VersaStep trocar hernia rate in unclosed fascial defects in bariatric patients.

OBJECTIVE: Use of the VersaStep trocar system (US Surgical, Norwalk, CT) has the perceived advantage of minimal trocar-related hernias in patients undergoing Roux-en-Y gastric bypass surgery (RYGB). We performed a retrospective review of our last 747 consecutive operative procedures using these trocars. METHODS AND PROCEDURES: The patient population was 747 consecutive patients who underwent laparoscopic RYGB at Duke University Health System Weight Loss Surgery Center from January 2002 through April 2005. A total of 3735 radially expanded trocar sites were used. VersaStep trocars were used in all cases. The port configuration included one supraumbilical Hasson port, two 12-mm ports, and three 5-mm ports. The Hasson port was closed with a figure-of-eight number 1 Polysorb suture. All other trocar sites had no fascial closure. Intestinal anastomoses were created with a linear stapler in all of the laparoscopic cases, with hand suturing of the residual enterotomy. The fascial incisions were therefore not extended to accommodate an EEA stapler. The charts were reviewed for occurrence of subsequent trocar site hernias. RESULTS: There were no hernias at any of the VersaStep trocar sites-an incidence of 0%. There were nine incisional hernias at the Hasson port site which later required surgical repair-an incidence of 1.20%. CONCLUSIONS: There were no hernias detected at any of the 1494 12-mm or 2241 5-mm VersaStep trocar sites, despite lack of suture closure. At the Hasson port site, there was a hernia incidence of 1.20%. In the bariatric RYGB population, routine suture closure of the fascia or muscle is not necessary when using radially expanding VersaStep trocars.

A canine model of gastroesophageal reflux disease (GERD).

BACKGROUND: Although a variety of antireflux procedures and medications are used to treat gastroesophageal reflux disease (GERD), reliable large-animal models of GERD that can be used to objectively compare the efficacy of these treatments are lacking. METHODS: Esophageal manometry and 24-h gastroesophageal pH monitoring with event data were performed in 18 mongrel dogs with a cervical esophagopexy. We then calculated a modified DeMeester score: The Duke Canine reflux score (DCR). Thereafter, the animals underwent a 4-cm anterior distal esophageal myotomy, incision of the left diaphragmatic crus, and intrathoracic gastric cardiopexy. Postoperative 24-h pH and manometry were obtained 2 weeks later. RESULTS: The postoperative 24-h pH results showed a significant increase in the mean DCR score (5.9 +/- 4.5 vs 84.9 +/- 56.1, p < 0.0002), and manometry indicated a significant decrease in mean lower esophageal sphincter (LES) pressure (7.1 +/- 2.9 vs 3.2 +/- 2.5 mmHg, p < 0.0001). CONCLUSION: This technique reliably creates a canine model of GERD.

Histologic evaluation of fetal brains following maternal pneumoperitoneum.

BACKGROUND: The purpose of this study was to determine if maternal pneumoperitoneum with carbon dioxide (CO2) produces evidence of central nervous system (CNS) injury in preterm fetal guinea pigs. METHODS: Thirty pregnant guinea pigs at gestational day (GD) 45 were assigned at random to one of three treatment groups: anesthesia only, CO2 pneumoperitoneum (5 mmHg), or laparotomy. Dams were killed 3 or 5 days postprocedure and fetal brains (83 total) harvested and fixed for subsequent histopathologic evaluation. For comparative purposes, histologic features of fetal guinea pig brain injury were defined from examination of fetal brains harvested from an additional dam that underwent laparotomy with 20 min of uterine arterial occlusion. RESULTS: Carbon dioxide pneumoperitoneum did not increase maternal/fetal morbidity. No evidence of brain injury was found in fetuses from any of the treatment groups. CONCLUSION: Carbon dioxide pneumoperitoneum at 5 mmHg for 40 min in the pregnant guinea pig does not produce evidence of fetal brain injury.

Laparoscopy and the internet. A surgeon survey.

BACKGROUND: The Internet has become an important new tool for the delivery and acquisition of medical information. METHODS: A 13-item questionnaire designed to collect information on the attitudes and practices of surgeons regarding the use of the Internet as a medical resource was posted on the World Wide Web and also sent via e-mail. RESULTS: Over a 2-month period, 459 surgeons were enrolled in this study. Most of the respondents were identified as male surgeons (96%) between the ages of 31 and 50 years (79.25%). They accessed the Internet mainly from their homes (67.10%) and offices (17%) using 56 Kbps (34.86%) and 33.6 Kbps (21.79%) modems. These participants indicated that they use the Internet to expand their knowledge of general surgery (78.87%), learn more about technologies related to the practice of surgery (74.51%), access the Medline medical database (73.20%), and locate other resources for academic purposes (68%). Approximately half of them said that they favored the use of robotic assist devices in the operating room (53%), and most supported the use of technology for telementoring purposes (78%). Almost 80% professed an interest in video streaming technology applied to surgical education. CONCLUSIONS: This study showed that the Internet is a useful and powerful real-time survey tool that can help us to assess the impact of the World Wide Web and related technologies on surgical education and practice. However, the respondents in this study belong to a biased group that is already familiar with the Internet and computer technology and thus may not be representative of the surgical community as a whole.

National trends in gastroesophageal reflux surgery.

OBJECTIVES: To assess the surgical technique and the frequency of different types of antireflux surgery used in Canada after the introduction of laparoscopic antireflux surgery. DESIGN: Gastroesophageal reflux (GER) surgery and population data in fiscal years 1992 through 1996. were accessed through the Canadian Institute of Health Information, provincial health ministries, MED ECHO and Statistics Canada databases. Data were also analysed by province and nationally for type of surgery (e.g., open abdominal, thoracic, thoracoscopic and laparoscopic). RESULTS: National data showed a slight increase in GER surgery in the last 5 years. Laparoscopic surgery increased 2.8 fold in 1993 and 1.6 fold in 1995 over the previous years. Open abdominal cases decreased 1.1 fold from 1992 to 1996. Thoracic cases remained essentially unchanged. Provincial and regional disparities in procedures per 100,000 population exist (Ontario 7.1 versus Nova Scotia 20.7). Areas in which little or no laparoscopic surgery was done had an average increase of 3%, whereas areas in which laparoscopic surgery was done had an average increase of 16% in GER surgery during the course of the study. In provinces west of Quebec (with the exception of Manitoba) more than 50% of GER surgery is laparoscopic; in areas east of Ontario less than 25% of GER surgery is performed laparoscopically. Five provinces (Manitoba, Quebec, Nova Scotia, Prince Edward Island and Newfoundland) performed significantly fewer laparoscopic procedures than the national average. CONCLUSIONS: The frequency of GER surgery is increasing modestly in Canada and is performed most often by the open abdominal route. Regional disparities in open and laparoscopic techniques are apparent. Laparoscopic surgery for GER is increasing rapidly and accounts for the decrease in open GER surgery.