Jennwood Chen

Dual Ring Wound Protector Reduces Circular Stapler Related Surgical Site Infections in Patients Undergoing Laparoscopic Roux-En-Y Gastric Bypass

BackgroundWhile there are various techniques to create the gastrojejunostomy during a laparoscopic Roux-en-Y gastric bypass (LRYGB), many surgeons prefer using a circular stapler. One drawback of this method, however, is the higher incidence of surgical site infections (SSIs). To investigate the effect of a dual ring wound protector on SSIs during LRYGB.MethodsIn April 2016, our bariatric surgical group implemented an intervention whereby a dual ring wound protector in conjunction with a conical EEA stapler introducer was used when creating the gastrojejunostomy. SSIs from pre- and post-intervention were compared using Fisher’s exact test. Only LRYGBs performed with a circular stapler were included in our analysis. Student’s t test and χ2 were used to compare pre- and post-intervention groups with respect to demographics and co-morbidities.ResultsBetween April 2015 and January 31st, 2017, our surgeons performed 158 LRYGBs using a circular stapler for the gastrojejunostomy. There were 84 patients (53%) in the pre-intervention group and 74 (47%) in the post-intervention group. The pre- and post-intervention groups were not statistically different. The SSI rate for the pre-intervention group was 9.5% while the SSI rate was 1.35% in the post-intervention group (p = 0.0371). The use of a dual ring wound protector for LRYGBs with circular stapled gastrojejunostomy was associated with an 86% relative risk reduction in SSIs.ConclusionUsing a dual ring wound protector in conjunction with a conical EEA introducer for LRYGBs with circular stapled gastrojejunostomy significantly decreased SSIs.

Adolescents and Bariatric Surgery: Techniques and Outcomes

Obesity has become an increasingly common problem in adolescent populations in the United States and worldwide. Although bariatric surgery has been offered to adolescents with morbid obesity for several decades, it remains controversial. Bariatric surgery is performed for adolescents with increasing frequency, and early data shows that, in experienced centers, adolescent bariatric surgery can be done safely with durable weight loss and resolution of obesity-related comorbidities. This chapter reviews the definition, demographics, and health implications of adolescent obesity, describes the most common adolescent bariatric surgical procedures and their outcomes, and outlines the key components of an adolescent bariatric surgical program.

Watchful waiting versus elective repair for asymptomatic and minimally symptomatic paraesophageal hernias: A cost-effectiveness analysis

OBJECTIVE To evaluate the decision of watchful waiting (WW) versus elective laparoscopic hernia repair (ELHR) for minimally symptomatic paraesophageal hernias (PEH) with respect to cost-effectiveness. BACKGROUND The current recommendation for minimally symptomatic PEHs is watchful waiting. This standard is based on a decision analysis from 2002 that compared the two strategies on quality-adjusted life-years (QALYs). Since that time, the safety of ELHR has improved. A cost-effectiveness study for PEH repair has not been reported. METHODS A Markov decision model was developed to compare the strategies of WW and ELHR for minimally symptomatic PEH. Input variables were estimated from published studies. Cost data was obtained from Medicare. Outcomes for the two strategies were cost and QALYs. RESULTS ELHR was superior to the WW strategy in terms of quality of life, but it was more costly. The average cost for a patient in the ELHR arm was 11,771 dollars while for the WW arm it was 2207. CONCLUSION This study shows that WW and ELHR both have benefits in the management of minimally symptomatic paraesophageal hernias.

Validation of a Laparoscopic Ferromagnetic Technology-based Vessel Sealing Device and Comparative Study to Ultrasonic and Bipolar Laparoscopic Devices

Introduction: Ferromagnetic heating is a new electrosurgery energy modality that has proven effective in hemostatic tissue dissection as well as sealing and dividing blood vessels and vascularized tissue. The purpose of this study was to evaluate a ferromagnetic-based laparoscopic vessel sealing device with respect to sealing and dividing vessels and vascularized tissue and to compare performance against current vessel sealing technologies. Materials and Methods: A laparoscopic vessel sealing device, Laparoscopic FMsealer (LFM), was studied for efficacy in sealing and dividing blood vessels and comparative studies against predicate ultrasonic, Harmonic Ace+(US), and/or bipolar, LigaSure 5 mm Blunt Tip and/or Maryland (BP), devices in vivo using a swine model and in vitro for comparison of seal burst pressure and reliability. Mann-Whitney and Student t test were used for statistical comparisons. Results: In division of 10 cm swine small bowel mesentery in vivo, the laparoscopic FMsealer [12.4±1.8 sec (mean±SD)], was faster compared with US (26.8±2.5 s) and BP (30.0±2.7 s), P<0.05 LFM versus US and BP. Blinded histologic evaluation of 5 mm vessel seals in vivo showed seal lateral thermal spread to be superior in LFM (1678±433 &mgr;m) and BP (1796±337 &mgr;m) versus US (2032±387 &mgr;m), P<0.001. In vitro, seal burst strength and success of sealing 2 to 4 mm arteries were as follows (mean±SD mm Hg, % success burst strength >240 mm Hg): LFM (1079±494 mm Hg, 98.1% success) versus BP (1012±463, 99.0%), P=NS. For 5 to 7 mm arteries: LFM (1098±502 mm Hg, 95.3% success) versus BP (715±440, 91.8%), P<0.001 in burst strength and P=NS in % success. Five 60 kg female swine underwent 21-day survival studies following ligation of vessels ranging from 1 to 7 mm in diameter (n=186 total vessels). Primary seal was successful in 97%, 99% including salvage seals. There was no evidence of postoperative bleeding at sealed vessels at 21-day necropsy. Conclusion: The Laparoscopic FMsealer is an effective tool for sealing and dividing blood vessels and vascularized tissue and compares favorably to current technologies in clinically relevant end points.

Coding for Laparoscopic Surgery

Laparoscopic approaches to conventional surgery are a fundamental technique in every general surgeon’s armamentarium. While the origins of laparoscopy dates back more than a century [1], the technique, as practiced today, is relatively new. That said, once introduced to the United States, the development of laparoscopy grew exponentially.