Abdominal wall hernia. In brief.
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Hernia, Abdominal↗
Biomedical subjects
Adrian E Park
Publications and source records attributed to Adrian E Park.
Endoscopic placement of radiopaque markers for focused evaluation of intestinal motility.
Using traditional techniques in novel ways often can improve management of common surgical problems. Additionally, established products may find new utility when deployed in a slightly different fashion to enhance patient care in a clinically relevant way. This article describes endoscopic placement of radiopaque markers into the proximal small intestine as a means to evaluate motility in a focused fashion. A method to delineate the location of dysmotility in a patient with several potential sites is described. This technique is safe, feasible, reasonably inexpensive, and is easily performed by a skilled endoscopist. Moreover, this technique has the added benefit of providing functional data in a timely fashion.
Capsules↗
Laparoscopic splenectomy: what barriers remain?
Conditions that once were considered either relative or absolute contraindications for laparoscopic splenectomy have become fewer and less significant in the overall assessment of candidates for this procedure. Advances in surgical technique, operative conduct, and instrumentation have made it feasible to perform splenectomy laparoscopically with good outcomes and minimal morbidity in a variety of different pathologic conditions. Obesity, malignancy, pregnancy, and splenomegaly are assessed here in detail.
Contraindications↗
Management of gastroesophageal reflux disease: medications, surgery, or endoscopic therapy? (Current status and trends).
Gastroesophageal reflux disease (GERD) is a common chronic disorder in the Western world. The basic cause of GERD has been well characterized--the fundamental defect is a loss of integrity of the gastroesophageal barrier. What is less clear is the most appropriate means of addressing this reflux. GERD has a variety of symptoms, ranging from typical presentations of heartburn and regurgitation (without esophagitis) to atypical presentations, such as severe erosive esophagitis and its associated complications. Because of its symptomatic diversity, physicians may select from a variety of therapeutic approaches. Medical therapy aims at decreasing acidity by suppressing proton secretion and has been well established. Available medications include antacids and alginates, H2-receptor antagonists, motility agents, and proton pump inhibitors (PPIs). Antireflux surgery, commonly performed laparoscopically, aims at reinforcing and repairing the defective barrier through plication of the gastric fundus. The earliest performed successful procedures were the Nissen and Toupet fundoplications, to which several modifications have since been made. It has been demonstrated in preliminary studies and long-term outcomes of such open surgery and preliminary studies of such laparoscopic surgery that antireflux surgery is an effective approach, with overall outcomes superior to those achieved with medications. The precise indications for the surgical treatment of patients with GERD, however, remain controversial. In recent years, endoscopic intraluminal antireflux approaches have attracted the attention of physicians, surgeons, and commercial companies, especially after the approval of two endoscopic intraluminal methods by the United States FDA in 2000. The common element is prevention of acid reflux by construction of a functional or controlled barrier in the lower esophageal sphincter zone. Three main methods are currently employed: endoscopic intraluminal valvuloplasty, endoscopic radiofrequency therapy, and endoscopic injection or implantation of foreign material. The endoluminal suturing method is highly demanding technically, and its short-term results are encouraging, although largely dependent on the experience of the endoscopist. Several prospective cohort studies have shown that the radiofrequency procedure (Stretta) significantly improves GERD symptoms and quality of life while reducing esophageal acid exposure and eliminating the need for antisecretory medications in the majority of patients within 6-12 months. Most recently, some researchers have studied the endoluminal implantation of polymers, such as Plexiglas (polymethyl-methylacrylate), Gatekeeper hydrogel, and Enteryx (ethylene vinyl alcohol copolymer). The preliminary results of these studies showed that the implantation method was feasible and safe; however, the only multicenter trial related to outcome that has been published has included just 1 year of follow-up. Here, we review the treatment of GERD: medical, surgical, and endoscopic. In addition, we provide an algorithm based on symptoms and response to treatment for management of these patients.
Algorithms↗
A novel intestinal anastomotic device in a porcine model.
The purpose of this study was to evaluate a novel, intraluminally deployed anastomotic device (AD). A survival study was conducted in 18 farm pigs. One early subject was excluded and replaced due to premature expiration. Six animals were placed in 1 of 3 cohorts, with euthanasia and AD explantation planned at 2, 4, and 6 weeks. A distal small intestinal side-side [functional end-end] anastomosis using the AD was performed via midline laparotomy. Fluoroscopy with double-contrast dilute barium and burst pressure measurements were performed in 4 animals in each group. Two animals in each cohort underwent fluoroscopy without contrast and resection for histology. Mucosal healing, inflammation, anastomotic alignment of the muscularis propria, and fibrosis were graded on a 4-point scale. All animals survived to the date of planned euthanasia except the excluded subject, who expired from causes unrelated to the device. Normal weight gain was seen in all. Sixteen of 18 devices sloughed prior to extraction without evidence of injury or obstruction during the survival period or at necropsy. Filling pressures of >200 mm Hg were reached; no leakage was seen. Mucosal healing and continuity were graded good to excellent at 2 weeks and excellent at 4 and 6 weeks. Inflammation improved with time, with moderate change at 2 weeks and mild at 6 weeks. Anastomotic fibrosis was mild at 2 weeks, mild to minimal at 4 weeks, and minimal at 6 weeks. The anastomotic alignment was 100 per cent except in 1 animal at 2 weeks with >50 per cent but <100 per cent alignment. The AD resulted in a stable, functional anastomosis without narrowing. All tested anastomoses withstood supraphysiologic insufflation pressures without evidence of disruption. The applicability of this novel device will be explored for use in other gastrointestinal and biliary anastomoses using minimally invasive deployment techniques.
Anastomosis, Surgical↗
Training competent minimal access surgeons: review of tools, metrics, and techniques across the spectrum of technology.
Technology has transformed the face of surgical technique among the disciplines of surgery. This revolution has created a strong demand from the public for the availability of minimally invasive surgical (MIS) interventions. Significant pressure has been placed on both industry and medicine to develop, test, and implement devices and procedures at a rapid pace. Unfortunately, this pace has at times surpassed the system's ability to train and prepare a corps of surgeons competent in both the technical and cognitive aspects of minimal access surgery. The economic constraints of surgical practice, coupled with recently introduced work-hour restrictions, have made the delivery of minimally invasive surgical education a challenging endeavor. Much work has been done in academic and private institutions to address this need. Solutions traversing the spectrum of technology have been developed, tested, and implemented in training. The purpose of this review is to highlight these solutions on the basis of their validity, utility, and overall contribution toward achieving the goal of producing competent minimally invasive surgeons. The body of literature suggests multiple valid training and assessment constructs exist. However, the overall utility of many validated "high-end" training technologies is limited by cost and access. Efforts should be aimed at creating valid training and assessment paradigms that can be applied by the broadest group of trainees, from medical students to surgeons, in active practice.
Clinical Competence↗
A valid method of laparoscopic simulation training and competence assessment.
BACKGROUND: The purpose of our study was to evaluate the construct validity of laparoscopic technical performance measures and the face validity of three laparoscopic simulations. MATERIALS AND METHODS: Subjects (N = 27) of varying levels of surgical experience performed three laparoscopic simulations, representing appendectomy (LA), cholecystectomy (LC), and inguinal hemiorrhaphy (LH). Five laparoscopic surgeons, blinded to the identity of the subjects, rated the subjects on procedural competence on a binary scale and in four skills categories on a 5-point scale: clinical judgment, dexterity, serial/simultaneous complexity, and spatial orientation. Using a task-specific checklist, non-clinical staff assessed the technical errors. The level of surgical experience was correlated with the ratings, the technical errors, and the time for each procedure. Subject responses to a survey regarding the utility of the inanimate models were evaluated. RESULTS: Years of experience directly correlated with the skills ratings (all P < 0.001) and with the competence ratings across the three procedures (P < 0.01). Experience inversely correlated with the time for each procedure (P < 0.01) and the technical error total across the three models (P < 0.05). Nearly all subjects agreed that the corresponding procedures were well represented by the simulations (LA 96%, LC 96%, LH 100%). CONCLUSION: The laparoscopic simulations demonstrated both face and construct validity. Regardless of the level of surgical experience, the subjects found the models to be suitable representations of actual laparoscopic procedures. Task speed improved with surgical experience. More importantly, the quality of performance increased with experience, as shown by the improvement in the skills assessments by expert laparoscopic surgeons.
Appendectomy↗
Inclusion of 3-D computed tomography rendering and immersive VR in a third year medical student surgery curriculum.
Computed tomography (CT) scans are frequently used for preoperative evaluation of patients undergoing complex surgery and are therefore commonly encountered by medical students on their surgical rotations. Interpretation of these CT scan images is therefore an integral component of all medical students' surgical rotations. Additionally, advanced rendering available from modem scanners and registration of multimodal or serial scans require the student to understand how volumetric anatomy relates to cross-sectional anatomy. The utility of three-dimensional (3-D) models for conveying surgical anatomy has been demonstrated. Immersive 3-D VR overcomes many of the conceptual limitations encountered when conveying or teaching 3-D relationships via 2-D images traditionally produced by these scans. We are currently using augmented reality as a teaching tool and have incorporated 3-D immersive environments in the third year medical student Surgery rotation. Initial results suggest that this is an effective tool for teaching third year medical students. 3-D CT rendering and immersive VR provide an effective process for utilizing CT datasets to teach surgical anatomy to medical students.
Computer Simulation↗
Urgent laparoscopic splenectomy in a morbidly obese pregnant woman: case report and literature review.
Laparoscopic splenectomy (LS) has undergone significant evolution since its introduction more than a decade ago. It clearly has been shown to be advantageous in comparison with open splenectomy and is considered by some to be the treatment of choice for routine uncomplicated elective splenectomy. When LS was first introduced, contraindications to the procedure included pregnancy, obesity, and splenomegaly. Both technologic advances and experience with the technique have enabled surgeons to perform LS for a growing number of indications with seemingly fewer contraindications. Here, we present a case of successful LS in a morbidly obese pregnant woman with splenomegaly and hemolysis secondary to hereditary spherocytosis.
Adult↗
Therapeutic laparoscopy of the pancreas.
OBJECTIVE: To communicate results of laparoscopic treatment of pancreatic pseudocyst (PP) and resection of benign lesions of the pancreas. Perioperative data, surgical outcomes, techniques and insights from 54 cases are presented. SUMMARY BACKGROUND DATA: Although laparoscopic therapy for other solid organs has been widely adopted, reports of therapeutic laparoscopy of the pancreas have been few and of limited numbers, and its role in pancreatic disease is still unclear. METHODS: Eighteen men and 11 women were selected for laparoscopic PP surgery. Four distinct laparoscopic approaches were used. An additional 9 men and 16 women underwent laparoscopic distal pancreatectomy (LDP) using a technique similar to the lesser sac approach. RESULTS: Laparoscopic PP surgery was completed successfully in 28 of 29 patients. The overall mean operative time was 2.8 hours and the mean postoperative length of stay was 4.4 days. Of the techniques described, the authors prefer cyst gastrostomy by the lesser sac approach or the minilaparoscopic cystic gastrostomy. LDP was attempted in 25 patients and completed successfully in 23. One underwent a successful hand-assisted enucleation of an insulinoma. In 12 cases the spleen was preserved. Mean operative time was 3.7 hours, and mean postoperative length of stay was 4.1 days. CONCLUSIONS: In the authors' experience, minimally invasive treatment of PP produces good results and avoids difficulties linked with percutaneous drainage or endoscopic internal procedures. However, combining upper endoscopy with intragastric laparoscopic surgery offers advantages of both. LDP compares well to open procedures and often allows preservation of the spleen.
Adult↗
Advancements in immersive VR as a tool for preoperative planning for laparoscopic surgery.
The utility of three-dimensional (3D) models for planning laparoscopic surgery and surgical training has been demonstrated. (1) Computed tomography (CT) scans with oral and intravenous contrast medium are frequently used for preoperative evaluation of patients undergoing complex laparoscopic surgery. Immersive 3D VR overcomes many of the conceptual limitations encountered when conveying or teaching 3D relationships via 2D images traditionally produced by these scans. Over the past year we have made advancements in several areas. First, we have improved the quality of our datasets by utilizing higher resolution multi-detector scans and altering the protocols used. Second, we now register multiple isosurface views with standard axial views and volume textured views to provide additional information and perspective. Third, we now routinely use auto-segmentation techniques to visualize individual structures.
Computer Simulation↗
Laparoscopic incisional hernia repair: a technical advance.
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Fasciotomy↗
Laparoscopic adrenalectomy: indications and technique.
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Adrenal Gland Neoplasms↗
Combined use of calcium infusion localization and a minimally invasive surgical procedure in the management of insulinoma.
OBJECTIVE: To review our experience with current diagnostic localization techniques and a minimally invasive laparoscopic surgical procedure in the management of insulinoma. METHODS: We describe five patients with insulinoma, the results of diagnostic studies, and a proposed algorithm for management of this rare tumor. RESULTS: Four female patients and one male patient (age range, 34 to 72 years) underwent supervised fasting (mean duration, 12 hours; range, 3 to 28 hours) to establish the diagnosis of insulinoma. These patients had glucose values that ranged from 38 to 41 mg/dL and associated serum insulin levels of 11.3 to 61 microU/mL. C-peptide values ranged from 3.4 to 11.5 ng/mL, and proinsulin levels (measured in four patients) were 32.9 to 82 pmol/L. These biochemical findings were diagnostic for insulin-mediated hypoglycemia, and the high proinsulin and C-peptide levels, in conjunction with negative results of serum measurements for sulfonylureas, excluded an exogenous source of insulin as the cause of hypoglycemia. Four of the five study patients had nondiagnostic results of noninvasive localization studies and underwent selective arterial injection of calcium with hepatic venous sampling to help localize the insulinomas within the pancreas. This procedure correctly localized the lesion in three patients and was associated with no complications. In all five patients, surgical resection of a solitary insulinoma (with use of laparoscopic procedures in four, one of which was converted to an open procedure) yielded resolution of the hypoglycemia. CONCLUSION: The combination of calcium infusion localization and a minimally invasive surgical procedure is an efficient management approach in the diagnosis and treatment of insulinoma.
Adult↗