Mehmet Ali Yerdel

Effect of Single-Dose Prophylactic Ampicillin and Sulbactam on Wound Infection After Tension-Free Inguinal Hernia Repair With Polypropylene Mesh: The Randomized, Double-Blind, Prospective Trial

ObjectiveTo assess the value of single-dose, intravenous, prophylactic ampicillin and sulbactam (AS) in the prevention of wound infections during open prosthetic inguinal hernia repair by a double-blind, prospective, randomized trial. Summary Background DataThe use of antibiotic prophylaxis during open prosthetic inguinal hernia surgery is controversial, and no prospective trial has been conducted to examine this issue. MethodsPatients undergoing unilateral, primary inguinal hernia repair electively with the Lichtenstein technique using polypropylene mesh were randomized to receive 1.5 g intravenous AS before the incision or an equal volume of placebo according to a predetermined code of which the surgeons were unaware. Patients with recurrent, femoral, bilateral, giant, or incarcerated hernias or any systemic diseases were excluded. Age, sex, body mass index, American Society of Anesthesiologists score, type of hernia, type of anesthesia, duration of surgery, and use of drains were recorded. Infection was defined according to the criteria of Centers for Disease Control. Patients were evaluated 1 week, 1 month, 6 months, and 1 year after surgery by an independent surgeon. All complications were recorded. Results were assessed using chi-square, Fisher’s exact, and Student t tests as appropriate. ResultsBetween September 1996 and July 1998, 280 patients (140 AS, 140 placebo group) entered the protocol. Four patients from the AS group and seven from the placebo group were excluded because of inadvertent antibiotic administration or follow-up problems. Groups were well matched for all the variables studied and postoperative complications, excluding wound infections, which occurred at a rate of 0.7% in the AS group and 9% in the placebo group (P = .00153). Twelve patients in the placebo group developed wound infections, requiring five repeat hospital admissions in three patients. These three patients suffered deep infections reaching the graft, which resulted in graft loss in two. The single infected patient in the AS group had his graft removed as well because of deep persistent infection. ConclusionsThis study documented a significant (10-fold) decrease in overall wound infections when single-dose, intravenous AS was used during Lichtenstein hernia repair. Deep infections and wound infection-related readmissions were also reduced by the use of AS. Proponents of mesh repairs may therefore be advised to use prophylactic single-dose intravenous antibiotic coverage in the light of the results of this trial. AS proved to be an effective antimicrobial agent.

Direct trocar insertion versus veress needle insertion in laparoscopic cholecystectomy

BACKGROUND Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. The safety of direct disposable shielded trocar insertion for the creation of pneumoperitoneum was assessed by comparing with Veress needle insertion during laparoscopic cholecystectomy (LC). METHODS One thousand five hundred patients undergoing LC with pneumoperitoneum were included in this study. In 470 patients the Veress needle insertion technique was used, and in 1,030 patients direct trocar insertion technique was used. Patients having indications for open trocar insertion were excluded from the study. RESULTS Complication rate was significantly higher in the Veress needle group (14% versus 0.9%; P <0.01), and the two major complications, gastric perforation and iliac artery laceration, were also encountered in this group. CONCLUSIONS Our results suggest that with a lower complication rate, direct insertion of the disposable trocar is a safe alternative to Veress needle insertion technique for the creation of pneumoperitoneum. Such an approach has further advantages such as less cost/instrumentation and rapid creation of pneumoperitoneum.

REPAIR OF MIDLINE INCISIONAL HERNIAS USING POLYPROPYLENE GRAFTS

We report herein our results of routinely performing tension-free repair for midline incisional hernias larger than 3 cm using a woven polypropylene graft between January 1990 and December 1995. Included in this study were 45 patients, 34 (73.1%) of whom had previously undergone a primary repair which had failed. The follow-up period ranged from 3 to 56 months with a mean of 36 months. Only one patient (2.2%) suffered a recurrence of the hernia. Although three (6.6%) developed a wound infection, one (2.2%) developed a wound sinus, and two (4.4%) developed wound seroma, none of these complications required removal of the graft. The findings of this study led us to conclude that Prolene grafts could be used as routine prosthetic material in the repair of incisional hernias. Moreover, during the follow-up period we observed that the modifications we made in the operative technique had a significantly positive effect on the outcome of the patients.

Laparoscopic repair of an incarcerated bochdalek hernia in an elderly man

Congenital posterolateral diaphragmatic defects, such as Bochdalek hernias (BHs), usually present during the neonatal period with respiratory symptoms and are associated with significant mortality (1). However, a subset of patients with BHs may remain asymptomatic during childhood, and the condition may present as a surgical emergency in adulthood (2). Surgical repair of the defect is the recommended therapy for all patients with BHs, regardless of the presence of symptoms (3). Traditionally, the repair of diaphragmatic defects has been performed via laparotomy or thoracotomy, but the use of laparoscopy has challenged the use of these traditional procedures. However, the laparoscopic management of incarcerated BH is rarely reported. In the present paper, we report the case of a patient who presented with a partial colonic obstruction that was caused by an incarcerated transverse colon through a Bochdalek defect and treated using a laparoscopic approach.

Surgical Treatment of Symptomatic Cavernous Hemangiomas of the Liver

Abstract Background: Elective surgery for liver hemangiomas is still controversial. Material and Methods: Twenty-one patients, all symptomatic, underwent surgery for liver hemangiomas between August 1986 and June 2001. The primary indications for surgery were abdominal pain in 12 patients, pain and enlargement in 4, bleeding after needle biopsy in 1 and diagnostic uncertainty and suspicion of malignancy in 4. Results: Enucleation was the choice of operation in 18 patients. Hospital mortality and morbidity were 0% and 9.52 % respectively. Mean follow-up period was 58.55 months (2-180). Mean hospitalization time was 15.6 days (8-75) and mean transfusion requirement was 2.1 units (0-18) of erythrocyte suspension. The median largest dimension of the major lesions was 12.71 cm (2-30). Conclusion: Elective surgery is indicated in a small subset of patients with hemangiomas because of abdominal pain, enlargement, diagnostic uncertainty and bleeding after needle biopsy. The results of surgery without any mortality and minimal morbidity are safe and effective. Enucleation is the preferred operation and can be performed rapidly and safely.

Enucleation of centrally located giant hepatic hemangioma: report of two cases.

Two centrally located giant hepatic hemangiomas were referred with severe pain, one of which had a protruding abdominal mass was listed for transplantation at another center. Tumors were 35 and 30 cm at their longest diameter. One was centrally located involving the hilum and segments VI/VII and II/III were partially spared. Volumetric analysis and imaging suggested enucleation is feasible if the left lateral segment and the right posterior sector are left intact. Operation was straightforward except few breaks in enucleation technique in an effort to secure the venous drainage of the remnant liver. She had an uneventful recovery except a biliary fistula through the operatively severed left hepatic duct, which was repaired over a stent. This was managed by lateral segmentectomy and resection of the fistula after the enlargement of the right posterior sector was confirmed volumetrically. The other tumor-involved segments II, III, IV, V, and VIII and the hilum were totally hemangiomatic. Enucleation and postoperative recovery was uneventful. The era of liver transplantation enhanced our knowledge about complex liver surgery and these cases are good examples about the feasibility of enucleation even in extremely complicated liver hemangiomas saving both the patients and a donor liver.

Could the use of interposition grafts for arterial reconstruction be avoided by more caudate graft placement in living donor liver transplantation

One of the major challenges in living donor liver transplantation (LDLT) is short and small vessels (particularly the hepatic artery), particularly in segmental liver grafts from living donors. In the present study we report an alternative surgical technique that avoids interpositional vessel grafts or tension on the connection by anastomizing the allograft hepatic vein to the recipient inferior vena cava in a more caudate location. From March 2000 to January 2003, 28 patients (11 women/17 men) underwent 28 LDLT. Until June 2001, the preferred technique for hepatic vein anastomosis was end-to-end anastomosis between the allograft hepatic vein and the recipient hepatic vein (HV-HV) (n = 10). Thereafter an end-to-side anastomosis was performed between allograft hepatic vein and recipient inferior vena cava (HV-IVC) (n = 18). The level of venotomy on the recipient vena cava was decided according to the pre-anastomotic placement of the allograft in the recipient hepatectomy site with sufficient width to have an hepatic artery anastomosis without tension or need for an interposition graft during hepatic artery and portal vein anastomoses. Except the right lobe allograft with anterior and posterior portal branches, all portal and hepatic artery anastomoses were constructed without an interposition graft or tension in the HV-IVC group. Only one hepatic artery thrombosis developed in the HV-IVC group. As a result, this technique may avoid both hepatic artery thrombosis and the use of interposition grafts in living donor liver transplantation.

Laparoscopic Nissen versus Toupet fundoplication: assessment of operative outcomes.

BACKGROUND This study was designed to analyze the outcomes of Nissen fundoplication (NF) versus Toupet fundoplication (TF) in patients undergoing laparoscopic antireflux surgery (LARS). METHODS All perioperative data, operative/postoperative complications, and follow-up data were prospectively recorded. All patients were seen on the 2nd month postoperatively and by yearly intervals thereafter. All patients have at least 12-month follow-up. Using SPSS software, groups were compared by t-test and chi-square tests as appropriate. RESULTS One thousand consecutive patients underwent primary LARS from May 2004 to August 2009. Six hundred eighty-four patients had NF and 316 had TF fundoplication. The mean follow-up of the NF (51.26 months) group was slightly longer than the TF group (43.53 months) (P=.018). There was no mortality and conversion. Esophageal perforation, jejunal perforation, and pulmonary emboli were the sole three major complications in separate patients. Dysphagia occurred in 15.4% and 9.9% in NF and TF, respectively (P=.001). Corresponding numbers for bloating were 19.6% and 10.8% in NF and TF, respectively (P=.001). Seventeen patients underwent reinterventions such as dilatation and re-do surgery and all 17 were in the NF group (P<.05). All other minor complications were similar except hiccups, which were seen in 30 patients and all were in the NF group (P<.05). Recurrence of reflux was observed in 1.8% and 2.2% of the NF and TF, respectively (P=.620). CONCLUSION Both NF and TF are effective procedures in controlling the acid-reflux symptoms. The functional side effects appear more often in the NF group. These side effects can be minimized and reinterventions for severe/prolonged dysphagia can be avoided with TF.

Laparoscopic management of totally intra-thoracic stomach with chronic volvulus

AIM To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus (IGV) and to assess the preoperative work-up. METHODS A retrospective review of a prospectively collected database of patient medical records identified 14 patients who underwent a laparoscopic repair of IGV. The procedure included reduction of the stomach into the abdomen, total sac excision, reinforced hiatoplasty with mesh and construction of a partial fundoplication. All perioperative data, operative details and complications were recorded. All patients had at least 6 mo of follow-up. RESULTS There were 4 male and 10 female patients. The mean age and the mean body mass index were 66 years and 28.7 kg/m(2), respectively. All patients presented with epigastric discomfort and early satiety. There was no mortality, and none of the cases were converted to an open procedure. The mean operative time was 235 min, and the mean length of hospitalization was 2 d. There were no intraoperative complications. Four minor complications occurred in 3 patients including pleural effusion, subcutaneous emphysema, dysphagia and delayed gastric emptying. All minor complications resolved spontaneously without any intervention. During the mean follow-up of 29 mo, one patient had a radiological wrap herniation without volvulus. She remains symptom free with daily medication. CONCLUSION The laparoscopic management of IGV is a safe but technically demanding procedure. The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery.

Is Concomitant Cholecystectomy Safe During Laparoscopic Anti-Reflux Surgery?

OBJECTIVE The goal of this study is to prospectively evaluate the safety of concomitant cholecystectomy during laparoscopic anti-reflux surgery (LARS). METHODS A total of 1000 patients underwent LARS between May 2004 and August 2009. Patients who had a LARS procedure alone were defined as group A and those who had cholecystectomy during the LARS were defined as group B. All data, including demographics, operative details, perioperative complications, and outcomes, were recorded to the prospective database. Chi-square and t-test were used for statistical analysis. RESULTS There were 934 (93.4%) patients in group A and 66 (6.6%) in group B. Cholelithiasis (n = 48) and gallbladder polyp larger than 10 mm (n = 18) were the indications for cholecystectomy. Demographic characteristics were similar among the groups. There were no mortality and conversion. The mean operating time was 50 minutes for group A and 80 minutes for group B (P = 0.0001). The mean hospital stay was 1 day for each group. The mean follow-up was 35 and 38 months for groups A and B, respectively (P = 0.195). Esophageal perforation, jejunal perforation, and pulmonary emboli were the major complications and were seen only in group A (P = 0.790). All other peroperative minor complications and postoperative dysphagia, bloating, and reflux recurrence were similar between the two groups (P > 0.05). CONCLUSION LARS and cholecystectomy can be performed safely during the same session without increasing the rates of morbidity and recurrence of reflux.