Symptomatic diaphragmatic herniation following open and minimally invasive oesophagectomy: experience from a UK specialist unit.

BACKGROUND: The uptake of minimally invasive oesophagectomy (MIO) in the UK has increased dramatically in recent years. Post-oesophagectomy diaphragmatic hernias (PODHs) are rare, but may be influenced by the type of approach to resection. The aim of this study was to compare the incidence of symptomatic PODH following open and MIO in a UK specialist centre. METHODS: Consecutive patients undergoing oesophagectomy for malignant disease between 1996 and 2012 were included. A standardised, radical approach to the abdominal phase was employed, irrespective of the type of procedure undertaken. Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database. RESULTS: A total of 273 oesophagectomies were performed (205 open; 68 MIO). There were 62 hybrid MIOs (laparoscopic abdomen and thoracotomy) and six total MIOs. Seven patients required conversion and were analysed as part of the open cohort. Nine patients (13.2 %) developed a PODH in the MIO cohort compared with two patients (1.0 %) in the open cohort, (p < 0.001). Five patients developed hernias in the early post-operative period (days 2-10): all following MIO. Both PODHs in the open cohort occurred following transhiatal oesophagectomy. All PODHs were symptomatic and required surgical repair. CT thorax confirmed the diagnosis in 10 patients. Seven hernias were repaired laparoscopically, including two cases in the early post-operative period. PODHs were repaired using the following techniques: suture (n = 6), mesh reinforcement (n = 4) and omentopexy to the anterior abdominal wall without hiatal closure (n = 1). There were two recurrences (18 %). CONCLUSIONS: The incidence of symptomatic PODH may be higher following MIO compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and omentopexy to the abdominal wall may reduce the incidence of herniation.

Resection of giant gastric GIST with a new generation ultrasonic scalpel device.

Gastrointestinal stroma tumours (GIST) are the most common mesenchymal tumour in the digestive tract and commonly found in the stomach. The patient described in this report presented with collapse and a palpable abdominal mass. He was found to have a large gastric GIST that penetrated through the mesocolon. Resection of the GIST was technically challenging but facilitated by a new generation ultrasonic scalpel device. In resection of gastric cancer the use of ultrasonic scalpels has been shown to reduce operating time, blood loss and length of stay. We feel that in technically challenging cases of gastric GIST the use of an ultrasonic scalpel device may be justified as well.

Fixation of the access-port is not required in gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding (LAGB) is increasingly performed in patients with morbid obesity. Suturing of the access-port in LAGB can be difficult and time consuming but is felt necessary by many surgeons to prevent migration and facilitate band adjustments. METHODS: Between 2003 and 2006, 226 patients underwent LAGB with the MIDband. All surgery was performed by the pars flaccida approach. The access-port was positioned in a subcutaneous pouch adjacent to the left hypochondrial port site and was not secured. Regular follow-up and band fills were offered. All band or port-related complications were duly recorded. A patient satisfaction survey was also conducted among 50 randomly selected post-banding patients. RESULTS: Mean age was 41.65 years (range 18-73 years) and mean BMI was 45.85 kg/m2 (range 34.0-74.93 kg/m2). The access-port was inaccessible at first attempt in 5 (2%) patients. 4 of these required radiological imaging to identify the port orientation and 1 required multiple attempts at port puncture with subsequent re-operation due to tube puncture. 91% of patients reported no significant trouble other than mild discomfort and prominence of the port. CONCLUSION: This study shows non-fixation of the access-port to be safe and effective with good patient acceptability. In addition, it avoids the need for regular X-ray localization of the port.