Track topics on Twitter Track topics that are important to you
The main goal of this study is to describe the trends in the incidence rate of internal hernia presentation after different modifications of the mesenteric closure technique after primary laparoscopic Roux-en-Y gastric bypass (RYGB) surgery from 1997-2009.
The main goal of this study is to describe and analyze the trends in the incidence rate of internal hernia presentation after different modifications of the mesenteric closure technique after Primary Laparoscopic RYGB Surgery from 1997 to 2009.
Secondary study aims are to describe the following points 1. Clinical presentation, whether acute (small bowel obstruction), chronic (intermittent abdominal pain), or incidental finding -(asymptomatic); 2. Preoperative image studies. The percentage of patients that underwent preoperative CT/contrast studies as well as the percentage of patients that had positive, undetermined, and normal results; 3. Site of internal herniation including transverse mesocolon, jejunal mesentery, and Peterson's space as well as single vs. multiple internal hernias. This study along with the existing literature will allow us to formulate preliminary clinical recommendations.
This research is in line with the most current provocative new ideas and recent high impact publications. Most literature points towards the antecolic routing of the Roux limb to decrease the incidence rate of internal hernia formation. However, with this study we will demonstrate the statistically and clinically significant decrement of internal hernia formation with the improvement of the closure technique with a retrocolic antegastric routing of the Roux limb.
The epidemic of overweight and obesity in the United States of America along with its comorbidities continues to expand. Bariatric surgery has demonstrated to be the most effective and sustained method to control severe obesity and its comorbidities. For instance, type 2 diabetes mellitus was completely resolved in 76.8 percent, systemic arterial hypertension was resolved in 61.7 percent, dyslipidemia improved in 70 percent, and obstructive sleep apnea-hypopnea syndrome was resolved in 85.7 percent. Furthermore, bariatric surgery significantly increases life expectancy (89 percent) and decreases overall mortality (30 to 40 percent), particularly deaths from diabetes, heart disease, and cancer. Lastly, preliminary evidence about downstream savings associated with bariatric surgery offset the initial costs in 2 to 4 years.
Since 1998, there has been a substantially progressive increase in bariatric surgery. In 2005, the American Society of Metabolic and Bariatric Surgery "ASMBS" reported that 81 percent of bariatric procedures were approached laparoscopically. 205,000 people, in 2007, had bariatric surgery in the United States from which approximately 80 percentage of these were Gastric Bypass. Moreover, there is a mismatch between eligibility and receipt of bariatric surgery with just less than 1% of the eligible population being treated for morbid obesity through bariatric surgery10. Along with the increasing number of elective primary weight loss procedures, up to 20 percent of post RYGB patients cannot sustain their weight loss beyond 2 to 3 years after the primary bariatric procedure11. Thus, revisional surgery for poor weight loss and reoperations for technical or mechanical complications will rise in a parallel manner. RYGB is consistently considered the revisional procedure of choice for failed restrictive procedures.
At present there are three broad categories of bariatric procedures according to its mechanism of action 1. purely restrictive, 2. primarily restrictive with some malabsorption, and 3. primarily malabsorptive with some restriction. Modern standard bariatric procedures recognized by the American Society for Metabolic and Bariatric Surgery "ASMBS" include the following 1. adjustable gastric band, 2. sleeve gastrectomy, 3. gastric bypass, 4. biliopancreatic diversion, and 5. duodenal switch.
There are no multi center, randomized, double blinded control trials comparing the different standard bariatric procedures. Gastric bypass is the oldest available bariatric procedure; without any randomized controlled trials, it is considered the gold standard procedure in the United States.
Incisional hernias occur at a higher incidence rate after open RYGB, approximately 20 percent, whereas after laparoscopic Roux-en-Y gastric bypass "RYGB", the incidence rate is very low. Conversely, Internal hernia is a rare complication with the open approach whereas after laparoscopic RYGB the incidence rate has been reported somewhere between 0.2 to 8.6 percent. The most accepted theory is due to decreased adhesion formation after laparoscopic surgery compared to open surgery.
Other factors associated with a higher incidence of internal hernia formation after RYGB are 1. childbearing age with the consequent pregnancy after RYGB, 2. Roux limb routing, 3. Closure of mesenteric and or mesocolic defects.
Although there have been no randomized controlled trials comparing different techniques of laparoscopic RYGB, several authors have report lower rates after modifying their technique from a retrocolic to an antecolic approach. On the other hand, others support meticulous defect closure as the most important factor in reducing hernia formation.
The method of fixation and mesenteric closure has evolved. Initially, as with the open approach, defects were not closed. Then, absorbable sutures were used which were changed for interrupted non-absorbable sutures. Lastly, continuous non-absorbable material for closing all defects was recommended by Sugerman.
Summarizing, there is no high level of evidence for recommending the best strategy to decrease the incidence rate the potentially devastating complication of internal hernia after laparoscopic RYGB. After reviewing the literature the trend is toward lower rates of internal hernia formation with antecolic compared to retrocolic, and with defect closure compared to nonclosure. There is great variation in the incidence rate among the reported series reflecting incomplete follow-up and other factors may affect outcomes. With this study, we will analyze the trends in the incidence rate of internal hernia formation among different subgroups in our consecutive series of more than 7,500 laparoscopic retrocolic RYGB with a hand-sawn gastrojejunostomy. With this consecutive series, we will confirm reports of small series that meticulous closure technique of mesocolic/mesenteric defects with continuous nonabsorbable material clinically and statistically decreases the formation rate of internal hernias after laparoscopic gastric bypass.
Observational Model: Cohort, Time Perspective: Retrospective
UCSF Fresno Center for Medical Education and Research, Department of Surgery
University of California, San Francisco
Published on BioPortfolio: 2014-07-24T14:10:29-0400
This study will collect data on patients undergoing hernia repair using the Bard Ventrio Hernia Patch. The study will evaluate hernia recurrence rates, operating time, quality of life and...
This study will determine whether laparoscopic and open hernia repair have the same recurrence and complication rates in the under 60yr old age group. The overall financial costs of each r...
This study compares the outcome of the four most commonly used operations for the repair of primary groin hernia including the new key hole surgical techniques. It aims at answering the qu...
Inguinal hernia repair is one of the most commonly performed general surgery operations. However, to date, the ideal surgical approach for inguinal hernia surgery. The investigators theref...
This investigation will be a double-armed, randomized (Blinded patients and Blinded examiner) prospective study designed to collect perioperative and postoperative data to compare the QOL ...
An incarcerated inguinal hernia is a textbook example of a basic and straightforward diagnosis. In rare cases, an incarcerated hernia may be a symptom of more complex underlying pathology. In this cas...
We report a rare case of an incarcerated retroperitoneal hernia with or involving the small bowel through the orifice between the right external and internal iliac vessels. A 39-year-old woman was adm...
Laparoscopic inguinal hernia repair in children is in evolution. Multiple methods of passing the suture around the peritoneum at the level of the internal inguinal ring exist. Cauterization of the per...
Despite a multitude of evidence-based prediction models and risk factors for postoperative complications after ventral hernia repair, estimating a patient's risk of postoperative complications after v...
A protrusion of abdominal structures through the retaining ABDOMINAL WALL. It involves two parts: an opening in the abdominal wall, and a hernia sac consisting of PERITONEUM and abdominal contents. Abdominal hernias include groin hernia (HERNIA, FEMORAL; HERNIA, INGUINAL) and VENTRAL HERNIA.
Protrusion of tissue, structure, or part of an organ through the muscular tissue or the membrane by which it is normally contained. Hernia may involve tissues such as the ABDOMINAL WALL or the respiratory DIAPHRAGM. Hernias may be internal, external, congenital, or acquired.
An abdominal hernia with an external bulge in the GROIN region. It can be classified by the location of herniation. Indirect inguinal hernias occur through the internal inguinal ring. Direct inguinal hernias occur through defects in the ABDOMINAL WALL (transversalis fascia) in Hesselbach's triangle. The former type is commonly seen in children and young adults; the latter in adults.
A pelvic hernia through the obturator foramen, a large aperture in the hip bone normally covered by a membrane. Obturator hernia can lead to intestinal incarceration and INTESTINAL OBSTRUCTION.
A groin hernia occurring inferior to the inguinal ligament and medial to the FEMORAL VEIN and FEMORAL ARTERY. The femoral hernia sac has a small neck but may enlarge considerably when it enters the subcutaneous tissue of the thigh. It is caused by defects in the ABDOMINAL WALL.
Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. Some illnesses can be excruci...
Obesity is the condition in which excess fat has accumulated in the body (mostly in subcutaneous tissues). clinical obesity is considered to be present when a person has a BMI of over 30 (Oxford Dictionary of Medicine). It is becoming increasing common i...