Mohamed H. Elgamal

Early experience with lidocaine patch for postoperative pain control after laparoscopic ventral hernia repair.

INTRODUCTION Reduced postoperative pain is one of the many factors that have driven the growing emphasis on the role of laparoscopic surgery for surgical management. Several studies have documented the advantages of the laparoscopic repair of ventral hernias compared to the open ventral herniorraphy. However, the laparoscopic approach may be associated with more postoperative pain initially. In this preliminary study, we present data from our early experience with the use of a lidocaine patch for pain control in the immediate postoperative period following laparoscopic ventral hernia repair (LVH). METHODS Thirty consecutive patients underwent laparoscopic ventral herniorraphy (LVH) and were selected randomly and placed into one of two groups. In one group, we placed a lidocaine patch (LP) (Lidoderm, Endo Pharmaceuticals, Inc., Chadds Ford, PA) on the anterior abdominal wall corresponding to the placement site of the underlying mesh in fifteen patients (Group A). In the second group, we did not place a LP on the abdominal wall of fifteen consecutive patients (Group B). We assessed all patients according to their demographic data, Body Mass Index (BMI), American Society of Anesthesiologists (ASA) score, the size of the abdominal wall defect (AWD), area of mesh (size) used, operative time, length of hospital stay (LOA), morbidity, and the individual patients pain score at discharge, two weeks and two months postoperatively. RESULTS The two groups were similar with respect to demographics, BMI, ASA, AWD, size of mesh, LOS and morbidity. Group A had a statistically significant reduction in their postoperative pain score at discharge when compared to Group B (3.13+/-1.68 and 4.8+/-1.42, respectively, p value=0.0067). CONCLUSION In this preliminary study, the use of a lidocaine patch in the management of postoperative pain following laparoscopic ventral herniorraphy is a safe and promising modality to consider in the management of postoperative pain control.

Simple technique for single incision transumbilical laparoscopic appendectomy

INTRODUCTION Acute appendicitis is one of the most commonly encountered surgical problems in everyday practice. With the recent increase in popularity of single incision laparoscopic surgery (SILS), several techniques for SILS appendectomy have already been described. We herein describe our own simplified technique for single incision transumbilical laparoscopic appendectomy. MATERIALS AND METHODS From December 2008 to August 2009, a total of 26 patients consented for single incision laparoscopic appendectomy for acute appendicitis. Preoperative, intraoperative and postoperative data were collected. RESULTS Our technique was successful in 19 out of 26 (73.1%) patients, while seven patients required the placement of additional trocars. None of the patients needed conversion to an open approach. Mean OR time was 45.9 min. The mean length of stay was 1.1 day. Only one patient had developed postoperative umbilical wound infection. CONCLUSION Our technique for single incision laparoscopic transumbilical appendectomy is safe feasible, and reproducible. Prospective randomized studies comparing the single incision laparoscopic approach with its conventional multiport counterpart are necessary to confirm the conclusions of our early experience.

The Effect of Laparoscopic Roux-en-Y Gastric Bypass on Fibromyalgia

BackgroundFibromyalgia is a chronic debilitating disorder affecting 3–5% of the US population. Treatment of this disorder is a challenge. The incidental finding of improvement of fibromyalgia following laparoscopic Roux-en-Y gastric bypass stimulated us to study this phenomenon.MethodsA retrospective chart review of patients with fibromyalgia who underwent laparoscopic Roux-en-Y gastric bypass.ResultsPostoperative decrease in median of BMI from 49.4 to 29.7 was significant (p value = 0.0010). This was associated with statistically significant improvement in median of pain score (p value = 0.0010) and median points of tenderness (p value = 0.0010).ConclusionSignificant weight loss following laparoscopic Roux-en-Y gastric bypass is associated with resolution or improvement of fibromyalgia. Consequently, the bariatric surgeon should be a member of the multidisciplinary team approach for treating fibromyalgia.

Early Experience with Intraluminal Reinforcement of Stapled Gastrojejunostomy During Laparoscopic Roux-En-Y Gastric Bypass

BackgroundThe use of extraluminal staple-line buttressing material during laparoscopic Roux-en-y gastric bypass has shown the potential to reduce staple-line leak and bleeding. We herein present our early experience with intraluminal reinforcement of linear-cutting stapled gastrojejunal anastomosis with the use of bioabsorbable glycolide copolymer staple-line reinforcement.MethodsLaparoscopic Roux-en-Y gastric bypass was performed in 80 consecutive non-randomized morbidly obese patients. Gastrojejunal anastomosis was performed using a linear-cutting stapler without staple-line reinforcement in 40 patients (group A), while in the other 40 patients (group B), gastrojejunostomy was performed using a linear cutting stapler with intraluminal reinforcement material (bioabsorbable glycolide copolymer). Demographic data were collected. The rate of gastrojejunal anastomotic leak, bleeding, and stricture was determined.ResultsThere was a statistically significant reduction in bleeding complications between the two groups (15% bleeding in group A vs. no bleeding in group B, P value = 0.0255). Stricture rate was higher in-group A (10% group A vs. 2.5% in group B); however, the difference was not statistically significant (P value = 0.2007). None of our patients developed a gastrojejunal leak.ConclusionIntraluminal reinforcement of gastrojejunal anastomosis during laparoscopic gastric bypass is safe and feasible. The use of intraluminal bioabsorbable glycolide copolymer staple-line reinforcement significantly reduces the incidence of gastrojejunal bleeding.

Takotsubo cardiomyopathy in a patient with an ascending colon mass

ABSTRACT Takotsubo cardiomyopathy (TTC) is a syndrome characterized by transient regional systolic dysfunction of the left ventricle in the absence of angiographic evidence of obstructive coronary artery disease (CAD). A variety of stress-related triggers, including malignancies, have been reported in patients with TTC. However, to our knowledge, a recent diagnosis of a colon mass preceding the development of TTC has not been reported. We report on a female patient who was recently diagnosed with a colon mass by colonoscopy who was then scheduled to undergo robotic hemicolectomy, but was subsequently admitted to our hospital for intractable nausea and abdominal pain. While admitted, she developed transient ventricular tachycardia with elevated cardiac markers. The echocardiogram revealed markedly decreased ejection fraction and mid to distal apical akinesis with regional wall motion abnormalities. Coronary angiogram demonstrated no significant CAD, consistent with the diagnosis of TTC. The recently diagnosed colon mass was the most likely stress trigger in the development of TTC.

Reply to: 464_2009_331: Re: A simplified laparoscopic ventral hernia repair: the scroll technique (2008: 22(11) 2527–2531)

We thank Hussain et al. for their interest in our article, ‘‘A simplified laparoscopic ventral hernia repair: the scroll technique’’ [1]. Regarding our case of mesh infection, this patient has a history of skin graft to cover exposed bowel. He developed an incisional hernia that was repaired laparoscopically with ePTFE mesh. Postoperatively, the patient developed necrosis of the skin graft with mesh exposure. Long course of antibiotic and wound care failed to salvage the mesh. We and others agree that in the vast majority of cases removal of exposed (infected) mesh is necessary, particularly if the prosthesis contains a component of ePTFE [2]. The patient underwent mesh removal and wound care and delayed repair of the hernia with biological mesh. We looked at port site hernia during the follow-up period; however, we did not have any case incisional hernia at 12-mm trocar site. This is attributed to the fact that the open Hasson is a muscle splitting and we routinely close all 10-mm and larger port sites. It is our observation that the incidence of palpable seroma is high with PTFE mesh. This may be attributed to the poor tissue ingrowths of the ePTFE to the abdominal wall. Susmallian et al. found that the incidence of seroma after laparoscopic repair of hernia with PTFE patch was 100% on ultrasonic studies [3]. In an effort to diminish the seroma formation, we and others place an abdominal binder, for 1 month, while the patient is still on the operating table. This seems to decrease both the size and duration of the seromas that are clinically significant by as much as 50% [4]. Hussain et al. have described the introduction of the mesh through a trocar, which is placed in the center of the hernia defect itself [5]. Although this technique simplifies the procedure, it also creates some concerns. The proximity of the trocar incision to the mesh may facilitate extension of this trocar site infection to the mesh. In addition, the proximity of the hernia sac (the site of seroma formation) and the central port may facilitate leak of seroma fluid through the central port incision.