The guidelines for the management of hiatal hernia are a series of systematically developed statements to assist physicians’ and patients’ decisions about the appropriate use of laparoscopic surgery for hiatal hernia. The statements included in this guideline are the product of a systematic review of published literature on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted and expert opinion sought where the evidence is lacking.

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Guidelines for the management of hiatal hernia

As innovation continues to move 21st century surgery forward, one of the emerging concepts is single-port or single-incision laparoscopic surgery. The fundamental idea is to have all of the laparoscopic working ports entering the abdominal wall through the same incision. The major drawback to such a surgical approach is that the concept of ‘‘triangulation’’ to which laparoscopic surgeons have grown accustomed in terms of both the instruments and scope is lacking. This, however, seems to be overshadowed by the increasing acceptability of in-line viewing, with the reemphasis on surgeons performing flexible endoscopy and on newer ideas such as natural orifice translumenal endoscopic surgery (NOTES). This very paradigm shift has energized both surgeons and industry to research important issues and develop new technology to make concepts such as single-port laparoscopic surgery become a reality. As part of the effort put forth by the technology committee of the Society of Gastrointestinal and Endoscopic Surgeons (SAGES) to inform surgeons about cutting edge technology, this article is published both to clarify understanding of the single-port laparoscopic surgery concept and to categorize the currently available tools and techniques.

Single-port laparoscopic surgery: an overview

Objective:Our objective was to evaluate the safety and durability of biologic mesh for single-staged reconstruction of contaminated fields.Introduction:The presence of contamination during ventral hernia repair (VHR) poses a significant challenge. Some advocate for a multistaged reconstructive appro

A 5-year clinical experience with single-staged repairs of infected and contaminated abdominal wall defects utilizing biologic mesh.

A Comprehensive Review of Single-Incision Laparoscopic Surgery (SILS) and Natural Orifice Transluminal Endoscopic Surgery (NOTES) Techniques for Cholecystectomy

OBJECTIVE: To compare short-term surgical outcomes and quality of life (QOL) between single-port laparoscopic cholecystectomy (SPLC) and classic 4-port laparoscopic cholecystectomy (CLC). BACKGROUND: There is significant interest in further reducing the trauma associated with surgical procedures. Although a number of observational studies have suggested that SPLC is a feasible alternative to CLC, there is a lack of data from randomized studies validating any benefit over CLC. METHODS: Eligible patients were randomized to receive SPLC or CLC. Operative and perioperative outcomes, including cosmesis and QOL were analyzed. RESULTS: Forty-three patients were randomized to SPLC (n = 21) or CLC (n = 22). There were no significant differences between groups for most preoperative demographics, American Society of Anesthesiology score, gallstone characteristics, local inflammation, blood loss, or length of stay. Patients undergoing SPLC were older than those receiving CLC (57.3 years vs. 45.8 years, P < 0.05). Operative times for SPLC were greater than CLC (88.5 minutes vs. 44.8 minutes, P < 0.05). Overall and cosmetic satisfaction, QOL as determined by the SF-36 survey, postoperative complications, and post-operative pain scores between discharge and 2-week postoperative visit were not significantly different between groups. Wound infection rates were similar in both groups. The SPLC group contained 1 retained bile duct stone, 1-port site hernia, and 1 postoperative port site hemorrhage. CONCLUSIONS: SPLC procedure time was longer and incurred more complications than CLC without significant benefits in patient satisfaction, postoperative pain and QOL. SPLC may be offered in carefully selected patients. Larger randomized trials performed later in the learning curve with SPLC may identify more subtle advantages of one method over another.

Randomized controlled trial comparing single-port laparoscopic cholecystectomy and four-port laparoscopic cholecystectomy.

Transumbilical gelport access technique for performing single incision laparoscopic surgery (SILS)

Multiple techniques have been used for the repair of complex abdominal wall defects after recurrent incisional hernias with varying rates of success. Primary repair has been associated with high recurrence rates, and prosthetic mesh placement is contraindicated in contaminated surgical fields. The development of biologic prostheses has changed the approach to these difficult problems. This study evaluates the management of complex abdominal wall defects using acellular porcine dermal collagen. Between August 2006 and May 2007, 18 patients underwent abdominal wall reconstruction for complex defects with acellular porcine dermal collagen (CollaMend; Bard Inc., Warwick, RI). Patient demographics, preoperative risk factors, previous herniorrhaphy attempts, postoperative complications, recurrences, and long-term results were retrospectively reviewed. Records were reviewed at a mean follow up of 7.3 months; the recurrence rate was 44.4 per cent. A total of 38.9 per cent (seven of 18) developed a postoperative wound complications, including infection in 22.2 per cent (four of 18). All of the patients with infection required prosthesis removal as a result of encapsulation rather than incorporation of the biologic prosthesis. Acellular porcine dermal collagen has the potential for reconstruction of abdominal wall defects with postoperative wound occurrences comparable with other biologic materials. Encapsulation of the material was a major problem in cases with wound infection that required graft removal rather than local wound measures. Hernia recurrence and dehiscence of the graft were problems in noncompromised surgical fields.

Management of complex abdominal wall defects using acellular porcine dermal collagen.

Reports of long-term outcomes for laparoscopic Heller myotomy (LHM) are scarce. In this work, outcomes of LHM for achalasia in patients who underwent surgery more than 10 years prior were investigated. A cohort of patients treated with LHM and partial fundoplication for achalasia between 1993 and 1996 was followed for long-term outcomes, which were compared to baseline data at presentation. Thirty-two consecutive patients were identified, and follow-up information was obtained for 20 patients (62.5%). Mean follow-up was 11.2 years (range 10.3 to 12.3 years). Three patients (9.4%) were deceased (mean of 40 months postoperation). Of the 17 living patients, dysphagia was rated as severe in one (5.9%), mild to moderate in eight (47.1%), and absent in eight (47.1%). This was a significant improvement from preoperative scores in which dysphagia was rated as severe in 42.9%, mild to moderate in 57.1%, and absent in 0% (p < 0.05). In addition, 10-year dysphagia scores were unchanged from those at short-term follow-up (mean 27 months, p = 0.84). Other symptoms of heartburn, chest pain, voice symptoms, cough, and asthma were reported in fewer than 30% of patients at 10 years. Esophageal dilation following surgery was required in three patients, and two patients required repeat operations (esophagectomy in one patient, hiatal hernia in one patient). Satisfaction with the operation was reported by 16 patients (94.1%) at 10 years. Most patients who underwent LHM with partial fundoplication reported satisfaction 10 years after the operation. A small number of patients required additional intervention. Dysphagia scores at 10 years were not different from those collected at short-term follow-up. Our data suggest that the efficacy of LHM is sustained at 10-year follow-up.

Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability

The recurrence rate for paraesophageal hernias (PEH) can be as high as 30% following laparoscopic repair The aim of this study was to determine the severity of symptoms in patients with recurrences and the need for reoperation 10 years after surgery Consecutive laparoscopic paraesophageal cases performed at a single institution between 1993 and 1996 were identified from the institution’s foregut database Patients were asked about the presence and severity of symptoms (heartburn, chest pain, regurgitation, and dysphagia) Patients were also asked whether they had (1) been diagnosed with hernia recurrence or (2) undergone repeat surgical intervention Complete follow-up was obtainable in 31 of the total of 52 patients (60%) The proportion of patients reporting moderate/severe symptoms was less at 10 years than preoperatively: heartburn 12% versus 54% (p < 0001), chest pain 9% versus 36% (p = 001), regurgitation 6% versus 50% (p < 0001), and dysphagia 3% versus 30% (p = 0001) Two patients underwent repeat surgical intervention for symptomatic recurrences within the first postoperative year Eight more patients have been diagnosed with hernia recurrences on either contrast esophagram or upper endoscopy but had not required reoperation At ten years, more patients with hernia recurrence had heartburn than those who did not have recurrences (60% versus 14%; p < 005) Despite a hiatal hernia recurrence rate of 32% 10 years after surgery, laparoscopic PEH was a successful procedure in the majority of patients; most remained symptomatically improved and required no further intervention 10 years after surgery

Do recurrences after paraesophageal hernia repair matter? : Ten-year follow-up after laparoscopic repair

Recurrence of incisional hernia may be as high as 50 per cent. Abnormal collagen I/III ratios have been observed within scar tissue of patients with recurrent incisional hernias. We sought to determine whether collagen composition in primary, nonscarred tissue was similarly affected in these patients. In this prospective, case-control study, nonscarred, primary abdominal wall skin and fascia biopsies were obtained in 12 patients with a history of recurrent incisional hernias and 11 control subjects without any history of hernia while undergoing abdominal laparoscopic surgery. Tissue protein expression of collagen I and III was assessed by immunohistochemistry followed by densitometry analysis. The collagen I/III ratio in skin biopsies from the recurrent hernia group was significantly less compared with control subjects (0.88 +/- 0.01 versus 0.98 +/- 0.04, respectively, P < 0.05). Fascia biopsies from patients with recurrent hernias was not significantly decreased in collagen I/III ratio compared with control subjects (0.90 +/- 0.04 versus 0.94 +/- 0.03, respectively, P = 0.17). Decreased collagen I/III ratios within the skin of patients with recurrent hernias not involved with scar or healing tissue suggest an underlying collagen composition defect. Such a primary collagen defect, in addition to abnormal scar formation, likely plays a significant role in the pathogenesis of recurrent incisional hernias.

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Brent C. White

Papers

Transumbilical gelport access technique for performing single incision laparoscopic surgery (SILS)

Management of complex abdominal wall defects using acellular porcine dermal collagen.

Ten-year follow-up of laparoscopic Heller myotomy for achalasia shows durability

Do recurrences after paraesophageal hernia repair matter? : Ten-year follow-up after laparoscopic repair

Abnormal primary tissue collagen composition in the skin of recurrent incisional hernia patients.