Large ventral hernias: to drain And what to drain That is the question!

BACKGROUND: Drain placement is common practice in repair of ventral hernias, specifically complex hernias. There is little-to-no evidence for benefit of drains and best practice in-terms of number, position, duration of use and type of drains. This study investigates drain profile in open repair of large ventral hernias. METHODS: A retrospective two-centres audit with data collected via electronic and paper-based medical records from the 1 February 2015 to 29 June 2020. All elective and emergency cases were included. Main outcomes included surgical site infection (SSI), seroma and hematoma formation. RESULTS: A total of 186 patients included, out of those 128(68.5%) had drain placed. Drain placement had a higher incidence of SSI (20.3% in drain group and 15.5% in no drain group), however, drains were more likely to be placed in complex ventral hernias. Drain practice varied significantly between surgeons, however, there was a clear trend to higher SSI rates with longer duration of drain use (specifically longer than 5 days, p-value: 0.05) and higher drain output on removal (specifically higher than 150 ml/24 h, p-value 0.004), furthermore, prolonged use did not decrease risk of seroma formation. Drain position, number of drains and suction pressure did not affect seroma or SSI rates. CONCLUSION: Our data suggests no clear benefits of drain usage in most ventral hernia repairs. Prolonged drain use led to higher risk of SSI and did not decrease rate of seroma formation. If used, we recommend use of short drain duration<5 days. Further RCTs to evaluate drain placement in large ventral hernias are needed.

Early outcomes of two-stage minimally invasive oesophagectomy in an Australian institution.

BACKGROUND: Minimally invasive oesophagectomy (MIO) has a steep learning curve. We report our outcomes of a standardized 25 mm circular-stapled anastomosis using a trans-orally placed anvil (Orvil™). The objective of this study is to report the initial experience of introducing two-stage MIO to an Australian tertiary health service. METHODS: We describe our consecutive case series of all MIOs performed from a prospectively maintained database. We assessed the morbidity and mortality of MIO at our institution. We compared our first 30 cases to the second cohort of 32 cases. RESULTS: There were 62 two-stage MIOs performed from 2011 to 2015. The average age was 65 years. Median length of stay was 13 days (5-72 days). Median number of total lymph nodes was 14. Conversion occurred in three patients (5%). Major morbidity was 45%. Delayed gastric emptying 6% (n = 4), pneumonia 6% (n = 4), chyle leak 6% (n = 4), pulmonary embolus 2% (n = 1) and grade II or III anastomotic leak 5% (n = 4). One conduit ischaemia (2%) required reoperation and formation of oesophagostomy. There was one post-operative death within 30 days. There were five post-oesophagectomy hiatal hernias requiring re-operation (8%). There was a significant improvement in operative time (minutes) from the first to second cohort 588 versus 464 (P-value 0.01). CONCLUSION: The introduction of two-stage MIO to the Australian setting can be safely instituted. Our unit was still within a learning curve after 30 cases.

Acute visceral obstruction.

Gastric volvulus is a rare cause for acute visceral obstruction, with a high mortality rate that rises with delay in definitive treatment. A 33-year-old woman with a rare chromosomal mutation (46,XX,del(6)(q25.1q25.3)) presented with evidence of acute visceral obstruction. Diagnostic difficulties delayed treatment and she clinically deteriorated. Urgent CT imaging revealed acute mesentero-axial gastric volvulus. At laparotomy, global failure of colonic and splenic fixation was found. The viscera were de-rotated, the stomach salvaged and gastropexy and colopexy were performed. This is the first report of gastric volvulus secondary to congenital absence of colonic and splenic ligamentous attachments occurring in a patient over 30 years of age. This case is interesting not only due to unique pathology, but also highlights that general surgeons must be aware of the possibility of unusual causes for intestinal obstruction in patients with recognised genetic abnormalities, even in adult cases, to avoid harmful diagnostic delay.

Diagnosis and management of gastric leaks after laparoscopic sleeve gastrectomy for morbid obesity.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is increasingly being recognised as a valid stand-alone procedure for the surgical management of morbid obesity. The leak rate from the gastric staple line ranges from 1.4% to 20%. From our experience of management of LSG leaks, we have been able to formulate an algorithm-based approach to the management of these patients. METHODS: All patients referred to our hospital within a 24-month period with a diagnosis of gastric staple line leak in the background of a previous LSG were included in the study. A retrospective case note review was undertaken for these patients and an algorithm formulated. RESULTS: There were fourteen patients in the study. There were four males and ten females. Patients were managed with a combination of laparotomy, laparoscopy, endoscopic covered stenting, percutaneous radiologically guided drainage,jejunal enteric feeding and total parenteral nutrition. In five patients, re-look laparoscopy or laparotomy with washout and drainage was performed. The remaining eight patients were managed conservatively. There were no deaths. CONCLUSIONS: Although it is often disappointing when LSG leaks do occur, with adherence to the basic tenets of the surgical management of enterocutaneous fistulae as well as early detection and a high index of suspicion, these complications can be successfully managed using an algorithm-based multi-disciplinary team approach.