Eliezer Avinoach

Laparoscopic management of acute small bowel obstruction

BackgroundAs minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).MethodsFrom December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.ResultsPostoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.ConclusionsLaparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.

Laparoscopic Gastric Banding in Adolescents

Background: Adolescent obesity has undesirable short- and long-term effects. Laparoscopic adjustable gastric banding has been considered a procedure of choice for adolescent morbid obesity. We retrospectively evaluated our single-team banding experience in the adolescent population. Methods: We reviewed the medical and clinic records and conducted telephone questionnaire interviews, to evaluate the results of banding using the Swedish adjustable gastric band (SAGB®) in the 60 adolescents at our institution who had been followed ≥3 years. Results: An average of 39.5 months of follow-up has been conducted in the patients who have been followed ≥3 years. Mean age at the time of the operation was 16 years (9 to 18). 60% reported a family history of obesity. Associated co-morbidities included hypertension, diabetes, sleep apnea and asthma. Mean preoperative BMI was 43 (35-61) kg/m2. Mean postoperative BMI after 39.5 months follow-up was 30 (20-39) kg/m2. No co-morbidities have existed after the operation. 6 patients (10%) underwent band repositioning and 2 patients underwent band removal, due to slippage; 7 of the 8 slippages occurred with an earlier perigastric technique which transgressed lesser sac. There was no mortality. Average postoperative hospital stay was 24 hours. Conclusions: Gastric banding in adolescents is a safe, satisfactory and reversible weight reduction procedure.

Laparoscopic repair of large incisional hernias

Background: Traditional approaches to incisional hernias (IH)—particularly in cases with large fascial defects—are plagued by a significant recurrence rate as well as frequent wound infections. The laparoscopic repair of incisional hernias was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. Several years ago, we adopted the laparoscopic technique in our department and set out to appraise its touted advantages. Methods: During the years 1997–2000, 103 patients underwent laparoscopic IH repair with implanted Dual Gore-tex mesh. Forty percent of them were obese, and 41% had undergone more than one previous attempt at conventional repair. All patients were discharged home within 24–72 hs. Results: In three patients, the operation was converted to open surgery due to severe adhesions and technical difficulties. In two cases, inadvertent enterotomies were repaired laparoscopically, and since there was no major spillage, the repair was continued as planned, with no adverse consequences. Twelve patients underwent additional laparoscopic procedures at the initial operation. Two graft infections and four recurrences were observed during the 1–49 month follow-up period. Conclusions: Laparoscopic IH repair is technically feasible and safe in patients with large fascial defects as well as in obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence.

The effect of a high partial pressure of carbon dioxide environment on metabolism and immune functions of human peritoneal cells—Relevance to carbon dioxide pneumoperitoneum☆☆☆

OBJECTIVE Our purpose was to evaluate in vitro the effect of a high partial pressure of carbon dioxide environment used in laparoscopy on metabolic and immune response of various human peritoneal cells. STUDY DESIGN Polymorphonuclear leukocytes were obtained from 5 healthy volunteers, peritoneal macrophages were obtained from the effluent of 8 patients undergoing continuous ambulatory peritoneal dialysis, and human peritoneal mesothelial cell cultures were prepared from omentum derived from 5 patients undergoing elective surgery. The cells were exposed to a laparoscopy-like environment (1 atmosphere carbon dioxide and 0.2 atmosphere oxygen), to a control gas mixture (1 atmosphere helium and 0.2 atmosphere oxygen), or air for 3 hours. After exposure to gas mixtures, cell functions were tested at various recovery periods. RESULTS Three hours of exposure to a high partial pressure of carbon dioxide had no effect on viability of peritoneal macrophages and human peritoneal mesothelial cells, tested by trypan blue dye uptake and lactate dehydrogenase release. A high partial pressure of carbon dioxide decreased the mitochondrial dehydrogenases activity of peritoneal macrophages and human peritoneal macrophage cells by 60%, assayed by 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide reduction. High partial pressure of carbon dioxide blocked the superoxide release from activated polymorphonuclear leukocytes and the secretion of interleukin 1beta from stimulated peritoneal macrophages, and human peritoneal macrophage cells were decreased by 15% and 30% and the secretion of tumor necrosis factor-alpha from peritoneal macrophages was suppressed by 85%. Mitochondrial activity, polymorphonuclear leukocyte function, and interleukin 1beta and tumor necrosis factor-alpha secretion returned to normal after a recovery period of 12 to 24 hours, 4.5 hours, and 24 hours, respectively. In the control experiments exposure of cells to helium had no suppressive effect. CONCLUSIONS Exposure of cells to a high partial pressure of carbon dioxide environment suppresses the inflammatory and metabolic responses of peritoneal cells. We suggest that this suppressive effect may contribute to the low postsurgery adhesion formation and the reduction in postoperative pain observed in laparoscopy. Nevertheless, the suppression of the immune response should also be taken into account for operations involving a high risk of bacterial dissemination.

The use of laparoscopy in abdominal emergencies

Background: The purpose of this article is to describe our experience using laparoscopy in the management of emergent and acute abdominal conditions. Methods: Between March 1997 and November 2001, 277 consecutive minimally invasive procedures were performed for various nontrauma surgical emergencies. The indications for operation were nonspecific abdominal pain in 129 cases (46%), peritonitis in 64 cases (23%), small bowel obstruction in 52 cases (19%), complications after previous surgery or invasive procedures in 24 cases (9%), and sepsis of unknown origin in 8 cases (3%). Results: Laparoscopy obtained a correct diagnosis in 98.6% of the cases. In 207 patients (75%), the procedure was completed laparoscopically. An additional 35 patients (12.5%) required a target incision. The remaining 35 patients (12.5%) underwent formal laparotomy. The morbidity rate was 5.8%. No laparoscopy-related mortality was observed. Conclusions: For patients with abdominal emergencies, the laparoscopic approach provides diagnostic accuracy and therapeutic options, avoids extensive preoperative studies, averts delays in operative intervention, and appears to reduce morbidity.

Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery

BackgroundLaparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations.MethodsA retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery.ResultsLaparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures.ConclusionLaparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.

Major respiratory adverse events after laparascopic gastric banding surgery for morbid obesity.

BACKGROUND Laparoscopic adjustable gastric banding surgery has become one of the most common restrictive surgical procedures for treatment of morbid obesity worldwide. Although short-term respiratory complications are well known, long-term data is scarce. We investigated the manifestations of major pulmonary complications showed at least six months after the procedure. METHODS A retrospective cohort study was conducted at a tertiary university medical center in the five years period of 2006-2010. We included every patient who had had major respiratory complication who needed hospitalization, at least 6 months after laparoscopic adjustable gastric banding procedure. Demographic, pre-operative and post-operative clinical data were collected. We documented respiratory symptoms, results of physical examination, pulmonary function tests, and imaging as well as therapies given and outcome. RESULTS Out of 2100 patients who underwent LAGB, thirty subjects, mean age of 45.7 (range 29-64) with an equal number of males and females were included. Mean interval between operation and onset of respiratory symptoms was 51.5 months (range 10-150 months). All had dyspeptic complaints which included: regurgitation, fullness after meals, dysphagia and food aspiration with esophageal dilatation. Major respiratory complications included aspiration pneumonia (19) including pulmonary abscess (4) and empyema (2), exacerbation of asthma (3) and hemoptysis (1). Additionally we documented the emergence of chronic diseases such as interstitial lung disease (5) and bronchiectasis (3). One patient developed acute respiratory distress syndrome due to aspiration pneumonia and eventually died in the intensive care unit. The main mode of therapy was deflation of the gastric band. Those who refused to deflate or remove the gastric banding continued to suffer from dyspeptic and respiratory symptoms including recurrent pulmonary abscess. CONCLUSION Although laparoscopic adjustable gastric banding surgery has few short-term risks and is highly effective at achieving weight reduction, we found an increased risk for major respiratory complications in the long-term period. The obesity epidemic and the increased use of surgical techniques to treat obesity will most likely lead to an increase in the incidence of long-term post-operative respiratory complications. This entity is probably under-reported and needs further research into how to reduce its incidence and morbidity.

Presentation and management of port disconnection after laparoscopic adjustable gastric banding

AimLaparoscopic adjustable gastric banding (LAGB) is a common and effective minimally invasive procedure in the treatment of morbid obesity. Port and connection tube complications are rarely reported. The aim of this study was to find presenting signs and predictors of tube disconnection from the access port that allow prompt diagnosis and appropriate treatment.Patients and methodsA retrospective chart review was performed on the 29 patients who underwent 31 laparoscopic reconnections of the connecting tube following LAGB during a 10-year period.ResultsPresenting signs were sudden lower-abdominal pain and free food passage following by weight gain and inability for band adjustment. Additional imaging was used to confirm diagnosis in the first three patients. Diagnostic laparoscopy for suspected acute appendicitis found tube disconnection from the port in one patient. Laparoscopic reconnection was successful in all patients. Access port exchange was done in 23 cases. Two patients had recurrent port disconnection. Band exchange was performed after second port reconnection.ConclusionSudden onset of flank or abdominal pain, free eating, weight gain, and inability to adjust the band are signs of port disconnection after LAGB. Education and information for medical staff and patients can help in early recognition of this complication and avoid unnecessary investigations.