Open Abdominal Approach Research Articles

Long-term outcomes by a transanal approach to total mesorectal excision for rectal cancer.

The challenge of performing a good total mesorectal excision (TME) dissection, particularly in the distal 1/3 of the rectum, has spurred interest in new techniques. Robotic surgery is advocated by some, and more recently, a "new" approach, the transanal total mesorectal excision, has been popularized to address this problem. While great interest in this technique exists, little long-term outcome data are available. We have been utilizing a transanal abdominal transanal approach to TME in order to facilitate the distal dissection, and here, we provide our long-term outcomes using this approach in the management of rectal cancer. From a prospectively maintained rectal cancer database, we identified 373 consecutive rectal cancers treated with sphincter preservation surgery through a combined transanal and abdominal approach to TME. Perioperative, pathological, and oncologic outcomes were analyzed. Three hundred and seventy-three patients with rectal cancer underwent a transanally initiated TME with mean follow-up of 5.5years. 91% of cancers were in the distal rectum. 68.9% were men and 53.2% of cancers were tethered or fixed on presentation. 97.7% received neoadjuvant radiotherapy (mean 5405cGy, 5-fluorouracil based); average time from completion of neoadjuvant therapy to surgery was 11weeks. 180 and 193 patients underwent completion of their operation through open and laparoscopic abdominal approaches. 96% of TME specimens were complete/near complete, 94% had a negative circumferential resection margin, and 98.6% had a negative distal margin. Perioperative morbidity and mortality rates were 13.4 and 0.3%. Overall local recurrence (LR), DM, and Kaplan-Meier 5-year actuarial survival were 7.4, 19.5, and 90%, respectively. This is the first report of long-term data using a transanal approach to TME supporting this approach for rectal cancer. Our data with 5-year follow-up show that adequate distal and circumferential margins with very good-quality TME specimens, and a low risk for LR with excellent overall survival can be achieved using this technique. Our long-term results support the promising reports of early experiences in the literature.

Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature.

The incidence of perineal hernia after abdominoperineal excision and extralevator abdominoperineal excision ranges from 1 to 26%. In this systematic review, we compared surgical options and postoperative outcomes of perineal hernia repair in this setting from 2012 to 2016 with findings in a review of publications 1944-2011. We searched the PubMed database using the keywords "hernia" AND "perineum" identified 392 papers published from 1946 to 2016. Two hundred and ninety-six papers published before 2012 were excluded and 96 were found to be potentially relevant. Twenty-one studies with a total of 108 patients were included in the final analysis. Perineal hernia repair was performed using the perineal approach in 75 patients (69.44%), the laparoscopic approach in 25 patients (23.14%), the open abdominal approach in three patients (2.77%) and the laparoscopic perineal approach in three patients (2.77%) and the open abdominoperineal approach in two patients (1.8%). Non-absorbable mesh was used in 41 (37.96%) of cases, composite mesh in 20 (18.51%) and biological mesh in 19 (17.59%). Flap reconstruction was used in 25 patients (23.14%). First and second recurrences were observed in 26 (24.07%) and 7 (26.92%) cases, respectively. Comparison of perineal hernia repair from 1944 to 2011 and from 2012 to 2016 showed that perineal and laparoscopic approaches are currently the most commonly used techniques. Primary defect closure was abandoned in favor of synthetic or composite mesh placement. Use of flap reconstruction spread rapidly and the recurrence rate was low. Randomized control trials and a larger sample size are needed to confirm these data and to develop a gold standard treatment for secondary hernia repair after abdominoperineal excision or extralevator abdominoperineal excision.

Does Universal Insurance Mitigate Racial Differences in Minimally Invasive Hysterectomy?

Study ObjectiveTo determine if racial differences exist in receipt of minimally invasive hysterectomy (defined as total vaginal hysterectomy [TVH] and total laparoscopic hysterectomy [TLH]) compared with an open approach (total abdominal hysterectomy [TAH]) within a universally insured patient population. DesignRetrospective data analysis (Canadian Task Force classification II-2). SettingThe 2006–2010 national TRICARE (universal insurance coverage to US Armed Services members and their dependents) longitudinal claims data. PatientsWomen aged 18 years and above who underwent hysterectomy stratified into 4 racial groups: white, African American, Asian, and “other.” InterventionReceipt of hysterectomy (TAH, TVH, or TLH). Measurements and Main ResultsWe used risk-adjusted multinomial logistic regression models to determine the relative risk ratios of receipt of TVH and TLH compared with TAH in each racial group compared with referent category of white patients for benign conditions. Among 33 015 patients identified, 60.82% (n = 20 079) were white, 26.11% (n = 8621) African American, 4.63% (n = 1529) Asian, and 8.44% (n = 2786) other. Most hysterectomies (83.9%) were for benign indications. Nearly 42% of hysterectomies (n = 13 917) were TAH, 27% (n = 8937) were TVH, and 30% (n = 10 161) were TLH. Overall, 36.37% of white patients received TAH compared with 53.40% of African American patients and 51.01% of Asian patients (p < .001). On multinomial logistic regression analyses, African American patients were significantly less likely than white patients to receive TVH (relative risk ratio [RRR], .63; 95% confidence interval [CI], .58–.69) or TLH (RRR, .65; 95% CI, .60–.71) compared with TAH. Similarly, Asian patients were less likely than white patients to receive TVH (RRR, .71; 95% CI, .60–.84) or TLH (RRR, .69; 95% CI, .58–.83) compared with TAH. Analyses by benign indications for surgery showed similar trends. ConclusionWe demonstrate that racial minority patients are less likely to receive a minimally invasive surgical approach compared with an open abdominal approach despite universal insurance coverage. Further work is warranted to better understand factors other than insurance access that may contribute to racial differences in surgical approach to hysterectomies.

Robotic repair of a Morgagni diaphragmatic hernia

Robotic surgery is a high technology minimally invasive system. Morgagni's hernia is a rare congenital diaphragmatic hernia subtype that occurs in relation to the sternum anteriorly. Classically, symptomatic Morgagni's hernia is repaired by open abdominal approaches to reduce the hernia contents and suture the defect primarily or by patching large defects with a synthetic mesh. Recently, authors advocate the use of laparoscopic surgical techniques to repair such hernias especially the elective ones. This case discusses Morgagni's hernia repair using robotic surgery.

Antibiotic prophylaxis in gynecological surgery. A literature review

Gynecological surgical procedures are associated with significant morbidity, and a major impact on the quality of life. The antibiotic prophylaxis should minimize the risk of postoperative infections complications, preventing in the same time the adverse effects of long-term antibiotic usage. The aim of this paper is to detail the current recommendations for antibiotic prophylaxis in gynecological surgical procedures performed by open abdominal or laparoscopic approach. We have performed a review of the English language literature from the PubMed/Medline database using the following search details: (“Antibiotic Prophylaxis”[Mesh]) AND “Gynecologic Surgical Procedures”[Mesh]. We used the similar articles function to find additional secondary resources. Antibiotic prophylaxis should not be performed in elective laparoscopic gynecological procedures without the opening of the uterus or vagina. During hysterectomy for benign or malignant disease, the first dose of antibiotic prophylaxis should be infused one hour prior to skin incision, excepting Vancomycin and Fluoroquinolone that should be started two hours before. The antibiotic should be repeated if the duration of the surgery lasts more than two half-lives of the drug or the intraoperative bleeding is greater than 1500 mL. The antibiotic prophylaxis should be discontinued within the first 24 hours after surgery. Timely administration of adequate antibiotics and a meticulous surgical technique are mandatory for effectively decreasing the risk of postoperative infectious complications. Thorough adherence to international recommendations for antibiotic prophylaxis discontinuation within 24 hours should minimize the adverse events of antibiotic usage.

Existe-t-il des critères de choix entre les voies abdominale et vaginale dans la cure du prolapsus génital ?

The never ending debate over the surgical approach of genital prolapse repair (abdominal versus vaginal route) is as passionate as ever. The available literature may support a multidisciplinary analysis of our expert daily practice. Our purpose was to define selection criteria for surgical approach between abdominal and vaginal route in the management of genital prolapse by reviewing the literature. Systematically review of the literature concerning comparative anatomical and functionnal results of surgery of pelvic organ prolaps by vaginal or abdominal route. We were confronted to the lack of data in the literature, with few prospective randomized comparative studies. Many limitations were identified such as small populations in the studies, no description of sub-population, multiplicity of surgical procedures. Moreover, vaginal route was compared to sacral colpopexy by open abdominal approach, whereas laparoscopic sacrocolpopexy is now recommended. Only one prospective randomized comparative trial assessed laparoscopic sacrocolpopexy and vaginal approach, in which was used a mesh withdrawn from the market. The lack of available randomized trials makes it impossible to define HAS compliant guidelines on this topic. However, selection criteria for each surgical approach and technique were drawn from experts' advices. © 2016 Published by Elsevier Masson SAS.

Surgical management of a giant inguinoscrotal hernia: A case report

Inguinal hernias are among the most common clinical entities encountered by general surgeons. Most defects are small, relatively benign, and easily repaired using standardized and broadly accepted techniques. Large hernias that extend below the mid-point of the inner thigh in the standing position, known as giant inguinal hernias (GIH), are uncommon in the Western world. We present the case of a 71-year-old man who presented with a giant left inguinoscrotal hernia that extended below the knee and was complicated by symptoms of intractable constipation, exercise intolerance, and weakness. This hernia was repaired utilizing an open abdominal midline approach, with retroperitoneal reinforcement of the fascial defect using prosthetic mesh according to the method first described by Stoppa. A long segment of sigmoid colon was entrapped within and densely adherent to the scrotum, necessitating segmental resection with creation of an end colostomy. This was reversed in a subsequent procedure. Several months after his operation, the patient has returned to normal activities without recurrence of prior abdominal symptoms. Although challenging even in the hands of experienced surgeons, surgical correction remains the only mode of treatment that offers patients with GIH satisfactory quality of life.

Outcome of Non-Descent Vaginal Hysterectomy at a Single Centre in Sri Lanka: an Observational Study

Introduction: Hysterectomy is the commonest major gynaecological surgery performed worldwide. Though many routes of hysterectomy are described, open abdominal approach remains the commonest route to date for indications other than genital prolapse. There is evidence of advantages of non-descent vaginal hysterectomy (NDVH) over abdominal hysterectomy in such indications. However, the acceptance rate for vaginal approach by the gynaecologists remains low. We describe the outcome data of a series of non-descent vaginal hysterectomies performed in a single centre in Sri Lanka. Objectives: To describe the post-operative outcome and complications of NDVH for benign indications of uteri less than 14 weeks size. Method: An observational study was undertaken at the ward 14 of The De Soysa Maternity Hospital, Colombo over a period of one year from May 2007 to April 2008 among women who underwent NDVH for benign conditions. Those with co-existing genital prolapse requiring surgical correction, uteri larger than 14 weeks, a history of previous abdominal surgery and medical co-morbidities were excluded from the study. Results: The study included 53 patients who underwent NDVH. The majority had a normal sized uterus 39 (73.6%). There was a statistically significant improvement in post-operative urinary index compared to pre-operative urinary index [Kruskal-Wallis test-6.155, degrees of freedom = 2, p Conclusions: The outcome and complication rates of non-descent vaginal hysterectomy this series were comparable with evidence from literature. Therefore, we conclude that NDVH is a feasible option for benign gynaecological conditions with a uterus less than 14 weeks in size in the current gynaecological practice of Sri Lanka. Sri Lanka Journal of Obstetrics and Gynaecology Vol.37(3) 2015: 42-46

Impact of Obesity on Surgical Treatment for Endometrial Cancer: A Multicenter Study Comparing Laparoscopy vs Open Surgery, with Propensity-Matched Analysis

ObjectiveTo evaluate the impact of obesity on the outcomes of surgical treatment for endometrial cancer in general and also comparing laparoscopic and open abdominal approach. DesignRetrospective case-control study (Canadian Task Force classification II-1). SettingObstetrics and Gynecology Department, University of Insubria, Varese, Catholic University of the Sacred Heart, Rome, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, and Sant'Orsola-Malpighi Hospital, Bologna, Italy. PatientsData of consecutive patients who underwent surgery for endometrial cancer in 4 centers were reviewed. Univariate and multivariable analyses were performed. Adjustment for potential selection bias in surgical approach was made using propensity score (PS) matching. InterventionsLaparoscopic or open surgical treatment for endometrial cancer. Measurements and Main ResultsA total of 1266 patients were included, including 764 in the laparoscopy group and 502 in the open surgery group. A total of 391 patients (30.9%) were obese, including 238 (18.8%) with class I obesity, 89 (7%) with class II obesity, and 64 (5.1%) with class III obesity. The total number of complications, risk of wound complications, and venous thromboembolic events were higher in obese women compared with nonobese women. Blood transfusions, incidence/severity of postoperative complications, and postoperative hospital stay were significantly higher in the open surgery group compared with the laparoscopy group, irrespective of obesity. These differences remained significant in both multivariable analysis and PS-matched analysis. The percentage of patients who received lymphadenectomy declined significantly in patients with BMI ≥40 in both the laparoscopy and open surgery groups. Conversions from the initially intended minimally invasive approach to open surgery were 1.1% to 2.2% for women with BMI <40, but increased in those with BMI ≥40 (8.6%; p = .05). PS analysis showed a lower complication rate, shorter hospital stay, and greater likelihood of receiving lymphadenectomy in obese women in the laparoscopic group. ConclusionLaparoscopy for endometrial cancer retains its advantages over open surgery, even in obese patients. However, operating on obese patients can be challenging regardless of the surgical approach taken, especially in cases of morbid adiposity.

Surgical treatments for rectal prolapse: how does a perineal approach compare in the laparoscopic era?

Patients with rectal prolapse often have significant comorbidities that lead surgeons to select a perineal resection for treatment despite a reported higher recurrence rate over abdominal approaches. There is a lack of data to support this practice in the laparoscopic era. The objective of this study was to evaluate if risk-adjusted morbidity of perineal surgery for rectal prolapse is actually lower than laparoscopic surgery. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database as performed for patients undergoing surgical treatment of rectal prolapse between 2005 and 2011. Outcomes were analyzed according to procedure-type: laparoscopic rectopexy (LR), laparoscopic resection/rectopexy (LRR), open rectopexy (OR), open resection/rectopexy (ORR), and perineal resection (PR). A multivariate logistic regression was used to compare risk-adjusted morbidity and mortality between each procedure. Main outcome measures were 30-day morbidity and mortality. Among 3,254 cases sampled, a laparoscopic approach was used in 22 %, an open abdominal approach in 30 %, and PR in 48 %. Patients undergoing PR were older (76) and had a higher ASA (3) compared to laparoscopic (58, 2) and open abdominal procedures (58, 2). Risk-adjusted mortality could not be assessed due to a low overall incidence of mortality (0.01 %). Overall morbidity was 9.3 %. ORR was associated with a higher risk-adjusted morbidity compared to PR (OR: 1.89 CI (1.19-2.99), p = 0.03). There were no significant differences in risk-adjusted morbidity found between LR and LRR compared to PR (OR 0.44 CI (0.19-1.03), p = 0.18; OR 1.55 CI (0.86-2.77), p = 0.18). Laparoscopic cases averaged 27 min longer than open cases (p < 0.001). Laparoscopic rectal prolapse surgery has comparable morbidity and mortality to perineal surgery. A randomized trial is indicated to validate these findings and to assess recurrence rates and functional outcomes.

Perioperative and long-term outcomes of laparoscopic, open abdominal, and vaginal surgery for endometrial cancer in patients aged 80 years or older.

This study was undertaken to evaluate the safety, feasibility, and the long-term effectiveness of laparoscopy in endometrial cancer patients aged 80 years or older. Data of consecutive patients aged 80 years and older undergoing laparoscopic, open abdominal, and vaginal approaches were compared. Postoperative complications were graded per the Accordion Severity Classification. Survival outcomes within the first 5 years were analyzed using the Kaplan-Meier method. Among 726 patients, 63 (9%) were aged 80 years and older. Laparoscopic, open abdominal, and vaginal surgery were performed in 22 (35%), 25 (40%), and 16 (25%) cases, respectively. All laparoscopic procedures were completed laparoscopically, whereas a conversion from vaginal to open procedure occurred (0% vs 6%; P = 0.42). Patients undergoing laparoscopy experienced similar operative time (P > 0.05), lower blood loss (P < 0.05), and shorter hospital stay (P < 0.05) than patients undergoing open and vaginal surgery. No intraoperative complications were recorded. Laparoscopy is related to a lower rate of postoperative complications (P = 0.09) and Accordion grade greater than or equal to 2 complications (P = 0.05) in comparison to open abdominal and vaginal surgery. The route of surgical approaches did not influence the 5-year disease-free (P = 0.97, log-rank test) and overall (P = 0.94, log-rank test) survivals. Laparoscopy seems to represent a safe and effective treatment of endometrial cancer in women aged 80 years or older. Our data suggest that in elderly women, laparoscopic surgery improves perioperative outcomes compared with open and vaginal approaches without compromising long-term survival.

Laparoscopic Versus Open Abdominal Management of Cervical Cancer: Long-Term Results From a Propensity-Matched Analysis

Study ObjectiveTo compare perioperative and long-term outcomes related to laparoscopic and open abdominal surgical management of cervical cancer. DesignPropensity-matched comparison of prospectively collected data (Canadian Task Force classification II-1). SettingUniversity teaching hospital. PatientsSixty-five propensity-matched patient pairs (130 patients) undergoing either laparoscopy or open abdominal surgical procedures to treat cervical cancer. InterventionRadical hysterectomy plus lymphadenectomy was performed via the laparoscopic (LRH) or open abdominal approach (RAH). Measurement and Main ResultsBaseline characteristics of the study populations were similar. In the LRH group the procedure was converted to open surgery in 2 patients (2%). Compared with the RAH group, patients undergoing LRH experienced less blood loss (200 vs 500 mL; p < .001), a lower transfusion rate (6% vs 22%; p = .02), similar operative time (245 vs 259.5 minutes; p = .26), and shorter length of hospital stay (4 vs 8 days; p < .001). No between-group differences in intraoperative complications were recorded (p = 1.0); however, a trend toward a lower postoperative complication rate (Accordion system grade ≥3) was observed for LRH compared with RAH (4 patients [6%]) vs 12 patients [18%]; p = .06). Five-year disease-free survival (p = .6, log-rank test) and overall survival (p = .31, log-rank test) did not differ statistically between women undergoing LRH or RAH. ConclusionLaparoscopy ensures the same results as open surgery insofar as radicality and long-term survival. Use of the laparoscopic approach is associated with improved short-term results, minimizing the occurrence of severe postoperative complications.

Results of a prospective, randomized, controlled study of the use of carboxymethylcellulose sodium hyaluronate adhesion barrier in trauma open abdomens

The open abdominal (OA) approach is a management strategy used in the most severely injured trauma patients. In addition to the morbidity and mortality, a major challenge is the gradual development of dense adhesions that make reoperations progressively more difficult. This randomized, prospective, proof-of-concept study was conducted to determine the effect of carboxymethylcellulose sodium hyaluronate adhesion barrier (CMHAB; Seprafilm, Genzyme Biosurgery, Bridgewater, NJ) on abdominal adhesions and wound characteristics in trauma open abdomens. A prospective, randomized, controlled study of wound and adhesion characteristics with or without CMHAB was conducted at 5 level I trauma centers. Consenting patients were randomized to either CMHAB or no adhesion barrier (NAB) groups. We evaluated patient demographics, injury characteristics/severity, reason for OA management, wound sizes (transverse/longitudinal), Zuhlke adhesion score, abdominal contamination score, hospital/intensive care durations of stay, morbidity, and mortality. Thirty patients were enrolled (17 randomized to CMHAB; 13 randomized to NAB) with mean age of 40.3, Injury Severity Score of 30, Abbreviated Injury Score (AIS)-abdomen of 3.68, APACHE II score of 14.4, and 67% blunt trauma mechanism. The groups were well-matched with regard to age, sex, Injury Severity Score/abdominal AIS, penetrating/blunt injury rates, initial lactate/base deficit, mortality, OA indications, and contamination scores. There were no differences in nonabdominal or abdominal complications (ie, fistula, abscess, wound related) between the groups. Patients with CMHAB had shorter intensive care unit durations of stay (15 vs 22 days; P < .05). Intraoperative adhesion scores were not different during the first four operations but diverged significantly at the 5th operative intervention or after about 1 week of OA therapy. After the 5th operation, adhesion scores in the NAB group were 67% greater (approximately 1 Zuhlke point) than the CMHAB group. We did not note differences between wound sizes over time, closure types, or wound closure characteristics between CMHAB and NAB. Although CMHAB did not eliminate adhesions in this proof-of-concept study, it limited their severity, particularly in abdomens left open >9 days or requiring ≥5 operations. There was no difference in wound sizes, overall or abdominal complications, or mortality between the groups. Further research is warranted to better delineate potential benefits of CMHAB, especially in the setting of reoperations in post-OA patients.

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions

Comparison of Perioperative Complications by Route of Hysterectomy Performed for Benign Conditions

Laparoscopic resection of retrorectal tumors: a feasibility study in 12 consecutive patients

Surgical approaches for retrorectal tumors (RRT) are either abdominal, dorsal trans-sacrococcygeal, or perineal. Very few cases have been reported so far concerning a laparoscopic approach. The aim of this study was to assess the results of laparoscopy for the treatment of RRT. All patients who underwent laparoscopy for RRT between 2003 and 2012 were reviewed. Data included patient and tumor characteristics, surgical morbidity, and mortality. A total of 12 consecutive women with a median age of 55 years underwent laparoscopy for RRT. Median operative time was 145 min (range 70-215). Two conversions in laparotomy occurred, and one patient needed a temporary diverting ileostomy for rectal injury. Postoperatively, two patients presented urinary tract infections. Median length of stay was 8 days (range 4-16). Pathological examinations showed complete resections (R0) for ten benign tumors and one malignant tumor (Ewing sarcoma). One lesion was incompletely resected, a colloid sarcoma (R1 status), and was re-operated on by laparotomy after neoadjuvant chemoradiation. No local recurrence was observed after a median follow-up of 34 months (range 12-79) for benign lesions, and 28 and 71 months for the two patients who underwent resection of Ewing and colloid sarcoma, respectively. Laparoscopic resection for RRT seems feasible and safe. It allows complete excision of tumors located in the retrorectal space with low morbidity. Thus, this approach can be a valid alternative to standard Kraske or open abdominal approaches for the treatment of RRT.

Achieving consensus on the definition of conversion to laparotomy: a Delphi study among general surgeons, gynecologists, and urologists

In laparoscopic surgery, conversion to laparotomy is associated with worse clinical outcomes, especially if the conversion is due to a complication. Although apparently important, no commonly used definition of conversion exists. The aim of this study was to achieve multidisciplinary consensus on a uniform definition of conversion. On the basis of definitions currently used in the literature, a web-based Delphi consensus study was conducted among members of all four Dutch endoscopic societies. The rate of agreement (RoA) was calculated; a RoA of >70% suggested consensus. The survey was completed by 268 respondents in the first Delphi round (response rate, 45.6%); 43% were general surgeons, 49% gynecologists, and 8% urologists. Average ± standard deviation laparoscopic experience was 12.5 ± 7.2 years. On the basis of the results of round 1, a consensus definition was compiled. Conversion to laparotomy is an intraoperative switch from a laparoscopic to an open abdominal approach that meets the criteria of one of the two subtypes: strategic conversion, a standard laparotomy that is made directly after the assessment of the feasibility of completing the procedure laparoscopically and because of anticipated operative difficulty or logistic considerations; and reactive conversion, the need for a laparotomy because of a complication or (extension of an incision) because of (anticipated) operative difficulty after a considerable amount of dissection (i.e., >15 min in time). A laparotomy after a diagnostic laparoscopy (i.e., to assess the curability of the disease) should not be considered a conversion. In the second Delphi round, a RoA of 90% was achieved with this definition. After two Delphi rounds, consensus on a uniform multidisciplinary definition of conversion was achieved within a representative group of general surgeons, gynecologists, and urologists. An unambiguous interpretation will result in a more reliable clinical registration of conversion and scientific evaluation of the feasibility of a laparoscopic procedure.

Vaginal repair of ureterovaginal fistula may be suitable for selected cases

Ureterovaginal fistula (UVF) is an uncommon but devastating complication of gynecologic surgery. Management includes ureteral stenting for 6-8 weeks. For stent failure, ureteroneocystostomy (UNC) through an open, laparoscopic, or robotic abdominal approach is the classic alternative. Originally pioneered for repair of vesicovaginal fistulas (VVF), the use of the vaginal approach in UVF is scarcely reported in the literature. We report the successful repair of UVF performed exclusively through the vaginal approach in two women after robotic hysterectomy. In select clinical scenarios, this approach may be applied, as it provides a minimally invasive option for managing UVF after failure of ureteral stenting.

Open versus Laparoscopic Hiatal Hernia Repair

The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database. The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for demographics and comorbidities while looking for independent risk factors for mortality. In total, 23,514 patients met the inclusion criteria. By surgical approach, 55% of patients underwent open abdominal, 35% laparoscopic, and 10% open thoracic repairs. Length of stay was significantly reduced for all patients after laparoscopic repair (P < .001). Age ≥60 years and nonwhite ethnicity were associated with significantly higher odds of death. Laparoscopic repair and obesity were associated with lower odds of death in the uncomplicated group. Laparoscopic repair of paraesophageal hiatal hernia is associated with a lower mortality in the uncomplicated group. However, older age and Hispanic ethnicity increased the odds of death.

Multidetector CT Evaluation of Food Stasis in Remnant Stomach and Body Fat Change after Subtotal Gastrectomy by Laparoscopic versus Open Abdominal Approach

Multidetector CT Evaluation of Food Stasis in Remnant Stomach and Body Fat Change after Subtotal Gastrectomy by Laparoscopic versus Open Abdominal Approach

Retained Rectum in a Patient Status Post Total Proctocolectomy for Ileocolonic Crohn’s Disease

A 28-year-old female with a twenty-year history of penetrating ileocolonic Crohn’s disease status post total proctocolectomy (TPC) presented to the inflammatory bowel disease clinic with 4 months of a draining perianal abscess. The discharge was serosanguineous mixed with mucoid tissue soiling 5 feminine pads daily. Three years prior to presentation she had an emergent subtotal colectomy with ileostomy for a colonic perforation while on adalimumab. Subsequent to her surgery, adalimumab was discontinued and she was maintained in clinical remission on mesalamine and azathioprine. One year later, a necrotic rectal stump precluded an attempt to restore continuity and underwent completion proctectomy through a perineal approach and maintained her permanent ileostomy. She remained on mesalamine and azathioprine with stable ostomy output and without any gastrointestinal symptoms until her current presentation. Her exam was significant for a 3 cm midline draining open wound at the level of her prior anus with surrounding erythema but no fluctuance. The site was exquisitely tender to palpation and blood mixed with pus was easily expressed. CT and magnetic resonance imaging of the pelvis revealed a perianal fistula communicating with a hyperintense lesion within the presacral fat and posterior to the uterus measuring 16 × 19 × 26 mm suggestive of a remnant rectal pouch. Additionally, there was evidence of a fistulous track from the rectal remnant to the perineum and a rectovaginal fistula. Initial therapy with oral metronidazole improved her perineal pain and drainage. She underwent a redo abdominoperineal resection where the remnant rectum was identified and completely resected. A rectovaginal fistula was identified in the posterior vaginal wall and excised. The histopathology of the specimen was significant for colonic tissue with chronic active colitis and transmural inflammation. After surgical excision of the active diseased colonic remnant tissue her fistulas healed and her perineal pain ceased. This is an unusual case of an unintentionally retained rectum in a patient status post proctocolectomy presenting as active perianal Crohn’s disease. Approximately 75% of all CD patients will require surgery during their lifetime, which can include a total colectomy in medically refractory Crohn’s colitis. Patients with rectal and perianal involvement of Crohn’s undergo TPC and end ileostomy given the high rates of complications in the excluded rectal stump. In patients with acute complications from Crohn’s colitis requiring urgent colonic resections, TPC is typically done in a two-step fashion, as was the intent with this patient. Routinely, due to the length of remaining distal rectum within the pelvic floor, an open abdominal approach is required to assure all colonic tissue is excised. The surgical perineal approach to removing the distal segment in this patient underestimated the length of the remaining colon within the pelvis leading to the retained rectum. Having completely removed the anal canal with adjacent rectal tissue and the proximal colon in the initial surgery, the patient was left with a “floating” segment of rectum within the pelvic floor, which maintained active CD. This case illustrates an unusual surgical complication of a completion proctectomy in Crohn’s.