Laparoscopic right hemicolectomy with intracorporeal anastomosis and natural orifice surgery extraction/minimal extraction site surgery in the obese

Background: Despite advantages associated with laparoscopic colorectal surgery, there is significant morbidity associated with incisions required for specimen extraction and restoration of bowel continuity. In laparoscopic colorectal surgery, the length of the longest incision depends upon that required to facilitate extra-corporeal steps. The purpose of this study was to analyse obese patients (body mass index >30 kg/m2) who have undergone laparoscopic small bowel or right-sided colonic resection with intracorporeal anastomosis (ICA) and natural orifice surgery extraction (NOSE)/minimal extraction site (MES) surgery. Methods: A retrospective review of 11 obese patients who have undergone laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES was conducted. Results: Mean body mass index was 40.4 kg/m2 (range 32.7–56 kg/m2) in 11 patients. Procedures performed were laparoscopic right hemicolectomy (7) – one with high anterior resection, pelvic peritonectomy, bilateral salpingo-oophorectomy and greater omentectomy, small bowel resection (2), transverse colotomy (1) and segmental transverse colectomy (1). All colonic specimens were extracted via NOSE (vaginal colpotomy or transcolonic), except two requiring a miniaturized extraction wound. Small bowel specimens were extracted via a 12-mm port hole, without extension. Mean operating time was 240 min (range 100–510 min). Mean time to discharge was 4 days (range 4–6 days). Complications included a superficial wound infection in a patient presenting with an obstructed tumour and a second patient developed a seroma following small bowel resection for an incarcerated hernia. Conclusion: Obese patients can undergo laparoscopic small bowel and right-sided colonic resection with ICA and NOSE/MES surgery and benefit from short length of stay and low morbidity

Short-term outcomes of parastomal hernia prophylaxis with Stapled Mesh stomA Reinforcement Technique (SMART) in permanent stomas

Background: Parastomal hernias occur in 50–80% after stoma formation. Even with mesh repairs, recurrence can be as high as 33%. Stapled Mesh stomA Reinforcement Technique (SMART) places a prophylactic onlay mesh in the trephine during permanent stoma formation to prevent parastomal hernia. Our study aims to describe the short-term outcomes of SMART procedures. Methods: A prospective study of patients receiving the SMART procedure from 2015 to 2020 was conducted. Inclusion criteria: non-Crohn's colorectal and urological surgery with permanent stoma formation. The SMART surgical technique incorporates a 70-mm circular piece of polypropylene mesh by stapling it to the muscular abdominal wall using a circular stapler, and attaching the edge of the mesh to the deep fascia. Results: Fifty patients had a total of 53 SMART procedures. Median follow-up was 27 months. Procedures included: 35 end colostomies, five end ileostomies, eight ileal urinary conduits and five double-barrelled wet colostomies. Four patients had parastomal hernia during follow-up. One was acute, on day 1, due to very large size of trephine, one in a double-barrelled wet stoma that was repaired laparoscopically, one had a stomal prolapse requiring revision at 3 years and one patient had early small bowel obstruction due to very small size of trephine requiring another surgery. There were no wound infections or mesh-related sepsis. Conclusion: Symptomatic parastomal herniation occurred in 8% of the study population, and most complications were due to incorrect choice of stapled trephine diameter. Longer term follow-up is required to assess for problematic parastomal hernia

Australian experience of side-to-side isoperistaltic stricturoplasty in Crohn's disease

Background: The Michelassi stricturoplasty has demonstrated efficacy for Crohn's disease in European and American series but has not had uptake in Australia. We report the short-term results of side-to-side isoperistaltic stricturoplasty (SSIS) in an Australian Practice. Methods: Between March 2015 and October 2021 SSIS procedures were performed on Crohn's patients with long segment Crohn's strictures associated with obstructive symptoms, despite best medical therapy. Surgical demographics and results were recorded via inpatient and outpatient follow-up in a prospective database. Results: Twenty-one SSIS performed in 16 patients, nine female, mean age 40 years. Single incision laparoscopic surgery (SILS) was used in 10 patients. The standard Michelassi SSIS used for 11 strictures and a Poggioli variant used for 10. Mean stricture length 32 cm (range 5–100); mean SSIS length 24 cm (range 6–55). Associated bowel resection in seven cases with a mean length of 47 mm. Ten patients had an average of three additional stricturoplasties. Complications included central line sepsis in one, deep surgical site infection in one and superficial wound infection in four patients. Mean duration of operation; 346 min and length of stay 10 days. Conclusion: SSIS techniques are safe for the management of long segment stricturing Crohn's disease. Although not widely used in Australia, surgeons should consider the Michelassi stricturoplasty, and its variants, for long Crohn's strictures as they are isoperistaltic whilst avoiding bowel resection and blind pouches

Natural orifice specimen extraction for colorectal surgery : early adoption in a Western population

Aim: Natural orifice specimen extraction (NOSE) challenges the limits of minimally invasive colorectal surgery by exploiting a natural opening for specimen delivery. Technically challenging, it is less painful, requires smaller wounds and abolishes the possibility of incisional hernia. These advantages of NOSE are seen in the obese (body mass index [BMI] >30 kg/m2). This audit aims to demonstrate the feasibility of NOSE colectomy in an Australian population. Method: Prospective data collected from 2007 to the present were retrospectively analysed. Only patients with mucosally benign colorectal conditions were included: complex diverticulosis, post-malignant polypectomy and volvulus. Left sided mucosal malignancies were excluded. Study end-points included postoperative length of stay, anastomotic leak rate and wound complications. Results: In total, 159 patients underwent NOSE, mean age 59 years (19–88), mean BMI 28.2 kg/m2 (17–45). Ten (6.2%) patients developed retroperitoneal small bowel herniation; seven required further surgery. There were five (3.1%) anastomotic leaks, seven (4.4%) postoperative ileus and three (1.9%) anastomotic bleeds. One (0.6%) patient had a superficial wound infection. There were no port site hernias. Patients with BMI <30 kg/m2 (98 patients) and BMI >30 kg/m2 (59 patients) were compared; there was no difference in anastomotic leak rate (P = 0.60), complication rate (P = 0.71) and length of stay (P = 0.63). However, duration of operation increased with BMI (P = 0.000). Conclusion: This large series of NOSE colectomy from Australia suggests that NOSE is comparable to conventional laparoscopic colectomy in terms of postoperative outcome. Given that obesity has not featured in the NOSE literature, our study suggests that NOSE, for benign disease, is safe in obese patients, without added morbidity

Concomitant abdominoplasty and laparoscopic umbilical hernia repair

Background: Umbilical hernia is a common finding in patients undergoing abdominoplasty, especially those who are postpartum with rectus divarication. Concurrent surgical treatment of the umbilical hernia at abdominoplasty presents a "vascular challenge" due to the disruption of dermal blood supply to the umbilicus, leaving the stalk as the sole axis of perfusion. To date, there have been no surgical techniques described to adequately address large umbilical herniae during abdominoplasty. Objectives: To present an effective and safe technique that can address large umbilical herniae during abdominoplasty. Methods: A prospective series of 10 consecutive patients, undergoing concurrent abdominoplasty and laparoscopic umbilical hernia repair between 2014 and 2017 were included in the study. All procedures were performed by the same general surgeon and plastic surgeon at the Macquarie University Hospital in North Ryde, NSW, Australia. Data were collected with approval of our ethics committee. Results: At 12-month follow up there were no instances of umbilical necrosis, wound complications, seroma, or recurrent hernia. The mean body mass index was 23.8 kg/m2 (range, 16.1-30.1 kg/m2). Rectus divarication ranged from 35 to 80 mm (mean, 53.5 mm). Umbilical hernia repair took a mean of 25.9 minutes to complete (range, 18-35 minutes). Conclusions: We present a technique that avoids incision of the rectus fascia minimizes dissection of the umbilical stalk and is able to provide a gold standard hernia repair with mesh. This procedure is particularly suited to postpartum patients with large herniae (>3-4 cm diameter) and wide rectus divarication, where mesh repair with adequate overlap is the recommended treatment