Expert opinion on the basic surgical technique for laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair is currently the subject of intense debate, even though it provides a series of advantages over open surgery and is feasible and safe. Various studies have shown this technique to be as effective as open repair with a lower recurrence rate. Despite the excellent results of laparoscopic repair of ventral hernias, there are numerous controversies associated with this procedure. These controversies concern the indications and contraindications of the procedure, and technical aspects such as how to create the pneumoperitoneum, perform adhesiolysis, manage the hernia sac, and insert and fix the mesh to the anterior abdominal wall. Also controversial are outcome, complications related to postoperative seroma, and which type and size of mesh should be used. The present article aims primarily to address many of these issues, based on the experience of distinct surgeons with expertise in this approach, in order to provide data to establish a consensus on how laparoscopic ventral hernia repair should be performed.     

Abordaje laparoscópico del páncreas izquierdo

Introduction

Laparoscopic left-sided pancreatectomy (LLP) is an increasingly used surgical technique for the treatment of benign and malignant lesions of the left side of the pancreas. The results of LLP as a treatment for primary pancreatic lesions of the head and tail of the pancreas were evaluated.

La histerectomía laparoscópica: un abordaje posible. Estudio retrospectivo de las histerectomías laparoscópicas realizadas en un hospital público

Objective

To assess the outcomes of laparoscopic hysterectomy in a public hospital.

Material and methods

We performed a retrospective study of laparoscopic hysterectomies carried out between January 2005 and December 2007. The parameters evaluated were indication, type of hysterectomy, uterine weight, length of hospital stay, and complications.

Results

In the period analyzed, we performed 284 hysterectomies, of which 103 (36.36%) were laparoscopic. The morbidity rate was 9.7% and complications were related to the learning curve. The mean length of hospital stay was 2.56 days.

Conclusions

Laparoscopic hysterectomy is a safe procedure that requires a learning curve of 30-40 procedures. Due to its advantages, this option should be offered in all gynecology services.     

Laparoscopic treatment of achalasia: analysis of results and reflections on the technique

Introduction

Heller myotomy using the laparoscopic approach is the best treatment that we can offer to patients with achalasia. On not acting on the cause of the disease, we can only alleviate the persistence of the symptoms, but not make them disappear.

Objective

To analyse the results of our group in the treatment of achalasia by laparoscopy.

Material and methods

The pre- and post-operative results are analysed of a series of 20 patients intervened prospectively by laparoscopy of achalasia during a period from May 2003 to April 2010. For this we used a modification of the grading scale of pre- and post-operative symptoms described by Velanovich for GER (a scale from 0-5). Data on the complications and the hospital stay were also collected.

Results

A wide Heller myotomy was performed using a Dor type antireflux mechanism. There were no oesophageal perforations or complications during the surgery. Two (10%) patients had postoperative complications. The mean hospital stay was 3.11 ± 2.13 days. After a mean follow up of 55.8 ± 14.1 months, the symptoms studied had significantly decreased after the surgery. Only 3 (15%) patients had clinical symptoms of GER after surgery. Nineteen patients (95%) said they were satisfied with the operation.

Conclusions

The laparoscopic treatment of achalasia is a safe technique, reproducible and effective technique, which achieves very satisfactory control of the achalasia symptoms with a minimum of morbidity.     

Mesenteric closure in laparoscopic gastric bypass: surgical technique and literature review

Despite the advantages offered by laparoscopy in bariatric surgery, the incidence of a new complication that was uncommon in the previous era of open surgery--internal hernias--has increased. Most publications in the literature dealing with internal hernia describe the incidence and form of presentation of this entity but few explain how these complications can be prevented. In this review article we describe a technique to close mesenteric defects in retrocolic Roux-en-Y laparoscopic gastric bypass with permanent, continuous running suture (ethibond). We also review the literature in MEDLINE (www.ncbi.nlm.nih.gov/entrez/ using the key words: obesity, laparoscopy, gastric bypass, internal hernia, Petersen hernia) and references from articles of interest to determine the real incidence of this complication. Our technique has proven to be safe, reliable and reproducible and has greatly diminished the incidence of internal hernias. However, our data need to be analyzed in the future to determine whether the technique described eliminates this complication. The optimal results achieved with complete closure of all mesenteric defects have also been observed by other authors.     

Controversies in the current management of traumatic abdominal wall hernias

The management of traumatic abdominal wall hernias is controversial. We performed a MEDLINE search and report a personal series of 10 patients. Cases were classified according to the cause of injury. Fifty-six percent were caused by car accidents and 14% by bicycle accidents. Diagnosis was clinical in 22% and surgical in 13% and intra-abdominal lesions were found in 67%. Treatment was delayed in 12%. In our series, 55% were lumbar hernias due to traffic accidents and all were associated with pelvic fracture. Treatment was delayed in 50%, including laparoscopic surgery with good results. In conclusion, traumatic hernias due to road traffic accidents are frequently associated with intra-abdominal lesions. The diagnostic technique of choice is computed tomography and delayed surgery (laparoscopy) is an effective option.     

Anesthesia for bariatric surgery: 8-Year retrospective study: Are our patients now easier to manage?

ObjectivesTo review the perioperative management of patients who had undergone bariatric surgery in our institution during an 8-year period, with the aim of identifying variables that correlated with improved clinical outcomes and changes in perioperative practice.MethodsThis was a retrospective observational study of 437 patients who had undergone bariatric surgery from January 2005 to June 2013. Of these patients, 163 had undergone open or laparoscopic biliopancreatic diversion (Group 1), and 274 had been managed according to a Tailored Laparoscopic Approach Program (TLAP) (Group 2). We analyzed major cardiocirculatory, pulmonary, and surgery-related complications, mortality rate, intensive care unit (ICU) admissions, post-anesthetic care unit (PACU) length of stay, and perioperative management standards, throughout the study period.ResultsChanges were observed in anesthetic patterns and perioperative care standards during the study period: 25% of patients had combined epidural anesthesia in 2005, compared with none at present; ICU admissions decreased from 28.6% in 2005 to 3.1% at present; and time in PACU declined from a median of 23 h in 2005 to 5.12 h at present. Duration of postoperative opioid therapy was also significantly reduced (from 48 h to 6 h). Group 2 had a significantly lower mortality rate than Group 1 (0.37% versus 4.3%, respectively, P = 0.004).ConclusionsIn our institution, adoption of a TLAP for bariatric surgery has led to changes in perioperative care standards that have been followed by clear improvements according to morbidity, mortality and management indicators.     

Predictors of postoperative complications and readmissions in laparoscopic pancreas resection: Results of a cohort 105 consecutive cases. A retrospective study

IntroductionLaparoscopic resection of the pancreas (LRP) has been implemented to a varying degree because it is technically demanding and requires a long learning curve. In the present study we analyze the risk factors for complications and hospital readmissions in a single center study of 105 consecutive LRPs.MethodsWe conducted a retrospective study using a prospective database. Data were collected on age, gender, BMI, ASA score, type of surgery, histologic type, operative time, hospital stay, postoperative complications, degree of severity and hospital readmission.ResultsThe cohort included 105 patients, 63 females and 42 males with a median age and BMI of 58 (53–70) and 25.5 (22,2–27.9) respectively.Eighteen (17%) central pancreatectomies, 5 (4.8%) enucleations, 81 (77.6%) distal pancreatectomies and one total pancreatectomy were performed.Fifty-six patients (53.3%) experienced some type of complication, of which 13 (12.3%) were severe (Clavien-Dindo > IIIb) and 11 (10.5%) patients were readmitted in the first 30 days after surgery.In the univariate analysis, age, male gender, ASA score, central pancreatectomy and operative time were significantly associated with the development of complications (P <0.05). In the multivariate analysis, male gender (OR 7.97; 95% CI 1.08–58.88)), severe complications (OR 59.40; 95% CI, 7.69–458.99), and the development of intrabdominal collections (OR 8.97; 95% CI, 1.28–63.02)) were associated with hospital readmission.ConclusionsAge, male gender, ASA score, operative time and central pancreatectomy are associated with a higher incidence of complications. Male gender, severe complications and intraabdominal collections are associated with more hospital readmissions.