Short-Term (30-Day) Morbidity of Biliopancreatic Diversion Compared to Roux-en-Y Gastric Bypass as Revisional Procedures for Failed Vertical Banded Gastroplasty.

BACKGROUND: Silastic ring vertical gastroplasty (SRVG) and vertical banded gastroplasty (VBG) are associated with a high failure rate due to weight regain and complications at long-term follow-up. Consequently, surgical correction for such procedures is warranted. Controversy exists as to which surgical procedure is the ideal choice for such correction. Our aim is to compare short-term outcome of Roux-en-Y gastric bypass (RYGB) and biliopancreatic diversion (BPD) repair for failed VBG/SRVG bariatric procedures. METHODS: The medical records of patients with failed SRVG who underwent corrective procedures at our institute between 2004 and 2018 were retrospectively reviewed. Patients characteristics, surgical approaches, and intraoperative and post-operative complications were examined and compared. RESULTS: Sixty patients in total underwent a surgical corrective procedure for failed SRVG. Thirty-one patients underwent RYGB, and 29 patients underwent BPD. Major complications were seen more in the RYGB group (35% = 11) compared to the BPD (6.9% = 2). Even though anastomotic leak rates were not statistically significant (p = 0.053), an apparent tendency for such a complication was noted in the RYGB group. RYGB procedure had an increased 30-day complication rate (p = 0.055) compared to RYGB. Laparoscopic approach had statistically fewer complications than open approach. No mortality was observed in either group. CONCLUSION: Our study showed that BPD is a safe option with less complication rates than RYGB in the short-term period for surgical correction of failed VBG/SRVG procedures.

The Relationship Between Tachycardia After Laparoscopic Sleeve Gastrectomy and the Development of Postoperative Complications.

BACKGROUND: Bariatric surgery can be associated with severe complications. Tachycardia is an important indicator of certain complications, such as anastomotic leak and hemorrhage. Our aim was to examine the relationship between tachycardia following sleeve gastrectomy and the appearance of associated complications. METHODS: Patients who underwent sleeve gastrectomy over a 2-year period were included in the study. Participants were divided into two groups: the first included patients who suffered from postoperative tachycardia and the second patients with normal postoperative heart rates. Complications in both groups were examined. Other parameters that predict the onset of complications were also reviewed. RESULTS: A total of 457 patients were included. Postoperative tachycardia was measured in 181 (39.6%) patients; 17 (3.7%) suffered from bleeding and 4 (1%) from staple line leakage. Postoperative bleeding was more common among patients with tachycardia than among those without (14 (7.7%) vs. 3 (1.1%), respectively). Patients in the tachycardia group had more staple line leakages than those in the normal heart rate group (3 (2%) vs. 1 (0%), respectively); tachycardia was also attributed to postoperative pain or other minor complications in 160 (88%) patients. Age ≥ 40 years was found to be predictive factor for postoperative complications. CONCLUSIONS: The most common causes of tachycardia postoperatively were pain and minor complications. Tachycardia is an essential indicator of postoperative minor and major complications, mainly staple line leakage and bleeding. This should prompt immediate medical intervention in order to avoid serious adverse events.

Gastric and urinary bladder pressures correlate with intra-abdominal pressure in patients with morbid obesity.

Intra-abdominal pressure (IAP) affects cardio-respiratory and hemodynamic parameters and can be measured directly or indirectly by measuring gastric or urinary bladder pressure. The aim of this study was to investigate the correlation between IAP, gastric pressure and urinary bladder pressure in patients with morbid obesity, at normal and elevated levels of IAP in two positions. As well, to examine the effects of increasing IAP and patient's position on hemodynamic and respiratory parameters. Twelve patients undergoing laparoscopic bariatric surgery were included. IAP, gastric pressure, and urinary bladder pressure were measured while patients were in the supine position and after 45° anti-Trendelenburg tilt. Mean inspiratory pressure, peak inspiratory pressure, and tidal volume were recorded and assessed. In supine position; directly measured IAP was 9.1 ± 1.8 mmHg, compared to 10 ± 3.6 and 8.9 ± 2.9 mmHg in the stomach and bladder, respectively. Increasing IAP to 15 mmHg resulted in an increased gastric pressure of 17 ± 3.8 mmHg, and urinary bladder pressure of 14.8 ± 3.9 mmHg. Gastric and urinary bladder pressures strongly correlated with IAP (R = 0.875 and 0.847, respectively). With 45° anti-Trendelenburg tilt; directly measured IAP was 9.4 ± 2.2 mmHg, and pressures of 10.8 ± 3.8 mmHg and 9.2 ± 3.8 mmHg were measured in the stomach and the bladder, respectively. Increasing IAP to 15 mmHg resulted in elevating gastric and bladder pressures to 16.6 ± 5.3 and 13.3 ± 4 mmHg, respectively. Gastric and urinary bladder pressures had good correlation with IAP (R = 0.843 and 0.819, respectively). Changing patient position from supine to 45° anti-Trendelenburg position resulted in decreased mean and peak inspiratory pressures, and increased tidal volume. Basal IAP is high in patients with morbid obesity. IAP shows positive correlation to gastric and urinary bladder pressures at both normal and elevated levels of IAP. Anti-Trendelenburg tilt of mechanically ventilated morbidly obese patients resulted in favorable effects on respiratory parameters.Trial Registration: The study was retrospectively registered in the NIH registry. Registration number is pending.

Amylase Is Not a Useful Indicator for Leakage Detection Following Sleeve Gastrectomy: A Prospective Study.

Introduction. Gastric leak after laparoscopic sleeve gastrectomy (LSG) is a severe complication that may lead to sepsis and even death. Early diagnosis and treatment are critical. The aims of this prospective study are to establish normal amylase levels and investigate elevated amylase levels, especially in the drain, for detecting anastomotic leakage following LSG. Material and Methods. One hundred sixty-one patients who underwent LSG during 1 year at Rambam Health Care Campus were included prospectively in the study. Demographic and medical background, peri- and postoperative complications, and laboratory data including amylase levels in blood, urine, and drain were evaluated. Univariate and multivariate analyses were performed to examine independent variables that can predict increases in amylase values. Results. Thirty-five (21.8%) patients had high levels of amylase in blood, urine, and/or drain and 126 (78.2%) normal values of amylase until discharge. No significant differences were found in operation duration, length of hospitalization, or occurrence of complications. One patient had a staple-line leak diagnosed in the third postoperative day that was treated conservatively with endoscopic approach. His amylase levels in the blood and drain were normal, with only a slight hyperamylasuria. Conclusions. High amylase levels after LSG does not necessarily indicate a major complication such as staple-line leak, and in the vast majority of cases, it seems to have no clinical relevancy. Therefore, it should not automatically lead to a full investigation in the absence of further clinical signs. It is suggested that there is no clinical justification to test amylase routinely after LSG.

Practices and attitudes of bariatric surgeons in Israel during the first phase of the COVID-19 pandemic.

INTRODUCTION: Israel ranks very high globally in performing bariatric surgery (BS) per capita. In the first phase of the COVID-19 pandemic the bariatric surgeons' community faced many concerns and challenges, especially in light of a decree issued by the Ministry of Health (MOH) on March 22nd, to ban all elective surgery in public hospitals. The aim of this study is to portray the practices and attitudes of Israeli bariatric surgeons in the first phase of the pandemic. METHODS: Anonymous web-based questionnaire sent to all active bariatric surgeons in Israel. Statistical analysis was performed using SAS software package. RESULTS: 53 out of 63 (84%) active surgeons responded to the survey. 18% practice in the public sector only, 4% in the private sector only and 78% in both sectors. 76% practice BS for more than 10 years and 68% perform more than 100 procedures a year. Almost all the surgeons (98%) experienced a tremendous decrease in operations. Nevertheless, there were substantial differences by sectors. In the public sector, 86% of the surgeons ceased to operate while 14% did not comply with the government's decree. In the public sector 69% of the surgeons were instructed by the administrators to stop operating. The majority of surgeons who continued to operate (77%) changed nothing in the indications or contra-indications for surgery. Among the surgeons who opted to refrain from operating on special sub-groups, the most frequent reasons were pulmonary disease (82%), age above 60 (64%), Ischemic heart disease (55%) and living in heavily affected communities. Roughly only half (57%) of the surgeons implemented changes in informed consent and operating room (OR) measures, contrary to guidelines and recommendations by leading professional societies. When asked about future conditions for reestablishing elective procedures, the reply frequencies were as follows: no special measures - 40%; PCR negativity - 27%; IgG positivity - 15%; waiting until the end of the pandemic- 9%. CONCLUSIONS: We showed in this nation-wide survey that the variance between surgeons, regarding present and future reactions to the COVID-19 pandemic, is high. There were substantial differences between the private and the public sectors. Although the instructions given by the MOH for the public sector were quite clear, the compliance by surgeons and administrators was far from complete. The administrators in the public sector, but more so in the private sector were ambiguous in instructing staff, leading surgeons to a more "personal non-structured" practice in the first phase of the pandemic. These facts must be considered by regulators, administrators and surgeons when planning for reestablishing elective BS or in case a second wave of the pandemic is on its way.

Is early appendectomy in adults diagnosed with acute appendicitis mandatory? A prospective study.

INTRODUCTION: Prompt appendectomy has long been the standard of care for acute appendicitis in order to prevent complications such as perforation, abscess formation, and diffuse purulent or fecal peritonitis, all resulting in increased morbidity and even mortality. Our study was designed to examine whether the time from the beginning of symptoms to operation correlates with the pathological degree of appendicitis, incidence of postoperative complications, or increased length of hospital stay. METHODS: A prospective study of 171 patients who underwent emergent appendectomy for acute appendicitis in the course of 2 years was conducted in a single tertiary medical center. The following parameters were monitored and correlated: demographics, time from the onset of symptoms until the arrival to the emergency department (patient interval (PI)), time from arrival to the emergency department (ED) until appendectomy (hospital interval (HI)), time from the onset of symptoms until appendectomy (total interval (TI)), physical examination, preoperative physical findings, laboratory data, pathologic findings, complications, and length of hospital stay. RESULTS: The degree of pathology and complications were analyzed according to the time intervals. The time elapsed from the onset of symptoms to surgery was associated with higher pathology grade (p = 0.01). We found that longer time from the onset of symptoms to hospital arrival correlates with higher pathology grade (p = 0.04), while there was no correlation between the hospital interval and pathology grade (p = 0.68). A significant correlation was found between the pathology grade and the incidence of postoperative complications as well as with increased length of hospital stay (p = 0.000). CONCLUSION: Time elapsed from the symptom onset to appendectomy correlates with increased pathology grade and complication rate. This correlation was not related to the HI. Since the HI in our study was short, we recommend an early appendectomy in adults in order to shorten the TI and the resulting complications.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES: To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING: University hospital, Israel. METHODS: Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS: There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS: Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.

Comparison of Rhabdomyolysis Markers in Patients Undergoing Bariatric Surgery with Propofol and Inhalation-based Anesthesia.

BACKGROUND: Rhabdomyolysis is a relatively uncommon, severe complication of anesthesia and surgery in the morbidly obese. As the use of propofol-based anesthesia has been associated with an increased risk of rhabdomyolysis and metabolic acidosis, this pilot study was designed to assess the effect of propofol anesthesia on the incidence of rhabdomyolysis in morbidly obese patients undergoing bariatric surgery. METHODS: Thirty, morbidly obese patients (body mass index 43 ± 3 kg/m(2)) scheduled for bariatric laparoscopic sleeve gastrectomy were randomized to receive either propofol (P) or inhalational anesthetic (I)-based balanced general anesthesia. A sample of venous blood gas analysis including pH, bicarbonate concentrations, and calculated base excess was taken at the end of the operation. Creatine phosphokinase (CPK), troponin I, blood urea nitrogen, and creatinine plasma concentrations were measured at the end of the surgery and again 24 h later. RESULTS: All patients enrolled to the study completed it without significant complications. CPK, troponin I, blood urea nitrogen, and creatinine plasma concentrations at the end of the operation and at 24 h, as well as the bicarbonate concentration and the base excess at the end of the operation were not significantly different between the two study groups. A statistically significant mild respiratory acidosis was noted in the inhalational anesthetic group (pH 7.30 ± 0.04 vs. 7.36 ± 0.02 in the propofol group) CONCLUSIONS: This small-size pilot study may suggest that propofol-based anesthesia is not related to increased incidence of rhabdomyolysis in morbidly obese patients undergoing short, uncomplicated bariatric surgery.

Endoscopic removal of partially migrated intragastric bands following surgical gastroplasty: a prospective case series.

BACKGROUND: The intragastric migration of a surgically placed adjustable gastric band is believed to occur slowly, over months to years. Band removal procedures necessitate surgical laparotomy, thus increasing the risk of complications. METHODS: The endoscopic technique for band removal described in this case-series provides a minimally invasive approach. RESULTS: Fifteen patients referred for endoscopic removal of a partially migrated intragastric band. The partially migrated intragastric bands were all successfully removed in a mean of 1.1 endoscopic sessions. No patient required subsequent surgical intervention, and there were no immediate or delayed adverse events including no infections, bleeding, or perforations. CONCLUSIONS: Endoscopic removal of partially migrated intragastric bands appears feasible, effective, safe, and is a minimally invasive alternative to repeat surgery.

Fast-track rehabilitation accelerates recovery after laparoscopic colorectal surgery.

BACKGROUND: Fast-track (FT) rehabilitation protocols have been shown to be successful in reducing both hospital stay and postoperative complications, as well as enhancing overall postoperative patient recovery. We are reporting the outcomes of our first group of patients undergoing colorectal surgery following the FT protocol. PATIENTS AND METHODS: We performed a prospective study of patients, between January 1, 2007 and January 31, 2010, who underwent laparoscopic colorectal resections in accordance with the guidelines of FT rehabilitation protocol. Recovery parameters including time to removal of naso-gastric tube and urinary catheter, time to bowel function and to resume diet, and length of hospital stay were evaluated. Postoperative outcomes, that is, postoperative complications and mortality, reoperations, and readmissions were also studied. RESULTS: A total of 71 patients, 30 women and 41 men, underwent FT rehabilitation for laparoscopic colorectal surgery. The mean age of the patients was 60 ± 16 years. The most common surgical procedures were right hemicolectomy 30% and anterior resection 27%. Liquid and regular diet were initiated on postoperative day 1.2 ± 0.4 and 2.1 ± 0.4, respectively. Overall postoperative morbidity was 8.5%. The mean length of stay was 4.4 ± 1.7 days, with only 3 readmissions. Forty-five patients fulfilled the FT care plan and were discharged on postoperative day 3. No reoperations or mortality were observed. CONCLUSIONS: FT rehabilitation results in favorable postoperative outcomes. Our data provides evidence and suggests that FT protocols should be implemented as a reliable method of preparation and recovery for laparoscopic colorectal surgery.

Laparoscopic implantation of distal peritoneal ventriculoperitoneal shunt catheter: a comparative study.

OBJECTIVE: Ventriculoperitoneal shunts (VPS) are a common treatment for hydrocephalus. Placement of the distal abdominal catheter can be difficult in the setting of advanced age, previous abdominal surgeries, obesity, or chronic illnesses. At our institute, complex patients are treated using a multidisciplinary team of a neurosurgeon and a laparoscopic surgeon. We evaluated the influence on prognosis of a laparoscopically assisted VPS placement using a single-port technique as compared with the conventional mini-laparotomy approach. METHODS: Between 2006 and 2010, 302 patients were operated for hydrocephalus or shunt dysfunction. Among these, a total of 48 patients were operated on using the single-trocar laparoscopy. Neurosurgeons and laparoscopic surgeons logged the presenting symptoms, past medical history, chronic diseases, past surgical procedures, the actual surgical procedure and intraoperative findings. Outcome data were collected at several time points, using several independent outcome parameters. RESULTS: The laparoscopic group was significantly older, had more chronic diseases, and had more prior abdominal and shunt operations. However, this group had the same outcome as the minilaparotomy group.. CONCLUSIONS: The outcome of elderly patients, patients with chronic diseases and obesity, and patients who underwent previous abdominal or shunt operations equals the outcome of young, otherwise healthy patients, if the laparoscopic single-port technique for distal catheter placement during VPS procedure is used. The laparoscopic technique reduces surgical complications.

The use of VivaSight™ single lumen endotracheal tube in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: The population of obese patients is progressively growing and bariatric operations are becoming increasingly common. Morbidly obese patients require special anesthetic care and are often considered to be difficult to ventilate and intubate. The VivaSight™ Single Lumen tube is an endotracheal tube with a camera embedded in its tip. The view from the tip appears continuously on a monitor in the anesthesiologist's vicinity. The aim of this study was to assess the VivaSight™ in comparison with conventional endotracheal tube as an aid in the intubation and surveillance of tube position during surgery of obese patients. METHODS: This is a prospective study of 72 adult obese patients who underwent laparoscopic sleeve gastrectomy. The patients were randomly assigned to be intubated by either the VivaSight™ (40 patients, test group) or a conventional endotracheal tube (32 patients, control group). Data on the patients, the pre-operative airway evaluation, the endotracheal intubation and the post-operative outcome were collected and compared. RESULTS: The Mallampati scores were significantly higher in the test group than in the control group. Endotracheal intubation took 29 ± 10 and 24 ± 8 seconds using the VivaSight™ and a conventional tube respectively (p = 0.02). Three of the patients in the control group, while none of those in the test group, had soft tissue injury (p < 0.05). CONCLUSION: We found the VivaSight™ SL to be helpful in the endotracheal intubation and continuous surveillance of tube position in morbidly obese patients undergoing laparoscopic sleeve gastrectomy.

Laparoscopic hernia repair: nonfixation mesh is feasibly?

BACKGROUND: Several surgical techniques have been developed over the past years, and total extraperitoneal and transabdominal preperitoneal inguinal hernia repair are the endoscopic techniques that are most commonly used. AIM: To describe and discuss Dulucq's technique and the modifications of using 3-D mesh in total extraperitoneal inguinal hernia repair. METHODS: Patients who underwent an elective inguinal hernia repair were enrolled prospectively in this study. Operative and postoperative course were studied. RESULTS: A total of 261 hernia repairs were included in the study. The hernias were repaired by total extraperitoneal technique; two hernias (0.75%) were converted to open anterior Liechtenstein technique. Mean operative time was 43.38 min in unilateral hernia and 53.36 min in bilateral hernia. Most of the patients (95%) were discharged at the same day of the surgery. The overall postoperative morbidity rate was 5.7%. The incidence of recurrence rate was 0.0% in median follow-up period of 26 months. CONCLUSION: Total extraperitoneal hernioplasty is a very effective and safe procedure in the hands of experienced surgeons with specific training. It is an interesting option in bilateral and recurrent hernia as it obtains satisfactory results in terms of postoperative pain and morbidity.

Laparoscopic totally extraperitoneal hernioplasty with nonfixation of three-dimensional mesh: Dulucq's technique.

INTRODUCTION: The inguinal hernia repair has been a controversial area in the surgical practice ever since it has been conceived. The fact that numerous different procedures are in use reflects the complexity of inguinal hernia and its repair. AIM: The purposes of this study were to describe Dulucq's technique and the modifications of using 3-D mesh in laparoscopic totally extraperitoneal inguinal hernia repair. METHODS: Surgical technique of laparoscopic totally extraperitoneal hernia repair is detailed on the text. CONCLUSION: Laparoscopic totally extraperitoneal is preferred over transabdominal preperitoneal hernia as the peritoneum is not violated. The dissection must always be done with the same stages, without monopolar diathermy and the patient in a slight Trendelenburg position. Following these recommendations, the laparoscopic totally extraperitoneal hernioplasty is feasible with fewer intra-abdominal complications.

Correção de hérnia laparoscópica: tela sem fixação é viável? / Laparoscopic hernia repair: nonfixation mesh is feasibly?

RACIONAL: Várias técnicas cirúrgicas têm sido desenvolvidas ao longo dos últimos anos, e a correção de hérnia inguinal pré-peritoneal totalmente extraperitoneal e transabdominal são as técnicas endoscópicas que são mais comumente utilizadas. OBJETIVOS: Descrever e discutir a técnica de Dulucq e as modificações do uso da tela 3-D na correção de hérnia inguinal totalmente extraperitoneal. MÉTODOS: Foram incluídos prospectivamente neste estudo pacientes submetidos à correção de hérnia inguinal eletiva. Foram estudados os aspectos operatórios e pós-operatórios. RESULTADOS: Um total de 261 correções herniárias foram incluídas neste estudo. Elas foram realizadas pela técnica totalmente extraperitoneal; duas (0,75%) foram convertidos para técnica anterior de Liechtenstein. O tempo operatório médio foi de 43,38 min em hérnia unilateral e 53,36 min em hérnia bilateral. A maioria dos pacientes (95%) teve alta no mesmo dia da operação. A taxa de morbidade pós-operatória foi de 5,7%. A incidência de recidiva foi de 0,0% em média de 26 meses. CONCLUSÃO: Hernioplastia totalmente extraperitoneal é procedimento eficaz e seguro nas mãos de cirurgiões experientes e com formação específica. É uma opção interessante para hérnia bilateral e recidivante, uma vez que obtém resultados satisfatórios em termos de dor pós-operatória e morbidade.

BACKGROUND: Several surgical techniques have been developed over the past years, and total extraperitoneal and transabdominal preperitoneal inguinal hernia repair are the endoscopic techniques that are most commonly used. AIM: To describe and discuss Dulucq's technique and the modifications of using 3-D mesh in total extraperitoneal inguinal hernia repair. METHODS: Patients who underwent an elective inguinal hernia repair were enrolled prospectively in this study. Operative and postoperative course were studied. RESULTS: A total of 261 hernia repairs were included in the study. The hernias were repaired by total extraperitoneal technique; two hernias (0.75%) were converted to open anterior Liechtenstein technique. Mean operative time was 43.38 min in unilateral hernia and 53.36 min in bilateral hernia. Most of the patients (95%) were discharged at the same day of the surgery. The overall postoperative morbidity rate was 5.7%. The incidence of recurrence rate was 0.0% in median follow-up period of 26 months. CONCLUSION: Total extraperitoneal hernioplasty is a very effective and safe procedure in the hands of experienced surgeons with specific training. It is an interesting option in bilateral and recurrent hernia as it obtains satisfactory results in terms of postoperative pain and morbidity.

Hernioplastia laparoscópica totalmente extraperitoneal com tela 3-D sem fixação: técnica de Dulucq / Laparoscopic totally extraperitoneal hernioplasty with nonfixation of three-dimensional mesh: Dulucq's technique

INTRODUÇÃO: A reparação da hérnia inguinal tem sido área controversa na prática cirúrgica, desde que desde que ela foi concebida. O fato de que inúmeros procedimentos diferentes estão em uso reflete a complexidade de hérnia inguinal e seu reparo. OBJETIVO: Descrever a técnica de Dulucq e as modificações do uso da tela 3-D na correção de hérnia inguinal laparoscópica totalmente extraperitoneal. MÉTODOS: A técnica da correção da hérnia laparoscópica totalmente extraperitoneal é detalhada no texto. CONCLUSÃO: Correção laparoscópica totalmente extraperitoneal é preferível à correção de hérnias transabdominais pré-peritoneais porque o peritônio não é violado. A dissecção deve ser sempre realizada nos mesmos passos, sem utilizar cautério monopolar e o paciente em leve posição de Trendelemburg. Com estas recomendações, a hernioplastia laparoscópica totalmente extraperitoneal é factível com poucas complicações intra-abdominais.

INTRODUCTION: The inguinal hernia repair has been a controversial area in the surgical practice ever since it has been conceived. The fact that numerous different procedures are in use reflects the complexity of inguinal hernia and its repair. AIM: The purposes of this study were to describe Dulucq's technique and the modifications of using 3-D mesh in laparoscopic totally extraperitoneal inguinal hernia repair. METHODS: Surgical technique of laparoscopic totally extraperitoneal hernia repair is detailed on the text. CONCLUSION: Laparoscopic totally extraperitoneal is preferred over transabdominal preperitoneal hernia as the peritoneum is not violated. The dissection must always be done with the same stages, without monopolar diathermy and the patient in a slight Trendelenburg position. Following these recommendations, the laparoscopic totally extraperitoneal hernioplasty is feasible with fewer intra-abdominal complications.

Gastric leaks after sleeve gastrectomy: a multicenter experience with 2,834 patients.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) remains under scrutiny as a stand-alone bariatric procedure. The most feared complication after LSG is staple line leak. METHODS: Eight bariatric centers in Israel participated in this study. A retrospective analysis was performed by querying all the LSG cases performed between June 2006 and June 2010. The data collected included patient demographics, anthropometrics, and operative and perioperative parameters. RESULTS: Among the 2,834 patients who underwent LSG, 44 (1.5%) with gastric leaks were identified. Of these 44 patients, 30 (68%) were women. The patients had a mean age of 41.5 years and a body mass index (BMI) of 45.4 kg/m(2). Intraoperative leak tests and routine postoperative swallow studies were performed with 33 patients, and all but one patient (3%) failed to detect the leaks. Leaks were diagnosed at a median of 7 days postoperatively: early (0-2 days) in nine cases (20%), intermediately (3-14 days) in 32 cases (73%), and late (>14 days) in three cases (7%). For 38 patients (86%), there was clinical suspicion, later confirmed by imaging or operative findings. Computed tomography, swallow studies, and methylene blue tests were performed for 37, 21, and 15 patients, respectively, and the results were positive, respectively, for 31 (84%), 11 (50%), and 9 (60%) of these patients. Reoperation was performed for 27 of the patients (61%). Other treatment methods included percutaneous drainage (n = 28, 63.6%), endoscopic placement of stents (n = 11, 25%), clips (n = 1, 2.3%), and fibrin glue (n = 1, 2.3%). In 33 of the patients (75%), the leak site was found in the upper sleeve near the gastroesophageal junction. The median time to leak closure was 40 days (range, 2-270 days), and the overall leak-related mortality rate was 0.14% (4/2,834). CONCLUSION: Gastric leak is the most common cause of major morbidity and mortality after LSG. Routine tests to rule out leaks seem to be superfluous. Rather, selective utilization is recommended. Management options vary, depending mainly on patient disposition. An accepted algorithm for the diagnosis and treatment of gastric leak has yet to be proposed.