Previous Open Abdominal Surgery Research Articles

Impact of Previous Open Abdominal Surgery on Open Abdominal Aortic Repair: A Study from the NSQIP Database

While endovascular aneurysm repair has become a first-line strategy in many centers, open surgical repair (OSR) of abdominal aortic aneurysms (AAAs) is still the best option for certain patients. A significant number of patients who are offered OSR for AAA have been previously submitted to other open abdominal surgeries (PAS). It is unclear, however, how this may impact their outcomes. The purpose of this study was to determine if there is an association between PAS and outcomes of OSR of AAA. This is a retrospective cohort study based on clinical data from the American College of Surgeons National Surgical Quality Improvement Program database, including all patients undergoing elective OSR for AAA between 2011 and 2017. Excluded were patients with missing data on prior abdominal surgery, supramesenteric clamping, or urgent repairs. Patients with prior abdominal surgery (PAS) and patients without prior abdominal surgeries (nonPAS) were compared. The primary outcome was 30-day postoperative mortality. Secondary outcomes were operating time, ischemic colitis, postoperative complications, and lengths of hospital stay. Of the 2034 patients included, 27% had previous open abdominal surgery and 73% did not. Overall, the median age was 71(interquartile range 65-76), 72% of patients were male, 44% were smokers, and the average body mass index was 27kg/m2. Univariate analysis showed no difference in postoperative 30-day mortality (4.0% PAS vs. 4.1% nonPAS, P=0.91) or overall postoperative complication rates (33% PAS vs. 29% nonPAS, P=0.07). Previous open abdominal surgery was significantly associated with longer operating times (P=0.032) and an almost doubled rate of ischemic colitis (4.7% PAS vs. 2.6% nonPAS, P=0.02). Postoperative intensive care unit and hospitalization were also significantly longer in patients with prior abdominal surgery (P=0.005 and P=0.014, respectively). Finally, there were significantly less patients discharged home, as opposed to institutionalized care (75.7% PAS down from 82.4% nonPAS, P=0.001). Despite these initial univariate analysis results, on multivariate analysis, PAS actually did not prove to be a statistically significant independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. This study suggests that patients who have undergone PAS may have some disadvantages in OSR of AAA. However, these negative trends do not go so far as to statistically significantly identify PAS as an independent risk factor for 30-day mortality, ischemic colitis, or longer operating times. As such, we suggest that a history of previous open abdominal surgery, in and of its own, should not exclude patients from consideration for open aortic abdominal aneurysm repair.

Management of incisional hernias in renal transplant patients

BackgroundIncisional hernia (IH) remains one of the most common complications following abdominal organ transplantation with no consensus on the optimal management. This study is a narrative review of the incidence, risk factors, diagnosis, and management of IH post-transplantation. MethodsA literature search using the EMBASE and MEDLINE from 1.1.2016 to 15.8.2002 was conducted. Included studies reported on IH after open abdominal organ transplantation. The outcomes included in our analysis were the incidence of IH, significant patient risk factors, the diagnostic approach used to detect IH, and proposed strategies for the management of IH. 54 publications that involved 9336 transplant patients who developed IH were included. ResultsThe incidence of IH ranged from 1.7 % to 43 % in liver transplant patients and was lower following kidney transplantation (1.1 %-7.0 %). Patient risk factors predisposing to IH were body mass index>30, age (>50), smoking history, previous open abdominal surgery, open surgical repair, a Mercedes or inverse T incision and surgical site infections. The most common diagnostic approach for IH is clinical examination, followed by US or CT imaging in cases of complex IH. Following IH repair, recurrence rates ranged from 0 to 76.9 %, and complication rates from 12 % - 52.9 %, the most common of which were surgical site occurrences (11.0–79.2 %) including infection (0 - 65.4 %) and seroma formation (0–8 %). Management of IH should include preoperative optimisation of patients through weight reduction, smoking cessation and adjustment of immunosuppression using a multidisciplinary (MDT) approach. Mesh repair, either open or laparoscopic, is the gold standard for the treatment of IH, resulting in a significantly lower recurrence rate than primary closure. There is no consensus on the type and positioning of mesh, and very limited studies have reported on other perioperative factors such as wound closure. ConclusionsPrehabilitation and MDT approach are important in ensuring good outcomes following IH repair. Further prospective studies and the establishment of a relevant registry are required to propose a consensus pathway for IH repair in the transplanted population.

Previous Abdominal Scars among Patients Undergoing Laparoscopic Cholecystectomy in a Tertiary Care Centre.

Abdominal scars result from various open abdominal surgeries. Laparoscopic surgery in previous open abdominal surgery possesses various challenges to the surgeon like gaining access to the abdominal cavity, and difficulty in dissection due to dense adhesions from previous surgeries for various intraabdominal pathologies. This study aimed to find out the prevalence of previous abdominal scars among patients undergoing laparoscopic cholecystectomy in a tertiary care centre. A descriptive cross-sectional study was conducted among patients undergoing laparoscopic cholecystectomy in a tertiary care centre from 1 May 2022 to 30 April 2023 after taking ethical approval from the Institutional Review Committee. Palmer's point approach via Hassen open technique or direct optical entry was used for cases with previous abdominal scars to gain access to the abdominal cavity. Patients with symptomatic gallstone diseases were included in the study whereas patients with cholecystitis, pancreatitis, and previous cesarean scar were excluded. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Among 160 patients undergoing laparoscopic cholecystectomy, previous abdominal scars was found in 40 (25%) patients. The prevalence of previous abdominal scars contributing to intraoperative and post-operative difficulties among patients undergoing laparoscopic cholecystectomy was found to be higher than in studies done in similar settings. laparoscopic cholecystectomy; open surgery; prevalence.

Robotic biliary surgery for benign and malignant bile duct obstruction: a case series.

The majority of patients with benign or malignant biliary obstruction require surgical treatment with a bilio-enteric anastomosis. This requires fine dissection and advanced suturing. Robotic surgery may overcome some major limitations of conventional laparoscopic surgery. The precise role of robotic biliary surgery is, however, still to be defined. In our institution, patients requiring complex bile duct surgery were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed. A total number of 14 patients underwent robotic biliary surgery for a variety of benign and malignant indications between September 2020 and May 2021. Six of fourteen patients (43%) had previous open abdominal surgery. Median blood loss was 25mL (range 10-120mL). There were no intra-operative complications and no conversions. Length of stay was between 3 and 11days without major postoperative morbidity. Robotic surgery for benign and malignant bile duct obstruction is efficient and safe in experienced hands. Referral to a high-volume expert center is, however, advised.

Abdominal-based adipocutaneous advancement flap for reconstructing inguinal defects with contraindications to standard reconstructive approaches: a simple and safe salvage reconstructive option.

BackgroundGroin wounds occurring after vascular surgical site infection, oncologic resection, or occasionally orthopedic surgery and trauma may represent a surgical challenge. Reconstruction of these defects by the usual workhorse flaps may be contraindicated following previous surgery and in patients with lower limb lymphedema or extreme morbidity.MethodsThis study included 15 consecutive patients presenting with inguinal wounds after vascular or general surgery that required debridement and soft tissue coverage. All cases had absolute or relative contraindications to conventional reconstructive techniques, including a compromised deep femoral artery network, limb lymphedema, scarring of potential flap harvesting sites, or poor overall condition. Abdominal adipocutaneous excess enabled the performance of adipocutaneous advancement flaps in an abdominoplasty-like fashion. Immediate and long-term outcomes were analyzed.ResultsSoft tissue coverage was effective in all cases. Two patients required re-intervention due to flap-related complications (venous congestion and partial flap necrosis). All patients fully recovered over a mean±standard deviation follow-up of 2.4±1.5 years.ConclusionsAbdominal flaps can be an effective and simple alternative technique for inguinal coverage with reproducible outcomes. In our experience, the main indications are a compromised deep femoral artery network and poor thigh tissue quality. Relative contraindications, such as previous open abdominal surgery, should be considered.

Factors influencing postoperative abdominal pain in DIEP flap breast reconstruction.

Identification of a subgroup of patients with severe postoperative pain is important for adequate pain management for enhanced, fast recovery after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The purpose of this study was to identify factors influencing postoperative abdominal pain in patients undergoing DIEP flap breast reconstruction. Consecutive patients who underwent unilateral breast reconstruction using DIEP free flaps from October 2018 to July 2020 were included in this study. Visual analog scale (VAS)-guided postoperative pain scores were documented every 3 hours until 48 hours postoperatively. Factors affecting patient-reported pain scores were analyzed using a linear mixed-effects model. Independent variables included patient characteristics, history of previous open abdominal surgery, and operative factors including the flap size, flap weight, use of a unipedicled or bipedicled flap, number of perforators, timing of reconstruction, and use of a catheter-based subcutaneous plane block in the abdomen. A catheter was placed above the rectus fascia during closure, and analgesics were continuously infused during the 48 hours using an ON-Q Pain Relief System (I-Flow Co., Lake Forest, CA, USA). Fifty-five patients were included in the analysis. In the linear mixed effect model using multiple clinical variables, the harvested flap weight was significantly associated with the degree of pain (β coefficient =0.157, P=0.008). The pain degrees significantly decreased according to postoperative days (β coefficient =-0.649, P<0.001). The flap type (unipedicle or bipedicle), number of perforators, timing of reconstruction, and history of previous abdominal surgery did not influence pain degrees. The use of subcutaneous plane block did not affect the degree of pain or dose of analgesics used. A larger flap weight is associated with an increased degree of pain in patients undergoing DIEP flap breast reconstructions. Vigorous pain management might be necessary when a large flap is elevated.

The impact of previous open abdominal surgery on the outcome of laparoscopic colorectal surgery

The impact of previous open abdominal surgery on the outcome of laparoscopic colorectal surgery

Optically guided peritoneal access in pediatric laparoscopy: is it a good alternative for open access? A prospective comparative study

Background A minimally invasive approach has become the method of choice for treating many surgical cases. The superiority of open peritoneal access is owing to the low probability of visceral injury. Optically guided trocars were designed to decrease the injury risk to intra-abdominal contents by permitting the surgeon to see abdominal wall layers while traversing it and abdominal contents once access is complete. Materials and methods A prospective comparative study was done between optical trocar access using Fengh optical port, trocar model FLTC5 (Fengh medical Co. Ltd, Jiangsu, China), and open access using Hasson technique in pediatric patients. The study included 187 patients from the age of 1 year to the age of 16 years. Patients with previous open abdominal surgery, abdominal masses in the periumbilical region, and/or traumatic abdominal injury were excluded from the study. Access time and initial port insertion complications were reported to clarify safety and time for optical access. Results Optical access was done in 92 patients and open access in 95 patients. No visceral or major vascular complications were reported in both types of access. Access time in group IA (optical) was 58.06±16.1 s. in comparison with 175.7±54.7 s. in group IB (open) (P=0.0001*), and it was 49.7±9.4 s. in group IIA (optical) in comparison with 169.3±38.3 s. in group IIB (open) (P=0.0001*). Conclusions In selected cases, optical access is feasible, safe, and time-saving and avoids many problems in initial port insertion in pediatric laparoscopy.

Robotic-assisted and laparoscopic hernia repair: real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC).

Ventral hernia repair (VHR) is a commonly performed procedure and is especially prevalent in patients who have undergone previous open abdominal surgery: up to 28% of patients who have undergone laparotomy will develop a ventral hernia. There is increasing interest in robotic-assisted VHR (RVHR) as a minimally invasive approach to VHR not requiring myofascial release and in RVHR outcomes relative to outcomes associated with laparoscopic VHR (LVHR). We hypothesized real-world evidence from the Americas Hernia Society Quality Collaborative (AHSQC) database will indicate comparable clinical outcomes from RVHR and LVHR approaches not employing myofascial release. Retrospective, comparative analysis of prospectively collected data describing laparoscopic and robotic-assisted elective ventral hernia repair procedures reported in the multi-institutional AHSQC database. A one-to-one propensity score matching algorithm identified comparable groups of patients to adjust for potential selection bias that could result from surgeon choice of repair approach. Matched data describe preoperative characteristics and perioperative outcomes in 615 patients in each group. The following significant differences were observed among the 11 outcomes that were pre-specified. Operative time tended to be longer for the RVHR group compared to the LVHR group (p < 0.001). Length of stay differed between the two groups; while both groups had a median length of stay of 0, stay lengths tended to be longer in the LVHR group (p < 0.001). Rates of conversion to laparotomy were fewer for the RVHR group: < 1% and 2%, respectively (p = 0.007). Through 30days, there were fewer RVHR patient-clinic visits (p = 0.038). Both RVHR and LVHR perioperative results compare favorably with each other in most measures. Differences favored RVHR in terms of shorter LOS, fewer conversions to laparotomy, and fewer postoperative clinic visits; differences favored LVHR in terms of shorter operative times.

Robotic-assisted bladder neck procedures in children with neurogenic bladder.

To review the current status of robotic-assisted laparoscopic surgical techniques for bladder neck procedures in children with incontinence secondary to neurogenic bladder. A comprehensive review of the literature on robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 25years. These data were subsequently compared to published series of open bladder neck procedures and published results from robotic-assisted bladder neck reconstruction series completed at our institution. The principle bladder neck procedures for incontinence in pediatric patients with neurogenic bladder include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure, and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including low interoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation. Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with the previous open abdominal surgery.

Robotic-Assisted Bladder Neck Procedures for Incontinence in Pediatric Patients.

Purpose: To review the current status of bladder neck procedures for incontinence in pediatric patients, focusing on the increasing role of robotic-assisted laparoscopic surgical techniques.Methods: A comprehensive review of the literature on open and robotic-assisted bladder neck procedures was conducted, with a focus on articles published in the last 20 years. This data was subsequently compared with published results from robotic-assisted bladder neck reconstruction series completed at our institution.Results: The principal bladder neck procedures for incontinence in pediatric patients include: Artificial Urinary Sphincter, Bladder Neck Sling, Bladder Neck Closure and Bladder Neck Reconstruction. Continence rates range from 60 to 100% with a lack of expert consensus on the preferred procedure (or combination of procedures). Robotic-assisted approaches are associated with longer operative times, especially early in the surgical experience, but demonstrate equivalent continence rates with potential benefits including: low intraoperative blood loss, improved cosmesis, and decreased intra-abdominal adhesion formation.Conclusions: Robotic-assisted procedures of the bladder neck are safe, feasible, follow the same steps and principles as those of open surgery and produce equivalent continence rates. Robotic-assisted techniques can be adapted to a variety of bladder neck procedures and safely expanded to selected patients with previous open abdominal surgery.

Complex robotic lower urinary tract surgeries in patients with previous open surgery

PurposeWe describe our experience with robot assisted complex lower urinary tract reconstruction (CUTR) in patients with previous open abdominal surgery (PAS). Materials and MethodsPatients with any PAS undergoing robot assisted CUTR were included. CUTR was defined as bladder neck reconstruction (BNR) or continent catheterizable conduits (CCC) or both, redo surgery at the bladder neck for persistent incontinence, or any of the above with an antegrade enema channel creation (MACE). Ureteral and renal surgeries were excluded. Patient demographics, surgery performed, operative techniques, operative times and outcomes were assessed. Results36 patients met inclusion. 21 patients had multiple laparotomies for ventriculoperitoneal (VP) shunt revisions. 15 had laparotomy with other adjunct procedures in 14 and laparotomy with colostomy in 1. There were no access injuries and 5 conversions. Mean operative time was 8.2 hrs (4-12 hrs). Mean length of stay (LOS) was 74.9 hrs (23-216 hrs). The first 18 cases took longer than the last 18 cases (mean 9.1 hr vs mean 7.5 hr p= 0.002). Patients with multiple VP shunt revisions had higher conversion rates and higher mean operative times when compared to other patients (p=0.01 and p=0.002 respectively). Patients with multiple VP shunt revisions had longer LOS when compared to other patients (p= 0.02). ConclusionsRobot assisted CUTR in patients with PAS is safe and feasible. Longer operative times should be expected early in a surgeon’s experience. Multiple VP shunt revisions have higher conversion rates and longer operative times when compared to other indications for previous surgery.

Laparoscopic Gastric Bypass with Fundectomy and Gastric Remnant Exploration (LRYGBfse): Results at 5-Year Follow-up.

The laparoscopic Roux-en-Y gastric bypass (LRYGB) is the gold standard treatment for morbid obesity. After LRYGB, the endoscopic access to the gastric remnant and pancreaticobiliary system is challenging. The laparoscopic gastric bypass with fundectomy and exploration of the gastric remnant (LRYGBfse) was introduced in an attempt to overcome this limitation. The purpose of this study was to analyze the medium-term outcomes and safety of LRYGBfse. Observational prospective single-arm multicenter cohort study. Patients with BMI > 35kg/m2 were included. Previous open abdominal surgery was an exclusion criterion. Postoperative 1, 2, 3, and 5-year weight loss, BMI decrease, and percentage of excess weight loss (%EWL) were recorded. Wilcoxon signed rank sum test was used for paired data. Among 653 enrolled patients, 229 completed the 5-year follow-up. Preoperative median body weight (kg) and BMI (kg/m2) were 133.4kg (interquartile range (IQR) = 12.0) and 48.2kg/m2 (IQR = 10.1), respectively. Median 5-year body weight, BMI, and %EWL were 83.7 (IQR = 17.3), 31.2 (IQR = 7.7), and 74.8 (IQR = 23.4), respectively, all significantly improved compared to baseline (p = 0.002, p = 0.001, and p = 0.012, respectively). Comorbid improvement or resolution was observed in 88% of the patients. No major intraoperative complications were reported. Postoperative overall morbidity and mortality rates were 1 and 0%, respectively. Banding removal was necessary in one patient 62months after the index operation. The LRYGBfse seems safe and effective with durable results at 5-year follow-up. Endoscopic exploration of the gastric remnant is an additional valuable tool.

End-stage renal disease is a risk factor for complex laparoscopic cholecystectomy in patients waiting for renal transplantation.

Introduction:To date, there are no studies investigating whether laparoscopic cholecystectomy (LC) is technically more complex in patients waiting for kidney transplant. The aim of this study is to create a user-friendly score to identify high-risk cases for complex LC integrating end-stage renal disease (ESRD).Materials and Methods:We retrospectively analysed 321 patients undergoing LC during the period 2014–2016. Two groups were compared: ESRD group (n = 25) versus control group (n = 296). Concerning statistical analysis, continuous variables were compared using Kruskal–Wallis’ test, dummy variables with Chi-square test or Fisher's exact test when appropriate. A multivariable logistic regression analysis was performed to identify risk factors for complex LC. A backward conditional method was used to design the final model.Results:Seventy out of 321 (21.8%) cases were considered as complex, with a higher prevalence in the ESRD group (32.0 vs. 20.9%; P = 0.2). Using a multivariable logistic regression analysis, we formulated a score based on the independent risk factors for complex LC: 4×(previous cholecystitis) +5 × (previous ESRD) +1 × (age per decade) +2 × (previous open abdominal surgery). High-risk cases (score ≥ 10) were more commonly reported in the ESRD group (72.0 vs. 24.7%; P < 0.0001).Conclusion:Although several scores investigating the risk for complex LC have been proposed, none of them has focused on ESRD. This is the first series demonstrating that ESRD is an independent risk factor for technical complexity in LC. We developed a score to offer surgeons an extra tool for pre-operative evaluation of patients requiring LC.

Attempting a Laparoscopic Approach in Patients Undergoing Left-Sided Colorectal Surgery Who Have Had a Previous Laparotomy: Is it Feasible?

BackgroundThe feasibility of a laparoscopic approach in patients who have had a prior laparotomy (PL) remains controversial. We hypothesized that laparoscopic colorectal resection was safe and feasible in patients with previous open abdominal surgery. MethodsA retrospective review (2007–2015) of all patients undergoing laparoscopic resection for sigmoid and rectal adenocarcinoma with or without prior midline laparotomy (NPL) was performed. Primary endpoints included conversion and perioperative morbidity. Secondary endpoints included length of stay and perioperative outcomes. Demographics, surgical history, oncologic staging, and short-term outcomes were reviewed. ResultsWe identified 211 patients, of whom 33 (15.6%) had a prior laparotomy. Significantly more patients in the PL group were female (76.2 vs. 52.8%, p = 0.004). Patients with PL were of similar age to NPL patients (69.3 vs. 62.5, p = 0.09), and comorbidities, tumor staging, and neoadjuvant therapy were comparable between groups (all p > 0.05). Additional trocar placement was significantly higher in PL group (33.3 vs. 17.4%, p = 0.03), while conversion rate did not reach statistical significance (24.2 vs. 12.9%, p = 0.08). The postoperative complication rate was comparable between PL and NPL patients (33.3 vs. 25.3%, respectively, p = 0.2). ConclusionsPrior laparotomy should not be a contraindication to patients undergoing laparoscopic colorectal surgery, though surgeons should anticipate a higher likelihood of conversion to open.

Open abdominal surgery: a risk factor for future laparoscopic surgery?

BackgroundThis study seeks to investigate the outcomes of laparoscopic procedures in patients with previous open abdominal surgery. MethodsUsing data from the National Surgical Quality Improvement Program (2005 to 2009), we identified patients who had undergone laparoscopic cholecystectomy, Nissen fundoplication, Heller myotomy, splenectomy, Roux-en-Y, sleeve gastrectomy, gastric band, appendectomy, or colectomy. Patients were then classified as to whether adhesiolysis (AD) was also carried out. Bivariate and multivariate analysis was used to compare groups. ResultsA total of 162,415 patients met our inclusion criteria, comprising 4,501 (3%) in the AD group and 157,913 (97%) in the nonadhesiolysis (NAD) group. Patient who had received lysis of adhesion were older, had 41% higher odds of overall complications, 17% higher adjusted mean lysis of adhesion (P < .001), and 26% higher adjusted mean operation duration (P < .001). ConclusionsA history of previous open abdominal surgery increases the potential complication rate and hospital length of stay during subsequent laparoscopic surgery. The extent of this relationship deserves further investigation.

The Effect of Prior Abdominal Surgery on Abdominally Based Free Flaps in Breast Reconstruction

The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. Risk, III.

Left upper quadrant approach in gynecologic laparoscopic surgery

To review the use of the left upper quadrant approach in benign gynecologic laparoscopic surgery over a nine-year period. Retrospective review. Setting. University-affiliated hospital. Women who underwent laparoscopic gynecologic surgery the upper quadrant approach between January 2002 and December 2010. Medical records were reviewed. Demographic data, past surgical histories, indications for surgery and the use of the left upper quadrant approach, intraoperative findings, diagnosis and any complications. 143 patients were identified, accounting for 4.9% of all gynecologic laparoscopic surgery. The indications for using the left upper quadrant approach were: previous open abdominal surgery (113, 79.0%), surgery in the second trimester of pregnancy (16, 11.1%), presence of large pelvic mass (9, 6.2%), previous transverse rectus abdominis myocutaneous flap for breast reconstruction (3, 2.0%), previous periumbilical hernia repair (1, 0.6%) and previous laparoscopic umbilical wound dehiscence (1, 0.6%). In women with previous abdominal surgery, the overall incidence of adhesions between omentum and/or bowel to the anterior abdominal wall in the umbilical region was 58.4%. Twelve (8.3%) patients required conversion to laparotomy. One patient had subcutaneous surgical emphysema over the left upper quadrant entry site. The left upper quadrant approach is an effective, safe and easy technique for peritoneal cavity access in women undergoing laparoscopic gynecologic surgery and should be considered in women with risk factors of periumbilical adhesions and in the presence of a large pelvic mass.

Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass.

Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention. There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.