Gernot Köhler

Meta-analysis of randomized trials comparing nonpenetrating vs mechanical mesh fixation in laparoscopic inguinal hernia repair.

BACKGROUND Evidence for open groin hernia repair demonstrates less pain with bioglue mesh fixation compared with invasive methods. This study aimed to assess the short- and long-term effects of laparoscopic groin hernia repair with noninvasive and invasive mesh fixation. DATA SOURCES A systematic review of MEDLINE, CENTRAL, and OpenGrey was undertaken. Randomized trials assessing the outcome of laparoscopic groin hernia repair with invasive and noninvasive fixation methods were considered for data synthesis. Nine trials encompassing 1,454 patients subjected to laparoscopic hernia repair with mesh fixation using biologic or biosynthetic glue were identified. Short-term data were inadequate for data synthesis. Chronic pain was less frequently reported by patients subjected to repair with biologic glue fixation than with penetrating methods (odds ratio .46, 95% confidence interval .22 to .93). Duration of surgery, incidence of seroma/hematoma, morbidity, and recurrence were similar. CONCLUSIONS Laparoscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence. Longer term data on recurrence are necessary.

Small bowel obstruction after TAPP repair caused by a self-anchoring barbed suture device for peritoneal closure: case report and review of the literature

IntroductionTransabdominal preperitoneal hernioplasty (TAPP) is a common procedure for groin hernia repair in adults. The peritoneal closure after mesh placement can be performed in various ways. In any case, thorough closure is recommended to avoid mesh exposure to the viscera with the risk of adhesions and bowel incarceration into peritoneal defects. Postoperative intestinal obstructions can mainly occur due to adhesions or bowel herniation through peritoneal defects into the dissected preperitoneal space. Incarcerations can also occur as a consequence of trocar site herniation.Results and conclusionRecently barbed self-anchoring knotless suturing devices are frequently used for peritoneal closure. The correct handling of such sutures is crucial to avoid potential complications. Despite of accurate management, bowel adherence and injuries or volvulus can occur.MethodsWe present an unusual case of a postoperative small bowel obstruction owing to strained adhesions and ingrowth between a small bowel segment and a polyglyconate unidirectional self-anchoring barbed suture device. Medline and PudMed databases were searched using the below-mentioned keywords and the literature on efficacy and safety of barbed sutures for peritoneal closure is reviewed as well as the usage of such devices in other fields of surgery.

Comparison of a standard CO2 pressure pneumoperitoneum insufflator versus AirSeal™: study protocol of a randomized controlled trial

BackgroundAirSeal™ is a novel class of valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and carbon dioxide (CO2) recirculation during laparoscopic surgery. Comparison data to standard CO2 pressure pneumoperitoneum insufflators is scarce. The aim of this study is to evaluate the potential advantages of AirSeal™ compared to a standard CO2 insufflator.Methods/DesignThis is a single center randomized controlled trial comparing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair with AirSeal™ (group A) versus a standard CO2 pressure insufflator (group S). Patients are randomized using a web-based central randomization and registration system. Primary outcome measures will be operative time and level of postoperative shoulder pain by using the visual analog score (VAS). Secondary outcomes include the evaluation of immunological values through blood tests, anesthesiological parameters, surgical side effects and length of hospital stay. Taking into account an expected dropout rate of 5%, the total number of patients is 182 (n = 91 per group). All tests will be two-sided with a confidence level of 95% (P <0.05).DiscussionThe duration of an operation is an important factor in reducing the patient’s exposure to CO2 pneumoperitoneum and its adverse consequences. This trial will help to evaluate if the announced advantages of AirSeal™, such as clear sight of the operative site and an exceptionally stable working environment, will facilitate the course of selected procedures and influence operation time and patients clinical outcome.Trial registrationClinicalTrials.gov NCT01740011, registered 23 November 2012.

Magnetic Resonance–Visible Meshes for Laparoscopic Ventral Hernia Repair

Background and Objectives: We aimed to evaluate the first human use of magnetic resonance–visible implants for intraperitoneal onlay repair of incisional hernias regarding magnetic resonance presentability. Methods: Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance–visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces. Results: We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance–visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm2 vs 225 cm2; mean reduction of mesh area, 35 cm2; P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm2 vs 190 cm2; mean reduction of mesh area, 8 cm2; P < .001). Conclusion: The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.

Laparoscopic versus Open Obesity Surgery: A Meta-Analysis of Pulmonary Complications

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease

BackgroundEndoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect.MethodsThe study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1–4 using Hill’s classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05.ResultsA significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly.ConclusionsThe GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.

Magnetic resonance visible 3-D funnel meshes for laparoscopic parastomal hernia prevention and treatment

SummaryBackgroundFunnel mesh implants can be used for both prevention and repair of parastomal hernia (PSH). We aimed to prove the practice of such implants as well as the magnetic resonance (MR) presentability in humans.MethodsFive patients were surgically treated for laparoscopic PSH prevention, and five patients underwent laparoscopic repair of manifest and symptomatic PSH with iron-loaded 3-D funnel meshes in an intraperitoneal onlay technique. MR investigation was performed on postoperative day 7 to assess mesh delineation, and additionally 6 and 12 months postoperatively to evaluate hernia recurrences and biocompatibility of mesh integration.ResultsWe could demonstrate precise mesh depiction and delineation with MR in all 10 cases, as well as accurate assessment of the surrounding tissue. No funnel alterations and no functional change of the stoma bowel patency occurred due to the tightly fitting funnel implant. We documented no mesh-related complications, no PSH formation, and no stoma prolapse occurrence during the follow-up period of 1 year comprising all ten cases.ConclusionThe pilot use of a new method of MR investigation using a mesh with enhanced signal through the addition of iron particles into the polyvinylidene fluoride base material provides detailed mesh depiction. Furthermore, funnel mesh implantation seems to offer a safe and promising surgical alternative for both PSH prevention and treatment.

Volume and methodological quality of randomized controlled trials in laparoscopic surgery: assessment over a 10-year period

BACKGROUND Measures have been taken to improve methodological quality of randomized controlled trials (RCTs). This review systematically assessed the trends in volume and methodological quality of RCTs on minimally invasive surgery within a 10-year period. DATA SOURCES RCTs on minimally invasive surgery were searched in the 10 most cited general surgical journals and the 5 most cited journals of laparoscopic interest for the years 2002 and 2012. Bibliometric and methodological quality components were abstracted using the Scottish Intercollegiate Guidelines Network. The pooled number of RCTs from low-contribution regions demonstrated an increasing proportion of the total published RCTs, compensating for a concomitant decrease of the respective contributions from Europe and North America. International collaborations were more frequent in 2012. Acceptable or high quality RCTs accounted for 37.9% and 54.4% of RCTs published in 2002 and 2012, respectively. Components of external validity were poorly reported. CONCLUSIONS Both the volume and the reporting quality of laparoscopic RCTs have increased from 2002 to 2012, but there seems to be ample room for improvement of methodological quality.

Single-Port Parastomal Hernia Repair by Using 3-D Textile Implants

Background: Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall. Methods: We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications. Results: From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively. Conclusion: We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Early protective ileostomy closure following stoma formation with a dual-sided absorbable adhesive barrier

SummaryBackgroundUsually, a temporary and diverting ileostomy is reversed not earlier than 8 weeks because of adhesions and edema along with vulnerability of the intestinal wall. We aimed to evaluate whether early closure of loop ileostomy during index admission using an antiadhesive bioabsorbable membrane is feasible and safe.MethodsWe included all patients undergoing ileostomy formation due to conventional or laparoscopy-assisted colorectal resections and stoma closure within 2 weeks using a dual-sided film between January 2011 and June 2012. Evaluation comprised patients’ demographic and disease characteristics, with objective to assess the rate and time interval of planned early stoma closure and length of hospital stay. Complications were divided related to stoma formation and closure. Follow-up data were collected by defined oncological aftercare.ResultsA total of 14 patients with a median age of 66 years were included. Median length of hospital stay was 27 days (range, 19–34 days), time between stoma formation and closure was 10 days (range, 8–14 days), and time of discharge was 8 days (range, 6–10 days) after stoma closure. Two complications related to stoma formation occurred in the form of one parastomal hernia and one wound infection. Complications related to stoma closure occured in five patients—one small bowel anastomotic leak in one patient and incisional hernias at stoma site in four patients.ConclusionEarly ileostomy closure at index admission using an adhesive barrier appears to be a safe alternative to traditional closure.