The Role of Laparoscopy in Abdominal Trauma: A 10-Year Review.

Laparoscopy is accepted in penetrating abdominal trauma (PAT), but its role in blunt trauma (BAT) remains a controversial one. Our study assessed the utility of diagnostic laparoscopy (DL) and therapeutic laparoscopy (TL) in abdominal trauma between December 2006 and January 2016. We analysed the indication for laparoscopy, type of lesions, TL, conversion rate, complications and length of hospital stay. 49 patients had a DL: 42 males and 7 females, with a mean age of 36.1+-13.3. We had 20 PAT and 30BAT. The indications for laparoscopy were: diagnosis of penetration in PAT, suspicion of hollow organ injury or diaphragm injury, active bleeding in organ injuries in BAT. 11/48 of preoperative ultrasounds and 4/48 of CT's were false negative. In 3 of 20 PAT, DL was negative and in 4 nontherapeutic. There were 4 TL's and 7 conversions. The main injuries in BAT were: 9 hollow organ perforations, 6 mesenteric lacerations, 2 diaphragmatic and 2 splenic injuries. There were 10 TL's, 9 conversions and 14 TL. The operative time and length of hospital stay was higher in the conversion group. There were 6 complications and 3 mortalities. There were no missed injuries. An unnecessary laparotomy was avoided in 18/49 cases (36.73%). In selected cases of PAT and BAT with equivocal clinical and imaging diagnosis, laparoscopy is a useful tool with therapeutic role, that reduces unnecessary laparotomies, complication rate and hospital stay.

Laparoscopic Repair of Small Ventral Hernias Using the "Ventralex™ Hernia Patch".

Laparoscopy of abdominal wall defects becomes more and more actual, considering the well-known advantages of minimally invasive surgery, and the reduced incidence of post-operative ventral infections and recurrence rates compared to the the open repair with or without mesh. We hereby present the technique of the laparoscopic repair of small ventral hernias (defect 2 centimetres), using the Ventralex mesh, which is bi-faceted, polypropylene and PTFE, circular preformed, it has 8 centimeters in diameter, fixated with 4 transparietal sutures. The mesh is created for open surgery but it is placed in the intraperitoneal cavity. This technique was used for 28 patients,16 women and 12 men, with an average age of 53,3 years (29-72 years), consisting of: 22 umbilical hernias (UH), 2 epigastric hernias (EH), one left-side Spiegelian hernia, one incisional hernia after an open surgery for an umbilical hernia with a Ventralex mesh, and 2 trocar eventrations (TE) after a laparoscopic cholecystectomy. Mean operating time was 52 minutes (42-70 minutes), post-operative hospital stay of 1,8 days (1-5 days). The main advantages are: circular preformed mesh, diameter of 8 centimeters, transfascial suture fixation, correct mesh placement and unfolding may be verified by laparoscopy, reduced costs. The technique is easy to reproduce.

New Minimally Invasive Endoscopic and Surgical Therapies for Gastroesophageal Reflux Disease (GERD).

GERD has become one of the most frequent pathology of the upper GI tract. It is a spectrum disease and is a progressive disease as well. Serious and severe complications are possible. The mainstream therapy in most of the patients is the medical therapy with PPI's. The most severe cases with an impaired LES (Lower Esophageal Sphincter) function as well as important anatomical disruptions are of surgical indication, the gold standard being laparoscopic fundoplication, an elective therapy with long term follow up outcomes at the expense of de novo symptoms associated with fundoplications in general. 30% to 40% of the patients are PPI refractory with partial symptom control, but they are not willing to go for the laparoscopic fundoplication because of the invasive character and because of potential postfundoplications syndromes. There is a "treatment gap" for these patients with GERD. For a well selected patient population with GERD, with mild forms of the disease, without complications and without major anatomical disruptions (patients with small hiatal hernias), patients who are refractory on PPI medication, there are today new alternative therapies, minimally invasive. These therapies are less aggressive and basically with no side effects or new onset symptoms that Laparoscopic Fundoplications will give. These are endoscopic therapies which improve the LES function: Stretta utilizes radiofrequence therapy, a novel technique describes mucosal resection at the level of the cardia, while a partial fundoplication from within the stomach can be realized with EsophyX, Muse or Gerd-X. Form all these procedures, EsophyX is the most advanced with more than 20,000 patients treated worldwide, with good clinical outcomes and with no de novo symptoms. The laparoscopic techniques treat hiatal hernias larger than 2 cm. Linx utilizes a magnetic ring at the LES level. EndoStim utilizes electrodes in order to stimulate the LES muscle. These procedures are effective on short term and there are few patients treated with Linx or EndoStim. More research for Linx and EndoStim is necessary with randomized clinical trials, with improvement of the devices and with long term follow up.

Transoral Incisionless Fundoplication TIF 2.0 with "EsophyX Z®" Device for GERD: Seven Years after Endo Lumenal Fundoplication. World's First Case Report.

Transoral Incisionless Fundoplication (TIF) with EsophyX device for a well selected GERD patient population has proven its efficacy, safety and durability. We present a case report of a male, 63 y old, with typical and atypical GERD symptoms started 15 years ago. The esophagogastroduodenoscopy (EGD) showed a Hiatal Hernia (HH) of 3 cm and an erosive esophagitis Los Angeles Grade B. The first surgery was performed 7 years ago, in March 2009: a TIF with the EsophyX 2® device (EndoGastric Solution, Inc., Redmond, WA, United States). Post-surgery the symptoms were controlled, completely eliminated, the EGD showing the healing of the esophagitis. Six years after the surgery the sore throat re-appears, while the EGD shows a 2 cm hiatal hernia and erosive esophagitis Los Angeles Grade A. The Impedance pH-metry confirms GERD with a DeMeester score of 44.5. In 2016 (7 years after first procedure) a second and new TIF 2.0 procedure, this time with EsophyX Z device is performed. The EsophyX Z device is an automatic stapler-like fastener delivery system, easier of use, faster, safer and more reproducible (standardized fastener delivery). The time of the procedure was significantly reduced, compared to first procedure. The patient is now symptom free, EGD is normal, the impendance ph metry at 13 months post-surgery showed a normal DeMeester score at 8. This is a World's first case report of a TIF 2.0 procedure with EsophyX Z device 7 years after a first TIF procedure with EsophyX 2 device, with excellent results and a significant reduction of the time for the procedure.