Diego R. Camacho

Single-incision laparoscopic cholecystectomy learning curve experience seen in a single institution.

Introduction: Single-incision laparoscopic surgery (SILS) is laparoscopic surgery done by one incision through the umbilicus. Cholecystectomy lends itself well to a SILS approach. As these procedures have become more widely adapted, it is important to determine the approximate learning curve to decrease two surgical endpoints: (1) time to completion of the procedure; and (2) decreased incidence of conversion. Methods: We prospectively reviewed our series of 50 cholecystectomies done using the SILS approach between May 2008 to September 2008. All cases were performed by two advanced laparoscopic surgeons at a single institution. Data was collected immediately after the case and entered into an Excel database. Cases were performed by insufflating the abdomen with a Veress needle through the umbilicus followed by placement of 5-mm ports at the umbilicus. Results: Patient ages ranged between 21 and 82 years with a median age of 45 years. Body mass index (BMI) range was 21 to 42 kg/m2 with a mean of 30 kg/m2. Average length of time for cases was 1 hour 9 minutes with a range between 55 minutes and 120 minutes. The average length of time for the first 25 cases was 80 minutes. When compared with cases 26 to 50 the average length of time was 60 minutes (P<0.05). The conversion rate to conventional laparoscopic cholecystectomy was 10%. Conversion was accomplished through the addition of a 5-mm port elsewhere on the abdominal cavity. After the tenth case, the incidence of conversion went down to zero. When conversions were further stratified, they occurred within each individual surgeon’s first ten cases. Conclusions: The learning curve for successful consistent completion of SILS cholecystectomy cases appears to be after 25 cases. In addition, conversion rates drop dramatically after the first ten cases.

Single-incision laparoscopic-assisted right colon resection for cancer.

The authors suggest that laparoscopic right colectomy utilizing a single port may be performed with excellent cosmetic results.

Portomesenteric Vein Thrombosis, Bowel Gangrene, and Bilateral Pulmonary Artery Embolism Two Weeks after Laparoscopic Sleeve Gastrectomy.

Sleeve gastrectomy and gastric bypass surgery are popular and effective options for weight loss surgery. Portomesenteric vein thrombosis (PMVT) is a documented but rare complication of bariatric surgery. Proper surgical technique, careful postoperative prophylaxis, and early mobilization are essential to prevent this event. The diagnosis of PMVT in the postoperative period requires a high index of suspicion and early directed intervention to prevent a possibly fatal outcome. We present a case of PMVT complicated by small bowel ischemia resulting in gangrene that necessitated resection.

An intraoperative technique to reduce superficial surgical site infections in circular stapler-constructed laparoscopic Roux-en-Y gastric bypass

BACKGROUND Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been established as one of the most effective treatments for morbid obesity. Surgical site infections are the most common complication after LRYGB surgery. OBJECTIVE To compare the superficial surgical site infections (sSSI) rate before and after the implementation of our intraoperative technique. SETTING Academic medical center. METHODS Our intraoperative technique relies on sterile coverage of the circular stapler, sterile specimen-bag retrieval of the gastrojejunostomy enteric remnant, and port site Penrose drainage. We analyzed our sSSI outcomes before and after implementation of our technique in all LRYGBs performed by a single surgeon from 2009 to 2015. We took into account patient age; sex; baseline body mass index (BMI); smoking status; and co-morbidities such as diabetes, hypertension, and hyperlipidemia. χ(2) and multivariate analysis were performed. RESULTS We performed 486 LRYGBs in 2009-2015. The cohort before implementation of our technique (group 1) included 164 patients (33.7%) and the cohort after implementation (group 2) included 322 patients (66.3%). Both groups were similar in age, sex, smoking status, and rates of diabetes and hyperlipidemia but differed in BMI, operative time, and prevalence of hypertension. Hypertension was not a confounder for sSSI (P = .35). The sSSI rate was 9.15% for group 1 and 3.42% for group 2 (P = .0079). Controlling for BMI and operative time, multivariate analysis revealed a significant reduction in sSSI (odds ratio 2.98 [95% CI 1.33-6.69]) with our technique. CONCLUSIONS We describe a reproducible intraoperative technique that significantly reduces sSSI in LRYGB procedures. Our technique has the potential of hastening postoperative recovery.

Hydatid cyst disease revisited: optimal management of complex liver disease.

Cystic echinococcosis, although uncommon in the United States, remains an important disease entity due to the growing number of immigrants from other parts of the world where it remains endemic. For this reason, it is important for physicians, especially surgeons, to be aware of its clinical features and management. In many situations, chemotherapy is adequate. Because the result of medical therapy for hepatic echinococcosis is unpredictable, it is not appropriate in all patients as a standalone therapy. Generally, it is reserved for patients who are unable to tolerate surgical intervention or for those with the more virulent form of alveolar hydatid disease of the liver. It is also a useful adjunct to surgery. Surgical treatment remains the cornerstone in the management of hepatic hydatid cyst. The principles of surgical management consist of complete destruction of the parasite, sterilization of the cyst and excision of the germinal layer, daughter cysts with preservation of the normal hepatic parenchyma. In fulfilling these fundamental principles, a preoperative course of albendazole is given to sterilize the cyst and decrease the chance of anaphylaxis and the tension in the cyst wall, thus minimizing spillage during surgery. Intraoperatively, a scolicidal agent is instilled into the cyst for sterilization. Several scolicidal agents are available as adjunct for percutaneous and surgical use (hypertonic saline solution, 0.5% silver nitrate, 10% aqueous povidine, 2% formalin, and chlorhexidine), and the results of a meta-analysis conducted by Smego et al have shown that there is no significant differences in the outcomes. Also the choice of scolicidal agents does not appear to have any significant effect on the outcomes. The safety profiles of these agents have been called into question: For example, formalin is associated with sclerosan cholangitis. Some have even questioned the logic of scolicidal injection before cyst evacuation. The most effective agent has yet to be determined. Several surgical options are available to treat hepatic echinococcosis. In this issue of Southern Medical Journal, these options are extensively discussed. Before the early 1980s, radical surgical intervention was the standard treatment. With the advent of effective scolicidal agents, computed tomographyY or ultrasound-guided drainage is now possible. US-guided transhepatic percutaneous drainage (termed PAIR: puncture, aspiration, injection and re-aspiration) of cysts has been shown to have comparable cure rates, low recurrence, lower complication rates, and shorter hospital stays as compared to standard open surgical treatment. PAIR is particularly indicated in patients who have failed conservative treatment with scolicidal agents alone, and it is useful for treating other anatomic sites such as peritoneal, renal, pulmonary, and other visceral echinococcosis. Because PAIR has been shown to be effective, surgical treatment is reserved for patients with refractory disease or for those with complications such as cystobiliary fistula or obstruction. For patients who are suitable candidates for PAIR treatment, pretreatment with oral scolicidal agent begins 7 days before the planned procedure and continues for 28 days after treatment to decrease recurrence. Available surgical options include total pericystectomy, partial hepatectomy and lobectomy. Formal liver resection is reserved for peripherally located cyst particularly in segments II and III. It should not be used in centrally located lesions. Laparoscopy is the latest addition to the growing list of surgical techniques available for the treatment of hepatic hydatid cysts. The same principles of open surgery are applicable. Although experience with laparoscopy is limited, early results are encouraging and comparable to percutaneous techniques. Surgical resection may be complicated by bile leak from the residual cavity, biliary fistula, cholangitis, bleeding or intrabiliary rupture. Intrabiliary rupture with resultant cholangitis requires common bile duct exploration with extraction of the hydatid cysts, followed by primary closure and T-tube drainage. Endoscopic retrograde cholangiopancreatography (ERCP) also may be used to assist in postoperative management of these complications. Following surgical resection, the residual cavity is filled with omentum. All bile duct openings must be identified and ligated. Finally, it is hoped that with improvements in imaging, percutaneous drainage and effective scolicidal agents, radical surgical treatment will be a thing of the past, and this will translate into improved morbidity and mortality statistics.

Sleeve gastrectomy telementoring: a SAGES multi-institutional quality improvement initiative

BackgroundSleeve gastrectomy is a relatively new procedure that developed as a result of rapid innovation in the field of bariatric surgery. As with any newly developed operation, there is a learning curve that potentially can be associated with higher morbidity. Real-time surgical mentoring reduces the learning curve effect but can be time intensive for the mentor. The aim of this initiative was to evaluate the feasibility, effectiveness, and satisfaction of surgical telementoring for laparoscopic sleeve gastrectomy. This is the first national specialty society effort to determine if the “remote presence” of an expert surgeon (mentor) can help practicing surgeons improve skills.MethodsThe experience of 15 surgical trainees (mentees) who performed laparoscopic sleeve gastrectomy under real-time telementoring by 7 mentors was reviewed. Telementoring was implemented using the Visitor1® remote presence system with two-way live audio and video communication. The receiving platform utilized a conventional laptop, iPad, or iPhone. The mentee followed a structured telementoring program including didactic learning, live case teleobservation, and telementoring of 2–3 cases. A survey on the quality of the telecommunication and effectiveness of the mentoring was performed by the mentor and mentee on a scale of “exceeded,” “met,” “almost met,” or “failed to meet” expectations. The overall telementoring experience was rated on a scale of 1 for “poor” to 5 for “excellent.”ResultsBased on the mentees’ survey, the overall telementoring experience was rated as 4.8. Despite the mentees having experience with laparoscopic sleeve gastrectomy, most commented that the telementoring experience was an excellent educational tool and they learned some new techniques they plan to apply it in their practice. Based on the mentors’ survey, the overall telementoring experience was rated as 4.7. All mentors stated that they were satisfied with the telementoring sessions and there were no unexpected intraoperative occurrences. There were some logistical limitations including difficulties in scheduling of cases or the delay of cases.ConclusionsSurgical instruction by telementoring was shown to be feasible, practical, and successful, and was highly rated in this study by both the mentors and mentees. The currently utilized telementoring platform is thus an effective educational tool that can facilitate acquisition of surgical skills and assist with the conventional on-site surgical mentoring model.

Logistical considerations for establishing reliable surgical telementoring programs: a report of the SAGES Project 6 Logistics Working Group

Surgical telementoring programs (STMPs) as educational tools have consistently demonstrated success in the training of surgeons in a variety of surgical disciplines. The goal of an STMP is to train and educate practicing surgeons by improving or remediating surgical skills or assisting in the safe adoption of new procedures. STMPs may even have a role in assisting with recertification. In 2015, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched the SAGES Telementoring Initiative at the Project 6 Summit. Herein, we provide a report on the SAGES Project 6 Logistics working group and lay out a plan for the recommended logistical framework to carry out an STMP.

Dysphagia Due to an Esophageal Polyp After Gastric Bypass

Introduction: Hyperplastic inflammatory polyp (HIP) is an overgrowth of gastric mucosa associated with underlying chronic inflammation. Usually located in the gastric corpus and antrum, it has also been known to arise at the gastroesophageal (GE) junction. Case Description: We report a case of a large HIP located at the GE junction causing dysphagia in a patient who recently underwent a Roux-en-Y gastric bypass. The polyp was removed endoscopically with resolution of the patient’s symptoms. Discussion: We present an unusual case of HIP, the first such case in our experience, and report the successful restoration of oral intake in the patient.