Laparoscopic Cholecystectomy in a Patient with Situs Inversus Totalis: Port Placement and Dissection Techniques.

BACKGROUND Situs inversus is a rare congenital condition. Since 1991, more than 60 cases of laparoscopic cholecystectomy have been reported in patients with situs inversus. There are many different port placement techniques depending on the surgeon's preference. The fact that some of the critical dissection is easier performed by the left hand poses technical difficulty for right-handed surgeons. CASE REPORT A 56-year-old woman with known situs inversus totalis and extensive past surgical history presented with acute cholecystitis. A Veress needle was used to enter the abdomen at Palmer's point. Visiport was used to place the first 5-mm port at the left mid-clavicular line. The dissection was performed in a mirror image to the usual dissection through the epigastric port. CONCLUSIONS There have been several techniques described in the literature to facilitate the dissection in laparoscopic cholecystectomy in patients with situs inversus totalis. We argue that the first port should be placed at the mid-clavicular line with Visiport. The other ports should be placed in mirror image of the normally placed ports, including a 12-mm epigastric port, 5-mm or 11-mm paraumbilical port, and 5-mm port at the left anterior axillary line. For dissection, we argue that it is preferable to have 2 assistants with 1 retracting the gallbladder and the other holding the camera. This allows the primary surgeon to use the dominant hand during critical dissection in this unfamiliar anatomy.

Laparoscopic placement of the LINX® system in management of severe reflux after sleeve gastrectomy.

BACKGROUND: Management of severe reflux after sleeve gastrectomy (SG) is often done by conversion to Roux-en-Y gastric bypass (RYGB). The LINX® system could be an alternative treatment. METHOD: Between 2015 and 2017, 13 patients had LINX® system placed to manage their reflux after SG. Pre-operative evaluation included a barium swallow, endoscopy with pH monitor and esophageal motility. RESULTS: Ten females and three males with mean age of 49 ±â€¯13 years were evaluated. Their mean weight before placing the LINX® system was 193 ±â€¯45 lbs. and mean BMI of 33 ±â€¯6 kg/m2. The mean time between SG and placing the LINX® system was 43 ±â€¯19 months. The mean Bravo score was 46 ±â€¯26 (normal 14.7). One patient developed severe dysphagia post-operatively requiring removal of the LINX® after 18 days and one patient was lost to follow up. The mean follow-up in the remaining 11 patients was 26 ±â€¯12 months. The mean GERD-HRQL score dropped significantly from 47/75 ±â€¯17/75 to 12/75 ±â€¯14/75 (p = .0003). CONCLUSION: The LINX® system may be used as an alternative to RYGB conversion in managing refractory post-SG reflux.

Do gallstones found before sleeve gastrectomy behave the same as those formed after surgery due to weight loss?

BACKGROUND: Gallstone formation is prevalent in the bariatric population and after weight loss. We believe that gallstones found preoperatively behave differently and may not cause significant complications as those developing after weight loss. Thus, prophylactic cholecystectomy before or during sleeve gastrectomy (SG) may not be necessary. METHODS: Patients undergoing SG from January 2011 to May 2012 were evaluated for the presence of gallstones and development of symptoms or need for cholecystectomy postoperatively. RESULTS: Group 1 (n = 18) had gallstones preoperatively. Group 2 (n = 29) developed gallstones after weight loss. Both groups' demographics were similar. Symptomatic gallstones occurred in 1 patient (5.6%) in group 1 and in 9 patients (31.0%) in group 2 (P = .19). Percent excess body mass index loss (%EBL) was 58 ± 24% vs 70 ± 22% (P = .11) with a mean follow-up of 8.9 ± 6.2 and 14.7 ± 3.9 months for group 1 and group 2, respectively (P = .005). CONCLUSIONS: Asymptomatic gallstones found before SG tend to have less risk of becoming symptomatic than those formed after weight loss. There was no statistical significant difference because of small sample. Prophylactic cholecystectomy, however, may not be warranted in these patients.

Can morbidly obese patients with reflux be offered laparoscopic sleeve gastrectomy? A case report of 40 patients.

BACKGROUND: The incidence of reflux in obesity can reach greater than 35%. Most surgeons recommend Roux-en-y gastric bypass to patients with pre-existing reflux. One alternative to Roux-en-y gastric bypass is the addition of anterior fundoplication (AF) with posterior crural approximation (pCA) to laparoscopic sleeve gastrectomy (LSG) in patients with documented reflux. METHODS: Between February 2011 and April 2013 we reviewed data from the bariatric registry on weight loss, resolution of symptoms, and quality of life presurgery and postsurgery for all patients who consented to participate in the registry and underwent LSG with AF/pCA. RESULTS: Forty patients met inclusion criteria; 78% (31) were female. The mean initial weight was 298 ± 64 lbs. with mean BMI of 49 ± 8 kg/m(2). The mean DeMeester score was 36 ± 27 (normal <14.7). Nine (22.5%) patients had esophagitis. Thirty-six (90%) patients had hiatal hernia. There were no intraoperative complications. The mean operative time was 84 ± 20 minutes and the mean hospital stay was 1.6 ± .9 days. Postoperative complications included 1 fluid collection, 1 narrowing, 4 admissions for nausea and dehydration, 1 for pancreatitis, and 1 for deep vein thrombosis . Thirty-eight (95%) patients had immediate resolution of reflux, whereas 2 (5%) patients complained of worsening symptoms. On short-term follow-up of 24 ± 6 months, 55% of patients responded to the gastroesophageal reflux disease-health related quality of life questionnaire with improvement in their median score from 31/75 interquartile range (IQR 25) preoperatively to 0/75 (IQR 6.5) postoperatively (P < .0001). Their %excess body mass index loss was 69 ± 27%. CONCLUSIONS: Morbidly obese patients with documented reflux can be offered LSG with the addition of AF/pCA.

Laparoscopic Management of Severe Reflux After Sleeve Gastrectomy, in Selected Patients, Without Conversion to Roux-en-Y Gastric Bypass.

BACKGROUND: Treatment of severe reflux after laparoscopic sleeve gastrectomy (LSG) may require conversion to Roux-en-Y gastric bypass (RYGB). We conducted a pilot study to evaluate the feasibility and effectiveness of performing laparoscopic anterior fundoplication with posterior crura approximation (LAF/pCA), in selected patients, to correct the reflux without conversion to RYGB. PATIENTS AND METHODS: From October 2012 to April 2013, 6 patients with confirmed severe de novo reflux after LSG were treated with LAF/pCA. RESULTS: All patients were females with a mean age of 41.5±14.2 years. All patients had lost weight after initial LSG. The percentage excess body mass index (BMI) loss (%EBL) was 61.2±33.2%. The mean time from the initial LSG to LAF/pCA was 33.2±12.5 months. Four patients had reduction of gastric fundus size. One patient required resleeving. Reflux resolved immediately in all patients with a follow-up of 18.5±2.7 months. All patients continued to lose weight, with %EBL reaching 75.5±22.9% and a mean BMI of 32±7.3 kg/m(2). CONCLUSIONS: LAF/pCA with reduction of gastric fundus size, when needed, may be considered an alternative option to correct severe reflux after LSG in selected patients.

Early effects of bougie size on sleeve gastrectomy outcome.

BACKGROUND: When performing sleeve gastrectomy, a bougie (32 to 60 French) is used. We evaluated 2 different bougie sizes on early postoperative outcomes and long-term weight loss. METHODS: A 1-year prospective study was conducted on patients undergoing sleeve gastrectomy. In the first 6 months, patients had 32-French bougies (Group 1); in the second 6 months, they had 36-French bougies (Group 2). RESULTS: We evaluated 131 patients. No intraoperative complications or mortality occurred. Postoperatively, Group 1 (n = 72) had a longer hospital stay (1.6 ± .8 vs 1.3 ± .5 days, P = .04) and used more Ondansetron for nausea than Group 2 (n = 59) (6.7 ± 8.0 vs 5.3 ± 4.5 mg, P = .2, respectively). Ten (14%) patients in Group 1 returned to the emergency department compared with 5 (9%) in Group 2. One-year percent excess weight loss was similar (73.0 ± 20.6% vs 71.1 ± 20.9%, P = .73, respectively). CONCLUSIONS: The smaller bougie resulted in a longer hospital stay, with tendency toward increased nausea, more emergency department visits, and readmissions. Long-term weight loss was not affected.

Controlling difficult pelvic bleeding with argon beam coagulator during laparoscopic ultra low anterior resection.

In recent years, the standard of care for lower rectal tumors has developed to include a total mesorectal excision, which provides optimal long-term results. There has been debate with regard to the best approach for lower rectal tumors, conventional open versus less invasive procedures. As the trend toward less invasive surgical procedures progresses, similar complications, which are seen in open cases, are being encountered, such as the notorious presacral fascia bleed. These are small vessels, which are difficult to locate and control. Surgical literature suggests different methods during laparoscopic procedures. These include: placing lap pads and holding pressure, placing saline bag, placing tacks, using bone wax, and electrocautry at different settings. We present a case of a 57-year-old male, positive for lymph node disease, who underwent laparoscopic ultra low anterior resection with total mesorectal excision and protective loop ileostomy.

Single-incision laparoscopic cholecystectomy (SILC): a refined technique.

BACKGROUND: Reports of decreasing the number of incisions in laparoscopic procedures began appearing in the 1990s. A recent spark in pursuing such an approach has been accelerated by natural-orifice transluminal endoscopic surgery. METHOD: Several modifications in performing single-incision laparoscopic cholecystectomy (SILC) were introduced until it was possible to develop a simple and safe technique. RESULTS: SILC was completed in 61 of 71 operated patients. Fifty-five patients had SILC without cholangiography (average operative time, 49 minutes). Thirteen patients had SILC with cholangiography, 11 with negative results (average operative time, 67 minutes). Three patients needed additional trocars (bi-incision access surgery [BIAS]). None were converted to open procedures. Of the 69 patients with SILC or BIAS, 66 had same-day discharge, and 3 were discharged the following day. CONCLUSION: SILC or BIAS is effective for gallbladder removal, with comparable lengths of stay, operative times, and safety as the traditional method, with better cosmetic results.

Degloving of the renal capsule: a rare complication of laparoscopic live donor nephrectomy.

Laparoscopic live donor nephrectomy is becoming the procedure of choice for kidney procurement. In the course of 172 laparoscopic procurements, degloving of the renal capsule, a rare complication believed to be related to the method of extraction of the kidney, was encountered in 2 patients (1.2%). The complication was noted after revascularization of the kidney. A capsulotomy was performed to evacuate the subcapsular hematoma. No adverse effect was noted in the postoperative period in the transplanted kidneys.

Total laparoscopic live donor nephrectomy: a 6-year experience.

BACKGROUND: Since the introduction of the laparoscopic live donor nephrectomy in 1995, attempts have been made to depart from the total laparoscopic approach to the hand-assisted approach to decrease surgical time and complications. We present our 6-year experience with the total laparoscopic approach. METHODS: Between December 1998 and November 2004 there were 168 total laparoscopic live donor nephrectomies performed at our institution. There were 163 left nephrectomies and 5 right nephrectomies. RESULTS: The procedure was performed in a systematic approach. The surgical time deceased from an average of 2:27 hours in the first year to 1:34 hours in the last year of the study. The overall average warm ischemia time was 3.5 minutes. Major bleeding requiring conversion to an open procedure occurred in 2 (1.2%) donors. Minor bleeding that was controlled laparoscopically occurred in 9 (5.4%) donors. Degloving of the renal capsule occurred in 2 (1.2%) donors with no consequences. Minor mesenteric rent occurred in 7 (4.2%) donors. All mesenteric complications were recognized and repaired laparoscopically. No ureteral or bowel injuries occurred. There were no mortalities. Eighty-three percent of donors were discharged the next day. CONCLUSIONS: Total laparoscopic live donor nephrectomy is safe. It was performed successfully in 98.8% of donors with a short surgical time, low morbidity, and 0% mortality.

Management of blunt splenic injury in patients with concurrent infectious mononucleosis.

Selective nonoperative management is appropriate for most blunt splenic injuries in adults and children, but the efficacy of this approach is unknown when injury occurs in patients with concurrent infectious mononucleosis. We have reviewed our experience during the past 23 years with the selective nonoperative management of blunt splenic injury in these patients. Medical record review identified nine patients with blunt splenic injury and infectious mononucleosis from 1978 to 2001, representing 3.3 per cent of our total trauma population with blunt splenic injury treated during that interval. Two patients underwent immediate splenectomy because of hemodynamic instability. Seven patients were admitted with the intent to treat nonoperatively. Five patients were successfully managed nonoperatively. Two patients failed nonoperative management and underwent splenectomy, one because of hemodynamic instability and one because of an infected splenic hematoma. Concurrent infectious mononucleosis does not preclude the successful nonoperative management of blunt splenic injury. This small subset of patients may be managed nonoperatively using the same criteria as for patients whose splenic injuries are not complicated by infectious mononucleosis.

Prospective evaluation of criteria for the nonoperative management of blunt splenic trauma.

Recent reports have shown an increased mortality associated with the nonoperative management of blunt splenic injury. We have prospectively applied criteria developed from our previous 15-year experience for the nonoperative management (NOM) of blunt splenic injury. These criteria consist of 1) hemodynamic stability on admission or after initial resuscitation with up to two liters of crystalloid infusion, 2) no physical findings or any associated injuries necessitating laparotomy, and 3) a transfusion requirement attributable to the splenic injury of 2 units or less. From 1994 through 2000 a total of 99 patients presented with blunt splenic injury. Thirty-one patients (31%) underwent splenectomy secondary to hemodynamic instability. During the observation period eight of the 68 patients (12%) who initially met criteria for NOM developed hemodynamic instability and underwent splenectomy. All NOM failures occurred within 72 hours of admission. There was no mortality associated with splenic injury in the NOM (Group I) or in the group failing NOM (Group II), and no associated morbidities from the splenic injury were seen in either group. No significant differences were seen between Groups I and II in terms of age, gender, mechanism of injury, Injury Severity Score, admitting systolic blood pressure, admitting hemoglobin, transfusion requirements, intensive care unit length of stay, or total hospital length of stay (all P > 0.200). We conclude that established criteria for intervention and careful observation in an intensive care setting for at least 72 hours will minimize morbidity or mortality associated with blunt splenic injury in adults.

Simultaneous stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms.

PURPOSE: To describe a technique for concomitant endovascular stent-graft repair of thoracic and infrarenal abdominal aortic aneurysms. CASE REPORT: A 68-year-old man was found to have concomitant thoracic and abdominal aortic aneurysms. Both of the aneurysms were excluded successfully in one procedure using Talent stent-grafts. The patient tolerated the procedure well and was discharged on postoperative day 4. Aside from an infected groin wound, the patient did not have any complications. Computed tomographic scans at 6, 12, and 18 months showed proper position of both stents without evidence of endoleak. CONCLUSIONS: Simultaneous endovascular treatment of thoracic and infrarenal abdominal aortic aneurysms may represent a viable alternative for therapy in some patients.