Impartial long-term review of vertical banded gastroplasty in a low volume community hospital practice.

BACKGROUND: There is some concern whether bariatric surgery can be done well at low volumes or in a community hospital setting. This paper reports an impartial assessment of 25 vertical banded gastroplasties (VBG) over 13 years in a 228-bed non-teaching community hospital. METHODS: Charts were reviewed and patients interviewed by an independent investigator. Complications, weight loss, satisfaction and quality of life were assessed. RESULTS: There were no fatalities, no splenic tears, no stomal stenosis and no symptomatic gastroesophageal reflux. Two reoperations and five incisional hernias were noted. Hypertension was eliminated in 57% and dyspnea in 55%. BMI fell from 44.3 to 34.9 kg/m2 after 6.2 years. BMI decreased more than 10 kg/m2 (10-30) for 15 patients and less than 10 kg/m2 for 10 patients (4-10 for 7, 0 for 1 and a gain for 2). 56% of patients were fully satisfied with the results. Quality of life indicated excellent physical function, physical role and lack of body pain, good general health, social function, emotional role and mental health, but lower vitality. 100% felt better than a year ago. CONCLUSION: Results from a low-volume community hospital general surgical practice are similar to those from specialized series. Obesity is so common, its non-surgical treatment so ineffective and the VBG so well established, that excluding this intervention from community hospitals is untenable.

The tail of the learning curve for laparoscopic cholecystectomy.

BACKGROUND: This study estimates the number of laparoscopic cholecystectomies required until improvement ceases, assesses the magnitude of such improvement, and provides some insight into the mechanism by which it takes place. METHODS: Data from 500 consecutive laparoscopic cholecystectomies were analyzed from a prospective data base for number of short and long operations and operative time. RESULTS: There was a 40% decrease (P <0.05) in average operative time over the first 200 operations. Significant decrease in the number of longer operations, increase of shorter cases, and decrease in the range of operative time were noted. The major contributor was a marked shortening of longer cases, without much increased speed of shorter operations. CONCLUSIONS: For laparoscopic cholecystectomy, improvement persists for about 200 operations, resulting in a 40% reduction in operative time. The primary mechanism of improvement seems to be an ability to deal more effectively with difficult cases.

Blunt hasson trocar injury: long intra-abdominal trocar and lean patient--a dangerous combination.

Injury at the time of trocar placement with the Hasson approach is rare. The cone of the Hasson cannula is wedged into the skin for an air seal, and, using fascial sutures, fastened under tension to flanges of the cannula. The shorter the fascial securing suture, the greater the tension and the more secure the air seal. Flanges for securing the fascial suture were attached to the external cannula in early Hasson cannula models. With these, much of the trocar needs to be intra-abdominal in order to shorten the suture. For lean patients, with very little distance between the anterior and posterior abdominal walls, the force required to fasten the sutures to the flanges may allow an intra-abdominal trocar to damage intervening organs. Later versions of the cannula had the flanges attached to the cone, allowing for short suture without need for intra-abdominal cannula. These models avoid the possibility of such injury. An unusually lean patient underwent laparoscopic cholecystectomy using an older Hasson cannula with flanges for the fascial securing suture attached to the cannula. Postoperative changes in vital signs and hemoglobin led to a diagnosis of intra-abdominal bleeding, and laparotomy revealed a transsected branch of the middle colic artery. Earlier Hasson cannulas, where the flanges are attached to the cannula, should be replaced with those with flanges attached to the cone.

The umbilicus in laparoscopic surgery.

BACKGROUND: This study examines the factors related to infection and incisional herniation after laparoscopy at the umbilicus, as compared with those at remote sites. METHODS: From a prospective database of 561 cholecystectomies, 190 inguinal hernia repairs, 71 Nissen fundoplications, and 51 ventral hernia repairs, 873 consecutive Hasson cannula sites, 748 umbilicus sites, and 125 remote sites were analyzed. RESULTS: The wound infection rate was found to be 6%: 7% at the umbilicus (9% after cholecystectomy and 2% after other operations [p < 0.05]) and 0% at remote sites (p < 0.05). Excluding cholecystectomy, the umbilical infection rate was 2%, similar to that at remote sites. The postoperative ventral hernia rate was at 0.8%, the same at the umbilicus as elsewhere. The rate was similar for gallbladder and nongallbladder operations and correlated with the postoperative wound infection rate, but not with the preexisting fascial defect rate. CONCLUSIONS: Wound infection at the umbilicus is similar to that at other sites, except after cholecystectomy. Postoperative ventral hernia at the umbilicus is similar to that at other sites and not related to preexisting fascial defects.

A simple technique for laparoscopic vertical banded gastroplasty--the JOVO procedure.

A simple technique for laparoscopic vertical banded gastroplasty is described. With the surgeon to the patient's left, four trochars are placed as cephalad as possible. Short gastric vessels are divided and the posterior wall of the stomach mobilized. The ETS-Flex with Articulating Head (Ethicon Endosurgery Inc.) is used to divide the stomach close to a 42-french bougie against the lesser curvature. An additional stapler bite abuts directly against a 28-french bougie to obtain correct stoma size. A ribbon of Prolene mesh is pulled through a tunnel behind the stomach at the apex of the divided gastroplasty and sutured around the distal end of the gastroplasty. To date we have used this method successfully in 5 patients with 1-11 months of follow-up. Although we lack a sufficient number of patients or follow-up for definitive conclusions, we believe this technique will produce good results, as it reproduces exactly that used successfully in open surgery and our early results parallel those following open surgery.

Laparoscopic repair of inguinal hernias with higher risk for recurrence: independent assessment of results from 121 repairs.

This study attempts to determine by independent review the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair for hernias with increased risk for recurrence. Indicators used for increased recurrence risk were recurrent hernias or simultaneously repaired bilateral inguinal hernias. Office and hospital records of all such patients who had undergone TAPP repair were reviewed from one surgeon's 242-patient laparoscopic inguinal hernia database from 1992 to 1998. All were called for assessment by an independent surgeon at least 4 months postoperatively (median 34 months). Those unable to come in person were interviewed by telephone. There were 121 hernias: 34 recurrent and 100 bilateral (13 overlap). Recurrence rate was 3 per cent, which was similar for repair of bilateral and recurrent hernias. All recurrences occurred within 3 months of surgery. No unknown recurrence was detected by the independent observer. Laparoscopic TAPP inguinal hernia repair, often claimed as the method of choice for bilateral and recurrent hernia repair, is indeed a safe and effective procedure with a low early recurrent rate in these higher-risk situations.

Simple technique for laparoscopic paracolostomy hernia repair.

PURPOSE: The aim of this study was to describe a simple, minimally invasive, and effective technique for repair of paracolostomy hernia. METHODS: Mesh is fastened laparoscopically over the colostomy and hernial defect with wide overlap, without dissecting out the sac or repairing the defect, while ensuring enough room for the colon to prevent obstruction at the level of the mesh. RESULTS: The technique has been used successfully in four patients, with follow-up of 2 to 12 months. Operating time and length of stay were short, and there was no recurrence or prolapse of the colostomy. CONCLUSIONS: This seems to be an effective, simple, and minimally invasive technique for repairing a difficult problem. Although the number of cases is small and the follow-up has been short, the technique mimics that used in massive ventral hernia repair with good results.

Technique and early results of outpatient laparoscopic mesh onlay repair of ventral hernias.

BACKGROUND: This report describes the technique and early results of a simple outpatient laparoscopic ventral hernia repair. METHODS: Data were gathered prospectively for all laparoscopic ventral hernia repairs from January 1996 to December 1997 at a 228-bed hospital. Prolene mesh was stapled to the peritoneal surface of the abdominal wall, leaving sac in situ and mesh uncovered. Patients were seen by the operating surgeon within 2 months, and by an impartial surgeon (J.S.) after 3 to 14 months (average, 7 months; median, 6 months). RESULTS: Repairs involved 44 hernias with orifice sizes 2 to 20 cm in diameter, and an average area of 20 cm(2). Of these 44 hernias, 36 were postoperative and 8 primary. Furthermore, 20% were recurrent hernias. There were four conversions. The outpatient rate was 98%, with one readmission for ileus. The early recurrence rate was 5%. CONCLUSIONS: Laparoscopic mesh onlay repair is a safe, easy, and effective procedure with minimal discomfort and a low early recurrence rate that can be performed safely on an outpatient basis.

The road to ambulatory laparoscopic management of perforated appendicitis.

BACKGROUND: This study examines the contribution of increased laparoscopic skills to ambulatory management of perforated appendicitis. METHODS: All 38 perforated appendicitides from 151 laparoscopic appendectomies done by one surgeon were studied and ambulatory management (discharge less than 24 hours after surgery) of the last 18 perforations reported. RESULTS: Over 4 years, rate of attempted laparoscopic appendectomy rose from 67% to 100% for perforations. Conversion rate fell from 100% to 22%. Ileus and pain control were not problems for most laparoscopic perforations, so by the end of 1997, experience suggested these patients might be discharged within 24 hours. Ambulatory rate was 57% (conversions excluded). There were no readmissions for wound infections or postoperative abdominal abscesses. CONCLUSIONS: Increasing laparoscopic skills allows laparoscopic treatment of complicated appendicitis with a low conversion rate and no infectious complications. Over one half of these patients can be managed as outpatients without jeopardy to outcome.

Factors contributing to laparoscopic failure during the learning curve for laparoscopic Nissen fundoplication in a community hospital.

This study was done to determine the factors contributing to laparoscopic failure (conversion to open surgery or early reoperation) during the learning curve for laparoscopic Nissen fundoplication in a 228-bed nonteaching community hospital. Data were gathered prospectively for the first 100 consecutive patients booked for elective laparoscopic Nissen fundoplication by the four general surgeons at the hospital. All complications were recorded contemporaneously, and particular note was taken of the factors surrounding conversion to open surgery and reoperation within 100 days of surgery. There were no deaths. The conversion rate was 20% and the early reoperation rate 6%. There were two late recurrences. The average operative time was 117 minutes and the average length of stay 1.8 days; 37 operations were performed on outpatients. The laparoscopic failure rate was 26% (18/68) during a surgeon's first 20 operations and 11% (3/28) thereafter (P < 0.09); the corresponding conversion rates were 22% and 4% (P < 0.05). During a surgeon's first 20 operations, the laparoscopic failure rate rose from 21% (12/57) to 55% (6/11) (P < 0.04) if a second surgeon did not assist. After 20 operations, this difference lost its significance. Intrathoracic herniation of the stomach was found preoperatively in 11 (44%) of 25 operations followed by laparoscopic failure and (8%) 6 of 75 without (P < 0.0002). Laparoscopic failure had no correlation with patient age, sex, ASA classification, duration of symptoms, or referring physician's specialty. The individual learning curve for laparoscopic Nissen fundoplication requires about 20 operations to surmount. Factors leading to laparoscopic failure during the learning curve are the surgeon's inexperience, absence of experienced help, and the presence of intrathoracic herniation.

Hip fracture as a complication of hospitalization.

This work seeks to assess the possible contribution of hospitalization to hip fractures sustained in an acute care hospital and to determine the need for hospital care for these patients at the time of the fracture. Between 1988 and 1997 there was an average of 399 falls and four in-hospital hip fractures per year. For 14 percent, no predisposing factors for falling were noted, 38 percent of the fractures occurred within the first three days and 47 percent during the first week of hospitalization. Original admission did not seem warranted for 10 percent and 48 percent no longer required inpatient care at the time of the fracture. Most fractures occur early during hospitalization; some patients seem to have no predisposing factors for falling and about one-half may not require hospitalization at the time, all implicating hospitalization as a causative factor.

The learning curve in laparoscopic inguinal hernia repair for the community general surgeon.

OBJECTIVE: To determine the learning curve (number of operations required) to stabilize operating times and complication rates for a general surgeon doing laparoscopic inguinal hernia repair in a community practice. DESIGN: A prospective analysis. SETTING: A 256-bed secondary-care community hospital. PATIENTS: Ninety-eight consecutive patients booked for elective laparoscopic hernia repair on an outpatient basis. INTERVENTIONS: Using the transbdominal preperitoneal approach, 100 operations were carried out to repair 138 groins and a total of 164 separate hernial defects. OUTCOME MEASURES: The number of operations required to decrease operative times and complication rates to a steady level. RESULTS: There were no deaths. There were 5 conversions and 10 admissions, all occurring between the 1st and 46th operations. Two reoperations for reasons other than recurrence were required between the 45th and 55th operations. There were 24 other complications. Complications and surgical times began to level off after 50 operations. The 1 readmission was after the 42nd operation. There were 4 recurrences (2.9% recurrence rate), 2 in each group of 50 operations. Both groups of 2 recurrence occurred within the first 10 operations involving the use of a new stapler. Twenty-two other patients had open hernia repairs because laparoscopy was unsuitable for them. CONCLUSION: The learning curve for laparoscopic inguinal hernia repair in the hands of a general surgeon in community practice who is experienced in open herniorraphy and laparoscopic cholecystectomy is at least 50 operations.

Is outpatient surgery safe for the higher risk patient?

The trend toward outpatient surgery led to this study to determine the safety of elective outpatient laparoscopic surgery for the higher risk patient. One hundred consecutive higher risk patients from all patients scheduled for elective outpatient laparoscopic surgery were studied prospectively in a 256-bed community hospital. Seventeen percent of patients required admission. In each instance the need was readily evident in the perioperative observation period. Eighty-three percent of patients were stable and were successfully treated as outpatients. No patient who remained stable decompensated later, and none required readmission to treat complications resulting from outpatient status. The 2% readmission rate (for unrelated reasons) was comparable to the 2% readmission rate for low-risk patients. It was concluded that routine outpatient laparoscopic surgery is safe for elective higher risk patients. Problems requiring admission are readily evident during the period of observation and no patient who remains stable decompensates later.

The role of cost analysis in deciding whether to provide laparoscopic cholecystectomy in remote communities.

To review the role of cost analysis in deciding whether to provide laparoscopic cholecystectomy in a remote community, cholecystectomies for Baffin Region residents were reviewed. Actual cost was calculated using known travel costs, per diem costs, and length of stay (LOS) data. Laparoscopic cost was estimated using LOS and conversion data from the literature. Between 1992 and 1995, 72 patients from the Baffin Region had a cholecystectomy, 61 in Iqaluit and 11 in Montreal. Fifty-seven and five, respectively, were suitable candidates for laparoscopic surgery. LOS was 5.6 days in Iqaluit and 3.5 in Montreal. Annual cost was $167,465 (Canadian). Comparable laparoscopic cholecystectomy cost is $45,411, an annual saving of $122,054. Even after equipment depreciation, laparoscopy provides a calculated saving of over $100,000 a year. However, even maximal decrease in bed utilization is less than 0.5 bed per day. Such small decreases do not allow staffing reduction and, thus, most of the projected savings cannot be realized in practice. Therefore, neither costs nor savings can play a supportive role in a decision to provide laparoscopic cholecystectomy in remote communities. This decision would have to be based on other considerations.

Is outpatient cholecystectomy safe for the higher-risk elective patient?

BACKGROUND: This study was done to determine the safety of outpatient cholecystectomy for the higher-risk patient. METHODS: All patients over age 70 or with American Society of Anesthesiologists physical status classification of 3 or greater, from all 515 consecutive patients booked for elective cholecystectomy between April 1, 1994, and March 31, 1996, were reviewed. RESULTS: Of 85 higher-risk patients, 77 were booked as outpatients. Sixty-one were successfully completed as outpatients, with no complications or readmissions related to their outpatient status. Of 24 admitted patients, 15 had specific indications for hospitalization. Nine were admitted for reasons of "precaution." One of these developed a complication, possibly related to her inpatient status. The other eight could have been managed as outpatients. CONCLUSIONS: Outpatient cholecystectomy is safe for the higher-risk patient. Patients who recover uneventfully from surgery can be discharged without harmful effects. "Precautionary" hospitalization may be harmful.

Establishing outpatient cholecystectomy as a hospital routine.

OBJECTIVE: To determine the rate of outpatient cholecystectomies done voluntarily by surgeons and to identify any "correctable" factors leading to hospital admission, also to reassess the outpatient cholecystectomy rate after correcting the identified factors. DESIGN: A prospective analysis. SETTING: A 256-bed non-teaching acute-care community hospital on the outskirts of a major urban centre, served by 4 general surgeons. PATIENTS: All 515 patients booked for elective cholecystectomy at the hospital between Apr. 1, 1994, and Mar. 31, 1996, inclusive. INTERVENTION: Elective outpatient cholecystectomy. MAIN OUTCOME MEASURE: A successful procedure without compromise of safety. RESULTS: In the preliminary study, outpatient cholecystectomy was done in 75% of the patients. Variations in individual surgical practice, preoperative patient selection and inappropriate day surgery facilities were thought to be correctable factors leading to admission. After correction of the these factors (follow-up study), the rate of outpatient cholecystectomy rose to 95% (p < 0.001). Variations in individual surgical practice disappeared, and no patient required processing through inappropriate day surgery facilities. No patient suffered untoward effects from outpatient management. CONCLUSIONS: Outpatient cholecystectomy is a safe hospital routine for all elective procedures without selection. Voluntary acceptance of this routine leads to an initial 75% outpatient rate. Identifying and correcting modifiable factors led to a significant increase in the institutional outpatient rate, comparable to reported individual rates.

Outpatient treatment of spontaneous pneumothorax in a community hospital using a Heimlich flutter valve: a case series.

This is a case series of 14 consecutive patients treated as outpatients for spontaneous pneumothorax (SP) (1 January 1992 to 31 December 1995) by one surgeon in a community hospital setting. The purpose of this study was to examine the appropriateness and financial implications of routine outpatient management of SP with closed tube thoracostomy and the Heimlich valve. All 14 patients reviewed were successfully managed as outpatients, although 3 required an overnight admission because of anxiety, pain, or vasovagal reaction. The routine outpatient treatment of all cases of SP not requiring definitive surgical intervention may have saved more than $16,000.00 for the hospital and an estimated $500,000.00 for the province of Ontario during the 1993-1994 fiscal year. Our findings suggest that the Heimlich valve is an appropriate alternative for the management of SP in a nonteaching community hospital setting, with benefits to the patient and to the health care system.

Outpatient cholecystectomy.

One hundred consecutive patients requiring elective cholecystectomy in one surgeon's practice were booked as outpatients between April 1994, and July 1995. Two patients had massive adhesions and 18 had acute disease. Outpatient surgery was successful for 94 patients, who spent an average of less than 6 h in hospital. Six patients required postoperative admission, four because of conversion and two for other causes. There were three readmissions, unrelated to outpatient status: one to treat a wound infection, one to drain a subphrenic abscess, and one to repair an umbilical hernia. Complications were one subphrenic abscess, one case of significant atelectasis, and, at the umbilical incision seven wound infections, one hematoma and one postoperative hernia. Advanced age and increased comorbidity correlated significantly with the need for hospital admission, but were not contraindications, either alone or in combination, to outpatient surgery. Patient satisfaction was high.

Routine outpatient laparoscopic cholecystectomy.

OBJECTIVE: To determine what proportion of patients booked for elective cholecystectomy can be treated on an outpatient basis and what criteria will predict the need for hospital admission. DESIGN: A prospective analysis. SETTING: A 306-bed, nonteaching, acute-care community hospital on the outskirts of a major urban centre. PATIENTS: One hundred consecutive patients in private referral practice scheduled for outpatient laparoscopic surgery between November 1992 and January 1994. INTERVENTION: Laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: The proportion of patients who successfully avoided hospital admission, the degree of discomfort, complications and the objective criteria that assist in predicting the need for initial or eventual hospital admission. RESULTS: Outpatient cholecystectomy was successful in 87% of the patients, and patient acceptance of the procedure was good. Advanced age, major associated health problems, acute cholecystitis and longer operations were the criteria most likely to lead to hospital admission, although none of these factors, alone or in combination, was a contraindication to outpatient cholecystectomy. CONCLUSIONS: Outpatient laparoscopic cholecystectomy can be performed successfully in most patients. There are four criteria that increase the likelihood of hospital admission after this procedure.

Outpatient cholecystectomy: implications for hospital utilization.

One hundred consecutive outpatient cholecystectomies were reviewed to determine hospital utilization. Operative time was 43 minutes and total hospital time eight hours. Fifty patients required parenteral analgesia in the recovery room and five in day surgery. Eight patients were admitted postoperatively for an average hospital stay of 2.5 days. There was one readmission, no major complications and high patient satisfaction. Outpatient cholecystectomy may be possible for 90 percent of all elective patients.