Single-incision laparoscopic cholecystectomy with curved versus linear instruments assessed by systematic review and network meta-analysis of randomized trials.

BACKGROUND: Single-incision laparoscopic surgery poses significant ergonomic limitations. Curved instruments have been developed in order to address the issue of lack of triangulation. Direct comparison between single-incision laparoscopic surgeries with conventional linear and curved instruments has not been performed to date. METHODS: MEDLINE, CENTRAL and OpenGrey were searched to identify relevant randomized trials. A network meta-analysis was applied to compare operative risks, conversion, duration of surgery and the need for placement of an adjunct trocar in single-incision laparoscopic cholecystectomy with linear and curved instruments. The random-effects model was applied for two sets of comparisons, with conventional laparoscopic cholecystectomy as the reference treatment. Odds ratios, mean differences and 95% confidence intervals were calculated. RESULTS: Twenty-three randomized trials encompassing 1737 patients were included. The use of curved instruments was associated with increased operative time (mean difference 32.53 min, 95% CI 24.23-40.83) and higher odds for the use of an adjunct trocar (odds ratio 22.81, 95% CI 16.69-28.94) compared to the use of linear instruments. Perioperative risks could not be comparatively assessed due to the low number of events. CONCLUSION: Single-incision laparoscopic cholecystectomy with curved instruments may be associated with an increased level of operative difficulty, as reflected by the need for auxiliary measures for exposure and increased operative time as compared to the use of linear instruments. Current instrumentation requires further improvement, tailored to the features of single-incision laparoscopic surgery (CRD42015015721).

Obesity does not affect the outcome of laparoscopic antireflux surgery.

BACKGROUND: Obesity has been reported to adversely affect the outcome of laparoscopic antireflux surgery (LARS). This study examined pre- and postoperative clinical and objective outcomes and quality of life in obese and normal-weight patients following LARS at a specialized centre. METHODS: Prospective data from patients subjected to LARS (Nissen or Toupet fundoplication) for symptomatic gastroesophageal reflux disease in the General Public Hospital of Zell am See were analyzed. Patients were divided in two groups: normal weight [body mass index (BMI) 20-25 kg/m(2)] and obese (BMI ≥ 30 kg/m(2)). Gastrointestinal quality of life index (GIQLI), symptom grading, esophageal manometry and multichannel intraluminal impedance monitoring data were documented and compared preoperatively and at 1 year postoperatively. RESULT: The study cohort included forty normal-weight and forty obese patients. Mean follow-up was 14.7 ± 2.4 months. The mean GIQLI improved significantly after surgery in both groups (p < 0.001, for both). Clinical outcomes improved following surgery regardless of BMI. There were significant improvements of typical and atypical reflux symptoms in normal weight and obese (p = 0.007; p = 0.006, respectively), but no difference in gas bloat and bowel dysfunction symptoms could be found. No intra- or perioperative complications occurred. A total of six patients had to be reoperated (7.5 %), two (5 %) in the obese group and four (10 %) in the normal-weight group, because of recurrent hiatal hernia and slipping of the wrap or persistent dysphagia due to closure of the wrap. CONCLUSION: Obesity is not associated with a poorer clinical and objective outcome after LARS. Increased BMI seems not to be a risk factor for recurrent symptomatology and reoperation.

Laparoscopic colorectal surgery confers lower mortality in the elderly: a systematic review and meta-analysis of 66,483 patients.

BACKGROUND: Increasing life expectancy requires specific attention on geriatric patients. Data support a potential reduction of surgical morbidity for patients undergoing laparoscopic surgery as compared to conventional surgery. The aim of this study was to investigate the comparative effect of laparoscopic and open colorectal surgery on geriatric patients. METHODS: A systematic review of electronic information sources was undertaken. Studies that provided outcome data on patients aged 65 years or older, subjected to laparoscopic or open colorectal surgery, were considered. Mortality, morbidity, cardiac and pulmonary complications were the outcome measures of treatment effect. The methodological quality of selected studies was independently appraised by two reviewers. Random effects model was applied to synthesize outcome data. RESULTS: Twenty-seven articles providing data for 66,592 patients were included in the analysis. Patients undergoing laparoscopic surgery had a decreased risk for mortality (2.2 vs. 5.4 %; OR 0.55, 95 % CI 0.44-0.67), overall morbidity (19.3 vs. 26.7 %; OR 0.54, 95 % CI 0.46-0.63), cardiac (4.7 vs. 7.7 %; OR 0.60, 95 % CI 0.39-0.92) and respiratory complications (3.9 vs. 6.3 %; OR 0.67, 95 % CI 0.47-0.95). Sensitivity analysis including reports with similar age, American Society of Anesthesiologists score and/or similar prevalence of cardiopulmonary morbidity between the laparoscopic and the open treatment arm validated the outcome estimates of the primary analysis. CONCLUSIONS: This analysis supports a substantial benefit for elderly patients undergoing laparoscopic in comparison with open colorectal surgery. The comparative effect of either approach on geriatric patients with pulmonary and cardiac comorbidities is a subject of further investigation.

Laparoscopic versus open obesity surgery: a meta-analysis of pulmonary complications.

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

A systematic review and analysis of factors associated with methodological quality in laparoscopic randomized controlled trials.

Several methods for assessment of methodological quality in randomized controlled trials (RCTs) have been developed during the past few years. Factors associated with quality in laparoscopic surgery have not been defined till date. The aim of this study was to investigate the relationship between bibliometric and the methodological quality of laparoscopic RCTs. The PubMed search engine was queried to identify RCTs on minimally invasive surgery published in 2012 in the 10 highest impact factor surgery journals and the 5 highest impact factor laparoscopic journals. Eligible studies were blindly assessed by two independent investigators using the Scottish Intercollegiate Guidelines Network (SIGN) tool for RCTs. Univariate and multivariate analyses were performed to identify potential associations with methodological quality. A total of 114 relevant RCTs were identified. More than half of the trials were of high or acceptable quality. Half of the reports provided information on comparative demo graphic data and only 21% performed intention-to-treat analysis. RCTs with sample size of at least 60 patients presented higher methodological quality (p = 0.025). Upon multiple regression, reporting on preoperative care and the experience level of surgeons were independent factors of quality.

Laparoscopic augmentation of the diaphragmatic hiatus with biologic mesh versus suture repair: a systematic review and meta-analysis.

PURPOSE: Laparoscopic repair of large hiatal hernias is associated with high recurrence rates. Erosion and mesh migration are rare but devastating complications of synthetic mesh repair, whereas reoperation is accompanied by significant operative morbidity. The aim of this study was to estimate the comparative risk of hernia recurrence following primary suture or biologic mesh repair. METHODS: A systematic literature search of the MEDLINE database was performed and comparative data of relevant studies were combined using the Mantel-Haenszel meta-analysis model. The odds ratio (OR) for hernia recurrence with 95 % confidence interval (CI) was calculated. RESULTS: Five relevant studies (two randomized controlled trials and three case-control studies) and one follow-up report of a randomized trial, encompassing 295 patients, were identified. Small intestine submucosa and human acellular cadaveric dermis were used as mesh grafts. Short-term recurrence rates were 16.6 and 3.5 % for suture repair and biologic mesh repair, respectively (OR 3.74, 95 % CI 1.55-8.98, p = 0.003). Long-term recurrence based on data provided by one trial only was 51.3 and 42.4 %, respectively (OR 1.43, 95 % CI 0.56-3.63, p = 0.45). Sensitivity analysis of the two randomized trials at short-term follow up demonstrated no significant difference (OR 2.54, 95 % CI 0.92-7.02, p = 0.07). CONCLUSIONS: Biologic mesh repair of large hiatal hernias may confer short-term benefits in terms of hernia recurrence; however, the limited available information does not allow us to make conclusions about the long-term efficacy of biologic mesh in this setting. Individual biologic mesh grafts require further clinical assessment.

EAES recommendations for the management of gastroesophageal reflux disease.

BACKGROUND: Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux. METHODS: The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session. RESULTS: Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD. CONCLUSIONS: Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Current treatment concepts for groin hernia.

PURPOSE: The purpose of this study is to review the latest evidence on operative and perioperative management of patients with groin hernia. METHODS: A literature review of medical databases was undertaken. Recent scientific evidence provided by quality reports was selected and discussed critically. RESULTS: The Shouldice repair results in low recurrence rates compared to other tissue reconstructions. However, mesh repairs are superior to tissue reconstruction in terms of recurrence. Lichtenstein's technique remains the gold standard, with low incidence of hernia recurrence and minimal morbidity. Endoscopic techniques have been popularized during the past decades, as alternative approaches to open surgery. Both transabdominal preperitoneal repair (TAPP) and the totally extraperitoneal repair (TEP) are effective in the treatment of groin hernia, although the steep learning curve precludes popularization and may account for increased perioperative morbidity. CONCLUSIONS: Groin hernia surgery remains an evolving field of investigation. Mesh application remains the mainstay of durable results. Individual patient factors and hernia characteristics need to be taken into account when considering the most appropriate surgical practice.

Subjective and objective data on esophageal manometry and impedance pH monitoring 1 year after endoscopic full-thickness plication for the treatment of GERD by using multiple plication implants.

BACKGROUND: Subjective and especially objective data after endoluminal full-thickness gastroplication are scarce. OBJECTIVE: To evaluate symptoms and reflux activity 12 months after gastroplication by using multichannel intraluminal impedance monitoring. DESIGN: Open-label, prospective, single-center study. SETTING: Tertiary referral hospital in Zell am See, Austria. PATIENTS: Subjects without hiatal hernias with documented GERD and persistent or recurrent symptoms despite treatment with a proton pump inhibitor. INTERVENTIONS: A total of 36 patients underwent endoscopic full-thickness gastroplication with 1 or more Plicator implants. MAIN OUTCOME MEASUREMENTS: Mean Gastrointestinal Quality of Life Index and reflux-specific symptom scores significantly improved on follow-up (P < .01). Atypical reflux, gas/bloating, and bowel dysfunction-specific symptom scores as well as belching and dysphagia scores improved. Twenty-two patients returned for esophageal manometry and multichannel intraluminal impedance testing 1 year after surgery. DeMeester scores decreased from 20 to 10 (P < .029). The median numbers of total, acid, proximal, upright, and recumbent reflux episodes were all significantly reduced (P < .05). Manometric data were virtually unchanged. The percentage of patients taking proton pump inhibitors on daily basis after the procedure was 11.5%. There was only 1 postprocedure incident (bleeding) that required intervention. Three of 36 patients (8.3%) were considered treatment failures because of persistent symptoms and were assigned to undergo laparoscopic fundoplication. LIMITATIONS: No randomized comparison with a sham procedure or laparoscopic fundoplication; follow-up interval. CONCLUSIONS: Endoscopic plication is safe and improves objective and subjective parameters at 1-year follow-up, without side effects seen after laparoscopic fundoplication. Further studies on the clinical merit of this procedure in specific patient populations are warranted.

Blunt versus bladed trocars in laparoscopic surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: Trocar-associated visceral injuries are rare but potentially fatal complications of laparoscopic access. More commonly, abdominal wall bleeding occurs, which usually requires hemostatic measures and prolongs operative time. Blunt-tipped trocars have been postulated to carry a lower risk of abdominal wall bleeding and intra-abdominal injuries. The aim of the present systematic review and meta-analysis was to comparatively evaluate the relative risks of abdominal wall bleeding, visceral injuries, and overall complications with the use of bladed and blunt-tipped laparoscopic trocars. METHODS: The databases of Medline, EMBASE, and the Cochrane Central Register of Randomized Trials were searched to identify randomized studies that compared trocar-associated complications with the use of blunt and bladed trocars. Primary outcome measure was the relative risk of abdominal wall trocar site bleeding, and secondary outcome measures included visceral injuries and overall complications. Outcome data were pooled and combined overall effect sizes were calculated using the fixed- or random-effects model. RESULTS: Eight eligible randomized trials were identified; they included 720 patients with a median Jadad score of 4. The incidence of abdominal wall bleeding for the blunt and the bladed trocar group was 3 and 9 %, respectively [odds ratio (OR) 0.42, 95 % confidence interval (CI) 0.21-0.88]. Trocar-associated morbidity rate, excluding bleeding events of the abdominal wall, was documented at 0.2 and 0.7 % of the blunt and the bladed trocar arm, respectively (OR 0.43, 95 % CI 0.06-2.97). The overall trocar-associated morbidity rate was 3 % in the blunt trocar group and 10 % in the bladed trocar group (OR 0.38, 95 % CI 0.19-0.77). CONCLUSIONS: Reliable data support a lower relative risk of trocar site bleeding and overall complications with blunt laparoscopic cannulas than bladed trocars. Transition to blunt trocars for secondary cannulation of the abdominal wall is thus strongly recommended. Larger patient populations are required to estimate the relative risk of visceral injuries.

Comparison of results from a randomized trial 1 year after laparoscopic Nissen and Toupet fundoplications.

BACKGROUND: The fundoplication of choice for the surgical treatment of gastroesophageal reflux disease (GERD) still is debated. Multichannel intraluminal impedance monitoring (MII) has not been used to compare objective data, and comparative subjective data on laparoscopic Nissen and Toupet fundoplications are scarce. METHODS: This study randomly allocated 125 patients with documented chronic GERD to either laparoscopic floppy Nissen fundoplication (LNF; n = 62) or laparoscopic Toupet fundoplication (LTF; n = 63). The Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 1 year after surgery. The pre- and postprocedure data were compared. Statistical significance was set at a p value lower than 0.01 (NCT01321294). RESULTS: Both procedures resulted in significantly improved GIQLI and GERD symptoms. Preoperative dysphagia improved in both groups, but the improvement reached significance only in the LTF group. The ability to belch was shown to be significantly more decreased after LNF than after LTF. Gas-bloat and "atypical" extraesophageal symptoms also were decreased after surgery (p < 0.01). However, bowel symptoms were virtually unchanged in both groups. Both procedures resulted in significantly improved lower esophageal sphincter pressures. The improvement was greater in the LNF group than in the LTF group (p < 0.01). The DeMeester score and the numbers of total, acid, proximal, upright, and recumbent reflux episodes decreased in both groups after surgery (p < 0.01). No significant difference between the procedures in terms of MII data was found. Six patients (4.8 %) had to undergo reoperation because of intrathoracic slipping of the wrap. All the patients had undergone LNF. CONCLUSIONS: Both procedures proved to be equally effective in improving quality of life and GERD symptoms. However, the reoperation and dysphagia rates were lower and the ability to belch was higher after LTF than after LNF.

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease.

BACKGROUND: Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect. METHODS: The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05. RESULTS: A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly. CONCLUSIONS: The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

Meta-analysis of laparoscopic versus open repair of perforated peptic ulcer.

BACKGROUND AND OBJECTIVES: Laparoscopic treatment of perforated peptic ulcer (PPU) has been introduced as an alternative procedure to open surgery. It has been postulated that the minimally invasive approach involves less operative stress and results in decreased morbidity and mortality. METHODS: We conducted a meta-analysis of randomized trials to test this hypothesis. Medline, EMBASE, and the Cochrane Central Register of Randomized Trials databases were searched, with no date or language restrictions. RESULTS: Our literature search identified 4 randomized trials, with a cumulative number of 289 patients, that compared the laparoscopic approach with open sutured repair of perforated ulcer. Analysis of outcomes did not favor either approach in terms of morbidity, mortality, and reoperation rate, although odds ratios seemed to consistently support the laparoscopic approach. Results did not determine the comparative efficiency and safety of laparoscopic or open approach for PPU. CONCLUSION: In view of an increased interest in the laparoscopic approach, further randomized trials are considered essential to determine the relative effectiveness of laparoscopic and open repair of PPU.

Laparoscopic Nissen versus Toupet fundoplication: objective and subjective results of a prospective randomized trial.

BACKGROUND: Although symptom outcomes following laparoscopic fundoplication have been adequately evaluated in the past, comparative subjective data of laparoscopic Nissen and Toupet fundoplications are scarce. Multichannel intraluminal impedance monitoring (MII) has not been used so far for comparison of objective data. METHODS: One hundred patients with documented chronic gastroesophageal reflux disease (GERD) were randomly allocated to either floppy Nissen fundoplication (group I, n = 50) or Toupet fundoplication (group II, n = 50). Gastrointestinal Quality of Life Index (GIQLI), symptom grading, esophageal manometry, and MII data were documented preoperatively and 3 months after surgery. Subjective and objective outcome data were compared to those of healthy individuals. RESULTS: Symptom intensity was significantly more severe and GIQLI showed impairment in the examined patient population compared to healthy controls. Both procedures resulted in a significant improvement in GIQLI and GERD symptoms (p < 0.01). Dysphagia improved significantly only in group II, while cough, asthma, and distortion of taste improved significantly in both groups. Hoarseness symptoms showed some degree of improvement in both groups but reached statistical significance only in group I. Postoperatively, bowel symptoms partly increased and the ability to belch decreased in both groups (p < 0.05). Comparison of postoperative GIQLI and symptom scores showed no significant difference between the two groups, except for the ability to belch, which was more impaired after Nissen fundoplication. Both procedures resulted in a significant improvement in lower esophageal sphincter (LES) pressure; however, the improvement was greater in group I than in group II. MII data showed more reflux control after Nissen, but the differences between the procedures were not significant. CONCLUSIONS: Both procedures equally improve quality of life and GERD symptoms. Bowel symptoms may increase after both procedures at the 3-month follow-up. Manometry and MII data favor Nissen fundoplication, but dysphagia and the inability to belch are more common compared to Toupet fundoplication.

Endoscopic full-thickness plication versus laparoscopic fundoplication: a prospective study on quality of life and symptom control.

BACKGROUND: Endoscopic antireflux techniques have emerged as alternative therapies for gastroesophageal reflux disease (GERD). Endoscopic plication receives continuing interest as an effective and safe procedure. This treatment option has not been the subject of comparison with well-established operative therapies to date. The present study aimed at comparatively evaluating the effectiveness of endoscopic plication and laparoscopic fundoplication in terms of quality of life and symptom control. METHODS: Between October 2006 and April 2010, 60 patients with documented GERD were randomly assigned to undergo either endoscopic plication or laparoscopic fundoplication. Quality-of-life scores and symptom grading were recorded before treatment and at 3- and 12-month follow-up. Outcomes were compared with the statistical significance set at a p value of 0.05. RESULTS: Twenty-nine patients from the endoscopic group and 27 patients from the operative group were available at follow-up. Quality-of-life scores showed a substantial and similar increase for both groups after treatment. Symptoms of heartburn (p < 0.02), regurgitation (p < 0.004), and asthma (p = 0.03) were significantly improved in the endoscopic group, whereas laparoscopic fundoplication was more effective in controlling symptoms of heartburn (p < 0.01) and regurgitation (p < 0.05) compared to the endoscopic procedure. CONCLUSIONS: Endoscopic plication and laparoscopic fundoplication resulted in significant symptom improvement with similar quality-of-life scores in a selected patient population with GERD, whereas operative treatment was more effective in the relief of heartburn and regurgitation at the expense of higher short-term dysphagia rates.

Mesh-reinforced hiatal hernia repair: a review on the effect on postoperative dysphagia and recurrence.

PURPOSE: The objective of the present study was to review the pertinent literature and analyze the evidence for and against the use of mesh for hiatal hernia repair, with a focus on the effects on recurrence and postoperative dysphagia. METHODS: A literature search was performed between January 1990 and March 2010. Studies were considered for inclusion, provided (1) they comprised a series of at least 20 patients, (2) they documented a follow-up period of at least 6 months, (3) they reported on the outcome as expressed by hernia recurrence rates, and (4) they reported on type of mesh material, hiatal closure, and antireflux surgery. RESULTS: Twenty-three articles enrolling a cumulative number of 1,446 patients fulfilled the inclusion criteria. Polypropylene meshes seem to be associated with low recurrence rates (0-22.7%, median 1.9%) and acceptable dysphagia rates (0-21.7%, median 3.9%). Higher dysphagia rates after polytetrafluoroethylene (PTFE) and expanded PTFE (ePTFE) mesh hiatoplasty have been recorded (15.5-34.3%). Even though the use of novel biologic implants for hiatal repair is still in its infancy, the existing results from clinical research are promising. CONCLUSIONS: Polypropylene meshes seem to provide durable results with low dysphagia rates. Unacceptably high recurrence rates for PTFE/ePTFE meshes have been reported. Biologic implant engineering represents a promising field in hiatal hernia surgery.

Single-incision laparoscopic cholecystectomy: a systematic review.

BACKGROUND: Laparoscopic techniques induced a tremendous revolution in surgery of the biliary tract, mainly due to improved results compared with the open approach and secondary because of their cosmetic advantage. A trend toward even more minimally invasive approaches has led to techniques of single-incision and natural orifice laparoscopic surgery. Because the evaluation of single-incision laparoscopic cholecystectomy (SILC) is rather fragmentary by single-institution small patient series, this article intends to examine the success and the risks of the technique, and attempts to determine its potential limitations. METHODS: A systematic review of the literature was performed to identify relevant articles. Studies enrolling at least ten patients who underwent SILC and reporting on analytical complication data were considered for inclusion. RESULTS: The literature search identified 29 studies, which included a total of 1,166 patients. Success and complication rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2 min and mean adjusted hospital stay was 1.4 days. Analysis of outcome exhibited higher complication rates for studies with a mean patient age older than 45 years (p=0.04), and higher operative time for studies with a mean body mass index>30 kg/m2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min). Acute cholecystitis as inclusion criterion was a factor for technical failure (success rate 59.9 vs. 93.0%, p=0.005) and resulted in an increase of operative time (78.1 vs. 70.6 min). Suture suspension of the gallbladder yielded significantly lower complication rates compared with instrument usage (3.3 vs. 13.3%, p<0.0001). CONCLUSIONS: The clinical application of SILC exhibited satisfactory results. Cases of acute cholecystitis and older patients should be approached with caution, whereas improvement of the instrumentation is necessary.

Influence of the size of the hiatus on the rate of reherniation after laparoscopic fundoplication and refundopilication with mesh hiatoplasty.

BACKGROUND: Intrathoracic wrap migration is the most frequent morphological anatomic reason for failure of laparoscopic antireflux surgery (LARS). This study investigates whether the size of the esophageal hiatus is a factor in reherniation after LARS with mesh hiatoplasty and after primary failed hiatal closure. METHODS: Fifty-four patients who underwent a laparoscopic 270° Toupet fundoplication with simple sutured crura and posterior onlay of Parietex mesh prosthesis between October 2003 and June 2008 were evaluated with respect to the occurrence of postoperative intrathoracic wrap migration/reherniation. Indication for mesh hiatoplasty was a hiatus with a hiatal surface area (HSA) of at least 5.60 cm(2) or slippage after the first LARS. The integrity of repair was assessed using a barium swallow test. Cinematography was performed at a median of 25.6 months (3-63 months after operation) and was completed in 49 of 54 patients (90%). Follow-up was completed in 24 patients who underwent primary LARS (group A) and 25 patients who underwent a laparoscopic refundoplication (group B). RESULTS: In group A, the occurrence of postoperative wrap reherniation was diagnosed in 20.8% of the patients, compared to 40% in group B. In both groups only one patient with recurrent hiatal hernia was symptomatic. In group A, patients who developed a recurrent hernia had a larger HSA than patients without postoperative reherniation. There was a huge difference in the size of the HSA between symptomatic and asymptomatic patients with reherniation. In comparison, group B patients had HSA of similar size in all described cases. CONCLUSION: In primary intervention, recurrence of hiatal hernia is more likely the larger the HSA is. The size of the hiatus is a major contributing factor to the possibility of reherniation. After failed primary hiatal closure, the size of the hiatal defect is no marker for the possibility of reherniation.