Brian P. Jacob

Minimally invasive endoscopic thyroidectomy by a cervical approach

Background: The technique of thyroidectomy mandates adequate visualization of the operative field to identify pertinent anatomical structures. The purpose of this prospective review was to assess the feasability and safety of endoscopic thyroidectomy by a cervical approach. Methods: All patients who underwent endoscopic thyroidectomy were assessed by retrospective review of a prospective database. Results: Thirty-eight patients underwent endoscopic thyroidectomy by a cervical approach. Thirty-five of 38 cases were successfully completed endoscopically with a mean OR time of 190 min. One patient experienced a permanent recurrent laryngeal palsy. Conclusion: Endoscopic thyroidectomy by a cervical approach is a feasible procedure. As in conventional thyroid surgery, great care should be exercised when dissecting the recurrent laryngeal nerve.

Laparoscopic colectomy for colon adenocarcinoma An 11-year retrospective review with 5-year survival rates

BackgroundLaparoscopic colectomy for the management of colon cancer remains a controversial therapeutic option, especially when the outcomes are compared with the historically accepted survival data and recurrence rates after open surgery. The purpose of this study was to evaluate the 5-year overall and disease-free survival rates after laparoscopic colon resection for invasive colon adenocarcinoma.MethodsA total of 129 patients underwent consecutive laparoscopic colectomies for colon adenocarcinoma (between April 1992 and 2004 January) by a single surgeon at a single institution. Records were analyzed retrospectively and follow-up data was obtained. The Student t-test, Cox regression analysis, and Kaplan-Meier survival data were used for statistical analysis.ResultsAfter patients with noninvasive disease on final pathology were excluded, the study population comprised 88 patients who underwent laparoscopic colectomies for invasive colon cancer with > 2 years of follow-up. Of these cases, 81 (93%) were amenable for complete follow-up at 11years (41 women and 40 men; mean age, 76 years). Mean follow-up was 61 months. There was one perioperative death (1.2%), and the overall postoperative morbidity rate was 13.6%. The average number of lymph nodes harvested was 10.1 (±6). There were no port site recurrences. The Kaplan-Meier survival data were as follows for 5-year overall survival and 5-year disease-free survival, respectively stage I (n = 34) 89% and 89%; stage II (n = 22), 65% and 59%; stage III (n = 19), 72% and 67%; stages I–III combined, (n = 75), 77% and 73%.ConclusionsFor this specific cohort of patients undergoing curative laparoscopic colectomies for invasive colon adenocarcinoma, the mean follow-up was > 5 years. Overall survival and disease-free survival for stage I, II, and III colon cancer as well as for stages I–III combined are favorable and comparable to historically acceptable open colectomy survival rates. Overall survival and disease-free survival after laparoscopic colectomy for invasive colon cancer is no worse, and perhaps better than, the previously reported rates for the same procedure done by an open technique.

Effect of standard vs extended Roux limb length on weight loss outcomes after laparoscopic Roux-en-Y gastric bypass

Background: Increasing the length of the Roux limb in open Roux-en-Y gastric bypass (RYGB) effectively increases excess weight loss in superobese patients with a body mass index (BMI) >50 kg/m2. Extending the RYGB limb length for obese patients with a BMI < 50 could produce similar results. The purpose of this study was to compare the outcomes of superobese patients undergoing laparoscopic RYGB with standard (≤100-cm) with those undergoing the procedure with an extended (150-cm) Roux limb length over 1-year period of follow-up. Methods: Retrospective data over 2.5 years were reviewed to identify patients with a BMI < 50 who underwent primary laparoscopic RYGB with 1-year follow-up (n = 58). Forty-five patients (sRYGB group) received limb lengths ≤ 100 cm, including 45 cm (n = 1), 50 cm (n = 2), 60 cm (n = 6), 65 cm (n = 1), 70 cm (n = 1), 75 cm (n = 3), and 100 cm (n = 31). Thirteen patients (eRYGB group) received 150-cm limbs. Postoperative weight loss was compared at 3 weeks, 3 months, 6 months, and 1 year. Results: Comparing the sRYGB vs the eRYGB group (average ± SD), respectively: There were no significant differences in age (41.5 ± 11.0 vs 38.0 ± 11.9 years), preoperative weight (119.2 ± 11.9 vs 127.8 ± 12.5 kg), BMI (43.7 ± 3.0 vs 45.2 ± 3.5 kg/m2), operative time (167.1 ± 72.7 vs 156.5 ± 62.4 min), estimated blood loss (129.9 ± 101.1 vs 166.8 ± 127.3 cc), or length of stay (median, 3 vs 3 days; range, 2–18 vs 3–19). Body weight decreased over time in both groups, except in the sRYGB group between 3 and 6 months and 6 and 12 months after surgery and in the eRYGB group between 6 and 12 months. BMI also decreased over time, except in the eRYGB group between 6 and 12 months. Absolute weight loss leveled out between 6 and 12 months in both groups, with no increase after 6 months. Percent of excess weight loss did not increase in the eRYGB group after 6 months. An extended Roux limb did not significantly affect body weight, BMI, absolute weight loss, or precent of excess weight loss at any time point when the two groups were compared. A trend toward an increased proportion of patients with >50% excess weight loss (p = 0.07) was observed in the extended Roux limb group. Conclusions: In this series, no difference in weight loss outcome variables were observed up to 1 year after laparoscopic RYGB. Thus, extending Roux limb length from ≤100 cm to 150 cm did not significantly improve weight loss outcome in patients with a BMI < 50 kg/m2.

Single incision total extraperitoneal (one SITE) laparoscopic inguinal hernia repair using a single access port device

To the Editors, Performing laparoscopic operations through one single skin incision has recently emerged as a possible alternative to conventional laparoscopy in a variety of surgical cases. To date, however, other than cosmesis, there is no evidence yet to suggest any signiWcant patient advantages for singleincision laparoscopic surgery. Nonetheless, single-incision cases were reported as early as in 1998 [1, 2], and, recently, the term “single incision laparoscopic surgery” (SILSTM) has been described for a large number of urologic, gynecologic, bariatric, and general surgical procedures, and its use seems to be rapidly growing. Annually in the United States, there are about 800,000 inguinal hernias performed, of which approximately 140,000 are performed laparoscopically by either the transabdominal (TAPP) or total extraperitoneal (TEP) approaches. While the indications and contraindications have yet to be described, the use of SILSTM techniques to perform laparoscopic inguinal hernia repairs is already being described [3]. SILSTM techniques are currently being performed using one of two entry methods. On the one hand, a single skin incision can be made, followed by the insertion of multiple trocars through separate points of the fascia. Alternatively, through a single skin and fascial incision, a single-port access device can be inserted and multiple trocars can be inserted through these devices. We began using single-incision techniques for TEP hernia repairs in December of 2008, and we would like to report our group’s initial experience with SILSTM inguinal hernia repairs using a singleaccess port device. The technical steps of a single incision TEP inguinal hernia are very similar to that of a traditional laparoscopic TEP inguinal hernia, and no special instruments are required. We begin by making an infraumbilical skin incision measuring 25 mm in length. The incision is made partially over the midline and is extended to over the anterior fascia of the left rectus muscle. The anterior fascia is held with two stay sutures and divided longitudinally for approximately 25 mm. The current size of the available single-incision port devices mandate this size incision. The posterior fascia at this level is identiWed and the rectus muscle is retracted laterally, allowing us to create a plane deep to the rectus muscle down to the level of the pubic bone using a dilating balloon trocar. The balloon dilator is then removed and replaced with a single-access port device (Covidien, Norwalk, CT, USA). Through this device, we insert a 12-mm trocar and two 5-mm trocars. Using a 45° 10-mm laparoscope, we then performed a routine TEP inguinal hernia repair. Standard laparoscopic instruments and mesh are then utilized for the operation. We have completed a total SILSTM inguinal hernia repair using this single-port access device in three patients. In our Wrst case, a direct inguinal and a femoral defect were discovered on the right. When the left groin was explored, a small direct defect was found. A 4 £ 6-in polypropylene mesh was inserted through the 12-mm port and secured on each side using four to Wve spiral tacks, as is our routine. The operation was straightforward and took 73 min. The patient was discharged home the same day and the postoperative course was uneventful. At the 2-week follow-up appointment, there was no evidence of recurrence and no obvious wound complications, including no evidence of an incisional hernia. The next two cases were performed in males with bilateral indirect inguinal hernias. One of these patients had B. P. Jacob (&) · W. Tong · M. Reiner · A. Vine · L. B. Katz Laparoscopic Surgical Center of New York, Mount Sinai Medical Center, New York, NY 10028, USA e-mail: bpjacob@gmail.com

Placement of a laparoscopic adjustable gastric band after failed sleeve gastrectomy

Originally introduced in 1988 as part of a duodenal switch operation [1,2], the laparoscopic sleeve gastrectomy (LSG) has become a popular primary procedure for morbidly obese patients. Although LSG is most often indicated for the super obese patient group, its use has recently been advocated for multiple subsets of the morbidly obese population, including patients with a body mass index 35 kg/m 2 with co-morbidities, patients with contraindications for gastric adjustable banding, morbidly obese adolescents, and those patients for whom malabsorptive procedures would be contraindicated [3,4]. Long-term follow-up after LSG as a primary procedure, however, is not yet available, and concerns regarding its efficacy persist. Because the use of LSG is increasing, we could begin to see an increased number of failures; thus, it will be important to define an approach for failed LSG. To illustrate 1 method of managing this problem, we report the placement of a laparoscopic adjustable gastric band (LGB) after failed LSG.

Taking Posterior Rectus Sheath Laparoscopically to Reinforce the Gastrojejunostomy in Laparoscopic Roux-en-Y Gastric Bypass

Background: The Roux-en-Y gastric bypass (RYGBP) is now performed laparoscopically widely with low morbidity and mortality. However, in some cases long-term adequate weight loss is not satisfied because of dilatation of the gastrojejunostomy. Therefore, a prosthetic material and bio-membranes have been used to prevent dilatation. In this study, we used posterior rectus sheath by laparoscopy, to evaluate feasibility and safety of the procedure. Methods: 20 Yorkshire pigs, under general anesthesia, had a standard laparoscopic RYGBP. In addition, 10 had their gastrojejunostomy anastomosis wrapped with 2x10 cm posterior rectus sheath. Clinical and operative outcome after operation were compared with the control group of laparoscopic RYGBP cases. Results: The median weight of the pigs was 46.1 kg (range 42-51) in the posterior rectus sheath-applied group and 45.2 kg (range 42-49) in the control group. All gastrojejunostomies in the posterior rectus sheath-applied group were successfully reinforced laparoscopically. Both groups loss weight compared with their normal growth weight, but there was no significant difference in the median weight loss between the two groups. Two pigs in the posterior rectus sheath-applied group developed a stenosis at the gastrojejunostomy anastomosis following RYGBP. All pigs in the posterior rectus sheath-applied group were found to develop hypertrophic smooth muscle and connective tissue scarring at the gastrojejunostomy on histologic examination. Conclusion: Laparoscopic application of posterior rectus sheath around the gastrojejunostomy in laparoscopic RYGBP is feasible and safe. The sheath-applied group developed stenosis and connective tissue scarring. Additional research is needed to evaluate effectiveness in preventing dilation of the anastomosis.

When sleeve gastrectomy fails: adding a laparoscopic adjustable gastric band to increase restriction

The use of laparoscopic sleeve gastrectomy (LSG) as a procedure for morbid obesity has recently increased. The LSG procedure is used most often as a part of a biliopancreatic diversion with duodenal switch (BPDDS) or as a first stage that can be converted to a BPDDS or Roux-en-Y gastric bypass (RYGB) [1, 2]. However, the surgical indications for LSG have rapidly expanded, and some centers use the sleeve as the primary operation for morbid obesity [3, 4].The utility of LSG as a primary procedure is controversial, with consensus lacking in the literature. Whether the etiology of failed sufficient weight loss is the result of an inadequate sleeve or attributable to dilation or hypertrophy of the sleeve, the incidence of failed sleeve gastrectomies may be significant.In the treatment of a patient with a failed LSG, the options typically include creation of a tighter sleeve or conversion to biliopancreatic diversion or RYGB [5]. These procedures, however, are complex and can carry significant morbidity.The authors report a case of a morbidly obese 42-year-old man who failed to lose sufficient weight after an LSG. Because the patient was dependent on several oral antipsychotic medications, he refused any malabsorptive procedure, and a decision was made to proceed with laparoscopic adjustable gastric banding (LAGB). The case proceeded successfully, and at this writing, 9 months after surgery, the patient has achieved a 57% excess weight loss from an original weight of 390 lb.The insertion of an LAGB into its normal anatomic position is feasible after a sleeve gastrectomy, and its use can induce sufficient restriction and weight loss results equivalent to those of a sleeve or band alone and possibly better.

International Hernia Collaboration Consensus on Nomenclature of Abdominal Wall Hernia Repair

It is with great interest that we read the manuscript ‘‘Nomenclature in Abdominal Wall Hernias: Is it time for Consensus?’’ by Parker et al. [1]. We agree with the authors that a consensus is needed to avoid errors in interpretation of the literature or of operative reports. When performing meta-analyses of studies, it is essential to be able to group the studies correctly when doing sub-analysis according to mesh position. Nevertheless, the authors have left in their paper several options for the different positions of the mesh in relation to the abdominal wall anatomy. A working group of the European Hernia Society [2] has previously published an unambiguous nomenclature, but this proposal has not penetrated the surgical literature widely. Nowadays there are social media tools to contact a large group of interested surgeons to ask their input for choosing their preferred nomenclature. The International Hernia Collaboration (IHC) is a closed FaceBook group established in December 2012 in New York by Brian Jacob, with currently more than 3500 members worldwide that have a specific focus and interest in abdominal wall surgery [3]. We performed a survey on IHC including the attached figure indicating position A to E to ask the members for their preferred nomenclature (Fig. 1). The survey was posted on IHC on May 7, 2017, for a period of 1 week, and the data were extracted on May 14, 2017. In total, 111 IHC members have responded: North America 44%, Europe 23%, South America 16%, Asia 14%, Africa 2% and

Dual endoscopic-assisted endoluminal colostomy reversal: A feasibility study

Background: Emergent colostomies are associated with increased morbidity related to second closure operations. The purpose of this canine pilot study was to create a minimally invasive procedure that would reduce the time interval and morbidity involved with colostomy reversals after left colon end colostomies. Methods: Six mongrel dogs underwent modified laparoscopic Hartmann’s procedures in which the stapled end of the rectal stump was approximated to the left colon proximal to the stoma. After 1 week, they underwent an endoluminal colostomy reversal with a computer-mediated, circular stapling device and varying anvil insertion methods. Variables recorded included anvil insertion technique and feasibility, OR time, complications, and number of days to first meal and bowel movement. A contrast enema performed 1 week post colostomy reversal ruled out anastomosis leaks and stenosis. The dogs were euthanized and subjected to necropsy. Results: Of four anvil insertion techniques tested, the most feasible employed a large-bore needle to perforate through the stapled end of the Hartmann pouch into the lumen of the left colon. Simultaneous endoluminal views of the rectal stump with a sigmoidoscope and the left colon lumen with an endoscope permitted a controlled and safe needle puncture. Through the needle, a guide wire was inserted to withdraw the anvil via the colostomy into place. A transanally inserted stapler was then married to the anvil under fluoroscopic guidance, thus completing the anastomosis. The colostomy was then taken down and transected at the level of the colocolostomy. Average operating time was 126 min (range 90–180), diet was tolerated within 1.5 days, and average number of days to first bowel movement was 2.5. The absence of stenosis, leaks, and inadvertent visceral injuries confirmed feasibility. Conclusions: In this canine model, a dual endoscopic-assisted colostomy reversal with a computer-mediated, circular stapling device is feasible. Using this technique, colostomy reversals can possibly be performed 1 week post-colostomy without entering the peritoneal cavity, thus reducing the number of invasive operations and subsequent morbidity required to manage emergent colon perforations.

Long-term follow-up evaluation for a canine model of gastroesophageal reflux disease.

We were excited to read the article by McMahon and colleagues (Surg Endosc 2002; 16: 67–74) because we also have been working to create a canine model for gastroesophageal reflux disease (GERD). In their article, they concluded that successful performance of an esophageal myotomy and intrathoracic gastric cardiopexy produces significant reflux 4 weeks after reflux induction, thus making their canine model the standard for studying GERD [1]. Our model for reflux induction was performed using a simple esophageal myectomy, and we similarly recorded significant levels of reflux postoperatively, suggesting that we too had created a stable model in animals for creating reflux. However, although our initial results immediately after reflux induction were promising, our long-term follow-up results at 6 months failed to show persistent, significant reflux, and instead showed a significant decline in the amount of reflux. We agree that a successful animal model for GERD would greatly improve the medical and surgical community’s ability to test new antireflux medications and operations. At this writing, however, no stable, longterm model exists. As with the Duke canine model, we began by measuring a baseline manometry and 24-h pH using manometry and pH probes the same as those used by the Duke group (Medtronic Functional Diagnostics, Minneapolis, MN, USA). In our model, reflux was similarly defined as the total time in 24 h that the pH was less than 4.0. For each 24-h pH session, the pH probes were inserted transnasally in anesthetized dogs, and probe placement was confirmed routinely with an endoscope. After measurement of baseline 24-h pH values, each dog underwent a reflux induction procedure through a laparotomy and a 180 esophagocardiomyectomy that extended 4 to 6 cm proximally and 2 cm distally to the gastroesophageal junction. At the end of the procedure, esophagoscopy was performed to rule out esophageal perforation. The dogs were allowed to heal, and then were evaluated 2 weeks postoperatively for reflux using 24-h pH and manometry. Long-term follow-up evaluation consisted of manometry and 24-h pH studies 4 months and 6 months after reflux induction. As with McMahon and colleagues, all of our dogs showed minimal reflux at baseline, and significant reflux, as compared with baseline, 2 weeks after the reflux induction operation. To our surprise, however, 4 months after reflux induction, our dogs failed to show consistent reflux, and instead showed a decline in reflux by an average of 55% (range, 50–66%), as compared with postoperative value at 2 weeks. The animals were studied again at 6 months and found to have an even greater reduction in reflux (average, 89%; range, 75–99%) from the postoperative values at 2 weeks, with a concomitant rise in lower esophageal sphincter (LES) pressures on manometry. We thought these dynamic changes seen over time in our animal model might be secondary to scar formation, and necropsy indeed showed significant scar tissue adherent to the operative site. Whereas we share McMahon and colleague’s enthusiasm for creating a model for GERD, on the basis of our long-term follow-up results, we are hesitant to suggest that the canine is a stable model. Although we are still in the process of continuing our study, our group wanted to share these preliminary, yet vitally important findings, at this time. Because the Duke model uses a cardiopexy as part of the reflux induction procedure (differing from our model), which may maintain an open LES, we look forward to their longterm results before recommending the canine as a stable, standardized model for GERD.