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Kent W Kercher

Publications and source records attributed to Kent W Kercher.

At least 19 recordsLinked to original sources
PubMed2006

Outcomes of adrenal cortical carcinoma in the United States.

BACKGROUND: Improvements in the sensitivity of radiographic imaging have lead to an increase in the number of adrenal masses diagnosed. The purpose of this study is to determine if technologic advancements have resulted in the diagnosis of earlier-staged adrenal cortical cancer (ACC) and to determine if the survival of patients with ACC has improved over the past 15 years. METHODS: Patients with ACC were identified in the Surveillance, Epidemiology, and End Results database between 1988 and 2002. Changes in demographics, stage, size, and treatment were analyzed by standard statistical testing. RESULTS: We identified 602 patients with a mean age of 53 years and an average tumor size of 11.8 cm. Two hundred thirty-eight (39.5%) patients presented with localized disease (stages I and II), and 311 (52%) patients presented with advanced disease (stages III and IV). The comparison of smaller lesions and number of patients were 5 to 6 cm in 24 (4%) patients, 4 to 5 cm in 27 (4.5%) patients, and <4 cm in 19 (3.1%) patients. Patients with masses less than 5 cm were statistically more likely to have localized disease (P <. 001). Age (P = .10), tumor size (P = .85), tumor stage (P = .45), and 5-year survival (P = .5) did not change over the 15-year study. CONCLUSIONS: Over the 15-year study, patients with ACC were not diagnosed at an earlier stage or with tumors smaller, and survival did not improve.

Adrenal Cortex Neoplasms↗
PubMed2006

Textile analysis of heavy weight, mid-weight, and light weight polypropylene mesh in a porcine ventral hernia model.

BACKGROUND: The purpose of this study was to assess the burst strength and stiffness of heavy weight (HW), mid-weight (MW), and light weight (LW) polypropylene mesh pre-implantation and 5 months post-implantation in a porcine ventral hernia model. MATERIALS AND METHODS: HW (95 g/cm2), MW (45 g/cm2), and LW (28 g/cm2) polypropylene were tested as dry samples (n = 8/mesh) before implantation using a stamp strain machine. Three weeks after creating four hernia defects in each mini-pig (n = 18), the polypropylene meshes (8 x 10 cm; 24/mesh type) were implanted in the preperitoneal space, ensuring 2 cm overlap circumferentially. At 5 months, the mesh was harvested en bloc with the abdominal wall. Testing of burst strength and stiffness was repeated on the ex vivo specimens. RESULTS: After implantation in the pig for 5 months, the mean burst strength and stiffness of HW and MW meshes remains the same. LW mesh with an absorbable monofilament in its weave has significant reductions in mean burst strength (P = 0.01) and mean stiffness (P < 0.0001). The burst strength for all meshes tested was much higher than measured for the abdominal wall fascia alone. The degree of shrinkage of the various weight meshes did not differ. CONCLUSION: A reduction in mean burst strength and stiffness occurs after 5 months implantation of LW polypropylene mesh with an absorbable monofilament. All meshes exhibited burst strengths that were much greater than the burst strength of the abdominal wall fascia alone. After tissue incorporation, the LW polypropylene mesh maintains mean burst strength comparable to MW polypropylene mesh, while becoming less stiff than HW mesh. Long-term, this may contribute to more physiological abdominal wall compliance after LW polypropylene mesh implantation.

Animals↗
PubMed2006

Open preperitoneal retrofascial mesh repair for multiply recurrent ventral incisional hernias.

BACKGROUND: Because herniorrhaphy failure and complication rates appear proportional to the number of previous repairs, multiply recurrent hernias (MRH) represent a formidable challenge. We sought to determine the safety and efficacy of open preperitoneal retrofascial mesh repair of MRH. STUDY DESIGN: We conducted a retrospective review of consecutive patients undergoing an open preperitoneal retrofascial mesh repair of multiply (two or more) recurrent hernias at a tertiary care referral center. RESULTS: From January 2001 to May 2005, 128 patients underwent surgical repair of an MRH; 32 of these underwent an open preperitoneal repair. The average body mass index was 39.1 +/- 8.4 kg/m2 (range 28.9 to 61.0 kg/m2). All patients had significant comorbidities; 18.8% were smokers. The number of previous herniorrhaphies was 3.6 (range 2 to 24). Polypropylene mesh was used in all patients, including lightweight polypropylene in 10 (31.2%) patients. The average mesh size was 937 +/- 531 cm2 (range 225 to 1,800 cm2). There were no major intraoperative complications. Wound infection occurred in 4 patients (12.5%, all smokers), requiring partial mesh excision in 1 patient. Univariate analysis revealed smoking as the only predictor of wound or mesh-related morbidity (p = 0.0004). At a mean followup of 28.1 months (range 8 to 60 months), there has been 1 recurrence (3.1%) in the patient requiring partial mesh removal. CONCLUSIONS: Open preperitoneal retrofascial mesh repair resulted in an effective herniorrhaphy with low perioperative morbidity in patients with MRH. Smoking cessation appears to be important in minimizing infectious complications. Given the technical challenge, surgical care of patients with MRH may be best provided in referral centers with interest and expertise in complex hernia repairs.

Adult↗
PubMed2006

Laparoscopic ventral hernia repair in obese patients: a new standard of care.

HYPOTHESIS: Ventral abdominal hernias represent a frequent and often formidable clinical problem, especially in obese patients. Because laparoscopic ventral hernia repair (LVHR) results in few complications and a low recurrence rate, the use of minimally invasive techniques in this subgroup of patients may minimize perioperative complications and failure rates. DESIGN: Retrospective review of prospectively collected data. SETTING: Tertiary care hospital. PATIENTS: One hundred sixty-three obese patients (body mass index [calculated as weight in kilograms divided by the square of height in meters], > or =30) who underwent LVHR at our institution between July 1, 1998, and December 31, 2003. INTERVENTION: Laparoscopic ventral hernia repair with an expanded polytetrafluoroethylene mesh. MAIN OUTCOME MEASURES: Patient age, sex, body mass index, size of fascial defect and mesh, operating time, operative blood loss, length of hospitalization, complications, and hernia recurrences. RESULTS: Ninety-eight women and 65 men, with a mean body mass index of 38, underwent LVHR. Twenty patients (12.3%) had 21 postoperative complications. There was no perioperative mortality. The mean length of hospital stay was 2.6 days. The recurrence rate was 5.5% at a mean follow-up of 25 months (range, 1-73 months). CONCLUSIONS: A low rate of conversion to laparotomy, minimal perioperative morbidity, and the absence of perioperative mortality in this series indicate the safety of LVHR in obese patients with complex hernias. In addition, a success rate of more than 94.5% suggests improved efficacy of LVHR compared with the historical rates among control subjects undergoing open surgery. In experienced hands, LVHR may be the approach of choice for most patients with a body mass index of 30 or more.

Adult↗
PubMed2006

Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism.

BACKGROUND: Retrieval of optional vena cava filters (VCF) has been demonstrated to be safe and feasible in injured patients in 4 recent studies. However, 2 pulmonary emboli PE were reported in these studies with mean implant durations less than 19 days. In light of these occurrences, we changed our practice for VCF retrieval when patients had recovered from their injuries and at least 30 days after their discharge, or had been stable on therapeutic anticoagulation for deep venous thrombosis (DVT) or PE for at least 2 weeks. The aim of the current study was to assess the safety of this approach. METHODS: A review of prospectively collected data on optional VCF over a 16-month period. The filters were inserted prophylactically per an institutional practice guideline or for the presence of DVT or PE with a contraindication and/or complication to anticoagulation. All patients underwent duplex imaging of the lower extremities and had pre- and post- retrieval cavagrams. Demographics, duration of implantation, and complications were recorded. RESULTS: Eighty-three patients had optional VCF inserted since the change in our clinical practice. Indications included prophylaxis for high-risk trauma patients (n = 58), DVT or PE with acute contraindication to therapeutic anticoagulation (n = 22), or complications of anticoagulation (n = 3). Two patients developed lower extremity DVT after filter insertion and 1 patient developed a vena cava thrombosis. Retrieval was successful in 47 of 54 cases (87%) attempted. Median implantation duration was 142 days (range 17-475). A filter strut fracture occurred during retrieval without further consequences. No post-insertion or post-retrieval PE occurred in this study. CONCLUSION: Extended intervals for retrieval of VCF are safe and may maximize protection against pulmonary embolism.

Adolescent↗
PubMed2006

Nine-year experience with insertion of vena cava filters in the intensive care unit.

BACKGROUND: Vena cava filter insertion (VCF) is traditionally performed in a radiology suite or in the operating room. We reviewed our experience of bedside VCF insertion in the intensive care unit (ICU) performed by general surgeons. METHODS: A prospective, observational study of bedside VCF insertion in the ICU was performed by general surgeons between February 1996 and June 2005. Demographic data and procedural complications were recorded. RESULTS: Four hundred three patients underwent bedside VCF insertion. Complications included 1 groin hematoma, 2 misplacements, and a right ventricular perforation from a dilator requiring surgical repair. DVT occurred in 38 patients (8.5%); 14 occurred at the insertion site. There were 2 pulmonary embolisms (<1%) after VCF. Contrast-related renal failure occurred in 2 of the first 35 patients; carbon dioxide gas is now used for contrast in high-risk patients. CONCLUSIONS: Bedside insertion of VCF in the ICU by surgeons is safe and effective.

Adult↗
PubMed2006

Laparoscopic versus open colostomy reversal: a comparative analysis.

Open colostomy reversal carries significant rates of wound infection, anastomotic leak, and incisional hernia which often limit its acceptance. We hypothesized that the laparoscopic approach to the restoration of intestinal continuity may result in lower perioperative morbidity and faster postoperative recovery. Twenty-two cases of laparoscopic colostomy reversals performed at a single institution were identified and compared to 22 randomly selected open colostomy closures performed during the same time period. Patients were compared based on demographics, previous indications for colostomy procedures, and perioperative outcomes. A total of 152 patients underwent reversal of left-sided colostomies during the study period. The laparoscopic approach was successful in 20 of 22 cases; there were 2 conversions to open (9%) secondary to inability to adequately mobilize the rectal stump. The laparoscopic and open groups were comparable based on mean age (54 years versus 49 years; P = 0.23), BMI (26 kg/m(2) versus 27 kg/m(2); P = 0.66), gender (9% males versus 13% males; P = 0.23), ASA Class (2.6 versus 2.3; P = 0.07), and history of previous intra-abdominal sepsis (17 versus 16 cases). Operative times were similar (158 versus 189 minutes; P = 0.16), and estimated blood loss was significantly less in the laparoscopic group (113 versus 270 ml; P = 0.01). No intraoperative complications occurred in the laparoscopic group and two enterotomies occurred in the open group. The laparoscopic group had earlier passage of flatus (3.5 versus 5.0 days; P = 0.001) and shorter hospitalization (4.2 versus 7.3 days; P = 0.001). Perioperative complications occurred in 3 (14%) laparoscopic and 13 (59%) open cases (P = 0.01). There was no mortality in this series. The laparoscopic approach can be safely used in the restoration of intestinal continuity. It results in a decreased perioperative morbidity and faster recovery, and it offers distinct advantages over the open approach to colostomy reversal.

Adult↗
PubMed2006

Long-term outcomes of laparoscopic resection of gastric gastrointestinal stromal tumors.

OBJECTIVE: Gastric gastrointestinal stromal tumors (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of minimally invasive resection of gastric GIST has been established, the long-term safety and efficacy of these techniques are unclear. We hypothesized that complete resection of gastric GISTs using a combination of laparoscopic or laparoendoscopic techniques results in low perioperative morbidity and an effective long-term control of the disease. METHODS: Between August 1996 and June 2005, 50 consecutive patients undergoing laparoscopic or laparoendoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics and outcomes, operative findings, morbidity, and histopathologic characteristics of the tumor. Patient and tumor characteristics were analyzed to identify risk factors for tumor recurrence. RESULTS: Fifty patients, mean age 60 years (range, 34-84 years), underwent 47 local and 3 segmental laparoscopic gastric resections. GI bleeding and dyspepsia were the most common symptoms. Mean tumor size was 4.4 cm (range, 1.0-8.5 cm) with the majority of the lesions located in the proximal stomach. Mean operative time was 135 minutes (range, 49-295 minutes), the mean blood loss was 85 mL (range, 10-450 mL), and the mean length of hospitalization was 3.8 days (range 1-10 days). There were no major perioperative complications or mortalities. All lesions had negative resection margins (range, 2-45 mm). Nine patients had 10 or more mitotic figures per 50 high power fields, while 11 had ulceration and/or necrosis of the lesion. At a mean follow-up of 36 months, 46 (92%) patients were disease free, 1 patient was alive with disease, 1 patient with metastases died of a cardiac event, and 2 (4%) patients died of metastatic disease. No local or port site recurrences have been identified. Patient age, tumor size, mitotic index, tumor ulceration, and necrosis were statistically associated with tumor recurrence. The presence of 10 or more mitotic figures per 50 high power fields was an independent predictor of disease progression (P = 0.006). CONCLUSION: A laparoscopic approach to surgical resection of gastric GIST is associated with low morbidity and short hospitalization. As found in historical series of open operative resection, the tumor mitotic index predicts local recurrence. The long-term disease-free survival of 92% in our study establishes laparoscopic resection as safe and effective in treating gastric GISTs. Given these findings as well as the advantages afforded by minimally invasive surgery, a laparoscopic approach may be the preferred resection technique in most patients with small- and medium-sized gastric GISTs.

Adult↗
PubMed2006

Minimally invasive management of colon cancer.

One of the most controversial issues in minimally invasive surgery has been the implementation of laparoscopic techniques for the curative resection of colorectal malignancies. Initial concerns included the potential violation of oncologic principles, the effects of carbon dioxide, and the phenomenon of port site tumor recurrence. Basic science research and large randomized controlled trials are now demonstrating that these fears were unjustified. Long-term outcomes of laparoscopic colon resection compared with open colon resection for malignancy are comparable, and there may even be a survival benefit for a subset of patients who undergo laparoscopic resection.

Colectomy↗
PubMed2006

Laparoscopic expertise increases hospital volume of adrenal surgery.

The laparoscopic approach is preferred for most adrenal tumors but technical challenges limit its use. We evaluated the effects of the availability of laparoscopic expertise on the volume of the adrenal surgery at a tertiary care hospital. Patients undergoing adrenalectomy 5 years before and 5 years after an advanced laparoscopic program was established were retrospectively reviewed. The average annual volume increased from 2 cases during the first period to 15 cases during the 5 years (1999-2003) after laparoscopic expertise became available. The average distance of travel to the hospital was significantly greater for the latter patients and significantly more patients were referred from outside of a 30-mile radius. Although the average statewide annual number of adrenalectomies has not significantly changed, the proportion of adrenalectomies performed at our institution rose. Offering a laparoscopic approach has altered physicians' referral patterns and has significantly increased the volume of adrenal surgery at the institution.

Adrenal Gland Diseases↗
PubMed2006

Advantages of laparoscopic appendectomy in the elderly.

Laparoscopic appendectomy (LA) has gained in popularity in recent years. The number of elderly patients undergoing appendectomy has increased as that segment of the population has increased in number; however, the utility and benefits of LA in the elderly population are not well established. We hypothesized that LA in the elderly has distinctive advantages in perioperative outcomes over open appendectomy (OA). We queried the 1997 to 2003 North Carolina Hospital Association Patient Data System for all patients with the primary ICD-9 procedure code for OA and LA. Patients > or = 65 years of age (elderly) were identified and reviewed. Outcomes including length of stay (LOS), charges, complications, discharge location, and mortality were compared between the groups. There were 29,244 appendectomies performed in adult patients (>18 years old) with 2,722 of these in the elderly. The annual percentage of LA performed in the elderly increased from 1997 to 2003 (11.9-26.9%, P < 0.0001). When compared with OA, elderly patients undergoing LA had a shorter LOS (4.6 vs 7.3 days, P = 0.0001), a higher rate of discharge to home (91.4 vs 78.9%, P = 0.0001) as opposed to a step-down facility, fewer complications (13.0 vs 22.4%, P = 0.0001), and a lower mortality rate (0.4 vs 2.1%, P = 0.007). When LA was compared with OA in elderly patients with perforated appendicitis, LA resulted in a shorter LOS (6.8 vs 9.0 days, P = 0.0001), a higher rate of discharge to home (86.6 vs 70.9%, P = 0.0001), but equivalent total charges (dollars 22,334 vs dollars 23,855, P = 0.93) and mortality (1.0 vs 2.98%, P = 0.10). When elderly patients that underwent LA were compared with adult patients (18-64 years old), they had higher total charges (dollars 16,670 vs dollars 11,160, P = 0.0001) but equivalent mortality (0.37 vs 0.15%, P = 0.20). The use of laparoscopy in the elderly has significantly increased in recent years. In general, the safety and efficacy of LA is demonstrated by a reduction in mortality, complications, and LOS when compared with OA. The laparoscopic approach to the perforated appendix in the elderly patient has advantages over OA in terms of decreased LOS and a higher rate of discharge to home as opposed to rehabilitation centers, nursing homes, or skilled nursing care. When compared with all younger adults, the laparoscopic approach in the elderly was associated with equal mortality rates even though hospitalization charges were higher. Laparoscopy may be the preferred approach in elderly patients who require appendectomy.

Aged↗
PubMed2006

Prospective evaluation of adhesion formation and shrinkage of intra-abdominal prosthetics in a rabbit model.

Laparoscopic ventral hernia repair requires an intraperitoneal prosthetic; however, these materials are not without consequences. We evaluated host reaction to intraperitoneal placement of various prosthetics and the functional outcomes in an animal model. Mesh (n = 15 per mesh type) was implanted on intact peritoneum in New Zealand white rabbits. The mesh types included ePTFE (DualMesh), ePTFE and polypropylene (Composix), polypropylene and oxidized regenerated cellulose (Proceed), and polypropylene (Marlex). Adhesion formation was evaluated at 1, 4, 8, and 16 weeks using 2-mm mini-laparoscopy. Adhesion area, adhesion tenacity, prosthetic shrinkage, and compliance were evaluated after mesh explantation at 16 weeks. DualMesh had significantly less adhesions than Proceed, Composix, or Marlex at 1, 4, 8, and 16 weeks (P < 0.0001). Marlex had significantly more adhesions than other meshes at each time point (P < 0.0001). There were no statistically significant differences in adhesions between Proceed and Composix meshes. After mesh explantation, the mean area of adhesions for Proceed (4.6%) was less than for Marlex (21.7%; P = 0.001). The adhesions to Marlex were statistically more tenacious than the DualMesh and Composix groups. Overall prosthetic shrinkage was statistically greater for DualMesh (34.7%) than for the remaining mesh types (P < 0.01). Mesh compliance was similar between the groups. Prosthetic materials demonstrate a wide variety of characteristics when placed inside the abdomen. Marlex formed more adhesions with greater tenacity than the other mesh types. DualMesh resulted in minimal adhesions, but it shrank more than the other mesh types. Each prosthetic generates a varied host reaction. Better understanding of these reactions can allow a suitable prosthetic to be chosen for a given patient in clinical practice.

Animals↗
PubMed2006

Current aspects of surgical management of GERD.

Gastroesophageal reflux disease (GERD) is one of the most common pathologies treated by primary care physicians. Despite advances in antacid pharmacological treatments, many patients remain refractory to maximal medical therapy. In addition, many others are either unable to tolerate the side effects of the drugs or simply are unwilling to receive life-long daily medications. Laparoscopic Nissen fundoplication has evolved as the surgical procedure of choice for patients with GERD. Although the durability of surgical management has been questioned, experienced surgeons achieve long-term reflux cure rates of about 85% to 95%. Barrett's esophagus has recently been considered an additional indication for surgical therapy of reflux due to evidence of dysplasia regression following a 360 degrees fundoplication. However, the timing of surgical intervention and the exact procedure for patients with both short- and long-segment Barrett's esophagus remains debatable. Esophageal dysmotility in surgical patients with GERD has traditionally been approached by "tailoring" the degree of fundoplication. Recent evidence suggests that partial fundoplication may not be effective and that full fundoplication should still be employed. The degree of dysmotility prohibitive to a full 360 degrees fundoplication remains controversial and should be addressed with future randomized trials. Finally, patients with failed fundoplication represent a formidable diagnostic dilemma and a technical challenge. In experienced hands, these patients can still benefit from minimally-invasive restorative or "re-do" fundoplications with minimal perioperative morbidity and good long-term results.

Clinical Trials as Topic↗
PubMed2006

Asymptomatic thrombus trapping in vena cava filters: a case series.

The prophylactic use of vena cava filters (VCFs) remains controversial. Class I data supporting the placement of prophylactic VCFs are lacking. In addition, there are concerns regarding the long-term effects of permanent VCF placement in patients with a relatively brief period of thromboembolic risk. Venous thromboembolism can be a lethal event, occurring without a prodrome. Yet, this condition is potentially preventable. The efficacy of VCFs is difficult to determine, as it is likely that when a VCF actually traps a thrombus, the event is clinically asymptomatic. We present three cases of asymptomatic thrombus trapping in VCFs, recognized through incidental radiographic studies.

Adolescent↗
PubMed2006

Intra-abdominal placement of antimicrobial-impregnated mesh is associated with noninfectious fever.

The antimicrobial, silver/chlorhexidine, when impregnated on mesh has been demonstrated to resist mesh infection in in vitro and in vivo models. The clinical, human systemic response to intraperitoneal placement of silver/chlorhexidine-impregnated mesh has not been investigated to date. Between October 2002 and November 2004, all in-patients undergoing laparoscopic ventral hernia repair were retrospectively analyzed. All repairs used expanded polytetraflouroethylene (ePTFE) Dual Mesh (DM) or ePTFE impregnated with silver/chlorhexidine, Dual Mesh Plus (DM+). Patient demographics, hernia characteristics, mesh type, operative details, and hospital course data were collected. Noninfectious fevers were defined as a temperature greater than 100.4 F without an identified source. Standard statistical methods were used. During the 2-year study period, 120 patients underwent laparoscopic ventral hernia repair (DM = 55, DM+ = 65). The two groups were similarly matched in terms of age, body mass index, American Society of Anesthesiologists score, defect size, and mesh size. Postoperative fever without an identified source occurred in 10 (18.2%) patients with DM and in 25 (38.5%) patients using DM+ (P = 0.015). A multivariant analysis revealed that only mesh type and body mass index predicted postoperative fever. All fevers resolved within the first 72 hours in the DM patients; however, 16 per cent of the DM+ group had persistent fevers of unknown origin after 72 hours. Within the DM+ group, patients with postoperative fevers had significantly longer postoperative stays (4.8 days vs 3.0 days; P = 0.009). The use of antimicrobial-impregnated ePTFE mesh with silver/chlorhexidine in laparoscopic ventral hernia repair is associated with noninfectious postoperative fever. In our patients, the evaluation and management of these fevers resulted in a significantly longer hospital stay.

Adult↗
PubMed2005

Normal intraabdominal pressure in healthy adults.

BACKGROUND: Intraabdominal pressure (IAP) has been considered responsible for adverse effects in trauma and other abdominal catastrophes as well as in formation and recurrence of hernias. To date, little information is available concerning IAP in normal persons. Our purpose in this study was to measure the normal range of IAP in healthy, nonobese adults and correlate these measurements with sex and body mass index (BMI). METHODS: After Institutional Review Board approval, 20 healthy young adults (< or =30 years old) with no prior history of abdominal surgery were enrolled. Pressure readings were obtained through a transurethral bladder (Foley) catheter. Each subject performed 13 different tasks including standing, sitting, bending at the waist, bending at the knees, performing abdominal crunches, jumping, climbing stairs, bench-pressing 25 pounds, arm curling 10 pounds, and performing a Valsalva and coughing while sitting and also while standing. Data were analyzed by Student's t-test and Pearson's correlation coefficients. RESULTS: Intraabdominal pressure was measured in 10 male and 10 female subjects. The mean age of the study group was 22.7 years (range, 18-30 years), and BMI averaged 24.6 kg/m(2) (range, 18.4-31.9 kg/m(2)). Mean IAP for sitting and standing were 16.7 and 20 mm Hg. Coughing and jumping generated the highest IAP (107.6 and 171 mm Hg, respectively). Lifting 10-pound weights and bending at the knees did not generate excessive levels of pressure with the maximum average of 25.5 mm Hg. The mean pressures were not different when comparing males and females during each maneuver. There was a significant correlation between higher BMI and increased IAP in 5 of 13 exercises. CONCLUSION: Normal IAP correlates with BMI but does not vary based on sex. The highest intraabdominal pressures in healthy patients are generated during coughing and jumping. Based on our observations, patients with higher BMI and chronic cough appear to generate significant elevation in IAP. Thus, this group of patients may potentially be at increased risk for abdominal wall hernia formation following surgery.

Abdomen↗
PubMed2005

Advantages of mini-laparoscopic vs conventional laparoscopic cholecystectomy: results of a prospective randomized trial.

HYPOTHESIS: The use of smaller instruments during laparoscopic cholecystectomy (LC) has been proposed to reduce postoperative pain and improve cosmesis. However, despite several recent trials, the effects of the use of miniaturized instruments for LC are not well established. We hypothesized that LC using miniports (M-LC) is safe and produces less incisional pain and better cosmetic results than LC performed conventionally (C-LC). DESIGN: A patient- and observer-blinded, randomized, prospective clinical trial. SETTING: A tertiary care, university-based hospital. PATIENTS: Seventy-nine patients scheduled for an elective LC who agreed to participate in this trial were randomized to undergo surgery using 1 of the 2 instrument sets. The criteria for exclusion were American Society of Anesthesiologists class III or IV, age older than 70 years, liver or coagulation disorders, previous major abdominal surgical procedures, and acute cholecystitis or acute choledocholithiasis. INTERVENTION: Laparoscopic cholecystectomy performed with either conventional or miniaturized instruments. MAIN OUTCOME MEASURES: Patients' age, sex, operative time, operative blood loss, intraoperative complications, early and late postoperative incisional pain, and cosmetic results. RESULTS: Thirty-three C-LCs and 34 M-LCs were performed and analyzed. There were 8 conversions (24%) to the standard technique in the M-LC group. No intraoperative or major postoperative complications occurred in either group. The average incisional pain score on the first postoperative day was significantly less in the M-LC group (3.9 vs 4.9; P = .04). No significant differences occurred in the mean scores for pain on postoperative days 3, 7, and 28. However, 90% of patients in the M-LC group and only 74% of patients in the C-LC group had no pain (visual analog scale score of 0) at 28 days postoperatively (P = .05). Cosmetic results were superior in the M-LC group according to both the study nurse's and the patients' assessments (38.9 vs 28.9; P<.001, and 38.8 vs 33.4; P = .001, respectively). CONCLUSIONS: Laparoscopic cholecystectomy can be safely performed using 10-mm umbilical, 5-mm epigastric, 2-mm subcostal, and 2-mm lateral ports. The use of mini-laparoscopic techniques resulted in decreased early postoperative incisional pain, avoided late incisional discomfort, and produced superior cosmetic results. Although improved instrument durability and better optics are needed for widespread use of miniport techniques, this approach can be routinely offered to many properly selected patients undergoing elective LC.

Analgesia↗