Aviad Hoffman

Laparoscopic colectomy without mechanical bowel preparation

BackgroundMechanical bowel preparation prior to colorectal surgery may reduce infectious complications, facilitate tumor localization, and allow intraoperative colonoscopy, if required. However, recent data suggest that mechanical bowel preparation may not facilitate a reduction in infectious complications. During laparoscopic colectomy, manual palpation is blunt, thereby potentially compromising tumor localization. The aim of this study was to assess the utility of mechanical bowel preparation in laparoscopic colectomy.Materials and methodsA retrospective medical record review of all patients who underwent laparoscopic colectomy was performed. Patients were divided into two groups: those who had preoperative mechanical bowel preparation (Group A) or those who did not (Group B). All relevant perioperative data were reviewed and compared.ResultsTwo hundred patients underwent laparoscopic colectomy; 68 (34%) were in Group A and 132 (66%) were in Group B. Sixteen (8%) patients required intraoperative colonoscopy for localization and were evenly distributed between the two groups. The incidence of conversion to laparotomy was slightly higher in Group B (14 vs 9%) due to difficult localization in some cases; however, this difference did not reach statistical significance. Furthermore, there was no significant difference in the postoperative complication rate between the two groups. Specifically, an anastomotic leak and a wound infection were recorded in 4 and 12% of patients in Group A compared to 3 and 17% in Group B, respectively.ConclusionsLaparoscopic colectomy may be safely performed without preoperative mechanical bowel preparation, although difficult localization may lead to a slightly higher conversion rate. Appropriate patient selection for laparoscopic colectomy without mechanical bowel preparation is essential. Furthermore, bowel preparation should be considered in cases of small and nonpalpable lesions.

The combined laparoscopic approach for the treatment of incarcerated inguinal hernia

BackgroundThe traditional open approach to incarcerated inguinal hernia has several drawbacks including difficulty avoiding tension in the swollen and edematous tissues leading to a higher recurrence rate, possible contamination of the mesh if it is implanted in an area of bowel strangulation, and proper evaluation of whether ischemic bowel requires resection or not, which may mandate laparotomy. This study aimed to evaluate an approach that combines intraperitoneal laparoscopic exploration with hernia reduction and total extraperitoneal (TEP) repair of the hernia.MethodsAn exploratory laparoscopy is performed. The incarcerated content is gently retracted into the abdominal cavity and inspected. If no resection is needed, the gas is deflated, the umbilical trocar is removed, and the preperitoneal space is accessed with a Hasson trocar inserted behind the rectus muscle toward the pelvis. Two additional 5-mm trocars are inserted into the preperitoneal space in the lower midline. A standard TEP repair with mesh is performed.ResultsBetween 2005 and 2008, 15 patients underwent laparoscopic exploration for incarcerated inguinal hernia followed by TEP repair. Of the 15 patients, 8 had acute incarceration and 7 had chronic irreducible hernia. Reduction of the incarcerated content was straightforward, and no bowel resection was needed. No major complications or wound or mesh infections occurred.ConclusionThe combined laparoscopic approach offers a solution to incarceration of inguinal hernias while taking advantage of each separate approach. The first part of the procedure enables easy reduction of the incarcerated content and assessment of its viability. The second part enables a simple and standard repair, similar to that for an elective case. If bowel necrosis is suspected preoperatively, an open anterior approach should be taken to avoid possible intraabdominal contamination.

Volvulus and bowel obstruction in ATR‐X syndrome—clinical report and review of literature

Alpha thalassemia‐mental retardation, X‐linked (ATR‐X) syndrome is a rare genetic disorder with a variety of clinical manifestations. Gastrointestinal symptoms described in this syndrome include difficulties in feeding, regurgitation and vomiting which may lead to aspiration pneumonia, abdominal pain, distention, and constipation. We present a 19‐year‐old male diagnosed with ATR‐X syndrome, who suffered from recurrent colonic volvulus that ultimately led to bowel necrosis with severe septic shock requiring emergent surgical intervention. During 1 year, the patient was readmitted four times due to poor oral intake, dehydration and abdominal distention. Investigation revealed partial small bowel volvulus which resolved with non‐operative treatment. Small and large bowel volvulus are uncommon and life‐threatening gastrointestinal manifestations of ATR‐X patients, which may contribute to the common phenomenon of prolonged food refusal in these patients.