Assessment Of Bowel Viability Research Articles

Strangulated Richter's Hernia in an Indirect Inguinal Hernia

Introduction: Richter's hernia is an abdominal hernia in which part of the circumference of the intestine is incarcerated in the hernia sac. Case report: We report a case of Richter's hernia incarcerated through an indirect inguinal hernia. The patient presented with an occlusive syndrome with an imaging appearance of a right inguinal hernial strangulation bowel obstruction. Surgical exploration revealed the presence of an indirect inguinal Richter's hernia with a viable bowel. Discussion: Richter's hernia is a rare hernia of the abdominal wall, it is known by the unusual clinical presentation and the often erroneous late diagnosis that leads to high morbidity and mortality rates. Therefore, with high clinical suspicion, an abdominal CT scan is recommended to establish a prompt diagnosis, as timely surgical intervention is important to reduce mortality. Conclusion: Surgery is the basis of its treatment, but prompt surgical intervention remains. Assessment of bowel viability is an essential part of the repair.

Simultaneous Winslow and Petersen’s Hernias after a Roux-en-Y Gastric Bypass Causing Bowel Obstruction: Laparoscopic Management and Review of the Literature

AbstractInternal hernias after Roux-en-Y gastric bypass are one of the most common complications in bariatric surgery leading to hospital readmissions with or without surgery. Due to the insidious and non-specific clinical presentation combined with difficult radiological identification, internal hernias remain a diagnostic and therapeutic challenge. Delay in diagnosis and treatment can lead to severe morbidity and mortality. We report the case of a patient presenting an unusual intestinal obstruction due to two simultaneous and distinct internals hernias affecting the Petersen’s defect and the foramen of Winslow 4 years after a laparoscopic gastric bypass. A 41-year-old female patient with a history of robotic laparoscopic Roux-en-Y gastric bypass presented with proximal small bowel obstruction symptoms and epigastric pain. Computed tomography showed two simultaneous internal hernias, one affecting the Petersen’s defect and the other affecting the foramen of Winslow with an incarcerated transverse colon. We performed an explorative laparoscopy to reduce both hernias and, after an assessment of bowel viability by indocyanine green angiography, we closed both defects with interrupted non-absorbable sutures to prevent recurrence. The follow-up of more than 1 year has been uneventful. In the cases of obstruction and hospital admission after gastric bypass, we suggest that patients undergo a computed tomography directly after the initial examination. Internal hernia diagnosis is often delicate and requires surgical exploration since bowel strangulation can lead to dramatic outcomes. The operation can be safely done laparoscopically, and all internal hernia defects should be repaired with non-absorbable sutures.

Characterization of Near-Infrared Imaging and Indocyanine-Green Use Amongst General Surgeons: A Survey of 263 General Surgeons

BackgroundNear-infrared fluorescence imaging (NIRFI) is an increasingly utilized imaging modality, however its use amongst general surgeons and its barriers to adoption have not yet been characterized.MethodsThis survey was sent to Canadian Association of General Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons members. Survey development occurred through consensus of NIRFI experienced surgeons.ResultsSurvey completion rate for those opening the email was 16.0% (n = 263). Most respondents had used NIRFI (n = 161, 61.2%). Training, higher volumes, and bariatric, thoracic, or foregut subspecialty were associated with use (P < .001).Common reasons for NIRFI included anastomotic assessment (n = 117, 72.7%), cholangiography (n = 106, 65.8%), macroscopic angiography (n = 66, 41.0%), and bowel viability assessment (n = 101, 62.7%). Technical knowledge, training and poor evidence were cited as common barriers to NIRFI adoption.ConclusionsNIRFI use is common with high case volume, bariatric, foregut, and thoracic surgery practices associated with adoption. Barriers to use appear to be lack of awareness, low confidence in current evidence, and inadequate training. High quality randomized studies evaluating NIRFI are needed to improve confidence in current evidence; if deemed beneficial, training will be imperative for NIRFI adoption.

Fluorescence Angiography for Peri-Operative Assessment of Bowel Viability in Patients with Mesenteric Ischaemia

Fluorescence Angiography for Peri-Operative Assessment of Bowel Viability in Patients with Mesenteric Ischaemia

The use of tissue oxygen measurements compared to indocyanine green imaging for the assessment of intraoperative tissue viability of human bowel.

Adequate tissue oxygenation and perfusion remain fundamental to safe bowel resection surgery. Near infrared (NIR) imaging using indocyanine green has proven itself superior to clinical evaluation alone in assessing bowel perfusion, but requires expensive equipment not readily available in many centers. We studied the IntraOx device (Vioptix Inc, Newark, CA USA), a handheld, tissue oxygen saturation assessment tool, to assess whether tissue bed oxygen saturation (StO2) is comparable to NIR assessment of bowel viability. Patients undergoing elective colon resection for benign and malignant disease were included. After choosing a clinical margin (CM) and dividing the mesentery, StO2 was measured at 5-cm intervals along the colon. A tissue oxygen saturation margin (TOM) was assigned where StO2 dropped off by at least 10 percentage points. NIR perfusion was then assessed to determine NIR margin (NIRM). Intraoperative and postoperative data were collected. 32 consecutive patients undergoing colectomies were analyzed. IntraOx sensitivity was 90.6%, specificity was 94.3%. The mean StO2 difference across the NIRM was 23.1%. In all but one case, the TOM matched the NIRM. In 3 cases, the TOM and NIRM concurred, but were a mean of 3.3cm proximal to the CM and altered the surgical plan. At 4-week follow-up, no significant complications were reported. The IntraOx device consistently identified a margin of significant saturation "drop-off" which correlated with the findings on NIR perfusion and clinical assessment. These early data indicate that StO2 measurement may be equivalent to NIR assessment of bowel perfusion. In addition, the IntraOx device may be a more cost-effective solution for surgeons looking for adjunctive evaluation of bowel viability. More study is warranted in a larger group of patients to confirm these preliminary findings and to judge the impact of StO2 assessment on reducing anastomotic leaks.

The use of indocyanine green fluorescence to define bowel microcirculation during laparoscopic surgery for acute small bowel obstruction.

Although there is growing evidence to support the feasibility of a minimally invasive approach for acute small bowel obstruction, the inability to adequately evaluate compromised bowel segments has been cited as a major limitation. The aim of this work is to report a novel application of extemporaneous indocyanine green (ICG) fluorescence to assess bowel viability where there is a concern for ischaemic damage. After the cause of obstruction has been identified and resolved, and where there are dubious signs of bowel ischaemia present, fluorescent selective angiography is undertaken. The segment of bowel in question is observed under both normal and fluorescent light to assess local microcirculation. The adequacy of both the arterial supply and the venous drainage is thus appraised to define bowel viability. Among 71 patients who have undergone surgery for acute small bowel obstruction with a laparoscopic approach, seven received extemporaneous ICG fluorescence assessment of bowel viability. Different presentations with their relevant management are described. Selective use of intraoperative fluorescent angiography may overcome some of the intrinsic limitations of laparoscopy in assessing bowel viability during surgery for acute small bowel obstruction.

Management of Acute Mesenteric Venous Thrombosis: A Systematic Review of Contemporary Studies.

Background and Aims:Acute mesenteric venous thrombosis accounts for up to 20% of all patients with acute mesenteric ischemia in high-income countries. Acute mesenteric venous thrombosis is nowadays relatively more often diagnosed with intravenous contrast-enhanced computed tomography in the portal phase than at explorative laparotomy No high-quality comparative studies between anticoagulation alone, endovascular therapy, or surgery exists. The aim of the present systematic review was to offer a contemporary overview on management.Materials and Methods:Eleven relevant published original studies with series of at least ten patients were retrieved from a Pub Med search between 2015 and 2020 using the Medical Subject Heading term “mesenteric venous thrombosis.”Results:When MVT is diagnosed early, immediate anticoagulation with either unfractionated heparin or subcutaneous low-molecular-weight heparin should commence. Surgeons need to be aware of the importance to scrutinize the computed tomography images themselves for assessment of secondary intestinal abnormalities to mesenteric venous thrombosis and the risk of bowel resection and worse prognosis. Progression toward peritonitis is an indication for explorative laparotomy and assessment of bowel viability. Frank transmural small bowel necrosis should be resected and bowel anastomosis may be delayed for several days until second look. Meanwhile, intravenous full-dose unfractionated heparin should be given at the end of the first operation. Postoperative major intra-abdominal or gastrointestinal bleeding occurs rarely, but the heparin effect can instantaneously be reversed by protamine sulfate. Patients who do not improve during conservative therapy with anticoagulation alone but without developing peritonitis may be subjected to endovascular therapy in expert centers. When the patient’s intestinal function has recovered, with or without bowel resection, switch from parenteral unfractionated heparin or low-molecular-weight heparin therapy to oral anticoagulation can be performed. There is a trend that direct oral anticoagulants are increasingly used instead of vitamin K antagonists. Up to now, direct oral anticoagulants have been shown to be equally effective with the same rate of bleeding complications. Patients with no strong permanent trigger factor for mesenteric venous thrombosis such as intra-abdominal cancer should undergo blood screening for inherited and acquired thrombophilia.Conclusion:Early diagnosis with emergency computed tomography with intravenous contrast-enhancement and imaging in the portal phase and anticoagulation therapy is necessary to be able to have a succesful non-operative succesful course.

Evaluation of the efficacy of wireless sterilizable pulse oximeter in assessment of bowel viability during surgery

Background Intestinal viability is crucial before commencement of any anastomoses or establishment of stomas after resection of the gut for any surgical reason, and depending on the clinical sense and subjective methods alone may result in disastrous results and complications affecting the outcomes of the surgical procedures. There are many techniques available nowadays for assessing bowel viability, but most of them are technically demanding and not usually available in the operating theater, besides the cost of many of them, which may represent another added burden. For all the aforementioned reasons, the wireless pulse oximeter (PO) has emerged as a possible new method which can aid in assessment of bowel viability during surgeries with the advantages of availability, low cost, and simple rapid way of gut viability assessment. Purpose The aim of this study was to evaluate the capability of the wireless PO in discrimination between viable and nonviable intestine intraoperatively before establishment of stomas or intestinal anastomoses. Study design This was a prospective study that included 40 patients who were evaluated intraoperatively by the wireless PO to assess the viability of the proximal and distal ends of the intestine. The intestinal viability in the first 10 patients was also evaluated by the fluorescein dye in addition to the PO. Here, fluorescein was used as a well-established method to validate the new technique of the PO. All the readings were recorded, and patients were followed up for 2 weeks postoperatively to detect any complications related to intestinal ischemia. Results Three cases were complicated: two cases of failed anastomosis with leakage and the third case was ischemic end colostomy stoma. The mean values of PO readings in the noncomplicated group (37 cases) were 95.65 and 96.32% in the proximal and distal segments, respectively, whereas in the complicated group (three cases), mean values were 89 and 87% in the proximal and distal segments, respectively. Conclusion The PO device is safe, portable, and nonsophisticated, which can be used easily by surgeons in assessment of bowel viability during surgery. It takes less time to assess the intestinal viability and is very cost-effective, as one device can be used in multiple patients.

Bowel viability assessment during surgery (review of the literature)

The problem of bowel viability assessment during surgery is still opened. High value predictive and economically available technique is thought to decrease postoperative morbidity and mortality during elective and urgent abdominal surgery. To evaluate the available techniques for intraoperative bowel viability assessment, the search of Russian and foreign up-to-date literature was performed. Parameters of techniques are analyzed: intraoperative clinical application, invasiveness, objectivity and quantification of viability parameters, predictive value for necrosis and anastomotic leakage. There is still no standardised and available for every operative theatre method for bowel viability assessment during surgery. Numerous of techniques such as near-infrared fluorescence (NIR) angiography, using indocyanine green (ICG), optical coherence tomography (OCT), laser doppler flowmetry (LDF) are proposed to be more evaluated and perspective. Autofluorescence spectroscopy for NADH and flavoproteins seems to be a promising tool for early detection of nonviable bowel segments.

The most recent recommendations for the surgical treatment of inguinal hernia

The publication of new guidelines in recent years shows that surgical treatment of inguinal hernia remains topical. The main goal is to improve patient outcomes, specifically to decrease recurrence rates and reduce chronic pain. The main purpose of this article is to summarize the latest recommendations in surgical treatment of the groin hernias, especially in the case of strangulation. The authors made literature review of all the guidelines published by the hernia societies, including related articles, in the last ten years. The use of the EHS classification system is suggested. In elective operations, mesh repair is recommended. The Lichtenstein technique is the standard in open inguinal hernia repair. Transabdominal preperitoneal and totally extraperitoneal approach have comparable outcomes. Their clear advantages include minimal invasiveness. Mesh repair is recommended also in the case of strangulation, but only in clean and clean-contami-nated operations. Alaparoscopic approach should be considered as well. Inter alia, it allows an assessment of bowel viability during the whole procedure. The need of bowel resection is hence lower compared to open surgery. If it is not possible to use the mesh, the Shouldice method is regarded as the best non-mesh repair technique. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is recommended. Hernioscopy is asimple and safe procedure that uses the hernia sac for insertion of aport following insufflation and diagnostic examination. It requires less advanced laparoscopic skills than does emergency laparoscopic hernia repair. It can be performed even by surgeons who lack sufficient experience with laparoscopy. In elective procedures, the mesh repair is recommended. It is recommended also in the case of strangulation, but not in acontaminated-dirty surgical field. If there is concern about bowel viability, visualization, either by formal laparoscopy, hernia sac laparoscopy or laparotomy, is needed.

Technical aspects of abdominal ultrasound and color Doppler assessment of bowel viability in necrotizing enterocolitis.

Technical aspects of abdominal ultrasound and color Doppler assessment of bowel viability in necrotizing enterocolitis.

Investigating viability of intestine using spectroscopy: a pilot study

BackgroundThe differentiation of “viable” from “nonviable” bowel remains a challenge in the treatment of acute mesenteric ischemia. In this study, diffuse reflectance spectroscopy (DRS) was used to investigate the viability of bowel tissue after ischemia and reperfusion in an animal model in vivo and in real time. MethodsA total of 25 females Sprague–Dawley rats were divided into five groups based on different bowel ischemia times. In each study group for four of them, the superior mesenteric artery was occluded using a vascular clamp for a different period (i.e. 30, 45, 60, and 90 min; n = 5 for each group). Intestinal reperfusion was accomplished by releasing the clamps after the given occlusion period for each group. Spectra were acquired by gently touching the optical fiber probe to the bowel tissue before the induce ischemia, at the end of the induced ischemia, and after the reperfusion. The data acquired before the ischemia were used as a control group. Without occluding the superior mesenteric artery, the spectra were acquired on the bowel with the same time intervals of the experiments were used as a sham group (n = 5). Subsequently, the same bowel segments were sent for histopathologic examination. ResultsBased on the correlation between the spectra acquired from the bowel segments and the results from the histopathologic investigation, DRS is able to differentiate the histopathologic grading that appears when the Chiu/Park score ≥5 (i.e., high-level ischemic injury) than Chiu/Park score <5. Eight out of nine low-level ischemic injury tissue samples were correctly defined using the spectroscopic classification system. All eleven high-level ischemic injury tissues that were histopathologically assigned grade 5 and above were correctly defined using the spectroscopic classification system in the ischemia–reperfusion groups. ConclusionsDRS could potentially be used intraoperatively for the assessment of bowel viability in real time. These preliminary findings suggest that DRS has the potential to reduce unnecessary resection of viable tissue or insufficient resection of nonviable tissues may reduce the mortality and morbidity rates of intestinal ischemia–reperfusion as acute mesenteric ischemia.

Diagnostic Laparoscopy Through Deep Inguinal Ring

To systematically review the published literature on the role of diagnostic laparoscopy through deep inguinal ring (DL-DR) during groin hernia repair. Standard electronic databases were searched reporting article in any language on the role of DL-DR during groin hernia repair regardless of the age and sex of patients. Thirty-one articles on 5745 patients undergoing DL-DR during groin hernia repair were retrieved from the electronic databases. There was 1 randomized, controlled trial, 7 case reports and 2 case series on 58 adult patients mainly targeting assessment of bowel viability following spontaneous reduction of the strangulated groin hernia. Twenty-one articles, either retrospective or prospective case series on 5687 were reported on pediatric patients aiming to detect a contralateral patent processus vaginalis or synchronous groin hernia. Overall, the laparoscopy group had a reduced operative time, reduced length of hospital stay, lower complication rate, and earlier return to normal activity. DL-DR success rates were reported in >95% of patients. Contralateral patent processus vaginalis indicative of inguinal hernia was found in >48% of children. There was no major morbidity reported in any group. DL-DR during groin hernia repair may be performed safely when indicated. The routine use of DL-DR is an established practice in pediatric surgery. There is still insufficient evidence to recommend the routine use of DL-DR in adults.

How to assess intestinal viability during surgery: A review of techniques

Objective and quantitative intraoperative methods of bowel viability assessment are essential in gastrointestinal surgery. Exact determination of the borderline of the viable bowel with the help of an objective test could result in a decrease of postoperative ischemic complications. An accurate, reproducible and cost effective method is desirable in every operating theater dealing with abdominal operations. Numerous techniques assessing various parameters of intestinal viability are described by the studies. However, there is no consensus about their clinical use. To evaluate the available methods, a systematic search of the English literature was performed. Virtues and drawbacks of the techniques and possibilities of clinical application are reviewed. Valuable parameters related to postoperative intestinal anastomotic or stoma complications are analyzed. Important issues in the measurement and interpretation of bowel viability are discussed. To date, only a few methods are applicable in surgical practice. Further studies are needed to determine the limiting values of intestinal tissue oxygenation and flow indicative of ischemic complications and to standardize the methods.

Ischemic bowel after laparoscopic Roux-en-Y gastric bypass: limited resection based on fluorescein assessment of bowel viability

Small bowel obstruction (SBO) occurs in 1.5–4% of patients after laparoscopic Roux-en-Y gastric bypass (LRYGB) [1–5] and results from internal hernia in 30–50% of cases [1, 6]. Three potential internal hernia defects result from RYGB: the jejunojejunostomy mesenteric defect, Petersen’s defect, and the transverse mesocolon defect [2]. Routine closure of all three defects with continuous nonabsorbable suture has been advocated [7].

Laparoscopic Management of Non-Viable Bowel Following Reduction en masse

We read with interest the technical note explaining laparoscopic assessment of bowel viability following reduction en masse. However, the article did not make any suggestion of management strategy for non-viable bowel following reduction en masse. Following our recent experience of this, we would like to recommend a management approach in this situation. We performed an open inguinal hernia repair for a gentleman presenting with an incarcerated inguinal hernia. Reduction en masse occurred peri-operatively; we opened the hernia sac and inserted a 12-mm Excel laparoscopic port (Ethicon) into the abdominal cavity. Following induction of a pneunioperitoneuni, we found 14 cm of non-viable small bowel. We inserted a second 12-mm laparoscopic umbilical port and, using a laparoscopic Babcock, grasped the section of non-viable small bowel. Following hernioplasty, we extended the umbilical port to approximately 4 cm and delivered the small bowel, resecting the necrotic segment. This laparoscopic-assisted, small bowel resection saved the patient a full laparotomy and expedited his postoperative recovery. By performing the small bowel resection through the extended umbilical port site, we prevented contamination of the hernia repair. This technique offers an innovative, and less invasive, method of managing non-viable small bowel following reduction en masse.

Necrotizing Enterocolitis: Assessment of Bowel Viability With Color Doppler US

Necrotizing Enterocolitis: Assessment of Bowel Viability With Color Doppler US

Peroperative evaluation of the viability of ischaemic colon in primates.

Abstract An experimental model of ischaemic colitis was produced in 14 rhesus monkeys by complete vascular occlusion to the splenic flexure for periods varying from 4 to 8.5 hours. Clinical assessment of bowel viability following revascularization was inaccurate in 10 monkeys. Reactive hyperaemia was quantitatively measured using 99mtechnetium-tagged albumin micro-spheres and this correlated well with autopsy findings – a marked hyperaemic response suggested a transient form of ischaemic colitis; a diminished or absent hyperaemic response predicted the development of strictures or gangrene of the colon segment. A clinical trial is currently being organized to assess the viability of ischaemic bowel at laparotomy.

Necrotizing Enterocolitis: Assessment of Bowel Viability with Color Doppler US

To determine whether absence of bowel wall perfusion at color Doppler ultrasonography (US) is indicative of bowel necrosis in neonates with necrotizing enterocolitis (NEC). This study was approved by the research ethics board, and informed consent was obtained. Sixty-two neonates enrolled in the prospective study underwent US of the bowel wall. Neonates were divided into two groups. Group A included 30 control subjects with gestational ages (GAs) ranging from 24 to 41 weeks. Group B included 32 neonates with GAs ranging from 24 to 40 weeks who were clinically proved to have or suspected of having NEC. All neonates in group B underwent abdominal radiography. Normative values were calculated in group A. In group B, the sensitivities and specificities of color Doppler US and abdominal radiography for detection of bowel necrosis were computed by using the modified Bell staging criteria for NEC as the reference standard. Two neonates were excluded from group B; thus, a total of 60 neonates were included in the study. In group A, bowel wall thickness ranged from 1.1 to 2.6 mm. Bowel wall perfusion was detected with color Doppler US in all 30 neonates. Color Doppler signals ranged from one to nine dots per square centimeter. Twenty-two of 30 neonates in group B received a diagnosis of NEC. Mild to moderate NEC was diagnosed in 12 neonates. Color Doppler US depicted an isolated segment of bowel-absent blood flow in two neonates; this finding was confirmed with laparotomy. In 10 neonates with severe NEC, color Doppler US depicted isolated or multiple segments of bowel with absent perfusion. Pneumoperitoneum was present in only four neonates. The remaining eight neonates at risk for NEC had no evidence of loops without perfusion at color Doppler US. The sensitivity of free air at abdominal radiography as a positive sign for severe NEC with necrotic bowel was 40% compared with the 100% sensitivity of absence of flow at color Doppler US (P = .03). Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC.

Can laparoscopy be performed safely early after laparotomy?

Early subsequent laparotomy has high morbidity and mortality rates. The majority of these procedures, such as control of intraabdominal bleeding, management of intraabdominal sepsis, assessment of bowel viability, or anastomotic suture line, which are performed during early subsequent laparotomy, can be managed safely by laparoscopy, with resultant decreased mortality and morbidity rates. However, fear of dehiscence and ventral hernia prevents widespread use of laparoscopy. The aim of this experimental study was to compare the deleterious effects of subsequent laparotomy with laparoscopy in abdominal wounds during the early postceliotomy period. A 4-cm median laparotomy was performed in 120 Wistar-Albino rats that were classified into three groups. The control group (1) did not receive additional treatment. On the third postoperative day, early subsequent laparotomy and pneumoperitoneum were performed in group 2 and group 3 rats, respectively. Ten rats from each group were selected randomly and killed after 5 days, 1 week, 2 weeks, and 4 weeks. Bursting pressure and tensile strength of the abdominal wound were assessed. Results of the study showed impaired abdominal wound healing in subsequent laparotomy group rats (group 2) (P < 0.05). Pneumoperitoneum did not cause statistical differences in wound healing parameters when compared with control group rats (P > 0.05). In conclusion, pneumoperitoneum does not affect abdominal wound healing adversely, but early subsequent laparotomy impairs wound healing severely. Laparoscopy would be an alternative to high-risk early subsequent relaparotomy.