Current Trends in Gastrointestinal Laparoscopic Surgery

In gastrointestinal and endoscopic surgery, the progress in devices and techniques over the last two decades has been unprecedented. However, ensuring the safety of new techniques has its challenges. The US FDA regulates diagnostics, drugs and devices-it does not regulate new procedures.

Guidelines have been given for various newer laparoscopic procedures, to ensure the safety of patients as compared to conventional options.

Laparoscopic Ventral Hernia Repair: Guidelines

Laparoscopic ventral hernia repair (LVHR) has gained popularity in recent years. The goals of ventral hernia repair are relief of patient symptoms and/or cure of the hernia with minimization of recurrence rates.

The guideline has been divided into following topics:

1. Laparoscopic vs. Open Repair
2. Preoperative Considerations
3. Operative Technique
4. Postoperative Management: Avoiding and Treating Problems

I. Laparoscopic vs. Open Repair

Laparoscopic ventral hernia repair, compared to open repair, has a lower rate of wound infections. Recurrence rates and postoperative pain are similar between the two techniques, during mid-term follow-up. The advantages offered by LVHR over open hernia repair in terms of decreased wound complication rates should be taken into consideration by surgeons and disclosed to patients during consultation and discussion of surgical options. (++++, strong recommendation)

II. Preoperative Considerations

A. Indications and Patient Selection

Surgeons should base their decision to perform LVHR on the anticipated complexity of the operation, the resources available at their institutions, and their experience and training with this operation. Prior hernia repairs, large defect sizes, and incarcerated hernias increase the difficulty and duration of the procedure and should be taken into consideration by surgeons (++, weak recommendation).

B. Special Considerations

Special situations such as loss of domain, presence of abdominal skin grafts or active enterocutaneous fistulas, the need to remove previously placed prosthetic mesh, or large abdominal wall defects may represent contraindications to laparoscopic repair. (++, weak recommendation)

C. Diagnosis

While most ventral hernias are easily diagnosed based on clinical examination, a preoperative abdominal CT scan or ultrasound may be considered for select patients with suspected ventral hernias to confirm the diagnosis or to aid the surgeon with preoperative planning. (++, weak recommendation)

D. Bowel Preparation

Mechanical bowel preparation prior to LVHR may be useful in select cases, but additional evidence on its risks/benefits is needed before a recommendation can be provided.

E. Patient Position

Patient positioning should use all appropriate precautions to prevent patient injury while enabling access to the needed abdominal wall and allow for adequate-size mesh placement and fixation. Supine position with the arms tucked will offer the most versatile position when performing LVHR. Hernias requiring lateral or posterior access should be performed with the patient in a full or partial lateral position. (++, strong recommendation)

F. Urinary Bladder Catheter

Placement of a urinary bladder catheter during LVHR should be determined based on the anticipated duration of the procedure and the location of the hernia. For LVHR near the symphysis that requires dissection and prosthetic fixation to the pubic bone, the placement of a 3-way catheter should be considered to allow drainage and easy instillation of sterile saline solution to distend the bladder, which may help in recognizing and avoiding bladder injuries. (+, weak recommendation)

G. Prophylactic Antibiotics

A single dose, first-generation cephalosporin (cefazolin) should be given preoperatively for LVHR. Vancomycin should be added in patients colonized with MRSA. Vancomycin or Clindamycin should be given to patients allergic to cephalosporins. (+++, strong recommendation)

H. Plastic Adhesive Drape

Antimicrobial-impregnated plastic adhesive drapes are often used during LVHR, but the current literature neither supports nor discourages their use, as no evidence exists that they decrease surgical-site infection or increase complications. (+, weak recommendation)

III. Operative Technique

A. Abdominal Access and Trocar Placement

• The location of initial abdominal access (primary port placement) for LVHR should not be immediately over the hernia and should be as far from the prior incision as possible. The ideal location for the port may be the left or right upper quadrant, but location should be modified according to the patient’s surgical history and anatomy. (++, strong recommendation)
• A Veress needle, open Hasson technique, and/or optical trocar entry may all safely be used for primary port placement during LVHR. The specific technique and location used should be primarily based on the surgeon’s experience and outcomes with the technique and take into consideration the patient’s surgical history and anatomy. (++, weak recommendation)
• Secondary port placement should be performed under direct vision and working ports placed as lateral from the hernia defect as possible to allow the surgeon to work in an ergonomically favorable position for adhesiolysis and placement/fixation of the prosthesis. (+ +, strong recommendation)

B. Adhesiolysis

• Adhesiolysis should be performed carefully with sharp and/or blunt dissection and sparing use of energy for hemostasis to avoid inadvertent delayed enterotomy. Clips, sutures and hemostatic agents are preferable to energy application to achieve hemostasis near the bowel.(+,strong recommendation)
• The adhesiolysis should include the entire old incision. Dependent on the hernia location, the falciform and umbilical ligaments may need to be taken down and the space of Retzius dissected to identify occult hernia defects and allow adequate exposure of the abdominal wall for placement of an appropriately sized prosthesis. (++, weak recommendation)
• The surgeon should inspect the bowel after adhesions are taken down as the adhesiolysis progresses and/or at the conclusion of the entire adhesiolysis to rule out any inadvertent enterotomies. (+, weak recommendation)

C. Measuring the Hernia Defect

Surgeons should measure and document the size of the hernia defect they are repairing. The total area encompassing all the

defects should be measured, and surgeons should be familiar with internal and external measurement techniques for all hernia locations, as well as how to avoid common measurement errors. (++, strong recommendation)

D. Closing the Hernia Defect

Closure of hernia defect should be undertaken at the surgeon’s discretion, as theoretical advantages exist but have not been proven definitively by good quality comparative studies. Further evidence is needed. (++, weak recommendation)

E. Prosthetic Choice, Overlap and Fixation

• The prosthesis used during LVHR should be designed to bridge a defect in the abdominal wall and sized with appropriate overlap for the size and location of the defect (++, strong recommendation)
• Fixation type and amount should be appropriate for the size, shape and location of the defect. Increased fixation strength is required as the defect becomes larger and the prosthetic/ defect ratio decreases. (++, strong recommendation)
• Fixation to the bony/ligamentous portions of the pelvis should be used for defects near the symphysis pubis. (+, weak recommendation)
• Fixation into the rectus muscle and lateral/posterior abdominal wall should be used with caution to avoid injury to the epigastric vessels, peripheral nerves, ureters, and retroperitoneal vascular structures. (++, strong recommendation)
• Fixation above the costal margin should be used with caution to prevnt cardiac and lungin juries (++, strong recommendation)

IV. Postoperative Management: Avoiding and Treating Problems

A. Pain Management

Persistent pain following laparoscopic ventral hernia repair should be treated with analgesics, anti-inflammatory medications, steroids, trigger point injection or nerve block. (+, weak recommendation)

B. Seroma Management

• Seroma following laparoscopic ventral hernia repair should be expected. There are no measures proven to reduce this occurrence. Most seromas spontaneously resolve. (+, weak recommendation)
• Treatment of seroma for symptoms may be necessary and if aspiration is not helpful excision of the sac surrounding the seroma may be necessary. (+, weak recommendation).

C. Postoperative Ileus

Patients developing a postoperative ileus should be initially treated non-operatively with fluid administration, bowel rest, and/or gastric decompression. (+, Weak recommendation)

D. Management of Enterotomies

1. Recognized Intraoperative Enterotomy

The laparoscopic repair of a hernia with a permanent synthetic mesh immediately following an enterotomy should be carefully considered in light of a paucity of evidence and the potential for infectious complications. A tailored approach may include open or laparoscopic techniques and should be based upon operative findings, degree of contamination, surgeon experience, and patient’s best interest. The possibility of enterotomy and management options should be discussed with the patient preoperatively. (+, weak recommendation)

2. Delayed Enterotomy

Patients with a delayed intestinal injury following laparoscopic hernia repair should be returned to the operating room for bowel repair, resection, and/or GI tract diversion. Consideration should be given to mesh removal at the time of re-operation. (+, strong recommendation)

3. Surgical-Site Infections

Laparoscopic ventral hernia repair leads to fewer surgical-site infections compared to open repair and should therefore be considered in patients with higher risk for infection. (+++, strong recommendation)

4. Cellulitis

Postoperative cellulitis following laparoscopic ventral hernia repair may be treated with a short course of antibiotics. (+, weak recommendation)

5. Mesh Infection

Infected prosthetic mesh salvage may be successful with a combination of antibiotics, percutaneous drainage, and/or wound debridement with negative pressure wound therapy placement. When this approach fails (or in septic patients), mesh excision should be undertaken. (+,weak recommendation)

Laparoscopic Peritoneal Dialysis Access Surgery: Guidelines

Patient Selection

• Contraindications for laparoscopic peritoneal dialysis (PD) catheter placement include active abdominal infection and uncorrectable mechanical defects of the abdominal wall. (+++ Evidence, Strong recommendation)
• History of prior abdominal surgery, regardless of how many, is not a contraindication to laparoscopic PD catheter insertion. It is appropriate for surgeons with experience in advanced laparoscopy to attempt lysis of adhesions and catheter placement in these patients. (++Evidence, Strong recommendation)
• Patients with abdominal wall hernias should be diagnosed and repaired before or at the same time as PD catheter insertion. A repair should be chosen that minimizes peritoneal dissection and does not place mesh intraperitoneally. (++ Evidence, Weak recommendation)
• Peritoneal dialysis may be initiated in patients with intraabdominal foreign bodies such as after open abdominal aortic aneurysm graft repair, but a four month waiting period is recommended. Very limited data exists regarding peritoneal dialysis in the presence of an adjustable gastric band. (++ Evidence, Weak recommendation)
• Peritoneal dialysis may be safely initiated in patients with ve nt r i c u l o p e r i to n e a l s h u nt s . ( + + Ev i d e n c e , We a k recommendation)
• Gastrostomy tubes can be used in pediatric patients on peritoneal dialysis, though placement by blind percutaneous endoscopic technique (PEG) appears to be associated with higher infection rates compared to open insertion. (++ Evidence, Weak recommendation)
• Laparoscopic PD catheter insertion with carbon dioxide pneumoperitoneum requires general anesthesia. Patients who are at high risk to undergo general anesthesia should be considered for a technique of catheter insertion that only requires local anesthesia and sedation, such as open insertion or fluoroscopically guided percutaneous insertion. Laparoscopic insertion using nitrous oxide pneumoperitoneum and local anesthesia is also an option where available. (++ Evidence, Weak recommendation)

Insertion Options

For peritoneal access, blind percutaneous, open surgical, peritoneoscopic, fluoroscopically guided percutaneous, and laparoscopic insertion procedures, when performed by experienced operators, are feasible and safe with acceptable outcomes. (++++, Strong recommendation)

Advanced Laparoscopic Techniques to avoid Catheter Dysfunction

• Laparoscopic lysis of adhesions should be incorporated to reduce catheter dysfunction.(+++ Evidence, Strong recommendation)
• Laparoscopic suture fixation of the PD catheter may reduce catheter dysfunction but additional evidence is needed. (++ Evidence, Weak recommendation)
• Rectus sheath tunneling helps prevent migration and may be superior to suture fixation since it does not require added ports and instruments. (++ Evidence, Weak recommendation)
• Omentopexy in adults is a safe adjunct to laparoscopic PD catheter insertion and should be incorporated either routinely or selectively to reduce catheter dysfunction. (+++ Evidence, Weak recommendation)
• Omentectomy should be considered in pediatric patients undergoing peritoneal dialysis catheter placement (++ Evidence, Weak recommendation)
• The combination of lysis of adhesions, rectus sheath tunneling and omentopexy in combination offers the lowest rate of postoperative PD catheter dysfunction and should be a preferred technique in adults. (+++ Evidence, Strong recommendation)

Perioperative Considerations

• Presurgical assessment should include thorough examination for hernias and the catheter exit site should be marked before surgery. (+ Evidence, Weak recommendation)
• A need for preoperative bowel preparation has not been conclusively demonstrated and further evidence is needed before a recommendation can be provided.
• Prophylactic antibiotics should be used prior to laparoscopic insertion of PD catheter. Vancomycin may be superior to first generation cephalosporins in minimizing early peritonitis after PD insertion but local resistance patterns should be also considered when choosing the preoperative antibiotic ( +++ Evidence, Strong recommendation)

Surgical Technique

• Peritoneal access during lap PD insertion should be obtained away from previous scars; surgeons should use the technique they are most comfortable and experienced with. (++ Evidence, Weak recommendation)
• The surgeon should minimize the size and number of ports used and place them in a manner that optimizes visualization of the catheter peritoneal insertion point and the pelvis. (++ Evidence, Weak recommendation)
• When inserting the PD catheter through the abdominal wall, the deep cuff should be placed inside the rectus sheath. (++ Evidence, Strong recommendation).
• The superficial PD catheter cuff should be 2 cm from the skin exit site in children and at least 2 cm in adults to prevent future cuff extrusion. (+Evidence, Weak recommendation) (++Evidence, Weak recommendation)

Postoperative Protocol

• Minimizing dressing changes and handling may be beneficial in the first two postoperative weeks. (+ Evidence, Weak recommendation)
• Adequate time should be given after surgery for healing before PD is initiated and the current standard is two weeks. A more urgent start should be considered when the benefits outweigh the risks (++ Evidence, Weak recommendation)

Outcomes by Surgical Procedure

• Blind percutaneous PD catheter insertion has acceptable malfunction and leak rates compared with open insertion in patients who have never had prior abdominal surgery. The technique may be especially useful in high-risk patients for general anesthesia as it can be performed at the bedside, under local anesthesia by trained nephrologists. However, bowel perforation and bleeding risk should be considered (+++ Evidence, Weak recommendation)
• Open surgical insertion continues to be a standard to which others are compared. It is safe (low perforation rate) and effective and can be performed under local anesthesia and sedation. It appears to have higher leak and dysfunction rates compared to image guided percutaneous and advanced l a p a r o s c o p i c i n s e r t i o n . ( + + + E v i d e n c e , W e a k recommendation)
• Peritoneoscopic insertion is a technique used worldwide, mostly by “interventional” nephrologists. It has been studied in patients who have had prior surgery, but there is at least a 1% perforation rate. It appears to be comparable to open surgical insertion in experienced hands, but has not been compared to laparoscopic and fluoroscopic guided p e r c u t a n e o u s i n s e r t i o n . ( + + E v i d e n c e , W e a k recommendation)
• In patients without prior abdominal surgery, percutaneous fluoroscopic PD catheter insertion results in similar or better complication rates and dysfunction rates compared to open or basic laparoscopic insertion, and avoids general anesthesia. (+++ Evidence, Weak recommendation)
• Basic laparoscopic insertion without using techniques to minimize catheter dysfunction results in similar dysfunction r a t e s a s o p e n i n s e r t i o n . ( + + + E v i d e n c e , S t r o n g recommendation)
• Advanced laparoscopic PD catheter insertion using lysis of adhesions, catheter fixation preferably with rectus sheath tunnel, and omentopexy performed in combination has the lowest reported rate of catheter dysfunction in adults, even in patients with prior abdominal surgery. (+++ Evidence, Strong recommendation)

Early Postoperative Complications

• Bleeding after PD catheter insertion may occur from inferior epigastric artery injury or lysis of adhesions and should be managed according to standard surgical principles. The insertion point should be at the medial border of the rectus sheath to avoid arterial injury. Coagulation parameters should be assessed and corrected pre-operatively. (+Evidence, Weak recommendation)
• Dialysate leaks after PD catheter placement may be amenable to treatment, and potentially preventable, with the use of fibrin glue, particularly in the pediatric population. (++Evidence, Weak recommendation)
• Exit site infection is managed by oral antibiotics. Chronic exit site and cuff infections may be managed by catheter salvage consisting of unroofing the track, shaving the superficial cuff a n d u s i n g a n e w e x i t s i t e . ( + + E v i d e n c e , We a k recommendation)
• Pain during PD is a rare complication that is usually amenable to medical management but occasionally requires repositioning or removal of the catheter. (++Evidence, Weak recommendation)

PD Catheter Malfunction

• Malfunctioning peritoneal dialysis catheters should be evaluated by physical examination and plain radiographs to rule out constipation. If negative, further studies such as catheterography or CT peritoneography, followed by diagnostic laparoscopy are indicated. (++ Evidence, Weak recommendation)
• Non-operative treatments of malfunctioning PD catheters which have been proven effective include flushing, thrombolytics and fluoroscopic wire manipulation. (++ Evidence, Weak recommendation)
• Patients with malfunctioning peritoneal dialysis catheters not amenable to nonoperative measures should undergo laparoscopy with catheter repositioning, adhesiolysis, omentectomy or omentopexy. Patency should be assured by stripping and flushing. Suture fixation of the catheter to the pelvis or polypropylene sling may be utilized to reduce catheter migration. Surgical techniques for catheter salvage require individualization based upon operative findings. (+++ Evidence, Strong recommendation)

Sources:

1. Earle D, Roth S, Saber A, et al. SAGES Guidelines Committee. Guidelines for Laparoscopic Ventral Hernia Repair
2. Haggerty S, Roth S, Walsh D, et al. SAGES Guidelines Committee. Guidelines for Laparoscopic Peritoneal Dialysis Access Surgery