Faculty Bibliography

BACKGROUND: There are only scant published reports of totally extraperitoneal (TEP) repair of recurrence after a primary TEP procedure. Furthermore, at least two authors have made the statement that such an operation is virtually impossible. METHODS: We have been performing TEP repair of recurrence after TEP since we 1996, and here we present a retrospective review of our experience with the procedure. We employ a method not varying greatly from the standard TEP done for primary hernia. RESULTS: All cases were started laparoscopically, and only one of 20 had to be converted to open. Of these cases, 12 were for same-side recurrence and eight for a contralateral new hernia. With a follow-up of 28-74 months, there have been no fatalities, no complications, and no re-recurrence. CONCLUSION: We have found that TEP repair of recurrent inguinal hernia after a primary TEP repair is entirely feasible technically as well as entirely safe.

BACKGROUND: The Lap-Band is a gastric restrictive procedure for the treatment of morbid obesity. We review the etiology of obstructive complications that present in the first postoperative 24 h. METHODS: Fifty-six Lap-Band procedures were performed by one surgeon between January and September 2002. RESULTS: Six patients presented with obstruction within 24 h of surgery: gastric slippage in three patients, gastric edema in one patient, and esophageal hypomotility in two patients. CONCLUSIONS: Placing the band in an esophagogastric position as per Belachew and Weiner reduced our incidence of gastric slippage to none. Endoscopy with placement of a nasogastric feeding tube can relieve obstruction caused by esophageal hypomotility. Gastric edema with no clinical signs of obstruction will resolve with time. Clinicians must be aware of the unique complications that come with the advent of this new procedure.

PURPOSE: Because most surgery patients now recover at home rather than in the hospital, we wanted to determine whether postoperative home visits by the operating surgeon would improve medical outcomes, and whether this innovation would strengthen resident training. METHODS: A surgeon who had performed 347 procedures during a 7-month period attempted to do a home visit to each patient within 48 hours after surgery. RESULTS: Many patients had to be disqualified for various reasons, leaving 143 candidates. Of these, 44 declined to be seen, and others could not be located, so that 82 were actually visited. There were no readmissions, and no findings that might have altered the course of postoperative treatment. CONCLUSIONS: These visits seemed to reinforce patient-physician relationships, but they did not influence medical outcomes. It was felt that a phone call would probably have done as well. In addition, because of new regulations governing resident working hours, it did not appear that this was a feasible educational experience.

OBJECTIVE: As surgeons become more experienced with basic laparoscopic procedures like cholecystectomy, they are able to expand this approach to less common operations. However, without laparoscopic suturing skills, like those obtained with Nissen fundoplication, many operations cannot be completed laparoscopically. We present a series of 10 patients with less common surgical illnesses who were successfully treated with minimal access techniques and intracorporeal suturing. METHODS: Over a 6-month period at 2 medical centers, 10 patients underwent operations with laparoscopic intracorporeal suturing and knot tying. Diagnoses included bowel obstruction due to gallstone ileus (n=1), perforated uterus from an intrauterine device (n=1), urinary bladder diverticulum (n=1), bleeding Meckel's diverticulum (n=3), and perforated duodenal ulcer (n=4). RESULTS: Each patient was treated with standard surgical interventions performed entirely laparoscopically with intracorporeal suturing. No morbidity or mortality occurred in any patient due to the operation. CONCLUSIONS: Although each of these operations has been previously reported, as a series, they point out the importance of mastering laparoscopic suturing. Although devices are commercially available to facilitate certain suturing scenarios, we encourage residents and fellows to sew manually. We believe that none of these operations could have been completed as effectively by using a suture device. The ability to suture laparoscopically markedly broadens the number of clinical scenarios in which minimal access techniques can be used.