Laparoscopic Total Extraperitoneal Hernia Repair Outcomes.

BACKGROUND AND OBJECTIVES: Laparoscopic inguinal hernia repair has become increasingly popular as an alternative to open surgery. The purpose of this study was to evaluate the safety and effectiveness of the laparoscopic total extraperitoneal procedure with the use of staple fixation and polypropylene mesh. METHODS: A retrospective chart review examined outcomes of 1240 laparoscopic hernia operations in 783 patients, focusing on intraoperative and early postoperative complications, pain, and time until return to work and normal physical activities. RESULTS: There were no intraoperative complications in this series; 106 patients experienced early postoperative complications across 8 evaluated categories: urinary retention (4.1%), seroma (3.0%), testicular/hemiscrotal swelling (1.9%), testicular atrophy (0%), hydrocele (0.6%), mesh infection (0.1%), and neurological symptoms (transient, 1.0%; persistent, 0.2%). Patients used an average of 5.6 Percocet pills after the procedure, and mean times until return to work and normal activities, including their routine exercise regimen, were 3.0 and 3.8 days, respectively. CONCLUSION: Complication rates and convalescence times were considered equivalent or superior to those found in other studies assessing both laparoscopic and open techniques. The usage of multiple Endostaples did not result in increased neurologic complications in the early postoperative period when compared with findings in the literature. In the hands of an experienced surgeon, total extraperitoneal repair is a safe, effective alternative to open inguinal hernia repair.

The use of self-gripping (Progrip™) mesh during laparoscopic total extraperitoneal (TEP) inguinal hernia repair: a prospective feasibility and long-term outcomes study.

BACKGROUND: The use of self-gripping mesh during laparoscopic TEP inguinal hernia repairs may eliminate the need for any additional fixation, and thus reduce post-operative pain without the added concern for mesh migration. Long-term outcomes are not yet prospectively studied in a controlled fashion. METHODS: Under IRB approval, from January 2011-April 2013, 91 hernias were repaired laparoscopically with self-gripping mesh without additional fixation. Patients were followed for at least 1 year. Demographics and intraoperative data (defect location, size, and mesh deployment time) are recorded. VAS is used in the recovery room (RR) to score pain, and the Carolinas Comfort Scale ™ (CCS), a validated 0-5 pain/quality of life (QoL) score where a mean score of >1.0 means symptomatic pain, is employed at 2 weeks and at 1 year. Morbidities, narcotic usage, days to full activity and return to work, and CCS scores are reported. RESULTS: Sixty two patients, with 91 hernias repaired with self-gripping mesh, completed follow-up at a mean time period of 14.8 months. Seventeen hernias were direct defects (average size 3.0 cm). Mesh deployment time was 193.7 s. RR pain was 1.1/10 using a VAS. Total average oxycodone/acetaminophen (5 mg/325 mg) usage = 5.0 tablets, days to full activity was 1.6, and return to work was 4.2 days. Thirteen small asymptomatic seromas were palpated without any recurrences or groin tenderness, and all seromas resolved by the 6 month visit. Transient testis discomfort was reported in five patients. Urinary retention was 3.2%. Mean CCS™ scores at the first visit for groin pain laying, bending, sitting, walking, and step-climbing were 0.2, 0.5, 0.4, 0.3, and 0.3, respectively. At the first post op visit, 4.8% had symptomatic pain (CCS > 1). At 14.8 months, no patients reported symptomatic pain with CCS scores for all 62 patients averaging 0.02, (range 0-0.43). There are no recurrences thus far. CONCLUSIONS: Self-gripping mesh can be safely used during laparoscopic TEP inguinal hernia repairs; our cohort had a rapid recovery, and at the 1-year follow-up visit, there were no recurrences and no patients reported any chronic pain as defined by a CCS™ > 1.

A demand-centered, hybrid life-cycle methodology for city-scale greenhouse gas inventories.

Greenhouse gas (GHG) accounting for individual cities is confounded by spatial scale and boundary effects that impact the allocation of regional material and energy flows. This paper develops a demand-centered, hybrid life-cycle-based methodology for conducting city-scale GHG inventories that incorporates (1) spatial allocation of surface and airline travel across colocated cities in larger metropolitan regions, and, (2) life-cycle assessment (LCA) to quantify the embodied energy of key urban materials--food, water, fuel, and concrete. The hybrid methodology enables cities to separately report the GHG impact associated with direct end-use of energy by cities (consistent with EPA and IPCC methods), as well as the impact of extra-boundary activities such as air travel and production of key urban materials (consistent with Scope 3 protocols recommended by the World Resources Institute). Application of this hybrid methodology to Denver, Colorado, yielded a more holistic GHG inventory that approaches a GHG footprint computation, with consistency of inclusions across spatial scale as well as convergence of city-scale per capita GHG emissions (approximately 25 mt CO2e/person/year) with state and national data. The method is shown to have significant policy impacts, and also demonstrates the utility of benchmarks in understanding energy use in various city sectors.

Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks.

BACKGROUND AND OBJECTIVES: Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods. METHODS: Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Twenty-nine had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. CONCLUSIONS: Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.

Laparoscopic surgery for diverticular disease complicated by fistulae.

OBJECTIVES: Elective laparoscopic surgery for recurrent, uncomplicated diverticular disease is considered safe and effective; however, little data exist on complicated cases. We investigated laparoscopic sigmoid resection for diverticulitis complicated by fistulae. METHODS: We conducted a retrospective review of patients who underwent laparoscopic treatment of enteric fistulae complicating diverticular disease performed by 4 surgeons at the Mount Sinai Medical Center. RESULTS: From 1994 to 2004, 14 patients underwent elective laparoscopic sigmoid resections for diverticular disease complicated by enteric fistulae. Patients' mean age was 62 and 4 were female. Multiple fistulae were present in 21%. Types of fistulae included 8 colovesical, 5 enterocolic, 2 colovaginal, 1 colosalpingal, and 1 colocutaneous. All patients successfully underwent sigmoidectomy, and 14% required additional bowel resections. No cases were proximally diverted. Conversion to open was necessary in 36% of cases, all due to dense adhesions and severe inflammation. The mean operative time was 209 minutes, and the mean blood loss was 326 mL. Two (14%) postoperative complications occurred, including one anastomotic bleed and one prolonged ileus. No anastomotic leaks or mortalities occurred. The mean postoperative stay was 6 days. CONCLUSION: Laparoscopic management of diverticular disease complicated by fistulae can be performed effectively and safely. The conversion rate is higher than traditionally accepted rates of uncomplicated cases of diverticulitis and is associated with severe adhesions and inflammation.

Laparoscopic splenectomy: a selected retrospective review.

Previous investigators have suggested that laparoscopic splenectomy should be the procedure of choice for the treatment of benign hematologic disorders unresponsive to medical therapy. To evaluate the safety and utility of laparoscopic splenectomy for a variety of splenic disorders, we reviewed our collective experience at 2 institutions. We studied our 8-year experience by retrospective chart review. Patient demographic data, splenic pathology, intraoperative events, concomitant procedures, and all adverse perioperative events were recorded. A total of 131 patients had laparoscopic splenectomy, and there were 8 conversions to open surgery. Pathology included 63 with idiopathic thrombocytopenic purpura (ITP), 23 malignancies, 12 thrombotic thrombocytopenic purpura (TTP), 10 autoimmune hemolytic anemia (AIHA), and 23 others. Accessory spleens were noted in 21 patients (16%). Concomitant surgical procedures included 12 hepatic biopsies, 4 distal pancreatectomies, 4 cholecystectomies, and 7 others. Mean operative time was 170 minutes. There were 16 major complications in 16 patients and 2 deaths. Median postoperative length of stay was 3 days. Conversions, due mostly to bleeding, are related to splenic pathology and medical comorbidity and are not temporally related to surgical experience (learning curve). The morbidity, mortality, and conversion rates were low. Laparoscopic splenectomy permits an appropriate abdominal exploration and is associated with a short hospital stay. It is the procedure of choice for most indications for splenectomy.

Development of a successful non-heart-beating organ donation program.

To help alleviate the organ shortage, transplant centers are using organs from expanded-criteria donors, who were considered unsuitable just a few years ago, such as non-heart-beating donors. In 1998, we made a concerted effort to increase the number of non-heart-beating donors recovered by our organ procurement organization. In this paper, we discuss the steps in establishing this program, including transplant center support, estimating the number of potential non-heart-beating donors, organ procurement support, protocol development, hospital development, education, putting the protocol into practice, follow-up, and effect of the program on organ procurement. With the establishment of this program, the number of non-heart-beating donors increased from 2% to 5% per year to over 10% for the past 2 years. From these donors, 61 of 82 recovered kidneys were transplanted into 58 patients, and 18 of 20 recovered livers were transplanted. A non-heart-beating donor program can significantly add to the number of organ transplants and successful transplantations.