Staple Line Reinforcement During Laparoscopic Sleeve Gastrectomy: Absorbable Monofilament, Barbed Suture, Fibrin Glue, or Nothing? Results of a Prospective Randomized Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is associated with serious complications, such as staple line (SL) leaks and bleeding. In order to prevent the occurrence of these complications, surgeons have advocated the need to strengthen the staple line. The aim of this randomized controlled study was to compare the efficacy of three different ways of strengthening of the SL in LSG in preventing surgical post-operative complications. METHODS: Between April 2012 and December 2014, 600 patients (pts) scheduled for LSG were prospectively randomized into groups without SL reinforcement (group A) or with SL reinforcement including fibrin glue coverage (group B), or oversewn SL with imbricating absorbable (Monocryl™; group C) or barbed (V lock®) running suture (group D). Primary endpoints were post-operative leaks, bleeding, and stenosis, while secondary outcomes consisted of the time to perform the staple line reinforcement (SLR) and total operative time. RESULTS: Mean SLR operative time was lower for group B (3.4 ± 1.3 min) compared with that for groups C (26.8 ± 8.5 min) and D (21.1 ± 8.4 min) (p < 0.0001). Mean total operative time was 100.7 ± 16.4 min (group A), 104.4 ± 22.1 min (group B), 126.2 ± 18.9 min (group C), and 124.6 ± 22.8 (group D) (p < 0.0001). Post-operative leaks, bleeding, and stenosis were recorded in 14 pts (2.3 %), 5 pts (0.8 %), and 7 pts (1.1 %), respectively, without statistical difference between the groups. CONCLUSION: Our study suggests that SLR during LSG, with an imbricating or non-imbricating running suture or with fibrin glue, is an unrewarding surgical act with the sole effect of prolonging the operative time.

Gastrobronchial fistula: A rare complication of sleeve gastrectomy.

Gastrobronchial fistula is a rare complication of sleeve gastrectomy. In this case presentation, the diagnosis of gastrobronchial fistula was made by endoscopic contrast injection into the fistulous tract.

High-grade poorly differentiated retroperitoneal sarcoma. Report of a case and review of the literature.

Retroperitoneal sarcomas (RPS) are uncommon tumors associated with a poor prognosis. This is particularly true in case of high-grade sarcomas of specific histological subtypes, as demonstrated by the largest surveys of the last decade. Up to the present day, unfortunately there are no powerful tools available except for surgery. On the other hand, the resection rate of RPS is significantly increased over the last decades allowing to deliver the best treatment available. This paper reports on the case of a young patient who was incidentally diagnosed with a retroperitoneal mass. The patient underwent surgery in our department and the histological report showed a spindle cell sarcoma of high grade of malignancy with an incomplete muscular phenotype. The patient was discharged on the seventh postoperative day and he is still free of local and distant recurrence.

Is fixation during gastric banding necessary? A randomised clinical study.

Anterior fixation via a gastro-gastric suture in laparoscopic adjustable gastric banding (LAGB) is commonly performed to prevent band-related complications. However, the necessity of this common technique has never been proven. Not fixing the band would be time sparing and would reduce adhesions on the stomach and probably make revisional surgery easier. This study was conceived as a 3-year randomised clinical trial to test the safety and efficacy of the non-fixation technique. From December 2006 to December 2007, 81 patients undergoing LAGB were randomly distributed into two groups: group A, with gastro-gastric sutures (n = 41) and group B, without gastro-gastric fixation (n = 40). The two groups were equivalent regarding initial body mass index (BMI), age and sex ratio. The main outcome was postoperative complications and secondary outcomes were operative time and weight loss expressed by the percentage of excess BMI loss (%EBMIL). All patients were prospectively followed up for 2 years. The mean preoperative BMI was 42.5 kg/m² (35-56). All patients were available for follow-up at 2 years. The mean overall preoperative time was 82 ± 20 min for the fixation group and 72 ± 20 min for the non-fixation group (p = 0.13). The mean hospital stay was 4.1 ± 1.5 days (no significant difference between the two groups). The 2-year %EBMIL was 35.9 for group A and 39.4 for group B (p = NS). The mean BMI at 2 years was 36.3 and 36.1, respectively, with no statistical difference. We observed three early band slippages in the non-fixation group and none in the fixation group. Three bands were removed during the second year of follow-up for causes other than band slippage (no significant difference between the two groups). This study was interrupted before a statistical significance could be reached, under the general agreement of all participating surgeons, because of the three unexpected early band slippages. For the patients who did not suffer from this complication, we did not observe any differences between the two groups in terms of late complications and weight loss. The operative time was shorter in the non-fixation group. This randomised clinical trial suggests that care should be taken when not fixating the LAGB because of the risk of early postoperative band slippage. We suggest that fixing the LAGB by gastro-gastric sutures should remain common practice.

Papillary carcinoma of the thyroglossal duct cyst: report of two cases.

AIM: To present two cases of papillary carcinoma of the thyroglossal duct cyst (TDC) and to report their management. PATIENTS AND METHODS: Two patients, a 47-year-old woman and a 60-year-old man, were operated in 2006 and 2008 in the Department of Digestive and Metabolic Surgery of the "Jean Verdier" Hospital. RESULTS: The diagnosis of papillary carcinoma was established after the pathological examination carried out on the thyroglossal duct cyst, after its complete surgical excision. A total thyroidectomy followed by a treatment by radioactive iodine and a substitutive hormonal therapy were carried out in the second time for one of the two patients. For the other patient, a total thyroidectomy followed by a substitute hormonal therapy, were achieved. The evolution was favorable, with a follow-up of four years for the first patient and two years for the second one. DISCUSSION: Total thyroidectomy after the complete excision of the cyst is currently the recommended treatment for the papillary carcinoma of the TDC. It was shown that a latent thyroid cancer could develop even 15 years after the initial excision of the thyroglossal cyst. The treatment is curative in 95% of the cases. CONCLUSIONS: Current treatment of papillary carcinoma of the thyroglossal duct cyst is well codified, allowing an excellent prognostic.

A "self adhering" prosthesis for hernia repair: experimental study.

BACKGROUND: Prosthetic reinforcement is now routine in the management of inguinal and incisional hernia, and it significantly reduces the risk of recurrence. After surgery, chronic pain is often attributed to the characteristics of the mesh and to the method of fixation in the wound, with a potential risk of nerve or muscle injuries. AIM: To evaluate the properties of a new "self adhering" prosthesis in an experimental animal study. MATERIALS AND METHODS: The self adhering prosthesis, a lightweight (40 mg/m(2)) polypropylene mesh coated with a synthetic glue on one side, was implanted laparoscopically in pigs. Removal of the prosthesis was performed at one day, one week and one month post operatively. A macroscopic and microscopic evaluation was performed. The results, using a quantitative score, were compared to those of a control group using the same polypropylene mesh without glue, but fixed by staples. RESULTS: The operative time was significantly lower in the self adhering group: 23 min (15-32) versus 31 min (21-40) (P = 0.01). The average time interval from the introduction of the mesh into the preperitoneal space until the appearance of the first tough adhesion was 3 min (2-4). In the control group, the mesh handling time was 8.3 min (5-14) (P = 0.01). At the time of implantation, the score was at a maximum value in all cases for the self adhering prostheses, especially concerning handling and adhesiveness. Upon removal, this score was noted to be good or very good in 90-100% of the cases. There was a good integration in the muscle confirmed histologically, and there was no shrinkage, no mobilisation and no migration. At one month, the thickness of the fibrosis at the limits of the meshes was significantly higher for the self adhering prostheses (P = 0.02). CONCLUSION: In this experimental study, the self adhering prosthesis demonstrated its adhesive properties and its ability to be well tolerated, with a good macroscopic and microscopic integration into the abdominal wound. This should allow us to perform a clinical prospective study in an open and laparoscopic approach with the double objective of reducing post operative pain induced by mechanical fixation and decreasing the cost of these procedures by reducing the operative time and by eliminating staple fixation.

Tracheal intubation of morbidly obese patients: a randomized trial comparing performance of Macintosh and Airtraq laryngoscopes.

BACKGROUND: The Airtraq laryngoscope is designed to allow visualization of the glottis without alignment of the oral, pharyngeal, and laryngeal axes. We hypothesized that this new airway device would facilitate tracheal intubation of morbidly obese patients. We compared tracheal intubation performance of standard Macintosh laryngoscope with the Airtraq laryngoscope in morbidly obese patients. METHODS: One hundred and six consecutive ASA I-III morbidly obese patients undergoing surgery were randomized to intubation with the Macintosh laryngoscope or the Airtraq laryngoscope. Induction of anaesthesia was standardized. If tracheal intubation failed within 120 s with the Macintosh or Airtraq , laryngoscopes were switched. Success rate, SpO2, duration of tracheal intubation, and quality of airway management were evaluated and compared between the groups. RESULTS: Preoperative characteristics of the patients were similar in both groups. In the Airtraq group, tracheal intubation was successfully carried out in all patients within 120 s. In the Macintosh laryngoscope group, six patients required intubation with the Airtraq laryngoscope. The mean (SD) time taken for tracheal intubation was 24 (16) and 56 (23) s, respectively, with the Airtraq and Macintosh laryngoscopes, (P<0.001). SpO2 was better maintained in the Airtraq group than in the Macintosh laryngoscope group with one and nine patients, respectively, demonstrating drops of SpO2 to 92% or less (P<0.05). CONCLUSIONS: In this study, the Airtraq laryngoscope shortened the duration of tracheal intubation and prevented reductions in arterial oxygen saturation in morbidly obese patients.

A comparison of two techniques for inserting the Airtraq laryngoscope in morbidly obese patients.

We postulated that video-controlled tracheal intubation with the Airtraq laryngoscope using the reverse manoeuvre instead of the standard technique of insertion could facilitate the airway management of morbidly obese patients. For the reverse manoeuvre the laryngoscope is inserted 180 degrees opposite to that recommended, and once in place rotated into the conventional pharyngeal position. Eighty (40 lean and 40 morbidly obese) ASA I-III adult patients were randomly allocated to four equal groups to compare the standard technique to the reverse manoeuvre for inserting the Airtraq laryngoscope. Video-controlled and clinical tracheal intubation characteristics were recorded. The reverse manoeuvre did not influence tracheal intubation characteristics in the group of lean patients. In the group of morbidly obese patients, the standard technique of insertion was not satisfactory in 20% of cases and the reverse manoeuvre facilitated, speeded and secured tracheal intubation.

[Comparison of quality of life in morbidly obese patients and healthy volunteers. A prospective study using the GIQLI questionnaire]. / Qualité de vie des patients obèses relevant d'un traitement chirurgical comparée à celle d'une population témoin. Etude prospective utilisant le questionnaire GIQLI.

BACKGROUND: Morbid obesity decreases the quality of life. The aims of surgical and medical treatment are weight loss, reduction of co-morbidity, and improved quality of life. AIMS: To compare the quality of life between obese patients (BMI: 40 or>35+comorbidity) and healthy volunteers using the GIQLI (Gastrointestinal Quality of Life) questionnaire. PATIENTS: Between January 2001 and December 2002, 127 morbidly obese patients (109 female, 18 male) with a mean age of 40.1 years were surgically treated with laparoscopic gastric banding. Quality of life, as measured by the GIQLI questionnaire, was systematically evaluated pre-operatively. During the same period, a control group of 125 healthy volunteers of comparable age, gender, and prior surgical history were evaluated using the same questionnaire. RESULT: The two groups, while comparable in age and gender, were significantly different in terms of weight (123 vs. 66 kg), BMI (44.3 vs. 22.2) (p<0.001), co-morbidity factors (p=0.001), and professional activity (p=0.02). The mean global GICLI score was 122 for healthy individuals and 95 for morbidly obese patients. (p=0.001), and the differences were most marked in the super obese. These differences particularly involved social dysfunction, physical status, and emotional symptoms but were not significantly different for gastrointestinal symptoms. CONCLUSION: The quality of life in morbidly obese and super obese patients is significantly diminished from that of a control population. There was good correlation between the degree of obesity (BMI) and the alteration of the GIQLI global and subscales scores. Quality of life should be systematically evaluated before and after both medical and surgical therapy.

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh.

BACKGROUND: Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon. AIMS: The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair. MATERIALS AND METHODS: Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m(2) and a mean hernia surface of 182 cm(2). Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs. RESULTS: Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8-88). CONCLUSION: Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.

[Value of the informed consent in digestive surgery? Prospective study 259 cases]. / Le consentement éclairé: quelle est sa valeur en chirurgie digestive? Etude prospective sur 259 cas.

SITUATION: In 1997 the Supreme Court of Justice decreed that "the doctor is responsible for giving his patient certain information and is obliged to prove that the information has been given". French surgical societies recommend using a form of informed consent signed by the patient applicable to all practices. AIMS: To evaluate a step taken systematically since 1999 in our department. PATIENTS AND METHODS: A prospective study was put into place for 259 patients candidate for elective surgery. All patients signed and returned the "informed consent" before surgery. The day of leaving the hospital, they answered a post-operative questionnaire to evaluate what they remembered of the "informed consent form" and the quality of information. RESULTS: Ninety three per cent of them remembered it. Eight per cent signed it without reading it. Eighty two per cent of the patients think that this document is useful for their medical records. Among the patients who did not read the informed consent form: 38% wished it gave more information, whereas only 16% of those who had read it, considered the given information inadequate. This difference is statistically (p=0.03) significant. CONCLUSION: The informed consent form gives a lot of information to the patients, but the surgeon is still obliged to do likewise. Patients who did not read the consent were less satisfied with the given information than those who had read it. The positive reaction of the patients in favour of the form makes it evident that the existence of the form reassures them.

Inguinal hernia repair: the choice of prosthesis outweighs that of technique.

BACKGROUND: The use of prostheses in inguinal hernia repair reduces the incidence of recurrence. Quality of life and pain after hernia repair are largely correlated with the technique and type of prosthesis. AIMS OF STUDY: To evaluate the 2-year incidence of recurrence and pain for two types of hernioplasty, Lichtenstein repair and laparoscopy (totally extraperitoneal approach or TEP), and two types of mesh, polypropylene mesh and beta-D: -glucan-coated mesh (Glucamesh). PATIENTS: A total of 410 consecutive patients of mean age 54 years (18-84) underwent repair of inguinal hernias, 96 (23%) of which were bilateral and 56 (13%) recurrent. A total of 273 (66.5%) patients underwent Lichtenstein repair: 215 (78.7%) with polypropylene mesh, 58 (21.3%) with Glucamesh; 137 patients underwent laparoscopy: 80 (58.4%) with polypropylene mesh, 57 (41.6%) with Glucamesh. In each group, the populations were comparable and the techniques utilized were identical. METHODS: The patients were followed-up for at least 2 years, after which the incidence of recurrence was determined, and chronic pain was assessed by means of a visual analog scale and a validated questionnaire. RESULTS: A total of 349 patients (85.1%) were reassessed, 117 of whom had undergone laparoscopy and 232 Lichtenstein repair. There were ten recurrences (2.8%), and incidence which was independent of the technique (laparoscopy 1.7% vs. Lichtenstein 3.4%) (ns) and the type of prosthesis (Glucamesh 1.9% vs. polypropylene 2.4%) (ns). Chronic pain was noted in 69 patients (19.7%) and severe pain in 11 (3.1%). The incidence of chronic pain was the same for the two techniques: laparoscopy 17.9% vs. Lichtenstein 20.7% (ns). The same was true for severe pain: laparoscopy 3.4% vs Lichtenstein 3% (ns). The incidence of chronic pain was closely correlated with the type of prosthesis utilized: Glucamesh 4.8% vs. polypropylene 26.5% (P = 0.02), irrespective of the technique. The same was true for severe pain (0.9 vs. 4%) (P = 0.02). CONCLUSION: The utilization of beta-D: -glucan-coated mesh did not involve more recurrence and was accompanied by a significant decrease in chronic pain at 2 years, independent of the technique. After 2 years, the results of hernia repair show that the choice of prosthesis was more determinant than choice of technique.

Impact of peritoneal tears on the outcome and late results (4 years) of endoscopic totally extra-peritoneal inguinal hernioplasty.

BACKGROUND: The reported rate of intra-operative peritoneal laceration during endoscopic extra-peritoneal hernioplasty (TEP) ranges from 10 to 64%. AIMS: To evaluate in a prospective study the predictive factors of peritoneal tears, their consequences in terms of outcome and late results. PATIENTS AND METHODS: Between July 1994 and December 2000, we performed 467 endoscopic extra-peritoneal hernia repairs (TEP). In 14.8% of the cases, single or multiples recurrences after conventional open herniotomy were treated. One hundred and forty-nine patients (38%) had had previous surgery (appendectomy); 277 procedures (70.8%) were performed by experienced surgeons and 114 (29.2%) by surgical trainees. We used a diathermic hook in 26.3% of the procedures. The mean follow-up period was 68 months (48-100). RESULTS: Peritoneal tears occurred in 43 patients (10.9%). Six of them (13%) required operative closure, and six a conversion (four Lichtenstein, one Shouldice, and one TAPP). In 37 cases (86%), the tears were not closed. Peritoneal tears were significantly correlated with surgical experience, Nyhus classification, scar adhesion from previous surgery and the use of sharp instruments. Peritoneal tears interfere significantly (P=0.001) with the operating time (82 vs. 63 min) and conversion rate (13.9 vs. 1.7%). It does not affect the outcome and late results in terms of recurrences, pain, or small bowel obstruction. CONCLUSION: Our data suggest that peritoneal tears in the vast majority of cases may be safely managed without peritoneal closure. In case of peritoneal laceration, the operative time was significantly longer, and the conversion rate was increased. These situations do not affect the outcome and late complications compared with the procedures without peritoneal tears.

[Surgical training and inguinal hernia repair]. / L'enseignement de la chirurgie influence-t-il les résultats des cures de hernies de l'aine?

AIMS: To evaluate influence of surgical experience on inguinal hernia repair. PATIENTS: From 1997 to 2003, 380 patients (mean age 55 years old) with primary unilateral inguinal hernia were treated by Lichtenstein technique. METHODS: In this retrospective study, surgeons were classified in three groups: group 1: hernia repair was performed by an experimented surgeon (consultant or senior registrar) and a young surgical trainee (resident) (161 cases); group 2: surgery was performed by a junior surgeon (resident) under the control of an experimented surgeon (135 cases) and in the group 3 (84 cases), Lichtenstein technique was performed by two residents, alone, supervised by an experimented surgeon, in the operative room. Evaluation criterion were operative time, hospital stay, morbidity, time to return to normal and professional activities, recurrences and chronic pain with a follow up of, at least, 2 years. RESULTS: The three groups were comparable in term of socio economic data, hernia and follow up. The only significant (P=0.01) difference concern operative time which increased from 20% for group 2 and 3 (residents) compared to the group 1. There was also no difference between junior and senior resident. CONCLUSION: Lichtenstein hernia repair should be performed by young surgeon in training alone in condition of precise teaching organization and experimented surgeon supervision. For patient, in this condition, there is no trouble in term of surgical results.

[Are there predictive items of successful surgery in morbid obesity treated by adjustable gastric banding: a prospective study]. / Existe-t-il des facteurs prédictifs de succès dans le traitement de l'obésité morbide par anneau périgastrique modulable? Etude prospective.

BACKGROUND: Surgical treatment of morbid obesity by perigastric adjustable banding give at mid term follow up, contrasted results which associate success, failure and intermediate situations. AIMS: The objective of this work was to prospectively validate predicting items that would predict success in the surgical treatment of morbid obesity by adjustable gastric banding. MATERIAL AND METHODS: Eighty patients with morbid obesity have been treated with adjustable gastric banding. Seventy-one women, and nine men with a mean age of 37.8 years (20-59) with a mean follow up of 17 months (12-52). They have been classified in three groups: success, failure, and intermediate results. Uni- and multivariate analysis was performed on six criteria: age, sex, professional activity, metabolic disorders, length of obesity and body mass index (BMI). RESULTS: Concerning age, sex, professional activity, metabolic disorders, and length of obesity, there was no difference between the three groups. However, a BMI more than 50 kg/m(2) has a strong predictive value. Patients called "super obese", BMI >50, has a high rate of failure (64%) even the weight loss is often important in absolute value, but the BMI at the follow up remain high and more than 40. In this situation: gastric banding does not seem a good treatment because it does not protect these patients against the lethal risk of their comorbidities. CONCLUSION: In this study, there is not a specific candidate "profile" to a successful treatment of morbid obesity by adjustable gastric banding. Meanwhile the initial BMI appear to be a predictive factor of success or failure. In the case of patients with high BMI >50 (super obese) gastric banding did not seen to be a good treatment and another technical approach (gastric bypass) must be discussed.

[Use of prosthesis in inguinal hernia repair]. / Place des prothèses dans les cures de hernies inguinales.

AIMS: To evaluate the use of mesh in the evolution of hernia repair technique during a period of twelve years. PATIENTS--METHODS: From january 1991, to december 2002, 1306 patients 1136 men, 190 women, with inguinal hernia, with a mean age of 47.4 years old (15-98) have had an elective surgical repair. 1097 (83.9 per cent) were unilateral. 209 (16.1 per cent) were recurrent hernia. Clinical data, operative technique have been prospectively evaluated: Four techniques were used: Shouldice procedure, Stoppa operation and laparoscopic repair (TEP) in 1992 and Lichtenstein technique since 1993. RESULTS: During the study, meshes were used in 65.7 per cent of the patients respectively 33.3 per cent for Lichtenstein, 26.9 per cent for laparoscopic repair and only 5.3 per cent for Stoppa open procedure. During the study, prosthesis rate increased from 9.1 to 85.4 per cent for primary hernia and from 10 to 100 per cent for recurrent hernias. To day, Stoppa procedure is not yet performed. Herniorraphies decrease from 91.9 to 14.6 per cent. CONCLUSIONS: "Tension free" techniques represent 85.4 per cent of all procedures at the end of the study, specially Lichtenstein operation (65 per cent) which seems to become the new "Gold Standart" in inguinal hernia repair.

[Colorectal cancer: 74 patients treated by laparoscopic resection with a mean follow-up of 5 years]. / Cancer colorectal: 74 patients traités par laparoscopie avec un recul moyen de 5 ans.

OBJECTIVE: The aims of this study were to analyse the results and long term outcome in a prospective non randomised trial of 74 patients treated by laparoscopic colo-rectal resection for cancer, and to determine wether survival and recurrence are or are not compromised by an initial laparoscopic approach. PATIENTS AND METHODS: Seventy-four patients with colo-rectal carcinoma were included in a prospective trial and treated by laparoscopic resection. All patients were reviewed at 1, 3, and 6 months interval. A median of 5 years follow up was available. Forty-eight patients (65%) had more than 3 years of follow up. RESULTS: Six conversions (8.1%) were necessary: 2 for tumor invasion of adjacent organs, 2 for limited margin resection in lower rectal tumors, 1 for small bowel injury and 1 for obesity. After surgery, passing flatus occurred at 34.3 +/- 16.7 h and oral intake could be reinstaured at 42.6 +/- 22 h. Mean postoperative stay was 8.2 +/- 3.4 days. No death occurred. The overall morbidity was about 13.5%. The rate of late complications was 5.4%. Two port site metastasis (2.6%) were seen in locally advanced carcinoma. Recurrence rate at 5 years was 0% for Dukes A, 20% for Dukes B, 39.2% for Dukes C. Survival rate at 5 years was 100% for Dukes A, 80% for Dukes B, and 60.7% for Dukes C. These results are similar to those of conventional open surgery. CONCLUSION: Laparoscopic colorectal resection for cancer can be performed safely, with a low morbidity and rare late complications. Long term follow up (5 years) assessment shows similar outcome compared with conventional surgery.