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공개·회원 9명

Placement Talk With Anubhav Malik! ((LINK))

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Placement talk with Anubhav Malik!

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Methods and Procedures: We performed a retrospective observational study, reviewing all patients at a single 625 bed community-based hospital undergoing robotic TAPP inguinal hernia repairs between January 2018 and December 2019. Data points collected including patient sex, age, race, BMI, intraoperative Foley placement, unilateral vs bilateral repair, paralytic reversal agents, local/regional anesthetic type and dose, and duration of surgery. The primary outcome measured was PACU LOS. A multivariate analysis was performed to determine which factors had a significant correlation with increased PACU LOS.

Discussion: It is our experience that eTEP incisional hernia repair can be performed simultaneously with other minimally invasive operations safely and without significant added morbidity. This technique allows for a completely minimally invasive approach to minimize surgical pain, length of hospital stay, and morbidity. The main challenges that we faced were port placement, patient positioning, and specimen extraction, which can be overcome with close collaboration amongst surgeons. In our early experience, the hernia repair did not appear to add any hospital days or wound morbidity, although patients did report more abdominal wall pain.

Methods. We retrospectively reviewed the outcomes of all patients who underwent laparoscopic hernia repairs in our institution from March 2017 to September 2020 using Synecor mesh. Our technique involves primary fascial closure and Intraperitoneal Onlay Mesh (IPOM) placement with endoscopic component separation when indicated. We evaluated patient demographics, operative parameters, morbidity, follow-up time, and recurrence.

Introduction: Laparoscopic inguinal hernioplasty is widely accepted as a viable alternative to open hernioplasty. However, the ideal management of inguinoscrotal hernias remains controversial. The extensive dissection required to fully reduce the hernia sac is associated with an increased risk of injury to cord structures, testicular ischemia, hematoma, and seroma. The rates of seroma formation are reported as high as 66% in some inguinoscrotal hernia series. An alternative technique, primary abandon-of-the-sac (PAS), was recently described in the literature in which the hernia sac is divided at the level of the internal inguinal ring and left in situ prior to dissection of the myopectineal orifice and mesh placement. We present our initial experience with the PAS modification to transabdominal preperitoneal hernioplasty (TAPP), comparing these patients to another group in whom the hernia sac is abandoned distally late in dissection due to difficulty in safely isolating it from cord structures.

Introduction: This study was performed to assess the safety and efficacy of the Su2ura Approximation Device, a newly developed instrument for the approximation of soft tissue defects, investigated here for laparoscopic closure of primary umbilical hernia defect with intraperitoneal mesh placement (IPOM).

Conclusions: TAPP technique in subcostal hernia repair allows for placement of a much larger mesh than an anterior approach surgery, and is closer to current recommendations, especially for patients with additional risk factors, i.e. obesity. TAPP allows a mesh to be introduced into preperitoneal space, allowing to avoid direct contact between mesh and intestines, providing wide mesh overlap above costal margin in subdiaphragmatic plane. Laparoscopic subcostal TAPP is feasible and safe, and may be considered as an alternative for open approach methods.

Conclusions: Despite the lack of complex hernia repair standards, at our high-volume referral institution we have identified personal practice standards with acceptable complication rates that may serve to guide the hernia community. These include retrorectus mesh placement with ACS/TAR, wide bony overlap, extensive fixation, and combined specialty operations.

Emergency room events: The patient is a nineteen-year-old female with autism and developmental delay with chronic aerophagia since early childhood. patient was planned to receive venting gastrostomy tube placement in accordance with standard treatment for aerophagia refractory to medical or therapeutic management. On presentation she was tachycardic and tachypnic in obvious distress with a massively distended and tight abdomen. Plain films were obtained showing massively dilated loops of bowel (Fig. 1).

Heart failure demands substantial health care resources. Many patients with advanced heart failure require cardiac transplantation. A significant number of these patients undergo left ventricular assist device (LVAD) placement as a bridge to transplantation. Unfortunately, many patients are ineligible for transplant due to an elevated body mass index (BMI). We and others have advocated for sleeve gastrectomy as an avenue for weight loss to achieve a BMI which would allow a patient to be listed for transplant. Here, we present the case of a patient whose heart function improved enough after sleeve gastrectomy to have his LVAD removed.

First, patient positioning involves supine position without the need for steep reverse Trendelenburg. In conjunction, subcostal port placements play a critical role for exposure, including one for liver retraction using a grasper holding the diaphragm from the subxiphoid port to give adequate exposure. In case of poor visualization due to size of the liver, mobilization of the left lateral segment of the liver allows work to be done anterior to it.

Background: The COVID-19 (SARS-CoV-2) pandemic is a global concern and has changed the way we practice medicine in acute hospital settings. This is true with regards to patient triage, patient risk assessments, use of personal protective equipment (PPE) and environmental disinfection. Transmission of Covid-19 is primarily through respiratory droplets generated through talking, coughing or sneezing. There is, however, a potential risk that respiratory droplets settling on inanimate surfaces and objects in the hospital environment could provide a reservoir for nosocomial infections in patients and pose a health care risk to medical staff. Indeed, there have been previous reports of healthcare- associated outbreaks in hospitals. Several authors have argued that the risk of transmission via fomites may be insignificant but this not a view shared by The World Health Organization (WHO). The WHO does not rule out the possibility that fomites may play a role in the spread of Covid-19. Environmental contamination with SARS-Cov-2 in healthcare institutions has been shown to vary according to function or service provide by a unit or department. Information that identifies hospital areas that have a propensity for higher environmental burden may inform the practice of Infection Control and environmental cleaning and decontamination in healthcare institutions.

Methods: A ventral hernia repair curriculum, incorporating didactic content followed by hands-on practice, is being developed using a modified laparotomy closure model previously developed by our group. The Abdominal Wall Surgical Skills Operational Model (AWSSOM) has pertinent abdominal wall layers used in various ventral hernia repairs. The cognitive objectives of the curriculum include correct identification of the abdominal wall layers and neurovascular structures, classification of types of ventral hernias, differentiation of distinct repair techniques with mesh placement, and listing the steps of various ventral hernia repairs. Psychomotor objectives include the performance of an onlay, sublay/retrorectus, and underlay mesh repair. Learners will be assessed using a pre/post-curriculum design based on the learning objectives for both didactic and hands-on practice. In addition, the confidence of procedural performance in the operating room will be assessed before and after curriculum implementation.

Introduction: Most of the literature on the use of stenting for the management of malignant gastric outlet obstruction is for palliation and often amalgamates multiple pathologies. Patients with gastric lymphoma and gastric outlet obstruction often have a favorable prognosis and are frequently treated with curative intent. Many endoscopists avoid placement of uncovered stents despite their favorable anti-migration properties for fear that following completion of lymphoma therapy they may cause significant morbidity.

Case Description: We present a case of 73 year old female with known paraoesophageal hernia, transferred to a tertiary facility with mesoaxial volvulus resulting in obstruction and ischemic necrosis of the stomach. The patient required emergent total gastrectomy with delayed reconstruction. The initial procedure was performed laparoscopically and converted to open due to poor visualization. After a 48 h period of resuscitation she returned for an esophagojejunostomy with roux en y reconstruction and jejunostomy feeding access. At the subsequent procedure, it was noted that the esophageal stump did not reach the hiatus and a standard OrVil placement was not technically feasible. Therefore, Endoscopic guidance was used to assist in the placement of the OrVil anvil. A large bore angiocath was used to puncture the distal esophageal stump under direct endoscopic visualization, a soft suture was inserted through this, grasped with forceps and pulled out of the mouth similar to the Gauderer-Ponsky technique (Figure A). The OrVil was then attached to the suture and pulled through the mouth and esophagus through the distal stump. This created a snug fit around the anvil which was then connected to the EEA stapler in the standard fashion.


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