Ryan M. Juza

Clinical and surgical anatomy of the liver: a review for clinicians.

The liver is the largest gland in the body occupying 2.5% of total body weight and providing a host of functions necessary for maintaining normal physiological homeostasis. Despite the complexity of its functions, the liver has a homogenous appearance, making hepatic anatomy a challenging topic of discussion. To address this issue, scholars have devoted time to establishing a framework for describing hepatic anatomy to aid clinicians. Work by the anatomist Sir James Cantlie provided the first accurate division between the right and left liver in 1897. The French surgeon and anatomist Claude Couinaud provided additional insight by introducing the Couinaud segments on the basis of hepatic vasculature. These fundamental studies provided a framework for medical and surgical discussions of hepatic anatomy and were essential for the advancement of modern medicine. In this article, the authors review the normal anatomy and physiology of the liver with a view to enhancing the clinicians knowledge base. They also provide a convenient model to assist with understanding and discussion of liver anatomy. Clin. Anat. 27:764–769, 2014.

Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management

BACKGROUND Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. METHODS A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. RESULTS One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42). CONCLUSION SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.

Transversus Abdominis Release for Abdominal Wall Reconstruction: Early Experience with a Novel Technique

BACKGROUND Ventral hernias are common sequelae of abdominal surgery. Recently, transversus abdominis release has emerged as a viable option for large or recurrent ventral hernias. Our objective was to determine the outcomes of posterior component separation via transversus abdominis release for the treatment of abdominal wall hernias in the first series of patients at one institution. METHODS We performed a retrospective review of a prospectively maintained database of open ventral hernia repair patients to identify patients who underwent posterior component separation via transversus abdominis release at one institution from 2012 to 2015. Patients who were at least 1 year out from surgery were included. Patient demographic characteristics, operative details, perioperative and postoperative complications, and recurrences were analyzed. Postoperative imaging was reviewed for evidence of morbidity or recurrence. RESULTS Thirty-seven patients met inclusion criteria; 23 (62.2%) of these patients were female, with a mean age of 57.5 ± 11 years and median BMI of 32.1 kg/m(2) (range 23.6 to 44.0 kg/m(2)). All patients underwent repair with mesh (81.1% polypropylene, 5.4% porcine dermal matrix, and 13.5% biologic/permanent synthetic hybrid). Median defect size was 392 cm(2) (range 250 to 2,700 cm(2)) and median mesh area was 930 cm(2) (range 600 to 3,600 cm(2)). Approximately 24% (9 of 37) of patients experienced a postoperative complication; ileus was the most common (4 patients). Surgical site events requiring intervention (ie drainage and antibiotics) developed in 2 patients. Median follow-up period was 21 months (range 12 to 42 months), during which one recurrence was identified (2.7%). CONCLUSIONS Posterior component separation via transversus abdominis release is a safe and effective method of ventral herniorrhaphy with favorable rates of wound morbidity and recurrence.

How I do it: novel parastomal herniorrhaphy utilizing transversus abdominis release

IntroductionParastomal hernias are a complex surgical problem affecting a large number of patients. Recurrences continue to occur despite various methods of repair. We present a novel method of open parastomal hernia repair with retromuscular mesh reinforcement in a modified Sugarbaker configuration.MethodsA full mildline laparotomy is performed and all adhesions are taken down. We then perform an open parastomal hernia repair by utilizing retromuscular dissection, posterior component separation via transversus abdominis release, and lateralization of the bowel utilizing a modified Sugarbaker mesh configuration within the retromuscular space. We demonstrate this technique in a cadaveric model for illustrative purposes.DiscussionThis repair provides the benefits of an open posterior component separation with transversus abdominis release and maintains the biomechanics of a functional abdominal wall, all while simultaneously benefitting from the advantages of mesh reinforcement in a modified Sugarbaker configuration. Our clinical experience with this novel technique to this point has been positive.

Intraoperative Considerations for Robotic Repair

Much like laparoscopic hernioplasty, the keys to performing a successful robotic hernia repair lie as much in the attention to ancillary details of the procedure as they do in performing the actual operative steps. Seemingly mundane details like room setup, patient positioning, port placement, and instrumentation all ultimately facilitate the successful completion of the robotic-assisted case. In this chapter we will discuss intraoperative considerations for robotic hernia repair including a review of the technical aspects of the procedures and will provide details and helpful tips for managing difficulties unique to robotic-assisted hernia repair. As of the writing of this chapter, the da Vinci system is the only device available in the United States for hernia repair and our discussion will focus entirely on this system.

Colonoscopic-assisted percutaneous endoscopic gastrostomy tube placement

Percutaneous endoscopic gastrostomy (PEG) tube placement has become the mainstay for durable enteral access, eliminating the need for surgical gastrostomy [1, 2]. Placement requires a safe tract through the abdominal wall directly into the stomach. Colon interposition between the stomach and abdominal wall is uncommon, but precludes PEG tube placement [3]. In cases where the colon directly interferes with PEG tube placement, we have employed multimodal therapy by performing simultaneous colonoscopy, fluoroscopy, and upper endoscopy to permit PEG technique placement.

Managing Complications of Open Hernia Repair

Despite advances in technical aspects of herniorraphy and in the medical optimization and management of comorbidities, complications following open hernia repair remain a persistent source of morbidity for the patient undergoing hernia repair. This chapter reviews the spectrum and management of complications following open hernia repair. In particular, we focus on surgical site occurrence, renal, pulmonary, mesh-related, and iatrogenic complications as these are more common occurrences in open hernia repair (especially those conducted with component separation methodologies). After reading this chapter, the reader should have a better understanding of the spectrum and breadth of open hernia repair complications and will be able to describe management options for each of these complications.

Endoscopic rescue of a dislodged transabdominal decompressive esophagostomy tube

Transabdominal tube drainage is a well-described surgical technique for drainage of a blind-ending luminal structure, particularly in the emergent setting. The potential adverse events of transabdominal drainage include tube dislodgement leading to free perforation and sepsis, with associated high morbidity and mortality. The methods described in the medical literature for rescuing or repairing dislodged transabdominal drainage tubes include open, laparoscopic, and, recently, natural orifice transluminal endoscopic surgery (NOTES) techniques. We report the case of a dislodged transabdominal esophagostomy tube during the late postoperative period of a patient who had undergone total gastrectomy for full-thickness necrosis (Fig. 1). A NOTES approach was combined with a modified percutaneous endoscopic gastrostomy technique for exchange of a new esophagostomy drainage tube through the original tract (Video 1, available online at www.