Search

Bariatric surgery (BS) is the most effective therapy for morbid obesity. Cortisol and DHEA are steroid hormones with opposing effects, thus using Cortisol/DHEA ratio (C/D) rather than the use of either hormone alone has been found to predict health outcomes more reliably. It was interesting to study C/D as an indicator of favorable metabolic and cardiovascular outcomes after BS.To assess C/D in morbidly obese patients before and after BS in relation to metabolic parameters and cardiovascular performance.Forty morbidly obese patients were followed prospectively for 1 year after BS. Fasting blood glucose (FBG), fasting insulin (FI), C/D, lipid profile, high-sensitive CRP (hs-CRP), and echocardiography were done before BS and at 3 months and 1 year post BS.A total of 40 morbidly obese patients undergone sleeve gastrectomy. Blood pressure, FBG, FI, hs-CRP, C/D were significantly decreased after BS (p 0.001). At 1 year post BS; significant reduction in left ventricular posterior wall thickness (LVPW) (p 0.001), left ventricular mass (LVM) (p = 0.003), relative wall thickness (RWT) (p 0.001) with a significant improvement in early diastolic velocity (E) (p 0.001), early diastolic velocity/late diastolic velocity (E/A) (p = 0.01). After BS; C/D significantly positively correlated with FBG (p = 0.019), hs-CRP (p = 0.008), interventricular septum thickness (IVS) (p = 0.028), LVPW (p = 0.028), relative wall thickness (RWT) (p = 0.022), early diastolic velocity /early diastolic velocity (E') measured by pulsed tissue Doppler imaging (E/E') (p = 0.001), and significantly negatively correlated with E' (p = 0.032). C/D was the single significant independent variable affecting E' and E/E' post BS.C/D can be used as a surrogate marker of the improved FBG and the resolution of inflammation post BS. C/D is an independent predictor of diastolic function improvement post BS.

Background: LSG is an easy and safe technique with a shorter learning curve. The risk of staple-line bleeding, leakage, and dehiscence are much higher because of long staple-line. This study was carried out to detect the importance of staple-line reinforcement. Methods: Between April 2010 and September 2013, 166 consecutive patients with a diagnosis of morbid obesity based on the guidelines issued by IFSO who underwent LSG and completed their follow-up for a minimum one year were classified into; (group A) 84 patients with and (group B) 82 patients without staple-line reinforcement at Alexandria University. Outcome parameters including; leakage, bleeding, operative time, surgical complications, hospital stay, and follow-up details, were collected. Results: The demographic parameters were comparable in the two groups. No conversion to open surgery was detected. There was insignificant leakage rate as 2(2.4%) cases were found in group B and none in group A (P=0.86). There was insignificant difference between both groups as regard bleeding from staple-line, short gastric vessels or splenic tear. No stenosis was found in either group. The mean operative time in group A (99.7±19.1 minutes) was significantly longer than in group B (76.3±9.5 minutes) (P=0.015). Hospital stay was significantly prolonged in group B (2.5±4.9 days) than group A (1.95±0.4 days) (P=0.031). No significant difference was found regarding the other outcome parameters. Conclusions: LSG is an effective and safe bariatric procedure with low incidence of complications and mortality in our experience. Reinforcement of the staple-line did not have any additional benefit, although a larger study is required to reach a definitive conclusion.

omega-loop. The DIA is created as an end-to-side anastomosis completely handsewn. The ileum with the marked location for the CC-BPL anastomosis is positioned closely to the BPL six centimeters proximal to the DIA. A side-to-side CC-BPL anastomosis is performed. By dividing the bowel between the two anastomosis the omega-loop-construction is transformed into a Roux-y construction. The mesenteric defects are closed with nonresorbable staples. Conclusion: In our experience, the SOFY Duodenal Switch with an omega-loop transferred to a Roux-y construction is the most feasible procedure regarding operating time, overview of the anatomically correct positioning of the different limbs and the surgical workflow. The closure of the mesenteric defects is facilitated presumably leading to a lower rate in internal herniation.

The relation between the resected gastric volume and the weight loss after laparoscopic sleeve gastrectomy appears conflicting in the literature. Both the residual and the resected volumes represent the total gastric volume, and if the weight loss is related to one of the two volumes, it should be related to the other. While some reports indicate that the weight loss is related to the resected gastric volume, others state that the weight loss is not related to the residual volume. The aim is to investigate the influence of the resected gastric volume on the weight loss after surgery.The study included 287 consecutive patients. Gastrectomy was performed encroaching over a 38-Fr calibrating tube all the way to the angle of His. Filling volume of the resected stomach, with tap water, was measured. Patients were analyzed into group 1 with BMI ≤50 kg/m(2) and group 250 kg/m(2).Females represented 74 % of cases. Mean age was 32.9 ± 9.5 years; preoperative BMI = 48.7 ± 7.9 kg/m(2). The mean resected gastric volume was 1525 ± 408 ml, and it was significantly lower in females compared to that in males (1443 ± 311 vs 1824 ± 502 ml, p 0.001). Data were analyzed in two groups: group 1 with BMI ≤5050 kg/m(2) and group 250 kg/m(2). Both groups were similar in preoperative BMI (p = 0.399) and excess weight percent (EW%) (p = 0.33). Group 2 had a resected gastric volume (1663 ± 424.7 ml) greater than that of group 1 (1440 ± 347 ml; p 0.001). The percentage of excess weight loss (EWL%) was 57.9 ± 14.5 % at 6 months (62.7 ± 13.5 % vs 48.34 ± 11.29 %, p 0.001), 77 ± 19 % at 12 months (84 ± 19.6 % vs 68 ± 14.2 %, p = 0.001), 76.6 ± 7.4 % at 18 months (79.7 ± 4.8 vs 74.7 ± 8.2 %, p = 0.5), and 75.8 ± 11.5 % at 24 months (81.7 ± 11.17 vs 70 ± 11 %, p = 0.8) (group 1 vs group 2, respectively). At 12 months, 86 % patients achieved more than 50 % EWL% (100 % of group 1 vs 60 % of group 2). Preoperative BMI correlated with resected gastric volume (r = 0.239, p = 0.004). In multiple regression, the initial BMI was a predictor of EWL% at 6 and 12 months (r partial = -0.65, p 0.0001) while the resected gastric volume was not.The resected gastric volume is related to the total gastric volume when the technique is standardized and the residual volume is calibrated using a consistent technique. It is not in itself a predictor of weight loss, but it is related to the initial BMI which predicts the weight loss.

Laparoscopic gastric greater curvature plication (LGGCP) is a novel bariatric procedure. Its outcome as a standalone procedure has been studied in the literature. We herein describe a comparative study between LGGCP versus laparoscopic sleeve gastrectomy (LSG). The objective of this study was to analyze %excess weight loss (%EWL), co-morbidity improvement and complication rate in both groups at 1, 3, 6, 12 months follow-up.Retrospective study of 140 patients undergoing LGGCP and LSG between July 2011 and March 2012 at University of Alexandria, Egypt. Data on patient demography, operative time, length of stay, body mass index (BMI) were collected.Baseline characteristics were similar for both groups, except for preoperative BMI that was higher among the LSG group. Follow up rate was 98% (n = LGCCP: 68 - LSG: 69) at 6 months and 81% (n = LGGCP: 54 - LSG: 60) at 1 year. The mean operative time and mean length of stay were longer in the LSG group (P = .03) and (P = .02), respectively. There were 4 (6.5%) readmissions and 2 (3.2%) reoperations in the LGGCP group compared to 3 (3.8%) readmission and 2 (2.6%) reoperations in the LSG group. At 6 months follow-up the mean %EWL for LGGCP and LSG was 40.4±11.9% and 47.1±13.9% (P.001), while at 1 year it was 52.1±15.1% and 68.1±15.8% (P.001), respectively. Both techniques showed similar results in co-morbidity improvement at 1 year.In the short term, both techniques were comparable as regards to co-morbidity resolution. However, LSG appears to have achieved a higher weight loss.

Identifying factors that influence weight loss after bariatric surgery is one way to predict a successful surgical outcome. Knowledge of the effect of gender on weight loss after bariatric surgery has not been well demonstrated in the literature despite being noted in every day practice. The aim of this study was to find the influence of gender on long-term weight loss after bariatric surgery.A retrospective analysis of data retrieved from a prospectively maintained bariatric database was conducted.The study included 640 consecutive patients. Their mean age was 38 ± 10 years, mean preoperative body mass index was 44.9 ± 8.4 kg/m2, and mean preoperative excess weight (EW %) was 108.3 ± 38.4%. The mean of the average excess weight loss (EWL %) was 43.3 ± 42.4%. Three procedures were utilized: Roux-en-Y gastric bypass (RYGB), vertical banded gastroplasty (VBG), and gastric banding (GB). Both VBG and RYGB induced significantly more EWL % than GB (d = 22.1%, p0.001 and d = 16, p = 0.02, respectively). In patients who underwent VBG and GB, males had significantly lower preoperative EW % (Student t = -4.86, p0.001, and Student t = 4.69, p0.001, respectively), and postoperative mean of the average EWL % (Student t = -2.43, p = 0.016, and Student t = -3.33, p = 0.002, respectively) than females. In patients who underwent RYGB, there were no differences in the preoperative EW % (t = -1.03, p = 0.309) or the mean of the average EWL % (t = 0.406, p = 0.688). The simple linear regression model used to explain the variability in EWL %, accounted for by the variability in the preoperative EW %, was significant (F = 180, p0.001). Analysis of the residual errors in predicting the EWL % revealed no significant difference between males and females after VBG and after RYGB (t = 0.117, p = 0.907 and t = 1.052, p = 0.3, respectively), while it was significant after GB (t = -2.999, p = 0.003).From our experience, we suggest that GB not to be offered as a first choice for obese male patients.

Background: The aim of this study was to describe the clinical presentation and out- comes of treatment in patients who develop gastrointestinal leaks after different bariatric surgeries. Methods: Retrospective review of 632 consecutive bariatric surgical procedures performed from 1999-2009 in Alexandria University Hospital, Egypt. Results: Leakage occurred in 10 patients. Symptoms and signs included tachycardia, fever, tachyp- nea, left shoulder pain, abdominal pain, chest pain, and/or change in the nature of the drain efflu- ent. The earliest signs of presentation were tachycardia and unilateral decrease in air entry in all patients. The average time to diagnosis was 3.9 ± 2.6 days. In four patients contrast study was neg- ative (40%). Six leaks occurred after laparoscopic sleeve gastrectomy (6.3%), 2 after laparoscopic gastric bypass (3.6%), one after open gastric bypass (2.3%), and 1 after laparoscopic vertical banded gastroplasty (2.4%). The most common leak location was at the esophagogastric junction (70%). Four patients (40%) required reoperations. A percutaneous abdominal drainage was placed in five patients (50%). In 2 patients (20%), the prophylactic drain was maintained in situ till cessa- tion of leakage. Two patients (20%) died. Mean hospital length of stay was 13.9 ± 7.8 days. Conclusions: Tachycardia and unequal breath sound in the early postoperative course are worrisome signs that warrant laparoscopic exploration even if contrast studies were negative. Patients with signs of sepsis or hemodynamic instability require emergent exploration. Leaks that are more insidious may be treated successfully with percutaneous drainage or maintenance of prophylactic drains. a 2012 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. All rights reserved.

Background: The surgical management of morbid obesity is faced by several challenges. Alternative therapeutic strategies could have an important role in the perioperative risk reduction. The BioEnterics(®) intragastric balloon (BIB) (Inamed Health, Santa Barbara, CA) has been described as being effective in weight reduction and is used as a bridge before bariatric surgery. This study examined the efficacy of BIB in obese Egyptian patients and the value of the extended low caloric liquid diet program in weight loss.A retrospective review of a prospectively maintained bariatric database was conducted. Weight changes and complications data were analyzed. Indications for BIB placement were discussed.Records of 55 patients (11 males and 44 females) were retrieved. The mean initial body mass index (BMI) was 45.3±11 kg/m(2). The mean of excess body weight percentage was 111.96±53.2%. Nausea was reported in 30 patients (54.5%). Epigastric discomfort was reported in 23 patients (41.8 %), and vomiting was reported in 27 patients (49.1%). Six patients (10.9%) had an early removal of the balloon, whereas 4 (7.2%) had delayed removal (more than 6 months). The mean excess weight loss percentage (EWL%) was 17.2%. There was significant reduction in patients' BMI from 45.3 to 38.3 kg/m(2) (P.001). There was no significant correlation between the EWL% and the gender, age, or initial BMI. Two patients had second balloon insertions without complications. There was no significant difference in the EWL% between the 1-week liquid diet group and the extended (4-week) low caloric diet group.The BIB is effective and safe in weight reduction in obese Egyptian patients. The impact of extended liquid dieting period is not significant.

Background: Varicocele is an abnormal dilation of the pampiniform plexus that constitutes the primary drainage of the testis. It is found approximately in 15% of male adolescents with a left sided predominance. Laparoscopic varicocelectomy has been proposed as an alternative surgical procedure for the repair of varicocele with reported benefits of better convalescence, minimal invasiveness and less analgesic requirement postoperatively Patients and methods: The study was done in ElFayoum UniversityHospitalfromNovember 2011 till November 2012 and it included twenty cases with varicocele. The patients were divided into two groups: The first group (10 patients) was subjected to laparoscopic staple interruption for treatment of varicocele with cutting the gonadal vein or veins in between the clips, the second group (10 patients) was subjected to laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips. Results: All the procedures in the two groups were completed satisfactorily, with no intraoperative complications. No significant difference was found in the operative time between the two groups (25.5±3.12minutes and 26.2±4.23 minutes for group I and II respectively) (p=0.889). Most patients in the two groups had moderate pain, with no significant difference between the two groups (p=0.801). The hospital stay was not significantly different among the patients of the two study groups (1.7±0.82 days in group I and 1.5±0.68 days in group II) (p=0.870). There were no post operative complications, only one patient in the 2nd group experienced recurrence symptoms of varicocele. Conclusion: In conclusion, laparoscopic staple interruption for treatment of varicocele without cutting inbetween the clips is more superior to traditional laparoscopic staple interruption with cutting the gonadal vein or veins inbetween the clips for treatment of varicocele regarding the lower risk to cut the vas deference or spermatic artery. The spermatic count was the same as well as the spermatic motility and abnormal forms.

Background Hyperbaric oxygen (HBO) is used as part of treatment in a variety of clinical conditions. Its use in the treatment of ulcerative colitis has been reported in few clinical reports. Objective We report the effect of HBO on refractory ulcerative colitis exploring one potential mechanism of action. Design A review of records of patients with refractory ulcerative colitis who received HBO was conducted. Clinical and histopathological scoring was utilised to evaluate the response to HBO therapy (HBOT). Results All patients manifested clinical improvement by the 40th cycle of HBOT. The median number of stool frequency dropped from seven motions/day (range=3–20) to 1/day (range=0.5–3), which was significant (z=−4.6, p

The aim of this study was to compare the surgical outcome of day-case laparoscopic cholecystectomy (DCLC) performed with the patient under spinal anesthesia with that performed with the patients under general anesthesia in the management of symptomatic uncomplicated gallstone disease.One hundred eighty patients were prospectively randomized to either the spinal anesthesia DCLC group (SA-DCLC group) or the general anesthesia DCLC group (GA-DCLC group). Intraoperative events related to spinal anesthesia, postoperative complications, and pain scores were recorded. The incidences of both overnight stay and readmissions were also recorded. Patient satisfaction values as to the anesthetic technique and same-day discharge were assessed by direct questionnaire at the end of the first postoperative week.In both groups, all procedures were completed laparoscopically. In the SA-DCLC group, there were 4 (4.4%) anesthetic conversions due to intolerable right shoulder pain, and those 4 patients were excluded from further analysis. In the SA-DCLC group, all patients were discharged on the same day. Overnight stay was required in 8 patients (8.9%) in the GA-DCLC group (P.001). The cause of overnight stay was nausea and vomiting in 4 patients (4.4%), inadequate pain control in 3 patients (3.3%), and unexplained hypotension in 1 patient (1.1%). Readmission was required in 1 patient (1.1%) in the GA-DCLC group. The difference in patient satisfaction scores with regard to both anesthetic technique and same-day discharge was not statistically significant between the two groups studied.DCLC performed with the patient under spinal anesthesia is feasible and safe and is associated with less postoperative pain and lower incidence of postoperative nausea and vomiting and therefore a lower incidence of overnight stay compared with that performed with the patient under general anesthesia.

Background: Pancreatico-duodenectomy is the only potentially curative treatment of pancreatic cancer and is considered one of the most technically demanding and challenging procedures. Survival after surgery of pancreatic cancer is still poor. Aim of the study: was to estimate the resectability rate of pancreatic and periampullary tumors presenting with jaundice and to assess the outcome of tumors treated by pancreatico­ duodenectomy. Patients and methods: Throughout a 5-year period from 2006 to 2011, 378 patients presented with tumors involving the head of pancreas or periampullary region. Pancreatico-duodenectomy was performed for 65 (17.2%) patients with resectable tumors. Follow up was done for 3 years. Univariate and multivariate analyses were done for factors affecting the postoperative survival. Results: Resectability was feasible in 17.2% of patients. After pancreatico-duodenectomy, complications occurred in 32.3% of patients. Pylorus preservation did not affect the rate of complications. The 1-, 2- and 3-year survival rates were 64.6%, 43.1% and 35.4% respectively. Survival more than 3 years was significantly related to tumor diameter up to 3cm,free resection margin, absence of lymph nodes involvement, well differentiation of the tumors and periampullary tumors. By multivariate regression analysis, tumor diameter not exceeding 3cm and absence of lymph nodes involvement were found to be the most predictive factors correlated to survival more than 3 years. Conclusion: The malignant pancreatic tumors have a low resectability rate. Most of pancreatic tumors present in late stages. Tumors not exceeding 3cm in diameter and absence of lymph nodes involvement were predictive of probable 3 year survival. Key words: Pancreatic carcinoma, jaundice, resectability, surgical outcome

Intragastric balloon (IGB) is one of the available options for the management of morbid obesity. The procedure is generally safe and of moderate efficacy in most of the cases. One of the reported complications of IGB is gastric perforation. The management of this complication is classically surgical. To our knowledge, conservative management for gastric perforation secondary to IGB has not been reported. A 27-year-old female patient presented with sudden abdominal pain in the left upper quadrant, 2 months after having an IGB placed. The provisional diagnosis was gastric perforation. Balloon extraction was performed and a conservative management of the gastric perforation was pursued successfully. We therefore propose that this sort of management might be adopted in carefully selected cases.

Disabling pain for many patients with irresectable pancreatic cancer is poorly managed and can remain a significant problem until death. The aim of this study was to evaluate the safety and efficacy of thoracoscopic splanchnicectomy for pain control in patients with irresectable pancreatic cancer.Thirteen patients suffering from intractable pain due to irresectable pancreatic cancer underwent 15 attempted thoracoscopic splanchnicectomy procedures. All patients were opiate dependent. Right-sided splanchnicectomy was performed for a dominantly right-sided pain, whereas a centralized, bilateral, or left-sided pain was managed by left splanchnicectomy. If pain recurred, patients were offered to have the procedure repeated on the contralateral side.Thoracoscopic splanchnicectomy procedure was a technical failure because of pleural adhesions in 1 patient. Fourteen (10 left- and 4 right-sided) thoracoscopic splanchnicectomies were successfully completed in 12 patients. Immediate pain relief was achieved in all 12 patients after unilateral thoracoscopic splanchnicectomy. Pain relief persisted until death in 8 patients and until the latest postoperative follow-up visit at 5 months in 1 patient. Two patients required a contralateral procedure for pain recurrence. A 3rd patient had a recurrent pain but refused contralateral intervention. Except for the latter, none of the patients required opioids.Thoracoscopic splanchnicectomy is a safe, simple, and effective minimally invasive procedure. It offers a substantial relief of pain in patients with unresectable pancreatic cancer.

Use of prosthetic repairs in the management of strangulated hernias has so far been very limited due to the fear of an associated higher incidence of complications, especially those related to the presence of the mesh. The aim of this study was to prospectively determine whether the use of the Lichtenstein repair in the management of strangulated groin hernias was associated with a higher rate of wound infection and/or mesh-related complications than in the elective setting.The results obtained from the use of the Lichtenstein repair in the management of 25 patients with strangulated groin hernias (group I) were compared to those of another 25 age- and sex-matched patients undergoing Lichtenstein repair for elective groin hernia repair (group II).In group I, one patient (4%) developed a scrotal hematoma. No other postoperative complications were encountered, whether related or unrelated to the presence of the mesh. No complications were encountered in group II patients. Throughout the 20-month duration of the present study, no mesh had to be removed and no recurrences were encountered in either group.The good short-term results of the present study in terms of absence of wound infection, mesh-related complications and recurrence suggest that use of the Lichtenstein repair in the management of strangulated groin hernias is safe and is not associated with a higher rate of complications compared to its use in the elective setting.

Donor safety is a major concern in live organ donation. Live donor laparoscopic liver procurement is an advanced surgical procedure that is performed in highly specialized centers. Since its first report, not much progress has been endeavored for that procedure. We planned to include all the randomized and comparative nonrandomized studies. Patients’ population: live donors who are submitted to organ procurement via laparoscopy. Out of 5,636 records retrieved from the literature, only seven nonrandomized studies were included in this review, which encompassed 418 patients, 151 patients of whom underwent laparoscopic procurement. The quality scores for the included studies ranged from 66 to 76 %. The operative time was significantly shorter in the conventional open group (SD = 0.863, 95 % CI 0.107–1.819). Blood loss in the laparoscopic group was comparable with the conventional open approach (SD = −0.307, 95 % CI −0.807 to 0.192). In subgroup analysis, laparoscopy was protective against blood loss in laparoscopic parenchymal dissection (SD = −1.168, 95 % CI −1.758 to −0.577). The hospital stay was equal in both groups. Patients in laparoscopic group consumed fewer analgesics compared with conventional open group (SD = −0.33, 95 % CI −0.63 to −0.03). Analgesics use was lower in the laparoscopic group compared with the conventional approach. The rate of Clavien complications was equal in both groups (OR 0.721, 95 % CI 0.303–1.716). No difference was found between subgroup analysis based on the harvested liver lobe. Funnel plot and statistical methods used revealed low probability of publication BIAS. Live donor laparoscopic liver procurement could be as safe as the conventional open approach. Lower blood loss and lower consumtion of analgesics might be offered in the laparoscopic approach.

Background: Truncal vagotomy and gastro-jejunostomy is an effective procedure for Gastric Outlet Obstruction. The authors' experience with the procedure is presented and an alternative technique for creating the gastro-jejunostomy is described. Methods: From January 2005 through June 2007, 18 patients with gastric outlet obstruction secondary to a cicatrizing peptic duodenal ulcer underwent laparoscopic truncal vagotomy and an ante-colic laparoscopic-assisted stapled gastro-jejunostomy. Results: All procedures were completed laparoscopically with a mean operative time of 81.2 ± 11.1 minutes. Anastomotic leak was encountered in 1 (5.5%) patient and bile vomiting in 2 patients (11%). The mean follow-up duration was 22.8 ± 9.8 months. None of the patients developed recurrent obstruction. Conclusions: The procedure is feasible, safe, and provides an effective cure for gastric outlet obstruction. The laparoscopic-assisted stapled gastro-jejunostomy reduces the operative time and may reduce the cost of...

Surgical interventions have proven to be more effective than other measures in the treatment of morbid obesity. The short-term outcomes of the various surgical interventions have been well documented in the literature, with fewer reports on long-term outcomes. The reported long-term outcome of the vertical-banded gastroplasty (VBG) is conflicting. The aim of the present study was to evaluate our long-term experience with VBG. A retrospective review of a prospectively maintained database was conducted. Records of patients who underwent VBG five or more years ago were retrieved. An analysis of the long-term weight changes and reported complications was conducted. The study included 150 patients: 43 males (29 %) and 107 females (71 %). Their mean age was 30 years old (12–53), and the mean body mass index (BMI) was 47 ± 8.4 kg/m2. Patients were followed up for an average of 8 years (5–11). More than 60 % of patients had good long-term weight loss (EWL > 50 %). A significant negative correlation was found between the excess weight loss percent (EWL%) and the pre-operative BMI (p

Laparoscopic cholecystectomy is one of the most common surgical procedures. Here we report our experience with the use of monopolar electrocautery to control the cystic artery during laparoscopic cholecystectomy.Data regarding the site, number, size, and method of control of the cystic artery during laparoscopic cholecystectomy were prospectively collected. Other data collected included the operative time, intraoperative difficulties, and postoperative complications.The study included 158 laparoscopic cholecystectomies. Two arteries were controlled in 25 patients (15.8%) and one artery in 122 patients (77.2%), while the cystic artery was not identified in 11 patients (7%). The artery was graded as small, medium, and large in 43, 72, and 32 patients, respectively. Patients with unidentified cystic artery were excluded from our data analysis. The artery was controlled using monopolar electrocautery in 114 patients (77.5%) and by metal clips in 33 patients (22.5%). The cystic artery was controlled lateral to the cystic lymph node in the majority of patients (68%). Neither bleeding nor bile duct injury was encountered throughout the study period.Electrocautery is safe and effective for control of the cystic artery during laparoscopic cholecystectomy. A future randomized study is needed to confirm the findings of the present study.

To determine the outcome of open preperitoneal mesh repair of recurrent inguinal hernia. A prospective study included 45 consecutive male patients with unilateral recurrent inguinal hernias which were repaired using a polypropylene mesh (15 × 15 cm) placed in the preperitoneal space and anchored by several sutures. All postoperative complications were minor. There were two superficial wound infections, one seroma, two hematomas, and two cases of urine retention. Follow-up was completed for all patients for a mean of 31.3 ± 10.8 months. No recurrences were found. One patient developed hydrocele of the distal hernial sac. None of the patients developed testicular atrophy, vaginal hydrocele, or chronic residual neuralgia. Open preperitoneal mesh repair for recurrent inguinal hernia has a low complication rate and is highly effective in preventing re-recurrence. It is easy to learn and should be the general surgeons’ procedure of choice for recurrent inguinal hernia repair.

Ultrasonically activated devices have been used in gallbladder dissection in the laparoscopic cholecystectomy with encouraging results. The aim of this study was to compare between the safety and efficacy of the harmonic shears and the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy.In this prospective study, 120 patients with symptomatic gallstone disease were randomly assigned to either the harmonic scalpel laparoscopic cholecystectomy group (HS group=60 patients) where closure and division of the cystic duct was achieved solely by the harmonic shears or the clip and cautery laparoscopic cholecystectomy group (CC group=60 patients).Neither minor nor major bile leaks were encountered in either group. Similarly, no bile-duct injuries were encountered in the present study. The incidence of gallbladder perforation was statistically significantly higher in the CC group, compared to the HS group (30 vs. 10%, respectively; P=0.002). The median operative time was statistically significantly shorter in the HS group than in the CC group (32 vs. 40 minutes, respectively; P=0.000). No statistically significant difference was found in the incidence of postoperative complications between both groups.The harmonic shears are as safe and effective as the commonly used clip and cautery technique in achieving safe closure and division of the cystic duct in the laparoscopic cholecystectomy. Further, it provides a superior alternative to the currently used high-frequency monopolar technology in terms of shorter operative time and lower incidence of gallbladder perforation.

Background Laparoscopic sleeve gastrectomy (LSG) is one of the common bariatric procedures for the treatment of morbid obesity. One of the most drastic complications of this procedure is leak. Objective The aim of the study was to discuss the possible technical factors that might contribute to the occurrence of postoperative leak and how to avoid it through analyzing our series. Materials and methods Analysis of the influence of technical adaptations on the outcome of LSG was performed in a nested case-control group of patients. The main modification adapted was performing invaginating sutures over the staple line. The primary outcome was the occurrence of leak. The secondary outcomes were bleeding, operative time, prolonged hospital stay, back pain, and mortality. Results The group who had invaginating sutures (group 2) had a significantly lower frequency of leak (0%) than those without invaginating sutures (7.3%; group 1) (PF = 0.016). There was no significant difference in the occurrence of postoperative bleeding or mortality between the groups (PF = 0.162 and 0.250, respectively). The frequencies of a hospital stay longer than 48 h and back pain were significantly higher in group 1 (PF = 0.004, PF There were no significant differences between groups in the preoperative BMI (Student's t = 0−0.763, P = 0.45) or the age (Student's t = −0.5, P = 0.61). The operative time was longer in group 1 (Student's t = 3.56, P Conclusion From our experience, leak after LSG could be minimized by invaginating sutures of the staple line and by adapting the ergonomic trocar positioning described herein.