Case report: Laparoscopic totally extraperitoneal repair of an obturator hernia with self-gripping mesh under spinal anaesthesia.

INTRODUCTION: Obturator hernias account for less than 0.073% of all hernias and less than 1.6% of all cases of mechanical bowel obstructions. PRESENTATION OF CASE: We present a case of a 79 year-old elderly female with two recurrent bowel obstructions that have resolved with conservative management. On the third presentation we performed a totally extraperitoneal repair (TEP) with conscious sedation and a L3/4 spinal block. An obturator defect was patched with a self gripping mesh (progrip). The patient was discharged day 2 post operatively. DISCUSSION: Laparoscopic surgery can be safely performed in high risk patients with careful monitoring. Laparoscopic surgery is usually associated with a shorter post-operative length of stay. CONCLUSION: This case demonstrates the successful but unconventional repair of an obturator hernia in a patient who had a high risk of significant morbidity and mortality with a more conventional anaesthesia and surgery.

Laparoscopic inguinal hernia repair without mesh fixation, early results of a large randomised clinical trial.

BACKGROUND: A new persistent groin pain is reported by a significant number of patients following laparoscopic totally extraperitoneal hernia repair (TEP). Mesh fixation has been implicated as a possible cause, but is widely considered essential for mesh stabilization and early recurrence prevention. This study investigates whether any association exists between mesh fixation by metal tacks and the incidence of new groin pain or early hernia recurrence. METHODS: A prospective multicenter double-blinded randomised trial was conducted between December 2004 and January 2006. Standardized TEP repair was performed with a rectangular 10 x 15cm polypropylene mesh. Hernia were randomized to either mesh fixation by metal tacks or left entirely unfixated. Clinical review by physical examination was performed by a separate blinded surgeon after a minimum of six months, with another review planned after two years. The incidence of new groin pain and recurrence were compared. RESULTS: Five hundred herniae in 360 patients were entered into the study. At the first wave of clinical follow-up (median eight, range 6-13 postoperative months) a new pain was reported by 38 versus 23% (p = 0.003), occurring at least once a week in 22 versus 15% (p = 0.049), or several times per week in 16 versus 8% (p = 0.009) for fixated versus unfixated repairs, respectively. Patients with bilateral repairs were five times more likely to report the unfixated side being more comfortable (p = 0.006). There was one recurrence in the fixated group (1/247) whilst none have yet occurred in the unfixated group. Fixation increased operative costs by approximately 375 AUD. CONCLUSION: Mesh fixation in TEP is associated with increased operative cost and chronic pain but no difference in the risk of hernia recurrence at six months was observed.

Laparoscopic gastric resection for benign and malignant conditions: lessons learned from 35 consecutive cases.

INTRODUCTION: Despite significant advances in laparoscopy, gastric surgery is still generally carried out by conventional open techniques. The aim of the study was to report the short- and medium-term outcomes of gastric surgery when carried out laparoscopically for a variety of benign and malignant conditions. METHODS: A retrospective review was carried out for all patients who underwent a laparoscopic gastric resection between January 2000 and September 2006. Follow up was carried out at the private consulting rooms and by telephone interview. RESULTS: Thirty-five consecutive laparoscopic gastric resection were carried out in 31 patients for a variety of benign lesions, six early gastric cancer and 13 adenocarcinomas. The totally intracorporeal laparoscopic procedures included four total, eight distal and 21 partial gastrectomies. There were two open conversions (6%). There was one in-hospital mortality (3%) and one non-fatal anastomotic leak. Median operative duration and length of stay were 75, 205 and 252 min and 5, 6.5 and 8 days for laparoscopic partial, distal and total gastrectomy, respectively. After malignant resections, there were six recurrences; however, 15 patients remained disease-free at up to 60 months follow up. CONCLUSION: Laparoscopic gastric resection is feasible with good short- and medium-term results and may be an appropriate treatment option in selected cases.

Laparoscopic bile duct exploration: results of 160 consecutive cases with 2-year follow up.

BACKGROUND: Despite numerous reports showing the advantages of laparoscopic common bile duct exploration (LCBDE), many general surgeons, particularly those working outside of nonspecialist units, continue to rely heavily on endoscopic retrograde cholangiography with sphincterotomy (ERCP) to manage bile duct stones (BDS). This article investigates the performance of LCBDE when adopted as the preferred first-line management of both suspected and incidental BDS by general surgeons in a regional setting. METHODS: A retrospective review was conducted of all patients in whom LCBDE was attempted by a regional general surgical unit. The unit policy was to preferentially treat all incidental and suspected BDS (except in ascending cholangitis or severe pancreatitis) by LCBDE, with ERCP used only if unsuccessful. In addition to chart review, formal prospective follow up by telephone interview was carried out. RESULTS: A total of 160 consecutive patients with BDS (mean age 66.9 years, 65% suspected and 35% incidental) underwent attempted LCBDE between January 2000 and July 2005. Successful clearance was achieved in 84.3% according to chart review. However, four additional cases of retained choledocholithiasis shown by late telephone interview (median interval 2.5 years) yielded a more accurate clearance rate of 81.8%. Major morbidity occurred in 13.8%, including biliary leak in 7.5% and one late biliary stricture (0.6%). Median length of hospital stay was 4.8 days. In-hospital mortality was 0.6%. CONCLUSION: Laparoscopic common bile duct exploration remains an effective, efficient and safe first-line treatment of BDS even when carried out in regional nonspecialist units. In spite of the wide availability of ERCP, general surgeons should be encouraged to continue performing LCBDE in order to optimise patient care and maintain important surgical skills.

Early Australian experience in robotic sleeve gastrectomy: a single site series.

BACKGROUND: The use of robotic platforms in bariatric surgery has recently gained relevance. With an increased use of this technology come concerns regarding learning curve effects during the initial implementation phase. The sleeve gastrectomy though may represent an ideal training procedure for introducing the robot into bariatric surgical practice. The present review of the first 10 consecutive robotic sleeve gastrectomy procedures performed in an Australian bariatric programme by a single surgeon describes the evolution of the technique, learning curve and initial patient outcomes. METHODS: Between 2014 and 2015, robotic sleeve gastrectomies were performed as primary and revisional procedures by a consistent surgeon-assistant team. Technique evolution and theatre set-up were documented. Patient demographics, operative time (robot docking and total operation time), additional operative procedures performed, operative and post-operative complications at 1, 3 and 6 months post-procedure and weight loss achieved at 6 months were retrospectively reviewed from a prospectively maintained database. RESULTS: Ten robotic sleeve gastrectomies were performed without significant operative complications. One patient was treated as an outpatient with oral antibiotics for a superficial wound infection. The median total operative time was 123 min (interquartile range (IQR) 108.8-142.5), with a median incision to docking time of 19 min (IQR 15.0-31.8). Length of stay in hospital was 2-3 days. Median excess weight loss achieved at 6 months was 50% (IQR 33.9-66.5). CONCLUSION: This study describes a method of safely introducing the da Vinci robot into bariatric surgical practice.

A case report of gastric lymphocytic phlebitis, a rare mimic for malignancy.

INTRODUCTION: Lymphocytic phlebitis is a benign condition characterised by inflammation of the veins and rarely affects the gastrointestinal tract. Reported cases present as acute abdomen and involve the colon or small intestine. We report the fourth case of gastric lymphocytic phlebitis in the literature. PRESENTATION OF CASE: A 74-year-old female presented with eight weeks of abdominal pain. Findings at endoscopy were suggestive of a malignant ulcer on the greater curvature of antrum, while biopsies showed chronic gastritis without malignancy. Appearance at diagnostic laparoscopy was consistent with a malignant gastric ulcer with serosal changes. Due to persistent pain and the macroscopic appearance, she proceeded to have an open subtotal gastrectomy and D2 lymph node clearance. Despite macroscopic appearance, the microscopic examination demonstrated no malignancy, and was consistent with lymphocytic phlebitis with overlying ulceration. DISCUSSION: This case was a mimic for gastric malignancy, with the benign diagnosis only being made after surgical resection. Gastric lymphocytic phlebitis is a rare differential diagnosis for gastric ulcers when biopsies are negative, although preoperative diagnosis is difficult given the lesions do not involve the mucosa. CONCLUSION: If clinical history and endoscopic findings are suspicious for malignancy, despite normal biopsies, an aggressive surgical resection remains reasonable given the rarity gastric lymphocytic phlebitis.

Perforated diverticulitis managed by laparoscopic lavage.

BACKGROUND: Traditionally the management of acute diverticulitis complicated by perforation has been the Hartmann's procedure, which may be associated with significant morbidity and mortality and the unpleasantness of a colostomy. We present our early experience in managing perforated diverticulitis acutely by laparoscopic lavage and drainage. METHODS: A retrospective review was conducted of all patients with surgically confirmed perforated diverticulitis. Details concerning the nature of presentation, operative findings, postoperative course and medium-term progress were investigated. RESULTS: Fourteen patients with a mean age of 57.2 years were identified over a 3-year period. All patients presented with peritonitis and systemic sepsis. Ten patients had extraluminal gas on preoperative imaging. Laparoscopic lavage and drainage, without resection or stoma, was the initial management in all cases. Sigmoid diverticulitis was confirmed in all cases, complicated by Hinchey grade 3 purulent peritonitis in 10 patients, grade 2 contamination in 2 patients and grade 4 faeculent peritonitis in 2 patients. Eleven patients (79%) improved and were discharged following a median of 6.5 days (range, 5-32 days). Three patients did not improve and underwent acute resection. Eight patients have subsequently undergone elective resection without a stoma at a mean interval of 6 weeks, which was carried out laparoscopically in all but one case. CONCLUSION: Laparoscopic lavage and drainage in the acute management of perforated acute diverticulitis may be a promising alternative to more radical procedures, including the Hartmann's procedure. Acute resection should still be carried out in patients found to have faecal peritonitis or who fail to improve following lavage.