John Romanelli

Single-port laparoscopic surgery: an overview

As innovation continues to move 21st century surgery forward, one of the emerging concepts is single-port or single-incision laparoscopic surgery. The fundamental idea is to have all of the laparoscopic working ports entering the abdominal wall through the same incision. The major drawback to such a surgical approach is that the concept of ‘‘triangulation’’ to which laparoscopic surgeons have grown accustomed in terms of both the instruments and scope is lacking. This, however, seems to be overshadowed by the increasing acceptability of in-line viewing, with the reemphasis on surgeons performing flexible endoscopy and on newer ideas such as natural orifice translumenal endoscopic surgery (NOTES). This very paradigm shift has energized both surgeons and industry to research important issues and develop new technology to make concepts such as single-port laparoscopic surgery become a reality. As part of the effort put forth by the technology committee of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) to inform surgeons about cutting edge technology, this article is published both to clarify understanding of the single-port laparoscopic surgery concept and to categorize the currently available tools and techniques.

Hand-assisted laparoscopic surgery in the United States: an overview.

Hand-assisted laparoscopic surgery (HALS) was developed to bridge the gap between open surgery and advanced laparoscopic surgery. Advantages of the hand in the abdomen include tactile feedback, the ability to palpate, blunt dissection, organ retraction, control of bleeding, and rapid organ removal. There are 3 commercially available devices in the United States, as well as a fourth in Europe and a fifth in Japan. Uses for HALS include procedures requiring intact specimen removal, complex laparoscopic procedures, preventing open conversion, and overcoming a technical obstacle. HALS procedures, such as esophagectomy, gastrectomy, hepatectomy, pancreatectomy, splenectomy, bariatric surgery, colectomy, nephrectomy, hysterectomy, and aortobifemoral bypass, have all been reported in the literature. Improvement in instrumentation, specifically with newer generation devices, will allow HALS to become more popular. We advocate the use of HALS specifically for laparoscopic colectomy, laparoscopic splenectomy for massive splenomegaly, and for living-related donor nephrectomy. Copyright

Laparoscopic surgery for abdominal aortic aneurysms Technical elements of the procedure and a preliminary report of the first 22 patients

AbstractBackground: Laparoscopic surgery for infrarenal aortic aneurysms is based on the principle of retroperitoneal exclusion of the aneurysm sac with aortofemoral or aortoiliac bypass. Methods: Of 22 patients who met the selection criteria, 20 successfully underwent laparoscopic aortic surgery at Morristown Memorial Hospital between February and October 1997. Technical elements and steps of this operation are described and illustrated. Results: Within 30 days of surgery, 2 patients died and 9 had various major and minor perioperative complications. As a group, the laparoscopic patients had less postoperative pain, needed fewer hours of ventilator support, had shorter intensive care unit (ICU) and hospital lengths of stay, and resumed diet and normal activity earlier than the historical norms for patients undergoing transabdominal or retroperitoneal aortic resections at the same institution. Conclusions: These early observations suggest that the laparoscopic treatment of infrarenal abdominal aneurysms may have several significant potential benefits. Long-term results and randomized prospective studies with patients matched by risk stratification will be needed to confirm these impressions.

Evaluation of Clinical Outcomes for Gastric Bypass Surgery: Results from a Comprehensive Follow-up Study

BackgroundLaparoscopic gastric bypass (LGB) surgery markedly increases percent excess weight loss (%EWL) and obesity-related co-morbidities. However, poor study quality and minimal exploration of clinical, behavioral, and psychosocial mechanisms of weight loss have characterized research to date.MethodsWe conducted a comprehensive assessment of n=100 LGB patients surveyed 2–3 years following surgery using standardized measures.ResultsMean %EWL at follow-up was 59.1±17.2%. This high level of weight loss was associated with a low rate of metabolic syndrome (10.6%), although medications were commonly used to achieve control. Mean adherence to daily vitamin and mineral supplements important to the management of LGB was only 57.6%, and suboptimal blood chemistry levels were found for ferritin (32% of patients), hematocrit (27%), thiamine (25%), and vitamin D (19%). Aerobic exercise level (R2=0.08) and pre-surgical weight (R2=0.04) were significantly associated with %EWL, but recommended eating style, fluid intake, clinic follow-up, and support group attendance were not. Psychosocial adjustment results showed an absence of symptomatic depression (0%), common use of antidepressant medications (32.0%), low emotional distress related to the post-surgical lifestyle (19.8±14.0; scale range 0–100), a high level of perceived benefit from weight loss in terms of functioning and emotional well-being (82.7±17.9; scale range 0–100), and a change in marital status for 26% of patients.ConclusionsAt 2–3 years following LGB surgery aerobic exercise, but not diet, fluid intake, or attendance at clinic visits or support groups, is associated with %EWL. Depression is symptomatically controlled by medications, lifestyle related distress is low, and marital status is significantly impacted.

Best Practice Updates for Surgical Care in Weight Loss Surgery

To update evidence‐based best practice guidelines for surgical care in weight loss surgery (WLS). Systematic search of English‐language literature on WLS in MEDLINE, EMBASE, and the Cochrane Library between April 2004 and May 2007. Use of key words to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence‐based models. Evidence‐based best practice recommendations from the most recent literature on surgical methods and technologies, risks and benefits, outcomes, and surgeon qualifications and credentialing. We identified >135 articles; the 65 most relevant were reviewed in detail. Regular updates of evidence‐based recommendations for best practices in WLS are required to address rapid changes in surgical techniques and patient demographics. Key factors in patient safety include surgical risk factors, type of procedure, surgeon training, and facility certification.

Natural orifice transluminal endoscopic surgery gastrotomy closure in porcine explants with the Padlock-G clip using the Lock-It system

BACKGROUND AND STUDY AIMS The success of transgastric surgery depends on reliable, secure closure of the gastrotomy. Few tests of the integrity of these closures have been published. This study aimed to determine whether a gastrotomy suitable for a NOTES procedure can be closed safely and effectively from within the stomach using a novel endoscopically placed device, the Padlock-G with the Lock-It delivery system. METHODS In a series of eight consecutive porcine gastric explants gastrotomy was performed in an ex vivo animal laboratory, the gastrotomy being closed with the Padlock-G followed by burst pressure testing after completion of the procedure. Gastrotomies were made in porcine explants. T-tags were placed on either side of the gastrotomy, and, with the T-tags pulled into an endoscopic cap, the Padlock-G was deployed. Gastric transmural pressure gradients at bursting of these closures were measured during insufflation of the explanted stomachs with a high-pressure insufflator. RESULTS The mean burst pressure of the gastrotomy closures was 68.0 mm Hg (range: 45 - 107 mm Hg). All of the stomachs ultimately ruptured at the closure sites, with the exception of the stomach that ruptured at the highest value (107 mm Hg), which ruptured at a site approximately 5 cm away from the closure site. All of the closures were accomplished in 30 minutes or less. CONCLUSIONS The Padlock-G clip provides a secure gastric closure for natural-orifice surgery.

Laparoscopic Aortic Aneurysm Resection

PURPOSE To describe a laparoscopic technique for resection of infrarenal abdominal aortic aneurysms (AAAs). METHODS The operation is based on the principle of retroperitoneal reinforced staple exclusion of the aneurysm sac with aortobifemoral or aortoiliac bypass using gas and gasless laparoscopic techniques. Patients were eligible for this procedure if their infrarenal AAAs (with or without iliac artery involvement) were considered appropriate for surgical resection; however, renal or other visceral arterial stenoses, aneurysmal disease requiring surgical treatment, and/or aneurysms of the hypogastric arteries excluded patients from laparoscopic AAA resection. RESULTS Of 31 candidates for this procedure, 9 were excluded owing to high surgical risk. Twenty-two patients (16 males; age range 62 to 88 years) were deemed appropriate for the laparoscopic procedure. Maximum aneurysm diameter ranged from 4.0 to 8.0 cm. The operation was completed successfully in 20 (91%) patients. Two (9%) deaths in high-risk patients admitted early to the study occurred within 30 days of surgery. The only major complication was an injured ureter, for which a nephrectomy was performed. Comparison to a historical cohort of conventionally treated patients showed that the study group needed less ventilator support, had shorter intensive care and hospital stays, and resumed diet earlier despite relatively prolonged anesthesia and aortic clamping times. CONCLUSIONS The laparoscopic approach to infrarenal AAAs appears feasible, with several potential advantages in low- and moderate-risk patients. Once the technique is optimized, randomized prospective studies will be needed to verify the apparent benefits demonstrated by these initial patients.

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non‐HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non‐HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non‐HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non‐HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Calcium oxalate supersaturation increases early after Roux-en-Y gastric bypass

BACKGROUND Calcium oxalate (CaOx) nephrolithiasis is an adverse effect of Roux-en-Y gastric bypass surgery (RYGB). It is unknown when the increased risk for CaOx stone formation occurs after surgery. METHODS We studied 13 morbidly obese adults undergoing RYGB with 24-hour urine collections at 4 weeks before and 1, 2, 4, and 6 months after surgery and computed CaOx relative saturation ratio (RSR) by EQUIL2. RESULTS Eleven patients were female, mean ± standard deviation age was 41.1 ± 7.2 years, and none had diabetes or chronic kidney disease. Median (interquartile range) urinary oxalate excretion increased linearly from 12.6 (10.9-37.9) mg/24 hr at baseline to 28.4 (14.4-44.0) mg/24 hr at 6 months (slope = .188; P = .005). CaOx RSR increased significantly at 2 months after RYGB (1.4 [1.2-2.4] to 4.9 [1.7-10.0]; P = .017) and rose throughout the study to 5.7 (3.7-12.2) at 6 months (P = .001) with a positive linear slope (.255; P = .001). One patient had critical CaOx supersaturation (RSR = 34.7) and severe hyperoxaluria (101.7 mg/24 hr) at 6 months after RYGB. Significant decreases over time were seen in urine volume and sodium and potassium excretion, but no changes were noted in urinary pH, calcium, magnesium, or citrate. CONCLUSIONS Our data suggest that CaOx RSR, and thus risk for nephrolithiasis, rises as early as 2 months after RYGB and increases gradually in the first 6 months, largely because of reduced urine volume and increased urinary oxalate excretion. Interventions to reduce CaOx RSR, such as adequate fluid intake and agents to bind enteric oxalate, need to be evaluated in patients at risk for nephrolithiasis after RYGB.

Gastrotomy Closure with the Lock-It System and the Padlock-G clip: A Survival Study in a Porcine Model

BACKGROUND AND STUDY AIMS The success of natural orifice surgery depends on secure closure of the transmural gut opening, so a rapid, secure, and easy-to-place closure method is desirable. Our aim was to determine whether a gastrotomy can be closed safely and effectively from within the stomach in a survival model by using a novel, endoscopically placed device: the Padlock-G system. PATIENTS AND METHODS This was a pilot study of 4 survival animals in an animal laboratory setting. Gastrotomies were made in the stomachs of laboratory swine, and the abdomen was explored by using a standard gastroscope. Gastrotomies were then closed by using the Padlock-G system. Survival for 2 or 6 weeks was the primary outcome measurement. Secondary outcomes included ease of use, visual assessment of closure integrity immediately and at necropsy, presence of adhesions, evidence of infection, and histologic appearance at the closure sites. RESULTS All animals thrived, ate normally, and gained weight. None developed fever, tachycardia, or signs of peritoneal irritation. Closure-site inspection at necropsy revealed excellent healing, with epithelial growth over the Padlock-G. There were no ulcers, serosal surfaces were tightly closed, and no defects could be seen. There were no signs of peritoneal inflammation, intra-abdominal adhesions, or gastric spillage. Histologic evaluation showed organizing granulation tissue with fibrosis, vascular proliferation, and mild chronic inflammatory infiltrate (i.e., scar). CONCLUSIONS The Padlock-G is easy to place, provides a durable closure, and allows survival animals to thrive without adverse sequellae. This device provides a suitable closure system for transgastric NOTES.