F. Brody

Recurrence after laparoscopic ventral hernia repair.

Background: Although the early results of laparoscopic ventral hernia repair have shown a low recurrence rate, there is a paucity of long-term data. This study reviews a single institutions experience with laparoscopic ventral hernia repair (LVHR). Methods: We carried out a retrospective analysis of all LVHR performed at the Cleveland Clinic Foundation from January 1996 to March 2001. Recurrence rates were determined by physical exam or telephone follow-up. Factors predictive of recurrence were determined using Cox regression. Results: Of 100 ventral hernias completed laparoscopically, 96 were available for long-term follow-up (average, 30 months; range 4–65). There were no deaths and major morbidity occurred in seven patients. Recurrences were identified in 17 patients. Nine recurrences occurred in the 1st postoperative year; however, hernia recurrence continued throughout the period of follow-up. Multivariate analysis showed that a prior failed hernia repair was associated with a more likely chance of another recurrence (65% vs 35%, odds ratio (OR) 3.6; p = 0.05) and that an increased estimated blood loss (106 cc vs 51 cc, OR 1.03; p = 0.005) predicted recurrence. Other variables, including body mass index (BMI) (32 vs 31 kg/m2, p = 0.38), defect size (115 cm2 vs 91 cm2; p = 0.23), size of mesh (468 cm2 vs 334 cm2, p = 0.19), type of mesh (p = 0.62), and mesh fixation (p = 0.99), did not predict recurrence. An additional 14 cases required conversion to an open operation, and seven of these cases (50%) had recurrence on long-term follow-up. Conclusion: Although LVHR remains the preferred method of hernia repair at our institution, this study documents a higher recurrence rate than many other short-term series. There results underscore the importance of long-term follow-up in assessing hernia surgery outcome.n

Outcome of laparoscopic splenectomy based on hematologic indication

Background: Laparoscopic splenectomy is the procedure of choice for elective splenectomy at the Cleveland Clinic Foundation. Although the literature clearly documents the technical feasibility and safety of laparoscopic splenectomy, little data exists concerning the results of this procedure based on the hematologic indication for splenectomy. We sought to examine the clinical experience with laparoscopic splenectomy in a single institution, with particular attention to morbidity and clinical outcomes based on hematologic disease process. Methods: This study retrospectively reviewed a consecutive series of laparoscopic splenectomies performed for nontraumatic, splenic pathology at the Cleveland Clinic Foundation from August 1995 to January 2001. Patient demographics, operative indications, morbidity, mortality, and clinical outcome were evaluated. Hematologic diagnostic groups were compared using Fisher’s exact tests and Wilcoxon rank-sum tests. Results: A total of 147 laparoscopic splenectomies were performed. Seven patients (5%) required conversion to open splenectomy. Indications for splenectomy included idiopathic thrombocytopenic purpura (ITP) in 65 patients, hematologic malignancy in 43 patients, autoimmune hemolytic anemia (AIHA) in 9 patients, thrombotic thrombocytopenic purpura (TTP) in 9 patients, splenomegaly in 5 patients, splenic cyst in 4 patients, splenic abscess in 3 patients, hereditary spherocytosis in 2 patients, splenic artery aneurysm in 2 patients, Felty’s syndrome in 1 patient, myelofibrosis in 1 patient, and other in 3 patients. Accessory spleens were identified in 20 patients (14%). Postoperative complications occurred in 23 (16%) patients. Patients with ITP had significantly shorter operation times (134 vs 163 min; p = 0.001), decreased estimated blood loss (126 vs 307 ml; p = 0.001), decreased length of hospital stay (2.8 vs 4.6 days; p < 0.001), and less chance of conversion (0 vs 7; p = 0.02) than patients with any other diagnosis. A mean follow-up period of 20 ± 14 months showed an 85% rate of remission for ITP, 89% for TTP, and 89% for AIHA. Patients with malignant disease had significantly larger spleens (822 vs 313 g; p < 0.001), more estimated blood loss (380 vs 168 ml; p = 0.04), and longer operative times (170 vs 142 min; p = 0.009), as compared patients treated for benign disease. However, the length of hospital stay (4.3 vs 3.6 days; p = 0.06) and complication rates (19% vs 14%; p = 0.08) were not significantly different between the two groups. Conclusions: When performed for ITP, laparoscopic splenectomy resulted in shorter operations, minimal blood loss, earlier discharge, no conversions, and excellent remission rates, as compared with other hematologic indications. Despite larger spleens, more blood loss, and longer operations in patients with hematologic malignancies, morbidity and length of hospital stay still were similar to those associated with benign indications for laparoscopic splenectomy. In conclusion, laparoscopic splenectomy is safe and efficacious for a multitude of benign and malignant hematologic indications, and our data compares favorably to those for open series.

Pancreatic complications following laparoscopic splenectomy

Background: Laparoscopic splenectomy (LS) has been widely accepted despite a paucity of outcome data. Therefore, we performed a review of LS to assess the pancreatic complications and outcomes associated with this procedure. Methods: Ninety-four splenectomies were performed for a variety of hematologic disorders. The patient was placed in the lateral position, and three or four trocars were used. Results: LS was completed successfully in 93 patients. One case was converted to an open splenectomy for suspected gastrotomy. Thirty of 32 patients with splenomegaly underwent successful LS. Fifteen patients (16%) had some evidence of pancreatic injury. Six patients had asymptomatic hyperamylasemia. An injury directly associated with an adverse outcome occurred in nine cases (9.5% overall); six patients had pancreatic collections, one had a pancreatic fistula, and two developed hyperamylasemia and pain altering the length of hospitalization. Four of these nine patients did not have elevated postoperative amylase levels and were readmitted with pancreatic complications. Conclusions: LS can be performed for most pathologic conditions. Pancreatic injury is the most common morbidity associated with LS. The detection of hyperamylasemia can alert the surgeon to a pancreatic injury and alter postoperative management.

Laparoscopic management and clinical outcome of emphysematous cholecystitis

Background: As opposed to acute, chronic, and acalculus cholecystitis, emphysematous cholecystitis (EC) is associated with significant morbidity and mortality. Only a few studies have specifically reviewed the operative management and clinical outcome of EC. This study documents the operative management and clinical outcome of EC at the Cleveland Clinic Foundation. Methods: Between January 1996 and June 1999, 18 consecutive patients underwent cholecystectomy for emphysematous cholecystitis at our institution. All charts were reviewed retrospectively, and patients undergoing concurrent procedures were excluded. Mean values ± standard deviation (SD) of the mean were calculated for patient demographics, preoperative white blood cell count (WBC), bilirubin, alkaline phosphatase, and length of hospital stay. Operative procedure (laparoscopic, converted, or open), preoperative imaging studies, operative time, ICU stay, morbidity, and mortality were reviewed. Results: Patients presented with a mean age of 53.4 years (range, 18-80) and a male/female ratio of 3.5 (14/4). There were no differences between groups in terms of patient demographics. Mean WBC on admission was 14.2 K/mL (range, 5.4-19.7). Mean alkaline phosphatase and total bilirubin were 115 U/L (range, 45-428) and 1.4 mg/dl (range, 0.5-3.4), respectively. Thirteen patients (72%) were completed laparoscopically, two patients (11%) were converted to an open procedure, and three patients (17%) had open surgery. Overall mean length of hospital stay was 5 days (range, 1-18). Two patients from the open group ultimately died 1 year later due to progression of preexisting illness. One of these patients had congestive heart failure and chronic renal failure; the other had metastatic malignant melanoma. None of the patients died in the immediate perioperative period. There were five complications (27.8%). Two patients presented with bleeding secondary to heparin and coumadin therapy. One developed sepsis, and another developed leakage from the cystic duct stump, necessitating an endoscopic retrograde cholangiopancreatogram (ERCP) with stent decompression. The fifth complication, ileus, required readmission 3 days postoperatively, but the patient responded to conservative management. Complications were evenly distributed between the three groups. There were two complications in the laparoscopic group, two in the open group, and one in the conversion group. All other patients were alive at the time of this publication. Conclusions: Using current techniques, patients with EC can be managed successfully utilizing laparoscopy. Morbidity and mortality appear to be slightly higher than published reports for acute, chronic, and acalculus cholecystitis. Conversion rates are comparable to patients with acute and chronic cholecystitis who undergo laparoscopic cholecystectomy. Based on these data, laparoscopic cholecystectomy should be considered the first-line treatment for patients with known or suspected EC.

Gastric Electrical Stimulation Significantly Increases Canine Lower Esophageal Sphincter Pressure

This study determined the effect of low-frequency and high-frequency gastric electrical stimulation (GES) on canine lower esophageal sphincter (LES) pressure and also evaluated the effect of such stimulation on neurohumoral factors that modulate LES pressure. Eight dogs were fitted with stimulation wires along the greater curvature of the stomach. A sleeve device measured LES pressure before, during, and after GES, and regulatory peptides were measured during fasting and after a meal. A consistent and significant rise in LES pressure was observed during GES, and it was sustained after GES was discontinued. Plasma concentration and area under the curve of pancreatic polypeptide, motilin, gastrin and neurotensin were not affected by GES. We conclude that acute low- and high-frequency GES significantly increases LES pressure. This effect may not be modulated by efferent vagal activity or release of regulatory peptides.

Laparoscopic lateral L4–L5 disc exposure

BackgroundThe anterior laparoscopic approach requires precarious dissection around the iliac vessels to expose the L4–L5 level. Furthermore, a retroperitoneal endoscopic approach to the L4–L5 level requires a technically demanding dissection to access the L5-S1 disc space. A unique lateral laparoscopic approach to the L4–L5 disc space allows concurrent access to the L5-S1 space while avoiding major dissection around the iliac vessels. This article describes this novel lateral approach and reviews the initial clinical outcomes.MethodsBetween January 1999 and April 2000, five patients underwent laparoscopic lateral L4–L5 disc exposure at the Cleveland Clinic Foundation. All charts were reviewed retrospectively. Mean values ±standard deviation were determined for patient demographics and operative characteristics. A standard fiveport laparoscopic technique was used. The sigmoid colon was retracted medially with an endoloop. The retroperitoneum was entered and the ureter and left iliac artery were retracted medially, whereas the psoas was retracted laterally. Fluoroscopy delineated the L4–L5 disc space allowing discectomy and cage insertion. Postoperatively, subjective patient satisfaction was obtained and radiologic evidence of fusion was assessed.ResultsAll five patients were males, with a mean age of 47.4±7 years and a body mass index of 30±6kg/m2. Four patients had an L4–L5 and L5-S1 fusion and one patient had an L4–L5 and L3–L4 fusion. Mean operative time was 349±32 min, with a mean blood loss of 210±74 cc. There were no intraoperative complications and no conversions, and postoperatively all patients were started on a clear liquid diet on postoperative day 1. The mean length of stay was 3.4±0.9 days. Patients returned to work in a mean of 12±7 weeks. All patients had evidence of fusion on their radiologic follow-up. Four patients were pain free, whereas one patient required intermittent narcotics at 1-year follow-up.ConclusionsFor multilevel fusions including the L4–L5 disc space, the lateral laparoscopic exposure is a safe and efficacious procedure allowing simultaneous access to multiple disc spaces while avoiding the sympathetic chain, ureter, and major vascular structures. The lateral approach affords excellent exposure for accurate deployment of the appropriate orthopedic hardware.

Gastric Electrical Stimulation Does Not Significantly Affect Canine Gastric Acid Secretion and 24-Hour Gastric pH

Gastric electrical stimulation (GES) was shown to improve symptoms in patients with gastroparesis. However, the underlying mechanisms remain unclear. This study assessed the influence of various patterns of GES on fasting and postprandial gastric acid secretion and 24-hr gastric pH. Eight healthy dogs were studied and we found that in the fasting state, low-frequency, long-pulse (6/12-cpm, 375-msec, 4-mA) GES at the proximal stomach significantly inhibited the secretion of gastric juice (P < 0.05). No such effect was observed during GES (6/12 cpm) at the distal stomach. In the postprandial period, low-frequency, long-pulse GES at both proximal and distal sites and at both frequencies did not significantly affect gastric acid secretion. High-frequency, short-pulse GES, investigated for obesity (21 Hz, 8 mA, and 250 μsec, with 2 secs on, 3 sec off), at the proximal and distal stomach did not significantly affect the 24-hr gastric pH profile. In conclusion, GES with various stimulation parameters, and at various sites, has little effect on gastric acid secretion. The clinical effects induced by GES at these parameters may not be related to their effect on gastric acid homeostasis.

An efficient technique for splenic pedicle retraction.

Laparoscopic splenectomy is an efficacious and well documented procedure. This advanced two-handed laparoscopic procedure is currently performed for a variety of hematologic malignancies and benign disorders. Currently, both anterior and lateral techniques are employed for laparoscopic splenic dissection. Regardless of approach, one of the final steps during this dissection entails ligation of the splenic pedicle. Depending on splenic anatomy, this step has a varying degree of difficulty. At the time of vascular ligation, the spleen remains attached only by its artery and vein. Without its attachments, the spleen can twist, wander, and flop throughout the left upper quadrant, making endovascular stapler application difficult. A thick splenic pedicle can also inhibit stapler application. Inappropriate application or wedging of the endovascular stapler across a fatty splenic pedicle may result in arterial or venous injuries, requiring conversion to an open procedure. A flexible 5 mm laparoscopic snake retractor (Genzyme Surgical Products, Tucker, GA, USA) enables easy retraction and ligation of the splenic hilum. When the lateral approach to splenectomy is used, the snake retractor is