Fundus first as the standard technique for laparoscopic cholecystectomy.

In previous studies the fundus first technique (FF) has been a cost-effective way to simplify the laparoscopic cholecystectomy (LC) and facilitate patient rehabilitation. The feasibility and safety profile when introducing FF as the standard technique were aimed in this study. Between 2004-2014, 29 surgeons performed 1425 LC with FF and 320 with a conventional technique. During the first year 56% were with FF and 98% during the last four years. More females, ultrasonic shears, urgent operations, daycare operations and a shorter operation time were found with FF. 63 (3.6%) complications occurred: 10 (0.6%) bleedings, 33 (1.9%) infections and 12 (0.7%) bile leakages. Leakage from cystic duct occurred in 4/112 (3.6%) when closed with ultrasonic shears and in 4/1633 (0.2%) with clips (p 0.008). A common bile duct lesion occurred in 1/1425 (0.07%) with FF and in 3/320 (0.9%) with the conventional approach (p 0.003). In a multivariate regression model, the conventional technique was a risk factor for bile duct injury with an odds ratio of 20.8 (95% CI 1.6-259.2). In conclusion FF was effectively established as the standard procedure and associated with lower rates of bile duct injuries. Clipless closure of the cystic duct increased the rate of leakage.

Trocar Site Hernia After Gastric Bypass.

BACKGROUND: The 5.2% rate of trocar site incisional hernia (TSIH) reported appears low in view of the proportion of TSIH repairs being performed. Detecting TSIH by clinical examination may be difficult in the obese. The correlation between clinical examination and a novel radiological examination for the detection of TSIH in obese patients was studied. MATERIALS AND METHODS: Twenty-six patients subjected to laparoscopic gastric bypass in 2010 underwent clinical and radiological examination by three independent assessors for each method, after a mean follow-up time of 33 months. The computed tomography was in the prone position upon a ring. RESULTS: At clinical examination, a TSIH was regarded to be present in six out of 26 patients and at CT scan in four. The Fleiss' Kappa for multiple raters was 0.40 (p = 0.184) with clinical examination and 1 (p <0.05) with CT scan. With CT scan, herniation was diagnosed in three of 26 umbilical trocar sites that had been closed at the index operation, and in one of the 130 other trocar sites that had not been closed. CONCLUSIONS: Clinical examination is not reliable when detecting TSIH in the obese. A CT scan in the prone position was extremely reliable and seems to have the potential of becoming the standard method for detecting TSIH in obese patients.

Detecting Incisional Hernia at Clinical and Radiological Examination.

PURPOSE: In clinical studies, incisional hernia is usually diagnosed by clinical examination. No other modality has been proven an aid in the diagnosis. The aim was to investigate the correlation between findings at clinical examination and at computed tomography when detecting incisional hernia after midline incisions. METHODS: Patients underwent clinical examination by three surgeons. Computed tomography was performed in both the supine position and in the prone position and was examined by three radiologists. The correlation between investigators and methods were estimated by calculating the Fleiss Kappa values. RESULTS: Twenty-four patients were assessed. For the clinical examination, the Kappa was 0.81. For computed tomography with the patient in the supine position, the Kappa was 0.94 and in the prone position it was 0.89. The Kappa for clinical examination and computed tomography combined was 0.80. CONCLUSIONS: At clinical examination, incisional hernia can be defined as any detectable defect in the abdominal wall with intra-abdominal contents protruding beyond the aponeurosis. The same definition can be used at computed tomography with the addition that any visible hernia sac is also regarded an incisional hernia. With this definition, there is very good agreement between investigators at clinical investigation and at computed tomography in the prone or in the supine position. The highest agreement among investigators is achieved with computed tomography in the supine position. In clinical studies, clinical examination seems adequate for diagnosing herniation but in overweight patients a CT-scan may be a further aid.

Parastomal hernia after ileal conduit with a prophylactic mesh: a 10 year consecutive case series.

OBJECTIVE: There are no data on the frequency of parastomal hernia (PSH) after ileal conduit with a prophylactic mesh. The primary objective of this study was to determine the prevalence of PSH. Secondary objectives were to elaborate whether age, gender, body mass index (BMI), previous laparotomy or diabetes influenced the outcome; and to find any mesh-related complications. MATERIALS AND METHODS: In a single centre during 2003-2012, a large-pore, lightweight mesh was placed in a sublay position in 114 consecutive patients with ileal conduits. Preoperative and postoperative patient data were retrospectively collected and cross-sectional follow-up was conducted. During the predefined clinical examination a PSH was defined as any protrusion in the vicinity of the ostomy with the patient straining in both an erect and a supine position. RESULTS: Fifty-eight patients (24 women and 34 men, mean age 69 years) had follow-up examinations after a mean of 35 months (median 32 months). Bladder cancer was the most common cause for surgery. Eight patients (14%) had a PSH. Age, gender, BMI, previous laparotomy and diabetes did not affect the outcome. No mesh-related complications occurred among the 114 patients with a prophylactic mesh. CONCLUSIONS: The prevalence of PSH after ileal conduit with a prophylactic mesh corresponded to that of colostomies with a prophylactic mesh. A prophylactic mesh did not seem to be associated with complications. The degree to which a prophylactic mesh may reduce the rate of PSH after an ileal conduit should be established in randomized trials.

Closure of midline laparotomies by means of small stitches: practical aspects of a new technique.

Randomized studies support the closure of midline incisions with a suture length to wound length ratio (SL:WL) of more than 4, accomplished with small tissue bites and short stitch intervals to decrease the risk of incisional hernia and wound infection. We investigated practical aspects of this technique possibly hampering the introduction of this technique. Patient data, operative variables and SL:WL ratio were collected at two hospitals: Sundsvall Hospital (SH) and Erasmus University Medical Center (EMC). A structured implementation of the technique had been performed at SH but not at EMC. Personnel were interviewed by questionnaire. At each hospital, 18 closures were analyzed. Closure time was significantly longer (p = 0.023) at SH (median 18 minutes, range: 9-59) than at EMC (median 13 minutes, range: 5-23). An SL:WL ratio of more than 4 was achieved in 8 of 18 cases at EMC and in all 18 cases at SH. We conclude that calculation of an SL:WL ratio is easily performed. Suturing with the small bite-short stitch interval technique of SH required 5 minutes extra, outweighing the morbidity of incisional hernia. Without a structured implementation to suture with an SL:WL ratio of more than 4, a lower ratio is often achieved.

Prevention of incisional hernias: how to close a midline incision.

The development of wound complications is closely related to the surgical technique at wound closure. The risk of the suture technique affecting the development of wound dehiscence and incisional hernia can be monitored through the suture length to wound length ratio. Midline incisions should be closed in one layer by a continuous-suture technique using a monofilament suture material tied with self-locking knots. Excessive tension should not be placed on the suture. Closure must always be with a suture length to wound length ratio higher than 4.

Symptoms after obstetric sphincter injuries have little effect on quality of life.

OBJECTIVE: To compare the prevalence of anal incontinence and dyspareunia in women with or without obstetric sphincter injury after standardizing the suture technique. DESIGN: Retrospective case-control study. SETTING: Regional hospital, Sweden. POPULATION: 305 women with an obstetric sphincter injury and 297 women with spontaneous vaginal delivery. METHODS: In order to standardize and improve the repairing skills of sphincter injuries, collaboration between obstetricians and colorectal surgeons was begun in 2000. Inner and external sphincters were repaired in two layers with continuous monofilament polidioxane sutures. The participating women received a questionnaire with validated questions on anal incontinence, dyspareunia and quality of life. The follow-up time was 15 months to 8 years. MAIN OUTCOME MEASURES: Anal incontinence, dyspareunia and quality of life. RESULTS: Of the sphincter group, 72% returned the questionnaire, as did 67% in the control group. Significantly more women in the sphincter group suffered from incontinence of flatus and loose stool compared to controls (p < 0.05). There was no significant difference of incontinence of solid stool, soiling, or fecal urgency between the groups. The quality of life questions showed no significant difference between the groups. In the sphincter group, there was significantly more superficial coital pain compared to controls (p= 0.02). Significantly more women with complete sphincter injury reported anal incontinence than women with a partial sphincter injury. CONCLUSION: In spite of increased rate of anal incontinence and dyspareunia after anal sphincter rupture, there was no statistically significant reduction in the women's quality of life.

Closing midline abdominal incisions.

BACKGROUND: The most important wound complications are surgical site infection, wound dehiscence and incisional hernia. Experimental and clinical evidences support that the development of wound complications is closely related to the surgical technique at wound closure. RESULTS: The suture technique monitored through the suture length-to-wound length ratio is of major importance for the development of wound complications. The risk of wound dehiscence is low with a high ratio. The ratio must be higher than 4; otherwise, the risk of developing an incisional hernia is increased four times. With a ratio higher than 4, both the rate of wound infection and incisional hernia are significantly lower if closure is done with small stitches placed 5 to 8 mm from the wound edge than with larger stitches placed more than 10 mm from the wound edge. CONCLUSIONS: Midline incisions should be closed in one layer by a continuous suture technique. A monofilament suture material should be used and be tied with self-locking knots. Excessive tension should not be placed on the suture. Wounds must always be closed with a suture length-to-wound length ratio higher than 4. The only way to ascertain this is to measure, calculate and document the ratio at every wound closure. A high ratio should be accomplished with many small stitches placed 5 to 8 mm from the wound edge at very short intervals.

Experiences with a prophylactic mesh in 93 consecutive ostomies.

BACKGROUND: Parastomal hernia may be present in half of patients after one year. A prophylactic low-weight prosthetic mesh in a sublay position at the index operation reduces the risk of parastomal hernia, without increasing the rate of complications. MATERIAL: Between April 2003 and November 2006 all patients with an ostomy created at an open laparotomy were followed for at least one year. RESULTS: A prophylactic mesh was used in 75 of 93 patients. In 9 a prophylactic mesh could not be placed due to scarring after previous surgery. In 9 a mesh was omitted after surgeon's decision. In 19 patients a mesh was used in severely contaminated wounds. With a mesh 6 of 73 (8%) patients developed a surgical site infection and without a mesh 4 of 15 (27%). With a mesh parastomal hernia was present in 8 of 61 (13%) patients and without a mesh in 8 of 12 (67%). CONCLUSIONS: Creating a stoma in routine open surgery a prophylactic mesh can be placed in most patients. A mesh does not increase the rate of complications and can be used in severely contaminated wounds.

Improved outcome after laparoscopic cholecystectomy with ultrasonic dissection: a randomized multicenter trial.

BACKGROUND: In conventional laparoscopic cholecystectomy, dissection with electrocautery starts at the triangle of Calot. In a randomized single-center trial, the fundus-first method (dome down) using ultrasonic dissection was faster, involved less pain or nausea, and had a shorter postoperative sick leave. This may relate to the fundus-first method or to the ultrasonic dissection. METHODS: In a multicenter trial, 243 elective patients were randomized to conventional laparoscopic cholecystectomy using electrocautery (n = 85) or the fundus-first method using either electrocautery (n = 81) or ultrasonic dissection (n = 77). RESULTS: The fundus-first method had a shorter operating time with ultrasonic dissection (58 min) than with electrocautery (74 min; p = 0.002). The fundus-first method using ultrasonic dissection compared with electrocautery or the conventional method produced less blood loss (12 vs. 53 or 36 ml; p < 0.001) and fewer gallbladder perforations (26% vs. 46% or 49%; p = 0.005). Also, the pain and nausea scores at 4 and 6 h were lower, and the sick leave was shorter (6.1 vs. 9.4 and 9 days, respectively; p < 0.001). CONCLUSION: The fundus-first method using ultrasonic dissection is associated with less blood loss, fewer gallbladder perforations, less pain and nausea, and shorter sick leave than the conventional and fundus-first method using electrocautery. The difference seems related to the use of ultrasonic dissection.

Effect of stitch length on wound complications after closure of midline incisions: a randomized controlled trial.

HYPOTHESIS: In midline incisions closed with a single-layer running suture, the rate of wound complications is lower when a suture length to wound length ratio of at least 4 is accomplished with a short stitch length rather than with a long one. DESIGN: Prospective randomized controlled trial. SETTING: Surgical department. PATIENTS: Patients operated on through a midline incision. INTERVENTION: Wound closure with a short stitch length (ie, placing stitches <10 mm from the wound edge) or a long stitch length. MAIN OUTCOME MEASURES: Wound dehiscence, surgical site infection, and incisional hernia. RESULTS: In all, 737 patients were randomized: 381 were allocated to a long stitch length and 356, to a short stitch length. Wound dehiscence occurred in 1 patient whose wound was closed with a long stitch length. Surgical site infection occurred in 35 of 343 patients (10.2%) in the long stitch group and in 17 of 326 (5.2%) in the short stitch group (P = .02). Incisional hernia was present in 49 of 272 patients (18.0%) in the long stitch group and in 14 of 250 (5.6%) in the short stitch group (P < .001). In multivariate analysis, a long stitch length was an independent risk factor for both surgical site infection and incisional hernia. CONCLUSION: In midline incisions closed with a running suture and having a suture length to wound length ratio of at least 4, current recommendations of placing stitches at least 10 mm from the wound edge should be changed to avoid patient suffering and costly wound complications. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00508053.

Preventing parastomal hernia with a prosthetic mesh: a 5-year follow-up of a randomized study.

BACKGROUND: Parastomal hernia is a major clinical problem. In a randomized, clinical trial, a prosthetic mesh in a sublay position at the index operation reduced the rate of parastomal hernia at 12-month follow-up, without any increase in the rate of complications. This study was designed to evaluate the rate of complications after 5 years. METHODS: Between January 2001 and April 2003, 54 patients who had a permanent ostomy were randomized to a conventional stoma or to a stoma with the addition of a mesh in a sublay position. A large-pore, lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material was used. RESULTS: After 5 years, 21 patients with a conventional stoma were alive and parastomal herniation was recorded in 17 patients, of whom repair had been demanded in 5. In 15 patients operated on with the addition of a mesh herniation, that did not require repair, was present in 2 (P<0.001). No fistulas or strictures developed. No mesh infection was noted and no mesh was removed during the study period. CONCLUSIONS: At stoma formation, a prophylactic low-weight mesh in a sublay position is a safe procedure that reduces the rate of parastomal hernia.

Perforated colonic diverticular disease: the importance of NSAIDs, opioids, corticosteroids, and calcium channel blockers.

PURPOSE: Perforated colonic diverticular disease is associated with a high rate of late sequel and mortality. The risk of colonic perforation may relate to intracolonic pressure and mucosal barrier function in the wall of diverticula. The use of substances affecting these parameters may therefore be associated with the risk of developing a perforation. The aim was to study the effect of nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, corticosteroids, calcium channel blockers, and antimuscarinics on perforation in diverticular disease. MATERIALS AND METHODS: A review of 54 patients with colonic diverticular perforation-forming the case group-and 183 patients with verified colonic diverticular disease-forming the control group-was done. Patient characteristics and drug use was registered. RESULTS: Case group and control group were comparable with respect to sex, age, and comorbidity. In multivariate analysis, the use of NSAIDs (OR 3.56; 95% CI 1.50-8.43), opioids (OR 4.51; 95% CI 1.67-12.18), and corticosteroids (OR 28.28; 95% CI 4.83-165.7) were significantly associated with perforated diverticular disease. Acetylsalicylic acid in cardiologic dose did not affect the rate of perforation (OR 0.66; 95% CI 0.27-1.61). The use of calcium channel blockers was associated with a reduced rate of diverticular complications (OR 0.14; 95% CI 0.02-0.95). CONCLUSIONS: The administration of NSAIDs, opioids, and corticosteroids are associated with an increased risk of colonic diverticular perforation. Acetylsalicylic acid in cardiologic dose does not affect the risk of perforation. Calcium channel blockers are associated with a reduced risk of perforation.

Parastomal hernias.

The incidence of parastomal hernias is probably 30% to 50%. Suture repair of a parastomal hernia or relocation of the stoma results in a high recurrence rate, whereas with mesh repair recurrence rates are lower. Several mesh repair techniques are used in open and laparoscopic surgery, but randomized trials comparing various techniques and with long-term follow-up are needed for better evidence.

Preventing and treating parastomal hernia.

Parastomal hernia represents a major surgical challenge. There is no uniform definition of parastomal hernia, and the true rate is therefore difficult to establish, although it is probably higher than 30%. Many surgical techniques have been tried to prevent and treat parastomal hernia; but despite these efforts, herniation continues to be a problem. The only method that has reduced the rate of parastomal hernia in a randomized trial is the use of a prophylactic prosthetic mesh. A large-pore low-weight mesh with reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the primary operation significantly reduces the rate of parastomal hernia. Recurrence rates after surgical treatment of parastomal hernia are high unless mesh is used. Relocation of the stoma, with prophylactic mesh in a sublay position at the new site and sublay mesh repairing the incisional hernia at the primary site, is the standard method for treating parastomal hernia in our department.

[Choose midline incision for the best access to the abdominal cavity]. / Välj medellinjesnitt för bästa åtkomst till bukhålan.

A midline incision or a wide transverse incision offers good access to the abdominal cavity. A midline incision should probably be preferred. Then no major nerve, muscle or vessel is severed and thereby subsequent neural or abdominal wall dysfunction may be avoided. Both incisions seem to be associated with similar pain, although a subcostal incision may be advantageous for gallbladder surgery. Respiratory function may be better with transverse incisions but there is no randomised study comparing incisions when a postoperative epidural is used. Wound dehiscence rates have not been proven to differ and the rate of incisional hernia is similar with both types of incision.

Preventing parastomal hernia with a prosthetic mesh.

HYPOTHESIS: Parastomal hernia is a common complication following colostomy. The lowest recurrence rate has been produced when repair is with a prosthetic mesh. This study evaluated the effect on stoma complications of using a mesh during the primary operation. DESIGN: Randomized clinical study. METHODS: Patients undergoing permanent colostomy were randomized to have either a conventional stoma or the addition of a mesh placed in a sublay position. The mesh used was a large-pore lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material. RESULTS: Twenty-seven patients had a conventional stoma, and in 27 patients the mesh was used. No infection, fistula formation, or pain occurred (observation time, 12-38 months). At the 12-month follow-up, parastomal hernia was present in 13 of 26 patients without a mesh and in 1 of 21 patients in whom the mesh was used. CONCLUSIONS: A lightweight mesh with a reduced polypropylene content and a high proportion of absorbable material placed in a sublay position at the stoma site is not associated with complications and significantly reduces the rate of parastomal hernia.

[Closure of midline incisions. A lot of small, same-size stitches in the aponeurosis improve wound healing]. / Förslutning av medellinjesnitt. Många små, likstora suturtag i aponeurosen främjar sårläkning.

The most important risk factor for the development of wound dehiscence and incisional hernia is the suture technique that is totally in the hands of the surgeon. A continuous suture line in one layer with a monofilament material should close midline incisions. Self-locking knots should be used for the anchor knots. The length of the suture used must be at least four times the length of the wound. The only way to ascertain a suture length to wound length ratio of at least four is to measure and document the ratio at every laparotomy. An adequate ratio should be achieved by placing many stitches into the aponeurosis. High tension on the suture should be avoided.