Robotic Fundoplication for Gastroesophageal Reflux Disease and Hiatal Hernia: Initial Experience and Outcome.

Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common clinical presentation. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery. Between March 2014 and August 2016, 50 patients (18 males and 32 females) underwent robotic fundoplication (17 sliding and 33 paraesophageal hernias). The mean age of the patients was 58 years. Biosynthetic mesh was used in 28 patients with paraesophageal hernia. The mean operative time was 115 minutes (90-132) in the sliding hiatal hernia group, whereas it was 200 minutes (180-210) in the paraesophageal hiatal hernia group. The mean hospital stay was 36 hours (24-96). Eight patients experienced mild dysphagia which resolved after four weeks. No postoperative dysphagia was recorded at 30-month median follow-up. We experienced one recurrence in the sliding hernia group and two recurrences in the paraesophageal hernia group, with two patients treated robotically. Robotic fundoplication in treating sliding hiatal hernia is feasible and safe but is more challenging in the large paraesophageal group. Improved patient outcomes hinge on the operative technique used and increasing surgeon experience. The increased dexterity that robotic surgery affords enables the esophageal surgeon to more adeptly apply the traditional principles of laparoscopic fundoplication.

Robotic Inguinal Hernia Repair: Technique and Early Experience.

Laparoscopic inguinal hernia repair has been shown to have multiple advantages compared with open repair such as less postoperative pain and earlier resume of daily activities with a comparable recurrence rate. We speculate robotic inguinal hernia repair may yield equivalent benefits, while providing the surgeon added dexterity. One hundred consecutive robotic inguinal hernia repairs with mesh were performed with a mean age of 56 years (25-96). Fifty-six unilateral hernias and 22 bilateral hernias were repaired amongst 62 males and 16 females. Polypropylene mesh was used for reconstruction. All but, two patients were completed robotically. Mean operative time was 52 minutes per hernia repair (45-67). Five patients were admitted overnight based on their advanced age. Regular diet was resumed immediately. Postoperative pain was minimal and regular activity was achieved after an average of four days. One patient recurred after three months in our earlier experience and he was repaired robotically. Mean follow-up time was 12 months. These data, compared with laparoscopic approach, suggest similar recurrence rates and postoperative pain. We believe comparative studies with laparoscopic approach need to be performed to assess the role robotic surgery has in the treatment of inguinal hernia repair.

LigaSure Vessel Sealing System in Altemeier's Procedure for Geriatric Patients.

The aim of this study is to describe the feasibility, safety, and efficiency of LigaSure™ Vessel Sealing System (LSVSS) in Altemeier's procedure for full-thickness rectal prolapse in a geriatric group of octogenarians and older. To the best of our knowledge, this is the first time a study on this procedure looks specifically at a very old patient group and LigaSure. A review of the literature was conducted on Pubmed Database. From April 2008 to October 2013, seven female patients (median age, 89 years) underwent Altemeier's procedure for prolapse using the LSVSS. Preoperative, intraoperative, and postoperative data were collected and analyzed for all patients. Five out of seven patients were ASA class III and had previous history of pelvic surgery. All had preexisting medical conditions other than the full-thickness rectal prolapse. Stapled anastomoses were performed in 6/7 cases with a circular stapling device. The median surgical time was 74 min. and intraoperative blood loss was minimal for all 7 patients. The median length of the resected specimen was 9 cm. There was no surgery-related mortality or recurrence. All patients had at least a 2-year follow-up. The use of the LSVSS in Altemeier's procedure is feasible, safe, and time-saving.

Mesh pouch pexy in the management of J-pouch prolapse.

J-pouch prolapse is a rare complication after IPAA. To date, limited data exist regarding management of this condition, with most reported cases involving suture pouch pexy. We present our experience and technique with 3 patients who were treated with transabdominal mesh pexy repair.

Normal alcohol metabolism after gastric banding and sleeve gastrectomy: a case-cross-over trial.

BACKGROUND: Severe obesity remains the leading public health concern of the industrialized world, with bariatric surgery as the only current effective enduring treatment. In addition to gastric bypass, gastric banding and sleeve gastrectomy have emerged as viable treatment options for the severely obese. Occasionally, poor postoperative psychological adjustment has been reported. It has been previously demonstrated that breath alcohol content (BAC) levels and time to sober were increased in postoperative gastric bypass patients. The aim of this study was to examine whether alcohol metabolism in patients undergoing restrictive-type bariatric procedures is also altered. STUDY DESIGN: Nine patients undergoing laparoscopic adjustable gastric banding (LAGB) and 7 patients undergoing laparoscopic sleeve gastrectomy (LSG) were recruited. Preoperatively, 3-month and 6-month BAC and time to sober were measured after administration of 5 ounces of red wine. In addition, participants were asked to complete a questionnaire of drinking habits. RESULT: The 16 total participants achieved a mean 44.7% 6-month excess weight loss. There were no significant changes in peak BAC or time to sober from preoperative levels (0.033%, 67.8 min, respectively) to 3 months (0.032%, 77.1 min, respectively, p = 0.421) or 6 months (0.035%, 81.2 min, respectively, p = 0.198). CONCLUSION: Patients undergoing LAGB and LSG do not share the same altered alcohol metabolism as seen in gastric bypass patients. However, all bariatric surgery patients should be counseled regarding alcohol use.

B-type natriuretic peptide increases after gastric bypass surgery and correlates with weight loss.

BACKGROUND: Coronary artery disease is the primary cause of death in the United States, with obesity as a leading preventable risk factor. Previous studies have established the beneficial effect of Roux-en-Y gastric bypass on both weight and cardiac risk factors. Further assessment of cardiac function may be accomplished using B-type natriuretic peptide (BNP), which has demonstrated clinical utility in diagnosing congestive heart failure. This study aimed to assess changes in BNP after intentional weight loss through gastric bypass surgery. METHODS: Plasma volume, weight, and BNP were measured preoperatively and at 3, 6, and 12 months postoperatively for 101 consecutive patients undergoing laparoscopic gastric bypass surgery by a single surgeon in an academic medical setting. Outcomes were compared by matched t-test. Multivariable linear regression and Pearson's correlation were used to examine predictors of pro-B-type natriuretic peptide (NT-proBNP) concentration. RESULTS: The concentration of BNP increased significantly from a mean preoperative level of 50.5 ng/l to postoperative levels of 73.9 ng/l at 3 months (P=0.013), 74.3 ng/l at 6 months (P<0.001), and 156.3 ng/l at 12 months (P<0.001). In addition, excess weight loss was the only statistically significant predictor of increased BNP concentration (odds ratio, 1.483; P<0.05). CONCLUSION: Gastric bypass leads to significant excess weight loss and surprisingly increased BNP concentrations. Correlation of BNP increase with weight loss suggests an additional novel mechanism for surgically induced weight loss.