 year. CONCLUSION: L5-S1 LAIF is feasible and safe with all the advantages of minimally invasive surgery. Fusion rates and pain improvement were comparable to those with an open repair.

A 46-year-old man with excruciating shoulder pain.

A 46-year-old man with no significant medical history presented to his local emergency department complaining of excruciating right shoulder pain. The patient was in his usual state of excellent health until 4 days prior, when right shoulder pain developed while he was using a chainsaw to cut wood. The next day, flu-like symptoms developed with fevers, chills, and headache. An MRI revealed that the right pectoralis major was torn from its attachment to the acromion. His shoulder pain intensified despite treatment with hydrocodone and acetaminophen, and the flu-like symptoms progressed over the next 2 days. Finally, on the day of hospital admission, he was weak and unable to arise out of bed. He was taken by family members to the local emergency department.