Serdar Yormaz

Clinical outcomes of single incision laparoscopic surgery and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair

Background: Laparoscopic surgery has been a frequently performed method for inguinal hernia repair. Studies have demonstrated that the laparoscopic transabdominal preperitoneal (TAPP) approach is an appropriate choice for inguinal hernia repair. Single-incision laparoscopic surgery (SILS) was developed to improve the cosmetic effects of conventional laparoscopy. The aim of this study was to evaluate the safety and feasibility of SILS-TAPP compared with TAPP technique. Materials and Methods: A total of 148 patients who underwent TAPP or SILS-TAPP in our surgery clinic between December 2012 and January 2015 were enrolled. Data including patient demographics, hernia characteristics, operative time, intraoperative and postoperative complications, length of hospital stay and recurrence rate were retrospectively collected. Results: In total, 60 SILS-TAPP and 88 TAPP procedures were performed in the study period. The two groups were similar in terms of gender, type of hernia, and American Society of Anesthesiologists (ASA) classification score. The patients in the SILS-TAPP group were younger when compared the TAPP group. Port site hernia (PSH) rate was significantly high in the SILS-TAPP group, and all PSHs were recorded in patients with severe comorbidities. The mean operative time has no significant difference in two groups. All SILS procedures were completed successfully without conversion to conventional laparoscopy or open repair. No intraoperative complication was recorded. There was no recurrence during the mean follow-up period of 15.2 ± 3.8 months. Conclusion: SILS TAPP for inguinal hernia repair seems to be a feasible, safe method, and is comparable with TAPP technique. However, randomized trials are required to evaluate long-term clinical outcomes.

Minimally invasive management of anastomotic leak after bariatric Roux-en-Y gastric bypass

The aim of this retrospective study was to examine the anastomotic erosion due to drain and success of fibrin sealant in its management. Between 2013 and 2014, 102 patients underwent LRYGB and gastrojejunal anastomotic leak occurred due to drain erosion in 2 of them. The diagnosis was established with saliva drainage and was confirmed by upper gastrointestinal series. The absence of hemodynamic instability was directed us to conservative treatment. During the endoscopy, dehiscence was assessed and fibrin sealant was applied. The leaks healed progressively in a few days, and the drains removed within 6 days. Seven and 9 days later, the patients were discharged without any problem. Anastomotic leaks after bariatric surgery can cause severe morbidity, cost, and effects quality of life. Hemodynamically stable and drained patients are candidates for conservative methods. Endoscopic injection of fibrin sealant has been successful in closing gastric leaks.

The effect of single incision laparoscopic cholecystectomy on systemic oxidative stress: a prospective clinical trial

Purpose Single incision laparoscopic cholecystectomy (SILC) has become a more frequently performed method for benign gallbladder diseases all over the world. The effects of SILC technique on oxidative stress have not been well documented. The aim of this study was to evaluate the effect of laparoscopic cholecystectomy techniques on systemic oxidative stress by using ischemia modified albumin (IMA). Methods In total, 70 patients who had been diagnosed with benign gallbladder pathology were enrolled for this prospective study. Twenty-one patients underwent SILC and 49 patients underwent laparoscopic cholecystectomy (LC). All operations were performed under a standard anesthesia protocol. Serum IMA levels were analysed before operation, 45 minutes and 24 hours after operation. Results Demographics and preoperative characteristics of the patients were similiar in each group. The mean duration of operation was 37.5 ± 12.5 and 44.6 ± 14.3 minutes in LC and SILC group, respectively. In both groups, there was no statistically significant difference in hospital stay, operative time, or conversion to open surgery. Operative technique did not effect the 45th minute and 24th hour IMA levels. However, prolonged operative time (>30 minutes) caused an early increase in the level of IMA. Twenty-fourth hour IMA levels were not different. Conclusion SILC is an effective and safe surgical prosedure for benign gallbladder diseases. Independent of the surgical technique for cholecystectomy, the prolonged operative time could increase the tissue ischemia.

The comparison of pulmonary functions After the bariatric surgery In Morbid obeses Versus Super Obeses

Objective: Nowadays, The increase in incidence of morbid obesity is one of the most common health problems in the world. Bariatric surgery has performed as a curative procedure for morbid obesity. It has give rise to lose excess weight, heal comorbidities and to improve pulmonary functions in obeses.. Our aim was to compare postoperative respiratory outcomes in morbidly obese patients who have underwent Laparoscopic sleeve gastrectomy. Material and Methods: Consecutive 124 morbid obese patients who were underwent Laparoscopic sleeve gastrectomy was followed up 6 months between the years of march 2014 to july 2016 retrospectively. Patients were divided into two groups A and B. Group A patients who have BMI between 40-45kg/m2 and group B patients who have BMI between 45-50kg/m2. FEV1, FVC, FEV1/FVC, MSV, DV/VO2, DV/VCO2, VO2peak results, body mass index, postoperative oxygen saturation and comorbidites, were compared between both groups. Students t test,chi-square test was used for the variables and homogeneity in the patient group. Preoperative and postoperative values between the groups were compared with the ANOVA test. Results: The mean age values, respiratory function values in both groups were similar in preoperatively. In our postoperative results, there was a significant difference in the FEV1, FVC, FEV1/FVC, MSV, DV/VO2, DV/VCO2, VO2 peak ratios and also identified significant difference in resolution and improvement of comorbidities. Conclusions: The results of the patients who underwent bariatric surgery and whose body mass index (BMI) was 4045kg / m2 were statistically significant compared to those with body mass index between 45-50kg / m2. The improvement in pulmonary functions and the effect of correction of comorbidities are higher in the morbidly obese group with laparoscopic sleeve gastrectomy.

An extremely rare case of complicated appendicitis: in utero appendix with fistula formation

A 43-year-old G4P4 woman was referred to our gynaecology clinic from emergency department with a right lower quadrant pain, bilateral pelvic tenderness, fever and signs of peritoneal irritation. She had no nausea, diarrhoea, constipation or other changes in bowel or bladder habits. She reports a gradual onset of symptoms of lower unilateral abdominal discomfort and abdominal cramping for 3 days. Discomfort has gradually worsened and pain tends to be accentuated by motion but did not improve with resting. Bimanual exam revealed uterine and adnexal tenderness, as well as pain with cervical motion. No abnormal vaginal discharge was present and qualitative B-hCG was negative. Significant laboratory values on admission were an elevated white blood cell count of 18 600/mL with a left shift and a C-reactive protein value of 88 mg/L. Sonographic imaging study of the pelvis revealed a normal sized uterus and a thick-walled unilocular cystic mass as fluid-filled structure; folded onto itself to form an ‘S’ shape in the right adnexal area. There was no free fluid in the pouch of Douglas. Based on the clinical findings and imaging studies, pelvic inflammatory disease (PID) was highly probable. After failed antibiotic therapy, the patient was scheduled for surgery 4 days after hospitalization. Patient was fully informed of the procedures and the possible risks of hysterectomy. Under general anaesthesia, vagina and abdomen were prepped and draped in the standard fashion. A Pfannenstiel incision was made. Surgical exploration revealed dense adhesions between uterus and appendix. Bilateral adnexa were normal. The appendix formed an S-shaped configuration and was noted to be enlarged, inflamed and adherent to uterine surface in its longitudinal plane (Fig. 1). The distal part of the appendix was embedded deeply into the uterus (Fig. 1). Local abscess and inflammatory process involving the entire anterior uterine wall were noted (Fig. 2). There were severe destructive effects of inflammatory reactions penetrating all layers of the uterus and permanently damaged areas. Patient who did not desire childbearing underwent an appendectomy and total abdominal hysterectomy. Patients had an uneventful post-operative period and she was discharged on day 5 following surgery. No delayed complications related to treatment and/or infection occurred during 6-month follow-up. Septic complications of acute appendicitis (AA) still pose multiple problems. Known potential complications of untreated or delayed management of AA include appendiceal perforation, periappendiceal abscess formation, peritonitis, bowel obstruction and rarely septic thrombosis of mesenteric vessels. The inflammation in AA may sometimes be enclosed by the patients own defence mechanisms, by the formation of an inflammatory phlegmon or a circumscribed abscess. In such cases, symptoms are dependent on the localization of the abscess and are often nonspecific. Thus, the correct diagnosis is usually not established until direct visualization at the time of surgery. Utero-appendiceal fistula is an extremely rare condition and this is the second case reported thus far. The first one was reported by Parsons et al. They reported a case with clinical and radiological evidence of pelvic sepsis and a medical history of endometrial ablation. On physical examination of our patient, pelvic and abdominal tenderness, pain with cervical motion and fever were noted. Presenting symptoms are similar to those of PID. Traditionally, it has been felt that the pathophysiological progressive nature of appendicitis ultimately leads to perforation. Abscess caused by perforated appendicitis and involving the tissues surrounding may be a contributory factor in fistula formation. A risk of full thickness uterine damage after endometrial ablation might be

Reply to the Letter to the Editor on “A New Algorithm to Reduce the Incidence of Gastroesophageal Reflux Symptoms after Laparoscopic Sleeve Gastrectomy”

Thank you very much for your kind attention to our manuscript. This study does not constitute our first experience with this topic. We fully understand that gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy is a serious complication of this surgical technique. Therefore, we developed a new algorithm to overcome this problem. In the literature, most reports of GERD are based on subjective observations. We aimed to evaluate the preoperative risk of GERD objectively and to highlight our methods of prevention. Insufficient dissection of retrogastric tissue and creation of a large sleeve pouch are not closely associated with GERD symptoms. Large sleeve gastrectomy is often related to weight regain and poor weight loss. Therefore, we do not need to explain the technical details of surgery. Many techniques for adjusting the final volume of the sleeve have already been described in the literature; some of these references were cited in our article. For this study, most of the bariatric operations were performed by a senior laparoscopic surgeon (H. Yilmaz) who has experience with over 500 laparoscopic sleeve gastrectomies, over 200 laparoscopic Roux-en-Y gastric bypasses, over 30 laparoscopic diverted sleeve gastrectomies with ileal transposition, over 20 laparoscopic pancreaticoduodenectomies, over 50 bariatric revisional surgeries, and over 500 single-incision laparoscopic surgeries of various types. Over the last 3 years, we have performed preoperative and postoperative gastric volumetric measurements for each patient using 3-D CT scans. These data are the subject of a separate ongoing study. The postoperative gastric volume of our patients is similar to that reported in the literature [1]. Some authors claim that the great majority of hiatal hernias are asymptomatic but that most of them can be detected during surgery. Therefore, these authors advocate the dissection of both diaphragmatic pillars to identify a missed hiatal hernia [2]. However, we think that the routine exploration of both pillars can be a possible cause of postoperative GERD, due to the division of the posterior ligaments of the gastroesophageal junction. Thus, we do not recommend the destruction of the ligaments around the abdominal esophagus (Fig. 1). In an attempt to avoid staple line leak, some surgeons inadvertently leave too much fundus during the operation. This phenomenon, called neofundus, was first described by Himpens et al. [3]. Residual fundus, or neofundus, is associated with the release of larger amounts of ghrelin, increased appetite of patients, and weight regain or insufficient weight loss after surgery. In our study group, only 4.9% of 402 patients required a revisional surgery due to weight regain or poor weight loss. Fundus dilation was detected in only three of these patients. Furthermore, we know that the embryonic rotation of the stomach creates a diverticulum on the posterior aspect of the stomach; we checked this area during resection and found no residual fundus. Because the stomach is extensible, we do not think that it is suitable to measure it with a tie. Insufficient tension on the tie can affect the measurements. At this point in the procedure, the experience and capability of the surgeon become more * Ilhan Ece ilhanece@yahoo.com

Comparison of mid-term clinical outcomes of laparoscopic partial cystectomy versus conventional partial cystectomy for the treatment of hepatic hydatid cyst

Background: The aim of this study was to compare the mid-term outcomes of open and laparoscopic partial cystectomy (LPC). Methods: The medical records of patients who underwent conventional partial cystectomy (CPC) and LPC for liver hydatid cyst from May 2010 to February 2015 were retrospectively reviewed. Operative time, blood loss, length of hospital stay, post-operative morbidity, mortality and mid-term follow-up outcomes were evaluated. Results: Amongst 130 patients, 38 patients were underwent LPC and 92 underwent CPC. Blood loss and post-operative complications were similar in both groups. The mean operative time in the LPC and the CPC groups was, respectively, 95.4 ± 13.1 and 63.5 ± 15.6 min, which showed a significant difference between the both groups. The mean length of hospital stay in CPC group was significantly longer when compared the LPC group. The mean diameter of cyst in LPC group was 6.1 ± 1.1 cm and 7.8 ± 2.1 cm in CPC group with a significant difference. The overall complication rates were 13.1% in LPC group and 17.3% in CPC group without significant difference. The most common complication was biliary leakage and surgical site infection. Conclusion: LPC for the surgical treatment of liver hydatid cyst appears to be safe and effective method with low morbidity rates in selected patients.

A New Approach to the Complicated Liver Hydatid Cyst – Laparoscopic Roux-en-Y Cystojejunostomy

Surgery is still the gold standard in the treatment of hepatic hydatid disease. One of the major problems associated with hydatid cyst surgery is biliary fistula. In this report, we aimed to describe a laparoscopic internal drainage method for the treatment of complicated hepatic hydatid cyst in order to prevent long-term biliary fistulas. A 44-year-old female was referred to our clinic with the complaints of flank pain. On computerized tomography of the abdomen, an 8-cm hydatid cyst was detected on the right lob of the liver. Laparoscopic exploration demonstrated a cysto-biliary communication, and laparoscopic cystojejunostomy was performed to prevent long-term bile leakage. The patient was discharged on postoperative day 5 without any problems. In 45th days, nearly complete obliteration of the cavity was observed. Laparoscopic cystojejunostomy can be an effective and safe surgical approach for the treatment of complicated hepatic hydatid cysts.