Abstract: BACKGROUND: Since the early 1990s, the laparoscopic approach to inguinal hernia repair using three ports has gained increased popularity worldwide. Recently, single-incision laparoscopic surgery to reduce the invasiveness of traditional laparoscopy further is under development. This study aimed to assess the safety and feasibility of the single-port approach for laparoscopic totally extraperitoneal (TEP) repair of inguinal hernia and to report the authors' initial experience using the TriPort system. METHODS: Between 18 October 2008 and 1 April 2009, 19 single-incision laparoscopic TEP repairs of inguinal hernia were performed for 16 patients at the Royal Surrey County Hospital, Guildford, United Kingdom. Data regarding patient demographics, type of hernia, operating time, complications, postoperative hospital stay, and recurrence were prospectively collected. The length of the incision at the time of the operation and at a clinic follow-up visit also was measured. RESULTS: All 16 patients were men, ranging in age from 21 to 87 years. Of the 16 men, 13 had a unilateral inguinal hernia. For 7 of the 13 men, the hernia was on the left side. The median operating time was 40 min for unilateral hernia and 70 min for bilateral hernia. There were no intraoperative complications and no deaths. Discharge was on the same day for 12 of the men, and within 24 h for the remaining 4 men. Minor wound complications developed for two men. One man reported transient pain in his testicle. There was no evidence of early recurrence during a median follow-up period of 72.5 days. The median incision length was 30 mm, and the median scar length at the clinic follow-up visit was 25 mm. CONCLUSION: The authors' experience has shown that single-port laparoscopic TEP inguinal hernia repair with the TriPort system is safe and feasible. Prospective randomized studies comparing single-access and conventional multiport laparoscopic TEP repairs with long-term follow-up evaluation are needed to confirm the authors' initial experience.
Abstract: BACKGROUND: The aim of the present study was to prospectively assess the feasibility, safety, and acceptability of performing day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease on a routine basis and to determine possible implications for health care costs to the hospital. METHODS: All patients undergoing laparoscopic fundoplication between November 2005 and November 2007 under the care of one surgeon were included in the study. Inclusion criteria were American Society of Anesthesiologists (ASA) grade I and II with adequate home support. The surgical procedure was laparoscopic modified Lind fundoplication in all the cases. Patients were reviewed in the clinic at 6 weeks and were subsequently assessed through a structured postal questionnaire at a median of 1 year. RESULTS: Over the 25-month period, a total of 130 laparoscopic modified Lind fundoplications were performed, of which 103 (79.2%) met the inclusion criteria for day-case surgery. The patients were 16 to 75 years of age. Ninety (87.4%) were discharged on the same day as planned, and 11 patients were admitted overnight because of nausea. At clinic follow-up at a median of 6 weeks all patients expressed satisfaction and were reflux free. There was a significant reduction of mean modified Visick score and visual analog scale for reflux at a median of 1 year after surgery. CONCLUSIONS: Routine day-case laparoscopic modified Lind fundoplication for gastroesophageal reflux disease is safe and well tolerated, with high levels of patient satisfaction and reduced costs to the hospital. Patients with ASA grade >2 and redo antireflux surgery should not be considered for day-case surgery. Hospital readmission was required in less than 3% of patients after discharge home, but those readmissions were not related to early discharge on the same day of surgery.
Abstract: INTRODUCTION: Despite increasing evidence of the benefits and safety of early laparoscopic cholecystectomy (LC) in acute gallstone disease, it is not widely practised in England. The Royal College of Surgeons of England support the separation of emergency and elective surgical care. The aim of this prospective study was to examine the impact of the implementation of 'Surgeon of the Week (SoW)' model on the number of early LCs performed and the efficiency of the emergency theatre activity in our hospital. This study also looked into its implications on specialist registrar training for early LC, and the financial impact to the hospital. PATIENTS AND METHODS: Between January 2007 and May 2008, demographic data, admission and discharge dates, complications, conversions to an open operation and deaths were collected for all patients who underwent early laparoscopic cholecystectomies. For ease of comparison, patients were divided into Group A representing before introduction of SoW (1 January 2007 to 30 August 2007) and Group B representing after introduction of SoW (1 October 2007 to 31 May 2008). The total numbers of operations performed in the emergency theatre list in the two groups were also calculated. RESULTS: A total of 1361 emergency operations were performed on the emergency theatre list in Group A, of which 951 were general surgical procedures. In Group B, the numbers of emergency procedures were 1537, of which 1138 were general surgical operations. There was a significant increase in the number of general surgical operations after introduction of SoW (P = 0.013). Before introduction of the SoW rota, 45 early LCs were performed. This increased to 118 after SoW which was significant (P < 0.001). In Group A, the number of early LCs performed by surgical trainees was 10 (22%). In Group B, the number of LCs performed by surgical trainees was 35 (30%; not significant). CONCLUSIONS: This study has demonstrated an increase in the efficiency of the emergency theatre with an increase in the number of early LCs on their index admission without extra morbidity following implementation of the SOW model in our hospital. We recommend the introduction of a suitable emergency surgical consultant on-call model separating emergency and elective surgical care depending on local circumstances. This can lead to significant cost savings and reduce re-admissions with gallstone-related complications.
Abstract: BACKGROUND: Day-surgery laparoscopic cholecystectomy (LC) should be the procedure of choice in patients with symptomatic gallstone disease. This article assesses feasibility, patient outcome and predictive factors for successful day-case laparoscopic cholecystectomy. METHOD: A retrospective analysis of our prospective database of 176 patients following laparoscopic cholecystectomy in a day-surgery unit was performed. A telephone interview was conducted within 24 h after discharge and again after 3 weeks. RESULTS: Of the 176 cases included in this study, 74% had biliary colic, cholecystitis (16%), pancreatitis (8%), and jaundice (2%). In addition to LC, nine patients (5.1%) underwent laparoscopic bile duct exploration and ten (5.7%) had an additional procedure performed. Eighty-six percent of the patients were discharged the same day. Multivariate analysis identified risk factors affecting same-day discharge, including age greater than 50 years and intraoperative complications. Bile duct exploration reduced the odds of discharge but did not reach significance. Postoperative telephone interviews identified high patient satisfaction with 86% of respondents recommending LC as a day-surgery procedure. CONCLUSION: Day-surgery LC is a safe procedure with an acceptable rate of patient discharge. However, intraoperative complications or age over 50 years adversely affected the same-day discharge rate and as such should be taken into consideration when planning day-case laparoscopic cholecystectomy.
Abstract: BACKGROUND: Laparoscopic Heller myotomy is the most effective therapy for achalasia. All case series have reported a minimum length of stay of more than 1 day. "True" day-case laparoscopic Heller myotomy has not been reported, so far. The aim of this study was to review our results with laparoscopic Heller myotomy with respect to the length of stay following the procedure. METHODS: All patients undergoing laparoscopic Heller myotomy between August 2000 and July 2007 under the care of one surgeon were included in the study. This was performed by incising 6 cm of distal esophageal musculature, extending to 2 cm below the gastroesophageal junction. The myotomy was covered by an anterior fundoplication. All patients were reviewed in the clinic at a median of 6 weeks after surgery and, thereafter, if necessary. RESULTS: Over the 7-year period, 24 consecutive patients with achalasia were treated in this manner. There were 13 women and 11 men, with an age range of 12-73 years. Intraoperative complications included mucosal perforation in 2 patients (sutured immediately) with no postoperative complications or conversion to open surgery. There were no deaths. The average length of stay was 1.9 days (range, 0-4). The last 2 patients were discharged on the same day, and the 5 previous to this were discharged within 23 hours of surgery. There were no adverse outcomes related to early discharge, and there were no readmissions. All patients reported good to excellent results with a relief of dysphagia on follow-up. Three patients (12%) developed recurrent dysphagia after an initial improvement, requiring dilatation only several months later. CONCLUSIONS: Based on our own experience, we believe that laparoscopic Heller myotomy with anterior partial fundoplication is safe and achieves a good outcome in the treatment of achalasia. It is well tolerated and can be considered a true day-case procedure.
Abstract: OBJECTIVE: Gallstones are a rare cause of duodenal or gastric outlet obstruction and therefore are not commonly suspected. Rigler's radiographic triad of pneumobilia, bowel obstruction, and an ectopic gallstone is seen in few of these patients. The symptoms are insidious and nonspecific, and the diagnosis is usually made radiologically. Although CT scans are far more sensitive, 25% of cases are still missed, often because the size of the offending gallstone is underestimated. CONCLUSION: Better assessment of stone size, and therefore higher accuracy of diagnosis, could be achieved if attention is paid to more subtle but nonetheless important signs. These include compressed air in dependent areas of the duodenal lumen, an area of soft-tissue rather than fluid density surrounding the calcified rim of the stone, and a faint radiolucency in or beyond this soft-tissue area that could represent laminations of fat or air in the stone.
Abstract: Laparoscopic appendectomy is an established procedure in the treatment of appendicitis. Complications of the procedure are related to the Veress needle and trocar insertions or pertain to actual operative procedures. Trocar-elated major bleeding is rare, and, if it occurs, is detected on the table or during the immediate postoperative period. Delay in recognition may lead to significant morbidity and mortality. We report a case of giant parietal wall hematoma in a 34-year-old female, presenting one week after discharge from the hospital. The hematoma was completely evacuated by exploration through paramedian incision, followed by an uneventful recovery.
Abstract: In spite of its inaccessibility, every conceivable object has been inserted into the urinary bladder. Such patients may have a psychiatric disorder with a sexual perversion or inquisitiveness (as in children) as the underlying cause. We report a case of an aluminum rod inserted into the urinary bladder by an adult male, which was removed successfully by surgery.
Abstract: AIM: To evaluate the efficacy of modified mesh rectopexy for complete rectal prolapse. SUBJECT AND METHODS: In a prospective study between 1989-1998, 47 patients (25 males and 22 females) underwent modified mesh rectopexy using a "Cross-shaped" knitted monofilament polypropylene. They were followed up for a period of four years postoperatively. RESULTS: Anatomical repair was achieved in all patients. Preoperative constipation, a complaint in 22 patients, was relieved in 13 patients and need for laxatives decreased in another four. There were no new cases of constipation. Sexual functions were not hampered irrespective of gender. The complications included prolonged ileus (4 patients), faecal impaction (1), partial mucosal prolapse (2) and post-operative obstruction (2). There was no recurrence. CONCLUSION: This technique aligns the rectum, avoids excessive mobilisation and division of lateral ligaments thus preventing constipation and preserving potency. We recommend this technique for patients with complete rectal prolapse with up to grade 1, 2 and 3 incontinence based on Browning and Parks classification.
Abstract: Tuberculosis of the stomach and duodenum is rare in patients with pulmonary tuberculosis. Primary involvement is even rarer. Two cases of primary tuberculosis of the localised to the pyloro-duodenal area are presented. The most common symptoms are non-specific leading to a difficulty in establishing a pre-operative diagnosis. A high degree of suspicion is therefore required for its diagnosis and to differentiate it from more frequent causes of gastric outlet obstruction such as chronic peptic ulcer disease and gastric carcinoma. The treatment of gastric tuberculosis is primarily medical with anti-tuberculous drug therapy. The role of surgery lies in the cases with obstruction following hypertrophic tuberculosis. The surgery done is usually a gastroenterostomy. With the relative rate of extra-pulmonary tuberculosis increasing, tuberculosis of the pyloro-duodenal area should be considered in the differential diagnosis of gastric outlet obstruction.
