Danny A. Sherwinter

Feasibility study of natural orifice transluminal endoscopic surgery inguinal hernia repair

BACKGROUND A potentially less-invasive technique, transluminal surgery, may reduce or eliminate pain and decrease time to full return of activities after abdominal operations. Inguinal hernia repair is perfectly suited to the transgastric endoscopic approach and has not been previously reported. OBJECTIVE Our purpose was to evaluate the feasibility of transgastric bilateral inguinal herniorrhaphy (BIH). DESIGN Feasibility study with a nonsurvival canine model. INTERVENTIONS Under general anesthesia, male mongrel dogs weighing 20 to 30 kg had a dual-channel endoscope introduced into the peritoneal cavity over a percutaneously placed guidewire. An overtube with an insufflation channel was used. Peritoneoscopy was performed, and bilateral deep and superficial inguinal rings were identified. The endoscope was removed, premounted with a 4 x 6 cm acellular human dermal implant and then readvanced intraperitoneally through the overtube. The implant was then deployed across the entire myopectineal orifice and draped over the cord structures. Bioglue was then applied endoscopically, and the implant was attached to the peritoneum. After completion of bilateral repairs, the animals were killed and necropsy performed. RESULTS Five dogs underwent pure natural orifice transluminal endoscopic surgery (NOTES) intraperitoneal onlay mesh (IPOM) BIH. Accurate placement and adequate myopectineal coverage was accomplished in all subjects. At necropsy no injuries to the major structures were noted but Bioglue misapplication with contamination of unintended sites did occur. LIMITATIONS Our study involved only a small number of subjects in nonsurvival experiments, and no gastric closure was used. CONCLUSIONS Many of the characteristics of inguinal hernia repair are especially well suited to the transgastric approach. The repair is in line with the transgastric endoscope vector, bilateral defects are adjacent, and the IPOM technique does not require significant manipulation or novel instrumentation.

Natural Orifice Translumenal Endoscopic Surgery Inguinal Hernia Repair: A Survival Canine Model

INTRODUCTION With over 20 million repairs performed worldwide annually, inguinal hernias represent a significant source of disability and loss of productivity. Natural orifice translumenal endoscopic surgery (NOTES™), as a potentially less invasive form of surgery may reduce postoperative disability and accelerate return to work. The objective of this study was to assess the safety and short-term effectiveness of transgastric inguinal herniorrhaphy using a biologic mesh in a survival canine model. MATERIALS AND METHODS Under general anesthesia with the animal in Trendelenburg position, a gastrostomy was created. A 4 × 6 cm acellular dermal implant was deployed endoscopically across the myopectineal orifice, draped over the cord structures, and secured with Bioglue. Following completion of bilateral repairs the animals were survived for 14 days. At the end of the study period, the animals were euthanized and a necropsy performed. Cultures of a random site within the peritoneal cavity and at the site of implant deployment were obtained. In addition, a visual inspection of the peritoneal cavity was performed. RESULTS All animals thrived postoperatively and did not manifest signs of peritonitis or sepsis at any point. At necropsy accurate placement and adequate myopectineal coverage was confirmed in all subjects. Cultures of a random site within the peritoneal cavity and at the site of implant deployment had no growth. DISCUSSION This study confirms that NOTES-inguinal herniorrhaphy using a biologic implant can be performed safely. In addition, the transgastric technique provided good short-term myopectineal coverage without infectious sequelae.

Laparoscopic distal pancreatectomy.

These authors conclude that laparoscopic distal pancreatectomy can be safely and effectively performed by surgeons skilled in basic laparoscopy and does not require specialized training or to be performed in a specialized center.

A Novel Retraction Instrument Improves the Safety of Single-Incision Laparoscopic Cholecystectomy in an Animal Model

INTRODUCTION Single-incision laparoscopic cholecystectomy (SILC) promises improved cosmesis and may further minimize the invasiveness of intraabdominal interventions but cannot come at the expense of patient safety. This study describes the evaluation of a novel 5-mm instrument designed for SILC that maintains an equivalent critical view to that obtained with standard multiport laparoscopic cholecystectomy (MLC). MATERIALS AND METHODS Sixteen animals were randomly assigned to one of four study arms. Four techniques for laparoscopic cholecystectomy were used: standard four-port MLC, three-instrument SILC (SILC-A), three-instrument SILC using a suture for lateral retraction (SILC-B), and three-instrument SILC using the novel instrument for retraction (SILC-C). Each case was timed and video-recorded. The video was cropped to obscure the method of retraction and evaluated by five experienced laparoscopic surgeons blinded to the technique used. Each case was rated subjectively on a safety and visualization scale of 1-4. RESULTS SILC-A and SILC-B cases were significantly longer in duration than both SILC-C and MLC cases. The safety and visualization scale results were lower for the SILC-A technique but were equivalent for the MLC, SILC-B, and SILC-C techniques. CONCLUSION This study introduces a novel instrument for gallbladder retraction. In this initial evaluation, the new instrument showed encouraging results in its ability to generate good visualization, support the safe critical view technique, and reduce the length of the procedure.

Thrombosis of the Lap-Band system

BackgroundThe laparoscopic adjustable gastric band (LAGB) has proven itself a procedure with excellent long-term weight loss results and extremely low morbidity and mortality. The LAGB has become an indispensable addition to the armamentarium of most bariatric surgeons. Commonly reported complications associated with the lap band system include gastric prolapse, band erosion, hardware infection, and port/tubing leakage.MethodsWe report a case of a patient suspected of having a Lap-Band leak. He presented with a clinical course of multiple adjustments without restriction and inability to aspirate the expected volume from the band. Following adjustment under fluoroscopy he became severely dysphagic. He underwent urgent operative exploration and was found to have an intact but overinflated band. Under close inspection, a clot in the proximal band was noted, acting as a ball valve allowing the addition of fluid but not aspiration.ConclusionsThis case highlights an unusual explanation for what is thought of as typical signs of band leakage. In addition it raises serious questions about the importance of preventing blood and particulate matter from entering the Lap-Band system both at the initial operation and at subsequent adjustments.

A Novel Adaptor Converts a Laparoscope Into a High-Definition Rigid Sigmoidoscope

The rigid sigmoidoscope is an important tool in a surgeon’s armamentarium, yet it has remained essentially unchanged despite poor imaging and the inability to project or record the images. Herein we report our initial experience with a novel introducer built from readily available operating room supplies and designed to convert any standard laparoscope into a high-definition rigid sigmoidoscope.

Experimental in vivo canine model for gastric prolapse of laparoscopic adjustable gastric band system

BACKGROUND The most prevalent long-term complications in patients undergoing laparoscopic adjustable gastric band (LAGB) surgery are symmetric pouch dilation and gastric prolapse (slippage). However, no published data or a reliable model are available to evaluate the actual mechanism of band slippage or how to prevent it. The objective of the present study was to construct an animal model of anterior gastric band prolapse and to use this model to evaluate the effectiveness of various arrangements of gastrogastric sutures and gastric wraps in preventing prolapse. METHODS The esophagus of male mongrel dogs was accessed through the left chest, and a pressure transducer and an insufflation catheter were introduced. An AP-S Lap-Band (Allergan, Irvine, CA) filled to 10 cm(3) was placed using the pars flaccida technique. A standardized cut of meat was placed into the esophagus to simulate food impaction at a tight LAGB. After the placement of multiple different gastrogastric suture configurations, air was insufflated into the gastric pouch by way of the esophagus. RESULTS Prolapse, identical to that seen in clinical practice, was reliably reproduced in this model by increased esophageal pressure acting on a LAGB outlet obstruction. In addition, prolapse was reproduced with all gastrogastric configurations that did not secure the anterior gastric wall to within 1.5 cm of the lesser curve. CONCLUSION The results of the present study support the theory that prolapse is caused by esophageal peristalsis against an occlusion at the level of the LAGB. In this canine model, gastrogastric sutures encompassing the anterior gastric wall were integral to preventing prolapse.

Adenomyomatous hyperplasia of distal common bile duct: a case report and review of the literature

Abstract Adenomyomatous hyperplasia (AH) is commonly found in the gallbladder and is considered a tumor-like inflammatory lesion arising from Rokitansky-Aschoff sinus. It is extremely rare in the extrahepatic bile duct and only 15 cases have been reported to date. We describe a 63-year-old male patient who presented with cholangitis, underwent an extensive diagnostic workup, and ultimately had a Whipple procedure. Final pathology showed a 2.0 × 1.5 × 0.5 cm3 granular lesion in the distal common bile duct. There was prominent biliary epithelial proliferation with tubular–papillary architecture and minimal nuclear atypia in association with chronic inflammation, stroma reaction and smooth muscle proliferation. AH of the extrahepatic bile duct is a benign process but often requires a major operation to definitively diagnose.

SAGES Technology and Value Assessment Committee safety and effectiveness analysis on immunofluorescence in the operating room for biliary visualization and perfusion assessment

The ability to assess tissue perfusion and identify vital structures in the operating room in order to potentially decrease complication rates remains a key goal for surgeons. The introduction of immunofluorescence utilizing indocyanine green intraoperatively to evaluate areas such as an anastomosis, a free flap, biliary anatomy, or lymphatics has the possibility of decreasing postoperative complications by addressing identification and perfusion concerns at the time of surgery. The use of laser-induced immunofluorescence using indocyanine green relies on similar principles as fluorescein technique, which was first proposed in 1942. Fluorescein angiography was initially used to evaluate vascularity of the eye and skin. Fluorescein angiography did not become clinically significant, however, due to difficulties with the tracer. Indocyanine green, a secondgeneration tracer, was developed in order to overcome the limitations of fluorescein. Indocyanine green (ICG) is a water-soluble lyophilized powder with a chemical formula of C43H47N2O6S2Na. It is a fluorophore that responds to near-infrared irradiation and absorbs light between the wavelengths of 790 and 805 nm and re-emits it with an excitation wavelength of 835 nm. The compound is administered intravenously, and when injected it binds to plasma proteins. ICG binds nearly exclusively to albumin on electrophoresis, with only minor binding to other serum proteins, as shown in Table 1 [1]. It is then taken up in the liver and excreted in bile. The half-life of ICG is 3–5 min and excreted by the liver in 15–20 min. Its short half-life, hepatic excretion, and unique wavelength emission in tissue providing images of both circulation and lymphatics make it well suited for use in the operative field. Contraindications for use of ICG are limited, but include patients with a known allergy or adverse reaction to ICG or iodine and those women who are pregnant or lactating. There have been reports of rare cases of anaphylactic shock and urticaria associated with ICG usage. ICG and Near-Infrared (NIR) imaging modalities have been used in a wide array of surgical procedures. Minimally invasive colorectal surgery, encompassing both laparoscopic and robotic techniques, has employed the use of immunofluorescence to evaluate the perfusion of the anastomosis. This includes anastomoses for colorectal cancer of the right and left colon, as well as rectal cancer resections. Further immunofluorescence imaging has been used to assess blood supply of anastomoses following pancreaticoduodenectomy and esophagectomy. Additional uses of this technology in general surgery include lymphadenectomy, donor nephrectomy, and liver resection to evaluate perfusion, and biliary anatomy during cholecystectomy. Fluorescence-guided surgery has been utilized in oncology surgery in attempts to achieve improved marginnegative status [2] although this analysis will not cover this use as it is outside of the focus of this evaluation. Finally, immunofluorescence has been used with some success in & David Renton david.renton@osumc.edu

Band Prolapse: Diagnosis and Management

Laparoscopic adjustable gastric band (LAGB) prolapse is a well-described complication following LAGB and is defined by the herniation of any portion of the gastric wall through the band in a proximal direction, with caudal migration of the band. Gastric band prolapse typically presents with some combination of food intolerance, nausea, vomiting, dysphagia, or worsening GERD. The mainstay of diagnosis is barium esophagography. Management of LAGB prolapse involves one of four options: a conservative non-operative approach, band removal, band revision (re-banding), and band removal with conversion to an alternate bariatric procedure. Limited and variable data preclude definitive recommendations regarding the optimal treatment, timing, and ideal revisional choice for these complex patients.