Laparoscopic Roux-en-Y Gastric Bypass: Preoperative Determinants of Prolonged Operative Times, Conversion to Open Gastric Bypasses, and Postoperative Complications

Background: We examined our database of 600 consecutive laparoscopic Roux-en-Y gastric bypasses (LRYGBP) to determine predictors of prolonged operations, conversion to open operations and postoperative complications. Methods: All were primary bariatric operations. Body habitus, gender, and previous surgery were evaluated. Results: Regression analysis showed the following parameters to correlate positively with increased operative time: 1) Waist, 2) BMI, 3) Weight, and 4) Waist/Hip ratio. Height and hip measurement did not correlate with operative time. No previous operations affected operative time. Conversion to open operation was necessary in 25/600 cases (4.2%). Conversion was necessary with larger waist measurement (P=0.00007) and increased waist/hip ratio (P=0.01) but not BMI. Conversion occurred more frequently in males (6/43, 14.0%) than females (19/557, 3.4%). This trend was statistically significant (P=0.006). An enlarged liver was responsible for 12/25 conversions. 6/12 patients with large livers had type II diabetes and 6/12 patients had biopsy-proven steatohepatitis. 2/12 had huge yellow-brown livers that were not biopsed. Liver function tests were normal in 8/8 patients preoperatively. Complications including leak (5), pulmonary embolus (2), hemorrhage (12), stenosis of the GI tract (24) and infection (7) occurred in 48/600 patients (8.0%). There were no deaths. Complications did not correlate with body habitus, gender, or previous surgery. Conclusion: Larger patients as measured by waist measurement, weight, and BMI but not previous surgery prolonged LRYGBP. Conversion to open surgery was more frequently necessary in patients with larger abdomens, central obesity, and type II diabetes. Complications did not correlate with any preoperative parameter measured.     

Revisional Bariatric Surgery - Safe and Effective

Background: Revision operations have traditionally been considered difficult and associated with a high complication and long-term failure rate. This paper demonstrates that revision and/or conversions to Roux-en-Y gastric bypass are generally safe as well as effective in long-term weight maintenance and control of co-morbidities. Methods: A retrospective study from January 1989 through August 1999 was done involving 141 patients who had had various gastroplasty (118), gastric banding (6), jejunoileal bypass (3), or loop (2) and Roux-en-Y gastric bypass (RYGBP) procedures (12), with either technical failures or poor long-term maintained weight loss. Results:The demographics were: mean pre-operative weight at original surgery 264 lbs (120 kg); postop weight at a mean elapsed time since surgery of 5 years, 4 months: 188 lbs (85 kg), or a mean excess weight loss of 59%. The mean BMI dropped from a pre-op 45 to a post-op 31.There were 7 complications which required emergency surgery (5%), which included 4 leaks, 2 subphrenic abscesses, and 1 wound dehiscence. Other complications included 4 hernias, 3 staple-line failures, 1 transient renal failure, and 3 incidences of peptic ulcer disease requiring surgery, giving a total major complication rate of 13% in 17 patients, with no deaths. An earlier experience of this author comparing conversion RYGBP vs revision gastroplasty found better morbidity rates and weight loss with those converted to RYGBP. Conclusion: Converting failed gastric limiting and other bariatric procedures to RYGBP was safe and effective. Technical approaches to each problem type encountered are presented.     

Roux-en-Y Gastric Bypass after Failed Vertical Banded Gastroplasty

BACKGROUND: Vertical banded gastroplasty (VBG) was the restrictive procedure of choice for many years. However, VBG has been associated with a high rate of long-term failure. We reviewed our experience of conversion of failed VBG to Roux-en-Y gastric bypass (RYGBP). METHODS: The data on all patients undergoing conversion of failed VBG to RYGBP were reviewed. Failed VBG was defined as insufficient weight loss (BMI > 35 kg/m2) and/or VBG-related complications. RESULTS: We performed 24 conversions from VBG to RYGBP. Median age was 40 +/- 8 years (range 28 to 61). Preoperative weight was 111 +/- 25 kg (range 85 to 181), and median BMI was 41 +/- 8 kg/m2 (range 30 to 69 kg/m2). Indication for conversion was: VBG failure in 18 patients and VBG complications in 6 patients. A gastrectomy (total or proximal) had to be performed in 5 cases (21%). The conversion was performed by laparoscopy in 13 cases. Postoperative complications occurred in 4 patients (16.7%). There were no leaks, nor mortality. Postoperative BMI was 31 kg/m2 (range 25 to 42) at a median follow-up of 12 months (range 3 to 36 months). The average percentage of excess weight loss was 62% at 1 year. CONCLUSION: VBG has been associated with a significant reoperation rate for failure and/or complications. Conversion to RYGBP is effective in terms of weight loss and treatment of complications after VBG. Gastrectomy and resection of the staple-line could reduce such complications as leaks and mucocele. Although technically challenging, conversion of VBG to RYGBP is feasible, with acceptable morbidity and no mortality. The conversion is feasible laparoscopically.     

Reoperative Laparoscopic Roux-en-Y Gastric Bypass: An Experience with 49 Cases

Background: Long-term complications leading to reoperation after primary bariatric surgery are not uncommon. Reoperations are particularly challenging because of tissue scarring and adhesions related to the first operation. Reoperations must address the complication(s) related to the scarring and, at the same time, prevent weight regain that would inevitably occur after simple reversal. Conversion to Roux-en-Y gastric bypass (RYGBP) has repeatedly been demonstrated to be the procedure of choice in most situations. It has traditionally been performed through an open approach. Our aim is to describe our experience with the laparoscopic approach in reoperations to RYGBP over the past 5 years. Methods: All patients undergoing laparoscopic RYGBP as a reoperation were included in this study. Patients with multiple previous operations or patients with band erosion after gastric banding were submitted to laparotomy. Data were collected prospectively. Results: Between June 1999 and August 2004, 49 patients (44 women, 5 men) underwent laparoscopic reoperative RYGBP. The first operation was gastric banding in 32 and vertical banded gastroplasty in 15. The mean duration of the reoperation was 195 minutes. No conversion to open was necessary. Overall morbidity was 20%, with major complications in 2 patients (4%). Weight loss, or weight maintenance, was satisfactory, with a BMI <35 kg/m² up to 4 years in close to 75% of the patients. Conclusions: Laparoscopic RYGBP can be safely performed as a reoperation in selected patients provided that the surgical expertise is available. These procedures are clearly more difficult than primary operations, as reflected by the long operative time. Overall morbidity and mortality, however, are not different. Long-term results regarding weight loss or weight maintenance are highly satisfactory, and comparable to those obtained after laparoscopic RYGBP as a primary operation.     

Laparoscopic kidney donation: The impact of adhesions

Background Adhesion formation following abdominal surgery causes substantial burden to society. Laparoscopic donor nephrectomy (LDN) offers an opportunity to study the prevalence of adhesions in healthy individuals. Furthermore we evaluated whether or not adhesions hindered LDN. Methods Data of 161 LDNs were prospectively collected. The presence of adhesions was documented. Parameters influenced by the presence of adhesions such as operation time, blood loss, and intraoperative complications were documented. Results Twenty-eight of 44 donors (64%) who had had prior abdominal surgery presented with adhesions at laparoscopy versus 61 of 107 donors (52%) who had no history of abdominal surgery (P = 0.22). Conversion and complication rate, operation times, and blood loss did not differ between those with and without a previous history of abdominal surgery. Blood loss and operation time did not differ between donors with and without adhesions. The number of conversions to open was significantly higher in donors with adhesions (9 versus 0, P = 0.005). Three conversions were due to adhesions. Conclusion Adhesions are present in a significant number of healthy individuals regardless of a history of previous abdominal operations. As these operations are of no predictive value for the number and complexity of adhesion formation, we advocate starting live kidney donation laparoscopically as the procedure can be most probably conducted successfully by this approach. None of the above mentioned authors have any conflict of interest. Niels Kok is partially funded by an unrestricted grant of the Dutch Kidney Foundation.     

Previous abdominal operations do not affect the outcomes of laparoscopic colorectal surgery

Background Previous abdominal surgery has been regarded as a relative contraindication for laparoscopic surgery. However, studies on laparoscopic cholecystectomy have showed that the presence of prior abdominal procedures does not affect the outcomes of surgery. This study aimed to investigate the impact of previous abdominal surgery on laparoscopic colorectal surgery.Methods This study enrolled 295 consecutive patients who underwent laparoscopic colorectal surgery from May 2000 to May 2003. The patients were divided into two groups: those with previous abdominal surgery (n = 84) and those without a prior operation (n = 211). The outcomes of surgery for the two groups were compared with respect to the duration of surgery, blood loss, conversion rate, time to return of bowel function, resumption of diet, complications, and the hospital stay.Results The study included 158 men and 137 women. The median age of the patients was 70 years (range, 33-91 years). Significantly more female patients and patients with benign diseases had prior abdominal surgery. Conversion was required for 17.8% of the patients with and 11.4% of the patients without previous surgery (p = 0.181). There were no differences in the operating time or blood loss between the two groups. The time to bowel movement and resumption of diet were similar in the two groups. The median hospital stay was 7 days for both groups. Of the 39 conversions, 28.2% were necessitated mainly by the presence of adhesions. In the patients who underwent conversion because of adhesions (n = 11), nine had prior surgery and two did not (p = 0.001).Conclusions The presence of prior surgery does not affect the operating time or blood loss of patients undergoing laparoscopic colorectal surgery. The conversion rate is not increased for patients with prior surgery. The postoperative outcomes in terms of ileus, complication rate, and hospital stay are not worse for patients with prior surgery. Previous abdominal surgery should not be considered as a contraindication for laparoscopic colorectal surgery.     

A method of assessing reasons for conversion during video-assisted thoracoscopic lobectomy

Conversion rates during video-assisted thoracoscopic lobectomy are reported, but no previous publications have classified the cause of conversion. The aim of the study was to develop a quality assessment tool [vascular, anatomy, lymph node, technical (VALT) 'Open'] to evaluate reasons and nature of conversion during the development of a video-assisted thoracoscopic lobectomy program. Between 2006 and 2008, 237 patients with a median age of 65 years underwent video-assisted thoracoscopic lobectomy primarily for lung. The number of video-assisted thoracoscopic lobectomy cases over open cases has increased over the period. Conversion rate has dropped from 15% (2006) to 11% (2008). A total of 32 cases required conversion. The VALT 'Open' classification for reason to convert and nature of conversion was used. The average length of stay was shorter for non-converted cases. No uncontrolled conversions where the patient was unstable were required, and in the 14 cases converted following some difficulty, such as pulmonary artery injury. A pattern to the learning curve became predictable. The quality assessment tool used (VALT 'Open') will allow cause of conversion and nature of conversion to be tracked and audited during the development of a video-assisted thoracoscopic surgery lobectomy program.     

The Utility of Contrast Studies and Drains in the Management of Patients after Roux-en-Y Gastric Bypass

Background: The role of routine post-operative contrast examination (UGI) and drainage of the gastrojejunostomy after Roux-en-Y gastric bypass (RYGBP) is controversial.The authors determined if early routine post-operative UGI detects occult anastomotic leaks, thereby altering treatment and withholding early feeding. Methods: Prospective data on 100 consecutive patients who underwent RYGBP from September 1998 to September 2000 was reviewed. Closed suction drains were routinely used. Within 36 hr postoperatively, all patients underwent UGI to evaluate the gastrojejunostomy. Patients were given liquids if the UGI showed no leak, and drains were removed 24 hr later. A blinded radiologist reviewed all the UGI. Results: 87 women and 13 men underwent 75 open and 25 laparoscopic RYGBP. BMI was 52.0 kg/m². 3 patients whose UGI showed a leak were treated nonoperatively with antibiotics, maintenance of drains, nasogastric tube and NPO. 2 of those patients developed purulent drainage within 24 hr after the UGI. None of the three patients required reoperation. 4 UGI were not available for the blinded reviewer who graded the remaining as satisfactory (94) and unsatisfactory (2). This reviewer disputed a leak in 1 of 3 previously reported leaks and reported a leak in a previously negative study. The latter patient subsequently required surgery for an uncontrolled leak. Conclusions: UGI can be used to withhold early oral intake in patients with radiographic leaks that would otherwise progress to clinically significant leaks. Surgical drains facilitate the non-operative management of such anastomotic leaks. Planned early UGI and surgical drains minimize the morbidity of anastomotic leaks after bariatric surgery.     

Pericholecystic adhesions in single v multiple gallstones and their consequences for laparoscopic cholecystectomy

BACKGROUND: Adhesions are amongst the common reasons for open conversion of laparoscopic cholecystectomy. It is not clear whether this problem is more common with single or multiple gallstones. PATIENTS AND METHODS: The clinical records of 110 patients with chronic cholelithiasis harboring multiple stones in the gallbladder (multiple stone group; MSG) and 45 patients with single stones in the gallbladder (SSG) undergoing laparoscopic cholecystectomy were analyzed for differences in the clinical presentation and outcome with special reference to the incidence of pericholecystic adhesions, size of the stones, and their implications for conversion and complications. RESULTS: Patients in the SSG had a significantly higher incidence of dense pericholecystic adhesions in the region of the porta hepatis (P = 0.003). Eleven patients in the SSG (24.4%) were converted to open cholecystectomy. Dense pericholecystic adhesions around the porta hepatis alone contributed to nine of these conversions (81.8%). The size of the stones was significantly greater (P < 0.001) in those patients of the SSG who required conversion to open cholecystectomy. Thirteen patients of the MSG (11.8%) required conversion to open cholecystectomy. Dense pericholecystic adhesions alone contributed to conversion in four cases (30.7%), and the size of the gallstones was not significantly different (P = 0.981) in patients with or without conversion to open cholecystectomy. There was no difference in the clinical presentation or complications in the two groups of patients. CONCLUSION: Dense adhesions in the porta hepatis are significantly more common in patients with single stones and are the most common reason for open conversion.     

Comparison of Risk Factors for Unplanned Conversion from Laparoscopic and Robotic to Open Colorectal Surgery Using the Michigan Surgical Quality Collaborative (MSQC) Database

Robotic colorectal surgery has been shown to have lower rates of unplanned conversion to open surgery when compared to laparoscopic surgery. Risk factors associated with conversion from robotic to open colectomy and comparisons of the risk factors between robotic and laparoscopic approaches have not been previously reported. Patients who underwent elective laparoscopic and robotic colorectal surgeries between July 1, 2012 and April 28, 2015, were identified in the Michigan Surgical Quality Collaborative registry. Candidate covariates were identified, and hierarchical logistic regression models were used to identify risk factors for conversion. There were 4796 cases that met study inclusion criteria. Conversion was required in 18.2 % of laparoscopic and 7.7 % of robotic cases (p?<?0.0001). Risk factors for conversion in the laparoscopic group included the following: moderate/severe adhesions, obesity, colorectal cancer, hypertension, rectal operations, urgent priority, and tobacco use. Risk factors for conversion in the robotic group included the following: severe adhesions, bleeding disorder, presence of cancer, cirrhosis, and use of statins. Higher surgeon volume was protective in both groups. Conversion rates are lower for robotic than for laparoscopic colorectal surgery with fewer predictors of conversion. Recognition of factors predicting conversion may allow surgeons to choose an operative approach that optimizes the benefits of the available technologies.     

Laparoscopic Gastric Bypass: Development of Technique,Respiratory Function,and Long-Term Outcome

Background: Roux-en-Y gastric bypass (RYGBP) is the preferred operation for the treatment of morbid obesity by many surgeons. Hereby we present the process by which laparoscopic RYGBP (LRYGBP) developed at our institution. Methods: Perioperative morbidity was recorded from 150 consecutive morbidly obese patients operated upon by RYGBP from August 1994 to March 2002. The first 76 consecutive patients have been followed up to 5 years postoperatively. A subgroup of 40 patients was recruited to evaluate the postoperative lung function in a randomized study between receiving and not receiving prophylactic chest physiotherapy. Results: In the whole series, there were 4 conversions to open surgery, 5 leaks, 12 postoperative bleedings and 1 intestinal obstruction. 1 patient succumbed after developing acute dilatation of the bypassed stomach. Respiratory function deteriorated significantly in all patients in the early postoperative period, irrespective if given physiotherapy. During the follow-up period, 3 patients developed mechanical obstruction of the Roux limb. Another patient had a perforated ulcer at the proximal pouch. Weight reduction averaged 70% of excess body weight at 2 years after surgery. Conclusions: LRYGBP is an effective treatment for morbid obesity. During the initial development, we experienced a number of serious complications. The complication rate decreased over time. Postoperative lung function was markedly impaired, but there were no beneficial effects of chest physiotherapy. Long-term weight loss after LRYGBP seems to be comparable to what has been reported after open RYGBP.     

Converted laparoscopic colectomy

Background The safety and benefits of laparoscopic colon resection are well documented. However, few reports have addressed the safety and comparative outcome of laparoscopic colon operations that necessitated conversion. Methods All consecutive laparoscopic colon resections performed by a single surgeon from July 1996 to October 2003 were assessed. Data obtained from a prospective computerized database included demographics, diagnosis, reason and time to conversion, length of stay, morbidity, and mortality. Additionally, all laparoscopic-converted colectomies were then matched with open colectomies by diagnosis and severity of disease and analyzed with respect to morbidity, mortality, and clinical outcome. Results A total of 143 laparoscopic colon resections were analyzed, 78 of which were left colon resections and 65 were right colon resections. The overall conversion rate was 19.6% (28 patients). The disease entities of the 28 converted patients were diverticulitis (16), polyps (four), Crohn’s disease (three), metastatic cancer (three), and others (two). Conversion was higher in the left-sided (24 patients, 30.8%) versus right-sided (four patients, 6.1%) procedures. There were no differences regarding age, gender, and comorbidities among the laparoscopic, open, and converted groups; the median follow-up was 39 months. The median length of stay was 6, 8, and 12 days for the laparoscopic, open, and converted groups, respectively. Right-sided conversions were due to the size of the inflammatory mass in three patients and intraoperative bleeding in one patient. Left-sided conversions were due to the inflammatory process extending beyond the sigmoid colon in 12 patients, adhesions in five, obesity in four, pericolonic abscess in two, and fixed mass in one patient. Postoperative morbidity was significantly higher for laparoscopic procedures that were converted to open procedures more than 30 min into the operation. Preoperative predictors of conversion were extent of inflammatory process beyond the sigmoid colon and obesity, whereas intraoperative predictors were adhesions and bleeding. Conclusions Laparoscopic-converted colon resection is associated with significantly greater morbidity, particularly wound complications and greater length of hospital stay, compared to open or laparoscopic colectomies. Prompt conversion (<30 min) may reduce the overall morbidity associated with converted procedures. Furthermore, thoughtful patient selection may decrease the conversion rate and thereby prevent the inherent morbidity associated with converted procedures.     

Laparoscopic cholecystectomy

In 1,300 patients undergoing laparoscopic cholecystectomy (LC) 56 patients (4.3%) required conversion to open cholecystectomy (OC); 41 (73%) of the conversions were elective, whereas 15 (27%) were enforced. The causes of the 56 conversions are described and analyzed. Logistic regression analysis of 23 parameters identified the following data as associated with a higher risk for conversion: pain or rigidity in the right upper abdomen (P<0.01), thickening of the gallbladder wall on preoperative ultrasound (P<0.05), intraoperatively found dense adhesions to the gallbladder or in Calot's triangle (P<0.001), and intraoperatively found acute inflammation of the gallbladder (P<0.01). Clinical findings of an acute cholecystitis associated with intraoperative dense scarring in Calot's triangle were the best factors predicting conversion from LC to OC. As a result of the study we preoperatively select our patients for either LC or OC, and a difficult case is performed by a more experienced surgeon to keep conversion rate and complications low.     

Which factors increase the risk of conversion to open surgery following endovascular abdominal aortic aneurysm repair? The EUROSTAR collaborators.

OBJECTIVE: to identify factors that increase the risk of conversion to open surgery following endovascular repair of abdominal aortic aneurysms (AAAs) and to assess their outcome. Design analysis of 1871 patients enrolled in the EUROSTAR collaborators registry. MATERIALS AND METHODS: patient characteristics, anatomic features of the aneurysm, type of endovascular device, institutional experience and the year in which the procedure was performed were related to risk of conversion. RESULTS: forty-nine patients (2.6%) required conversion. In 38 patients conversion was performed during the first postoperative month (primary conversions) and in 11 patients during follow-up (secondary conversions). Primary conversion was mostly due to access problems and device migration. Secondary conversions were performed for rupture in six and for a persistent endoleak, with or without aneurysmal growth, in five patients. Patients who were converted were significantly older, had a lower body weight, and had a higher prevalence of chronic obstructive pulmonary disease. Conversion was associated with shorter, wider infrarenal necks and larger aneurysms. The conversion rate was lower when a team had performed more than 30 procedures, and in procedures performed during the last two years of the study period. The conversion rate was higher with EVT or Talent devices. Patients who required primary conversion had an 18% mortality rate, compared to 2.5% mortality in patients without conversion (p<0.01). Secondary conversion was associated with a perioperative mortality of 27%, and when performed for rupture 50%. CONCLUSION: both primary conversion and secondary conversion for rupture carry a high operative mortality. Awareness of the risk factors may reduce conversion rate as well as early and medium term mortality.     

Laparoscopic revision of bariatric procedures: is it feasible?

Reoperative bariatric surgery is required in 10 per cent to 20 per cent of patients secondary to weight regain or complications of the previous procedure. This study evaluates the feasibility of performing the revision procedure laparoscopically. A retrospective review of all patients undergoing revision of a previous weight loss procedure between October 1998 and November 2003 was conducted. Demographics, indications for surgery, operative findings, and complications were reviewed. Thirty-nine revisions were performed in 37 patients. Indications for revision were failure to lose weight (22), gastric outlet stricture (10), refractory gastroesophageal reflux (GERD) (6), and blind loop syndrome (1). All 39 procedures were revised to Roux-en-Y gastric bypass (RYGBP), with 18 open revisions (OR) and 21 laparoscopic revisions (LR). Ten of the 21 LR (48%) were converted to an open procedure due to adhesions or unclear anatomy. Early complications requiring operation were noted in five procedures (two OR, three LR). Nine patients (seven OR, two LR) required surgery at least 3 months following their revision. One patient died (LR). The difference in body mass index (kg/m2) (BMI) pre- and post-op was 43.3+/-9.9 versus 37.4+/-9.2, P = 0.01 (follow-up 5 months), but no significant BMI differences between LR and OR patients were seen. Revisional bariatric surgery is associated with more complications requiring surgery early in the laparoscopic population versus more late complications in those approached open. Revisional bariatric surgery can be approached laparoscopically and with acceptable morbidity comparable to patients whose revision is approached open.     

Is Roux-en-Y gastric bypass safe after previous antireflux surgery? Technical feasibility and postoperative symptom assessment.

BACKGROUND: Clinically significant morbid obesity is associated with an increased risk of gastroesophageal reflux disease. Vertical Roux-en-Y gastric bypass (RYGBP) is known to eliminate acid (and bile) in the pouch of cardia, which would provide control of reflux symptoms. The aim of our study was to assess the technical considerations, morbidity, and safety of RYGBP after previous antireflux surgery and evaluate postoperative reflux symptoms. METHODS: Retrospective review of all patients undergoing RYGBP after previous antireflux surgery from three institutions. Follow-up (mean 18 months) data were obtained from medical records and by questionnaire. RESULTS: A total of 19 patients (18 women and 1 man) underwent standard (n = 18) or distal (n = 1) RYGBP 8 +/- 1 years after Nissen (n = 18) or Toupet (n = 1) fundoplication. Open RYGBP was undertaken in 17 of 19 patients. No postoperative deaths occurred. Substantive complications occurred in 4 patients (21%) and included hemorrhage requiring transfusion, concomitant splenectomy, and reoperation for suspected leak in 2. Of the 19 patients, 16 returned the questionnaire, 15 of whom reported subjective improvement in reflux symptoms after RYGBP compared with after antireflux surgery. No patient in this series required medical therapy for reflux symptoms at the last follow-up visit. The body mass index decreased from 42 +/- 2 kg/m(2) to 32 +/- 2 kg/m(2) (mean +/- SEM); all patients with >or=1 year of follow-up had a body mass index of 相似文献   

Complications of the Laparoscopic Roux-en-Y Gastric Bypass: 1,040 Patients - What Have We Learned?

Background:The Roux-en-Y gastric bypass (RYGBP) is one of the most common operations for morbid obesity. Laparoscopic techniques have been reported, but suffer from small numbers of patients, longer operative times and seemingly higher initial complication rates as compared to the traditional "open" procedure. The minimally invasive approach continues to be a challenge even to the most experienced laparoscopic surgeons.The purpose of this study is to describe our experience and complications of the laparoscopic Roux-en-Y gastric bypass with a totally hand-sewn gastrojejunostomy. Methods: 1,040 consecutive laparoscopic procedures were evaluated prospectively. Only patients who had a previous open gastric procedure were excluded initially. Eventually, even patients with failed "open" bariatric procedures and other gastric procedures were revised laparoscopically to the RYGBP. All patients met NIH criteria for consideration for weight reductive surgery. Results:There were no anastomotic leaks from the hand-sewn gastrojejunostomy. Early complications and open conversions were related to sub-optimal exposure and bowel fixation techniques. Several staple failures were attributed to a manufacturer redesign of an instrument. Average hospital stay was 1.9 days for all patients and 1.5 days for patients without complications. Operative times consistently approach 60 minutes. Average excess weight loss was 70% at 12 months.There were 5 deaths: perioperative pulmonary embolism (1), late pulmonary embolism (2), asthma (1), and suicide (1). Conclusions: The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.     

One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy

INTRODUCTION

The incidence of conversion from a laparoscopic to an open approach during nephrectomy is reported at 6-8%.¹ Conversion to an open procedure may be necessary to control haemorrhage or allow progress in dissection but the well established benefits of minimally invasive surgery (MIS) are obviously lost. Hand-assisted laparoscopy (HAL) also offers the benefits to the patient of MIS. We have used HAL to convert from the pure laparoscopic approach during difficult nephrectomies, rather than converting to traditional open surgery.

MATERIALS AND METHODS

A review of our prospective database was carried out to identify any conversions from the pure laparoscopic approach during nephrectomy or nephroureterectomy for benign or malignant disease.

RESULTS

A total of 87 laparoscopic nephrectomies (LNs) were identified over a 3-year period. There were five conversions to the HAL approach (5.7%) and no conversions to open surgery. The reason for conversion was failure to progress in all five cases. Operative times averaged 190 minutes with blood loss of 180ml. Histology revealed xanthogranulomatous pyelonephritis in four cases and renal cell carcinoma in one case. The median postoperative stay was 4 days.

CONCLUSIONS

Conversion to HAL during LN maintains the benefits of MIS in difficult nephrectomy and should be considered prior to converting to open surgery.     

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.