Faculty Bibliography

Techniques for laparoscopic Roux-en-Y gastric bypass vary in the creation of the jejuno-jejunostomy and the gastro-jejunostomy. Here we share the principles of the key steps in our long experience with this procedure and the evolution to its present-day form. 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. Second, starting with the creation of the jejuno-jejunostomy allows for freedom of movements and fluid creation of the anastomosis. Critical to this step is no division of the mesentery, to reduce risk of internal hernia. No stay sutures are needed. Common enterotomy is closed in a single layer hand-sewn anastomosis. Mesentery is closed with interrupted sutures with the inclusion of the "Brolin stitch" to prevent intussusception. Third, the G-J anastomosis has evolved in the past 20 years, starting with the laparoscopic retrocolic retrogastric anastomosis with the EEA 21 mm with a short biliary limb in 1997. Between 2000-2001, the technique shifted to retrocolic retrogastric side-to-side anastomosis with the GIA and handsewn entero-enterostomy (with a longer biliary limb of 100 cm). Since 2004, the technique now involves antecolic antegastric single-layer handsewn anastomosis without any division of mesentery. Vagus nerve is left intact during dissection and pouch creation. With 857 cases using this current technique, there has been 1 anastomotic leak, 1 leak from pouch due to infected hematoma, 1 internal hernia, 16 marginal ulcers (1.87%), 1 mortality, and 1 aborted case

BACKGROUND:Laparoscopic cholecystectomy is still fraught with bile duct injuries (BDI). A number of methods such as intra-operative cholangiography, use of indocyanine green (ICG) with infrared imaging, and the critical view of safety (CVS) have been suggested to ensure safer Laparoscopic cholecystectomy (LC).To these, we add posterior infundibular dissection as the initial operative maneuver during LC. Here, we report specific technical details of this approach developed over 30 years with no bile duct injuries and update our experience in 1402 LC. METHODS:In this manuscript, we present a detailed and illustrated description of a posterior infundibular dissection as the initial approach to laparoscopic cholecystectomy (LC). This technique developed after thirty years of experience with LC and have used it routinely over the past ten years with no bile duct injury. RESULTS:Between January of 2010 and December 2019, 1402 Laparoscopic cholecystectomies were performed using the posterior infundibular approach. Operations performed on elective basis constituted 80.3% (1122/1402) and 19.97% were emergent (280/1402). One intra-operative cholangiogram was performed after a posterior sectoral duct was identified. There was one conversion to open cholecystectomy due to bleeding. There were 4 bile leaks that were managed with endoscopic retrograde cholangio-pancreatography (ERCP). There were no bile duct injuries. CONCLUSION/CONCLUSIONS:Adopting an initial posterior mobilization of the gallbladder infundibulum lessens the need for medial and cephalad dissection to the node of Lund, allowing for a safer laparoscopic cholecystectomy. In fact the safety of the technique comes from the initial dissection of the lateral border of the infundibulum. The risk of BDI can be reduced to null as was our experience. This approach does not preclude the use of other intra-operative maneuvers or methods.

BACKGROUND:Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8 cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. METHODS:Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. RESULTS:Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3 days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. CONCLUSION/CONCLUSIONS:Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

In 2014 the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias". Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.

Background: We present a case of a 33-year-old female that underwent a laparoscopic Roux-En-Y gastric bypass 5 months prior that subsequently developed a gastrojejunostomy stricture treated with endoscopic balloon dilation. Following her third balloon dilation she developed severe abdominal pain and was found to have free air on an upright abdominal x-ray. The patient was immediately brought to the operating room for a diagnostic laparoscopy which demonstrated an anterior perforation of the gastrojejunostomy anastomosis. The decision was made to revise the anastomosis by performing a stricturoplasty where the perforation was extended longitudinally and closed transversely with interrupted silk sutures to both repair the perforation and resolve the anastomotic stricture. The patient had an uncomplicated postoperative course. Gastrojejunostomy strictures are a common complication after laparoscopic Roux-En-Y gastric bypass. There are multiple factors that may lead to the formation of a stricture including marginal ulcers or technical error. Anastomotic strictures are often managed endoscopically with serial balloon dilations. However, if endoscopy fails to relieve the stricture, the patient may need to undergo a laparoscopic gastrojejunostomy revision, which can be morbid. Additionally, anastomotic perforation represents a surgical emergency that warrants immediate exploration. This case presents a unique situation where both situations are present and more conservative measures such as endoscopic stenting are not feasible. By performing a revision stricturoplasty, we attempted to repair the perforation as well as lengthen the anastomosis to relieve the stenotic area. [Figure presented]
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Introduction: Even though the benefits of bariatric surgery are clear, patients often become fatigued with a process that can take 4-6 months. This leads to high attrition rates. We surveyed bariatric patients to identify barriers and increase retention.
Method(s): A total of 208 patients who did not undergo definitive bariatric procedure were identified and surveyed for specific barriers to completion during a 1-year period from January 1st to December 31st. Patients were called and asked an open-ended question regarding barriers. The responses were recorded and analyzed by 1 faculty member.
Result(s): We identified 9 specific barriers to completion of bariatric surgery: 17.8% due to medical issues, 28.4% change of heart, 15.7% insurance/financial issues, 12% tedious process, 2.4% pregnant/trying, 2% relocated, 8.7% unhappy with surgeon, 12% lost weight without operation, 1% exceeded institutional weight limit. Among medical barriers, cardiac (21.6%) and acute illness or medical emergency (48.6%) were the 2 most common. A total of 28.4% were afraid of surgical complications or unsure of the efficacy of bariatric surgery, 12% felt the clearance process was too tedious and fatigued before completion, 5 patients became pregnant, 4 relocated, 8.7% were unhappy with surgeon, or office staff, and 12% lost weight without operation.
Conclusion(s): In order to break the barriers to bariatric surgery, our institution has increased prime-time educational sessions for patients and outreach for referring providers. We have also acquired a medical weight loss specialist for retention of patients with borderline BMIs, and we offer less invasive techniques for patients who are wary of surgery.
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In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature.

Introduction: There is still controversy regarding whether or not a preoperative esophagogastroduodenoscopy (EGD) should be done before bariatric surgery; does it change surgical course, and does it prevent postoperative complications? Here we present a relevant case and review the current literature relating to preoperative EGDs in bariatric surgery. Case Presentation: A 51 year female presents for preoperative workup prior to undergoing a restrictive bariatric procedure. A standard institutional preoperative workup was performed without an EGD. Patient returned postoperative day number two with hematemesis. Emergent EGD showed clotted blood in the stomach and a Dieulafoy ulcer that was successfully clipped by the endoscopist.
Method(s): A literature review was performed using Pubmed. Search term ''EGD bariatric surgery'' was used.
Result(s): PubMed search returned 50 papers, and 13 were selected for review due to their relevance; 4 against EGD, 5 in favor of EGD, and 4 in favor if patient has reflux symptoms.
Discussion(s): A Dieulafoy ulcer is rare, accounting for 1-2% of upper gastrointestinal bleeding presentations. Our patient presented with classic findings of this lesion: larger diameter vessel on the lesser curve of the stomach, about 6 cm from the gastroesophageal junction, with vessel protruding through a mucosal defect with active arterial bleeding. It is uncertain if a preoperative EGD would have located this lesions and/or provided a means for intervention before presentation. Our literature review on the subject shows that preoperative EGD rarely changes surgical management. They do change medical management in a significant number of cases. With the majority of papers in favor of preoperative EGD (albeit 4 only if patient has symptoms of GERD) there is evidence in favor of performing a preoperative EGD before bariatric surgery.
Conclusion(s): The current literature is equivocal regarding a preoperative EGD as it rarely changes the surgical management, but often changes the medical management. Even though the yield is small, we recommend preoperative EGD before bariatric procedures for medical optimization; in order to avoid the potentially devastating consequences associated with a missed lesions such as the one presented

Introduction: The surgical management of arrested sharp foreign bodies (FB) in the small bowel is often managed with a concurrent approach that balances endoscopy, laparoscopy, and laparotomy for their removal. Controversy exists as to the timing of surgical intervention and the management of asymptomatic patients. Here we discuss the management and present a case series with a review of the current literature. Cases Series: Patient one underwent endoscopic retrieval of a wire bristle embedded in the duodenum. Patient two underwent diagnostic laparoscopy converted to open small bowel resection of chronically retained FB after it eroded through the bowel wall of the mid jejunum. Patient three underwent laparoscopic removal via enterotomy and primary repair of a chicken bone embedded in the terminal ileum.
Discussion(s): Any arrested sharp foreign body should be surgically removed in a timely fashion. The literature shows that longer delays to the operating room, and asymptomatic patients with retained small FBs, increases the risk of significant morbidity; such as migration of the FB through the bowel wall, enterocolic fistula, aortic - duodenal fistula, and frank acute perforation. Any known or suspected ingestion of a sharp FB should be staged with imaging if it is detectable. If progression fails, then surgery is indicated. If it has arrested in the stomach or duodenum endoscopic retrieval is appropriate. A skilled endoscopist can attempt balloon endoscopy for proximal jejunal FB retrieval, but retrieval should not be delayed. Laparoscopic retrieval is preferable when endoscopic attempts have failed. This can be performed via an enterotomy and primary repair for small FBs or laparoscopic small bowel resection with primary anastomosis. If there is frank perforation (or a skilled laparoscopic surgeon is not available) then a laparotomy and washout with resection of affected segment may be indicated.
Conclusion(s): Retrieval after ingestion of a sharp FB should be performed in a timely manner. A review of the literature shows that chronically retained FBs, and traditional long delays to monitor for transit of the FB increase morbidity and mortality

Introduction: There is uncertainty as to whether the incentive spirometer (IS) confers a clinical benefit or reduces inpatient pulmonary complications when correlated with the most common hospital diagnoses. Does the patient know how to use one correctly, is it prescribed for the appropriate diagnosis, and is it at the bedside? if so, is it within reach? Our study aims to determine the patterns of use of the incentive spirometer.
Method(s): From September 2016 to August 2017, patients admitted for more than 24 h were included.192 surgical and 206 medical patients were surveyed for usage and observed for receipt of the IS device. Questions asked where: Have you ever used the IS? ''Have you been instructed on how to use the incentive spirometer? Have you used it today? How many times in the last hour have you used the IS? What is the number one reason for you to not effectively use the IS? Other questions: Did the patient receive the IS device? Did the patient have the capacity to use the IS? Was the IS within reach? Was the package open? Did the patient demonstrate correct usage of the IS?'' We correlated our literature search with the top 10 most common admitting diagnosis and procedures at our institution.
Result(s): Of the 192 surgical patients observed, 147 received the device. 72% of these patients demonstrated correct usage. 60% used the device that day, but only 15.6% for the prescribed 10 times/hour. It was in reach of 80.3%. Average use per hour was 2.79 times. 3% of surgical patients did not have capacity. The IS was out of reach for 9%. 12% reported that they did not know how to use the device. The most frequently reported reason among surgery and medical patients for not using the IS appropriately was pain (60% and 67%, respectively). Of the 206 observed medical patients, only 22% (45 patients) have received the device with only half admitting to using it on the day of questioning. 22% of these patients didn't know how to use the IS, and it was out of reach in 7%. 80% had been educated. 57.8% showed correct usage. 100% of medical patients had capacity to use it. Medical patients use averaged 1.47 times per hour.
Conclusion(s): Our data show that the IS device has poor availability, improper application, and poor compliance among inpatient medical and surgical patients