Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience.

PURPOSE: This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution's experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result. METHODS: A single institution's systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of "defect closure" by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing. RESULTS: LIVHR was performed on 1326 patients, 52.57% female and 47.43% male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m2). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78%, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56%, with a low risk of infection <1%. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24% (VAS 5-7) that decreased to 2.56% on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74%, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72%. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5%), 45.23% were adhesion free, 42.06% had minor adhesions classified as Müller I, and 12.69% had serosal adhesions classified as Müller II. CONCLUSION: Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect's width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.

Injection of a sclerosing agent as first line treatment in anal fissure.

BACKGROUND: In our institution, the first line treatment in acute anal fissures (AAF) or chronic anal fissures (CAF) is the injection of a sclerosing agent consisting of phenol, menthol and peanut oil (Phenomen®, Sterop laboratory, Belgium) under the fissure after a local anaesthesia. This retrospective study presents the technique of injection, evaluates its efficacy and demonstrates the minimal occurrence of complications, continence problems and recurrences. METHODS: 129 patients with an anal fissure were treated between January 2010 and June 2011. 124 patients were reviewed retrospectively. 109 patients benefited from a sclerosis in our outpatient clinic. RESULTS: Of the 109 patients treated by a sclerosis, 58 had an AAF and 51 had a CAF. 53/58 AAF (91.4%) healed and 40/51 CAF (78.4%). Duration of pain after injection was 2 days or less in 55 cases (50.4%), 1 week or less in 35 cases (32.2%) and more than 1 week in 19 cases (17.4%). The complication rate was low (2.7%) : 2 necrosis of the skin and 1 abscess at the site of injection. The rate of troubles of continence was 2.7% : 2 cases of soiling and 1 case of incon-tinence for gas all resolving within a month. At the end of the study, a fissure had recurred in 17 patients (15.6%). CONCLUSIONS: The injection of a sclerosing agent under the fissure is performed in the practitioner's office. Healing rates are high, complications and recurrences are low. This therapeutic option may be a good alternative to classical treatments in case of anal fissures.

Laparoscopic selective diverticulectomy of the colon as first treatment in acute complicated diverticulitis.

We present the case of a 53 year-old male diagnosed with an acute complicated diverticulitis, with localized peritonitis, who underwent a laparoscopic excision of the affected sigmoid diverticula associated with peritoneal lavage and drainage. This approach was performed as first treatment of a Hinchey's IIb diverticulitis to avoid a laparotomy and/or colic resection with a temporary colostomy.

Laparoscopic Roux-en-Y Gastric bypass after failed vertical banded gastroplasty: a multicenter experience with 203 patients.

BACKGROUND: Vertical banded gastroplasty (VBG) has long been the main restrictive procedure for morbid obesity but has many long-term complications for which conversion to Roux-en-Y gastric bypass (RYGBP) is often considered the best option. METHODS: This series regroups patients operated on by three different surgeons in four different centers. All data were collected prospectively, then pooled and analyzed retrospectively. RESULTS: Out of 2,522 RYGBP performed between 1998 and 2010, 538 were reoperations, including 203 laparoscopic RYGBP after VBG. There were 175 women and 28 men. The mean BMI before VBG was 43.2 ± 6.3, and the mean BMI before reoperation was 37.4 ± 8.3. Most patients had more than one indication for reoperation and/or had regained significant weight. There was no conversion to open surgery. A total of 24 patients (11.8 %) developed complications, including nine (4.5 %) who required reoperation and one death. With a follow-up of 88.9 % after 8 years, the mean BMI after 1, 3, 5, 7, and 9 years was 29.1, 28.8, 28.7, 29.9, and 28.8, respectively. CONCLUSIONS: On the basis of this experience, the largest with laparoscopic reoperative RYGBP after failed VBG, we conclude that this procedure can safely be performed in experienced hands, with weight loss results similar to those observed after primary RYGBP. In patients with too difficult an anatomy below the cardia, dividing the esophagus just above the esophago-gastric junction and performing an esophagojejunostomy may be a safe alternative to converting to a Scopinaro-type BPD, obviating the additional long-term risks associated with malabsorption.

[Biliary ileus: diagnostic and therapeutic aspects. Report of a case]. / L'iléus biliaire : réflexions diagnostiques et thérapeutiques. A propos d'une observation.

We report a rare case of small bowel gallstone obstruction in a patient with cholecystointestinal fistula. Diagnosis of this condition is usually difficult and only achieved at surgery. We review the radiological findings, particularly the CT findings, helpful for diagnosis: ectopic gallstone, biliary gas and fistula. Early preoperative diagnosis could reduce morbidity and mortality. Treatment is surgical with enterolithotomy. There is some controversy over the need to repair the fistula.

Eighty-five redo surgeries after 733 laparoscopic treatments for ventral and incisional hernia: adhesion and recurrence analysis.

INTRODUCTION: This report reviews the clinical and functional outcomes of implanted meshes during a second-look evaluation of 85 cases after a large number (733) of laparoscopic incisional and ventral hernia repairs (LIVHR), of which 608 were controlled throughout a period of 5 to 10 years. This report demonstrates a minimal occurrence of adhesions and a low rate of recurrences and other complications related to mesh usage. METHODS: Eighty-five re-operated cases after LIVHR were reviewed retrospectively. In every redo surgery, the first trocar was always inserted on a lateral side, external to the previous skin incisions of the transabdominal fixations. Mueller's adhesion scale was used to estimate adhesion severity (Mueller 0 indicates no adhesion; Mueller I indicates adhesion of the omentum; and Mueller II indicates serosal adhesions). The mechanism of recurrence is of paramount interest and is analyzed herein. If recurrence was observed, the defect was closed and a larger mesh of Parietex was implanted under the previous one, with transparietal fixation achieved by pulling the threads with the Endoclose device. RESULTS: In all of our "second-look" surgeries, the neoperitoneum perfectly covered the mesh. In 47.05% of the cases, we observed no adhesions (Mueller 0), 42.3% had adhesions of the omentum (Mueller I), and 10.58% had serosal adhesions (Mueller II). There was no shrinking or wrinkling of the prosthesis in any of the cases, confirming its total peritonization on the anterior abdominal wall. Within the first 3 years, only 4.1% of the controlled patients contracted recurrences, with a mean follow-up of 52 months. CONCLUSION: With the double-suturing technique used for LIVHR and the use of a composite mesh, we observed a low rate of recurrences and limited side effects as compared with the use of tacks intra-abdominally. Redo surgeries after LIVHR are feasible, but care must be taken due to unpredictable mesh adhesions.

The suturing concept for laparoscopic mesh fixation in ventral and incisional hernia repair: Mid-term analysis of 400 cases.

BACKGROUND: The authors describe a minimally invasive treatment of moderate to large incisional and ventral hernia defects using Parietex composite mesh. METHODS: All defects are closed laparoscopically or through a minilaparotomy using sutures, and the composite mesh is fixed intraperitonally using transabdominal fixation with nonabsorbable sutures to avoid the use of staple or tack fixation, which has been associated with various complications, including major loop adhesion and mesh migration. The midterm results for 400 patients are presented in terms of efficacy and safety. RESULTS: During a mean follow-up period of 28 months for 80% of the patients, the median operating time was 74 min and the median hospital stay was 3 days. There were eight seromas (2%), all on large defects. Transient pain was experienced by 10 patients (2.5%), and resolved over time with analgesic treatment. There was one early case of sepsis (0.25%), attributable to secondary breakdown of the bowel wall in a case of recurrent incisional hernia, which led to removal of the mesh. Residual chronic parietal pain was reported for 10 patients (2.5%), 2 of whom were released after excision of neuroma; 3 trocar-site herniations (0.75%); and lipoma formation on the site of the hernia sac in 6 cases (1.5%). CONCLUSION: Laparoscopic ventral hernia treatment using Parietex composite mesh is an effective and safe procedure. Morbidity and recurrence rates are low, and the 2-year outcomes are promising, with no prosthesis migration or complication related to intraperitoneal positioning of the mesh.

The suturing concept for laparoscopic mesh fixation in ventral and incisional hernias: preliminary results.

Having found existing techniques for treatment of incisional hernias unsatisfactory, we developed a new laparoscopic approach with a Parietex Composite mesh. This study shows the preliminary results in order to analyze the validity of the concept on efficacy and safety. Three trocars are needed for this procedure. Non-reabsorbable sutures are mandatory for closure of large defects to avoid having to ultimately extrude the mesh. Ten to 12 cardinal stitches are applied on the polyester side of the mesh. The mesh is anchored to the anterior abdominal wall by transabdominal non-reabsorbable sutures without the use of staples or tacks. One hundred twenty patients with ventral and incisional hernias were included in this study. Early and late complications are reported, showing lower rates of morbidity and no mortality. This technique is satisfactory on the technical front, and the results are as good, or better, than in other trials.

Primary mechanical stapled anastomosis in surgery for colorectal emergencies.

From May 91 to March 99 a consecutive series of 100 acute obstructions or perforations of the left colon or rectum were treated by primary resection with mechanical anastomosis using a double or triple stapling technique without proximal colostomy. There were 8 postoperative deaths (8%) due to sepsis, acute respiratory distress syndrome, pulmonary embolism, stroke, and cachexy. Complications occurred in 29% of surviving patients. Clinical anastomotic leaks were observed in 7%, respiratory infection in 8%, wound infection in 8% and major cardiovascular problems in 4% of patients. The median hospital stay was 19 days. The morbidity and mortality of this series did not exceed the cumulative morbidity and mortality that can be expected after staged surgery. Compared with staged surgery, immediate resection and anastomosis using an entirely mechanical suture, thereby avoiding the problems of colostomy and reducing the length of hospital stay, has significant advantages for patients.

Hemodynamic changes during laparoscopic gastroplasty in morbidly obese patients.

BACKGROUND: In nonobese patients, peritoneal insufflation has consistently been shown to influence parameters of preload and afterload as well as cardiac output. Obese patients have an abnormal and particular cardiovascular status. The aim of this study was to investigate the hemodynamic changes induced by an increase of intra-abdominal pressure in morbidly obese patients (MOP). METHODS: Standard general anesthesia was administered to 15 informed MOP (body mass index > 40 kg/m2) scheduled for laparoscopic gastroplasty. Hemodynamic parameters were measured by thermodilution through a pulmonary artery catheter and through invasive blood pressure monitoring. RESULTS: CO2 insufflation with an intra-abdominal pressure of 17 mmHg caused a significant increase of mean arterial pressure (MAP) (33%, P = 0.005), mean pulmonary arterial pressure (MPAP) (40%, P = 0.001), pulmonary capillary wedge pressure (PCWP) (41%, P = 0.001), and central venous pressure (CVP) (55%, P = 0.001). The increase in diastolic filling pressures could be due to an increase in the filling volume or to a decrease in diastolic compliance. Ventricular volumes were not measured but we speculate that the rise in CVP, PCWP and MPAP is due to an increase in intrathoracic pressure as judged by the increase of pulmonary airway pressure. Stroke volume fell slightly (11%, P = 0.008), because of a reduction in transmural pressure and a fall in effective preload. Cardiac output rose slightly (16%, P = 0.005) because of an increase in heart rate (15%, P = 0.014) probably induced by sympathetic stimulation, which only became fully operative after 15 minutes. CONCLUSIONS: When compared to nonobese patients our obese patients tolerated the pneumoperitoneum surprisingly well, without experiencing fall in cardiac output. The hemodynamic consequences of peritoneal insufflation seem to be different in obese and nonobese patients.

Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients.

BACKGROUND: Obesity is an important respiratory risk factor after abdominal surgery. Laparoscopic surgical techniques seem beneficial in obese patients in terms of respiratory morbidity, with a faster return to normal respiratory function. However, there is little information about intraoperative respiratory mechanics and about patient tolerance to abdominal insufflation in the morbidly obese. METHODS: We studied respiratory mechanics and arterial blood gases in 15 morbidly obese patients (mean BMI = 45) undergoing laparoscopic gastroplasty under general anaesthesia and controlled ventilation. Respiratory mechanics were analysed using side-stream spirometry. RESULTS: When compared to preinsufflation values, servocontrolled abdominal insufflation to 2.26 kPa caused a significant decrease in respiratory system compliance (31%), a significant increase in peak (17%) and plateau (32%) airway pressures at constant tidal volume with a significant hypercapnia but no change in arterial O2 saturation. Respiratory system compliance and pulmonary insufflation pressures returned to baseline values after abdominal deflation. CONCLUSION: These alterations in pulmonary mechanics are less than those observed with comparable degrees of abdominal inflation in non-obese patients, and were well tolerated. From the point of view of intraoperative respiratory mechanics, laparoscopic surgery is safe in morbidly obese patients.

[Retroperitoneal leiomyosarcoma: case report and literature review]. / Leiomyosarcome rétropéritonéal: rapport d'un cas et revue de la littérature.

Retroperitoneal sarcomas are rare tumors, 25% of them are leiomyosarcomas. On the other hand, 19% of leiomyosarcomas are located in the retroperitoneum. Generally, the diagnosis is made at late stage due to poor symptomatology. Computed tomodensitometry is the most reliable diagnostic procedure. However, the final diagnosis is always obtained after histologic examination. Complete surgical excision is the best treatment. In fact, survival depends on histologic grading and resectability. The roles of radiation therapy and chemotherapy are not yet established.

Secondary psoas abscess twenty-seven years after nephrectomy.

Abscesses of the psoas muscle are due to a hematogenous dissemination, to the spread of infection from adjacent intestinal structures, to osteomyelitis of the spine or to tuberculous infection of a disc space. In contrast, psoas abscesses related to the urological tract have only been described on exception. The present report focuses on a right psoas abscess which developed 27 years after a nephrectomy. The infectious process resulted from the spread of an acute vesical infection through the residual ureter. Analysis of 4 other cases reported in the literature allows us to delineate the clinical features of psoas abscesses of urological origin.

[One-stage subtotal colectomy in the emergency treatment of occlusive left colonic neoplasms]. / La colectomie subtotale en un temps dans le traitement en urgence des néoplasies coliques gauches occlusives.

The authors present a series of 17 emergency subtotal colectomies as treatment of malignant occlusions of the left colon. They insist on the advantages of this operation as well as for the short term results (morbidity, mortality) and for the rare functional disease (diarrhea).

[Respiratory complications after repair of major abdominal hernia: value of the combination of propofol and epidural anesthesia]. / Complications respiratoires après cures d'éventrations volumineuses: intérêt de l'association propofol et péridurale.

Twenty patients with major abdominal hernia were treated by prosthesis interposed in pre or intraperitoneal position by medial incision. This surgery can produce healthy respiratory morbidity. Indeed, these patients are commonly obeses and smokers. The reintegration of the viscera in the abdominal cavity increases the pressure in this cavity and pertubs the diaphragmatic motility. The association of peridural technique and propofol perfusion gives an excellent awakening combined to a good postoperative analgesia. So this association permits to obtain from patient a helpful collaboration which limits dramatically the postoperative complications.

[The contribution of anterior seromyotomy with posterior truncal vagotomy in the treatment of chronic duodenal ulcer]. / Apport de la séromyotomie antérieure avec vagotomie tronculaire postérieure dans le traitement de l'ulcus duodénal chronique.

Contribution to the anterior seromyotomy and posterior truncal vagotomy in the treatment of chronic duodenal ulcer. The authors report a technique of anterior seromyotomy of the gastric lesser curvature with posterior truncal vagotomy for the surgical treatment of chronic duodenal ulcer disease. This technique offers more advantages than the highly selective vagotomy: it is an easier operation to perform, less time consuming and reproducible. Our results are similar to those following highly selective vagotomy.