Adrian Park

Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias.

Objective To evaluate the efficacy and safety of laparoscopic repair of ventral hernias. Summary Background Data The recurrence rate after standard repair of ventral hernias may be as high as 12–52%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair. Methods Data on all patients who underwent laparoscopic ventral hernia repair (LVHR) performed by 4 surgeons using a standardized procedure between November 1993 and October 2002 were collected prospectively (85% of patients) or retrospectively. Results LVHR was completed in 819 of the 850 patients (422 men; 428 women) in whom it was attempted. Thirty-four percent of completed LVHRs were for recurrent hernias. The patient mean body mass index was 32; the mean defect size was 118 cm2. Mesh, averaging 344 cm2, was used in all cases. Mean operating time was 120 min, mean estimated blood loss was 49 mL, and hospital stay averaged 2.3 days. There were 128 complications in 112 patients (13.2%). One patient died of a myocardial infarction. The most common complications were ileus (3%) and prolonged seroma (2.6%). During a mean follow-up time of 20.2 months (range, 1–94 months), the hernia recurrence rate was 4.7%. Recurrence was associated with large defects, obesity, previous open repairs, and perioperative complications. Conclusion In this large series, LVHR had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence.

Laparoscopic ventral and incisional hernia repair in 407 patients.

BACKGROUND Recurrence rates after primary repair of ventral and incisional hernias range from 25% to 52%. Recurrence after open surgery is less likely if mesh is used, but the wide fascial dissection and required flap creation increase complication rates. Laparoscopic techniques offer an alternative. STUDY DESIGN To assess the safety and efficacy of laparoscopic ventral and incisional herniorrhaphy, we reviewed the records of all our patients who underwent such a procedure from November 1993 to August 1999. A laparoscopic approach was attempted in all patients considered to require a mesh repair. Patient demographic characteristics, operative details, and outcomes were recorded. RESULTS Of 415 patients scheduled to undergo laparoscopic ventral or incisional herniorrhaphy, conversion to an open procedure was necessary in 8. All the remaining 407 patients (205 men and 202 women; mean age 53.2 years; range 13 to 88 years) were included in the study. Mean fascial defect size was 100.1 cm2 (range 1 to 480 cm2). In 97% of patients, expanded polytetrafluoroethylene mesh was used. Mean operating time was 97 minutes (range 11 to 270 minutes). Mean estimated blood loss was 35 mL (range 10 to 150 mL). Average hospital stay was 1.8 days (range 0 to 17 days). There were 53 complications (13.0%), including cellulitis of a trocar site, infection requiring mesh removal, prolonged suture pain, persistent seroma, intestinal injury, hematoma or postoperative bleeding, prolonged ileus, urinary retention, respiratory distress, fever, intraabdominal abscess, and trocar site herniation. There were no deaths. During a mean followup time of 23 months (range 1 to 60 months), there were 14 hernia recurrences (3.4%), 6 in patients in whom only a stapling device (no sutures) had been used to secure the mesh to the abdominal wall. CONCLUSIONS Laparoscopic repair was completed in 98.1% of patients in whom it was attempted. The complication rate was acceptable. A short hospital stay and minimal blood loss were documented. The recurrence rate was 3.4%. Laparoscopic ventral and incisional hernia repair appear to be safe and effective.

Transfer of training in acquiring laparoscopic skills.

BACKGROUND Building on skills already learned in acquiring more complex or related skills is termed transfer of training (TOT). This study examined the TOT effects of previous open and laparoscopic surgical experience on a laparoscopic training module. STUDY DESIGN Intracorporeal knot tying was chosen for evaluating TOT among three groups of surgical residents: interns (n = 11) with limited open and laparoscopic surgical experience, junior residents (n = 9) with recent and ongoing open and laparoscopic surgical experience, and senior residents (n = 8) with remote and limited laparoscopic experience but ongoing open surgical experience. After receiving a lecture, demonstration, and written instructions on three knot-tying techniques, residents rotated through three performance stations, one for each technique, over 2 days. After 15 minutes of practice, the residents were videotaped completing a test knot. Time to completion and economy of motion were recorded and analyzed. RESULTS Junior residents had fewer performance errors than senior residents (reported as mean +/- standard error of the mean) and were significantly faster than interns. No significant differences between interns and senior residents for mean time or error performance were observed. Senior residents did not demonstrate TOT from open surgical experience to laparoscopic knot tying. No significant differences were obtained across the three sessions for errors or for time. CONCLUSION No evidence was found for TOT from open surgical experience to newly introduced laparoscopic knot-tying techniques or from one skill training session to a different skill session at least 4 hours later. This study indicates that specific minimally invasive surgery training is needed to develop laparoscopic surgery skills.

Laparoscopic Curative Resection of Pheochromocytomas

Purpose:Pheochromocytomas are relatively uncommon tumors whose operative resection has clear medical and technical challenges. While the safety and efficacy of laparoscopic adrenalectomy are relatively well documented, few studies with extended follow-up have been conducted to measure the success of the procedure for the most challenging of the adrenal tumors. In addition, several reports question the applicability of a minimally invasive approach for sizeable pheochromocytomas. The purpose of our investigation was to assess the outcomes of laparoscopic adrenalectomy for pheochromocytomas in the largest study to date when performed by experienced laparoscopic surgeons. Methods:All pheochromocytomas removed by the authors from January 1995 to October 2004 were reviewed under an Institutional Review Board approved protocol. Eighty-five percent were documented in a prospective fashion. Results:Eighty consecutive patients underwent laparoscopic resection of 81 pheochromocytomas. Seventy-nine were found in the adrenal (42 left, 35 right, 1 bilateral); 2 were extra-adrenal paragangliomas. Eight patients had multiple endocrine neoplasia syndrome. Two lesions were malignant. There were 48 females and 32 males with a mean age of 45 years (range, 15–79 years). Mean tumor size was 5.0 cm (range, 2–12.1 cm); 41 of these lesions were 5 cm in size or larger. Average operative time and blood loss were 169 minutes (range, 69–375 minutes) and 97 mL (range, 20–500 mL), respectively. Intraoperative hypertension (systolic blood pressure, >170 mm Hg) was reported in 53% of patients and hypotension (systolic blood pressure, <90 mm Hg) in 28% of patients. There were no conversions to open surgery. Mean length of stay was 2.3 days (range, 1–10 days). There were 6 perioperative morbidities (7.5%) and no mortalities. No patient required a blood transfusion. No recurrence of endocrinopathy has been documented at a mean follow-up of 21.4 months. Conclusion:Laparoscopic resection of pheochromocytomas, including large lesions, can be accomplished safely by experienced surgeons. A short hospital stay with minimal operative morbidity and eradication of endocrinopathy support the minimally invasive approach for adrenalectomy in the setting of pheochromocytoma.

Laparoscopic pancreatic surgery

BACKGROUND Potential applications for laparoscopic surgery in pancreatic disease include (1) staging of pancreatic malignancies; (2) palliation of pancreatic malignancies; (3) pancreatic resections for benign and malignant disease; and (4) pancreatic drainage procedures. METHODS A review of the literature is presented. In addition, original data on a series of 5 laparoscopic pancreatic distal resections and 10 laparoscopic cystogastrostomies are presented. RESULTS AND CONCLUSIONS Laparoscopy may have a role in the staging of patients with pancreatic malignancies; however, with high-quality preoperative imaging, the percentage of patients who will benefit from laparoscopy may be as low as 5%. For palliation, both cholecystoenterostomy and choledochoenterostomy can be performed laparoscopically. The former is technically straightforward but has a higher failure rate; the latter is technically difficult and currently not suitable for widespread adoption. Laparoscopic gastroenterostomy is a straightforward means of palliating gastrointestinal obstruction. Patients appear to benefit from laparoscopic distal pancreatic resection but not from laparoscopic pancreaticoduodenectomy. Patients appear to benefit from laparoscopic pseudocyst decompression.

Laparoscopic repair of traumatic diaphragmatic injuries.

Background: The purpose of this study was to evaluate the feasibility and limitations of laparoscopic repair of traumatic diaphragmatic injuries. Methods: Laparoscopic repair of an acute traumatic diaphragmatic laceration or chronic traumatic diaphragmatic hernia was attempted in 17 patients between January 1997 and January 2001. The patients in the study included 13 men and 4 women with a mean age of 33.2 years (range, 15–63 years). Nine patients had a blunt injury, and eight patients had a penetrating injury. Laparoscopic repair was attempted for eight patients during their hospitalization for the traumatic injury (mean, 2.3 days; range, 0–6 days) and for ten patients with a chronic diaphragmatic hernia (mean, 89 months; range, 5–420 months). The chronic diaphragmatic hernias-presented with abdominal pain (9/9), or vomiting (3/9). Results: Thirteen traumatic diaphragmatic injuries were repaired laparoscopically, and four (2 acute and 2 chronic) required conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using expanded polytetrafluoroethylene (ePTFE), and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5–12 cm). The mean operative time was 134.7 min (range, 55–200 min). The mean estimated blood loss was 108.5 ml (range, 30–500 ml), and the postoperative length of stay was 4.4 days (range, 1–12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n = 2) or communicating with the esophageal hiatus (n = 2). One patient also required spleneotomy for an unrecognized splenic laceration that had occurred at the time of the original trauma. The four patients undergoing laparotomy had a mean postoperative discharge date of 8.7 days (range, 6–14 days). Conclusions: Laparoscopy is an alternative approach to repairing acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias. Large traumatic diaphragmatic injuries adjacent to or including the esophageal hiatus are best approached via laparotomy.

Obesity and laparoscopic repair of ventral hernias

BACKGROUND Laparoscopic ventral hernia repair (LVHR) is gaining acceptance and compares favorably with open repair. Patients who are morbidly obese (MO) traditionally have been considered poor surgical candidates for ventral hernia repair because of their associated comorbidities and risk of postoperative wound infection and hernia recurrence. In this study we evaluated our experience with LVHR in patients who are obese and those who are morbidly obese. METHODS All 64 patients undergoing LVHR at the University of Kentucky between September 1997 and October 2000, representing 66 hernias, were entered prospectively into a database. Data before, during, and after surgery were collected as well as follow-up data. Patients were divided into three groups on the basis of body mass index (BMI): normal to overweight (BMI < or = 29); obese (BMI 30-39), and MO (BMI > or = 40). RESULTS There were 16 patients in the MO group, most of them women. The mean BMI was 43.9 (range, 40-60), and the mean age was 45.6 years (range, 25-68 years). The location of defects was similar among the groups, as were the number of prior repairs. The operative time and length of stay for the MO group tended to be longer than for the other two groups. Five minor complications occurred in the MO group. During a follow-up period ranging from 1 to 35 months, there were no recurrences. CONCLUSION Laparoscopic repair of ventral hernias in patients who are morbidly obese is both safe and feasible, and can be performed with minimal morbidity. At this writing, there have been no recurrences, but long-term follow-up evaluation is required.

Ongoing deficits in resident training for minimally invasive surgery

Patient preference has driven the adoption of minimally invasive surgery (MIS) techniques and altered surgical practice. MIS training in surgical residency programs must teach new skill sets with steep learning curves to enable residents to master key procedures. Because no nationally recognized MIS curriculum exists, this study asked experts in MIS which laparoscopic procedures should be taught and how many cases are required for competency. Expert recommendations were compared to the number of cases actually performed by residents (Residency Review Committee [RRC] data). A detailed survey was sent nationwide to all surgical residency programs (academic and private) known to offer training in MIS and/or have a leader in the field. The response rate was approximately 52%. RRC data were obtained from the resident statistics summary report for 1998–1999. Experts identified core procedures for MIS training and consistently voiced the opinion that to become competent, residents need to perform these procedures many more times than the RRC data indicate they currently do. At present, American surgical residency programs do not meet the suggested MIS case range or volume required for competency. Residency programs need to be restructured to incorporate sufficient exposure to core MIS procedures. More expert faculty must be recruited to train residents to meet the increasing demand for laparoscopy.

Laparoscopic adrenalectomy for pheochromocytoma

Background: Laparoscopic adrenalectomy for Conns syndrome, Cushings disease, cortisol-producing adenomas, and nonfunctioning adenomas has been well established. This study was intended to evaluate the clinical outcomes of patients undergoing laparoscopic adrenalectomy for pheochromocytoma, and to assess the efficacy and safety of a minimally invasive approach. Methods: Data were collected prospectively on all patients undergoing laparoscopic adrenalectomy for pheochromocytoma over a 5-year period. Results: In this study, 39 consecutive patients underwent laparoscopic resection of a pheochromocytoma: 38 adrenal (23 left, 15 right) and 1 extraadrenal paraganglioma. There were no conversions to open surgery. The mean tumor size was 5.2 cm (range, 2-12.1 cm). Average operative time was 159 min (range, 100-265 min), and average estimated blood loss was 72 ml (range, 30-350 ml). Intraoperative hypertension (systolic blood pressure > 170 mmHg) occurred in 67% of the patients, and hypotension (systolic blood pressure < 90 mmHg) in 39% of the patients. The mean length of stay was 2.1 days (range, 1-4 days). There were three minor postoperative complications. During a mean follow-up period of 14 months, there were no mortalities or recurrences of endocrinopathy. Conclusions: Laparoscopic resection of pheochromocytomas can be accomplished safely despite frequent episodes of hemodynamic variability equal to those of historic open control subjects. A short hospital stay with expedient recovery,minimal wound complications, and lack of endocrinopathy recurrence makes a minimally invasive approach the procedure of choice for the management of pheochromoctyoma.

Evaluating minimally invasive surgery training using low-cost mechanical simulations.

Background: The goal of this study was to develop, test, and validate the efficacy of inexpensive mechanical minimally invasive surgery (MIS) model simulations for training faculty, residents, and medical students. We sought to demonstrate that trained and experienced MIS surgeon raters could reliably rate the MIS skills acquired during these simulations. Methods: We developed three renewable models that represent difficult or challenging segments of laparoscopic procedures; laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), and laparoscopic inguinal hernia (LH). We videotaped 10 students, 12 surgical residents, and 1 surgeon receiving training on each of the models and again during their posttraining evaluation session. Five MIS surgeons then assessed the evaluation session performance. For each simulation, we asked them to rate overall competence (COM) and four skills: clinical judgment (respect for tissue) (CJ), dexterity (economy of movement) (DEX), serial/simultaneous complexity (SSC), and spatial orientation (SO). We computed intraclass correlation (ICC) coefficients to determine the extent of agreement (i.e., reliability) among ratings. Results: We obtained ICC values of 0.74, 0.84, and 0.81 for COM ratings on LH, LC, and LA, respectively. We also obtained the following ICC values for the same three models: CJ, 0.75, 0.83, and 0.89; DEX, 0.88, 0.86, and 0.89; SSC, 0.82, 0.82, and 0.82; and SO, 0.86, 0.86, and 0.87, respectively. Conclusions: We obtained very high reliability of performance ratings for competence and surgical skills using a mechanical simulator. Typically, faculty evaluations of residents in the operating room are much less reliable. In contrast, when faculty members observe residents in a controlled, standardized environment, their ratings can be very reliable.