Morbidity associated with laparoscopic repair of suprapubic hernias.

BACKGROUND: Laparoscopic suprapubic hernia repair (LSHR) is frequently a technically difficult procedure. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, and adequate mesh coverage with transfascial suture fixation. The aim of the current study was to document the complications and morbidity associated with the repair of suprapubic hernias. METHODS: A retrospective review of patients with complex suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. The operative techniques were similar and included dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper's ligaments, and extensive transfascial suture fixation of the mesh. RESULTS: A total of 47 patients were reviewed, 29 women and 18 men, with a mean age of 54 years. Patients averaged 3.5 previous abdominal surgeries (SD +/-2.3) and had a mean body mass index (BMI) of 35.1 (SD +/-7.5). Previous ventral hernia repairs had been performed in 57% of patients. Average defect size was 139.8 cm(2) (SD +/-126) and average mesh size was 453.8 (SD +/-329.0), with an average hernia-to-mesh ratio of 3.2. Median length of stay was 3 days with a mean follow-up of 2.6 months (SD +/-3.1). There were 18 complications (38%): symptomatic seroma (n = 4), prolonged ileus (n = 2), chronic pain (n = 2), postoperative urinary retention (n = 2), enterotomy (n = 1), intraoperative bladder injury (n = 1), postoperative urinary tract infection (n = 1), mesh infection (n = 1), rapid ventricular rate (n = 1), small bowel obstruction (n = 1), pulmonary embolism (n = 1), and pneumonia (n = 1). One patient required conversion to open ventral hernia repair, no injury was identified. Recurrence occurred in 3 patients (6.3%). The mechanisms of recurrence included reherniation at the level of the pubic tubercle, a lateral mesh recurrence in a patient with a high BMI and small abdominal excursion, and in a pregnant patient who developed a fixation suture hernia. CONCLUSIONS: Laparoscopic suprapubic hernia repair is safe and effective with a relatively low recurrence rate, considering the complexity of the repair.

Short esophagus: how much length can we get?

INTRODUCTION: Laparoscopic antireflux surgery requires an adequate length of intra-abdominal esophagus. Short esophagus can cause wrap herniation and poor clinical outcomes. The aim of the study is to measure maximum length of esophageal elongation with transhiatal mediastinal dissection. METHODS: This is a review of a prospective database created in the tertiary referral center between 2003 and 2006. One hundred and six patients with gastroesophageal reflux disease and suspected short esophagus on barium swallow were studied. Patients underwent antireflux surgery with extended transhiatal mediastinal dissection to elongate short esophagus. Routine measurement of intra-abdominal esophageal segment length with intraoperative esophagogastroscopy and laparoscopy was utilized to define the gastroesophageal junction (GEJ) in order to quantify total intra-abdominal esophageal length. Postoperative 24-h pH manometry, UGI series, and symptom scores were recorded to document the clinical outcomes. The aim of the dissection was to mobilize>or=3 cm of intra-abdominal esophagus. RESULTS: Total esophageal elongation was achieved with a mean of 2.65 (range 2-18) cm. Resultant intra-abdominal esophageal length was measured with a mean of 3.15 (range of 3 to 5) cm. None of the preoperative "short esophagus" required Collis' gastroplasty post extended mediastinal dissection. All preoperative symptom scores showed significant improvements with mean follow-up of 18 (9-36) months. Mean distal esophageal acid exposure normalized in all patients studied postoperatively. CONCLUSION: Short esophagus can be safely elongated with extended mediastinal esophageal dissection. This technique can obviate the need for Collis' gastroplasty and improve overall outcome after antireflux surgery. We recommend that extended transhiatal mediastinal dissection be performed to establish 3 cm of intra-abdominal esophagus at the time of antireflux procedures.

Long-term outcome of cruroplasty reinforcement with human acellular dermal matrix in large paraesophageal hiatal hernia.

BACKGROUND: Laparoscopic repair of a large hiatal hernia using simple sutures only for the cruroplasty is associated with a high recurrence rate. The solution was to place synthetic mesh over the cruroplasty thereby decreasing recurrence rates in exchange for complications, such as gastric and esophageal erosions. Our initial report investigated the use of human acellular dermal matrix (AlloDerm) as a more suitable alternative. This study highlights our long-term results>1 year of cruroplasty reinforcement with AlloDerm in the repair of large hiatal hernias. METHODS AND MATERIAL: This is a retrospective study performed at our university. Between 2005 and 2006, 52 consecutive patients with large hiatal hernias had the cruroplasty site reinforced with AlloDerm. The variables analyzed were age, sex, weight, height, hiatal hernia size, operative time, length of hospital stay, follow-up, and postoperative complications. RESULTS: The mean for age was 56.7 years, for weight was 87.9 kg, for height 117 cm, for hernia size was 5.75 cm, operative time was 121 min, and for hospital stay was 1.36 days. Complication included pneumothorax, 3 (5.5%); atelectasis, 1 (1.9%); urinary retention, 1 (1.9%); and recurrence, 2 (3.8%). CONCLUSION: Laparoscopic hiatal hernia repair with reinforcement using human acellular dermal matrix can be performed safely with a short hospital stay and low rate of complications, especially a low rate of recurrence.

One hundred consecutive laparoscopic Nissen's without the use of a bougie.

BACKGROUND: The creation of a floppy and symmetric fundoplication over a bougie has been the standard of care in laparoscopic surgery. The use of a bougie carries a risk of esophageal perforation but lowers the risk of postoperative dysphagia. Intraoperative esophagogastroduodenoscopy (IEGD) can be used to assess the orientation and position of a properly constructed Nissen. The aim of this study was to determine if IEGD can replace the routine use of a bougie in the creation of a fundoplication. METHODS: One hundred consecutive patients undergoing laparoscopic Nissen fundoplication from 2003 to 2005 were entered into a prospective database. IEGD was used in all patients instead of a bougie. Preoperative and postoperative data, including symptom scores, pH studies, manometry, and upper gastrointestinal studies, were analyzed. RESULTS: All 100 patients completed the study for a mean follow-up period of 18 months. The mean surgical time was 102 minutes. The mean intraoperative endoscopy time was 14 minutes. There were a total of 24 (24%) alterations of the fundoplication performed according to endoscopic wrap creation. The most common alteration was removal of a fundoplication stitch in 15 patients with a tight appearance of wrap. There were no major complications. Two patients required esophageal dilatation for mild to moderate dysphagia. CONCLUSIONS: IEGD is a valuable tool for laparoscopic Nissen fundoplication. IEGD helps to appreciate the true location of the gastroesophageal junction and allows for fundoplication adjustment based on additional visualization. The creation of a symmetric and floppy wrap during Nissen fundoplication can be facilitated greatly by intraoperative endoscopy and may lead to improved clinical outcomes without the risk of esophageal perforation.

48-Hour pH monitoring increases the risk of false positive studies when the capsule is prematurely passed.

Ambulatory wireless 48-h esophageal pH monitoring (Bravo Medtronic, Shoreview, MN, USA) has been shown to be more sensitive in detecting abnormal esophageal acid exposure compared with transnasal 24-h pH probes. However, accurate interpretation of the wireless monitoring data is paramount when contemplating surgical intervention for those with gastroesophageal reflux disease. The aim of this study is to evaluate the incidence of false-positive interpretations of this wireless monitoring data secondary to premature transit of the Bravo capsule into the stomach and subsequently into the duodenum prior to the completion of the 48-h study period. We reviewed 100 consecutive Bravo pH studies at our University Esophageal Motility Center. There were 58 women and 42 men included in our evaluation. Premature transit of the Bravo capsule into the stomach and subsequently into the small bowel was defined by a prolonged gastric pH phase with either evidence of alkalinization and no further reflux episodes or loss of communication with the Bravo capsule prior to the end of the 48-h data collection period. Of the 100 patients reviewed, 11% manifested evidence of early passage of the Bravo capsule resulting in a misinterpretation of the data as abnormal acid exposure. The mean time of inaccurate data after transit of the Bravo capsule was 18 h and 42 min. The mean length of time that the capsule was retained in the stomach prior to duodenal passage was 4 h. If the aforementioned data were included in the final interpretation of the study, it yielded a mean DeMeester score of 44.25 with a mean total time of pH <4 of 14.7% per case. Exclusion of the prolonged gastric phase from the final interpretation of each case resulted in a statistically significant reduction in the mean total time the pH <4 (4.33 vs. 14.7%, p < 0.05) and the mean DeMeester score (12.81 vs. 44.25 p < 0.05). The mean time from the initiation of esophageal pH data to the passage of the Bravo capsule into the stomach was 15 h and 22 min. The observation mandates meticulous inspection of the pH tracing by the interpreting physician throughout the entirety of a 48-h study to identify premature transit of the capsule. Tracings that show prolonged acid exposure or loss of communication with the Bravo capsule should be screened for the capsule's possible early dislodgement and premature advancement into the stomach.

Laparoscopic hiatal hernia repair with human acellular dermal matrix patch: our initial experience.

BACKGROUND: The laparoscopic repair of large hiatal hernia followed by an antireflux procedure is currently the gold standard therapy for gastroesophgeal reflux disease. However, it is recognized that recurrent hiatal herniation and wrap migration are major sources of operative failures in these patients. Some have described a reduction of such events with the placement of nonbiodegradable prosthetic patches over the primary cruroplasty. This prosthetic material may be associated with transesophageal and gastric erosions and a higher rate of postoperative dysphagia and chest pain when compared with simple suture cruroplasty alone. The aim of this study is to compare hiatal closure with a biodegradable patch (acellular dermal matrix) and simple suture curaplasty in patients undergoing laparoscopic antireflux surgery. METHODS: A total of 44 patients were prospectively enrolled in this study. Twenty-two consecutive patients undergoing large hiatal hernia repair (>5 cm) and fundoplication with primary suture cruroplasty only (group 1) were compared with 22 consecutive patients undergoing the same procedure with suture cruroplasty reinforced with an onlay acellular dermal matrix patch (group 2). The 2 groups were compared with regards to demographics, size of the hiatal hernia, pre- and postoperative symptom scores, pH studies, operative times, and hiatal hernia recurrence. RESULTS: Patients in both groups were well matched by age, weight, height, and size of hiatal hernia. There were similar preoperative values in esophageal manometry, 24-hour pH monitoring, and symptom scoring in both groups. Average operative time was 108 minutes in group 1 and 121 minutes in group 2. There were no major complications in either group. The median period of hospitalization was 1 day in both groups. Postoperative pH studies and symptoms score data were significantly improved in both groups. There was no significant difference in postoperative symptoms scores for dysphagia between the 2 groups. Two patients (one in each group) underwent esophageal dilatation for mild dysphagia postoperatively. In group 1, 2 patients (9%) had Nissen failure with hiatal hernia recurrences 6 months after surgery. There were no recurrences for the follow-up period in group 2. CONCLUSIONS: Our early results suggest that hiatal hernia repair reinforced with an acellular dermal matrix patch may reduce the incidence of recurrent herniation and wrap migration. In addition, the increase in postoperative dysphagia, chest pain, and esophageal erosions associated with nondegradable mesh has not been observed in those with an acellular dermal matrix patch to this point in our follow up. However, future investigation of the material for this particular application as well as longer follow-up is necessary.