H. Reza Zahiri

Laparoscopic Transversus Abdominis Release, a Novel Minimally Invasive Approach to Complex Abdominal Wall Reconstruction.

Background. Open abdominal wall reconstruction is used to repair complex abdominal wall hernias with contour abnormalities. We present a novel minimally invasive approach to address these types of defects, completed entirely laparoscopically. Methods. Three patients underwent laparoscopic abdominal wall reconstruction for complex hernias in August and September of 2015. Operative approach consisted of laparoscopic transversus abdominis components separation, defect closure, and wide mesh implantation in the retromuscular space. Results. Two males and one female with mean age and body mass index of 70 and 30.1, respectively, underwent a mean operation room time of 329 minutes. Estimated blood loss and length of stay were 91.7 cc and 4.7 days, respectively. No subcutaneous flaps were raised avoiding the need for subcutaneous drains. There were no perioperative complications. All of the subfascial drains were removed prior to patient discharge. On initial follow-up visit at 3 weeks, there was no evidence of wound complications, bulging, or hernia recurrences. Conclusion. Laparoscopic abdominal wall reconstruction with transversus abdominis release is a unique and feasible approach to complex abdominal wall defects with the potential to reduce pain, facilitate recovery, and decrease length of hospital stay for patients.

Patients are well served by Collis gastroplasty when indicated

Background: Debate persists over the impact of Collis gastroplasty (CG) on outcomes after anti reflux surgery. This study analyzed operative and quality of life (QOL) outcomes from one of the largest series of laparoscopic anti reflux surgery (LARS) with CG reported to date. Methods: A retrospective review was conducted to compare outcomes between patients undergoing LARS with CG versus without CG at two large centers with expertise in foregut surgery from October 2004‐December 2011 and July 2012‐September 2016. Demographic, perioperative, and QOL data were reviewed. Four validated surveys were used for QOL outcomes: reflux symptom index (RSI), gastroesophageal reflux disease health‐related QOL (GERD‐HRQL), laryngopharyngeal reflux health‐related QOL (LPR‐HRQL), and swallowing QOL (SWAL‐QL). Results: 480 patients consisted of 149 Collis vs 331 non‐Collis with mean age of 66.3 vs 58.9 years (P ≤ .001), BMI of 28.6 vs 29.7 (P = .040) and ASA score of 2.4 vs 2.2 (P = .005) were included. Collis patients underwent longer duration operations (133.2 mins vs 94.2; P ≤ .001) with greater duration of hospital stay (3.1 vs 1.8; P ≤ .001). Thirty‐day readmission and reoperation rates were equivalent between the two groups. Wound and non‐wound related complications were also comparable. After mean 12 month follow up, QOL assessment revealed significant improvements for all patients post‐surgery with comparable results between Collis and non‐Collis patients. Furthermore, CG did not contribute to post‐operative dysphagia, reflux, or a significant leak rate. Conclusion: Patients who require a CG to address a true short esophagus during LARS have comparable operative and QOL benefits as non‐Collis patients without added morbidity or mortality.

Updates on the Utility of Diagnostic Laparoscopy in the Management of Pneumatosis Intestinalis: An Improvement to the Current Treatment Algorithm

To the Editor: Pneumatosis cystoides intestinalis, more commonly pneumatosis intestinalis (PI), was first described by German anatomist Johann Georg Du Vernoi in 1783 during cadaveric dissections showing multiple obstructing gas-filled cysts within his specimen’s intestinal submucosa. PI has since become a secondary radiographic finding whose known pathophysiological mechanisms have been subdivided into 4 categories: mucosal disruption, increased mucosal permeability, pulmonary disease, and most commonly bowel necrosis. PI may present with symptoms including abdominal pain, constipation, diarrhea, weight loss, hematochezia, and tenesmus. Potential underlying conditions include chronic obstructive pulmonary disease, chronic immunosuppression, bowel obstruction, mesenteric ischemia, intestinal infarction, and toxic megacolon.

Laparoscopic Ventral and Incisional Hernia Repair with Closure of the Fascial Defect

Ventral and incisional hernia defects may be addressed by a variety of open or minimally invasive techniques. Laparoscopy is advantageous as it reduces wound morbidities, expedites return of bowel function, decreases hospital length of stay, and often offers superior cosmesis. Despite this, the vast majority of hernia repairs continue to be performed via traditional open surgical methods. In open hernia repair, recreation of the linea alba along with medializing of the rectus abdominis muscles to restore abdominal wall function is considered standard when possible. Yet, early experience with laparoscopic incisional hernia repair entailed simply bridging the primary fascial defect with mesh without closure. Recent evidence in favor of closure of the fascial defect suggests that it may reduce the rate of seroma formation, improve mesh integration, and reduce recurrence rates. Failure to close hernia defects may also lead to functional deficiencies and cosmetic dissatisfaction from bulging. This chapter overviews the approach at our center to laparoscopic ventral and incisional hernia repair with closure of the fascial defect.

Endoscopic and Laparoscopic Techniques of Minimally Invasive Components Separation for Abdominal Wall Reconstruction

Ventral and incisional hernia defects may be addressed by a variety of open or minimally invasive techniques. Laparoscopy has proven to be advantageous as it reduces wound morbidity, expedites return of bowel function, and decreases length of hospital stay. However, until recently, patients with a loss of domain or those having large hernia defects requiring components separation were relegated to open surgical techniques in order to address their complex defects. The following chapter overviews minimally invasive components separation with focus on relevant operative techniques and associated controversies.

Fundamentals of Prosthetic Materials for the Abdominal Wall

The use of mesh in the repair of fascial defects has served as a major advancement in the treatment of hernia disease. Contemporary studies show that prosthetic materials are used in the vast majority of ventral and inguinal hernias as data has consistently supported significant reduction in recurrence rates with their use. Innovative laparoscopic and robotic techniques have only expanded the use of mesh as surgeons can now introduce large prosthetic materials through small incisions to address larger and more complex defects. Concurrently, efforts to engineer the ideal mesh have resulted in a wide array of mesh products on the market. Despite some advances, the key question of what constitutes the ideal mesh continues to evade a definitive answer. Rather, it seems the ideal mesh is the one selected appropriately for the correct patient and operation. Despite this lack of clarity, numerous factors must be taken into consideration when selecting a prosthetic material for patients. These include patient comorbidity, hernia anatomy and surgical history, presence of wound contamination or prior wound complications, anatomic location in need of mesh deployment, defect size, and prevention of mesh contact with the viscera. The purpose of this chapter is to outline objective fundamentals of mesh selection and use for abdominal wall hernia repair to optimize outcomes.

Evidence-Based Optimal Fixation During Laparoscopic Hernia Repair: Sutures, Tacks, and Glues

Background Mesh fixation during ventral and inguinal hernia repair is a critical step which should aim to secure the mesh in place to prevent recurrence of hernia while promoting rapid ingrowth and reducing associated complications, pain, formation of adhesions, and mesh shrinkage. The purpose of this chapter is to provide an up-to-date and evidence-supported review of fixation products and techniques in laparoscopic ventral and inguinal hernia repair.