Article of interest: Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement

Balzer KM, et al. Anatomic guidelines for the prevention of abdominal wall hematoma induced by trocar placement. Surg Radiol Anat. 1999;21(2):87-9. Full-text for Emory users.

Abstract: A knowledge of the parietal structures of the abdominal wall is necessary to minimize risks of operative procedures like laparoscopy. For means to prevent intraoperative bleeding and the occurrence of abdominal wall hematoma, we studied the course of the inferior epigastric arteries and the ascending branch of the deep circumflex iliac artery in 21 human cadavers. The abdominal wall structures were dissected and the distances of the arteries in relation to anatomic structures such as the umbilicus, pubic symphysis, superior ischial spine and lower edge of the rib-cage were measured. Comparison of the morphometric results obtained with the location of 36 trocar incision sites recommended in the common literature yields the information that about half of these incision sites incur the risk of injuring the arteries.

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The use of mesh reinforcement in hiatal hernia repair

Rausa E, et al. Prosthetic Reinforcement in Hiatal Hernia Repair, Does Mesh Material Matter? A Systematic Review and Network Meta-Analysis. J Laparoendosc Adv Surg Tech A. 2021 Oct;31(10):1118-1123.

Results: Seventeen articles based on 1857 patients were enrolled in this article. The point estimation showed that when compared against the control group (NAM), the HH recurrence risk in AM and cruroplasty group was higher (relative ratio [RR] 2.3; CrI 0.8-6.3, RR 3.6; CrI 2.0-8.3, respectively). Postoperative complication rates were alike in all groups. The prevalence of mesh erosion after HHR is low.

Conclusions: This network meta-analysis showed that prosthetic reinforcement significantly reduced HH recurrence when compared with cruroplasty alone. However, there is not enough evidence to compare different mesh compositions.

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2020 WSES updated guidelines for the diagnosis and treatment of acute calculus cholecystitis

Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020 Nov 5;15(1):61. Free full-text.

Conclusions, knowledge gaps and research recommendations: “ELC has a central role in the management of patients with ACC. The value of surgical treatment for high-risk patients should lead to a distinction between high-risk patients and patients who are not suitable for surgery. Further evidence on the role of clinical judgement and the use of clinical scores as adjunctive tools to guide treatment of high-risk patients and patients who are not suitable for surgery is required. The development of local policies for safe laparoscopic cholecystectomy is recommended.”

2020 WSES Flowchart for the management of patients with acute calcolus cholecystitis.
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Post-Cholecystectomy Biliary Complications

Pesce A, et al. Iatrogenic bile duct injury: impact and management challenges. Clin Exp Gastroenterol. 2019 Mar 6;12:121-128. Free full-text.

“Iatrogenic BDIs represent a serious complication which can be brought on by cholecystectomy. The errors leading to laparoscopic bile duct lesions stem principally from misperception of the biliary anatomy. Any effort toward the reduction of the risk profile of everyday cholecystectomy is appreciated. The key points to successful treatment are characterized by early recognition, control of any intra-abdominal fluid collection and infection, nutritional balance, multidisciplinary approach, and surgical repair by an experienced surgeon in biliary reconstruction.”


Pekolj J, et al. Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg. 2013 May;216(5):894-901. Full-text for Emory users.

Results: Among 10,123 LC performed during the study period, 19 patients had a BDI sustained during the procedure. Intraoperative cholangiography was routinely used. Bile duct injury was diagnosed intraoperatively in 17 patients (89.4%). Mean age was 56.4 years (range 18 to 81 years) and 15 patients were women (88%). According to the Strasberg classification of BDI, there were 3 type C lesions, 12 type D lesions, and 2 type E2 lesions. There were no associated vascular injuries. Twelve cases (71%) were converted to open surgery. The repairs included 10 primary biliary closures, 4 Roux-en-Y hepaticojejunostomies, 2 end to end anastomosis, and 1 laparoscopic transpapillary drainage. Postoperative complications occurred in 5 patients (29.4%). During the follow-up period, early biliary strictures developed in 2 patients (11.7%) and were treated by percutaneous dilation and a Roux-en-Y hepaticojejunostomy with satisfactory long-term results.

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What is the utility of routine intraoperative cholangiography during laparoscopic cholecystectomy?

SAGES still recommends that practicing general surgeons learn how to do IOC (though once a surgeon is past their learning curve, it is not necessarily routinely recommended that it be done ‘routinely’).


Hope WW, et al. SAGES clinical spotlight review: intraoperative cholangiography. Surg Endosc. 2017 May;31(5): 2007-2016. Full-text for Emory users.

“The following clinical spotlight review regarding the intraoperative cholangiogram is intended for physicians who manage and treat gallbladder/biliary pathology and perform laparoscopic cholecystectomy. It is meant to critically review the technique of intraoperative cholangiography, alternatives for intraoperative biliary imaging, and the available evidence supporting their safety and efficacy.”

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Article of interest: Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB)

Nandipati KC, Lin E, Husain F, Srinivasan J, Sweeney JF, Davis SS. Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB). J Gastrointest Surg. 2012 Apr;16(4):675-81.

Full-text for Emory users.

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Totally Extra Peritoneal (e-TEP) Approach for Ventral Hernias

Bui NH, Jørgensen LN, Jensen KK. Laparoscopic intraperitoneal versus enhanced-view totally extraperitoneal retromuscular mesh repair for ventral hernia: a retrospective cohort study. Surg Endosc. 2021 Mar 15.

Full-text for Emory users.

Results: A total of 72 patients were included in the study, 43 and 29 of whom underwent IPOM and eTEP-RM repair, respectively. Patient demographics showed no differences in terms of gender, age, smoking and comorbidity. The median age was 57 years and body mass index 30.5 kg/m2. The rate of patients with incisional hernia was higher in the IPOM group (39.5% vs. 20.7%, p = 0.154). There was no difference in horizontal and vertical hernia size defect. The duration of surgery was significantly shorter for IPOM (mean 82.4 vs. 103.4 min, p = 0.010), whereas the length of stay was significantly longer after IPOM (median 1 days vs. 0 days (p < 0.001). The rate of patients requiring postoperative transversus abdominis plane (TAP) block or epidural analgesia was significantly higher after IPOM (33% vs. 0%, p = 0.002). A subgroup analysis on patients undergoing primary ventral hernia showed similar results.

Conclusion: The study found laparoscopic eTEP-RM safe and effective compared to traditional laparoscopic IPOM. The patients undergoing eTEP-RM had significantly reduced need for additional analgesic treatment and length of stay.

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