Technical Details of Laparoscopic Sleeve Gastrectomy Leading to Lowered Leak Rate: Discussion of 1070 Consecutive Cases

The effect of triclosan-coated sutures on the incidence of surgical site infection in laparoscopic sleeve gastrectomy, laparoscopic appendicectomy or laparoscopic cholecystectomy: A multi-centre, double-blind, randomized, intra-individual study

Surgical site infection (SSI) is a common cause of post-operative morbidity. According to the latest report announced by CDC, the SSI accounts for 20% of healthcare-associated infection with a high risk of mortality up to twofold to 11-fold increase with high economic burden for the prolonged hospital stay. Port site infection (PSI) is a subgroup of SSI occurring at the ports of laparoscopy. We tried to determine the efficacy of polyglactin 910 suture coated with triclosan in lowering the rate of PSI in some of the clean-contaminated wound surgeries. This study included 480 individuals eligible for laparoscopic cholecystectomy, appendicectomy or sleeve operations. Polyglactin 910 sutures coated with triclosan were used in one port site incision while polyglactin 910 sutures were used in the other port sites incisions. In patients who underwent laparoscopic cholecystectomy and appendicectomy, the incidence of PSI was significantly lower in the triclosan-coated sutures. In sleeve gastrectomy patients, although a lower number of triclosan-coated sutures developed PSI, there was no statistically significant difference between triclosan and non-triclosan-coated sutures. This study showed that using sutures coated with antiseptics like triclosan has clinical benefits to prevent SSIs in most of the laparoscopic surgeries.

MU-LapaRobot: A Corporative Surgical Robot for Laparoscopic Surgery

Objective:

Development of surgical instrument robot (MU-LapaRobot) for assisting in conventional laparoscopic surgery.

Methods:

A robot was designed based on instrument movement for a conventional procedure. The mechanism mimics and constrains manipulation movement through the wire-driven transmission. It is flexible for robot end-effector, which has a lightweight and small size. The usability of the robot is passive and active robot tasks with an interconnected driving system. Three main parts of the robot are robot end-effector, transmission, and a driving system.

Results:

On a robot platform, a parameter for setup is robot posture. The adjustment of robot position and projection of manipulation area is influenced by the accuracy of movement. To verify movement, command and exact movements are measured. Compensation with the control system is improved in order to improve the accuracy of the system.

Conclusion:

MU-LapaRobot provides surgical instrument manipulation by using wire-driven transmission with an effective system and requires less interference in the conventional operation.

The Impact of Staple Line Reinforcement Utilization on Bleeding and Leak Rates Following Sleeve Gastrectomy for Severe Obesity: a Propensity and Case-Control Matched Analysis

INTRODUCTION

Staple line reinforcement (SLR) is a commonly used technique during laparoscopic sleeve gastrectomy (SG) for severe obesity. There remains controversy over the potential benefit or risk associated with SLR. There are currently no consensus recommendations about SLR use. Its use is surgeon-dependent and remains controversial.

STUDY AIM

To determine the impact of staple line reinforcement on staple line leak and bleeding rates after sleeve gastrectomy.

METHODS

Using the Metabolic and Bariatric Surgery Quality Improvement Program Participant User File (MBSQIP-PUF) database, we identified patients who had a SG in 2015 and 2016. SLR utilization status was used to create two cohorts. An unmatched cohort analysis was performed, and the outcomes were compared. A propensity score and case-control matched cohort analysis were then performed, and the outcomes were compared. Statistical analysis was performed with SPSS and SAS.

RESULTS

Of the 189,173 SG cases identified, SLR utilization was noted in 127,521 (67.4%). In the unmatched analysis, bleeding and reoperation were significantly higher in the cohort without SLR utilization. In both propensity score and case-control matched analysis, bleeding and reoperation remained significantly higher in the cohort without SLR utilization. There was no difference in mortality and staple line leak rates between the cohorts.

CONCLUSIONS

SLR significantly reduces bleeding and reoperation rates following SG and has no deleterious impact on staple line leak rate. While further prospective studies factoring in the SLR method and staple characteristics are needed, this large database analysis supports the use of routine SLR during SG to reduce the risk of perioperative bleeding and reoperation.

Large Hiatal Hernia Repair with Urinary Bladder Matrix Graft Reinforcement and Concomitant Sleeve Gastrectomy

Background:

There is no current consensus on the management of large hiatal hernias concomitant with performance of a sleeve gastrectomy procedure. Proposed solutions have included performing a modified Nissen fundoplication, performing cruroplasty alone, utilizing the Linx device, performing cruroplasty with reinforcement material, and avoiding the sleeve procedure altogether in favor of a bypass procedure in order to minimize gastroesophageal reflux. Urinary bladder matrix (UBM) represents a biologically derived material for use in hiatal hernia repair reinforcement with the potential to improve durability of repair without incurring the risks of other reinforcement materials.

Methods:

This study reports the results of a retrospective chart review of 32 cases of large hiatal hernia repair utilizing both primary crural repair and UBM reinforcement concomitant with laparoscopic sleeve gastrectomy by a single surgeon. Hernia diameter averaged 6 cm (range 4–9 cm). After an average of 1 year followup, 30 patients were assessed for subjective symptoms of gastroesophageal reflux (GERD) using the Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) score. Twenty patients were evaluated with either upper gastrointestinal (GI) series, endoscopy, or both.

Results:

Each repair was successful and completed laparoscopically concomitant with sleeve gastrectomy. Anterior and posterior cruroplasty was performed using interrupted 0-Ethibond suture using the Endostitch device. The UBM graft exhibited favorable handling characteristics placed as a keyhole geometry sutured to the crura with absorbable suture. A careful chart review was undertaken to assess for complications. There have been no reoperations. After a median of 12 months (range, 4–27 months) of followup, an assessment of recurrences or long-term complications was completed. Median GERD-HRQL score was 6, with a range of 0 to 64 (of possible 75), indicating very low-level reflux symptomatology. Follow-up upper GI radiographs or endoscopy were obtained in 20 cases and show intact repairs.

Conclusion:

In this series of 32 cases, laparoscopic cruroplasty with UBM graft reinforcement has been effective and durable at 12 months of followup. This technique may offer one satisfactory solution for large hiatal hernia repair concomitant with laparoscopic sleeve gastrectomy that may achieve a durable repair with low GERD symptoms.

Complications of postlaparoscopic sleeve gastric resection: review of surgical technique

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a very frequent procedure in bariatric surgery. Despite its simplicity, it can have serious complications. Among these, gastric leak is one of the most feared complications. Numerous intraoperative maneuvers have been suggested in an attempt to decrease the incidence of leak. In our center, we decided to study one of the intraoperative measures proposed, which consists in positioning the suture machine to 1.5 cm from His corner.

METHODS

This retrospective study reported 101 cases of LSG performed in our center from 2012 to 2017. The patients were divided into two groups, with comparable anthropometric parameters and comparable inclusion criteria. In the two groups the operative technique used was the same, except for a maneuver: in the second group, attention was paid to keep a distance from the angle of at least 1.5 cm.

RESULTS

On a total of 101 procedures performed, the overall complication rate was 4,95%. In group 1 the rate of gastric staple line leak was 6.78%. In group 2 the rate was 2.38%.

CONCLUSIONS

The analyzed surgical technique seems to decrease the risk of leak without significantly impacting weight loss, and we have noticed in our clinical experience a decrease in the incidence of fistula from the time this measure was adopted. Also the statistical analysis encourage the continuation of experimentation.

Effects of bariatric surgery on knee osteoarthritis, knee pain and quality of life in female patients

OBJECTIVES

Bariatric surgery is an effective intervention for severe obesity and associated comorbidities. We compared symptoms, joint space and life quality of morbidly obese patients with symptomatic knee osteoarthritis before and after bariatric surgery.

METHODS

34 patients with knee osteoarthritis were evaluated with standing anteroposterior and lateral radiography, medial and lateral joint distances of the knees, Visual Analog Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire and the Short Form 36 (SF-36) before and 6 months after surgery.

RESULTS

Mean patient age was 48.53±6.91 years. Mean body mass index was 46.97±6.04 kg/m² and 34.41±5.62 kg/m² before and after surgery, respectively. SF-36 subscales were significantly higher after surgery (p<0.05), while mean VAS values and WOMAC scores were significantly lower postoperatively (p<0.001). Right knee medial and left knee lateral joint distance measurements were significantly higher postoperatively (p<0.05). BMI change, in linear regression analysis had no significant effect on VAS, WOMAC, SF-36 and knee lateral and medial joint distance measurements.

CONCLUSIONS

Although bariatric surgery might improve pain, life quality and functionality of knee osteoarthritis in early period, improvement is not directly related to weight loss amount.