Trends and outcomes of open, laparoscopic, and robotic inguinal hernia repair in the veterans affairs system.

PURPOSE: Robotic inguinal hernia repair (RHR) is an evolving technique but is comparatively expensive and has yet to show superior outcomes versus open (OHR) or laparoscopic (LHR) approaches. The utilization and clinical outcomes of RHR have not been reported within the veterans affairs (VA) system. This study analyzes trends in utilization and 30-day post-operative outcomes between OHR, LHR, and RHR in veterans. METHODS: This is a retrospective review of patients that underwent inguinal herniorrhaphy using the Veterans Affairs Quality Improvement Program database. Multivariable analysis of outcomes was performed adjusting for pre-operative confounding covariates between OHR, LHR, and RHR. Trends in utilization, complication rates, and operative times were also reported. RESULTS: From 2008-2019, 124,978 cases of inguinal herniorrhaphy were identified: 100,880 (80.7%) OHR, 18,035 (14.4%) LHR, and 6063 (4.9%) RHR. Compared to LHR, RHR was associated with 4.94 times higher odds of complications, 100 min longer mean operative time, and 1.5 days longer median length of stay (LOS). Compared to OHR, RHR was associated with 5.92 times higher odds of complications, 57 min longer mean operative time, and 1.1 days longer median LOS. Utilization of RHR and LHR significantly increased over time. RHR complication rates decreased over time (2008: 20.8% to 2019: 3.2%) along with mean operative times (2008: 4.9 h to 2019: 2.8 h; p < 0.05). CONCLUSION: While this study demonstrated inferior outcomes after RHR, the temporal trends are encouraging. This may be due to increased surgeon experience with robotics. Further prospective data will elucidate the role of RHR as this technique increases.

Umbilical hernia repair in pregnant patients: review of the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). METHODS: All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests. RESULTS: A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair. CONCLUSIONS: Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus.

Sports hernia repair with adductor tenotomy.

PURPOSE: Sports hernias, or athletic pubalgia, is common in athletes, and primarily involves injury to the fascia, muscles, and tendons of the inguinal region near their insertion onto the pubic bone. However, management varies widely, and rectus and adductor tenotomies have not been adequately described. The purpose of this manuscript is to demonstrate a suture repair and a rectus and adductor longus tenotomy technique for sports hernias. METHODS: After magnetic-resonance-imaging confirmation of sports hernias with rectus and adductor tendonitis, 22 patients underwent a suture herniorrhaphy with adductor tenotomy. The procedure is performed through a 4-cm incision, and a fascial release of the rectus abdominis and adductor tenotomy is performed to relieve the opposing vector forces on the pubic bone. RESULTS: All 22 patients returned to their respective sports and regained their ability to perform at a high level, including professional status. No further surgery was required. CONCLUSION: In athletes with MRI confirmation of rectus and adductor longus injuries, tenotomies along with a herniorraphy may improve outcomes. A suture repair to reinforce the inguinal floor prevents mesh-related complications, especially in young athletes.

Reverse shoulder arthroplasty with glenoid bone grafting for anterior glenoid rim fracture associated with glenohumeral dislocation and proximal humerus fracture.

BACKGROUND: Large fractures of the anterior glenoid rim can result in persisting instability and osteoarthritis of the glenohumeral joint When this fracture is associated with a glenohumeral dislocation and proximal humerus fracture could be a concern. The goal of this paper was to evaluate the clinical and radiological outcomes and complications of reverse shoulder arthroplasty (RSA) and glenoid bone graft in cases with a significant anterior glenoid fracture associated with a proximal humerus fracture. HYPOTHESIS: RSA and step bone graft harvested from proximal humeral head could be a viable option in the treatment of this complex injury. DESIGN: Retrospective case series. MATERIAL AND METHODS: Twenty-six patients underwent RSA and glenoid bone graft in a single stage procedure were evaluated at an average 32 months postoperatively. There were 18 women and 8 men with a mean age of 68.5 years (range 63-75 years). Reverse shoulder arthroplasty with a contoured glenoid bone graft placed underneath the baseplate using humeral head autograft was utilized in all cases. Clinical outcomes were evaluated with range of motion, Constant score and self-reported subjective outcome rated as excellent, good, fair or poor. Radiographic evaluation was performed to evaluate for baseplate displacement or loosening, bone graft union, resorption or collapse. RESULTS: At final follow-up, average active elevation was 135° (range 110°-145°), abduction 122° (range 60°-160°), and external rotation 30° (range 0 to 45°). The mean Constant score was 68.2 (range 54-83). The clinical results were rated as excellent by 15 patients, good by 9, and fair by 2. Radiographic evaluation showed the disc of cancellous bone graft healed without any signs of graft resorption or migration in all 26 cases. No reoperation was performed on any patient in this series. DISCUSSION/CONCLUSION: RSA with glenoid bone grafting produces satisfactory short-term outcomes with acceptable complication rates for treatment of patients greater than 60 years old with proximal humerus fractures associated with an anterior glenoid rim fracture. Further studies are necessary to determine the extended viability of this procedure. LEVEL OF EVIDENCE: III.

Gastric electrical stimulation with Enterra therapy improves symptoms of idiopathic gastroparesis.

BACKGROUND: Gastric electrical stimulation (GES) is a therapeutic option for intractable symptoms of gastroparesis (GP). Idiopathic GP (ID-GP) represents a subset of GP. AIMS: A prospective, multicenter, double-blinded, randomized, crossover study to evaluate the safety and efficacy of Enterra GES in the treatment of chronic vomiting in ID-GP. METHODS: Thirty-two ID-GP subjects (mean age 39; 81% F, mean 7.7 years of GP) were implanted with GES. The stimulator was turned ON for 1½ months followed by double-blind randomization to consecutive 3-month crossover periods with the device either ON or OFF. ON stimulation was followed in unblinded fashion for another 4.5 months. Twenty-five subjects completed the crossover phase and 21 finished 1 year of follow-up. KEY RESULTS: During the unblinded ON period, there was a reduction in weekly vomiting frequency (WVF) from baseline (61.2%, P < 0.001). There was a non-significant reduction in WVF between ON vs OFF periods (the primary outcome) with median reduction of 17% (P > 0.10). Seventy-five percent of patients preferred the ON vs OFF period (P = 0.021). At 1 year, WVF remained decreased (median reduction = 87%, P < 0.001), accompanied by improvements in GP symptoms, gastric emptying and days of hospitalization (P < 0.05). CONCLUSIONS & INFERENCES: (i) In this prospective study of Enterra GES for ID-GP, there was a reduction in vomiting during the initial ON period; (ii) The double-blind 3-month periods showed a non-significant reduction in vomiting in the ON vs OFF period, the primary outcome variable; (iii) At 12 months with ON stimulation, there was a sustained decrease in vomiting and days of hospitalizations.

Identification of cardiovascular genes in omentum from morbidly obese patients with type 2 diabetes.

BACKGROUND: The metabolic syndrome describes the association between obesity and co-morbidities including insulin resistance, hypertension, dyslipidemia, and cardiovascular (CV) disease. Adipokines produced from omentum contribute to the risk of CV disease and increase the inflammatory state. This study examines the gene expression differences in the omental tissue of morbidly obese diabetic and non-diabetic patients. METHODS: Twenty morbidly obese patients undergoing bariatric surgery were included. Ten patients were diabetic and 10 were non-diabetic. Omental samples were collected intraoperatively and snap frozen. Total RNA was extracted using the Trizol reagent and purified with the RNeasy kit (Qiagen). Microarray experiments were performed using the Affymetrix Gene 1.0 ST array and data was analyzed with the Partek 6.3 program using an unpaired t-test (P<0.05). The gene expression profiles of the diabetic group were compared with the non-diabetic group. Using the Ingenuity program, the gene list generated from the microarray analysis was evaluated and real-time quantitative PCR (qPCR) was used to validate the array data. RESULTS: Compared with the non-diabetic group, the diabetic obese patients showed 79 upregulated genes and 4 downregulated genes with >1.4-fold difference in expression. Ingenuity analysis showed numerous dysregulated genes associated with CV disease including leptin, Von Willebrand factor, P-selectin, angiopoietin-1 (ANGPT1), phospholipase A2 (group VII), and periostin osteoblast specific factor. Microarray results for the earlier mentioned genes were confirmed with qPCR. The results were analyzed with respect to the presence or absence of hyperlipidemia, hypertension, and coronary artery disease. In patients with hyperlipidemia, ANGPT1 and P-selectin were upregulated 1.9- and 2.9-fold, respectively. CONCLUSIONS: This microarray analysis of omental tissue from morbidly obese diabetic patients documents a host of upregulated genes related to CV disease. This study provides further evidence that diabetic status predisposes obese patients to a higher risk of developing CV disease.

Circadian patterns of gastric electrical and mechanical activity in dogs.

Gastric motor function assessment, in humans and animals, is typically performed for short recording periods. The aim of this article was to monitor gastric electrical and motor activity in the antrum and fundus simultaneously, for long periods, using a new implantable system. Ten dogs were implanted with fundic and antral electrodes for assessment of impedance and electrical activity. Dogs were studied while in cages, for periods of 22-26 h. From late evening and until feeding on the next day, slow wave (SW) rhythm demonstrated a distinct pattern of intermittent pauses (mean duration = 22.8 +/-4.1 s) that delineated groups of SW's. Phasic increases in fundic tone were seen mostly in association with SW pauses, and were highly correlated with antral contractions, R(2) = 0.652, P < 0.05. The SW rate (events per minute) in the postprandial period, fasting and night time was 4.2 +/- 0.2, 5 +/- 0.2 and 4.7 +/- 0.3, respectively, P < 0.05 postprandial vs other periods. Antral and fundic mechanical activities were highly correlated during fasting, particularly at night. This novel method of prolonged gastric recording provides valuable data on the mechanical and electrical activity of the stomach, not feasible by current methods of recording. During fasting, fundic and antral motor activities are highly correlated and are associated with periodic pauses in electrical activity.

Parastomal herniation of the gallbladder.

Parastomal hernias can occur in up to 31% of patients following an enterostomy (Cheung in Aust N Z J Surg 65:808-811, 1995). This type of hernia develops through an intentional fascial defect. Commonly, most parastomal hernias involve a reducible segment of omentum, small bowel, or colon. Typically, these hernias are asymptomatic and associated rarely with strangulation or obstruction. Patient preference and clinical scenario may dictate management of these hernias. Non-operative management of parastomal hernias includes abdominal binders and enterostomy belts. Operative management includes a host of options including mesh repair, a new stoma site, or revision. This paper documents the first reported case of a parastomal hernia involving the gallbladder. Optimal technique and site placement of a stoma are also discussed.

Laparoscopic splenectomy for lymphoproliferative disease.

BACKGROUND: Elective laparoscopic splenectomy (LS) achieves excellent results for benign hematologic diseases. The role of LS for hematologic malignancies is harder to define owing to associated splenomegaly and patient disease that may alter outcome. METHODS: Retrospective review of single institution experience 1996 through 2002. To limit variability of disease processes, only patients with immune thrombocytopenic purpura (ITP) and lymphoproliferative disease (LPD) were studied. RESULTS: A total of 211 LS have been performed, including 73 for LPD and 86 for ITP. Patients with LPD were significantly older, 61 vs 46 years p<0.001; male, 45 (62%) vs 33 (38%), p<0.001; and larger splenic weight, 680 vs 162 g, p<0.001. Fifty-nine patients (81%) with LPD were operated with standard LS with a conversion rate of 15%. Hand-assisted LS was performed in 14 patients (19%), and three were converted to open. Compared to ITP, patients with LPD had longer operative time, 148 vs 126 min, p<0001, and higher blood loss, 200 vs 100 cc, p = 0.004. There was one mortality (0.6%), and morbidity occurred in six patients (8%) with LPD and seven (8%) with ITP. The median length of stay was 3 days for LPD and 2 days for ITP, p = 0.03. Forty-six patients were principally operated for a diagnosis, and 27 (60%) were found to have lymphoma. CONCLUSIONS: LS can be performed safely in patients with LPD, and when used judiciously with hand-assisted techniques can be performed with low conversion and morbidity rates. Splenectomy plays an important role in establishing the diagnosis of lymphoma in LPD.

Laparoscopic resection of a periampullary villous adenoma.

BACKGROUND: Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach. CASE REPORT: A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction. CONCLUSIONS: Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions.

Gastric electrical stimulation at proximal stomach induces gastric relaxation in dogs.

Gastric electrical stimulation (GES) improves symptoms in patients with gastroparesis. However, the underlying mechanisms remain unclear. To determine if GES at proximal and distal stomach could affect the biomechanical properties of the stomach, thus contributing to the beneficial effect of GES. Four pairs of electrodes were implanted along the greater curvature of the stomach in seven dogs. Gastric tone and compliance was assessed with a barostat. Measurements were obtained randomly during control and proximal and distal stimulation (4 mA, 375 ms and 6/18 cpm). Data as mean or median (25-75th percentiles). Gastric compliance was not affected by proximal and distal GES. Gastric tone was significantly reduced during proximal GES: 82.0 (66.8, 89.1) mL vs control 49.7 (39.6,75.9) mL at 6 cpm (P = 0.016), and 90.6 (54.5, 117.9) mL vs control 62.8 (39.6, 75.9) mL at 18 cpm (P = 0.031). Tone was not affected by distal GES at 6 cpm: 95.8 (46.3, 106.7) mL vs control 75.2 (49.7, 86.1) mL (P = 0.47) and at 18 cpm: 80.4 (38.1, 170.3) mL vs control 62.8 (44.6, 156.3) mL (P = 0.44). Proximal GES induces gastric relaxation. This effect, if seen also in humans, may explain, in part, the symptomatic improvement associated with GES therapy in patients with gastroparesis.

Recurrence after laparoscopic ventral hernia repair.

BACKGROUND: Although the early results of laparoscopic ventral hernia repair have shown a low recurrence rate, there is a paucity of long-term data. This study reviews a single institution's experience with laparoscopic ventral hernia repair (LVHR). METHODS: We carried out a retrospective analysis of all LVHR performed at the Cleveland Clinic Foundation from January 1996 to March 2001. Recurrence rates were determined by physical exam or telephone follow-up. Factors predictive of recurrence were determined using Cox regression. RESULTS: Of 100 ventral hernias completed laparoscopically, 96 were available for long-term follow-up (average, 30 months; range 4-65). There were no deaths and major morbidity occurred in seven patients. Recurrences were identified in 17 patients. Nine recurrences occurred in the 1st postoperative year; however, hernia recurrence continued throughout the period of follow-up. Multivariate analysis showed that a prior failed hernia repair was associated with a more likely chance of another recurrence (65% vs 35%, odds ratio (OR) 3.6; p = 0.05) and that an increased estimated blood loss (106 cc vs 51 cc, OR 1.03; p = 0.005) predicted recurrence. Other variables, including body mass index (BMI) (32 vs 31 kg/m2, p = 0.38), defect size (115 cm2 vs 91 cm2; p = 0.23), size of mesh (468 cm2 vs 334 cm2, p = 0.19), type of mesh (p = 0.62), and mesh fixation (p = 0.99), did not predict recurrence. An additional 14 cases required conversion to an open operation, and seven of these cases (50%) had recurrence on long-term follow-up. CONCLUSION: Although LVHR remains the preferred method of hernia repair at our institution, this study documents a higher recurrence rate than many other short-term series. There results underscore the importance of long-term follow-up in assessing hernia surgery outcome.

MCP-1 is highly expressed in peritoneum following midline laparotomy with peritoneal abrasion in a murine model.

BACKGROUND: Monocyte chemoattractant protein-1 (MCP-1), a CC chemokine, is a potent attractant of monocytes both in vitro and in vivo. However, its role in the repair of peritoneal injury is not well established. This study characterizes MCP-1 expression in surgical wounds following peritoneal abrasion in a murine model. METHODS: Twenty-five C57 BL6 female mice underwent a 2-cm midline laparotomy with mechanical abrasion of the right peritoneal wall. The mice were sacrificed at various times ranging from 0 to 7 days. Hemotoxylin and eosin stained sections and tissue extracts were made using peritoneal samples from abraded and unabraded areas in each mouse. An enzyme-linked immunosorbent assay was performed on the specimens to quantitate MCP-1 expression. Values were compared using a t-test. RESULTS: At baseline, there was minimal expression of MCP-1 (<5 pg/mg protein). Following surgery, MCP-1 levels at abraded sites were significantly higher than those at both baseline and unabraded sites at all times up to a week following surgery. Histologic evaluation revealed peritoneal thickening and leukocytic infiltration of only abraded surfaces. CONCLUSION: MCP-1 is highly expressed in peritoneum following laparotomy with peritoneal abrasion. Elevations in MCP-1 levels are identified within 6 h of surgery and persist for up to 1 week. The histologic differences between abraded and unabraded areas may be attributable to differences in MCP-1 expression. Further studies using recombinant MCP-1 and anti-MCP-1 antibody may elucidate this relationship.

Laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy is currently the procedure of choice for elective splenectomy. This study reviews the initial 100 laparoscopic splenectomies completed at the Cleveland Clinic Foundation. METHODS: A retrospective review of elective laparoscopic splenectomy was performed to assess clinical outcomes at the Cleveland Clinic Foundation. Patient demographics, preoperative diagnoses, operative characteristics, morbidity, and mortality were evaluated. RESULTS: Of the 169 elective splenectomies completed over a 4-year period from 1995 to 1999, 100 were attempted laparoscopically. The proportions of all splenectomies attempted laparoscopically by year were 17%, 38%, 75%, and 72%. Nearly 70% of splenectomies were performed for idiopathic thrombocytopenic purpura or malignancy. Overall, the mean blood loss was 181 ml, and the mean operative time was 170 min. Splenomegaly occurred in 31% of the patients and accounted for longer operative times. Three patients required conversion to an open procedure. Postoperative complications were seen in 13% of the patients. One patient died in the postoperative period from staphylococcal sepsis, giving a mortality rate of 1%. CONCLUSIONS: Laparoscopic splenectomy currently is the procedure of choice for elective splenectomy at our institution. As compared with traditional open splenectomy, laparoscopic splenectomy results in minimal morbidity even in the setting of splenomegaly.

Outcome of laparoscopic splenectomy based on hematologic indication.

BACKGROUND: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. METHODS: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher's exact tests and Wilcoxon rank-sum tests. RESULTS: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty's syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 +/- 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. CONCLUSIONS: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.

Planned totally extraperitoneal laparoscopic Spigelian hernia repair.

A Spigelian hernia is a congenital defect in the tranversus aponeurosis fascia. Traditionally, an open anterior hernioplasty was used to repair these defects. Recently, laparoscopic approaches have been described. This report describes the first application of the totally extraperitoneal laparoscopic approach to a planned repair of a Spigelian hernia. The patient was a 62-year-old white female with a reducible left lower quadrant anterior abdominal wall bulge consistent with a Spigelian hernia. At the time of surgery, we exposed the posterior rectus fascia and modified our extraperitoneal inguinal hernia technique by passing the balloon dissector in a more lateral orientation. This created a unilateral preperitoneal space with adequate room for dissection and mesh fixation. The Spigelian defect was easily identified. Its preperitoneal fat contents were reduced, and a 5-mm laparoscopic tacking device was used to secure a piece of prolene mesh. The patient was discharged home with no complications. Placement of the mesh in the preperitoneal space avoids direct interaction of the mesh prosthesis and the intraperitoneal viscera. In conclusion, we find that a laparoscopic totally extraperitoneal approach is technically feasible and advantageous when a Spigelian hernia is diagnosed preoperatively.

Laparoscopic lateral L4-L5 disc exposure.

BACKGROUND: The anterior laparoscopic approach requires precarious dissection around the iliac vessels to expose the L4-L5 level. Furthermore, a retroperitoneal endoscopic approach to the L4-L5 level requires a technically demanding dissection to access the L5-S1 disc space. A unique lateral laparoscopic approach to the L4-L5 disc space allows concurrent access to the L5-S1 space while avoiding major dissection around the iliac vessels. This article describes this novel lateral approach and reviews the initial clinical outcomes. METHODS: Between January 1999 and April 2000, five patients underwent laparoscopic lateral L4-L5 disc exposure at the Cleveland Clinic Foundation. All charts were reviewed retrospectively. Mean values +/- standard deviation were determined for patient demographics and operative characteristics. A standard five-port laparoscopic technique was used. The sigmoid colon was retracted medially with an endoloop. The retroperitoneum was entered and the ureter and left iliac artery were retracted medially, whereas the psoas was retracted laterally. Fluoroscopy delineated the L4-L5 disc space allowing discectomy and cage insertion. Postoperatively, subjective patient satisfaction was obtained and radiologic evidence of fusion was assessed. RESULTS: All five patients were males, with a mean age of 47.4 +/- 7 years and a body mass index of 30 +/- 6 kg/m2. Four patients had an L4-L5 and L5-S1 fusion and one patient had an L4-L5 and L3-L4 fusion. Mean operative time was 349 +/- 32 min, with a mean blood loss of 210 +/- 74 cc. There were no intraoperative complications and no conversions, and postoperatively all patients were started on a clear liquid diet on postoperative day 1. The mean length of stay was 3.4 +/- 0.9 days. Patients returned to work in a mean of 12 +/- 7 weeks. All patients had evidence of fusion on their radiologic follow-up. Four patients were pain free, whereas one patient required intermittent narcotics at 1-year follow-up. CONCLUSIONS: For multilevel fusions including the L4-L5 disc space, the lateral laparoscopic exposure is a safe and efficacious procedure allowing simultaneous access to multiple disc spaces while avoiding the sympathetic chain, ureter, and major vascular structures. The lateral approach affords excellent exposure for accurate deployment of the appropriate orthopedic hardware.

Laparoscopic management and clinical outcome of emphysematous cholecystitis.

BACKGROUND: As opposed to acute, chronic, and acalculus cholecystitis, emphysematous cholecystitis (EC) is associated with significant morbidity and mortality. Only a few studies have specifically reviewed the operative management and clinical outcome of EC. This study documents the operative management and clinical outcome of EC at the Cleveland Clinic Foundation. METHODS: Between January 1996 and June 1999, 18 consecutive patients underwent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent procedures were excluded. Mean values +/- standard deviation (SD) of the mean were calculated for patient demographics, preoperative white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imaging studies, operative time, ICU stay, morbidity, and mortality were reviewed. RESULTS: Patients presented with a mean age of 53.4 years (range, 18-80) and a male/female ratio of 3.5 (14/4). There were no differences between groups in terms of patient demographics. Mean WBC on admission was 14.2 K/mL (range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen patients (72%) were completed laparoscopically, two patients (11%) were converted to an open procedure, and three patients (17%) had open surgery. Overall mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexisting illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the patients died in the immediate perioperative period. There were five complications (27.8%). Two patients presented with bleeding secondary to heparin and coumadin therapy. One developed sepsis, and another developed leakage from the cystic duct stump, necessitating an endoscopic retrograde cholangiopancreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the three groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. CONCLUSIONS: Using current techniques, patients with EC can be managed successfully utilizing laparoscopy. Morbidity and mortality appear to be slightly higher than published reports for acute, chronic, and acalculus cholecystitis. Conversion rates are comparable to patients with acute and chronic cholecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.