Keith W. Millikan

Complications of laparoscopic cholecystectomy: A national survey of 4,292 hospitals and an analysis of 77,604 cases

Complications of laparoscopic cholecystectomy were evaluated by a survey of surgical department chairpersons at 4,292 US hospitals. The 77,604 cases were reported by 1,750 respondents. Laparotomy was required for treatment of a complication in 1.2% of patients. The mean rate of bile duct injury (exclusive of cystic duct) was 0.6% and was significantly lower at institutions that had performed more than 100 cases. Bile duct injuries were recognized postoperatively in half of the cases and most frequently required anastomotic repair. Intraoperative cholangiography was practiced selectively by 52% of the respondents and routinely by 31%. Bowel and vascular injuries, which occurred in 0.14% and 0.25% of cases, respectively, were the most lethal complications. Postoperative bile leak was recognized in 0.3% of patients, most commonly originating from the cystic duct. Eighteen of 33 postoperative deaths resulted from operative injury. These data demonstrate that laparoscopic cholecystectomy is associated with low rates of morbidity and mortality but a significant rate of bile duct injury.

Incisional hernia repair

Incisional ventral hernias are a common problem encountered by surgeons, with over 100,000 repairs being performed annually in the United States. Although many predisposing factors for incisional ventral hernia are patient-related, some factors such as type of primary closure and materials used may reduce the overall incidence of incisional ventral hernia. With the advent of prosthetic meshes being used for incisional ventral hernia repair, the recurrence rate has dropped to approximately 10%. More recently, with the development of prosthetic mesh that is now safe to place intraperitoneally, the recurrence rate has dropped to under 5%. The current controversies that exist for incisional ventral hernia repair are which approach to use (open versus laparoscopic) and what type of fixation (partial- versus full-thickness abdominal muscular/fascial wall) is necessary to stabilize the position of the mesh while tissue ingrowth occurs. During the next decade the answers to these controversies should be available in the surgical literature.

INVASIVE THERAPY OF METASTATIC COLORECTAL CANCER TO THE LIVER

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

The management of hernia. Considerations in cost effectiveness.

Approximately 700,000 herniorrhaphies are performed annually in the United States for primary, recurrent, and bilateral inguinal hernias. This article describes the components of cost regarding the approach and management of groin hernias. The trends toward outpatient procedures, regional anesthetic agents, and early return to work are analyzed. The common types of repair are compared with reference to recurrence and complication rates. The advances and results of laparoscopic hernia are reviewed. In summary, a cost-effective approach for the management of inguinal hernias is presented that could reduce the yearly cost of hernia repair by hundreds of millions of dollars.

The impact of operative timing on outcomes of appendicitis: a National Surgical Quality Improvement Project analysis

BACKGROUND Surgery is indicated for acute uncomplicated appendicitis but the optimal timing is controversial. Recent literature is conflicting on the effect of time to intervention. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Project dataset for patients undergoing laparoscopic and open appendectomy between 2007 and 2012. Logistic regression was used to evaluate 30-day morbidity and mortality of intervention at different time periods, adjusting for preoperative risk factors. RESULTS A total of 69,926 patients undergoing appendectomy were identified. Groups were divided by time to intervention: group 1, less than 24 hours (n = 55,839; 79.9%); group 2, 24 to 48 hours (n = 13,409; 18.6%); and group 3, greater than 48 hours (n = 1,038; 1.5%). After adjustment, the risk of complication remained increased for group 3 versus group 1 or 2 (odds ratio 1.66, 95% confidence interval 1.34 to 2.07). CONCLUSIONS These data demonstrate equivalent outcomes between time to appendectomy of less than 24 and 24 to 48 hours. There was a 2-fold increase in complication rate for patients delayed longer than 48 hours.

Survival after repeat hepatic resection for recurrent colorectal hepatic metastases.

BACKGROUND This is a retrospective clinical study done to examine survival of patients undergoing repeat hepatic resection for recurrent colorectal hepatic metastases. METHODS The records of 131 patients undergoing hepatic resection for metastatic colorectal cancer were reviewed. Curative resection was performed in 107 of these patients. Thirty-one experienced recurrences confined to the liver. Thirteen (13 of 107, 12%) of them underwent resection and make up the study population. RESULTS The eight men (62%) and five women (38%) had a median age of 60 years (range, 32 to 75 years). In 30% of patients recurrence developed near the original resection site. In 70% the recurrences were remote from the original site. The patients underwent a total of six wedge resections, two left lateral segmentectomies, three right lobectomies, and two trisegmentectomies. Average blood loss was 2995 cc; average hospital stay was 17.2 days. Morbidity was 23% (3 of 13); mortality was 8% (1 of 13). Four patients died of recurrent disease, with a mean disease-free survival of 9.7 months (median, 7.5 months; range, 3 to 21 months) and mean total survival of 39 months (median, 24 months; range, 8 to 99 months). One of these patients had a second recurrence resected at month 21 and lived an additional 78 months. Seven patients were alive with no evidence of disease, with a mean follow-up time of 34.9 months (median, 14 months; range, 1 to 186 months). Actual 5-year survival was 23% (3 of 13). Actual disease-free 5-year survival was 15% (2 of 13). CONCLUSIONS In properly selected patients morbidity, mortality, and survival after repeat resection are similar to those after initial resection.

Abdominal wall reconstruction: a case series of ventral hernia repair using the component separation technique with biologic mesh

BACKGROUND Sixty-eight consecutive patients from October 2008 until February 2012 were selected for this retrospective review. METHODS A midline fascial closure with component separation was completed using biologic mesh onlay in all cases. Recurrence rates of the hernias, complication rates, patient satisfaction, and time to return to work/normal activities were investigated. RESULTS The recurrence rate was 1.5% (n = 65) with ongoing follow-ups (mean = 20 months). The average age was 57 years, and the average body mass index was 36 kg/m(2) (range 22 to 60). The average hernia defect was 20 cm (range 12 to 26) transversely. Wound infection and/or breakdown occurred in 32%, and seroma formation occurred in 9% of patients. Patient satisfaction was 3.63 of 4. The average time to return to work/normal activities was 16 weeks (range 1 to 76 weeks). CONCLUSIONS Large complex ventral hernias can be reliably repaired using the component separation technique. The short-term recurrence rate is significantly reduced in this case series using a biologic mesh onlay.

Superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy

PURPOSE: This article describes a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy. METHODS: A retrospective case review was performed. RESULTS: Data continue to grow regarding safety and technical feasibility of laparoscopic-assisted colectomy. As this minimally invasive alternative to open colonic resection becomes more popular, it is inevitable that information on benefits and complications associated with it will continue to expand. We report a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted colon resection. To our knowledge, this represents a complication of laparoscopic colon resection not previously reported in literature. CONCLUSION: Careful patient selection for this procedure is important. Additionally, the incision for extracorporeal resection and anastomosis in laparoscopic-assisted colectomy must be planned appropriately and carefully monitored intraoperatively to avoid potential complication of vascular trauma leading to mesenteric vein thrombosis.

The survival of stage III gastric cancer patients is affected by the number of lymph nodes removed

BACKGROUND Lymph node (LN) removal has been an important component in surgical treatment of gastric cancer. However, it is not clear whether the number of lymph nodes resected affects patient survival. METHODS We retrospectively reviewed the records of 147 patients with adenocarcinoma of the stomach who had undergone gastrectomy with curative intent between 1992 and 2001. Patients were divided into two groups: group I patients had < or =15 (n=124) and group II patients had >15 (n=23) LN reported. RESULTS The two groups were similar in age, gender distribution, and tumor locations. Group II patients had more advanced tumor, node, and overall staging. The median survival was 23.0 and 31.8 months for groups I and II, respectively. In stage III patients, median survival was 14.4 months for group I and 33.8 months for group II (P=.006). Group II patients also had more proximal lesions (P<.001) and a decreased positive to removed LN ratio (P=.014). CONCLUSION For stage III disease, removal of >15 LN appears to contribute to a considerable survival advantage. Because extended lymphadenectomy will most reliably allow >15 LN removed and add no operative morbidity and mortality, we strongly recommend it be considered in curative resections of gastric cancer.

The impact of laparoscopic cholecystectomy on the operative experience of surgical residents

SummaryThe impact of laparoscopic cholecystectomy (LC) on the operative experience of surgical residents was assessed in a series of 787 cholecystectomies. During an initial 18-month period, residents participated in LC as operating surgeon and as first assistant or camera operator in 33% and 97% of cases, respectively. Operative time, cholangiography rate, conversion rate, and complications were not adversely affected by resident operators. Residents performed 87% of concurrent planned open cholecystectomies (OC). In comparison to the 6 months preceding LC: (1) The mean number of resident OCs decreased significantly while the total number of resident cholecystectomies was unchanged; (2) the proportion of OCs performed by PGY5 residents significantly increased at the expense of junior resident cases. LC can be safely integrated into surgical resident training by standard methods as for open procedures. Although resident operative experience has been redistributed, initial experience does not suggest that qualification in open biliary surgery has been compromised.