Short-term results for laparoscopic ventral rectopexy using biological mesh for pelvic organ prolapse.

AIM: There is growing evidence that laparoscopic ventral rectopexy (LVR) is an effective treatment for pelvic organ prolapse and obstructive defaecation caused by rectocele. LVR is usually performed using synthetic mesh despite concerns about mesh erosion. We present our experience of using a porcine dermal collagen mesh (Permacol™) for LVR, which is the largest such case series to date. METHOD: Data on 65 patients were collected prospectively from May 2008 to October 2010. Outcome measures were complications, recurrence, length of hospital stay, patient satisfaction, Wexner constipation score and Wexner incontinence score. Preoperative and postoperative scores were compared using the two-tailed Wilcoxon signed rank test. P<0.05 was considered statistically significant. RESULTS: There were statistically significant improvements in the Wexner constipation scores at 6 months and 1 year (both P<0.0001) and in faecal incontinence scores at 6 months (P<0.0001) and 1year (P=0.0002). There were no cases of mesh erosion or mesh-related infection in our series. Recurrence of symptoms occurred in two patients (3.1%). Symptoms were rated as much better or better by 93% of patients at 6months and this was sustained at 1year (96%). CONCLUSION: In the short term, LVR using biological mesh is safe and as effective as synthetic mesh, with high patient satisfaction. Constipation and faecal incontinence scores were both improved.

Right lateral position for laparoscopic splenic flexure mobilization.

AIM: Standard laparoscopic splenic flexure mobilization is often hampered by redundant small bowel and usually necessitates additional ports. The retraction required runs the risk of inadvertent injury to the surrounding structures including the spleen. METHOD: We present a new technique that permits a safe, rapid and complete mobilization of the splenic flexure even for the more difficult patients. RESULTS: We have used it in 15 consecutive patients without mortality, re-operation or conversion to open surgery. CONCLUSION: The right lateral position for splenic flexure mobilization gives better exposure of the left upper quadrant allowing complete dissection of the splenic flexure from the tail of the pancreas facilitating mobilization even in more difficult cases.

Varices of the round ligament mimicking an inguinal hernia--an important differential diagnosis during pregnancy.

Pregnancy is a recognised risk factor for the development of inguinal hernias due to an increase in intra-abdominal pressure. Whilst often managed conservatively until after the pregnancy, if the hernia presents acutely as a painful or tender groin lump, urgent or emergency repair may be required. Many clinicians rely heavily on clinical examination alone in order to diagnose the presence of such a hernia. In pregnancy, however, in order to prevent unnecessary surgery, the use of ultrasound has a more important role to play in reaching this diagnosis. We report a cautionary case that highlights the need for ultrasound evaluation of all painful groin lumps in pregnant women prior to considering surgery.

Surgical training in gastrointestinal procedures within a UK gynaecological oncology subspecialty programme.

OBJECTIVE: An analysis of surgical experience in gastrointestinal procedures within a UK-based gynaecological oncology centre to which subspecialty fellows within the subject are exposed. DESIGN: Retrospective study. SETTING: Northern Gynaecological Oncology Centre, Gateshead, UK. POPULATION: All women undergoing bowel surgery over a six-year period, 1 January 2000 to 31 December 2005. METHODS: Cases were analysed by specialty and grade of surgeon performing the procedure. MAIN OUTCOME MEASURE: Proportion of cases to which subspecialty fellows were exposed. RESULTS: Two hundred and sixty-two women (11.5%) underwent bowel surgery out of 2280 women undergoing major surgery for gynaecological cancer. This included ovarian/primary peritoneal cancer in 186 women (71%). Of these 262 cases, 238 operations (91%) were performed by a gynaecological oncologist, 20 (7.5%) were performed jointly with the gastrointestinal surgeons and four (1.5%) were performed solely by the gastrointestinal surgeons. A gynaecological oncology subspecialty fellow performed 21 (8%) and assisted in an additional 204 operations (78%). Perioperative morbidity and mortality statistics in addition to overall survival outcomes were comparable to the published literature. CONCLUSIONS: A significant proportion of major surgical operations performed within a gynaecological oncology centre require gastrointestinal procedures. The majority of these procedures can be performed by gynaecological oncologists with an acceptable perioperative morbidity and mortality rate. Subspecialty training has the potential to allow trainees significant exposure to these procedures. An accredited post-Fellowship Training Programme can provide the opportunity for hands-on experience to allow gynaecological oncologists the confidence and credibility to perform these procedures independently.

A 6-year review of surgical morbidity and oncological outcome after high anterior resection for colorectal malignancy with and without splenic flexure mobilization.

OBJECTIVE: High anterior resection (HAR) for colorectal cancer is traditionally performed with routine mobilization of the splenic flexure. This is a retrospective review of mortality and morbidity following HAR in which the splenic flexure has been preserved. METHOD: From a prospective database, all patients who had undergone elective HAR for colorectal cancer between 1999 and 2005 were identified. Morbidity, mortality, pathology and survival data for patients having HAR with and without splenic flexure mobilization were analysed. RESULTS: A total of 707 patients were identified. Five hundred and thirty-one had HAR with preservation of the splenic flexure. In these patients outcome was: anastomotic leak (0.4%), wound infection (3.6%), anastomotic stricture (0.4%) and 30-day mortality (0.9%). No statistical significant difference was found for postoperative morbidity (P = 0.1926), 30-day mortality (P =0.3285), lymph node harvest (P = 0.2127) or survival (P = 0.1457) compared with patients in whom the splenic flexure was mobilized. Longitudinal resection margins were greater following HAR with splenic flexure mobilization (P < 0.0001). CONCLUSION: No morbidity, oncological or survival disadvantage in performing splenic flexure preserving HAR was found.