ABSTRACT
BACKGROUND: In laparoscopic surgery, the Veress needle technique is most often used to initiate a pneumoperitoneum. Although low, entry-related injuries of the intestines and major vascular structures occur in 0.04-0.1% of cases. Up to 50% of these injuries remain undiagnosed at the time of surgery, resulting in mortality rates between 2.5 and 30%. In an effort to minimize such injuries we objectively assessed a novel abdominal wall entry suction device (AWESD) that was hypothesized to lift the abdominal wall and create an additional post-peritoneum safe margin for safer Veress needle introduction. MATERIALS AND METHODS: A prospective pilot study was conducted in which CT-scans with and without AWESD application (centered above the umbilicus) were assessed to determine its effect on the distance from the linea alba to the intestines, vena cava and abdominal aorta. Paired measurements were subjected to the Wilcoxon signed rank test. RESULTS: Twelve participants were included. The AWESD significantly increased the median distance towards the intestines in the axial and sagittal plane (Pâ¯=â¯0.01 and Pâ¯=â¯0.006) from 0.93 (Inter Quartile Range (IQR): 0.33-1.51) and 0.85 (IQR: 0.32-1.47) to 1.35 (IQR: 0.39-2.27) and 1.25 (IQR: 0.42-2.10) centimeters, respectively. Similarly, for the median axial distances towards the vena cava and abdominal aorta (both Pâ¯=â¯0.002) that were increased from 10.00 (IQR: 7.18-11.12) and 9.33 (IQR: 6.55-10.28) to 13.23 (IQR: 11.76-14.31) and 12.49 (IQR: 10.98-13.32) centimeters, respectively. CONCLUSION: The AWESD significantly increased the distances between the peritoneum and main intra-abdominal structures. However, conclusions on subsequent increased safety cannot be drawn as high-volume studies are required to determine its clinical relevance.
ABSTRACT
PURPOSE: The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation. MATERIALS AND METHODS: A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy. RESULTS: Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation. CONCLUSION: 3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples.
