Laparoscopic Primary prosthetic repair of Hiatus hernia with GERD in 88 patients

Transcription

1 Minimally Invasive Surgery II 0185 Laparoscopic Primary prosthetic repair of Hiatus hernia with GERD in 88 patients V. Golash* Sultan Qaboos Hospital, Salalah, Oman Aim: The routine or selective use of mesh in the surgical management of Hiatus Hernia repair is controversial. Recurrence rate after primary hiatus hernia repair is high. Commonest cause of recurrence is the disruption of hiatal repair and migration of wrap in the chest. Several authors have reported lower rate of recurrences after hiatal closure with prosthesis. Prosthetic reinforcement is recommended for failed primary closure but based on high recurrence rate following the primary closure many authors are now routinely using prosthesis for primary repair as in laparoscopic mesh repair of ventral and inguinal hernia. We present our results of primary repair of the hiatus hernia with GERD with prosthesis. Methods: We reviewed the medical records of 88 patients (31 male and 57 female) who had prosthetic Hiatus hernia repair from January 2000 to June The mean age was 46 yrs. (range 25-69). All hiatus hernia from type I to IV and recurrent were included: 80 patients had sliding hernia, 5 Para-esophageal hernias, 2 with recurrence after laparoscopic Nissen Fundoplication and 1 patient after primary open Nissen Fundoplication. The hiatus size reported varied from 3-8 cm. The surgical procedures included 80 laparoscopic Nissen fundoplication, 4 Toupet fundoplication, 3 anterior gastropexy, and 1 patient had Collis gastroplasty. Posterior onlay mesh cruroplasty with 3x5cm mesh was done in 71 patients, circular mesh in 5, and posterior inlay mesh in 12 patients. Dual mesh was used in 5 patients and prolene in 83 patients. Procedure: the crurae were sutured with interrupted 2 O Ethibond suture and then an onlay mesh was stitched or stapled to crurae and diaphragm. When it was not possible to approximate the crurae without tension an inlay mesh was used to bridge the gap. The size and shape of mesh was tailored individually. Results: Mean Operation time was 180 minutes (range ). Concomitant procedures included cholecystectomy (25), ventral hernia repair (11) and inguinal hernia repair (2).There was no conversion to open, reoperation, mesh related complications, or intraoperative complications. One patient had significant dysphagia requiring dilatation. There were fewer postoperative complications of diarrhea (2), heartburn (5) and flatulence (7). In follow up patients, 22 had upper GI endoscopy and a barium meal was performed in 18 patients. The radiological recurrence was seen in 5, symptomatic recurrence in 3. Mean duration of follow up (67 patients) was 56 months (range months). Conclusions: Mesh cruroplasty is safe but further studies are needed to prove the superiority of mesh repair over simple cruroplasty over a long term. Type of mesh, Shape of mesh and placement is controversial.

2 Minimally Invasive Surgery II 0288 A Randomised Controlled Trial examining the role of Transversus Abdominis Plane (TAP) blocks in patients undergoing laparoscopic colorectal resections. C.J. Walter*, C. Maxwell-Armstrong, T. Pinkney, C. Gornall, A.G. Acheson Queen's Medical Centre, Nottingham, UK Aims: To assess the effects of transversus abdominis plane (TAP) blocks on opioid requirements in patients undergoing laparoscopic colorectal resections. Methods: Patients undergoing laparoscopic colorectal surgery at a single centre were randomised to receive either bilateral TAP blocks (ultrasound-guided TAP infiltration with 2mg/kg L-Bupivacaine up to a maximum dose of 150mg); or the control (no TAP block). The blocks were administered prior to surgery after the induction of a standardised anaesthetic by an anaesthetist who was otherwise uninvolved with the case. The patient, anaesthetist, surgeon and ward staff were blinded to treatment allocation. All patients received post-operative analgesia with paracetamol and a morphine PCA. Cumulative opioid consumption and pain scores were recorded at 2, 4, 6 and 24 hours postoperatively and compared between the 2 groups using an intention-to-treat analysis of the patients converted to open surgery. Results: The intervention, TAP block group, (n=33) and control group (n=35) were comparable for demographics, specimen pathology and type of procedure. Seven patients (2 of the TAP block group and 5 of the control group) were converted to open surgery. The cumulative morphine usage in those patients receiving a TAP block was significantly less than those patients who were randomised to no TAP block (see table). No differences were reported in pain scores or median length of stay (LOS) between the 2 groups. Conclusions: Pre-operative TAP blocks in patients undergoing laparoscopic colorectal resections reduced opioid usage in the first post-operative day in this study. No differences in pain scores or LOS were observed between the groups however this study was underpowered to demonstrate equivalence. Cumulative morphine use (mg) Time post-op 2 hours 4 hours 6 hours 24 hours TAP Group - median (IQR) 13 (11-16) 16 (14-26) 20 (15-29) 40 (25-63) No TAP Group - median (IQR) 18 (12-26) 26 (17-31) 32 (21-46) 60 (39-81) P Value <

3 Minimally Invasive Surgery II 0376 Laparoscopic surgical skills are significantly improved by the use of a portable laparoscopic simulator: results of a randomised controlled trial T. Johnston*, B. Tang, A. Alijani, R. Steele, G. Nabi 1 NHS Tayside, Scotland, UK, 2 University of Dundee, Scotland, UK Aims: This study aims to evaluate the role of a portable laparoscopic simulator (isim) in enhancing laparoscopic skills acquisition Methods: Core laparoscopic skills were identified by five experienced laparoscopic surgeons and modelled into exercises. Twenty surgical naive medical students had baseline laparoscopic skills assessed on a fixed simulator. Participants were randomised to either 14 hours training on a portable laparoscopic simulator over a three week period, or control with no training. Outcome measures included time to complete and global rating scores of a clipping and dissection task. At 3 weeks two expert laparoscopic surgeons blinded to the allocation of participants assessed their pre and post intervention performances recorded on a CD-ROM. Results: No differences were observed in baseline skills level between the two groups. The intervention group had better quality of scissor dissection (p0.0038); improved clipping skills (p0.0051) and took less time to accomplish the tasks (p0.0099) in comparison to control. Conclusions: Training on the portable Integrated Laparoscopic Simulator significantly improved core laparoscopic skills in medical students with no prior experience.

4 Minimally Invasive Surgery II 0445 Patients Opinion of Single Incision Laparoscopic Surgery N. Muhibullah*, S. Sarker Safety Innovations Unit, Worcestershire, UK Aims: SILS (single incision laparoscopic surgery) is a new surgical technique which allows patients to have one small incision during surgery. The paradigm shift in conventional laparoscopic surgery in the 1990 s was due to patient acceptance of the new technique. In this study we evaluate the opinion of patients of SILS. Methods: A questionnaire was constructed about SILS and conventional laparoscopic appendiectomy and cholecystectomy. 426 patients were questioned prospectively about key aspects of the operations. The groups were divided into <35 years and >35 years. Results: There were 426 patients questioned, 196 <35 years and 230 >35 years. 75% of the <35 years preferred a laparoscopic to a SILS approach. 95% of the >35 years preferred a laparoscopic to a SILS approach. 80% of the <35 years thought that SILS compared to a laparoscopic approach would have a higher complication, but a better cosmetic result and less pain. 95% of the >35 years thought that SILS compared to a laparoscopic approach would have a higher complication rate, but no improvement in cosmesis or pain. Conclusions: Our study demonstrates that although SILS is increasingly performed in the UK, it seems that it is less popular then conventional laparoscopic surgery. This is probably due to the possibility of more complications compared to the widely practised conventional laparoscopic surgery and no perceived significant improvement in cosmesis.

5 Minimally Invasive Surgery II 0474 Outcome of Minimally Invasive Pancreatic Necrosectomy without irrigation D.J. Malde*, S.S. Raza, N. Khan, A. Aldouri, A.M. Smith St James University Hospital, leeds, UK Aims: Necrotizing Pancreatitis with secondary infection of the pancreatic tissue is associated with significant morbidity and mortality. Current evidence suggests that a minimally invasive retroperitoneal necrosectomy (MIRP) is feasible, well tolerated and beneficial for the patient when compared with open surgery. Current minimal access techniques all recommend routine irrigation but we aim to show that comparable results can be achieved without irrigation. Methods: A total of 16 patients who underwent MIRP from September 2007 till April 2011 were included in the study. Results: The mean age was 52.5 years with 13 patients transferred from other centers. The etiology was gallstones (13), alcohol (1), idiopathic (1) and hyperlipidemia (1). The average time before 1 st necrosectomy was 50.2 days. The mean number of procedures was 3.3 (range 1-7) with one patient requiring an open procedure. 1 patient required post-necrosectomy ICU admission. 13 patients had nasojejunal feed and 4 patients started with parenteral feed which was later converted to nasojejunal. 5 patients developed a pancreatic fistula, 3 patients developed colonic fistula and 2 patients died. Mean inpatient stay was 82.6 days (range ). Conclusions: This series suggests that doing MIRP without irrigation has results comparable to other centers carrying out routine irrigation.

6 Minimally Invasive Surgery II 0602 The post-operative outcome after laparoscopic colorectal cancer surgery is better than after open surgery K. Haldane* 2, K. Potiszil 1, M. Hutton 1, A. Widdison 1 1 Royal Cornwall Hospital, Truro/Cornwall, UK, 2 Peninsula College of Medicine and Dentistry, Truro/Cornwall, UK Aims: To compare the post-operative outcome after laparoscopic colorectal cancer surgery (LS) with open surgery (OS). Methods: A single surgeons prospectively collected database of all patients with primary colorectal adenocarcinoma resected between was analysed. Emergency resections were excluded. The results for LS converted to OS were considered in the LS group. Results are expressed as median (IQR) and analysed using Mann Whitney U test. Results: 298 OS and 134 LS (2 converted) were performed. There was no difference in age (LS: OS = 71 (63-78): 71 (62-78) years) or gender (male LS: OS = 58%: 54%), in T stage or Dukes stage. Length of stay (LOS) after LS 4 (2-6) days was less than after OS 9 (7-13) days (P<0.01). This difference was the same in both the young (<70 years) and old (>70 years) and linear regression did not show a relationship between LOS and age for either group. LOS was less after laparoscopic right hemicolectomies (LS: OS = 2 (1-4): 8 (3-10) days, P<0.01), laparoscopic high anterior resections/left hemicolectomies (LS: OS = 3 (2-4): 8 (6-11) days, P<0.01) but not after laparoscopic Hartmanns/Low anterior resections (LS: OS = 6 (4-13):10 (8-14) days, P=0.3) when a stoma was made. Fewer patients developed complications after LS (19%) than after OS (33%, P=0.03). There was no difference in anastomotic leak rate (3%), reoperation rate (LS: OS = 9%: 6%) or risk of developing an intra-abdominal abscess (3%). Excluding patients with an anastomotic leak or re-operation the probability of a cardiopulmonary-renal complication were reduced after LS (2%) compared with OS (8%, P=0.01). The 30-day mortality after OS was 5% compared with 2% after LS (P=0.2). After OS the postoperative mortality increased with age (linear regression P<0.01) whereas there was no change after laparoscopic surgery (P=0.8). The post operative mortality among patients <70 years (LS: OS=3%: 2%) and >70 years (LS: OS=1%: 8%, P=0.4) was the not significantly different. Conclusions: The post-operative outcome after LS is better than after OS because the LOS and complication rate are reduced and the trend is toward reduced mortality in the elderly.

7 Minimally Invasive Surgery II 0636 Epidural vs Continuous Wound Infusion Analgesia following laparoscopic colonic resection: A double blinded randomised controlled pilot trial C. Boulind*, P. Ewings, I. Jenkins, J. Blazeby, N. Francis Yeovil District Hospital, Yeovil, Somerset, UK Aims: With the emerging new modalities of analgesia after laparoscopic colorectal (LCR) resection and the adoption of enhanced recovery, the role of epidural analgesia has been questioned. This NIHR funded pilot trial assessed the feasibility of an RCT comparing epidural and Wound Infusion Catheter (WIC) following LCR surgery. Methods: Patients undergoing elective LCR for tumours in two centres were randomised to epidural or WIC between April 2010 and May Sham epidural or WICs were used to blind surgeons, patients and outcome assessors. The primary outcome was the feasibility of a large RCT, and all outcomes for a definitive trial were tested, including the use of Visual Analogue Pain scores. The success of the double dummy blinding technique was assessed using a mixed methods approach including the Bang Blinding Index and qualitative interviewing. Results: Of 34 patients successfully randomised, 21 were male with mean age of 70 years. The predicted recruitment rate was maintained despite logistical challenges organising the trial. There was no mortality, 3 morbidities and data were collected for all outcomes. Most outcome data were successfully captured, patients remained blinded successfully and this pilot emphasised the need for rigorous standard operating procedures for data collection in a subsequent trial. The mean pain visual analogue score on day of discharge was 2.6 in the epidural group and 1.4 in the WIC group (SD 2.1). Median length of stay was 4 days in both arms (range 2-35, IQR 3-5). Mean use of additional analgesia (equivalent to mg iv morphine) was 12mg in the WIC arm and 9mg in the epidural arm. Qualitative interviews found that patients found participation in the trial acceptable and they would be willing to consider participation in a similar trial in the future. Conclusions: An RCT investigating the role of epidural and WIC for post-operative analgesia following laparoscopic colorectal resection is feasible and acceptable to patients with successful blinding. However, recruitment of centres in a large RCT may be difficult as many centres are moving away from the routine use of epidural following LCR resections

8 Minimally Invasive Surgery II 0679 Randomised comparison of long term recurrence after open and laparoscopic groin hernia repair S. Kumar* The Royal Infirmary, Edinburgh, UK Aim: To compare recurrences in patients randomised to laparoscopic and open groin hernia repair over 15 years. Methods: Patients presenting with groin hernia between Sept 1994 and March 1997 were assessed for recruitment into a randomised trial of open and laparoscopic repair. The patient demographics, type of hernia and type of repair etc. were prospectively entered into a database. The database was linked to the current hospital database to determine if the patient has died or has had further groin hernia surgery by March Hernia recurrence was defined by reoperation. Chi square test was used to determine significance between two groups of patients. The non-randomised group is included in this report. Results: Of the 582 patients assessed, 307(52.7%) were randomised to laparoscopic 153(49.1%) and 154 (50.1%) to open repair. There was no 30 day hospital mortality. 80/307 (26.0%) patients have died since hernia repair: laparoscopic, 42/80 (52.5%), open 38/80(47.5%), P >0.05. A recurrent or a contra-lateral hernia repair had been performed in 6(3.9%) of the laparoscopic and 5(3.2%) of the open repair patients, P > 0.05 at a mean follow up of 15 years. In the non-randomised group of 275/582 (47.2%) patients, a further hernia surgery had been performed in 8/131 (6.1%) after laparoscopic repair and 7/144 (4.8%) after open repair, P >0.05. Overall, patients who died had a mean age of 68.3 years (range 23 92) at initial hernia repair. Conclusions: A recurrent or a contra-lateral groin hernia was repaired in 3.5% of the patients at a mean follow up of 15 years. There was no significant difference between open and laparoscopic repair.

9 Minimally Invasive Surgery II 0698 Reversal of Hartmann s through stoma site-is this the way forward? A. Banerjee*, B. Banky, D. Borowski, T.S Gill, D. Garg University hospital of North Tees, Stockton on tees, UK Aims: Hartmann's procedure is commonly performed in UK, but rates of bowel restoration barely reach 25%. This is due to high complication rates, high-risk patient groups. In this study, we examined outcomes for different access techniques and compare them. Methods: Retrospective case-note analysis of patients who underwent reversal of Hartmann's operation between in one hospital. Results: Thirty-five patients underwent reversal of Hartmann's procedure; the initial procedure was done for diverticular disease in 25 (71.4%), cancer in seven (20.0%), colo-vesical fistula in one (2.8%) anastomotic dehiscence in one (2.8%) and one pseudomembranous colitis(2.8%). Twelve procedures were planned open, nine as conventional laparoscopic (CL) and fourteen single-port laparoscopic (SPA) operations. Mean operating time for open surgery was 181 minutes, and for SPA 146 minutes. CL group had five open conversions (55.6%), with average operating-times of 255 minutes compared to 185 minutes in CL-completed group. Two patients from the SPA group were converted(14%) and average operating time was 220 minutes. There was significant differences in hospital stay between the groups (open: 10 (range 5-29); LCcompleted: 6 (3-7); LC-converted: 18 (6-31); SPA: 5 (2-19days);SPA converted:27(9-44). Complication rate was 37.1%, with the highest in the converted groups; one death occurred(2.9%). Conclusions: Hartmann's reversal surgery is challenging and associated with high morbidity. In this study, there were no differences in length of surgery between open, CL-completed and SPA approaches, however significant difference in hospital stay were seen. Poor outcome was seen for CL-conversions, making consideration of early conversion important.

10 Minimally Invasive Surgery II 0953 Comparison of different laparoscopic bariatric surgery techniques: Gastric banding, sleeve gastrectomy and gastric bypass. M.A. Karim, C. Arneil*, A. Ali Ayr University Hospital, Ayr, UK Aims: The aim of this study is to compare the three most commonly performed bariatric procedures: gastric banding, sleeve gastrectomy and gastric bypass in terms of operative time, peri operative hospital stay, outcome and impact on health services before and after surgery. Methods: 73 bariatric procedures were performed between May 2008 and December The data collection period was on average 60 months pre-operatively and 24 months postoperatively. Data was analysed as per procedure type: operative time and hospital stay for procedure. We compared the impact on health services utilisation of each procedure (out patient clinic visits, Hospital admissions for co morbidities, annual duration of hospital stay) before and after bariatric surgery. Results: The total number of laparoscopic bariatric procedures was 73; consisting of 34 gastric bands, 28 sleeve gastrectomies and 11 gastric bypasses. Female: 58, male: 15; median age 45 years (range: years). There were24 patients with type II diabetes ( 5 gastric bands, 12 sleeve gastrectomies and 6 gastric bypasses.) Bariatric outcome: Median reduction in BMI at 12 months Gastric bypass: 35.2%, Gastric sleeve: 34.3%, Gastric banding: 14.9%. The average duration of hospital admission and duration of bariatric surgery was shortest for gastric banding and longest for gastric bypass. Health service utilisation: Gastric band patients had significant reductions in outpatient appointments post-operatively (47.3%; p=0.05), Gastric bypass and sleeve gastrectomy patients had significant post-operative reductions in annual hospital admissions (74.7% with p=0.01 and 45.0% with p=0.04 respectively) with reduced annual duration of hospital stay (79.2% with p=0.02 and 62.8% with p=0.004 respectively).glycaemic control: Gastric bypass patients had the highest average reduction in HbA1c compared to preoperative levels at 6 months (26% reduction, p = 0.06) and at one year (27% reduction, p = 0.09), compared to those for sleeve gastrectomy (17% reduction with p = 0.03 at 6 months and 21% at one year) and gastric banding (6 months: 11% reduction with p = 0.02; one year: 9.7% reduction with p =0.4). Conclusions: Gastric banding is less invasive compared to the other bariatric procedures however the outcome of sleeve gastrectomy and gastric bypass in terms of BMI reduction, glycaemic control and reduced utilisation of health services due to improved health,is better.