Laparoscopic hernia repair with adductor tenotomy for athletic pubalgia: an established procedure for an obscure entity.

INTRODUCTION: Athletic pubalgia is a syndrome of chronic lower abdomen and groin pain that occurs in athletes. It is the direct result of stress and microtears of the rectus abdominis inserting on the pubis from the antagonizing adductor longus muscles, and weakness of the posterior transversalis fascia and bulging of the inguinal floor. METHODS: Under IRB approval, we conducted a retrospective review of our prospectively competitive athlete patients with athletic pubalgia from 2007 to 2013. RESULTS: A cohort of 54 patients was examined. Mean age was 22.4 years. Most patients were football players (n = 23), triathlon (n = 11), track and field (n = 6), soccer players (n = 5), baseball players (n = 4), swimmers (n = 3), golfer (n = 1), and tennis player (n = 1). Fifty one were males and three were females. All patients failed medical therapy with physiotherapy prior to surgery. 76 % of patients had an MRI performed with 26 % having a right rectus abdominis stripping injury with concomitant strain at the adductor longus musculotendinous junction. 7 % of patients had mild nonspecific edema in the distal bilateral rectus abdominis muscles without evidence of a tear. Twenty patients had no findings on their preoperative MRI, and only one patient was noted to have an inguinal hernia on MRI. All patients underwent laparoscopic totally extraperitoneal inguinal hernia repair with synthetic mesh and ipsilateral adductor longus tenotomy. All patients were able to return to full sports-related activity in 24 days (range 21-28 days). One patient experienced urinary retention and another sustained an adductor brevis hematoma 3 months after completion of rehabilitation and surgical intervention. Mean follow up was 18 months. CONCLUSION: Athletic pubalgia is a disease with a multifactorial etiology that can be treated surgically by a laparoscopic totally extraperitoneal hernia repair with synthetic mesh accompanied with an ipsilateral adductor longus tenotomy allowing patients to return to sports-related activity early with minimal complications.

Esophageal perforation management using a multidisciplinary minimally invasive treatment algorithm.

BACKGROUND: The surgical management of esophageal perforation (EP) often results in mortality and significant morbidity. Recent less invasive approaches to EP management include endoscopic luminal stenting and minimally invasive surgical therapies. We wished to establish therapeutic efficacy of minimally invasive therapies in a consecutive series of patients. STUDY DESIGN: An IRB-approved retrospective review of all acute EPs between 2007 and 2013 at a single institution was performed. Patient demographic, clinical outcomes data, and hospital charges were collected. RESULTS: We reviewed 76 consecutive patients with acute EP presenting to our tertiary care center. Median age was 64 ± 16 years (range 25 to 87 years), with 50 men and 26 women. Ninety percent of EPs were in the distal esophagus, with 67% of iatrogenic perforations occurring within 4 cm of the gastroesophageal junction. All patients were treated within 24 hours of initial presentation with a removable covered esophageal stent. Leak occlusion was confirmed within 48 hours of esophageal stent placement in 68 patients. Median lengths of ICU and hospital stay were 3 and 10 days, respectively (range 1 to 86 days). One-third of the patients were noted to have prolonged intubation (>7 days) and pneumonia that required a tracheostomy. One in-hospital (1.3%) mortality occurred within 30 days. Median total hospital charges for EP were $85,945. CONCLUSIONS: Endoscopically placed removable esophageal stents with minimally invasive repair of the perforation and feeding access is an effective treatment method for patients with EP. This multidisciplinary method enabled us to care for severely ill patients while minimizing morbidity and mortality and avoiding open esophageal surgery.

Use of collapsible box trainer as a module for resident education.

BACKGROUND AND OBJECTIVES: We sought to determine whether training with a simple collapsible mobile box trainer leads to improved performance of fundamental laparoscopic skills (FLSs) during a 6-month interval versus validated laparoscopic box trainers and virtual-reality trainers, only accessible at a simulation training center. METHODS: With institutional review board approval, 20 first- and second-year general surgery residents were randomized to scheduled training sessions in a surgical simulation laboratory or training in the use of a portable, collapsible Train Anywhere Skill Kit (TASKit) (Ethicon Endo-Surgery Cincinnati, OH, USA) trainer. Training was geared toward the FLS set for a skill assessment examination at a 6-month interval. RESULTS: The residents who trained with the TASKit performed the peg-transfer, pattern-cut exercise, Endoloop, and intracorporeal knot-tying FLS tasks statistically more efficiently during their 6-month assessment versus their initial evaluation as compared with the group randomized to the simulation laboratory training. CONCLUSIONS: Using a simple collapsible mobile box trainer such as the TASKit can be a cost-effective method of training and preparing residents for FLS tasks considering the current cost associated with virtual and highdefinition surgical trainers. This mode of surgical training allows residents to practice in their own time by removing barriers associated with simulation centers.

Pre-therapy laparoscopic feeding jejunostomy is safe and effective in patients undergoing minimally invasive esophagectomy for cancer.

OBJECTIVE: Laparoscopic feeding jejunostomy is a safe and effective means of providing enteral nutrition in the preoperative phase to esophageal cancer patients. DESIGN: This research is a retrospective case series. SETTING: This study was conducted in a university tertiary care center. PATIENTS: Between August 2007 and April 2012, 153 laparoscopic feeding jejunostomies were performed in patients 10 weeks prior to their definitive minimally invasive esophagectomy. MAIN OUTCOME MEASURES: The outcome is measured based on the technique, safety, and feasibility of a laparoscopic feeding jejunostomy in the preoperative phase of esophageal cancer patients. RESULTS: One hundred fifty-three patients underwent a laparoscopic feeding jejunostomy approximately 1 and 10 week(s) prior to the start of their neoadjuvant therapy and definitive minimally invasive esophagectomy, respectively. Median age was 63 years. Of the patients, 75 % were males and 25 % were females. One hundred twenty-seven patients had gastroesophageal junction adenocarcinoma and 26 had squamous cell carcinoma. All patients completed their neoadjuvant chemoradiation therapy. The median operative time was 65 min. We had no intraoperative complications, perforation, postoperative bowel necrosis, bowel torsion, herniation, intraperitoneal leak, or mortality as a result of the laparoscopic feeding jejunostomy. Four patients were noted to have superficial skin infection around the tube, and 11 patients required a tube exchange for dislodgment, clogging, and leaking around the tube. All patients progressed to their definitive surgical esophageal resection. CONCLUSION: A laparoscopic feeding jejunostomy is technically feasible, safe, and can provide appropriate enteral nutrition in the preoperative phase of esophageal cancer patients.

Gastroesophageal reflux after sleeve gastrectomy in morbidly obese patients.

BACKGROUND: Gastroesophageal reflux disease (GERD) is highly prevalent in morbidly obese patients and a high body mass index is a risk factor for the development of this co-morbidity. The effect of laparoscopic sleeve gastrectomy (LSG) on GERD is poorly known. METHODS: We studied the effect of LSG on GERD in patients with morbid obesity. A retrospective review of 28 consecutive patients undergoing LSG for morbid obesity from September 2008 to September 2010 was performed. RESULTS: A total of 28 patients, 18 women and 10 men, were identified, with a mean age of 42 years (range 18-60). The mean weight and body mass index was 166 kg and 55.5 kg/m2, respectively. The mean percentage of excess weight loss was 40% (range 17-83), with a mean follow-up time of 32 weeks (range 8-92). All patients had a pre- and postoperative upper gastrointestinal radiographic swallow study as a part of their routine care. Of these patients, 18% were noted to have new-onset GERD on their postoperative upper gastrointestinal swallow test after their LSG procedure. Using the GERD score questionnaire, all patients were interviewed to evaluate their reflux symptoms. We had a 64% response rate, with 22% of patients indicating new-onset GERD symptoms despite receiving daily antireflux therapy. All respondents were extremely happy with their surgery and weight loss to date. CONCLUSION: LSG might increase the prevalence of GERD despite satisfactory weight loss. Additional studies evaluating esophageal manometry and ambulatory 24-hours pH-metry are needed to better evaluate the effect of LSG on gastroesophageal reflux symptoms.

Tissue compression analysis for magnetically anchored cautery dissector during single-site laparoscopic cholecystectomy.

INTRODUCTION: The purpose of this study was to evaluate the histological effects of dynamic abdominal wall compression using the magnetic anchoring and guidance system (MAGS) platform. METHODS: Cholecystectomy was performed in two nonsurvival and two survival pigs using a single-site laparoscopic (SSL) approach. A deployable MAGS cautery dissector was used to perform the entire dissection in conjunction with a laparoscope and other instruments. The abdominal wall areas corresponding to the region occupied by the MAGS platform were examined grossly and microscopically for signs of tissue damage. Gallbladder dissection time was 36 min with no complications. Compressed abdominal wall thickness was 1.4 cm. RESULTS: In all four animals, a very mild skin erythema was noted immediately postprocedure but was nonvisible within 20 min. Mild peritoneal blanching was noted in two animals, and one animal exhibited a 5-mm area of petechiae. Necropsy demonstrated no adhesions. Light microscopy documented no evidence of tissue injury for all specimens. DISCUSSION: This study demonstrated that the use of the MAGS cautery dissector for a SSL cholecystectomy was advantageous in providing triangulation and did not result in any significant gross or microscopic tissue damage despite the thin abdominal wall of the porcine model.