Esteban Varela

Single-incision laparoscopic cholecystectomy: initial evaluation of a large series of patients.

BackgroundFindings have shown that single-incision laparoscopic cholecystectomy (SILC) is feasible and reproducible. The authors have pioneered a two-trocar SILC technique at the University of Texas Southwestern. Their results for 100 patients are presented.MethodsFrom January 2008 to March 2009, 100 patients with symptomatic gallbladder disease underwent SILC through a 1.5- to 2-cm umbilical incision using a two-port (5-mm) technique. For nearly all the patients, a 30° angled scope was used. The gallbladder was retracted, with two or three sutures placed along the gallbladder. These sutures were either fixated internally or placed through the abdominal wall to obtain a critical view of Calot’s triangle. The SILC procedure was performed using standard technique with 5-mm reticulating or conventional laparoscopic instruments. The cystic duct and artery were well visualized, clipped, and divided. Cholecystectomy was completed with electrocautery, and the specimen was retrieved through the umbilical incision.ResultsIn this series, 80 women (85%) and 15 men (15%) with an average age of 33.8 years (range, 17–66 years) underwent SILC. Their mean BMI was 29.8 kg/m2 (range, 17–42.5 kg/m2), and 39% of these patients had undergone previous abdominal surgery. The mean operative time was 50.8 min (range, 23–120 min). The mean estimated blood loss was 22.3 ml (range, 5–125 ml), and 5% of the patients had an intraoperative cholangiogram. There were no conversions of the SILC technique. A two-trocar technique was feasible for 87% of the patients. For the remaining patients, either a three-channel port or three individual trocars were required. A SILC technique was used for 5% of the patients to manage acute cholecystitis or gallstone pancreatitis.ConclusionThe SILC technique with a two-trocar technique is safe, feasible, and reproducible. The operating times are reasonable and can be lessened with experience. Even complex cases can be managed with this technique. Excellent exposure of the critical view was obtained in all cases. The SILC procedure is becoming the standard of care for most of the authors’ elective patients with gallbladder disease. Clinical trials are warranted before the SILC technique is adopted universally.

Laparoscopic surgery is associated with a lower incidence of venous thromboembolism compared with open surgery.

Background:Although laparoscopy now plays a major role in most general surgical procedures, little is known about the relative risk of venous thromboembolism (VTE) after laparoscopic compared with open procedures. Objective:To compare the incidence of VTE after laparoscopic and open surgery over a 5-year period. Patients and Interventions:Clinical data of patients who underwent open or laparoscopic appendectomy, cholecystectomy, antireflux surgery, and gastric bypass between 2002 and 2006 were obtained from the University HealthSystem Consortium Clinical Database. The principal outcome measure was the incidence of venous thrombosis or pulmonary embolism occurring during the initial hospitalization after laparoscopic and open surgery. Results:During the 60-month period, a total of 138,595 patients underwent 1 of the 4 selected procedures. Overall, the incidence of VTE was significantly higher in open cases (271 of 46,105, 0.59%) compared with laparoscopic cases (259 of 92,490, 0.28%, P < 0.01). Our finding persists even when the groups were stratified according to level of severity of illness. The odds ratio (OR) for VTE in open procedures compared with laparoscopic procedures was 1.8 [95% confidence interval (CI) 1.3–2.5]. On subset analysis of individual procedures, patients with minor/moderate severity of illness level who underwent open cholecystectomy, antireflux surgery, and gastric bypass had a greater risk for developing perioperative VTE than patients who underwent laparoscopic cholecystectomy (OR: 2.0; 95% CI: 1.2–3.3; P < 0.01), antireflux surgery (OR: 24.7; 95% CI: 2.6–580.9; P < 0.01), and gastric bypass (OR: 3.4; 95% CI: 1.8–6.5; P < 0.01). Conclusions:Within the context of this large administrative clinical data set, the frequency of perioperative VTE is lower after laparoscopic compared with open surgery. The findings of this study can provide a basis to help surgeons estimate the risk of VTE and implement appropriate prophylaxis for patients undergoing laparoscopic surgical procedures.

Improved bariatric surgery outcomes for medicare beneficiaries after implementation of the medicare national coverage determination.

OBJECTIVE To compare the outcomes of Medicare beneficiaries who underwent bariatric surgery within 18 months before and after implementation of the national coverage determination (NCD) for bariatric surgery. DESIGN Analysis of the University HealthSystem Consortium database from October 1, 2004, through September 31, 2007. SETTING A total of 102 academic medical centers and approximately 150 of their affiliated hospitals, representing more than 90% of the nations nonprofit academic medical centers. PATIENTS Medicare and Medicaid patients who underwent bariatric surgery to treat morbid obesity. MAIN OUTCOME MEASURES Demographics, length of stay, 30-day readmission, morbidity, observed-to-expected mortality ratio, and costs. RESULTS A total of 3196 bariatric procedures were performed before and 3068 after the NCD. After the implementation of the NCD, the volume of gastric banding doubled and the proportion of laparoscopic gastric bypass increased from 60.0% to 77.2%. Patients who underwent bariatric surgery after the NCD benefited from a shorter length of stay (3.5 vs 3.1 days, P < .001) and lower overall complication rates (12.2% vs 10.0%, P < .001), with no significant differences in the in-hospital mortality rates (0.28% vs 0.20%). Among Medicare patients, there was a 29.3% reduction in the number of bariatric procedures performed within the first 2 quarters after the NCD. However, the number of procedures returned to baseline volume within 1 year and exceeded baseline volume after 2 years of the NCD. CONCLUSION The bariatric surgery NCD resulted in improved outcomes for Medicare beneficiaries without limiting access to care for individuals with medical disability.

Laparoscopic gastric ischemic conditioning prior to esophagogastrectomy: technique and review.

Esophagectomy can be associated with significant peri-operative morbidity such as leaks and strictures. Gastric ischemia as a result of gastric devascularization is one of the several contributing factors that may play a role in development of these complications. In an attempt to improve gastric tissue perfusion, a technique of gastric ischemic conditioning was proposed. For patients with esophageal cancer and at the time of laparoscopic staging, partial gastric devascularization is achieved by division of the left gastric vessels. Esophagectomy is subsequently performed several days after the gastric ischemic conditioning procedure. Our experience showed that preoperative ligation of left gastric vessels prior to esophagogastrectomy is technically feasible and safe and may decrease ischemic complications such as leaks and strictures.

Polyester Composite Mesh for Laparoscopic Paraesophageal Hernia Repair

Recent evidence supports the use of prosthetic reinforcement material during laparoscopic hiatal hernia repair; however, the search for appropriate prosthetic materials is still under investigation. In this article, the technical feasibility and the short-term outcomes of the use of polyester composite mesh for crural reinforcement was determined. A small series of patients with large paraesophageal hiatal hernias underwent laparoscopic repair with mesh (5 males; mean age = 62 ± 10 years; mean body mass index = 29 ± 1 kg/m2, and mean American Society of Anesthesiologists = 3 ± .4). There were no postoperative complications, deaths, or evidence of hernia recurrence documented by barium study at a median follow-up of 9 months. The use of the polyester composite mesh is technically feasible, has excellent intracorporeal handling characteristics, and holds suture readily. The short-term outcomes of the use of the polyester composite mesh for paraesophageal hernia repair reinforcement appeared to be favorable and are encouraging.

13. Minimally Invasive Esophagectomy

Minimally invasive esophagectomy (MIE) is an excellent treatment option in appropriately selected patients with benign or malignant esophagogastric pathology. For malignant disease, preoperative workup should include upper endoscopy with biopsy, endoscopic esophageal ultrasound, computed tomography scan of the chest and abdomen, and positron emission tomography. Our preferred technique for MIE is the laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy. This operation consists of laparoscopic gastric mobilization, construction of the gastric conduit to follow by thoracoscopic esophageal mobilization, resection of the esophageal specimen, and construction of a thoracoscopic esophagogastric anastomosis. MIE is safe, provides good oncologic outcomes, and advantages of the minimally invasive approach. Low perioperative mortality (<5%) can be achieved at centers performing high surgical volume.