Intestinal malrotation in the adult population: Diagnosis, management, and outcomes after laparoscopic Ladd procedure.

BACKGROUND: The Ladd procedure is the treatment of choice for patients with intestinal malrotation; however, the long-term outcomes of the laparoscopic Ladd procedure are not well documented. This study aimed to review the presentation, management, and outcomes of adult patients who underwent a laparoscopic Ladd procedure. METHODS: A retrospective review was conducted to identify adult patients with malrotation who underwent a laparoscopic Ladd procedure between January 1995 and June 2022 at the Mayo Clinic in Rochester, Minnesota. Patient details and follow-up data were obtained from the electronic medical records. Patients were invited to participate in a structured phone interview to assess symptoms and quality of life (QoL). RESULTS: A total of 44 patients underwent the laparoscopic Ladd procedure. Of the 44 patients, 42 (95.5 %) were symptomatic, with 7 (16.7 %) presenting with acute symptoms. Moreover, 8 laparoscopic procedures (13.6 %) required conversion to an open procedure. The median estimated blood loss was 20 mL (IQR, 10-50), operative time was 2.3 h (IQR, 1.8-2.8), and hospital length of stay was 2 days (IQR, 2-3). Postoperative ileus was the most common complication (18.0 %). The median follow-up was 8.00 years (IQR, 2.25-13.00), with more than 90.0 % of patients having partial or complete symptom resolution. Of note, 28 patients (63.6 %) completed phone interviews. Moreover, 1 patient (2.0 %) reported a postoperative volvulus. When asked to compare their current symptoms with those preoperatively, 78.6 % of patients noted that they were significantly better. Furthermore, 85.7 % of patients reported that their QoL was significantly better after surgery. Finally, 96.4 % of patients would recommend the procedure to a friend or family member with the same condition. CONCLUSION: The laparoscopic Ladd procedure is a safe and effective surgical procedure for adult patients with intestinal malrotation.

Robotic modified Sugarbaker technique for parastomal hernia repair: a standardized approach.

Parastomal hernia (PSH) is a prevalent long-term morbidity associated with stoma construction, and the optimal operative management remains uncertain. This study addresses the need for a standardized approach to symptomatic PSH repair, focusing on the robotic-assisted modified Sugarbaker technique with composite permanent mesh. The study, conducted in a high-volume colon and rectal surgery referral practice, outlines a systematic approach to patient selection, surgical procedures, and postoperative care. Preoperative evaluations include detailed medical and surgical histories, impact assessments of PSH, and oncological history reviews. The surgical technique involves the Da Vinci Xi™ robotic platform for adhesiolysis, hernia content reduction, stoma revision if needed, narrowing of the enlarged stoma trephine, lateralization of the stoma limb of bowel, and securing the mesh to the abdominal wall. Outcomes are reported for 102 patients undergoing robotic parastomal hernia repair from January 2021 to July 2023. Conversion to open surgery occurred in only one case (0.9%). Postoperative complications affected 39.2% of patients, with ileus being the most frequent (24.5%). Recurrence was observed in 5.8% of cases during an average follow-up of 10 months. In conclusion, parastomal hernia, a common complication post-stoma creation, demands surgical intervention. The robotic-assisted modified Sugarbaker repair technique, as outlined in this paper, offers promising results in terms of feasibility and outcomes.

Effect of previous abdominal surgery on robotic-assisted rectal cancer surgery.

BACKGROUND: The effect of previous abdominal surgery (PAS) in laparoscopic surgery is well known and significantly adds to longer hospital length of stay (LOS), postoperative ileus, and inadvertent enterotomies. However, little evidence exists in patients with PAS undergoing robotic-assisted (RA) rectal surgery. METHODS: All patients undergoing RA surgery for rectal cancer were reviewed. Patients with PAS were divided into minor and major PAS groups, defined as surgery involving >1 quadrant. The primary outcome was the risk of conversion to open surgery. RESULTS: A total of 750 patients were included, 531 in the no-PAS (NPAS) group, 31 in the major PAS group, and 188 in the minor PAS group. Patients in the major PAS group had significantly longer hospital LOS (P < .001) and lower adherence to enhanced recovery pathways (ERPs; P = .004). The conversion rates to open surgery were similar: 3.4% in the NPAS group, 5.9% in the minor PAS group, and 9.7% in the major PAS group (P = .113). Estimated blood loss (EBL; P = .961), operative times (OTs; P = .062), complication rates (P = .162), 30-day readmission (P = .691), and 30-day mortality (P = .494) were similar. Of note, 53 patients underwent lysis of adhesions (LOA). On multivariate analysis, EBL >500 mL and LOA significantly influenced conversion to open surgery. EBL >500 mL, age >65 years, conversion to open surgery, and prolonged OT were risk factors for prolonged LOS, whereas adherence to ERPs was a protector. CONCLUSION: PAS did not seem to affect the outcomes in RA rectal surgery. Given this finding, the robotic approach may ultimately provide patients with PAS with similar risk to patients without PAS.

Evolution of laparoscopic ileal pouch-anal anastomosis: impact of enhanced recovery program, medication changes, and staged approaches on outcomes.

BACKGROUND: Although laparoscopic Ileal pouch-anal anastomosis (IPAA) has become the gold standard in restorative proctocolectomy, surgical techniques have experienced minimal changes. In contrast, substantial shifts in perioperative care, marked by the enhanced recovery program (ERP), modifications in steroid use, and a shift to a 3-staged approach, have taken center stage. METHODS: Data extracted from our prospective IPAA database focused on the first 100 laparoscopic IPAA cases (historic group) and the latest 100 cases (modern group), aiming to measure the effect of these evolutions on postoperative outcomes. RESULTS: The historic IPAA group had more 2-staged procedures (92% proctocolectomy), whereas the modern group had a higher number of 3-staged procedures (86% proctectomy) (P < .001). Compared with patients in the modern group, patients in the historic group were more likely to be on steroids (5% vs 67%, respectively; P < .001) or immunomodulators (0% vs 31%, respectively; P < .001) at surgery. Compared with the historic group, the modern group had a shorter operative time (335.5 ± 78.4 vs 233.8 ± 81.6, respectively; P < .001) and length of stay (LOS; 5.4 ± 3.1 vs 4.2 ± 1.6 days, respectively; P < .001). Compared with the modern group, the historic group exhibited a higher 30-day morbidity rate (20% vs 33%, respectively; P = .04) and an elevated 30-day readmission rate (9% vs 21%, respectively; P = .02). Preoperative steroids use increased complications (odds ratio [OR], 3.4; P = .01), whereas 3-staged IPAA reduced complications (OR, 0.3; P = .03). ERP was identified as a factor that predicted shorter stays. CONCLUSION: Although ERP effectively reduced the LOS in IPAA surgery, it failed to reduce complications. Conversely, adopting a 3-staged IPAA approach proved beneficial in reducing morbidity, whereas preoperative steroid use increased complications.