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Background This study represents a prospective, multicenter, open-label study to assess the safety, performance, and outcomes of poly-4-hydroxybutyrate (P4HB, Phasix™) mesh for primary ventral, primary incisional, or multiply-recurrent hernia in subjects at risk for complications. This study reports 3-year clinical outcomes. Materials and methods P4HB mesh was implanted in 121 patients via retrorectus or onlay technique. Physical exam and/or quality of life surveys were completed at 1, 3, 6,12, 18, 24, and 36 months, with 5-year (60-month) follow-up ongoing. Results A total of n = 121 patients were implanted with P4HB mesh (n = 75 (62%) female) with a mean age of 54.7 ± 12.0 years and mean BMI of 32.2 ± 4.5 kg/m2 (±standard deviation). Comorbidities included: obesity (78.5%), active smokers (23.1%), COPD (28.1%), diabetes mellitus (33.1%), immunosuppression (8.3%), coronary artery disease (21.5%), chronic corticosteroid use (5.0%), hypo-albuminemia (2.5%), advanced age (5.0%), and renal insufficiency (0.8%). Hernias were repaired via retrorectus (n = 45, 37.2% with myofascial release (MR) or n = 43, 35.5% without MR), onlay (n = 8, 6.6% with MR or n = 24, 19.8% without MR), or not reported (n = 1, 0.8%). 82 patients (67.8%) completed 36-month follow-up. 17 patients (17.9% ± 0.4%) experienced hernia recurrence at 3 years, with n = 9 in the retrorectus group and n = 8 in the onlay group. SSI (n = 11) occurred in 9.3% ± 0.03% of patients. Conclusions Long-term outcomes following ventral hernia repair with P4HB mesh demonstrate low recurrence rates at 3-year (36-month) postoperative time frame with no patients developing late mesh complications or requiring mesh removal. 5-year (60-month) follow-up is ongoing., Highlights • Prospective, multicenter, open-label study of safety, performance, and outcomes. • Poly-4-hydroxybutyrate mesh implanted in n = 121 patients via retrorectus or onlay. • 82 patients (67.8%) completed 36-month follow-up. • Hernia recurrence (n = 17, 17.9% ± 0.4%) and SSI (n = 11, 9.3% ± 0.03%) at 3 years. • No patients developed late mesh complications or required mesh removal.

The COVID-19 pandemic created delays in surgical care. The population with obesity has a high risk of death from COVID-19. Prior literature shows the most effective way to combat obesity is by weight loss surgery. At different times throughout the COVID-19 pandemic, elective inpatient surgeries have been halted due to bed availability. Recognizing that major complications following bariatric surgery are extremely low (bleeding 0-4%, anastomotic leaks 0.8%), we felt outpatient bariatric surgery would be safe for low-risk patients. Complications such as DVT, PE, infection, and anastomotic leaks typically present after 7 days postoperatively, well outside the usual length of stay. Bleeding events, severe postoperative nausea, and dehydration typically occur in the first few days postoperatively. We designed a pathway focused on detecting and preventing these early post-op complications to allow safe outpatient bariatric surgery.We used a preoperative evaluation tool to risk stratify bariatric patients. During a 16-month period, 89 patients were identified as low risk for outpatient surgery. We designed a postoperative protocol that included IV hydration and PO intake goals to meet a safe discharge. We sent patients home with a pulse oximeter and had them self-monitor their pulse and oxygen saturation. We called all patients at 10 pm for a postoperative assessment and report of their vitals. Patients returned to clinic the following day and were seen by a provider, received IV hydration, and labs were drawn.80 of 89 patients (89.8%) were successfully discharged on POD 0. 3 patients were readmitted within 30 days. We had zero deaths in our study cohort and no morbidity that would have been prevented with postoperative admission.We demonstrate that by identifying low-risk patients for outpatient bariatric surgery and by implementing remote monitoring of vitals early outpatient follow-up, we were able to safely perform outpatient bariatric surgery.

Fully insertable robotic imaging devices represent a promising future of minimally invasive laparoscopic vision. Emerging research efforts in this field have resulted in several proof-of-concept prototypes. One common drawback of these designs derives from their clumsy tethering wires which not only cause operational interference but also reduce camera mobility. In this paper, a tetherless insertable surgical camera (s-CAM) robot with non-contact transabdominal actuation is presented for single-incision laparoscopic vision. Wireless video transmission and control communication using onboard power help eliminate cumbersome tethering wires. Furthermore, magnetic based camera actuation gets rid of intrinsic physical constraints of mechanical driving mechanisms, thereby improving camera mobility and reducing operational interference. In addition, a custom Bluetooth low energy (BLE) application profile and a real-time operating system (RTOS) based multitask programming framework are also proposed to facilitate embedded software design for insertable medical devices. Initial ex vivo test results of the s-CAM design have demonstrated technical feasibility of a tetherless insertable laparoscopic camera. Effective imaging is confirmed at as low as 500 lx illumination. Wireless laparoscopic vision is accessible within a distance of more than 10 m. Transabdominal BLE communication is stable at over −52 dBm and shows its potential for wireless control of insertable medical devices. RTOS based sfotware event response is bounded within 1 ms while the CPU usage is at 3∼5%. The device is able to work for 50 min with its onboard power. For the mobility, the robot can translate against the interior abdominal wall to reach full abdomen quadrants, tilt between −180∘ and +180∘, and pan in the range of 0∘∼360∘. The s-CAM has brought robotic laparoscopic imaging one step further toward less invasiveness and more dexterity.

This paper presents an initial prototype of an in vivo robotic laparoscopic camera that features optimized illumination to address the problems, i.e. inferior lighting uniformity and low optical efficiency, in the state-of-the-art designs of in vivo laparoscopic cameras. Benefiting from the transformable structure of the robotic camera, sufficient on-board space is created without sacrificing the camera's compactness to carry three dedicatedly designed freeform optical lenses for achieving the optimized illumination requirements. Designing miniature freeform optical lenses for extended light sources, such as LEDs, is a very challenging task that usually involves solving a nonstandard Monge–Ampere equation. In this paper, we approach the illumination optical design based on a ray-mapping method that is governed by a standard Monge–Ampere equation. We propose an effective numerical solver to compute the ray-mapping solution for constructing freeform lens surfaces. Experimental results prove the predicted performance of the illumination system design: greater than $97\%$ illuminance uniformity, greater than $80\%$ optical efficiency, and greater than 14,323 lx illuminance on a target plane with a distance of 100 mm. The effectiveness of this prototype is also experimentally verified by performing a suturing task in a simulated abdomen.

Long-term resorbable mesh represents a promising technology for complex ventral and incisional hernia repair (VIHR). Preclinical studies indicate that poly-4-hydroxybutyrate (P4HB) resorbable mesh supports strength restoration of the abdominal wall. This study evaluated outcomes of high-risk subjects undergoing VIHR with P4HB mesh. This was a prospective, multi-institutional study of subjects undergoing retrorectus or onlay VIHR. Inclusion criteria were CDC Class I, defect 10–350 cm2, ≤ 3 prior repairs, and ≥ 1 high-risk criteria (obesity (BMI: 30–40 kg/m2), active smoker, COPD, diabetes, immunosuppression, coronary artery disease, chronic corticosteroid use, hypoalbuminemia, advanced age, and renal insufficiency). Physical exam and/or quality of life surveys were performed at regular intervals through 18 months (to date) with longer-term, 36-month follow-up ongoing. One hundred and twenty-one subjects (46M, 75F) with an age of 54.7 ± 12.0 years and BMI of 32.2 ± 4.5 kg/m2 (mean ± SD), underwent VIHR. Comorbidities included the following: obesity (n = 95, 78.5%), hypertension (n = 72, 59.5%), cardiovascular disease (n = 42, 34.7%), diabetes (n = 40, 33.1%), COPD (n = 34, 28.1%), malignancy (n = 30, 24.8%), active smoker (n = 28, 23.1%), immunosuppression (n = 10, 8.3%), chronic corticosteroid use (n = 6, 5.0%), advanced age (n = 6, 5.0%), hypoalbuminemia (n = 3, 2.5%), and renal insufficiency (n = 1, 0.8%). Hernia types included the following: primary ventral (n = 17, 14%), primary incisional (n = 54, 45%), recurrent ventral (n = 15, 12%), and recurrent incisional hernia (n = 35, 29%). Defect and mesh size were 115.7 ± 80.6 and 580.9 ± 216.1 cm2 (mean ± SD), respectively. Repair types included the following: retrorectus (n = 43, 36%), retrorectus with additional myofascial release (n = 45, 37%), onlay (n = 24, 20%), and onlay with additional myofascial release (n = 8, 7%). 95 (79%) subjects completed 18-month follow-up to date. Postoperative wound infection, seroma requiring intervention, and hernia recurrence occurred in 11 (9%), 7 (6%), and 11 (9%) subjects, respectively. High-risk VIHR with P4HB mesh demonstrated positive outcomes and low incidence of hernia recurrence at 18 months. Longer-term 36-month follow-up is ongoing.

The US opioid epidemic is a public health crisis. Approximately 78 Americans die every day from opioid-related overdoses and prescription opioids are involved in at least half of those deaths [1]. ...

Fully insertable laparoscopic cameras feature more locomotive flexibility in a larger workspace compared to conventional trocar-based laparoscopes and thus represent a promising future of minimally invasive surgery. These cameras are principally anchored and actuated by transabdominal magnetic coupling. Although several proof-of-concept prototypes have shown the technical feasibility in terms of camera actuation and laparoscopic imaging, none of them are getting close to clinical practice due to concerns about safety. One common problem lies in that the interaction force between the camera and the abdominal wall tissue is completely unknown and not controlled. The camera is being manipulated in an open loop which exposes the patient to a high risk of being injured. In this paper, a noninvasive real-time camera-tissue interaction force measurement approach for an insertable laparoscopic camera is proposed, implemented, and validated.Ex-vivo experiments using a simulated abdominal cavity have demonstrated the effectiveness of this approach during anchoring, translation, and rotation camera behaviors. Potential surgical impacts enabled by the force feedback have also been exemplified by a robotic-assisted camera control experiment using shared autonomy.

This paper presents the design of a novel insertable robotic capsule camera system for single-incision laparoscopic surgery. This design features a unified mechanism for anchoring, navigating, and rotating a fully insertable camera by externally generated rotational magnetic field. The design is inspired by the spherical motor concept where the external stator generates anchoring and rotational magnetic field to control the motion of the insertable robotic capsule camera. The insertable camera body, which has no active locomotion mechanism onboard, is capsulated in a one-piece housing with two ring-shaped tail-end magnets and one cylindrical central magnet embedded onboard as a rotor. The stator positioned outside an abdominal cavity consists of both permanent magnets and electromagnetic coils for generating reliable rotational magnetic field. The initial prototype results in a compact insertable camera robot with a $\text{12.7}\;\text{mm}$ diameter and a $\text{68 mm}$ length. The design concepts are analyzed theoretically and verified experimentally. The experiments validate that the proposed camera robot design provides reliable camera fixation and locomotion capabilities under various testing conditions.

Aim Bariatric surgery induces significant weight loss, increases insulin sensitivity, and reduces mortality, but the underlying mechanisms are not clear. It was hypothesized that Roux‐en‐Y gastric bypass (RYGB) surgery improves metabolic profile along with weight loss. The objective of this pilot study was to evaluate changes in serum metabolites and fatty acids (FA) at 2 weeks and 6 months after RYGB. Materials and Methods Serum samples were collected pre‐surgery, at 2 weeks and 6 months post‐surgery from 20 patients undergoing RYGB surgery. Serum non‐esterified free FA (NEFA) were measured. Serum metabolites and FA were measured using nuclear magnetic resonance spectroscopy and improved direct fatty acid methyl ester synthesis and the gas chromatography/mass spectrometry method, respectively, in subjects who completed follow‐up at 6 months (n = 8). Results Mean (standard deviation) percent total weight loss was 6.70% (1.7) and 24.91% (6.63) at 2 weeks (n = 15) and 6 months (n = 8) post‐surgery, respectively. NEFA were significantly reduced at 6 months post‐surgery (P = 0.001, n = 8). Serum branched chain amino acids, 2‐aminobutyrate, butyrate, 2‐hydroxybutyrate, 3‐hydroxybutyrate, acetone, 2‐methylglutarate, and 2‐oxoisocaproate were significantly reduced, while serum alanine, glycine, pyruvate, and taurine were significantly elevated at 6 months post‐surgery compared with pre‐surgery (n = 8, P

This paper proposes a novel in-vivo robotic laparo-scopic camera design with an optimized illumination system, which is a crucial component for achieving high imaging quality. The robotic camera design with three extendable wings can reserve sufficient on-board space to harbor the optimized illumination system without affecting the compactness of the camera. We contribute a freeform optical lens design method and develop three miniature optical lenses for the LEDs to achieve greater than 95% illumination uniformity, greater than 14, 000 lx illuminance on a target plane with a distance of 100 mm, and greater than 89% optical efficiency. The prototype is implemented and experimentally tested, which demonstrates great performance of the in-vivo robotic laparoscopic camera and the significance of the optimized illumination system.

Robotic inguinal hernia is a controversial topic. The use of a robotic platform to perform a minimally invasive, preperitoneal hernia repair builds on the 20-year debate between traditional open versus laparoscopic inguinal hernia. In 2018, 80% of all inguinal hernia are repaired using an open technique, despite two decades of training and experience with laparoscopic inguinal hernia surgery. The robotic technique is based on the well-delineated transabdominal preperitoneal (TAPP) laparoscopic inguinal hernia repair. The lack of adoption of minimally invasive (MIS) techniques in inguinal hernia runs counter to trends of MIS increased adoption for procedures such as appendectomy, colectomy, cholecystectomy, and even ventral hernia. One would expect that adding more potential cost to the high cost of a laparoscopic inguinal repair would decrease the perceived value of the robotic inguinal hernia. This does not appear to be the case, as early trends are showing migration of both open and laparoscopic surgeons to the robotic platform. The central questions this chapter will address are how can the cost of robotic inguinal hernia surgery be minimized and in which patient population does the value proposition become positive.

Obese patients are predisposed to developing insulin resistance and associated metabolic diseases such as diabetes and cardiovascular disease. The objective of this study was to determine the effect of bariatric surgery on adipose-derived inflammatory cytokines (adipokines), which play a key role in insulin resistance and obesity. We hypothesized that there is a significant increase in serum and tissue anti-inflammatory adiponectin with a decrease in circulating pro-inflammatory TNF-α and MCP-1, leading to reduced inflammation post-bariatric surgery. In this study, we investigated the effects of laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic gastric band on serum and tissue levels of adiponectin and serum levels of MCP-1 and TNF-α. Samples of serum and adipose tissue were collected at the time of surgery, 2 weeks and 6 months postoperatively. Adipokine levels were assayed by ELISA kits. A significant increase in adiponectin levels 2 weeks after surgery was observed in the subcutaneous adipose tissue in both groups combined. Serum adiponectin in LRYGB patients showed an increasing trend, while MCP-1 showed a decreasing trend post-surgery. There was no difference in TNF-α among the groups. The number of patients enrolled did not allow for statistical power to be reached. Our results show significant and rapid increases in subcutaneous adipose adiponectin as early as 2 weeks post-bariatric surgery demonstrating reduced inflammation and possibly reduced insulin resistance. Future studies are warranted in larger cohorts with additional measurements of insulin sensitivity and inflammation.

BACKGROUND Insertable laparoscopic camera systems were developed to improve the minimally invasive surgeries. Robotic degrees of freedom for an insertable laparoscopic camera are required to adjust the camera's orientation and position inside an abdominal cavity. METHODS This paper demonstrates an insertable magnetic actuated robotic camera system with two-degree-of-freedom (2-DoF) orientation control for single incision laparoscopic surgery. The camera system design consists of an external magnetic control unit and a fully insertable camera capsule. This system features a unified mechanism for anchoring, navigating, and rotating the insertable camera capsule by externally generated rotational magnetic field from the control unit. The motor-free camera capsule is encapsulated in an one-piece housing with two ring-shaped tail-end magnets and one cylindrical central magnet. The control unit that positioned externally consists of both permanent magnets and electromagnetic coils to generate rotational magnetic field and control the camera capsule. RESULTS The experimental investigations indicated that the camera control system can achieve less than 1° control accuracies with average errors 0.594° and 0.524° for tilt motion and pan motion, respectively. CONCLUSION The designed control system provides fine orientation control for the insertable camera capsule which guarantees proper vision for the surgeon during single incision laparoscopic surgery.

This paper proposes an in vivo laparoscopic lighting system design to address the illumination issues, namely poor lighting uniformity and low optical efficiency, existing in the state-of-the-art in vivo laparoscopic cameras. The transformable design of the laparoscopic lighting system is capable of carrying purposefully designed freeform optical lenses for achieving lighting performance with high illuminance uniformity and high optical efficiency in a desired target region. To design freeform optical lenses for extended light sources such as LEDs with Lambertian light intensity distributions, we present an effective and complete freeform optical design method. The procedures include (1) ray map computation by numerically solving a standard Monge–Ampere equation; (2) initial freeform optical surface construction by using Snell’s law and a lens volume restriction; (3) correction of surface normal vectors due to accumulated errors from the initially constructed surfaces; and (4) feedback modification of the solution to deal with degraded illuminance uniformity caused by the extended sizes of the LEDs. We employed an optical design software package to evaluate the performance of our laparoscopic lighting system design. The simulation results show that our design achieves greater than 95% illuminance uniformity and greater than 89% optical efficiency (considering Fresnel losses) for illuminating the target surgical region.

The field of insertable laparoscopic robotic camera is gaining increasing attentions from researchers, surgeons, and also patients. Although many insertable laparoscope prototypes have been introduced, few of them get rid of the encumbrance tethering cable. In this paper, we proposed a hardware architecture for a magnetic actuated robotic surgical (MARS) camera, which facilitates a cable-free fully insertable laparoscopic surgical robotic camera with adequate in-vivo mobility. Modular design and preliminary test of on-board functional payloads have shown feasibility of a cable-free insertable wireless laparoscopic surgical camera based on off-the-shelf electronics and industrial wireless standards operating in ISM frequency bands at 2.4GHz. Potential improvements for laparoscopic surgery benefited from this hardware architecture include more dexterous in-vivo camera mobility and intuitive closed-loop robotic camera control.

Patients with ventral hernia and loss of domain represent some of the most complex hernia a surgeon may face. Loss of domain is where 50 % of the abdominal viscera reside outside the abdominal cavity. Emergency surgery with open abdomen management and morbid obesity with prior open abdominal surgery are the two most common reasons for loss of domain development. Restoring abdominal wall integrity and function via a hernia repair poses special consideration from a preoperative preparation and operative technique standpoint. Preoperative weight loss may decrease the intra-abdominal volume for the viscera to return at the time of the repair. Smoking cessation, wound care, exercise training, and diabetes management can reduce postoperative pulmonary and wound infections. In most cases, myofascial releases that lengthen the abdominal wall are necessary to optimized primary fascial closure of the abdomen. There are multiple surgical techniques that can be combined to enhance mesh implantation and restoration of abdominal wall function.

Athletic pubalgia (sports hernia) is a fashionable moniker used by both patients and physicians to describe what is a poorly understood and often erratically treated patient condition. Athletic pubalgia can more clearly be defined as pain in the groin region brought on by aggressive physical activity and relieved by activity cessation. Rather than being a single-entity disease with a root cause and simple treatment plan, sports hernia is a cluster of different diseases that have both overlapping symptoms and common physical triggers. This chapter aims to describe the individual disease entities and describe the often-subtle physical signs and symptoms that are commonly lumped together as sports hernia.

This paper demonstrates a Magnetic Actuated Robotic Surgical (MARS) camera system with two-degree-of-freedom (2-DOF) orientation control for single incision laparoscopic surgery. The MARS camera design that consists of a stator and a rotor features a unified mechanism for anchoring, navigating, and rotating the insertable camera by externally generated rotational magnetic field from the stator. The insertable camera that has no on-board motors is capsulated in a one-piece housing with two ring-shaped tail-end magnets and one cylindrical central magnet as the rotor. The stator positioned outside an abdominal cavity consists of both permanent magnets and electromagnetic coils to generate rotational magnetic field. A closed-loop control system was developed to enable automatic fine orientation control of the MARS camera. The experimental investigations indicated that our MARS camera can achieve 0.67° and 0.49° control accuracies for tilt and pan motions respectively.

BACKGROUND: The objective of our study was to assess the efficacy of multimodal hepatic cytoreduction in symptomatic patients with advanced hepatic metastases from carcinoid disease. METHODS: A retrospective analysis of prospectively collected data was performed. All consecutive patients, who underwent cytoreductive treatment for their metastatic carcinoid liver disease between October 1996 and October 2004, were enrolled. Treatment modalities included resection, radiofrequency with ethanol ablation, chemoembolization, or combined therapy. RESULTS: Fifteen patients, mean age 61 (SD 11) years, underwent cytoreduction. Twelve (80%) patients had extensive bilobar disease and 3 (20%) had solitary lesions. Eleven patients underwent one or more palliative surgical debulking procedures. Two patients had curative resection, and 2 patients had chemoembolization only due to unacceptable anesthesia risk. With a mean follow-up after 29 months (SD 22.1), 6 patients (40%) had stable disease, 8 (53.3%) had progression of disease and 1 (6.6%) had no disease at all. Death grasped 4 patients of which 2 died due to progression of disease. The median symptom relief period was 12 months. Overall survival was 57 months (mean) from the time of hepatic cytoreduction. CONCLUSIONS: Aggressive hepatic cytoreduction in patients with advanced metastatic carcinoid disease can achieve excellent overall survival but needs improvement in long-term symptom control.

New advances in endoscopic surgery make it imperative that future gastrointestinal surgeons obtain adequate endoscopy skills. An evaluation of the 2001–02 general surgery residency endoscopy experience at the University of Missouri revealed that chief residents were graduating with an average of 43 endoscopic cases. This met American Board of Surgery (ABS) and Accreditation Council for Graduate Medical Education (ACGME) requirements but is inadequate preparation for carrying out advanced endoscopic surgery. Our aim was to determine if endoscopy volume could be improved by dedicating specific staff surgeon time to a gastrointestinal diagnostic center at an affiliated Veterans Administration Hospital. During the academic years 2002–05, two general surgeons who routinely perform endoscopy staffed the gastrointestinal endoscopy center at the Harry S. Truman Hospital two days per week. A minimum of one categorical surgical resident participated during these endoscopy training days while on the Veterans Hospital surgical service. A retrospective observational review of ACGME surgery resident case logs from 2001 to 2005 was conducted to document the changes in resident endoscopy experience. The cases were compiled by postgraduate year (PGY). Resident endoscopy case volume increased 850% from 2001 to 2005. Graduating residents completed an average of 161 endoscopies. Endoscopic experience was attained at all levels of training: 26, 21, 34, 23, and 26 mean endoscopies/year for PGY-1 to PGY-5, respectively. Having specific endoscopy training days at a VA Hospital under the guidance of a dedicated staff surgeon is a successful method to improve surgical resident endoscopy case volume. An integrated endoscopy training curriculum results in early skills acquisition, continued proficiency throughout residency, and is an efficient way to obtain endoscopic skills. In addition, the foundation of flexible endoscopic skill and experience has allowed early integration of surgery residents into research efforts in natural orifice transluminal endoscopic surgery.

Laparoscopic appendectomy (LA) is safe and effective in cases of peritonitis, perforation, and abscess. We investigated our conversion rate and clinical outcomes in this patient population, as well as preoperative factors that predict operative conversion. A retrospective nonrandomized cohort of 92 patients underwent LA for acute appendicitis with peritonitis, perforation, or abscess at our institution between 1997 and 2002. Thirty-six of the 92 were converted to open appendectomy (OA), yielding a conversion rate of 39 per cent. The presence of phlegmon (42%), nonvisualized appendix (44%), technical failures (8%), and bleeding (6%) were reasons for conversion. Preoperative data had no predictive value for conversion. CT scan findings of free fluid, phlegmon, and abscess did not correlate with findings at the time of surgery. Total complication rates were 8.9 per cent in the LA group as compared to 50 per cent in the converted cohort. Postoperative data showed LA patients stayed 3.2 days versus 6.9 days for converted patients ( P = 0.01). LA patients had less pneumonia ( P = 0.02), intra-abdominal abscess ( P = 0.01), ileus ( P = 0.01), and readmissions ( P = 0.01). LA is safe and effective in patients with appendicitis with peritonitis, perforation, and abscess, resulting in shorter hospital stays and less complication.

Bariatric surgery is known to cause significant weight loss, reduction in insulin resistance, cardiovascular disease and mortality. We hypothesized that adipose and systemic inflammation will be de...

Solid-pseudopapillary tumor (SPT) of the pancreas is a rare lesion with low malignant potential occurring predominantly in young women. This is a report of two cases in young male patients. Clinical data were retrieved retrospectively from a prospective database of patients with pancreatic tumors. The two patients were Caucasian males, ages 34 years (Pt1) and 41 years (Pt2) at the time of diagnosis. Pt1 presented with intermittent epigastric pain, nausea, and vomiting. Computed tomography (CT) scan showed a 9-cm mass involving the pancreatic head. He underwent pancreaticoduodenectomy, with en bloc segmental colectomy due to mesocolon involvement. Pt2 was asymptomatic, diagnosed with abdominal mass by screening ultrasound. He had an 11-cm tumor involving the pancreatic tail encasing the splenic vessels on CT. He underwent distal pancreatectomy with splenectomy en bloc. Pathology in both cases was reviewed by staff pathologists as well as outside consultants. SPT is a rare tumor of the pancreas that is diagnosed primarily in young women. The cases presented here demonstrate SPT of the pancreas in two men. In both cases, the clinical presentation was relatively unremarkable. Both have had benign late postoperative courses, consistent with the low malignant potential of this lesion.

This chapter will focus in the interactions of prosthetic mesh material with the host tissues in the dynamics of hernia surgery. The prosthetic materials we implant in patients during a hernia repair are not inert to the body’s immune response. The base material composition and three-dimensional macrostructure of the mesh impacts the body’s response. Inadequate mesh fixation can result from inadequate technique or inadequate adherence of the mesh to the abdominal wall. Therefore, mesh used for hernia repairs requires the ability to incite great and durable tissue ingrowth. The focus of this chapter is to provide an updated literature review on the concept of fibrous ingrowth, also known as tissue ingrowth, as it relates to the human body’s ability to incorporate an implanted mesh. Future improvement in hernia outcomes will depend on a better understanding of how the patient, the surgical technique, and the mesh materials each impact each other in collaboration.

Parasternal pyoderma gangrenosum (PPG) is an exceedingly rare disease process most often observed in inflammatory bowel disease patients with an ileostomy. Fewer than 50 cases have been reported in the medical literature. The incidence is 0.6 per cent of patients with ileostomy and inflammatory bowel disease. The rarity of the disease leads to misdiagnosis and mistreatment of the lesion. The intense pain and disruption of ostomy function greatly impair affected individuals beyond the limit of their underlying disease. Current best care practices observed in small study series indicate long-term intensive medical therapy aimed at systemic disease suppression to optimize PPG wound healing. Our patient had no signs of active Crohn disease at the time of PPG presentation. She was initially treated with minimal wound debridement and intralesional triamcinolone. Finally under the care of an enterostomal/wound care therapist the patient achieved excellent PPG resolution in 6 months.

The purpose of this study was to investigate whether hand-assisted laparoscopic radical nephrectomy (HALN) has benefits over the traditional transabdominal radical nephrectomy. More specifically we focused on the use of the hand-assisted technique as a definitive oncologic procedure for renal cancers. This study is a retrospective nonrandomized study comparing 12 hand-assisted laparoscopic radical nephrectomies with 12 transabdominal radical nephrectomies. All patients included in the study had the preoperative diagnosis of renal mass. HALN population averaged 1.83 ± 1.64 (mean ± standard deviation) major comorbidities versus 1.08 ± 0.8 open ( P = 0.032). The HALN OR time averaged 103 ± 32.8 versus 57 ± 18.3 minutes open ( P = 0.001). The estimated blood loss mean for HALN was 83 versus 318 cm3 open ( P = 0.001). Length of stay for HALN was 4.9 ± 2.2 versus 5.9 ± 2.9 days ( P = 0.35). Days to regular diet was 2.9 ± 2.3 in HALN versus 3.5 ± 2.11 open ( P = 0.52). Days of intravenous pain medications were 1.8 ± 0.72 HALN versus 3.0 ± 1.28 open ( P = 0.016). Postoperative complication rates for the two groups were identical: two of 12 (ileus and post-operative bleeding). Tumor size mean was 6.8 ± 2.99 cm for HALN versus 4.2 ± 1.29 cm open ( P = 0.012). Tumor margins were negative for 12 of 12 in HALN versus 11 of 12 open. Selection bias (selecting ailing patients to the HALN cohort) diminished the statistical significance of our postoperative recovery data. It is likely that a prospectively randomized study with a larger population may prove the hand-assisted approach equal if not superior to the open technique. The use of HALN in patients with renal tumors is an effective alternative to traditional transabdominal radical nephrectomy.

These authors found that laparoscopic mesh repair of incidentally found Spigelian hernia resulted in a satisfactory repair with acceptable results., Background and Objectives: A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs. Methods: Case series and review of the literature. Cases: Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair. Conclusions: There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.

Background Treatment of adhesion-related complications is cost intensive and presents a considerable burden to the health care system. The objective of this study was to compare open (OLA) and laparoscopic lysis of adhesions (LLA) in the treatment of intestinal obstruction, based on a nationwide representative sample. Study Design Patients with intestinal obstruction undergoing OLA, LLA, and conversion were identified from the 2002 National Inpatient Sample. After propensity methods were used to adjust for covariates including patient demographics, hospital characteristics, and comorbidities, the impact of OLA and LLA was analyzed concerning in-hospital mortality, postoperative complications, length of stay (LOS), and in-hospital costs. Results Of 6,165 patients, 88.6% underwent OLA and 11.4% had LLA. Conversion was required in 17.2% of LLA patients. Unadjusted mortality was equal between LLA and conversion (1.7%) and half the rate compared with OLA (3.4%) (p = 0.014). After adjusting with propensity methods, the odds of complications in the LLA group (intention to treat) were 25% less than in the OLA (p = 0.008). The LLA group had a 27% shorter LOS (p = 0.0001) and was 9% less expensive than the OLA group (p = 0.0003). There was no statistical significant difference for LOS, complications, and costs between the conversion and OLA groups. Conclusions Results from this study suggest that when LLA is applied to selected patients with intestinal obstruction, there are reductions in postoperative complications, LOS, and costs. Prospective studies are needed to confirm these data and better identify the subgroup of patients who have improved outcomes with LLA.

Although laparoscopic appendectomy is widely used for treatment of appendicitis, it is still unclear if it is superior to the open approach.From the Nationwide Inpatient Sample 2000 to 2005, hospitalizations with the primary ICD-9 procedure code of laparoscopic (LA) and open appendectomy (OA) were included in this study. Outcomes of length of stay, costs, and complications were assessed by stratified analysis for uncomplicated and complicated appendicitis (perforation or abscess). Regression methods were used to adjust for covariates and to detect trends. Costs were rescaled using the hospital and related services portion of the Medical Consumer Price Index.Between 2000 and 2005, 132,663 (56.3%) patients underwent OA and 102,810 (43.7%) had LA. Frequency of LA increased from 32.2% to 58.0% (p0.001); conversion rates decreased from 9.9% to 6.9% (p0.001). Covariate adjusted length of stay for LA was approximately 15% shorter than for OA in both uncomplicated and complicated cases (p0.001). Adjusted costs for LA were 22% higher in uncomplicated appendicitis and 9% higher in patients with complicated appendicitis (p0.001). Costs and length of stay decreased over time in OA and LA. The risk for a complication was higher in the LA group (p0.05, odds ratio=1.07, 95% CI 1.00 to 1.14) with uncomplicated appendicitis.LA results in higher costs and increased morbidity for patients with uncomplicated appendicitis. Nevertheless, LA is increasingly used. Patients undergoing LA benefit from a slightly shorter hospital stay. In general, open appendectomy may be the preferred approach for patients with acute appendicitis, with indication for LA in selected subgroups of patients.