Preservation of deep epigastric perforators during anterior component separation technique (ACST) results in equivalent wound complications compared to transversus abdominis release (TAR).

PURPOSE: The use of component separation results in myofascial release and increased rates of fascial closure in abdominal wall reconstruction(AWR). These complex dissections have been associated with increased rates of wound complications with anterior component separation having the greatest wound morbidity. The aim of this paper was to compare the wound complication rate between perforator sparing anterior component separation(PS-ACST) and transversus abdominus release(TAR). METHODS: Patients were identified from a prospective, single institution hernia center database who underwent PS-ACST and TAR from 2015 to 2021. The primary outcome was wound complication rate. Standard statistical methods were used, univariate analysis and multivariable logistic regression were performed. RESULTS: A total of 172 patients met criteria, 39 had PS-ACST and 133 had TAR performed. The PS-ACST and TAR groups were similar in terms of diabetes (15.4% vs 28.6%, p = 0.097), but the PS-ACST group had a greater percentage of smokers (46.2% vs 14.3%, p < 0.001). The PS-ACST group had a larger hernia defect size (375.2 ± 156.7 vs 234.4 ± 126.9cm2, p < 0.001) and more patients who underwent preoperative Botulinum toxin A (BTA) injections (43.6% vs 6.0%, p < 0.001). The overall wound complication rate was not significantly different (23.1% vs 36.1%, p = 0.129) nor was the mesh infection rate (0% vs 1.6%, p = 0.438). Using logistic regression, none of the factors that were significantly different in the univariate analysis were associated with wound complication rate (all p > 0.05). CONCLUSION: PS-ACST and TAR are comparable in terms of wound complication rates. PS-ACST can be used for large hernia defects and promote fascial closure with low overall wound morbidity and perioperative complications.

Immunohistochemical analysis of host reaction to heavyweight-, reduced-weight-, and expanded polytetrafluoroethylene (ePTFE)-based meshes after short- and long-term intraabdominal implantations.

BACKGROUND: Prosthetic meshes induce a variety of inflammatory changes in the host, which may lead to excessive scarring with detrimental clinical consequences, especially in the long term. This study aimed to characterize the degree of short- and long-term inflammatory changes induced by common prosthetic meshes. METHODS: Twenty 4 x 4-cm samples each of expanded polytetrafluoroethylene (ePTFE), heavyweight polypropylene (hPP), ePTFE/heavyweight polypropylene (ePTFE/hPP), and reduced-weight polypropylene/regenerated cellulose (rPP) were implanted intraperitoneally in 40 rabbits for 4 or 12 months. After explantation, samples of mesh/tissue complex were analyzed for the degrees of cellular apoptosis (enzyme-linked immunoassay [ELISA]) and cellular turnover (mouse monoclonal antibody). RESULTS: In the short term, the degree of apoptosis in the hPP mesh was significantly higher than in the ePTFE and rPP groups. Similarly, it was higher in the ePTFE/hPP group than in either the ePTFE or the rPP group. The amount of Ki-67-positive cells was significantly higher in the hPP group than in the ePTFE or rPP group. The cell turnover in the ePTFE/hPP group was similar to that in the hPP group, but significantly higher than in either the ePTFE or the rPP group. The rPP group, in turn, had a higher Ki-67 score than the ePTFE group. In the long term, both the degree of apoptosis and Ki-67 positivity were significantly lower in the rPP and ePTFE groups than in either the ePTFE/hPP or the hPP group. A significant decrease in Ki-67 scores between the short and long-term groups was found only in the rPP group. CONCLUSION: In the short term, heavyweight polypropylene-based meshes were associated with significantly higher cell proliferation and death. A significantly higher degree of apoptosis and cell turnover were associated with heavyweight polypropylene-based meshes even 1 year after implantation, indicating ongoing inflammation and scar remodeling. On the other hand, ePTFE and reduced-weight polypropylene meshes were associated with nearly physiologic levels of inflammatory markers. Overall, an exaggerated and persistent host foreign body response to heavyweight polypropylene-based meshes indicates poor biocompatibility, with potential detrimental clinical sequela.

Staged hernia repair preceded by gastric bypass for the treatment of morbidly obese patients with complex ventral hernias.

BACKGROUND: Obesity may be the most predominant risk factor for recurrence following ventral hernia repair. This is secondary to significantly increased intra-abdominal pressures, higher rates of wound complications, and the technical difficulties encountered due to obesity. Medically managed weight loss prior to surgery is difficult. One potential strategy is to provide a surgical means to correct patient weight prior to hernia repair. METHODS: After institutional review board approval, we reviewed the medical records of all patients who underwent gastric bypass surgery prior to the definitive repair of a complex ventral hernia at our medical center. RESULTS: Twenty-seven morbidly obese patients with an average of 3.7 (range 1-10) failed ventral hernia repairs underwent gastric bypass prior to definitive ventral hernia repair. Twenty-two of the gastric bypasses were open operations and five were laparoscopic. The patients' average pre-bypass body mass index (BMI) was 51 kg/m2 (range 39-69 kg/m2), which decreased to an average of 33 kg/m2 (range 25-37 kg/m2) at the time of hernia repair at a mean of 1.3 years (range 0.9-3.1 years) after gastric bypass. Seven patients had hernia repair at the same time as their gastric bypass (four sutured, three biologic mesh), all of which recurred. Of the 27 patients, 19 had an open hernia repair and eight had a laparoscopic repair. Panniculectomy was performed concurrently in 15 patients who had an open repair. Prior to formal hernia repair, one patient required an urgent operation to repair a hernia incarceration and a small-bowel obstruction 11 months after gastric bypass. The average hernia and mesh size was 203 cm2 (range 24-1,350 cm2) and 1,040 cm2 (range 400-2,700 cm2), respectively. There have been no recurrences at an average follow-up of 20 months (range 2 months-5 years). CONCLUSION: Gastric bypass prior to staged ventral hernia repair in morbidly obese patients with complex ventral hernias is a safe and definitive method to effect weight loss and facilitate a durable hernia repair with a possible reduced risk of recurrence.

Severely disordered esophageal peristalsis is not a contraindication to laparoscopic Nissen fundoplication.

BACKGROUND: Laparoscopic Nissen fundoplication (LNF) is the preferred operation for the control of gastroesophageal reflux disease (GERD). The use of a full fundoplication for patients with esophageal dysmotility is controversial. Although LNF is known to be superior to a partial wrap for patients with weak peristalsis, its efficacy for patients with severe dysmotility is unknown. We hypothesized that LNF is also acceptable for patients with severe esophageal dysmotility. METHODS: A multicenter retrospective review of consecutive patients with severe esophageal dysmotility who underwent an LNF was performed. Severe dysmotility was defined by manometry showing an esophageal amplitude of 30 mmHg or less and/or 70% or more nonperistaltic esophageal body contractions. RESULTS: In this study, 48 patients with severe esophageal dysmotility underwent LNF. All the patients presented with symptoms of GERD, and 19 (39%) had preoperative dysphagia. A total of 10 patients had impaired esophageal body contractions, whereas 32 patients had an abnormal esophageal amplitude, and 6 patients had both. The average abnormal esophageal amplitude was 24.9 +/- 5.2 mmHg (range, 6.0-30 mmHg). The mean percentage of nonperistaltic esophageal body contractions was 79.4% +/- 8.3% (range, 70-100%). There were no intraoperative complications and no conversions. Postoperatively, early dysphagia occurred in 35 patients (73%). Five patients were treated with esophageal dilation, which was successful in three cases. One patient required a reoperative fundoplication. Overall, persistent dysphagia was found in two patients (4.2%), including one patient with severe preoperative dysphagia, which improved postoperatively. Abnormal peristalsis and/or distal amplitude improved postoperatively in 12 (80%) of retested patients. There were no cases of Barrett's progression to dysplasia or carcinoma. During an average follow-up period of 25.4 months (range, 1-46 months), eight patients (16%) were receiving antireflux medications, with six of these showing normal esophageal pH study results. CONCLUSION: The LNF procedure provides low rates of reflux recurrence with little long-term postoperative dysphagia experienced by patients with severely disordered esophageal peristalsis. Effective fundoplication improved esophageal motility for most of the patients. A 360 degrees fundoplication should not be contraindicated for patients with severe esophageal dysmotility.

Combined open and laparoscopic approach to chronic pain following open inguinal hernia repair.

INTRODUCTION: Chronic groin pain is the most common long-term complication after open inguinal hernia repair. Traditional surgical management of the associated neuralgia consists of injection therapy followed by groin exploration, mesh removal, and nerve transection. The resultant hernia defect may be difficult to repair from an anterior approach. We evaluate the outcomes of a combined laparoscopic and open approach for the treatment of chronic groin pain following open inguinal herniorrhaphy. METHODS: All patients who underwent groin exploration for chronic neuralgia after a prior open inguinal hernia repair were prospectively analyzed. Patient demographics, type of prior hernia repair, and prior nonoperative therapies were recorded. The operation consisted of a standard three trocar laparoscopic transabdominal preperitoneal hernia repair, followed by groin exploration, mesh removal, and nerve transection. Outcome measures included recurrent groin pain, numbness, hernia recurrence, and complications. RESULTS: Twelve patients (11 male and 1 female) with a mean age of 41 years (range 29-51) underwent combined laparoscopic and open treatment for chronic groin pain. Ten patients complained of unilateral neuralgia, one patient had bilateral complaints, and one patient complained of orchalgia. All patients failed at least two attempted percutaneous nerve blocks. Prior repairs included Lichtenstein (n=9), McVay (n=1), plug and patch (n=1), and Shouldice (n=1). There were no intraoperative complications or wound infections. With a minimum of 6 weeks follow up, all patients were significantly improved. One patient complained of intermittent minor discomfort that required no further therapy. Two patients had persistent numbness in the ilioinguinal nerve distribution but remained satisfied with the procedure. CONCLUSIONS: A combined laparoscopic and open approach for postherniorrhaphy groin pain results in good to excellent patient satisfaction with no perioperative morbidity. It may be the preferred technique for the definitive management of chronic neuralgia after prior open hernia repair.

Laparoscopic ventral hernia repair: a single center experience.

A retrospective chart review at the Carolinas Medical Center was performed on all patients who underwent laparoscopic ventral hernia repair (LVHR) from July 1998 through December 2003. LVHR was successfully completed in 270 of the 277 patients, or 98%, in whom it was attempted. Half of the patients (138/277) had at least one previous failed repair. The average defect measured 143.3 cm(2), and mesh was used in all repairs. The mean operating time was 168.3 min, mean blood loss was 50 cc, and average length of hospitalization was 3.0 days. Thirty-four complications occurred in 31 patients (11%). Only two mesh infections occurred (0.7%). At a mean follow-up period of 21 months, the rate of hernia recurrence was 4.7%. As experience grows and length of follow-up expands, LVHR may become the preferred approach for ventral hernia in difficult patients, especially obese patients and patients who have failed prior open repairs.

In vitro infectability of prosthetic mesh by methicillin-resistant Staphylococcus aureus.

Although mesh use is important for effective herniorrhaphy in adults, prosthetic infections can cause serious morbidity. Bacterial adherence to the mesh is a known precursor to prosthetic infection. We compared the ability of common mesh prosthetics to resist bacterial adherence. The meshes studied included polypropylene (Marlex, expanded polytetrafluoroethylene (PTFE) with and without silver chlorhexidine coating (DualMesh Plus and Dualmesh) composite meshes (Composix E/X, Proceed, and Parietex Composite) and lightweight polypropylene meshes (TiMesh, Ultrapro, and Vypro). Fifteen samples of each mesh type were individually inoculated with a suspension of 10(8 )methicillin-resistant Staphylococcus aureus (MRSA) in tryptic soy broth. After incubation at 37 degrees C for 1 h, the mesh pieces were then removed and serially washed. The colony-forming units (CFU) of MRSA present in the initial inoculum, at the end of the 1-h warm-water bath (broth count), and the pooled washes (wash count), were determined using serial dilutions and spot plating. The bacteria not accounted for in the broth or wash counts were considered adhered to the mesh. Samples of each mesh type were also analyzed using scanning electron microscopy (SEM). Data are presented as the mean percentage adherence with ANOVA and Tukey's test used to determine significance (P<0.05). The DualMesh Plus mesh had no detectable MRSA in the broth or the pooled wash samples. Dualmesh had less adherence compared with Marlex, Proceed, and Vypro (P<0.05). Conversely, Vypro had a statistically higher adherence (96%, P<0.05) as compared to TiMesh, Ultrapro, Composix E/X, and Parietex Composite. SEM confirmed bacterial adherence to all the mesh types except DualMesh Plus. The ability of a biomaterial to resist infection has an important clinical significance. DualMesh Plus, due to its antimicrobial coating, is the only mesh type of the nine tested that demonstrated a bactericidal property. Standard PTFE (Dualmesh) also had less bacterial adherence. Vypro demonstrated an increase in bacterial adherence; this was possibly due to the multifilament polyglactin 910 weaved within the prolene component of the mesh.

Multimedia article. Laparoscopic management of median arcuate ligament syndrome.

Median arcuate ligament syndrome is a rare disorder resulting from luminal narrowing of the celiac artery by the insertion of the diaphragmatic muscle fibers or fibrous bands of the celiac nervous plexus. The syndrome is characterized by weight loss, postprandial abdominal pain, nausea, vomiting, and an epigastric bruit. Surgical management entails complete division of the median arcuate ligament. The video demonstrates the laparoscopic release of the median arcuate ligament in a patient with median arcuate ligament syndrome. The patient is a 22-year-old male with a 6-month history of epigastric abdominal pain, nausea, vomiting, a 140-lb. weight loss, and an epigastric bruit on physical exam. Aortography demonstrated a >or=90% extrinsic compression of the celiac artery. A full laparoscopic skeletonization of the celiac artery and branch vessels was performed. Intraoperative duplex U/S demonstrated flow rate reduction after the median arcuate ligament release. A postoperative CT angiogram demonstrated no residual stenosis. The patient was discharged on postoperative day 3 and remained asymptomatic after 7 months of follow-up. Laparoscopic release of the median arcuate ligament is a novel approach to the management of celiac artery compression syndrome. The role of minimally invasive techniques to manage median arcuate ligament syndrome is evolving but they appear to be a safe alternative to open surgery.

Do patient or hospital demographics predict cholecystectomy outcomes? A nationwide study of 93,578 patients.

BACKGROUND: The purpose of this study was to examine the influence of patient and hospital demographics on cholecystectomy outcomes. METHODS: Year 2000 data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database was obtained for all patients undergoing inpatient cholecystectomy at 994 nationwide hospitals. Differences (p < 0.05) were determined using standard statistical methods. RESULTS: Of 93,578 cholecystectomies performed, 73.4% were performed laparoscopically. Length of hospital stay (LOS), charges, morbidity, and mortality were significantly less for laparoscopic cholecystectomy (LC). Increasing patient age was associated with increased LOS, charges, morbidity, mortality, and a decreased LC rate. Charges, LOS, morbidity, and mortality were highest for males with a lower LC rate than for females Mortality and LOS were higher, whereas morbidity was lower for African Americans than for whites. Hispanics had the shortest LOS, as well as the lowest morbidity and mortality rates. Laparoscopic cholecystectomy was performed more commonly for Hispanics than for whites or African Americans, with lower charges for whites. Medicare-insured patients incurred longer LOS as well as higher charges, morbidity, and mortality than Medicaid, private, and self-pay patients, and were the least likely to undergo LC. As median income decreases, LOS increases, and morbidity decreases with no mortality effect. Teaching hospitals had a longer LOS, higher charges, and mortality, and a lower LC rate, with no difference in morbidity, than nonteaching centers. As hospital size (number of beds) increased, LOS, and charges increased, with no difference in morbidity. Large hospitals had the highest mortality rates and the lowest incidence of LC. Urban hospitals had higher LOS and charges with a lower LC rate than rural hospitals. After control was used for all other covariates, increased age was a predictor of increased morbidity. Female gender, LC, and intraoperative cholangiogram all predicted decreased morbidity. Increased age, complications, and emergency surgery predicted increased mortality, with laparoscopy and intraoperative cholangiogram having protective effects. Patient income, insurance status, and race did not play a role in morbidity or mortality. Academic or teaching status of the hospital also did not influence patient outcomes. CONCLUSIONS: Patient and hospital demographics do affect the outcomes of patients undergoing inpatient cholecystectomy. Although male gender, African American race, Medicare-insured status, and large, urban hospitals are associated with less favorable cholecystectomy outcomes, only increased age predicts increased morbidity, whereas female gender, laparoscopy, and cholangiogram are protective. Increased age, complications, and emergency surgery predict mortality, with laparoscopy and intraoperative cholangiogram having protective effects.

Evaluation of adhesion formation, mesh fixation strength, and hydroxyproline content after intraabdominal placement of polytetrafluoroethylene mesh secured using titanium spiral tacks, nitinol anchors, and polypropylene suture or polyglactin 910 suture.

BACKGROUND: The purpose of this study is to evaluate fixation methods for polytetrafluoroethylene (ePTFE) mesh with an in vivo model of laparoscopic ventral hernia repair. METHODS: In 40 New Zealand white rabbits, a 4 x 4-cm ePTFE mesh (n = 80, two per animal) was attached to an intact peritoneum with polyglactin 910 (PG 910) (n = 20) or polypropylene (PP) (n = 20) suture, titanium spiral tacks (TS) (n = 20), or nitinol anchors (NA) (n = 20). Mesh was harvested at 8 and 16 weeks for fixation strength testing, adhesion assessment, and collagen (hydroxyproline) content. Fixation strength on day 0 was determined with mesh attached to harvested abdominal wall. Statistical significance was determined as p < 0.05. RESULTS: There was no difference in fixation strength between PP (39.1 N) and PG 910 (40.0 N) sutures at time zero. At week 8, PP (25.7 N) was significantly stronger (p < 0.05) than PG 910 (11.4 N) suture, but not at week 16. The fixation strength of TS and NA (day 0, 15.4 vs 7.4 N; week 8, 17.5 vs 15.3 N; week 16, 19.1 vs 13.8 N) was not significantly different. Fixation with PP suture was significantly (p < 0.05) stronger than that with TS and NA at day 0 (39.1, 15.4, and 7.4 N, respectively) but not at weeks 8 or 16. The fixation strength of suture decreased significantly (p < 0.05) from day 0 to week 16 (PP: day 0 = 39.1 N, week 8 = 25.7 N, week 16 = 21.4 N; PG 910: day 0 = 40.0 N, week 8 = 11.4 N, week 16 = 12.8 N). The fixation strength of NA and TS did not change significantly (NA: day 0 = 7.4 N, week 8 = 15.3 N, week 16 = 13.8 N; TS: week 0 = 15.4 N, week 8 = 17.5 N, week 16 = 19.1 N). There were no differences in adhesion area based on fixation device used; however, there were more (p < 0.05) mesh samples using NA with adhesions compared to TS and adhesion tenacity was greater (p < 0.05) compared to that of TS, PP, and PG. Hydroxyproline content at weeks 8 and 16 was similar for all fixation devices. CONCLUSIONS: The initial fixation strength for nonabsorbable suture is significantly greater than that of the metallic fixation devices, but after 8 weeks there is no difference. Laparoscopic ventral hernia repair without transabdominal suture fixation may be predisposed to acute failure. The metallic devices have similar fixation strength, although the incidence of adhesions and tenacity of adhesions appear to be greater with the nitinol anchors. Since these devices have similar fixation strengths and most likely provide adequate supplementation to transabdominal sutures for mesh fixation after laparoscopic ventral hernia repair, their use should be based on other factors, such as their propensity for adhesions, ease of application, and cost.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model.

BACKGROUND: The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation. METHODS: A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7. RESULTS: Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers. CONCLUSIONS: This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

Cirrhosis is not a contraindication to laparoscopic surgery.

BACKGROUND: Cirrhosis of the liver contributes significantly to morbidity and mortality in abdominal surgery. The proven benefits of laparoscopy seem especially applicable to patients with this complex disease. This study evaluates the safety and efficacy of laparoscopic procedures in a series of consecutively treated patients with biopsy-proven cirrhosis. METHODS: The medical records of all patients with biopsy-proven cirrhosis undergoing laparoscopic surgery at the authors' medical center between January 2000 and December 2003 were retrospectively reviewed. RESULTS: A total of 50 patients (27 men and 23 women) underwent 52 laparoscopic procedures. Among these 50 patients were 39 patients with Child-Pugh classification A cirrhosis, 10 with classification B, and 1 with classification C, who underwent a variety of laparoscopic procedures including cholecystectomy (n = 22), splenectomy (n = 18), colectomy (n = 4), diagnostic laparoscopy (n = 3), ventral hernia repair (n = 1), Nissen fundoplication (n = 1), Heller myotomy (n = 1), Roux-en-Y gastric bypass (n = 1), and radical nephrectomy (n = 1). There were two conversions (4%) to an open procedure. The mean operative time was 155 min. Estimated blood loss averaged 124 ml for all procedures, and 20 patients (40%) required perioperative transfusion of blood products. One patient required a single blood transfusion postoperatively because of anemia. No one experienced hepatic decompensation. Overall morbidity was 16%. There were no deaths. The mean length of hospitalization was 3 days. CONCLUSIONS: Although technically challenging because portal hypertension, varices, and thrombocytopenia frequently coexist, basic and advanced laparoscopic procedures are safe for patients with mild to moderate cirrhosis of the liver.

The susceptibility of prosthetic biomaterials to infection.

BACKGROUND: Despite the use of a sterile technique and the administration of prophylactic antibiotics during surgical procedures, mesh infection continues to complicate the use of biomaterials. The purpose of this study was to compare the susceptibility to infection of prosthetic biomaterials in a live-animal model. METHODS: The following seven prosthetic mesh biomaterials were used in this study. Expanded polytetrafluoroethylene (ePTFE) with silver/chlorhexidine (DM+), ePTFE (DM), porcine intestinal submucosa (S), polypropylene (M), ePTFE/polypropylene (X), hyaluronate/carboxymethylcellulose/polypropylene (SM), and human acellular dermal matrix (A). Lewis rats (n = 108) underwent creation of a single ventral hernia; 105 of them were repaired with a different mesh (2-cm2 piece). Twelve pieces of each mesh were inoculated at the time of hernia repair with 10(8) Staphylococcus aureus (n = 84). Three pieces of each mesh were placed without bacterial inoculation (n = 21). In three animals, no mesh was placed; instead, the peritoneum of the hernia defect was inoculated (n = 3). After 5 days, the animals were killed and the mesh was explanted (peritoneum for the nonmesh control). The mesh was vortex-washed and incubated in tryptic soy broth. Bacterial counts were determined using serial dilutions and spot plates and quantified in colony-forming units (CFU) per square centimeter of mesh present in the vortex wash fluid (wash count) and the soy broth (broth count). Data are presented as the mean log(10), with analysis of variance (ANOVA) and Tukey's test used to determine significance (p < 0.05). RESULTS: The DM+ material had no detectable live bacteria in the wash or broth counts in 10 of 12 tested samples (p = 0.05). Of the samples that showed bacterial growth, the peritoneum control group had a lower wash count than A (p = 0.05) and the lowest broth count of all the materials except for DM+ (p = 0.05). In addition, SM had a significantly lower wash count than A (p = 0.05), with no broth count difference. In regard to wash and broth counts, DM, M, X, SM, S, and A were no different (p = NS). CONCLUSIONS: The DM+ material was the least susceptible to infection. Impregnation with silver/chlorhexidine killed the inoculated bacteria, preventing their proliferation on the mesh surface. Other than DM+, native peritoneal tissue appears to be the least susceptible to infection. Silver/chlorhexidine appears to be an effective bactericidal agent for use with mesh biomaterials.

The laparoscopic repair of suprapubic ventral hernias.

BACKGROUND: The complexity of dissection and the close proximity of the hernia to bony, vascular, nerve, and urinary structures make the laparoscopic repair of suprapubic hernias (LRSPH) a formidable operation. We performed a prospective evaluation of the outcomes of patients undergoing LRSPH. METHODS: The study population comprised 36 patients undergoing LRSPH from July 1996 to January 2004. Patient demographics, hernia sizes, mesh types and sizes, perioperative outcomes, and recurrences were documented. After our early experience with this operation, the repair evolved to include transabdominal suture fixation to the pubic bone, Cooper's ligament, and above the iliopubic tract. RESULTS: There were 26 women and 10 men. They had a mean age of 55.9 years (range, 33-76) and a mean body mass index (BMI) of 31.0 kg/m2 (range, 22-67). Twenty-two (61%) of the repairs were for recurrent hernias, with an average of 2.3 previously failed open repairs each (range, 1-11). The mean hernia size was 191.4 cm2 (range, 20-768), and the average mesh size was 481.4 cm2 (range, 193-1,428). All repairs were performed with expanded polytetrafluoroethylene (ePTFE) mesh. Mean operating time was 178.7 min (range, 95-290). Mean blood loss was 40 cc (range, 20-100). One patient undergoing her fifth repair required conversion due to adhesions to a polypropylene mesh. Hospital stay averaged 2.4 days (range, 1-7). Mean follow-up was 21.1 months (range, 1-70). Complications (16.6%) included deep venous thrombosis (n = 1), prolonged pain for >6 weeks (n = 1), trocar site cellulitis (n = 1), ileus (n = 1), prolonged seroma (n = 1), and Clostridium difficile colitis (n = 1). Hernias recurred in two of our first nine patients, for an overall recurrence rate of 5.5%. Since we began using the technique of applying multiple sutures directly to the pubis and Cooper's ligament (in the subsequent 27 patients), no recurrences have been documented. CONCLUSIONS: Although technically demanding and time-consuming, the LRSPH is safe and technically feasible. Moreover, it results in a low recurrence rate and is applicable to large or multiply recurrent hernias. Transabdominal suture fixation to the bony and ligamentous structures produces a more durable hernia repair.

A novel technique of lumbar hernia repair using bone anchor fixation.

Lumbar hernias are difficult to repair due to their proximity to bone and inadequate surrounding tissue to buttress the repair. We analyzed the outcome of patients undergoing a novel retromuscular lumbar hernia repair technique. The repair was performed in ten patients using a polypropylene or polytetrafluoroethylene mesh placed in an extraperitoneal, retromuscular position with at least 5 cm overlap of the hernia defect. The mesh was fixed with circumferential, transfascial, permanent sutures and inferiorly fixed to the iliac crest by suture bone anchors. Five hernias were recurrent, and five were incarcerated; seven were incisional hernias, and three were posttraumatic. Back and abdominal pain was the most common presenting symptom. Mean hernia size was 227 cm(2) (60-504) with a mesh size of 620 cm(2) (224-936). Mean operative time was 181 min (120-269), with a mean blood loss of 128 ml (50-200). Mean length of stay was 5.2 days (2-10), and morphine equivalent requirement was 200 mg (47-460). There were no postoperative complications or deaths. After a mean follow-up of 40 months (3-99) there have been no recurrences. Our sublay repair of lumbar hernias with permanent suture fixation is safe and to date has resulted in no recurrences. Suture bone anchors ensure secure fixation of the mesh to the iliac crest and may eliminate a common area of recurrence.

Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series.

STUDY OBJECTIVES: Previous articles have promoted the early use of thoracotomy and decortication for refractory empyema. This study examines thoracoscopy and decortication at the time of initial chest tube placement in pediatric patients with parapneumonic empyema. DESIGN: We reviewed the medical records of 16 consecutive patients who were children with parapneumonic empyema. RESULTS: Thirteen children (group 1) underwent thoracoscopic decortication and tube thoracostomy as their initial operative procedures; 3 children (group 2) had tube thoracostomy alone. In both groups, chest tubes were removed prior to their discharge to home. The mean (+/- SD) operative time for thoracoscopy was 81 +/- 19 min with no complications. On average, chest tubes were removed by postoperative day 4. The mean time to discharge was 8.3 days. Two children eventually required lobectomy. The mean operative time for chest tube placement alone was 21 +/- 3 min. Children required chest tube drainage for an average of 12.3 days. The mean time to discharge was 16.6 days. Two patients required a total of five additional operative procedures, including two additional chest tube placements, two open decortications, and one lobectomy. CONCLUSIONS: Thoracoscopic decortication is effective in the early treatment of pediatric parapneumonic empyema. It facilitates visualization, evacuation, and mechanical decortication of the pleural space with no additional morbidity and may lead to reduced time for chest tube drainage, shorter hospitalization, and more rapid clinical recovery.

Minimally invasive management of paraesophageal herniation in the high-risk surgical patient.

BACKGROUND: Traditional management of symptomatic paraesophageal herniation involves hernia reduction, hiatal closure, and an antireflux procedure or gastropexy. Patients with significant comorbidities may not tolerate operative repair. A new technique, laparoscopic-assisted endoscopic reduction and fixation of the stomach, may provide a minimally invasive treatment alternative. METHODS: Eleven elderly patients with symptomatic paraesophageal herniation were managed with flexible endoscopy and double percutaneous endoscopic gastrostomy (PEG) tube insertion with or without laparoscopic assistance. RESULTS: All patients presented with a symptomatic paraesophageal hernia. Mean age was 78.3 years (range 72 to 84). Each was deemed at high risk for definitive repair due to preexisting coronary artery disease as well as at least two other serious comorbidities. Hernia reduction and intra-abdominal fixation of the stomach was achieved in each case using flexible endoscopy and double PEG insertion. Laparoscopic assistance for reduction and gastropexy was utilized in 9 cases. Mean operative time was 61 minutes (range 28 to 104). Average length of stay was 2.8 days (range 0 to 12). One minor and three major postoperative complications occurred. Over a mean follow-up of 4.1 months (range 2 to 7), all patients have resumed oral intake and achieved weight gain. CONCLUSIONS: Patients with symptomatic paraesophageal herniation require intervention to alleviate symptoms and avoid the complications of gastric incarceration. For the high-risk patient, endoscopic reduction and PEG with laparoscopic assistance appears to provide effective treatment.

Laparoscopic adrenalectomy for pheochromocytoma.

BACKGROUND: Laparoscopic adrenalectomy for Conn's syndrome, Cushing's disease, cortisol-producing adenomas, and nonfunctioning adenomas has been well established. This study was intended to evaluate the clinical outcomes of patients undergoing laparoscopic adrenalectomy for pheochromocytoma, and to assess the efficacy and safety of a minimally invasive approach. METHODS: Data were collected prospectively on all patients undergoing laparoscopic adrenalectomy for pheochromocytoma over a 5-year period. RESULTS: In this study, 39 consecutive patients underwent laparoscopic resection of a pheochromocytoma: 38 adrenal (23 left, 15 right) and 1 extraadrenal paraganglioma. There were no conversions to open surgery. The mean tumor size was 5.2 cm (range, 2-12.1 cm). Average operative time was 159 min (range, 100-265 min), and average estimated blood loss was 72 ml (range, 30-350 ml). Intraoperative hypertension (systolic blood pressure > 170 mmHg) occurred in 67% of the patients, and hypotension (systolic blood pressure < 90 mmHg) in 39% of the patients. The mean length of stay was 2.1 days (range, 1-4 days). There were three minor postoperative complications. During a mean follow-up period of 14 months, there were no mortalities or recurrences of endocrinopathy. CONCLUSIONS: Laparoscopic resection of pheochromocytomas can be accomplished safely despite frequent episodes of hemodynamic variability equal to those of historic open control subjects. A short hospital stay with expedient recovery,minimal wound complications, and lack of endocrinopathy recurrence makes a minimally invasive approach the procedure of choice for the management of pheochromoctyoma.

Laparoscopic repair of traumatic diaphragmatic injuries.

BACKGROUND: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. METHODS: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15-63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0-6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5-420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). RESULTS: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5-12 cm). The mean operative time was 134.7 min (range, 55-200 min). The mean estimated blood loss was 108.5 ml (range, 30-500 ml), and the postoperative length of stay was 4.4 days (range, 1-12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6-14 days). CONCLUSIONS: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.

Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries.

BACKGROUND: Advanced laparoscopic procedures have necessitated the development of new technology for vascular control. Suture ligation can be time-consuming and cumbersome during laparoscopic dissection. Titanium clips have been used for hemostasis, and recently plastic clips and energy sources such as ultrasonic coagulating shears and bipolar thermal energy devices have become popular. The purpose of this study was to compare the bursting pressure of arteries sealed with ultrasonic coagulating shears (UCS), electrothermal bipolar vessel sealer (EBVS), titanium laparoscopic clips (LCs), and plastic laparoscopic clips (PCs). In addition, the spread of thermal injury from the UCS and the EBVS was compared. METHODS: Arteries in three size groups (2-3, 4-5 and 6-7 mm) were harvested from freshly euthanized pigs. Each of the four devices was used to seal 16 specimens from each size group for burst testing. A 5-Fr catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end. This defined the bursting pressure in mmHg. The ultrasonic shears and bipolar thermal device were used to seal an additional 8 vessels in each size group, which were sent for histologic examination. These were examined with hematoxylin and eosin stains, and the extent of thermal injury, defined by coagulation necrosis, was measured in millimeters. Analysis of variance was performed and, where appropriate, a Tukey's test was also performed. RESULTS: The EBVS's mean burst pressure was statistically higher than that of the UCS at 4 or 5 mm (601 vs 205 mmHg) and 6 or 7 mm (442 vs 175 mmHg). EBVS had higher burst pressures for the 4 or 5-mm group (601 mmHg) and 6 or 7-mm group (442 mmHg) compared with its pressure at 2 or 3 mm (128 mmHg) ( p = 0.0001). The burst pressures of the UCS and EBVS at 2 or 3 mm were not significantly different. Both clips were statistically stronger than the thermal devices except at 4 or 5 mm, in which case the EBVS was as strong as the LC (601 vs 593 mmHg). The PC and LC were similar except at 4 or 5 mm, where the PC was superior (854 vs 593 mmHg). The PC burst pressure for 4 or 5 mm (854 mmHg) was statistically higher than that for vessels 2 or 3 mm (737 mmHg) but not different from the 6 or 7 mm pressure (767 mmHg). Thermal spread was not statistically different when comparing EBVS and UCS at any size (EBVS mean = 2.57 mm vs UCS mean = 2.18 mm). CONCLUSIONS: Both the PC and LC secured all vessel sizes to well above physiologic levels. The EBVS can be used confidently in vessels up to 7 mm. There is no difference in the thermal spread of the LigaSure vessel sealer and the UCS.