Peter Nottle

Complete evidence regarding major vascular injuries during laparoscopic access.

Recent reports by the Australian Safety and Efficacy Register for New interventions and Procedures (ASERNIP-S) and the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) concluded that insufficient evidence is available to assess the safety of the open versus closed laparoscopy in regard to major vascular and visceral injuries. The aim of this study was to assess the relative safety of open and closed laparoscopy with respect to rates of major vascular and visceral injuries. A combined prospective/retrospective review of a single-surgeon series of 5900 open laparoscopies was performed. A meta-analysis of all reported series of open and closed laparoscopy was conducted using PubMed and MEDLINE search engines to compare major vascular and visceral injury rates. Medicolegal and manufacturer device reports were also reviewed. The case series of 5900 open laparoscopies reported a single visceral injury and no major vascular injuries. The meta-analysis revealed 336 major vascular injuries in 760,890 closed laparoscopies, a mean rate of 0.044%, 1 injury per 2272 cases, compared with 0 injuries in 22,465 open laparoscopies (P = 0.003). Visceral injuries occurred more frequently, 515 injuries in 760,890 closed laparoscopies (mean rate, 0.07) and 11 injuries in 22,465 open laparoscopies (mean rate, 0.05; P = 0.18). Medicolegal and device reports revealed a further 647 major vascular injuries and 500 major visceral injuries. In contrast to the conclusion formed by the RANZCOG and ASERNIP-S, the available evidence shows that open laparoscopy eliminates the risk of major vascular injury and reduces the rate of major visceral injuries. Open laparoscopy using the Hasson cannula should be the preferred method of peritoneal access.

Preoperative screening for common bile duct stones with infusion cholangiography: review of 1000 patients.

OBJECTIVE The authors aimed to study the safety and accuracy of infusion cholangiography in patients undergoing laparoscopic cholecystectomy. SUMMARY BACKGROUND DATA Intravenous cholangiography is a theoretically attractive method of screening the common bile duct for stones. However, there still remain serious reservations regarding its safety and accuracy, despite some reports in the literature to the contrary. METHODS A personal series of 1000 patients undergoing routine preoperative infusion cholangiography was reviewed. RESULTS The cholangiograms detected bile duct stones with a sensitivity of 93.3% and a specificity of 99.3%. There were no serious contrast reactions, and the minor contrast reaction rate was 0.7%. CONCLUSIONS The authors conclude that infusion cholangiography is indeed safe and accurate and should play a substantial role in preoperative screening for incidental common bile duct stones.

EXTRAHEPATIC BILIARY ANATOMY AT LAPAROSCOPIC CHOLECYSTECTOMY: IS ABERRANT ANATOMY IMPORTANT?

Background:  The prevention of major duct injury at cholecystectomy relies on the accurate dissection of the cystic duct and artery, and avoidance of major adjacent biliary and vascular structures. Innumerable variations in the anatomy of the extrahepatic biliary tree and associated vasculature have been reported from radiographical and anatomical studies, and are cited as a potential cause of bile duct injury at cholecystectomy.

Laparoscopic repair of iatrogenic colonic perforation.

Perforation of the colon during colonoscopy can occur for a variety of reasons. When it is caused directly by the endoscope itself, operative intervention is virtually unavoidable. Current practice is laparotomy and repair or resection. Simple oversewing of the defect in a well-prepared colon is safe and effective if the diagnosis is made early. This can be carried out by the laparoscopic route; however, there are few cases of this being performed. We describe our technique for laparoscopic repair here, reviewing the literature on perforation and its management. With advanced laparoscopic techniques such as intracorporeal suturing becoming more widely practiced, a mind shift toward considering laparoscopy for treatment of these patients should be made. Laparoscopy does not exclude the conversion to laparotomy if required.

Patient and Parent Perspectives of Adolescent Laparoscopic Adjustable Gastric Banding (LAGB)

BackgroundAdolescent obesity is a significant global health challenge and severely obese adolescents commonly experience serious medical and psychosocial challenges. Consequently, severe adolescent obesity is increasingly being treated surgically. The limited available research examining the effectiveness of adolescent bariatric surgery focuses primarily on bio-medical outcomes. There is a need for a more comprehensive understanding of the behavioural, emotional and social factors which affect adolescents’ and parents’ experience of weight loss surgery.MethodsPatient and parents’ perspectives of adolescent LAGB were examined using a qualitative research methodology. Individual, semi-structured interviews were conducted with eight adolescent patients and five parents. Thematic analysis was used to identify key themes in the qualitative data.ResultsPatients and parents generally considered adolescent laparoscopic adjustable gastric banding (LAGB) to be a life-changing experience, resulting in physical and mental health benefits. Factors considered to facilitate weight loss following surgery included parental support and adherence to treatment guidelines. Many adolescents reported experiencing surgical weight loss stigma and challenging interpersonal outcomes after weight loss for which they felt unprepared.ConclusionsPatients and parents perceived LAGB positively. There are opportunities to improve both the experience and outcomes of adolescent LAGB through parental education and enhancements to surgical aftercare programmes.

Small Bowel Obstruction Creates a Closed Loop in Patients with a Laparoscopic Adjustable Gastric Band

We report on two cases of small bowel obstruction in the setting of a previous laparoscopic adjustable gastric band insertion. In both cases, a closed loop obstruction was created by the band and delayed diagnosis resulted in significant morbidity. Early recognition with deflation of the adjustable gastric band and nasogastric tube insertion is paramount to managing these patients.

Outcomes of high-volume bariatric surgery in the public system

Bariatric surgery has not been widely used in the Australian public health system. As obesity is strongly associated with socio‐economic status, excluding its use from the public system will deny many of the most in‐need access to a potentially very effective treatment. Alternatively, with rigorous follow‐up and behavioural change requirements, highly successful outcomes in the private system may not translate to the public system.

Outcomes of revision laparoscopic gastric banding: a retrospective study.

Obesity is a health problem approaching pandemic proportions. Laparoscopic adjustable gastric banding (LAGB) is the bariatric procedure of choice in Australia for effective surgical treatment of severe obesity. Complications of LAGB lead to a high proportion of patients requiring revision surgery. However, literature regarding outcomes and failure rates of revision bariatric surgery is scarce, such that the choice of procedure at reoperation remains controversial. This paper aims to present outcomes of revision laparoscopic gastric banding.

Indications and efficacy of endoscopic vacuum-assisted closure therapy for upper gastrointestinal perforations.

Endoscopic vacuum‐assisted closure (EndoVAC) therapy is a recent innovation described for use in upper gastrointestinal perforations and leaks, with reported success of 80–90%. It provides sepsis control and collapses the cavity preventing stasis, encouraging healing of the defect. Whilst promising, initial reports of this new technique have not established clear indications, feasibility and optimal technique.

Radical gastric cancer surgery results in widespread upregulation of pro-tumourigenic intraperitoneal cytokines: Pro-tumourigenic cytokines during gastric surgery

Radical surgical resection is the mainstay of curative treatment for oesophagogastric malignancy. However, survival and recurrence rates remain poor. Theoretical data suggests that the inflammatory response to surgery can promote tumour recurrence. The local and systemic inflammatory response to radical oesophagogastric cancer surgery has not been fully characterized. We aimed to measure this response, particularly factors associated with tumour implantation.