Robot-assisted laparoscopic cardiomyotomy.

INTRODUCTION: Robot-assisted laparoscopic surgery is an expanding field of medicine. In endoscopic microsurgery particularly, difficult maneuvers such as intracorporeal hand-sewn anastomoses or a narrow operating field are ideal indications for use of an operation robot. PATIENTS AND METHODS: Six patients, four men and two women, underwent robot-assisted laparoscopic cardiomyotomy for achalasia at a tertiary referral center with substantial expertise in robotic surgery. A detailed description of the operation technique is provided, together with a review of the literature. RESULTS: Robot-assisted laparoscopic cardiomyotomy was feasible without any particular problem and the postoperative course of all six patients was uneventful. The operation time was 236 (220-316) minutes, plus 38 (25-47) minutes for setup-time of the robot. At follow-up six months postoperatively, five of the six patients were free of significant dysphagia and all were free of reflux symptoms. DISCUSSION: There are several published reports, series and trials on robot-assisted laparoscopic cardiomyotomy. The general conclusion is that in experienced hands this operation is easy to perform, with a significantly lower rate of mucosal perforations, but that overall costs are higher, including a longer operation time during the learning curve. The avoidance of mucosal lacerations and their possible consequences has to be weighed against higher overall costs. CONCLUSION: Laparoscopic cardiomyotomy is the first standard laparoscopic operation where a clear advantage for use of an operation robot has been proven. Thus, wherever an operation robot is available it should be used for this procedure.

Laparoscopically implanted gastric pacemaker after kidney-pancreas transplantation: treatment of morbid obesity and diabetic gastroparesis.

Combined kidney-pancreas transplantation is the treatment of choice for end-stage diabetic nephropathy. Weight gain post-transplant increases the risk for post-transplant complications and death due to cardiovascular events. Gastric pacemakers have been used for therapy of diabetic gastropathy and for the treatment of moderate morbid obesity. We report a patient who experienced significant weight gain following successful kidney-pancreas transplantation and was thereafter successfully treated for diabetic gastroparesis and morbid obesity by use of a laparoscopically implanted gastric pacemaker.

Intragastric stimulation is ineffective after failed adjustable gastric banding.

BACKGROUND: Gastric pacing has gained popularity as an effective and safe minimally invasive procedure to treat morbid obesity. This study evaluates the outcome of gastric pacing as a bariatric re-do procedure in patients who developed failure after adjustable gastric banding (AGB) due to band migration. METHODS: 8 patients were enrolled in this analysis. After implantation of an AGB, they had developed band failure due to band migration. The implantable gastric stimulator (IGS) was implanted laparoscopically as a second-line operation after gastroscopic removal of the band. RESULTS: Median time (range) from AGB complication to implantation of the IGS was 42 (10.3-50.3) months. During that time, all 8 patients had regained significant weight. All IGS devices could be implanted laparoscopically, without intra- or perioperative complications. The minimal body weight following IGS implantation was reached after 5 (0-12) months. The median observation time was 23 (11.3-27.5) months. 1 year after IGS implantation (n=7), median weight was 116 (98-165) kg, equivalent to a median BMI of 41.1 (36.055.8) kg/m(2), which is not statistically different to preoperative values and therefore prompted us to stop our ongoing trial. In all but 2 patients, the IGS device was explanted. During the same procedure, patients underwent a gastric sleeve resection (n=4) or a Roux-en-Y gastric bypass (n=2). CONCLUSION: The implantation of an IGS was an ineffective second-line operation after AGB migration.

Severe intra-abdominal infection due to Streptococcus Milleri following adjustable gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding represents a safe and effective bariatric surgical method. Nevertheless, complications such as intraabdominal infections are associated with high morbidity and mortality. CASE REPORT: A 50-year old morbidly obese female patient underwent adjustable gastric banding with the Swedish band (SAGB). After an uneventful postoperative follow-up of 2 years, she developed band infection due to colon microperforation during endoscopic polypectomy. As the causative microorgansim, Streptococcus Milleri was revealed. Band removal was required, and recovery was quite prolonged. CONCLUSION: Intra-abdominal infection with Streptococcus Milleri can cause severe and life-threatening disease. Therefore, early diagnosis and surgical intervention combined with body weight adapted antibiotic therapy for a sufficiently long period of time seems necessary. In patients with intra-abdominal implanted devices such as the SAGB who undergo endoscopic polypectomy, antibiotic prophylaxis should therefore be considered.

Long-term follow-up after robotic cholecystectomy.

Most surgeons gain their first clinical experience with surgical robots when performing cholecystectomies. Although this procedure is rather easily applicable for the da Vinci surgical system, the long-term outcome after this operation has not yet been clarified. This study follows up our institutional first series of robotic cholecystectomies (June to November 2001). Patients were assessed on the basis of standardized management including a quality-of-life questionnaire, clinical examination, blood tests, and abdominal sonogram. The follow-up rate for 23 patients after robotic cholecystectomy was 100 per cent and the median follow-up time 33 (30-35) months. There was one (4%) recurrence of gallstone disease in a patient who suffered from solitary choledocholithiasis 29 months after robotic cholecystectomy. Abdominal sonogram, clinical examinations, and blood tests revealed no post-cholecystectomy-specific pathological findings. The main long-term symptoms were bloating (57%), heartburn (43%) and nausea (30%). Of the patients, 96 per cent (22 patients) felt that the operation had cured or significantly improved their specific preoperative symptoms. Long-term results after robotic laparoscopic cholecystectomy are excellent and comparable to those for the conventional laparoscopic procedure. The advanced vision control and instrument maneuverability of robotic surgery might open minimally invasive surgery also for complicated gallstone disease and bile duct surgery.

Ventral hernia repair in bariatric surgery.

BACKGROUND: Obesity is an important risk factor for perioperative complications including the development of ventral hernias. METHODS: This retrospective study comprises patients who underwent abdominal hernia repair simultaneously with or following implantation of a Swedish Adjustable Gastric Band(R) (SAGB). RESULTS: 9 out of 415 patients (2.2%) who received a SAGB between January 1996 and June 2001 underwent ventral hernia repair. In 6 patients, hernias preexisted from previous abdominal surgery at the time of the bariatric procedure, and another 3 hernias occurred at the median and left upper abdominal trocar position following SAGB placement. Median BMI at time of SAGB implantation was 44 (range 35-52), and at time of hernia repair was 36 (range 25-46). 2 hernias were repaired during SAGB placement, 3 during redo surgery, and 2 during abdominoplasty. In 2 patients, significant weight loss with loss of soft tissue support of the hernia sac led to recurrent episodes of small bowel obstruction necessitating emergency repair. Repair included direct defect closure in 7 patients and sublay polypropylene net implantation in 2 patients. Recoveries have been uneventful without wound infections or recurrence in all patients after a median follow-up of 34 months (range 13-69). CONCLUSION: In morbidly obese patients, the optimal management and timing of incisional hernia repair should weigh the risk of recurrence and perioperative complications against the risk of hernia-associated complications.