Laparoscopic vs robotic inguinal hernia repair: a comparison of learning curves and skill transference in general surgery residents.

BACKGROUND: There is no consensus on whether laparoscopic experience should be a prerequisite for robotic training. Further, there is limited information on skill transference between laparoscopic and robotic techniques. This study focused on the general surgery residents' learning curve and skill transference within the two minimally invasive platforms. METHODS: General surgery residents were observed during the performance of laparoscopic and robotic inguinal hernia repairs. The recorded data included objective measures (operative time, resident participation indicated by percent active time on console or laparoscopy relative to total case time, number of handoffs between the resident and attending), and subjective evaluations (preceptor and trainee assessments of operative performance) while controlling for case complexity, patient comorbidities, and residents' prior operative experience. Wilcoxon two-sample tests and Pearson Correlation coefficients were used for analysis. RESULTS: Twenty laparoscopic and forty-four robotic cases were observed. Mean operative times were 90 min for robotic and 95 min for laparoscopic cases (P = 0.4590). Residents' active participation time was 66% on the robotic platform and 37% for laparoscopic (P = < 0.0001). On average, hand-offs occurred 9.7 times during robotic cases and 6.3 times during laparoscopic cases (P = 0.0131). The mean number of cases per resident was 5.86 robotic and 1.67 laparoscopic (P = 0.0312). For robotic cases, there was a strong correlation between percent active resident participation and their prior robotic experience (r = 0.78) while there was a weaker correlation with prior laparoscopic experience (r = 0.47). On the other hand, prior robotic experience had minimal correlation with the percent active resident participation in laparoscopic cases (r = 0.12) and a weak correlation with prior laparoscopic experience (r = 0.37). CONCLUSION: The robotic platform may be a more effective teaching tool with a higher degree of entrustability indicated by the higher mean resident participation. We observed a greater degree of skill transference from laparoscopy to the robot, indicated by a higher degree of correlation between the resident's prior laparoscopic experience and the percent console time in robotic cases. There was minimal correlation between residents' prior robotic experience and their participation in laparoscopic cases. Our findings suggest that the learning curve for the robot may be shorter as prior robotic experience had a much stronger association with future robotic performance compared to the association observed in laparoscopy.

Virtual Interviews for Surgical Fellowship are an Acceptable Alternative to In-Person Interviews for Applicants and Faculty Alike.

Background: In-person interviews have traditionally been an integral part of the fellowship application process to allow faculty and applicants to interact and evaluate the intangible aspects of the matching process. COVID-19 has forced a transition away from in-person interviews to a virtual platform. This study sought to track faculty and applicant perspectives on this transition. Study Design: Prospectively collected survey data was obtained from all participants after each of 3 consecutive virtual interview days for minimally invasive surgery fellowship at a single academic institution. Results: One hundred percent (27/27 applicants and 9/9 faculty) of interview participants completed the survey. Cost (100% applicants, 77.8% faculty) was perceived as the greatest barrier to in-person interviews, and "inability to get a feel for the program/applicant" was the largest concern for virtual interviews (66.7% applicants, 88.9% faculty). After interviews, most participants strongly agreed that they were able to assess education (66.7% applicants, 77.8% faculty), clinical experience (70.4% applicants, 77.8% faculty), and research potential (70.4% applicants, 88.9% faculty) through the virtual platform. Only 44.4% of each group strongly agreed that they could assess "overall fit" equally as well. Most faculty (6/9, 66.7%), but fewer applicants (10/27, 37.0%), were willing to completely eliminate in-person interviews. Conclusion: Virtual interviews may be an acceptable alternative to in-person interviews in times of COVID-19 and beyond. Offering a virtual format may help to eliminate costs associated with in-person visits while adequately assessing the fit of a program for both applicants and faculty, though applicants still desire an in-person option.

Abdominal core quality of life after ventral hernia repair: a comparison of open versus robotic-assisted retromuscular techniques.

BACKGROUND: Robotic-assisted retromuscular repairs reduce length of stay compared to open surgery. However, no study has evaluated the long-term impact on abdominal core quality of life. METHODS: Retrospective cohort study performed using prospectively collected data from the Americas Hernia Society Quality Collaborative (AHSQC) including adults who underwent open or robotic-assisted retromuscular, incisional hernia repair between 2013 and 2019. Differences in Hernia-Related Quality of Life Survey (HerQLes) scores at baseline and 1 year postoperatively were compared using multivariable regression models. Secondary outcomes included perioperative complications, wound morbidity, and hernia recurrence. RESULTS: 236 patients underwent open (N = 194) and robotic (N = 42) repairs. Median age was 61 years. The open group had larger hernia widths (median [IQR], 13 [9-16] vs. 7 [5-9] cm) and longer LOS (5 [4-6] vs. 1.5 [1-3] days). Median HerQLes summary scores at 1 year were similar at 88 [67, 93] points for open vs 90 [58, 94] for robotic arm. Wound morbidity rates were similar. On multivariate analysis, there was no difference in HerQLes summary score improvement 1 year after repair between techniques (3.3, CI [- 7.7, 14.3]; p = 0.52), however, patients with a comparatively larger hernia width of 7 cm had a 5.9 (CI [1.1, 10.8], p = 0.02) increase in HerQLes scores, and patients with a higher ASA class (3-5) saw an 11-point score improvement (CI [2.2, 20.0], p = 0.02) regardless of approach. Smoking, BMI above 30, or hernia recurrence had no significant impact, while COPD hindered scores (- 17.0, CI [- 32.3, - 1.7], p = 0.03). CONCLUSIONS: Improvement in abdominal core quality of life after repair is comparable between open and robotic retromuscular techniques. Larger hernia defects and higher ASA class patients benefitted the greatest. Robotic approaches offer shorter LOS with comparable recurrence and wound morbidity rates 1 year after surgery. The surgical approach should be personalized and guided by the surgeon's individual and institutional expertise.

Clinical spotlight review for the management of choledocholithiasis.

Choledocholithiasis is a common presentation of symptomatic cholelithiasis that can result in biliary obstruction, cholangitis, and pancreatitis. A systematic English literature search was conducted in PubMed to determine the appropriate management strategies for choledocholithiasis. The following clinical spotlight review is meant to critically review the available evidence and provide recommendations for the work-up, investigations as well as the endoscopic, surgical and percutaneous techniques in the management of choledocholithiasis.

Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS: We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS: The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION: When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

A retrospective comparison of robotic cholecystectomy versus laparoscopic cholecystectomy: operative outcomes and cost analysis.

INTRODUCTION: Robotic-assisted surgery is gaining popularity in general surgery. Our objective was to evaluate and compare operative outcomes and total costs for robotic cholecystectomy (RC) and laparoscopic cholecystectomy (LC). METHODS AND PROCEDURES: A retrospective review was performed for all patients who underwent single-procedure RC and LC from January 2011 to July 2015 by a single surgeon at a large academic medical center. Demographics, diagnosis, perioperative variables, postoperative complications, 30-day readmissions, and operative and hospital costs were collected and analyzed between those patient groups. RESULTS: A total of 237 patients underwent RC or LC, and comprised the study population. Ninety-seven patients (40.9 %) underwent LC, and 140 patients (50.1 %) underwent RC. Patients who underwent RC had a higher body mass index (p = 0.03), lower rates of coronary artery disease (p < 0.01), and higher rates of chronic cholecystitis (p < 0.01). There were lower rates of intraoperative cholangiography (p < 0.01) and conversion to an open procedure (p < 0.01), however longer operative times (p < 0.01) for patients in the RC group. There were no bile duct injuries in either group, no difference in bile leak rates (p = 0.65), or need for reoperation (p = 1.000). Cost analysis of outpatient-only procedures, excluding cases with conversion to open or use of intraoperative cholangiography, demonstrated higher total charges (p < 0.01) and cost (p < 0.01) and lower revenue (p < 0.01) for RC compared to LC, with no difference in total payments (p = 0.34). CONCLUSIONS: Robotic cholecystectomy appears to be safe although costlier in comparison with laparoscopic cholecystectomy. Further studies are needed to understand the long-term implications of robotic technology, the cost to the health care system, and its role in minimally invasive surgery.

Incidence of abdominal wall metastases following percutaneous endoscopic gastrostomy placement in patients with head and neck cancer.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes are an effective modality for enteral nutrition in patients with head and neck cancer; however, there have been documented case reports of "seeding" of the abdominal wall by the theoretic risk of dragging the tube along the tumor during PEG placement. The objective of this study is to determine the incidence and contributing risk factors leading to metastasis to the abdominal wall following PEG placement in patients with head and neck cancer. METHODS: A retrospective chart review was performed on patients diagnosed with head and neck malignancy who underwent PEG placement between 1/5/2009 and 12/22/2014. Variables collected included development of abdominal wall metastases, type of malignancy and tumor characteristics, smoking history, PEG placement technique, and survival following recurrence. Data were then analyzed for overall trends. RESULTS: Out of 777 patients analyzed, a total of five patients with head and neck malignancy were identified with abdominal wall metastasis following PEG tube placement with an overall incidence of 0.64% over an average follow-up of 27.55 months. All of these patients underwent PEG tube insertion via a Pull technique. One patient was found to have a clinically evident and symptomatic stomal metastasis, while the other four patients had radiologically detected metastases either on CT or PET scan. All of the identified patients were found to have stage IV oral cancer at time of initial diagnosis of their head and neck malignancy, followed by widespread distant metastatic disease at time of presentation with their PEG site stomal metastasis. CONCLUSION: Abdominal wall metastases following PEG placement are a rare but serious complication in patients with head and neck malignancy.

Near-infrared fluorescent cholangiography facilitates identification of biliary anatomy during laparoscopic cholecystectomy.

BACKGROUND: Intraoperative cholangiography (IOC) is the current gold standard for biliary imaging during laparoscopic cholecystectomy (LC). However, utilization of IOC remains low. Near-infrared fluorescence cholangiography (NIRF-C) is a novel, noninvasive method for real-time, intraoperative biliary mapping. Our aims were to assess the safety and efficacy of NIRF-C for identification of biliary anatomy during LC. METHODS: Patients were administered indocyanine green (ICG) prior to surgery. NIRF-C was used to identify extrahepatic biliary structures before and after partial and complete dissection of Calot's triangle. Routine IOC was performed in each case. Identification of biliary structures using NIRF-C and IOC, and time required to complete each procedure were collected. RESULTS: Eighty-two patients underwent elective LC with NIRF-C and IOC. Mean age and body mass index (BMI) were 42.6 ± 13.7 years and 31.5 ± 8.2 kg/m(2), respectively. ICG was administered 73.8 ± 26.4 min prior to incision. NIRF-C was significantly faster than IOC (1.9 ± 1.7 vs. 11.8 ± 5.3 min, p < 0.001). IOC was unobtainable in 20 (24.4 %) patients while NIRF-C did not visualize biliary structures in 4 (4.9 %) patients. After complete dissection, the rates of visualization of the cystic duct, common bile duct, and common hepatic duct using NIRF-C were 95.1, 76.8, and 69.5 %, respectively, compared to 72.0, 75.6, and 74.3 % for IOC. In 20 patients where IOC could not be obtained, NIRF-C successfully identified biliary structures in 80 % of the cases. Higher BMI was not a deterrent to visualization of anatomy with NIRF-C. No adverse events were observed with NIRF-C. CONCLUSIONS: NIRF-C is a safe and effective alternative to IOC for imaging extrahepatic biliary structures during LC. This technique should be evaluated further under a variety of acute and chronic gallbladder inflammatory conditions to determine its usefulness in biliary ductal identification.

N-Butyl-2-Cyanoacrylate Adhesive Versus Absorbable Tacks in Laparoscopic Groin Hernia Repair: A Multicenter Randomized Clinical Trial.

Objective: We aimed to determine whether n-butyl-2-cyanoacrylate (NB2C) adhesive is a safe and effective mechanism for nonpenetrating mesh and peritoneal fixation during laparoscopic groin hernia repair. Background: Chronic pain after laparoscopic groin hernia repair has been associated with penetrating fixation, but there had been no US Food and Drug Administration-approved devices for nonpenetrating fixation in this context. Methods: Patients undergoing laparoscopic transabdominal preperitoneal (TAP) or totally extraperitoneal (TEP) groin hernia repair with mesh at 1 of 5 academic medical centers were randomized to mesh (TAP/TEP) and peritoneal (TAP) fixation with NB2C adhesive or absorbable tacks. The primary outcome was improvement in pain (visual analog scale [VAS]) at 6 months. The noninferiority margin was 0.9 (α = 0.025; ß = 80%). Recurrence, successful use of the device, quality of life, and rates of adverse events (AEs) were secondary outcomes. Results: From 2019 to 2021, 284 patients were randomized to either NB2C adhesive or absorbable tacks (n = 142/142). Patient and hernia characteristics were comparable, and 65% were repaired using a TAP approach. The difference in VAS improvement at 6 months with NB2C adhesive was not inferior to absorbable tacks in intention-to-treat and per-protocol analyses, respectively (0.25 [95% CI, -0.33 to 0.82]; P = 0.013; 0.22 [95% CI, -0.36 to 0.80], noninferiority P = 0.011). There were no differences in secondary outcomes including recurrence, successful use of each device to fixate the mesh and peritoneum, quality of life, and additional VAS pain scores. Rates of adverse and serious AEs were also comparable. Conclusions: NB2C adhesive is safe and effective for mesh fixation and peritoneal closure during laparoscopic groin hernia repair.

Current national practice patterns for inpatient management of ventral abdominal wall hernia in the United States.

BACKGROUND: The health-care burden related to ventral hernia management is substantial, with more than 3 billion dollars in expenditures annually in the US. Previous studies have suggested that the utilization of laparoscopic repair remains relatively low although national volume estimates have not been reported. We sought to estimate the inpatient national volume of elective ventral hernia surgery and characterize the proportion of laparoscopic versus open operations. METHODS: We analyzed data from the Nationwide Inpatient Sample to identify adults with a diagnosis of an umbilical, incisional, or ventral hernia who underwent an elective inpatient repair between 2009 and 2010. Cases that involved other major abdominal or pelvic operations were excluded. Covariates included patient demographics, surgical approach, and use of mesh. National surgical volume estimates were generated and length of stay and total hospital charges were compared for laparoscopic versus open repairs. RESULTS: A total of 112,070 ventral hernia repairs were included in the analysis: 72.1 % (n = 80,793) were incisional hernia repairs, while umbilical hernia repairs comprised only 6.9 % (n = 7,788). Laparoscopy was utilized in 26.6 % (n = 29,870) of cases. Mesh was placed in 85.8 % (n = 96,265) of cases, including 49.3 % (n = 3,841) of umbilical hernia repairs and 90.1 % (n = 72,973) of incisional hernia repairs. Length of stay and total hospital charges were significantly lower for laparoscopic umbilical, incisional, and "other" ventral hernia repairs (p values all <0.001). Total hospital charges during this 2-year period approached 4 billion dollars ($746 million for laparoscopic repair; $3 billion for open repair). CONCLUSIONS: Utilization of laparoscopy for elective abdominal wall hernia repair remains relatively low in the US despite its excellent outcomes. Given the substantial financial burden associated with these hernias, future research focused on preventing the development and optimizing the surgical treatment of ventral abdominal wall hernias is warranted.

Laparoscopic ventral hernia repair: does primary repair in addition to placement of mesh decrease recurrence?

BACKGROUND: The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repair but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant. METHODS: A retrospective observational study was conducted on 193 patients who were treated with LVHR by two minimally invasive surgeons in a 24-month period. The patient population was broadly divided into two groups based on the laparoscopic repair of the fascial defect with mesh underlay, or with primary suture repair and mesh underlay (PSR + MU). Patient demographics, rates of hernia recurrence, and other associated complications were compared between the two groups. Patient variables and the clinical outcomes were analyzed with descriptive statistics and chi-square test. RESULTS: One hundred ninety-three consecutive patients underwent LVHR for incisional (n = 136), umbilical (n = 44), epigastric (n = 9), and parastomal (n = 4) hernia. Hernia recurrence was documented in eight patients (4.1%). The mean follow-up period was 10.5 months (range 1-36 months). Incisional hernias accounted for all eight recurrences. The rate of recurrence in those treated with PSR + MU was 3% (two of 67 cases) in comparison with 4.8% (six of 126 patients) associated with mesh alone. The rate of recurrence in the recurrent hernia group, treated with mesh only, was 10.5% (four of 38 patients) compared with 4.8% (one of 21 patients) in the PSR + MU group. CONCLUSIONS: Primary laparoscopic repair along with mesh placement for the management of ventral hernia was found to be effective in selected cases as evidenced by the low rate of recurrence when compared with conventional laparoscopic repair with mesh alone. Further retrospective and prospective studies, with larger patient enrollment, are warranted to confirm the benefit of this technique over traditional repair.

An analysis of readmission trends by urgency and race/ethnicity in the MBSAQIP registry, 2015-2018.

BACKGROUND: Large-scale analyses stratifying bariatric surgery readmissions by urgency are lacking. OBJECTIVES: Identify predictors of urgent/nonurgent readmission among "ideal" bariatric candidates, using a national registry. SETTING: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) national database. METHODS: We extracted an "ideal" patient cohort from the 2015-2018 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program (MBSAQIP) registry, characterized by only typical weight-related comorbidities (hypertension [HTN], obstructive sleep apnea [OSA], gastroesophageal reflux disease [GERD], and diabetes (insulin-dependent diabetes mellitus [IDDM] and non-insulin-dependent diabetes mellitus [NIDDM]) undergoing primary bariatric surgery with an uneventful postoperative course. Readmissions were classified as "urgent" (UR; e.g., leak, obstruction, bleeding) or "nonurgent" (NUR; e.g., dehydration, nonspecific abdominal pain). χ2 or t test analyses were used for bivariate significance testing. Multivariate logistic regression models were constructed to assess independent predictors of readmission. RESULTS: The cohort (N = 292,547) comprised 38.5% of all MBSAQIP patients (mean age [standard deviation] = 43.2 [11.7]; body mass index [BMI] = 44.9 [6.6]; 81% female; 62% White, 17% Black, 14% Hispanic). Total readmission rates were 2.75% (n = 8046) and decreased from 2015-2018 (3.00%-2.63%; P < .001). Independent predictors of readmissions included Roux-en-Y gastric bypass (RYGB) (odds ratio [OR] = 1.97, p < .001), Black (OR = 1.46, P < .001) and Hispanic race (OR = 1.14, P < .001), GERD (OR = 1.27, P < .001), HTN (OR = 1.08, P = .003), and IDDM (OR = 1.39, P < .001). NUR and UR readmission rates were 1.27% (n = 3702) and 1.06% (n = 3090), respectively. NURs decreased over time (1.42%-1.16%, P < .001), with no change in Urs (1.01%-1.06%, P = .51); this trend persisted in multivariate analysis (2017: NUR OR = .85, P < .001; 2018: NUR OR = .82, p < .001). Independent predictors of both URs and NURs included Black (NUR OR = 1.71, p < .001; UR OR = 1.27, p < .001) and Hispanic (NUR OR = 1.15, P < .001; UR OR = 1.19, P < .001) race, RYGB (NUR OR = 1.84, P < .001; UR OR = 2.34, P < .001), and GERD (NUR OR = 1.39, p < .001; UR OR = 1.17, P < .001). Female sex (NUR OR = 1.64, P < .001), age (NUR OR = .98, P < .001), HTN (NUR OR = 1.22, P < .001), and IDDM (NUR OR = 1.41, P < .001) predicted NURs, while higher BMI (UR OR = 1.01, P < .001), and OSA (UR OR = 1.10, P = .02) predicted URs. CONCLUSION: Readmission rates for "ideal" bariatric patients improved over time, driven by reductions in non-urgent etiologies. Racial disparities persist for both urgent and non-urgent causes of readmission.

Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach.

BACKGROUND: This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population. METHODS: Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center. RESULTS: An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center. CONCLUSIONS: Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.

A review of 130 humans enrolled in transgastric NOTES protocols at a single institution.

BACKGROUND: The methodology of Natural Orifice Translumenal Endoscopic Surgery (NOTES) has been validated in both human and animal models. Herein is a discussion of our experience gained from the initial 130 patients enrolled in transgastric pre-NOTES and NOTES protocols at our institution. METHODS: A retrospective review of our research database was performed for all patients enrolled in NOTES protocols. The infectious risk of a gastrotomy with and without a NOTES procedure was assessed in 100 patients. Eighty patients completed a true NOTES protocol looking at staging, access, and insufflation with select patients evaluating the potential for bacterial contamination of the abdominal compartment. RESULTS: A total of 130 patients have completed pre-NOTES and NOTES protocols at our institution. We observed no clinically significant contamination of the abdomen secondary to transgastric procedures in 100 patients. Diagnostic transgastric endoscopic peritoneoscopy (DTEP) was completed in 20 patients with pancreatic head masses and found to have a 95% concordance with laparoscopic exploration for assessment of peritoneal metastases. Blind endoscopic gastrotomy and DTEP were evaluated in 40 patients who underwent laparoscopic Roux-en-Y gastric bypass procedures (LSRYGB) and were found to be safe, reliable, and without a clinically significant risk of contamination. Endoscopic peritoneal insufflation was successfully established and correlated with standard laparoscopic insufflation in 20 patients. CONCLUSIONS: Transgastric NOTES is a safe alternative approach to accessing the peritoneal cavity in humans. The risk of bacterial contamination secondary to peroral and transgastric access is clinically insignificant. A device for the facile closure of the gastric defect is the sole factor limiting institution of this methodology as a standalone technique.

A comparison of outcomes between open and laparoscopic surgical repair of recurrent inguinal hernias.

BACKGROUND: Inguinal hernia recurrence after surgical repair is a major concern. The authors report their experience with open and laparoscopic repair of recurrent inguinal hernias. METHODS: After institutional review board approval, a retrospective review was performed with the charts of 197 patients who had undergone surgical repair of recurrent inguinal hernias from January 2000 through August 2009, and the data for 172 patients who met the inclusion criteria were analyzed. Surgical variables and clinical outcomes were compared using Student's t test, the Mann-Whitney U test, chi-square, and Fisher's exact test as appropriate. RESULTS: The review showed that 172 patients had undergone either open mesh repair (n=61) or laparoscopic mesh repair (n=111) for recurrent inguinal hernias. Postoperative complications were experienced by 8 patients in the open group and 17 patients in laparoscopic group (p=0.70). Five patients (8.2%) in the open group and four patients (3.6%) in the laparoscopic group had re-recurrent inguinal hernias (p=0.28). Four patients in the open group (9.5%) and no patients in the laparoscopic group had recurrence during long-term follow-up evaluation (p=0.046). In the laparoscopic group, 76 patients (68.5%) underwent total extraperitoneal (TEP) repair, and 35 patients (31.5%) had transabdominal preperitoneal (TAPP) repair. Postoperative complications were experienced by 13 patients in the TEP group and 4 patients in the TAPP group (p=0.44). Two patients (2.6%) in the TEP group and two patients (5.7%) in the TAPP group had re-recurrent inguinal hernias (p=0.59). CONCLUSIONS: This retrospective review showed no statistical difference in the re-recurrence rate between the two techniques during short-term follow-up evaluation. However, the laparoscopic technique had a significantly lower re-recurrence rate than the open technique during long-term follow-up evaluation. Both procedures were comparable in terms of intra- and postoperative complications. Among laparoscopic techniques, TEP and TAPP repair are acceptable methods for the repair of recurrent inguinal hernia. A multicenter prospective randomized control trial is needed to confirm the findings of this study.

Novel reconstruction of the extrahepatic biliary tree with a biosynthetic absorbable graft.

OBJECTIVES: The reference standard technique for the reconstruction of the extrahepatic biliary tree is Roux-en-Y hepaticojejunostomy. This procedure is not without complications and may not be feasible in some patients. This project sought to evaluate a novel approach for repairing common bile duct injuries with a biosynthetic graft. This allows for the reconstruction of the anatomy without necessitating an intestinal bypass. METHODS: Study subjects were 11 mongrel hounds. Utilizing an open approach, the common bile duct was transected in each animal. A 1-cm graft of a synthetic bioabsorbable prosthesis was interposed over a 5-Fr pancreatic stent and sewn in place as an interposition tube graft with absorbable sutures. Intraoperative cholangiograms and monthly liver function tests were completed. Animals were killed at 6, 7, 8, 10 and 12 months. RESULTS: The first five animals were killed early in the process of protocol development. One animal developed obstructive symptoms and was killed on postoperative day 14. The next five animals were longterm survivors without evidence of clinically significant graft stenosis. Mean alkaline phosphatase and total bilirubin were normal, at 140 U/l and 0.2 mg/dl, respectively. Histology showed the complete replacement of the graft with native tissue at 6 months. CONCLUSIONS: Biliary reconstruction using a synthetic bioabsorbable prosthetic as an interposition tube graft is feasible based on initial results.

Do gastrotomies require repair after endoscopic transgastric peritoneoscopy? A controlled study.

BACKGROUND: The optimal method for closing gastrotomies after transgastric instrumentation has yet to be determined. OBJECTIVE: To compare gastrotomy closure with endoscopically delivered bioabsorbable plugs with no closure. DESIGN: Prospective, controlled study. SETTING: Animal laboratory. SUBJECTS: Twenty-three dogs undergoing endoscopic transgastric peritoneoscopy between July and August 2007. INTERVENTIONS: Endoscopic anterior wall gastrotomies were performed with balloon dilation to allow passage of the endoscope into the peritoneal cavity. The plug group (n = 12) underwent endoscopic placement of a 4 x 6-cm bioabsorbable mesh plug in the perforation, whereas the no-treatment group (n = 11) did not. Animals underwent necropsy 2 weeks after the procedure. MAIN OUTCOME MEASUREMENTS: Complications related to gastrotomy closure, gastric burst pressures, relationship of burst perforation to gastrotomy, and the degree of adhesions and inflammation at the gastrotomy site. RESULTS: After the gastrotomy, all dogs survived without any complications. At necropsy, burst pressures were 77 +/- 11 mm Hg and 76 +/- 15 mm Hg (P = .9) in the plug group and no-treatment group, respectively. Perforations occurred at the site of the gastrotomy in 2 of 12 animals in the plug group and in none of the 11 dogs in the no-treatment group (P = .5). Finally, there were minimal adhesions in all dogs (11/11) in the no-treatment group and minimal adhesions in 3 and moderate adhesions or inflammatory masses in 9 of the 12 animals in the plug group (P = .004). LIMITATIONS: Small number of subjects, animal model, no randomization. Gastrotomy trauma during short peritoneoscopy may not be applicable to longer procedures. CONCLUSIONS: After endoscopic gastrotomy, animals that were left untreated did not show any clinical ill effects and demonstrated adequate healing, with fewer adhesions and less inflammation compared with those treated with a bioabsorbable plug.

Natural orifice surgery: initial US experience utilizing the StomaphyX device to reduce gastric pouches after Roux-en-Y gastric bypass.

INTRODUCTION: Weight gain after gastric bypass can occur in up to 10% of patients 5 years following and in about 20% of patients 10 years following surgery. The nadir weight is usually reached within the first 2 years after bypass surgery. However, weight may slowly be regained for numerous reasons. This phenomenon has been studied extensively, but there is often no one reason this occurs. Once psychological and dietary reasons have been investigated, revisional surgery may be the only alternative for treatment. Revisional gastric bypass surgery is associated with a much higher morbidity and mortality when compared with a primary gastric bypass procedure. PATIENTS AND METHODS: Thirty-nine patients underwent endoluminal gastric pouch reduction with the StomaphyX device after informed consent. The StomaphyX device is a sterile, single-use device for use in endoluminal transoral tissue approximation and ligation in the gastrointestinal (GI) tract. RESULTS: Average age was 47.8 (29-64) years, and 36/39 (92.3%) patients were female. Average body mass index (BMI) and weight prior to the StomaphyX procedure were 39.8 (22.7-63.2) kg/m(2) and 108.0 kg (65.90-172.2 kg). The average preprocedure excess body weight was 51.1 kg. Weight loss at 2 weeks (n = 39) was 3.8 kg (7.4% excess body weight loss, EBWL), at 1 month (n = 34) was 5.4 kg (10.6% EBWL), at 2 months (n = 26) was 6.7 kg (13.1% EBWL), at 3 months (n = 15) was 6.7 kg (13.1% EBWL), at 6 months (n = 14) was 8.7 kg (17.0% EBWL), and at 1 year (n = 6) was 10.0 kg (19.5% EBWL). No major complications were observed. The minor complications that were seen included a sore throat lasting less than 48 h in 34/39 patients (87.1%) and epigastric pain that lasted for a few days in 30/39 patients (76.9%). Three patients with chronic diarrhea had their symptoms resolved after the procedure. Eight patients with gastroesophageal reflux disease reported improvement in their symptoms post procedure. CONCLUSIONS: Endoluminal revision of gastric bypass patients with weight gain using the StomaphyX procedure may offer an alternative to open or laparoscopic revisional bariatric surgery.

Pheochromocytoma does not increase risk in laparoscopic adrenalectomy.

BACKGROUND: Laparoscopic adrenalectomy (LA) has become the standard approach to an adrenal mass. This technique provides for decreased convalescence, less postoperative pain, and improved cosmesis. The use of LA for pheochromocytoma (PHE) has been questioned due to concerns of increased morbidity and negative hemodynamic sequelae. This study aimed to compare the outcomes of LA for PHE with the results of LA for other adrenal pathologies. METHODS: A retrospective chart review was performed for an 11-year period from July 1997 to December 2008. Patient demographics, perioperative data, and outcomes were recorded. Statistical analysis was performed using SPSS 16.0. Statistical significance was defined as a p value less than 0.05. RESULTS: A total of 102 LA procedures were completed for 95 patients. The data for 33 PHE cases were compared with the data for 69 non-PHE cases (26 adenomas, 14 aldosteronomas, 5 cortisol-secreting tumors, 5 multinodular hyperplasias, and 19 other disorders). Five LA procedures were converted to open surgery. Four of these conversions involved patients with PHE (p = 0.03). There was no difference in the mean estimated blood loss (p = 0.2) or operative time (p = 0.1) between the two groups. The frequency of intraoperative hypertension and hypotension did not differ between the PHE and non-PHE cohorts. The complication rate was 7.5% for the PHE group and 6.9% for the non-PHE group (p = 0.7). The patients with PHE had a longer postoperative hospital stay (3.6 vs 2.3 days; p < 0.001) and overall hospital stay (4.9 vs 2.6 days; p < 0.001). Time in the intensive care unit (1.1 vs 0.1 days; p < 0.001) and time until oral intake (1.5 vs 1.0 days; p = 0.02) also were increased in the PHE population. There was one death in the PHE group secondary to congestive heart failure. CONCLUSIONS: Concerns of increased morbidity related to a laparoscopic approach for patients with a diagnosis of PHE are unfounded. In this series, the only disparity in outcomes between the two groups was an increased conversion rate with PHE.