Yuedong Wang

Laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension

Since the first laparoscopic splenectomy (LS) was reported in 1991, LS has become the gold standard for the removal of normal to moderately enlarged spleens in benign conditions. Compared with open splenectomy, fewer postsurgical complications and better postoperative recovery have been observed, but LS is contraindicated for hypersplenism secondary to liver cirrhosis in many institutions owing to technical difficulties associated with splenomegaly, well-developed collateral circulation, and increased risk of bleeding. With the improvements of laparoscopic technique, the concept is changing. This article aims to give an overview of the latest development in laparoscopic splenectomy for hypersplenism secondary to liver cirrhosis and portal hypertension. Despite a lack of randomized controlled trial, the publications obtained have shown that with meticulous surgical techniques and advanced instruments, LS is a technically feasible, safe, and effective procedure for hypersplenism secondary to cirrhosis and portal hypertension and contributes to decreased blood loss, shorter hospital stay, and less impairment of liver function. It is recommended that the dilated short gastric vessels and other enlarged collateral circulation surrounding the spleen be divided with the LigaSure vessel sealing equipment, and the splenic artery and vein be transected en bloc with the application of the endovascular stapler. To support the clinical evidence, further randomized controlled trials about this topic are necessary.

Laparoscopic greater curvature plication: Surgical techniques and early outcomes of a Chinese experience ☆

BACKGROUND Laparoscopic greater curvature plication (LGCP) is a novel restrictive bariatric procedure that can reduce the gastric volume by infolding the gastric greater curvature without gastrectomy. The objective of this study was to describe the surgical technique of LGCP and validate the efficacy and safety of LGCP for the treatment of obesity in obese Chinese patients with a relatively low body mass index (BMI). METHODS Twenty-two obese patients (mean age 33.8±6.0 years; mean BMI 37.0±7.0 kg/m(2)) underwent LGCP between September 2011 and September 2012. After dissecting the greater omentum and short gastric vessels, the gastric greater curvature plication with 2 rows of nonabsorbable suture was performed under the guidance of a 32-F bougie. The data were collected during follow-up examinations performed at 1, 3, 6, and 12 months postoperatively. RESULTS All procedures were performed laparoscopically. The mean operative time was 84.1 minutes (50-120 min), and the mean length of hospital stay was 3.8 days (2-10 d). There were no deaths or postoperative major complications that needed reoperation. The mean percentage of excess weight loss (%EWL) was 22.9%±6.9%, 38.6%±9.8%, 51.5%±13.5%, and 61.1%±15.9% at 1, 3, 6, and 12 months postoperatively. At 6 months, type 2 diabetes was in remission in 2 (50%) patients, hypertension in 1 (33.3%) patient, and dyslipidemia in 11 (78.6%) patients. Decreases in the index for homeostasis model assessment of insulin resistance (HOMA-IR) and in insulin and glucose concentrations were observed. CONCLUSIONS The early outcomes of LGCP as a novel treatment for obese Chinese with a relatively low BMI are satisfactory with respect to the effectiveness and low incidence of major complications. Additional long-term follow-up and prospective, comparative trials are still needed.

Laparoscopic Versus Open Pediatric Splenectomy for Massive Splenomegaly

Laparoscopic splenectomy (LS) has rapidly evolved into the technique of choice compared with open splenectomy (OS) because of the advantages of the minimally invasive approach. Splenomegaly increases the technical difficulties of LS. LS for massive splenomegaly has generally been found to fail in adults and children. With improvements in laparoscopic technique and accumulation of laparoscopic experience, however, concerns about completing the procedure in pediatric cases with even massive splenomegaly have been lowered. A retrospective review (April 1997-October 2009) of databases at 2 institutions identified 145 children undergoing splenectomy, 79 laparoscopic and 66 open. We defined splenic margin below the umbilicus or anteriorly extending over the midline as massive splenomegaly. By this definition, 22 cases of pediatric laparoscopic and 17 cases of open splenectomies for massive splenomegaly were performed. Perioperative and follow-up data of laparoscopic pediatric splenectomies were compared with those of open splenectomies, including operative time, bleeding, spleen size, complications, and hospital stay. There were no deaths, wound infections, or instances of pancreatitis. No accessory spleen was missed by laparoscopic; accessory spleens were missed in 2 patients in open splenectomies. The complication rate of laparoscopic versus open was 13.6% versus 41.2%. No subsequent surgery was necessary for dealing with complications both in laparoscopic and open series. Laparoscopic pediatric splenectomy for massive splenomegaly is a feasible, effective, and safe procedure and is associated with low morbidity and a short hospital stay.

Comparative study of laparoscopic sleeve gastrectomy with and without partial enterectomy and omentectomy.

BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is a novel bariatric surgical procedure that constitutes the first-stage procedure of laparoscopic Roux-en-Y gastric bypass in high-risk patients, the long-term results of which are unknown. Our objective was to establish whether partial enterectomy and omentectomy are necessary in addition to LSG to achieve weight loss in obese patients. The setting was a case series in a provincial hospital. METHODS A total of 40 obese patients (29 women and 11 men) were separated into 2 equal groups according to patient choice. Group 1 underwent LSG alone, and group 2 underwent LSG plus partial enterectomy and omentectomy. The partial enterectomy left the first 100 cm of the jejunum and the last 200 cm of the ileum. The data were collected during the follow-up examinations, performed at 1, 3, 6, and 12 months postoperatively. RESULTS The body mass index loss (BMIL) was 3.9 ± .5 kg/m(2) and 9.4 ± 1.3 kg/m(2) at 1 and 12 months in group 1, respectively. The BMIL was 4.5 ± .9 kg/m(2) and 10.4 ± 1.9 kg/m(2) at 1 and 12 months in group 2, respectively. At 1 and 12 months postoperatively, the percentage of excess body weight loss was 32.2% ± 12.6% and 81.5% ± 20.4% in group 1 and 35.5% ± 10.5% and 83.8% ± 24.5% in group 2, respectively. Except for the BMIL at 1 month after surgery, no significant differences were found in the BMIL or percentage of excess body weight loss. CONCLUSION LSG with and without partial enterectomy and omentectomy in our study was an effective method of bariatric surgery, but they did not differ in their effect on weight loss. However, the long-term effect of weight loss with LSG alone or combined with partial enterectomy and omentectomy needs additional study.

Primary Versus Secondary Splenic Pedicle Dissection in Laparoscopic Splenectomy for Splenic Diseases

BACKGROUND Some areas of laparoscopic splenectomy (LS), such as the approach to splenic pedicle dissection, remain controversial. Here we recommend a technique for dissecting the secondary splenic pedicle vessels on the basis of analysis of retrospective data. STUDY DESIGN A retrospective review (April 2006 to October 2011) of databases at 2 institutions identified 136 patients who had undergone LS. In 34 patients with massive splenomegaly, primary splenic pedicle dissection technique (PSPD) had been used in 19 patients and secondary splenic pedicle dissection technique (SSPD) had been used in 15 patients. In 102 patients with normal-sized spleen or moderate splenomegaly, PSPD had been used in 56 patients and SSPD in 46 patients. We compared perioperative and follow-up data. RESULTS Laparoscopic splenectomy was completed in 128 patients. In the massive splenomegaly group, the conversion rate was 5.3% for PSPD and 33.3% for SSPD, the complication rate was 42.1% vs 20%, hospital stay was 3.2 ± 2.0 days vs 7.5 ± 3.5 days, and transfusion requirement was 1.1 ± 1.2 U vs 3.2 ± 0.9 U, respectively. However, in the normal or moderate splenomegaly group, except for complications, there were no significant differences between PSPD and SSPD techniques in perioperative findings. In the 2 groups, there were significant differences between the PSPD and SSPD techniques in pancreatic leakage (15.8% vs 0 and 8.9% vs 0, respectively) and postoperative fever (15.8% vs 6.7% and 10.7% vs 2.2%, respectively). CONCLUSIONS Secondary splenic pedicle dissection can decrease the incidence of splenic fever and pancreatic leakage and is a valuable technique for LS for normal-sized spleen or moderate splenomegaly. It is not a safe procedure for massive splenomegaly because of the high conversion rate.

Laparoscopic Choledocholithotomy With a Novel Articulating Forceps

Purpose. The aim of this study was to assess the safety and effectiveness of laparoscopic common bile duct (CBD) exploration with a novel articulating forceps. Methods. A retrospective analysis was carried out of 90 patients who underwent laparoscopic transcholedochal CBD exploration for choledocholithiasis between May 2006 and June 2014. Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments (group A). Forty-five patients underwent laparoscopic choledocholithotomy using the routine instruments plus the novel articulating forceps (group B). The 2 group populations were similar with regard to demographic data and clinical presentations. Results. Laparoscopic transcholedochal CBD exploration was successful in all 90 patients. The mean diameter of the CBD was 14.42 mm in group A and 14.73 mm in group B (P > .05). The average number of stones extracted per patient was 4.22 in group A and 4.67 in group B (P > .05). The patients in group A had a significantly longer operative time than the patients in group B (109.38 vs 80.49 minutes; P < .01). The intraoperative blood loss was minimal in both groups, and no major complications were observed in either group. The mean hospitalization stay was 6.60 days in group A and 5.58 days in group B (P < .01). Conclusion. Laparoscopic transcholedochal CBD exploration with the novel articulating forceps is a safe and effective approach to the management of choledocholithiasis that offers a short operating time and short postoperative hospital stay.

Laparoscopic splenectomy and subsequent oncologic gastric surgery in cirrhotic patients with portal hypertension and hypersplenism

The first case was that of a 59-year-old male patient admitted to our department with recalcitrant epigastric pain, who already had hepatitis B virus (HBV)-related cirrhosis for 8 years. Endoscopy revealed esophageal varices in the distal esophagus without bleeding and a 2.5 cm ulcer lesion on the lesser curvature of the stomach. Biopsies revealed signet ring cell carcinoma. The second case was that of a 66-year-old female patient with HBV cirrhosis who had undergone a gastroscopy; biopsy confirmed gastric antrum cancer, and she was referred to our hospital from another hospital. She had been diagnosed with HBV-related cirrhosis 6 years ago but had no episodes of gastrointestinal bleeding. Both patients had thrombocytopenia and leucopenia.

Combined laparoscopic and open technique for repair of congenital abdominal hernia: A case report of prune belly syndrome

Background: Prune belly syndrome (PBS) is a rare congenital disorder among adults, and the way for repairing abdominal wall musculature has no unified standard. Materials and methods: We described combining laparoscopic and open technique in an adult male who presented with PBS. Physical examination and radiological imaging verified the case of PBS. The deficiency of abdominal wall musculature was repaired by combining laparoscopic and open technique using a double-deck complex patch. Results: The patient successfully underwent abdominal wall repair by combining laparoscopic and open technique. Postoperative recovery was uneventful, and improvement in symptom was significant in follow-up after 3, 6, 12, and 24 months. Conclusions: Combining laparoscopic and open technique for repair of deficiency of abdominal wall musculature in PBS was an exploratory way to improve life quality.

Laparoscopic Plicated Sleeve Gastrectomy: a Technical Report

The standard approach to laparoscopic sleeve gastrectomy (LSG) involves sleeve-forming through a vertical gastrectomy, producing a narrow, tubular stomach. Considerable laparoscopic skills are required to find a suitable size at which the pressure of the sleeve is not excessive and the restriction is sufficient for obtaining good weight-loss effect without increasing the risk of complications. There is no doubt that considerable technical details are required to create a “perfect sleeve.” We report our sleeve-forming technique for LSG involving both vertical gastrectomy and plication, which we have termed “laparoscopic plicated sleeve gastrectomy.” This technique was shown to be safe and efficacious for the treatment of severe obesity and can reduce technical difficulties in the creation of a “perfect sleeve.”