Faculty Bibliography

Laparoscopic totally extraperitoneal (TEP) inguinal hernia repair is an effective minimally invasive method for treating hernias that avoids entry into the abdomen. Its indications have developed and broadened over time to encompass almost the whole spectrum of groin hernias. A detailed description of the procedure is presented focusing on seven key steps. Moreover, pre- and intra-operative considerations, pearls and pitfalls are highlighted in order to maximize efficiency and safety when performing this procedure. The attached figures and accompanying narrated videos complement this manuscript by providing an audiovisual adjunct and to clarify technical and anatomical descriptions

Case Presentation: Patient is a 22 year old female with no significant past medical or surgical history presented to the emergency department with a 2 day history of worsening sharp right upper quadrant pain with associated nausea, vomiting, and PO intolerance. The pain started a few months prior, however it was self-limited with diet modifications. An ultrasound demonstrated a contracted gallbladder with a 15 mm gallbladder wall. White blood cell count was within normal limits and total bilirubin was slightly elevated to 1.8 mg/dL. No palpable mass was noted on physical exam. An MR cholangiopancreatography was performed which demonstrated a dilated gallbladder measuring 11.5 x 2.5 cm, a severely thickened gallbladder with a small intramural collection and multiple gallstones. The patient proceeded with a laparoscopic cholecystectomy. Intraoperatively, the omentum was densely adhered to the gallbladder and needle decompression of the gallbladder was unsuccessful due to the wall thickness. The gallbladder was subsequently removed without any complications. Patient's remaining hospital course was uncomplicated. Surgical pathology returned demonstrating acute on chronic cholecystitis.
Discussion(s): Cholecystomegaly or 'Giant Gallbladder' disease is a rare pathology encountered in the surgical world. There have been few reported cases, most of which occurred in the elderly ([65 years). Kuznetsov et al. defined an enlarged gallbladder to have a volume of 200-300 cc and a giant gallbladder as exceeding 1500 cc (the average weight of the liver). The etiology remains unknown, however certain factors exist to allow the gallbladder to reach this size without life-threatening sequela. Preoperative imaging, such as MR cholangiopancreatography, is important to differentiate biliary pathology and delineate anatomy. Removal of the gallbladder is recommended to prevent the development of complications like cholangitis or bowel obstruction. The cause of cholecystomegaly still remains uncertain and warrants further research. The management and treatment remains similar to acute cholecystitis

Introduction: The preoperative workup for the bariatric patient varies from institution to institution and uncertainty exists in the literature as to the utility of certain aspects of the workup; such as routine esophagogastroduodenoscopy (EGD), screening adults and adolescence for obstructive sleep apnea (OSA), and management of asymptomatic cholelithiasis. In this submission we review the literature on controversial aspects of the bariatric preoperative workup, discuss the issues, and offer our institutional recommendations.
Method(s): PUBMED search terms: 'EGD bariatric surgery,' 'cholecystectomy bariatric surgery,' 'obstructive sleep apnea bariatric surgery'. 850 total articles were returned and 20 from each category were selected by the authors for their direct relevance to the preoperative workup before bariatric surgery.
Result(s): After a review of the literature, we recommend OSA screening of adult bariatric patients with an approved questionnaire and treatment with continuous positive airway pressure therapy (CPAP) for 30 days preoperatively and continuation postoperatively. We recommend against routine screening and treatment of adolescence for OSA. We recommend against synchronous cholecystectomy with bariatric procedures for asymptomatic cholelithiasis. We recommend for the use of ursodeoxycholic acid pre and postoperatively for cholelithiasis prophylaxis. We recommend for the use of preoperative EGD in mucosal altering procedures, such as the Roux-en-Y gastric bypass, gastric sleeve, or duodenal switch. We recommend against a routine EGD before the gastric banding. We recommend routine proton pump inhibitor (PPI) use preoperatively when symptomatic.
Conclusion(s): When current literature is equivocal, clinical decision making and institutional guidelines target the best preoperative workup for each bariatric patient. The recommendations for our preoperative workup and algorithm for testing is driven by our clinical experience and best interpretation of available data

Background: Median arcuate ligament syndrome (MALS) is a rare and complex disease requiring various lab tests, CT abdominal scans, and abdominal ultrasounds in order to diagnose. Located near the first lumbar vertebra, the median arcuate ligament is a fibrous arch that usually crosses superior to the proximal portion of the celiac artery. In 10-24% of the general population this ligament originates from a more inferior position than normal, causing it to compress the celiac artery. This could possibly lead to mesenteric ischemia and abdominal pain in some of the population affected with this abnormality. The presentation of this syndrome is vague abdominal pain and in order to diagnose MALS, common disorders affecting other organs in the GI must be ruled out first. Case Report: The patient is an 80 year old Caucasian woman with refractory abdominal pain and weight loss for several months. Her pain presented 1 hour after meals causing her to eat less and lose weight. An abdominal ultrasound was performed and revealed several small stones in the gall bladder, but no wall thickening or other indications of cholecystitis. Initially she was diagnosed with biliary colic and was going to be managed with an elective laparoscopic cholecystectomy. However due to the excessive weight loss from food aversion and absence of specific right upper quadrant pain, an abdominal CT was done which showed extrinsic compression of the celiac artery with luminal narrowing in a manner consistent with MALS. A laparoscopic operation was performed to skeletonize the celiac artery and completely release it from the constricting median arcuate ligament. 10 days after the surgery the patient did not complain of any abdominal pain. Her only complication was due to dehydration and fatigue which required hospitalization with administration of IV fluids.
Conclusion(s): Skeletonization of the celiac artery by releasing the low lying median arcuate ligament via laparoscopic surgery is a highly effective treatment for MALS patients. This laparoscopic technique provides a quicker recovery time and is more efficacious in providing early symptom relief than having an open surgery

Introduction: Portomesenteric vein thrombosis (PMVT) is a rare but serious postoperative complication following bariatric surgery, with an incidence rate ranging from 0.3 to 1%. Due to the nonspecific symptoms, a high index of suspicion is needed to make the diagnosis. If left untreated, PMVT can progress to intestinal ischemia, perforation and peritonitis. Case Presentation: A 51-year-old female presented to the Emergency Department five days after laparoscopic sleeve gastrectomy (LSG) complaining of worsening abdominal pain and low grade fevers. A CT scan and upper GI series were performed with no evidence of leak or abscess, and the patient was admitted for observation. On hospital day two, the patient had worsening abdominal pain, and an episode of emesis. An ultrasound revealed a new moderate amount of intraperitoneal free fluid. A CT scan was repeated which revealed a thrombus in the splenic and superior mesenteric veins. Upon further discussion, the patient admitted to a previous diagnosis of antithrombin III deficiency and non compliance with anticoagulation. The patient was subsequently started on therapeutic anticoagulation with resolution of her abdominal pain. The remainder of the hospitalization was uncomplicated and she was discharged home on oral anticoagulation.
Discussion(s): It has been well established that morbid obesity is a significant prothrombotic factor for patients undergoing bariatric procedures. There has been increasing interest in identifying other factors which may contribute to hypercoagulability during these procedures. Possible etiologies for PMVT following LSG include thrombophilia, venous stasis from increased intra-abdominal pressure or patient positioning, and intraoperative manipulation of vasculature. Increasing interest has turned toward identifying patients who may be predisposed to PMVT following LSG. In a recent multicenter review of 40 patients who developed PMVT after LSG, 92% had a hematologic abnormality. The most common abnormality identified was elevation of Factor VIII (76%). Other significant abnormalities included deficiencies in antithrombin III, factor V leiden, and protein C/S.
Conclusion(s): Patients undergoing LSG have an increased risk of developing PMVT. A high index of suspicion is important for prompt diagnosis and expeditious treatment. Up to 90% of PMVT after LSG can be successfully treated with therapeutic anticoagulation alone

A 76-year-old woman with surgical history of Roux-en-Y gastric bypass presented with recurrent choledocholithiasis. Double balloon enteroscopy was unsuccessful in cannulating the biliary tree, thus, requiring surgically assisted endoscopic retrograde cholangiopancreaticogram (ERCP) access. Due to her stable clinical status, the non-urgent indication and multiple anticipated ERCPs for definitive biliary clearance, a more durable port of access to the ampulla was desired. A modified laparoscopic Janeway gastrostomy of the gastric remnant was performed and served as access for multiple subsequent endoscopic procedures with successful clearance of the biliary tree.