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PubMed1998

Does the mesh require fixation?

As the technique of laparoscopic mesh repair of groin hernia has evolved, the need for mesh fixation has been questioned. Staple fixation has resulted in nerve injury, and some recurrences have been attributed to the use of a mesh that is too small. Drawing on a successful experience from open preperitoneal techniques, laparoscopic surgeons are now reporting results using large mesh without fixation. Early reports show varying success with the technique. Although the problem of nerve damage has been solved, high recurrence rates are reported in which the technique has been used to repair recurrent hernias. Although further studies are required to establish the causes and natural history of mesh migration, initial experience with the technique appears promising.

Hernia, Inguinal↗
PubMed1994

Histological assessment of the distal 'doughnut' in patients undergoing stapled restorative proctocolectomy with high or low anal transection.

A non-randomized prospective study of 38 patients, 32 with ulcerative colitis and six with familial adenomatous polyposis (FAP), who underwent high or low anal transection during stapled restorative proctocolectomy was undertaken. The median (range) height of the staple line 6 months after operation was 5.2 (3.2-6.0) cm after high transection compared with 2.9 (1.8-3.6) cm after low transection. Nineteen of 20 patients after high anal transection had columnar epithelium in the distal 'doughnut' versus 16 of 18 after low transection. Active colitis was present in 12 of 19 'doughnuts' in patients with high anal transection and columnar mucosa and in seven of 16 after low transection. Nine patients (high transection two, low transection seven; P < 0.05) had striated muscle in the stapled distal 'doughnut'. Dysplasia was found in the resected colon in one patient with ulcerative colitis and adenocarcinoma in two colectomy specimens (ulcerative colitis, one; FAP, one). No dysplasia or carcinoma was seen in any of the 'doughnuts' from patients with ulcerative colitis. Four patients with FAP (high transection, two; low transection, two) had microadenoma in the distal 'doughnut'. Despite attempts to place a stapled pouch-anal anastomosis below the anal transition zone, it was not possible to remove columnar mucosa completely from the remaining anal canal in most patients (16 of 18). High anal transection and pouch-anal anastomosis should be the preferred option in restorative proctocolectomy, as a dentate-line anastomosis may not fully eliminate columnar epithelium and may involve resection of some of the external sphincter.

Adenocarcinoma↗
PubMed2006

Technique for instant stapling of the sigmoid mesentery and mesorectum in laparoscopic colorectal surgery.

BACKGROUND: Dissection of the mesentery of the distal sigmoid or rectum before transection with a linear stapler in laparoscopic colorectal surgery is time consuming, can cause irritating bleeding, and can harm the vascularization of the distal part of the bowel anastomosis. METHODS: A new linear stapling technique in laparoscopic colorectal surgery is presented. This technique is used to perform transection of the distal sigmoid or proximal rectum with a linear stapler by instant stapling of both the mesentery/mesorectal fat and the intestine instead of standard preliminary dissection. This technique was performed in a pilot study of 27 laparoscopic colorectal operations for benign or malignant disease. RESULTS: In none of the 27 patients was leakage of the anastomosis observed. CONCLUSIONS: This new technique is safe and effective. It saves time, avoids troublesome dissection of the mesentery/mesorectum, which can cause bleeding or damage to the bowel, and preserves vascularization of the distal part of the anastomosis.

Adult↗
PubMed2000

Laparascopically assisted vaginal resection of rectovaginal endometriosis.

BACKGROUND: We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. TECHNIQUE: The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. EXPERIENCE: Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. CONCLUSION: The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved.

Adult↗
PubMed2002

Preoperative management is more important than choice of sutured or stapled anastomosis in Crohn's disease.

OBJECTIVE: To find out if there were any differences in postoperative complications and anastomotic leak rate between sutured and stapled anastomoses after bowel resection in patients exposed to the same preoperative management programme. DESIGN: Prospective observational non-randomised study. SETTING: Colorectal unit, Sweden. PATIENTS: Between 1996 and 2000 bowel resections with anastomosis were done for 42 consecutive patients with Crohn's disease. 20 patients had their anastomoses sutured (sutured group) and 22 had their anastomosis stapled (stapled group) over two successive periods. MAIN OUTCOME MEASURES: Postoperative complications and anastomotic leak rate. RESULTS: None of the patients were on immunosuppressive treatment and about half in each group had had several weeks of preoperative enteral nutrition. No anastomotic-related complications and few other postoperative complications were noted, irrespective of the anastomotic technique used. CONCLUSION: A strategy to operate on Crohn patients without steroids and, if indicated, treated preoperatively with enteral nutrition and percutaneous drainage of abscesses resulted in no anastomotic leaks and few postoperative complications. These results were independent of the anastomotic technique used.

Adult↗
PubMed1997

Abdominoperineal excision of the rectum--an endangered operation. Norman Nigro Lectureship.

PURPOSE: This study was undertaken to test the efficacy of an extreme policy of sphincter conservation by combining precise total mesorectal excision with low stapling techniques and endoluminal lavage to guard against implantation. METHODS: A total of 136 consecutive operations for cancer below 5 cm from the anal verge has been prospectively documented and followed for a mean of 7.7 (range, 1-18) years. A total of 105 of the operations were anterior resections (77 percent), and 31 were abdominoperineal excisions (23 percent). RESULTS: The oncologic results in the 105 patients who underwent anterior resections appear greatly superior to those of the patients who underwent abdominoperineal excisions, although the number of abdominoperineal excisions was small (31). Actuarial local recurrence at six years for anterior resection and total mesorectal excision was 1 percent for 85 curative procedures and 4 percent for all cases (n = 100), compared with 33 and 47 percent for abdominoperineal excisions (n = 15 and 31). Only four recurrences were observed below the level of the levators, three in the wound of an abdominoperineal excision and one in a stapled anastomosis after a palliative excision. No cases of nodal metastasis in the ischiorectal fossa were observed. CONCLUSION: In a unit specializing in sphincter conservation, precise total mesorectal excision from above appears oncologically superior to abdominoperineal excision. Three-fourths of patients with carcinoma of the lower one-third of the rectum can be offered sphincter-conserving surgery, although temporary defunctioning is probably prudent in such cases. The wound of an abdominoperineal excision may be a prerequisite for perineal recurrence, which may often be caused by implantation.

Abdomen↗
PubMed2003

Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years.

PURPOSE: Stapling of the ileal pouch-anal anastomosis with preservation of the anal transitional zone remains controversial because of concerns about the potential risk of dysplasia and cancer. The natural history and optimal treatment of anal transitional zone dysplasia ten or more years after surgery are unknown. This study establishes the risk of dysplasia in the anal transitional zone and the outcome of a conservative management policy for anal transitional zone dysplasia, with a minimum of ten years' follow-up after ileal pouch-anal anastomosis. METHODS: A total of 289 patients undergoing anal transitional zone-sparing stapled ileal pouch-anal anastomosis for inflammatory bowel disease between 1986 and 1990 were studied. Patients undergoing anal transitional zone-sparing ileal pouch-anal anastomosis who were studied with serial anal transitional zone biopsies for at least ten years postoperatively were included (n = 178). Median follow-up was 130 (range, 120-157) months. RESULTS: Anal transitional zone dysplasia developed in 8 patients 4 to 123 (median, 9) months after surgery. There was no association with gender, age, preoperative disease duration, or extent of colitis, but the risk of anal transitional zone dysplasia was significantly associated with cancer or dysplasia as a preoperative diagnosis or in the proctocolectomy specimen. Dysplasia was high grade in two patients and low grade in six. Two patients with low-grade dysplasia on two or more occasions after detection of low-grade dysplasia underwent completion mucosectomy and perineal pouch advancement with neo-ileal pouch-anal anastomosis. One patient with high-grade dysplasia on two occasions was to undergo completion mucosectomy, but this was not technically feasible. Partial mucosectomy with vigorous anal transitional zone biopsy was performed with close postoperative surveillance. Biopsies were negative for dysplasia. The second recently diagnosed patient with high-grade dysplasia underwent examination under anesthesia with negative anal transitional zone biopsies and will be kept under close surveillance. No cancer in the anal transitional zone was found during the study period. The 4 other patients with low-grade dysplasia on 1 or 2 occasions were treated expectantly and have been dysplasia free for a median of 119 (range, 103-133) months. CONCLUSIONS: Anal transitional zone dysplasia after stapled ileal pouch-anal anastomosis is infrequent and is usually self-limiting. Anal transitional zone preservation did not lead to the development of cancer in the anal transitional zone with a minimum of ten years of follow-up. Long-term surveillance is recommended to monitor dysplasia. If repeat biopsy confirms persistent dysplasia, mucosectomy with perineal pouch advancement and neo-ileal pouch-anal anastomosis is recommended.

Adult↗
PubMed1993

Laparoscopic small bowel resection and anastomosis.

Our aim was to assess the feasibility and safety of performing totally intracorporeal laparoscopic small bowel resection and anastomosis using a linear stapling device. Laparoscopic small bowel resection and anastomosis were performed in five young domestic pigs. Five trocars were used (2-5 mm, 2-11 mm, and 1-12 mm) for video laparoscopic access to the peritoneal cavity. Segments of jejunum 5 to 10 cm long were excised using two firings of a 30-mm linear stapler (Endo-GIA). The bowel was anastomosed with the stapler in a functional end-to-end fashion, and the enterotomy was stapled closed. The excised bowel segment was then placed in a nylon entrapment sack, morcellated, and aspirated with an automatic electrical tissue morcellator. The pigs recovered uneventfully, were allowed oral feedings on the day after the operation, and gained weight normally in the postoperative period. Sacrifice after 4 to 10 weeks revealed few adhesions, no evidence of anastomotic leaks, and the anastomoses to be widely patent. Clinical application will be facilitated by the use of longer laparoscopic staplers, but surgeons must also develop suturing skills to assure safe performance of advanced laparoscopic surgery.

Anastomosis, Surgical↗
PubMed2004

Previous synovectomy or epiphyseal stapling and the influence on knee replacement in juvenile chronic arthritis.

Seventy-seven anatomically graduated components (AGC) total knee arthroplasties (TKA) were performed on 52 patients with juvenile chronic arthritis. According to the nature of previous surgery on the knee, the patients were subdivided into three groups. The mean age at onset of disease in 23 patients with previous synovectomy of the knee was 11 (1.5-16) years, the mean age at the time of synovectomy was 20 (4-42) and the mean age when arthroplasty was performed was 31 (18-45) years. In nine patients with previous epiphyseal stapling, the mean age at disease onset was 4 (1.5-8) years, at stapling 8 (4-16) years, and at arthroplasty 23 (18-30) years. In patients with no previous surgery, the mean age at disease onset in this group was 7 (1.5-16) years and the mean age at arthroplasty 34 (16-64) years. Patients with need for epiphyseal arrest had an early disease onset and knee replacement in early adulthood. The mean age at knee replacements was highest in the group with no prior surgery.

Adolescent↗
PubMed2002

Fully stapled gastric bypass with isolated pouch and terminal anastomosis: 1-3 year results.

BACKGROUND: Roux-en-Y gastric bypass is a bariatric procedure of choice. There is evidence supporting a small isolated pouch and a wide anastomosis. Gastric vascular anatomy renders the ventral aspect less suited for anastomotic construction. The lesser curvature has abundant blood supply that should preferably not be interfered with. Terminal anastomosis is a logical choice. METHODS: We devised a way of making a fully stapled gastric bypass with complete separation of a pouch that empties dependently. The technique obviates the oral passage of the stapler anvil. Such a procedure facilitates the creation of an "end-of-pouch to end-of-jejunal limb" wide-diameter anastomosis and precludes the risk of staple-line disruption. RESULTS: Since October 1997 we have performed 227 such anastomoses (146 primary, 81 reoperative procedures) in consecutive patients with no leaks, no gastro-gastric fistulas and no mortality. The postoperative hospital time was 3.6 (3-8) days (median, range). In primary operations baseline BMI was 47.5, 1-yr 29.7 and 3-yr 29.2. Corresponding values for reoperations were 39.3, 30.8 and 31.5. Weight loss was adequate, and complications were limited to three anastomotic ulcers and two narrow stomas without visible ulcers but necessitating endoscopic dilatation. CONCLUSION: The technique confers distinctive advantages.

Adult↗
PubMed2004

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patient's postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.

Adult↗
PubMed2003

Should 'doughnut' histology be routinely performed following anterior resection for rectal cancer?

Stapled low anterior resection is widely employed in the treatment of rectal adenocarcinoma. The technique yields two tissue 'doughnuts' which are often submitted for histological examination. This process is labour intensive and not part of the minimum data set for colorectal cancer histopathology reports. A consecutive series of anterior resection doughnuts from 125 patients was reviewed retrospectively to assess the impact of doughnut pathology on the management of patients. Four doughnuts had a histological abnormality reported but none of these altered treatment. Routine histological examination of 'doughnuts' is not beneficial to the management of patients undergoing surgery for rectal adenocarcinoma.

Adenocarcinoma↗
PubMed2006

Muscle-sparing thoracotomy combined with mechanically stapled lung resection for benign lung disorders: functional results and quality of life.

We set out to review our experience with resection of benign lung lesions performed using mechanical stapling devices via a muscle-sparing thoracotomy, and provide data on long-term morbidity, functional results, and quality of life (QOL). Fifty-two patients with a benign lung disorder were included in the study. All underwent a lung resection with mechanical staplers via a muscle-sparing thoracotomy. Medical records were retrospectively searched for postoperative complications. Nineteen patients (36.5%) also underwent a final follow-up including clinical examination, radiological investigations, functional tests, and assessment of QOL by a standardized questionnaire. No intra-operative complications occurred. The resection was anatomical (lobectomy) in 28 (53%) children and wedge in 25 (47%). Five cases (9.6%) required secondary surgery. Of the 19 children undergoing long-term follow-up, 3 (16%) had musculoskeletal anomalies and 6 (31.5%) respiratory symptoms. All X-rays were normal. Spirometry was abnormal in 9 cases (47.3%). QOL was excellent/good in 17 cases (89.5%) and sufficient in 2 (10.5%). An abnormal spirometric pattern was significantly more frequent in cases with a poorer QOL. In conclusion, stapled resection via a muscle-sparing thoracotomy is a good option to perform lung resections. However, a muscle-sparing approach does not avoid entirely long-term musculoskeletal complications. QOL is good in nearly 90% of cases, but respiratory symptoms and abnormal spirometric function can be found in one third and half of the patients, respectively. An abnormal spirometry is more common in patients with a poorer QOL. Systematic radiological follow-up is unnecessary.

Adolescent↗
PubMed1993

[The Knight-Griffen technique in colorectal surgery].

The use of stapling devices has changed the practice of colorectal surgery. The authors report their experience with the "double stapling" technique introduced by Knight and Griffen in 1980 for the performance of low colorectal anastomosis. They treated 42 patients, with a mean age of 63.2 years. In 34 surgery was performed for rectal adenocarcinoma, while 8 patients were being reoperated on for closure of a colostomy after Hartmann's operation. In one patient a diverting colostomy was fashioned because of poor bowel cleansing, secondary to a stenosing rectal carcinoma. Mortality was nil. There were no clinical anastomotic leaks. There were 2 cases of late postoperative anastomotic stenosis that responded to endoscopic pneumatic dilatation.

Adenocarcinoma↗
PubMedDate not supplied

Gait analysis of stapling for genu valgum.

Many authors have advocated stapling or epiphysiodesis of the distal medial femur as a means of correcting genu valgum. However, in the literature, aside from clinical improvement (appearance, pain, function), objective evidence of kinetic and kinematic improvement is lacking. Therefore, the authors undertook a prospective gait analysis evaluation of a series of patients treated for genu valgum, comparing pre- and postsurgical measurements to document the benefits of normalizing the mechanical axis. These results indicate that after surgery knee and hip angles and knee moments were returned to within the normal range for a similarly aged control group.

Adolescent↗
PubMed1997

Dyspnea response following bilateral thoracoscopic staple lung volume reduction surgery.

PURPOSE: Lung volume reduction surgery (LVRS) has shown promise for treating patients with severe emphysema in recent clinical trials. However, response following surgery is difficult to assess due to frequent discrepancies between subjective and objective outcomes. We evaluated the relationship between improvement in dyspnea and pulmonary function response in 145 consecutive patients with inhomogeneous emphysema enrolled in a bilateral thoracoscopic lung volume reduction protocol in order to assess predictors of improved dyspnea outcome and correlation of subjective and objective improvement measures. MATERIALS AND METHODS: Baseline complete pulmonary function testing, spirometry, gas exchange, plethysmography, gas dilution lung volumes, along with resting dyspnea index determinations were performed preoperatively, and repeated short term (mean, 33 days; n=129) and long term (>6 months; mean, 276 days; n=84) following surgery. RESULTS: Improvement in FEV1 percent predicted was significantly associated with improvement in dyspnea scores, though considerable variability exists (r=0.04, p<0.01, short term; r=0.4, p=0.1, long term). In this preselected patient group, those with the extreme degrees of hyperinflation may have less improvement in dyspnea following LVRS than those with milder preoperative hyperinflation. Greater improvement in dyspnea short term and long term was seen in patients with lower presenting residual volume/total lung capacity ratios (r=0.4, p=0.02, short term; r=0.4, p<0.05, long term). CONCLUSIONS: Bilateral thoracoscopic staple LVRS results in significant objective and subjective improvement in patients with severe emphysema and hyperinflation. There was considerable variability between improvement in dyspnea and improvement in spirometry, and preoperative predictors of response may differ between these outcome variables. Further studies are needed to define the long-term implications of these findings.

Aged↗
PubMed2005

Evaluation of the learning curve in ileal pouch-anal anastomosis surgery.

SUMMARY BACKGROUND DATA: We define the learning curve required to attain satisfactory training in ileal pouch-anal anastomosis (IPAA) and identify possible differences in the learning curve for stapled and hand-sewn IPAA surgery. Various studies have addressed the differences in failure rate between stapled and hand-sewn IPAA, but there is no literature that evaluates the differences in attaining satisfactory training in each of these techniques. METHODS: Data were collected from 1965 patients undergoing IPAA surgery by 12 surgeons in a single center between 1983 and 2001. Using ileoanal pouch failure as the primary end point, a parametric survival model was used to adjust for case mix (patient comorbidity, preoperative diagnosis, manometric findings, and prior anal pathology). A risk-adjusted cumulative sum (CUSUM) model was used for monitoring outcomes in IPAA surgery. RESULTS: The 5-year ileal pouch survival was 95.6% (median patient follow-up of 4.2 years; range 0-19 years). Fifty percent of trainee staff demonstrated a learning curve in IPAA surgery. Having adjusted for case mix, trainee staff undertaking stapled IPAA surgery showed an improvement in the pouch failure rate following an initial training period of 23 cases versus 40 cases for senior staff. The learning curve for hand-sewn IPAA surgery was quantified only for senior staff who attained adequate results following an initial period of 31 procedures. CONCLUSIONS: The CUSUM method was a useful tool for objectively measuring performance during the learning phase of IPAA surgery. With adequate training, supervision, and monitoring, the learning curve in IPAA surgery may be reduced even further.

Adult↗
PubMed2005

Creation of a permanent colostomy with the use of an intraluminal stapler device.

We present our experience with the use of the intraluminal stapler device for the purpose of creating of a permanent dermal colostomy in patients requiring acute emergency operations and for regularly scheduled procedures. The advantages of this method for surgeons who use stapling devices are controlled safety of the colostomy, reduced operation time, and the creation of a stable diameter of the colostomy. Furthermore, this method can be used in patients where a secondary operation is needed due to shrinkage or stricture of the primary colostomy during the first operation. This method has now been used in our clinic for five years with excellent results. All patients, including those having procedures related to colon cancer, are placed on a follow up protocol for three years and are closely monitored. This protocol has allowed us to closely follow these patients and any related complications such as stricture, stenosis, prolapse, in situ hernia, and ecstomosis.

Anastomosis, Surgical↗