Delphi consensus statement for understanding and managing the subcostal hernia: subcostal hernias collaborative report (scholar study)

INTRODUCTION

Subcostal hernias are categorized as L1 based on the European Hernia Society (EHS) classification and frequently involve M1, M2, and L2 sites. These are common after hepatopancreatic and biliary surgeries. The literature on subcostal hernias mostly comprises of retrospective reviews of small heterogenous cohorts, unsurprisingly leading to no consensus or guidelines. Given the limited literature and lack of consensus or guidelines for dealing with these hernias, we planned for a Delphi consensus to aid in decision making to repair subcostal hernias.

METHODS

We adopted a modified Delphi technique to establish consensus regarding the definition, characteristics, and surgical aspects of managing subcostal hernias (SCH). It was a four-phase Delphi study reflecting the widely accepted model, consisting of: 1. Creating a query. 2. Building an expert panel. 3. Executing the Delphi rounds. 4. Analysing, presenting, and reporting the Delphi results. More than 70% of agreement was defined as a consensus statement.

RESULTS

The 22 experts who agreed to participate in this Delphi process for Subcostal Hernias (SCH) comprised 7 UK surgeons, 6 mainland European surgeons, 4 Indians, 3 from the USA, and 2 from Southeast Asia. This Delphi study on subcostal hernias achieved consensus on the following areas-use of mesh in elective cases; the retromuscular position with strong discouragement for onlay mesh; use of macroporous medium-weight polypropylene mesh; use of the subcostal incision over midline incision if there is no previous midline incision; TAR over ACST; defect closure where MAS is used; transverse suturing over vertical suturing for closure of circular defects; and use of peritoneal flap when necessary.

CONCLUSION

This Delphi consensus defines subcostal hernias and gives insight into the consensus for incision, dissection plane, mesh placement, mesh type, and mesh fixation for these hernias.

Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus

There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.

Is Laparoscopic Roux-en-Y Gastric Bypass Still the Gold Standard Procedure for Indians? Mid- to Long-Term Outcomes from a Tertiary Care Center

PURPOSE

Laparoscopic Roux-en-Y gastric bypass (RYGB) is the oldest and most widely performed bariatric surgery worldwide. There is, however, a scarcity of mid- to long-term data of RYGB, especially from the Indian subcontinent.

MATERIALS AND METHODS

The study was a single-center, retrospective analysis from patients who underwent RYGB between January 2009 and November 2014 from a tertiary care center in India. Percent of total weight loss (%TWL) was taken as the primary outcome of the study. Secondary outcomes included type 2 diabetes mellitus (T2DM) remission, comorbidity resolution, revisional surgeries, and complications related to RYGB at 1 year, at 3 years, and during the long term, following surgery. Postoperative visits took place at 1 and 3 years, while the long-term outcome was at median 8.3 years (range 5.4-11.2 years), with a follow-up of 92.4% (488/528), 80.5% (424/527) and 69.5% (363/522), respectively.

RESULTS

Out of 528 patients studied, 56% were females. The mean body mass index (BMI) was 40.6 ± 6.9 kg/m². The %TWL in the long-term follow-up was 21.8 ± 11.3%. T2DM remission rates at 1 year, at 3 years, and during the long term were 84.5%, 70.0%, and 60.0%, respectively. Preoperative HBA1c (p = 0.002) and insulin usage (p = 0.016) had a significant predictive effect on T2DM remission. Gastroesophageal reflux disease (GERD) improved significantly (p < 0.001). Early (< 30 days) and late (> 30 days) complications were observed in 2.3% and 4.3% of the patients, respectively.

CONCLUSION

Weight loss during mid to long-term follow-up was maintained in the majority of the patients after RYGB. However, a small proportion had significant weight regain in the long term. T2DM, GERD, and other comorbidities were well improved after RYGB.

Lower oesophageal peptic stricture after laparoscopic sleeve gastrectomy: World's first case report

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery worldwide. De novo gastroesophageal reflux disease after LSG has been reported in the range of 0%–34.9%. Benign lower oesophageal peptic stricture is rare and has not been reported till date. We present the first case report of benign oesophageal peptic stricture post-sleeve gastrectomy and its management. The management modalities for peptic stricture post-LSG include proton pump inhibitors, endoscopic dilatation and surgical management. Revisional Roux-en-Y gastric bypass along with optimal usage of serial dilatation and medical treatment has been shown to be an effective treatment for the same.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis

Background

Chronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long-term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long-term follow-up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment.

Methods

This was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow-up of 1 year at a tertiary-care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency.

Results

Some 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow-up respectively.

Conclusion

Laparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

Gastroesophageal reflux-related physiologic changes after sleeve gastrectomy and Roux-en-Y gastric bypass: a prospective comparative study

BACKGROUND

The development of gastroesophageal reflux disease (GERD) after laparoscopic sleeve gastrectomy (LSG) is a major concern as it affects the quality of life of the patients and potentially exposes them to the complications of GERD. The reported incidence of GERD after LSG is up to 35%. Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the procedure of choice for patients with morbid obesity with GERD but objective evidence based on physiologic studies for the same are limited.

OBJECTIVE

The objectives of the study were to determine the physiologic changes related to gastroesophageal reflux based on symptoms index, 24-hour pH study, impedance, and manometry after LSG and LRYGB.

SETTINGS

Tertiary care teaching hospital, India.

METHODS

This registered study (CTRI/2017/06/008834) is a prospective, nonrandomized, open-label clinical trial comparing the incidence of GERD after LSG and LRYGB. In this study, non-GERD patients were evaluated for GERD based on clinical questionnaires, 24-hour pH study, and impedance manometry preoperatively and 6 months postoperatively.

RESULTS

Thirty patients underwent LSG, and 16 patients underwent LRYGB. The mean DeMeester score increased from 10.9 ± 11.8 to 40.2 ± 38.6 (P = .006) after LSG. The incidence of GERD after LSG was 66.6%. The increase in DeMeester score from 9.5 ± 4.6 to 12.2 ± 17.2 after LRYGB was not significant (P = .7). There was a significant increase in the nonacid reflux both after LSG and LRYGB.

CONCLUSION

The incidence of GERD after LSG is high, making it a contraindication for LSG. LRYGB remains the preferred procedure for patients with GERD. However, more studies are needed to understand the physiologic changes in patients with preexisting GERD.

Concomitant intraperitoneal onlay mesh repair with endoscopic component separation and sleeve gastrectomy

Bariatric surgery can be safely combined with laparoscopic intraperitoneal onlay mesh (IPOM) repair. In case of large ventral hernias, laparoendoscopic component separation can also be combined to achieve tension-free closure of the defect. Concomitant bariatric surgery and hernia repair also offer the additional benefit of reduction in recurrence of hernias as obesity, one of the risk factors, is treated in the process. We present a case of 60-year-old man with a body mass index of 45.3 kg/m2 with a large recurrent ventral hernia. We performed a lap sleeve gastrectomy with laparoendoscopic anterior component separation with IPOM. The operative steps included hernia contents reduction, conventional sleeve gastrectomy, anterior component separation on either side, intra-corporeal closure of hernia defect and placement of a composite mesh. Patient recovery was uneventful. Concomitant bariatric surgery with laparoendoscopic component separation with IPOM may be safe, but more studies are required.

Do Bariatric Surgery-Related Type 2 Diabetes Remission Predictors Add Clinical Value? A Study on Asian Indian Obese Diabetics

BACKGROUND

Bariatric surgery has emerged to be the most effective treatment strategy for the treatment of obesity and type 2 diabetes mellitus (T2DM) achieving high remission rates. Many factors have been evaluated with a potential to predict the improvement of glycemic control following bariatric procedures. This study aims to study the various predictive factors for T2DM and the ABCD score in obese diabetic patients undergoing bariatric surgery in a South Indian population.

METHODS

A total of 53 obese patients (BMI > 30 k/m²) with T2DM who underwent laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB) from March 2014 to March 2015 were selected for the study. The patients were followed up to study the effects of various predictors of T2DM remission at 1 year.

RESULTS

Out of the 53 patients, 35 (66%) underwent LSG and 18 (34%) underwent LGB. Patients (81.1%) had T2DM remission. Mean HbA1c values decreased from 8.07 ± 1.98 to 6.0 ± 0.71. Only higher pre-operative body weight (p = 0.04) and lower HbA1c level (p = 0.04) were significantly associated with T2DM remission. Higher absolute weight loss (p = 0.03) after surgery was also significantly associated with T2DM remission. ABCD score was not significantly associated with T2DM remission although patients with ABCD score higher than 7 demonstrated 100% remission rate.

CONCLUSION

Among all the factors, only higher pre-operative weight and better glycaemic control along with better post-operative weight loss were significantly associated with the remission of T2DM. Although not significantly associated with remission of T2DM, higher ABCD scores had higher likelihood of remission.

Deep vein thrombosis prophylaxis: Are we overdoing? An Asian survey on trends in bariatric surgery with a systematic review of literature

Background:

Obesity is a risk factor for deep vein thrombosis (DVT) and venous thromboembolism (VTE). VTE is the most common cause of mortality in patients undergoing bariatric surgery. There is considerable variation in practice regarding methods, dosages and duration of prophylaxis in this patient population. Most of the literature is based on Western patients and specific guidelines for Asians do not exist.

Methods:

We conducted a web-based survey amongst 11 surgeons from high-volume centres in Asia regarding their DVT prophylaxis measures in patients undergoing bariatric surgery. We collected and analysed the data.

Results:

The reported incidence of DVT and VTE ranged from 0% to 0.2%. Most surgeons (63.64%) preferred to use both mechanical and chemoprophylaxis with low-molecular-weight heparin being the most preferred form of chemoprophylaxis (81.82%). There was an equal distribution of weight-based, body mass index-based and fixed-dose regimens. Duration of chemoprophylaxis ranged from 3–5 days after surgery to 2 weeks after surgery. For high-risk patients, 60% surgeons preferred to start chemoprophylaxis at least 1 week before surgery. Routine use of inferior vena cava filters in high-risk patients was not preferred with some surgeons adopting a selective use (36.36%).

Conclusion:

The purpose of this survey was to understand the trends in DVT prophylaxis amongst different high-volume bariatric centres in Asia and to relate the same with the existing literature on the different steps in prophylaxis. There is, however, a need for consensus guidelines for DVT prophylaxis in Asian obese.

Evolution and Standardisation of Techniques in Single-Incision Laparoscopic Bariatric Surgery

Bariatric surgery has proven benefits for morbid obesity and its associated comorbidities. Laparoscopic approach is well established for bariatric surgery. Single-incision laparoscopic surgery (SILS) offers even more minimally invasive approach for the same with the added advantage of better cosmesis. We have developed and standardised the SILS approach at our institute. We share our experience and technical "tips" and modifications which we have learnt over the years. Technical details of performing sleeve gastrectomy and Roux-en-Y gastric bypass with special attention to liver retraction, techniques of dissection in difficult areas, creation of anastomoses and suturing have all been described. In our experience and in experience of others, single-incision bariatric surgery is feasible. Use of conventional laparoscopic instruments makes single-incision approach practical for day-to-day practice. Supervised training is essential to learn these techniques.

Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours

BACKGROUND

Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial.

METHODS

Patients with periampullary cancers were randomized to either laparoscopic or open pancreatoduodenectomy. The outcomes evaluated were hospital stay (primary outcome), and blood loss, radicality of surgery, duration of operation and complication rate (secondary outcomes).

RESULTS

Of 268 patients, 64 who met the eligibility criteria were randomized, 32 to each group. The median duration of postoperative hospital stay was longer for open pancreaticoduodenectomy than for laparoscopy (13 (range 6-30) versus 7 (5-52) days respectively; P = 0·001). Duration of operation was longer in the laparoscopy group. Blood loss was significantly greater in the open group (mean(s.d.) 401(46) versus 250(22) ml; P < 0·001). Number of nodes retrieved and R0 rate were similar in the two groups. There was no difference between the open and laparoscopic groups in delayed gastric emptying (7 of 32 versus 5 of 32), pancreatic fistula (6 of 32 versus 5 of 32) or postpancreatectomy haemorrhage (4 of 32 versus 3 of 32). Overall complications (defined according to the Clavien-Dindo classification) were similar (10 of 32 versus 8 of 32). There was one death in each group.

CONCLUSION

Laparoscopy offered a shorter hospital stay than open pancreatoduodenectomy in this randomized trial. Registration number: NCT02081131( http://www.clinicaltrials.gov).

Laparoscopic excision of rare case of recurrent presacral teratoma

Tumours of the presacral space are rare to present. Most of them are benign masses, very rarely malignant. Surgery is the mainstay of treatment as it establishes the diagnosis and prevents the adverse consequences associated with malignant degeneration and secondary bacterial infection. Their surgical excision is often difficult because of their anatomic location. Very few cases have been reported so far concerning a laparoscopic management of presacral tumour. We hereby present a young girl with recurrent presacral teratoma. She underwent laparoscopic successful excision of tumour with uneventful post-operative recovery. Here, we are highlighting the importance of laparoscopic approach for this scenario in terms additional advantages of minimally invasive approach such as better visualisation of the deep structures in the narrow presacral space, precise dissection in a limited space between the tumour and neighbouring structures with avoiding injury to neurovascular structure.

Laparoscopic management of symptomatic residual appendicular tip: A rare case report

Appendectomy is one of the most common emergency surgical procedures. Stump appendicitis is well-recognised entity has been described in the literature. Still, with recent advance in imaging technique, it remains as a clinical challenge for diagnosis and effective treatment. We present a case of 13-year-old boy who underwent laparoscopic appendectomy 3 months back and presented to us with acute abdomen associated with vomiting and fever. Imaging revealed the presence of a tubular residual inflamed tip of the appendix of size 4 cm laying in paracaecal position with approximately 50cc purulent collection around it. Subsequently, the patient underwent successful laparoscopic completion appendectomy with uneventful postoperative recovery. Histopathological examination confirmed that resected structure as an inflammatory residual appendix. For our knowledge, after an extensive search of English literature, no study had described about laparoscopic completion appendectomy for residual tip appendicitis. We authors hereby would like to emphasise the importance of complete removal of appendix not only stump part but also tip, especially in certain locations such as paracaecal, retrocaecal and subhepatic. Laparoscopy can be an option for the management of these patients, in selected cases, and with available expertise.

Training in Minimally Invasive Pancreatic Resections: a paradigm shift away from "See one, Do one, Teach one"

BACKGROUND

Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepato-pancreato-biliary practice, however, no standardization exists for its safe adoption. Novel strategies are presented for dissemination of safe MIPR.

METHODS

An international State-of-the-Art conference evaluating multiple aspects of MIPR was conducted by a panel of pancreas experts in Sao Paulo, Brazil on April 20, 2016. Training and education issues were discussed regarding the introduction of novel strategies for safe dissemination of MIPR.

RESULTS

The low volume of pancreatic resections per institution poses a challenge for surgeons to overcome their MIPR learning curve without deliberate training. A mastery-based simulation and biotissue curriculum can improve technical proficiency and allow for training of surgeons before the operating room. Video-based platforms allow for performance reporting and feedback necessary for coaching and surgical quality improvement. Centers of excellence with training involving a standardized approach and proctorship are important concepts that can be utilized in various formats internationally.

DISCUSSION

Surgical volume is not sufficient to ensure quality and patient safety in MIPR. Safe adoption of these complex procedures should consider innovative mastery-based training outside of the operating room, novel video based coaching techniques and prospective reporting of patient data and outcomes using standardized definitions.

Minimally invasive pancreatic resections: cost and value perspectives

BACKGROUND

The number of minimally invasive pancreatic resections (MIPR) performed for benign or malignant disease, have increased in recent years. However, there is limited information regarding cost/value implications.

METHODS

An international conference evaluating MIPR was held during the 12th Bi-Annual International Hepato-Pancreato-Biliary Association (IHPBA) World Congress in Sao Paulo, Brazil, on April 20th, 2016. This manuscript summarizes the presentations that reviewed current topics in cost and value as they pertain to MIPR.

RESULTS

Compared to the open approach, MIPR's are associated with higher operative costs but lower postoperative costs. However, measurements of patient value (defined as improvement in both quantity and quality of life) and financial value (using incremental cost-effectiveness ratio) are required to determine the true value at societal level.

CONCLUSION

Challenges remain as to how the potential benefits, both to the patient and the healthcare system as a whole, are measured. Research comparing MIPR versus other techniques for pancreatectomy will require appropriate and valid measurement tools, some of which are yet to be refined. Nonetheless, the experience to date would support the continued development of MIPR by experienced surgeons in high-volume pancreatic centers, married with appropriate review and recalibration.

Proceedings of the first international state-of-the-art conference on minimally-invasive pancreatic resection (MIPR)

The application of minimally-invasive techniques to major pancreatic resection (MIPR) has occurred steadily, but slowly, over the last two decades. Questions linger regarding its safety, efficacy, and broad applicability. On April 20th, 2016, the first International State-of-the-Art Conference on Minimally Invasive Pancreatic Resection convened in Sao Paulo, Brazil in conjunction with the International Hepato-Pancreato-Biliary Association's (IHPBA) 10th World Congress. This report describes the genesis, preparation, execution and output from this seminal event. Major themes explored include: (i) scrutiny of best-level evidence outcomes of both MIPR Distal Pancreatectomy (DP) and pancreatoduodenectomy (PD), (ii) Cost/Value/Quality of Life assessment of MIPR, (iii) topics in training, education and credentialing, and (iv) development of best approaches to analyze results of MIPR - including clinical trial design and registry development. Results of a worldwide survey of over 400 surgeons on the practice of MIPR were presented. The proceedings of this event serve as a platform for understanding the role of MIPR in pancreatic resection. Data and concepts presented at this meeting form the basis for further study, application and dissemination of MIPR.

A case report of modified laparoscopic keyhole plus repair for parastomal hernia following ileal conduit

Parastomal hernia is one of the most common but challenging complication after stoma formation. Modified Sugarbaker technique is the recommended procedure for repair parastomal hernia, however, keyhole repair technique had also been used in certain instances. In cases of parastomal hernia following ileal conduit procedure, the Sugarbaker technique is been described, although with associated theoretical risk of conduit failure. We are reporting a case of post-radical cystectomy with ileal conduit presented with symptomatic large parastomal hernia. Laparoscopic modified keyhole plus repair has been done successfully in this patient with no recurrence in 2 years of follow-up. The purpose of our case report is to describe our novel modification of the laparoscopic keyhole technique which can be a feasible and acceptable alternative surgical method in these types of patients.

Laparoscopic management of 'Y-shaped' gallbladder duplication with review of literature

Gallbladder duplication is a rare congenital malformation that occurs in about 1:4000 cases. Congenital anomalies of the gallbladder and anatomical variations of their position are associated with an increased risk of complications during laparoscopic cholecystectomy. We report a case of gallbladder duplication with symptomatic cholelithiasis, who presented with recurrent episodes of biliary colic and subsequently underwent laparoscopic cholecystectomy with intraoperative cholangiography. We also discussed in brief about the available literature support in relation to incidence of this disorder, imaging modalities used, intraoperative strategies and recommended measures for safe outcomes.

Ligation of the intersphincteric fistula tract for the treatment of fistula-in-ano: experience of a tertiary care centre in South India

AIM

Ligation of the intersphincteric fistula tract (LIFT) is a new sphincter-sparing surgical technique increasingly used to treat fistulae-in-ano yielding good results. The aim of this study was to evaluate its effectiveness in the treatment of complex fistulae-in-ano and to determine factors associated with recurrence and its subsequent management.

METHOD

A prospective observational study was performed of 167 patients with complex fistula-in-ano treated by LIFT from June 2013 to January 2014. In all patients a LIFT with partial core-out of the fistula tract was performed.

RESULTS

There were 167 patients of mean age 43.6 ± 12.8 years. Thirty-three fistulae were recurrent. 150 were trans-sphincteric, 16 were intersphincteric and one was a suprasphincteric fistula. The median postoperative stay was 2 (range: 1-14) days (mean = 2.4 days). At follow up there was no change in continence. The median healing time was 4 (range: 1-8) weeks. Two patients developed an intersphincteric abscess needing surgical drainage healing uneventfully. The mean follow up was 12.8 [median = 12 (range: 4-22)] months. The healing rate was 94.1%. Ten (5.9%) patients developed a recurrent fistula that was managed by a second LIFT procedure in seven, a sinus tract excision with curettage in two and seton placement in one. Recurrence was significantly associated with diabetes mellitus and perianal collections and showed an increased incidence with tract abscesses and multiple tracts.

CONCLUSION

LIFT has a high success rate in complex fistulae-in-ano. Recurrence is related to diabetes mellitus, perianal collections, tract abscesses and multiple tracts and a second LIFT procedure may be feasible and efficient.

Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas - case report

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us.

Long-term results of hepatic hydatid disease managed using palanivelu hydatid system: Indian experience in tertiary center

BACKGROUND

Incidence of hepatic hydatid disease is increasing due to globalization. Surgery is the gold standard treatment. Laparoscopy has gained enough evidence regarding its safety and efficacy. Complete evacuation of hydatid contents without spillage remains a challenge. We aimed to determine long-term results of hepatic hydatid disease managed laparoscopically using palanivelu hydatid system (PHS) at our institution.

METHODS

One hundred and five patients underwent laparoscopic surgical management using the PHS at our institute from May 1997 to May 2013. Clinical presentations, surgical strategy, postoperative morbidity, and long-term recurrence rate were evaluated.

RESULTS

Of the 105 patients, 76 were male and 29 female with a mean age of 32 years (range 14-71 years). The most common presentation was abdominal pain in 61 patients (58%). Sixteen patients had multiple cysts of which nine had involvement of both lobes. Seventy-seven (73.3%) cysts were uncomplicated. Nineteen (18.09%) had a cyst-biliary communication, two were ruptured cysts, and seven were recurrent cysts. All patients underwent successful laparoscopic management where conservative surgery was performed in 94 patients and radical surgery in 11 patients. Post-operative morbidity was seen in 18 (17.14 %) patients, which included deep cavity infection in two cases, post-operative bile leak in 13 cases, and duodenal injury in one case without any mortality. Mean long-term follow-up was 36 months (range 6 months-5 years) with recurrence in two cases.

CONCLUSION

Our long-term results with PHS showed good outcomes in the laparoscopic management of hepatic hydatid disease with conservative surgery as the preferred approach reserving radical surgery only in selected cases.

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

BACKGROUND

Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate.

METHODS

The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013.

RESULTS

Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%.

CONCLUSION

Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.

Combined surgical procedures using laparoendoscopic single-site surgery approach

INTRODUCTION

As our experience with laparoendoscopic single-site (LESS) surgeries increased, we considered how it might be employed if two or more surgeries were to be combined. LESS surgeries' cosmetic advantages, decreased parietal trauma and better patient satisfaction relative to standard multiport laparoscopy have been previously reported, but its special role in combined surgeries has never been stressed. In this series, we present the advantages of LESS procedure over multiport laparoscopy in combined surgical procedures. To the best of our knowledge, this has never been reported before.

METHODS

A retrospective analysis of 27 patients was performed. The patients underwent combined LESS procedures between February 2010 and January 2012 at GEM Hospital, Coimbatore, India. All patients were of ASA grade 1 or 2. Patients with previous surgery in the umbilical region were not offered single-incision surgery.

RESULTS

We successfully performed 27 combined LESS procedures over a span of 2 years. Twenty patients were women and seven were men. Mean age was 35.94 years (range, 10-66 years). Mean BMI was 27.2. There were no major intraoperative complications. Mean blood loss was 45.7 mL (range, 0.0-120.0 mL). Mean postoperative hospital stay was 3.08 days (range, 1-5 days).

CONCLUSION

When a suitable case of multiple pathologies is encountered and LESS surgery is feasible for all of them, performing LESS surgery not only has cosmetic advantages over standard laparoscopy, but it also avoids the need for additional ports to achieve adequate visualization and access. All quadrants of the abdomen remain under reach through umbilicus.

Is laparoscopic duodenojejunal bypass with sleeve an effective alternative to Roux en Y gastric bypass in morbidly obese patients: preliminary results of a randomized trial

BACKGROUND

The incidence of obesity and related metabolic disorders in India and that of stomach carcinoma is one of the highest in the world. Hence, one requires a procedure that allows postoperative surveillance of the stomach with the best outcomes in terms of weight control and resolution of co-morbidities. Here, we compare one such procedure, duodenojejunal bypass with sleeve against the standard Roux-en Y gastric bypass.

METHODS

Fifty-seven patients who were selected for a bypass procedure were randomized into two groups of laparoscopic duodenojejunal bypass with sleeve (DJB) and laparoscopic Roux en Y gastric bypass. The limb lengths were similar in both the groups, and the sleeve was done over a 36F bougie.

RESULTS

The mean body mass index and percent excess weight loss at the end of 3, 6, and 12 months between the groups were not statistically significant. The operating times were higher in the DJB group. The rate of resolution of diabetes, hypertension, and dyslipidemias were also similar with no statistical significance. There was 100% resolution of dyslipidemias in both groups. There was one patient in the DJB group who presented with internal herniation 1 month post-op and was managed surgically. There was no mortality in both the groups.

CONCLUSION

Laparoscopic duodenojejunal with sleeve gastrectomy, a procedure which combines the principles and advantages of sleeve gastrectomy and foregut hypothesis, is a safe and effective alternative to gastric bypass in weight reduction and resolution of co-morbidities especially for Asian countries. But, long-term follow-up is required.

Laparoendoscopic single-site lateral pancreaticojejunostomy

BACKGROUND

Chronic pancreatitis is mainly managed with drugs, but surgery is required in selected groups of patients. The Partington procedure is still the procedure of choice for patients with a dilated main pancreatic duct but without an inflammatory pancreatic head mass. The same equivalent can be achieved by laparoscopic approach. Laparoendoscopic single-site surgery gained tremendous attention in the past few years. Complex surgeries are being reported using this technique. We report in this paper the first laparoendoscopic single-site lateral pancreaticojejunostomy (LPJ) for chronic calcific pancreatitis with dilated pancreatic duct.

PATIENT AND METHOD

The procedure was performed on a 32-year-old female diagnosed to have chronic calcific pancreatitis. A single vertical 2.5-cm umbilical incision and one 10-mm and two 5-mm ports were made. The procedure was completed in 220 min without any intraoperative complication. There were no postoperative complications, and the patient was discharged on day 5 when she started taking routine diet.

CONCLUSION

This preliminary experience suggests that single-incision laparoscopic LPJ is feasible and safe when performed by an experienced laparoscopic surgeon. It has a cosmetic advantage over laparoscopic LPJ. However, it remains to be determined if this technique offers additional advantages of decreased analgesia, decreased hospital stay or cost effectiveness. Further studies are required to analyze these factors.

Laparoscopic duodenojejunal bypass with sleeve gastrectomy: preliminary results of a prospective series from India

BACKGROUND

Bariatric surgeries are now redefined as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. Duodenojejunal bypass (DJB) is a novel metabolic surgery based on foregut hypothesis. Reports describe DJB as a stand-alone procedure for the treatment of diabetes in nonobese subjects. For obese subjects, DJB is combined with sleeve gastrectomy. This combination of DJB and sleeve gastrectomy is proposed as an ideal alternative to Roux-en-Y gastric bypass (RYGB) with these advantages: (1) easy postoperative endoscopic surveillance, (2) preservation of the pyloric mechanism, which prevents dumping syndrome, and (3) reduced alimentary limb tension. This study aimed to analyze the short-term outcomes of laparoscopic DJB with sleeve gastrectomy for morbidly obese patients.

METHODS

At our institution, 38 patients who underwent laparoscopic DJB with sleeve gastrectomy were followed up. The inclusion criteria for the study were according to the Asian Pacific Bariatric Surgery Society guidelines. Sleeve gastrectomy was performed over a 36-Fr bougie, with the first part of the duodenum mobilized and transected. The jejunum was divided 50 cm distal to duodenojejunal flexure. A 75- to 150-cm alimentary limb was fashioned and brought in a retrocolic manner. End-to-end hand-sewn duodenojejunostomy was performed. Intestinal continuity was restored with a stapled jejunojejunostomy, and mesenteric rents were closed.

RESULTS

The study population consisted of 38 patients (15 men and 23 women) ranging in age from 31 to 48 years. During a mean follow-up period of 17 months, the excess body weight loss was 72%, with a 92% resolution of diabetes. One patient presented with internal herniation through the retrocolic window 1 month after the operation and was managed surgically without any complication. No other minor or major complications occurred, and there was no mortality.

CONCLUSION

Laparoscopic DJB with sleeve gastrectomy is safe and effective in achieving durable weight loss and excellent resolution of comorbidities. Long-term follow-up studies are needed.

Laparoscopic redo fundoplication for intrathoracic migration of wrap

Laparoscopic fundoplication is fast emerging as the treatment of choice of gastro-esophageal reflux disease. However, a complication peculiar to laparoscopic surgery for this disease is the intrathoracic migration of the wrap. This article describes a case of a male patient who developed this particular complication after laparoscopic total fundoplication. Following a trauma, wrap migration occurred. The typical history and symptomatology is described. The classical Barium swallow picture is enclosed. Laparoscopic redo fundoplication was carried out. The difficulties encountered are described. Postoperative wrap migration can be suspected clinically by the presence of a precipitating event and typical symptomatology. Confirmation is by a Barium swallow. Treatment is by redo surgery.

Minimally invasive oesophagectomy for carcinoma oesophagus--approaches and options in a high volume tertiary centre

Minimally invasive oesophagectomy is being increasingly performed for treatment of carcinoma oesophagus. In this article, we overview the different types of minimally invasive oesophagectomies we used in our experience. To present an overview of the different types of minimally invasive oesophagectomies used to treat carcinoma oesophagus and to propose a simple working algorithm for surgical management of carcinoma oesophagus, a retrospective review of patients with carcinoma oesophagus who were operated at this centre during the period 1997-2009 was made. Data regarding type of surgery, level of growth, type of carcinoma, and complications were reviewed. A total of 463 patients underwent minimally invasive oesophagectomy for carcinoma oesophagus. Of these, 121 patients (26%) were female. There were no conversions. The mean age of patients was 61.6 years (range 36 years-77 years). Most patients (n = 330; 71%) had squamous cell carcinoma while 133 patients (29%) had adenocarcinoma. Overall mortality was 0.9%. Overall morbidity was 16%. Minimally invasive approaches to oesophagectomy are safe and the type of approach has to be tailored for the histology, level and stage of growth.

Bariatric to metabolic surgery: management options and experience at a tertiary centre

Obesity proves to be a growing pandemic with severe health and economic implications. Bariatric surgeries are now recognised as metabolic surgeries given the excellent resolution of metabolic derangements accompanying obesity. This concept of metabolic surgery is now applied to non-obese population with metabolic disorders. The type II diabetes mellitus remission rates as high as 95% have been reported, least with restrictive procedures and maximum with malabsorptive procedures and such effect occurs even before substantial weight loss. This has led to increased understanding of diabetes pathophysiology and formulation of foregut and hindgut hypothesis. The aim of this study was to briefly review the management options for morbid obesity and present the results at a high volume centre. Data from 518 patients who underwent laparoscopic bariatric surgeries at this institute since 2002 were taken up for analysis retrospectively. Study population included 518 patients with 310 males and 208 females. Excess body weight loss and comorbidity resolution rates were analysed. Laparoscopic bariatric surgery is safe and effective for excess body weight loss and confers excellent resolution of associated comorbidities.

Laparoscopic totally extraperitoneal repair of inguinal hernia using two-hand approach--a gold standard alternative to open repair

As laparoscopy gained popularity, minimal invasive approach was also applied for hernia surgery. Unfortunately the initial efforts were disappointing due to high early recurrence rate. Experience led to refinement of technique, with acceptable recurrence rates. This combined with the advantages of minimal invasive surgery resulted in a gradual rise in worldwide acceptance of this technique. Our preferred approach for inguinal hernia repair is laparoscopic totally extraperitoneal (TEP); only in complicated hernias (sliding or incarcerated inguinal hernias) we use the transabdominal preperitoneal repair (TAPP) technique. Records of all patients who underwent TEP repair for inguinal hernia at our centre in last 15 years were retrospectively analysed. We have done 8659 hernias in 7023 patients by TEP approach. We have developed minor modifications for the TEP repair over the years. Out of total 8659 hernias 5262 was right sided and 3397 left sided. Of these, 5387 hernias were unilateral and the remainder were bilateral; 324 cases of recurrent hernias following open repair underwent TEP. Most of the patients were males with a mean age of 46 years. Indirect hernias were most common, followed by direct hernias. Right-sided hernias were more common than left-sided hernias. In 39 cases conversion to TAPP was needed. There were intra-operative problems in 250 patients (3.56%).Postoperative complications were seen in 192 patients (2.73%), majority of which were minor complications. There was no mortality. Recurrence rate was 0.39%. The TEP technique is comfortable and highly effective. Our port placement maintains triangular orientation that is considered vital to the ergonomics of laparoscopy. Nearly 98-99% of inguinal hernias can be treated by TEP approach with excellent results.

Evolution in techniques of laparoscopic pancreaticoduodenectomy: a decade long experience from a tertiary center

BACKGROUND

Laparoscopic pancreaticoduodenectomy is a technically demanding surgery performed only at few centers in the world. This article aims to describe the evolution of the technique and summarizes the results in our institute over the years.

METHODS

Prospective data of patients undergoing laparoscopic pancreaticoduodenectomy from March 1998 to January 2009 was retrospectively reviewed.

RESULTS

There were a total of 75 patients (22 females and 53 males) with a mean age of 62 (range, 28-76) years. Conversion rate was 0%, overall postoperative morbidity was 26.7% and mortality rate was 1. 33%. Pancreatic fistula was seen in 6.67%. The mean operating time was 357 min (range 270-650), and the mean blood loss was 74 ml (range 35-410). The average time to the first bowel movement was 3 days and mean hospital stay was 8.2 days (range 6-42). Resected margins were positive in 2.6% of cases. The mean number of retrieved lymph nodes for the malignant lesions was 14 (range 8-22).

CONCLUSION

Laparoscopic pancreaticoduodenectomy can be safely performed by highly skilled laparoscopic surgeons. This technique can achieve adequate margins and follow oncological principles. Randomized comparative trials are needed to establish the superiority of laparoscopy versus open surgery.

Laparoscopic repair of diastasis recti using the 'Venetian blinds' technique of plication with prosthetic reinforcement: a retrospective study

BACKGROUND

Diastasis is a separation of the two recti due to various reasons, and can be measured as the 'inter-recti distance' (IRD). Surgery for diastasis is controversial, while laparoscopic repair has rarely been reported. We describe our method of laparoscopic plication-the 'Venetian blinds' technique combined with mesh reinforcement for patients with diastasis of the recti.

MATERIALS AND METHODS

A total of 18 patients out of 35 that presented to us were operated. The common indications were cosmesis and discomfort while performing normal activities. Laparoscopic plication with the 'Venetian blinds' technique of the diastasis with prosthetic reinforcement was performed for all cases.

RESULTS

The mean body mass index (BMI) was 28.6 kg/m(2) (range 25-32.2) and obese patients had a larger IRD. The mean operating time was 113 min (range 72-154). Minor complications were present in five (27.77%) patients. The recurrence rate after 6-48 months follow up was 0% in this series.

DISCUSSION

Even though surgery for diastasis is controversial, we advocate repair for cosmesis and restoring function of the recti muscles. Our 'Venetian blinds' technique provides a solid repair and reduces the risk of seroma. The use of a prosthesis for the repair is mandatory to prevent recurrence. The adequacy of repair was assessed by measuring the IRD preoperatively and postoperatively with computed tomography (CT) scan. Laparoscopy provides all of the benefits of minimal access surgery.

Laparoscopic repair of parahiatal hernias with mesh: a retrospective study

BACKGROUND

Parahiatal hernias are very rare and distinct entities, the diagnosis of which is never made clinically. Laparoscopic repair has been reported in the literature. We present our experiences with the laparoscopic repair of this uncommon type of hernia.

PATIENTS AND METHODS

In our institute, we retrospectively identified a total of eight patients with parahiatal hernias from 1999 to 2007, of which four had primary and four had secondary defects. Laparoscopic crural repair was performed for all of the patients, fundoplication wherever indicated and meshplasty in the cases with large defects. Gastropexy was performed for the patient with volvulus.

RESULTS

The male:female ratio was 5:3, with a mean age of 46 years and a mean body mass index (BMI) of 29.3 kg/m2. The mean size of the defects was 18 cm2. The mean blood loss during surgery was 50 ml, the mean operative time was 103.5 min and the mean hospital stay was 4 days. One patient had the recurrence of symptoms 1 month after surgery. There were no conversions, recurrences or mortality.

DISCUSSION

Primary parahiatal hernias occur as a result of a congenital weakness and secondary defects follow hiatal surgery. The use of a mesh is advisable for large defects and defects of primary type. Secondary hernias following fundoplication do not need a redo fundoplication, but require an adequate crural repair with mesh. Laparoscopic repair of these uncommon hernias is safe, effective and provides all of the benefits of minimally invasive surgery.

Transumbilical flexible endoscopic cholecystectomy in humans: first feasibility study using a hybrid technique

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) procedures have been tested using numerous approaches, mainly in animals. In humans, only cholecystectomy has been assessed, using a combined transvaginal and transumbilical approach. We present another variant of a hybrid technique for cholecystectomy, namely the combination of a flexible transumbilical double-channel endoscope and a 3-mm rigid transcutaneous trocar placed in the left hypochondrium for liver retraction.

PATIENTS AND METHODS

The procedure was attempted in 10 well-selected young patients (M : F = 4 : 6, mean age 29.5 years). Instruments used through the two working channels of the endoscope were either a grasping forceps or snare for grasping and pulling and a hot-biopsy forceps for cold and hot preparation and dissection. Endoclips were used for cystic duct and artery closure. Postoperative analgesia consisted of one intravenous dose of analgesic, followed by oral administration for one further day. Follow-up visits were scheduled at 7 days, 30 days, 90 days, and 6 months.

RESULTS

In 4 of the 10 cases the operation had to be converted to conventional laparoscopic cholecystectomy due to difficulty in dissection (in 2 cases) or uncontrollable hemorrhage (2 cases). The mean operating time was 148 minutes. Of the 6 cases in which the procedure was finished by the new approach, cystic artery bleeding occurred in 1 and was successfully clipped. One further patient had a postoperative cystic duct leak with a bilioma, successfully treated by endoscopic retrograde cholangiopancreatography with stenting. Five of the six patients reported themselves as satisfied at 3- or 6-month follow-up.

CONCLUSIONS

So far, our endoscope-based transumbilical cholecystectomy technique has not yielded satisfactory results in humans. Further instrument and accessory improvements may increase both success rate and acceptance. Scarless surgery without the inherent risks of a transluminal approach may then become feasible.

Laparoscopic transhiatal approach for benign supra-diaphragmatic lesions of the esophagus: a replacement for thoracoscopy?

Benign esophageal lesions are rare conditions and tumors account for about 10% of all esophageal neoplasms. Epiphrenic diverticula occur in the distal esophagus (the lower 10 cm). Currently, thoracotomy/thoracoscopy is the most popular approach for these conditions. We present our experience of 13 patients (1994-2006) with benign supra-diaphragmatic esophageal lesions that we treated with a laparoscopic transhiatal approach. The lesions included in the series were lower esophageal tumors (n = 8) and epiphrenic diverticula (n = 5). Laparoscopic transhiatal stapler excisions of diverticulum and enucleation of tumors were performed for all patients. Intra-operative endoscopy was used in all the procedures. All patients had an uneventful recovery except one with posterior diverticulum, who had an anastomotic leak. He had a prolonged hospital stay and recovered eventually. There was no mortality. Benign lesions of the lower third of the esophagus can be adequately treated through the transhiatal route. This is probably superior to the traditional approaches of thoracotomy/thoracoscopy as it does away with increased morbidity while maintaining adequate access. An endoscopy is of great value in localizing the lesion and assessing the esophageal lumen size during the application of staples. A laparoscopic transhiatal excision is technically feasible for all benign supra-diaphragmatic lesions and epiphrenic diverticula and is the approach of choice.

Laparoscopic repair of suprapubic incisional hernias: suturing and intraperitoneal composite mesh onlay. A retrospective study

BACKGROUND

Suprapubic hernias are those defects located 4 cm from the pubic symphysis. Our aim is to highlight the laparoscopic repair of suprapubic incisional hernias.

PATIENTS AND METHODS

We retrospectively reviewed 17 patients with suprapubic incisional hernias from 1999 to 2007. A modified technique of laparoscopic intraperitoneal composite mesh onlay was performed for these patients.

RESULTS

There were 12 females and 5 males with a mean age of 55.9 years and a mean BMI of 30 kg/m(2). The mean hernia size was 87.5 cm(2), with an average mesh size of 234 cm(2). Mean follow-up was 9 months. Complications were seen in five patients, with an overall recurrence rate of 5.8%.

DISCUSSION

Suprapubic hernias are difficult to manage because of the complexity of dissection and their anatomic proximity to bony, vascular and nerve structures. The lower end of the mesh should be fixed to the Cooper's ligament and the pubic bone. Laparoscopic repair of these uncommon hernias is safe, effective and provides all the benefits of minimally invasive surgery.

Laparoscopic surgery for an unusual case of dysphagia: lower oesophageal leiomyoma co-existing with achalasia cardia

Benign tumours of the oesophagus are rare, with an incidence of ten percent. Leiomyomas are the most common benign tumours and are located frequently in the middle and lower third of the oesophagus. Coexisting achalasia cardia is very rare. We present a 63-year-old man with coexisting leiomyoma and achalasia presenting with dysphagia for 25 days. Endoscopy and manometry revealed achalasia cardia at the lower third. Barium swallow showed a tumour proximal to the narrowing. Laparoscopic transhiatal enucleation and cardiomyotomy with Toupet fundoplication was successfully performed. Several conditions have been described to coexist with achalasia cardia, such as cancer, paraoesophageal hernia and hiatal hernia. Based on our experience, we feel that lower oesophageal tumours are best approached by a laparoscopic transhiatal route and the presence of achalasia in this case did not change the approach as cardiomyotomy with fundoplication could also be simultaneously performed. Minimally-invasive surgery for benign oesophageal tumours reduces the morbidity of thoracotomy or laparotomy.

Laparoscopic restorative total proctocolectomy with ileal pouch anal anastomosis for familial adenomatous polyposis

BACKGROUND

Familial adenomatous polyposis is a hereditary disease characterized by the presence of thousands of colonic adenomas, which, if untreated, invariably undergo malignant transformation. Because this disease manifests at a young age, the laparoscopic approach to perform surgery would be desirable due to its cosmetic benefits. We describe our experience with this procedure and review the literature on the topic.

METHODS

This is a case series of 15 patients who underwent restorative proctocolectomy with ileo-anal pouch anastomosis for familial adenomatous polyposis between 2000 and 2007. The salient operative steps are described.

RESULTS

There were 9 males and 6 females, 32 to 52 years of age, with an average age of 44.8 years. The median body mass index was 21.5 (range, 17 to 28). Rectal cancer was already present in 4 patients at the time of diagnosis. The median operating time was 225 minutes. Mean blood loss was 60 mL, with none of the patients requiring perioperative blood transfusion. None of the surgeries required conversion to the open approach. Bowel function resumed on the second postoperative day in 12 patients and on the third postoperative day in 3 patients. The median hospital stay was 8 days. Postoperatively, there was no mortality and no serious morbidity.

CONCLUSION

Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis is a feasible surgery for familial adenomatous polyposis, and considering its cosmetic benefit, is a desirable option for this group of predominantly young patients.

Laparoscopic mesh repair of a Bochdalek diaphragmatic hernia with acute gastric volvulus in a pregnant patient

The advantages of minimally invasive therapy can be utilised in the surgical disorders of pregnant patients. To our knowledge, there has not been a previous report describing laparoscopic management of diaphragmatic hernia (with mesh) in pregnancy. A 23-year-old pregnant (second trimester) woman was admitted with vomiting, epigastric pain, oliguria and dyspnoea of one month duration. Investigations revealed posterolateral diaphragmatic hernia of Bochdalek with gastric volvulus. Successful laparoscopic mesh-plasty of the diaphragmatic hernia was performed without mortality or morbidity to both mother and child. Principles of laparoscopic surgery for diaphragmatic hernias remain the same. Pregnancy poses challenges to both surgeon and anaesthetist due to changes in the physiology. Acute diseases that threaten the life of mother and child have to be dealt with urgently. We conclude that even complex laparoscopic surgery during pregnancy is feasible.

Laparoscopic management of duodenal ulcer perforation: is it advantageous?

BACKGROUND

Surgery is the mainstay of treatment of patients with peptic duodenal perforation. With the advent of minimal access techniques, laparoscopy is being used for the treatment of this condition.

METHODS

Retrospective analysis of 120 consecutive patients (mean age 44.5 years; 111 men) with duodenal ulcer perforation who had undergone laparoscopic surgery.

RESULTS

87 patients had history of tobacco consumption, 12 were chronic NSAID users, 72 had Helicobacter pylori infection and 36 had a co-morbid condition. The mean time to surgery from onset of symptoms was 28.4 hours. The median operating time was 46 minutes. All patients underwent laparoscopic closure of the perforation with Graham's patch omentopexy; 12 patients underwent additional definitive ulcer surgery. The morbidity rate was 7.5%; no patient needed conversion to open surgery or died. The mean postoperative hospital stay was 5.8 days.

CONCLUSION

Results of laparoscopic management of perforated peptic ulcer are encouraging, with no conversion to open surgery, low morbidity and no mortality.

Laparoscopic appendectomy for appendicitis in uncommon situations: the advantages of a tailored approach

INTRODUCTION

Appendicitis in unusual locations or situations always poses a diagnostic dilemma and surgery is never straightforward. We aim to highlight the advantages of laparoscopy, including our own modifications, in some unusual presentations of appendicitis.

METHODS

We treated a total of 7,210 patients with appendicitis over 14 years from 1992 to 2006. In this study, we included patients with subhepatic appendicitis (0.08 percent), appendectomy in midgut malrotation (0.09 percent), appendicitis in situs inversus totalis (0.01 percent) and appendicitis in the lateral pouch position (0.01 percent). All patients underwent laparoscopic appendectomy.

RESULTS

Patients with subhepatic appendicitis, appendicitis in situs inversus and appendicitis in the lateral pouch position had an uneventful postoperative course. For the patients who underwent appendectomy as part of the treatment for malrotation and the patient with the perforated subhepatic appendix, hospital stay was slightly prolonged.

CONCLUSION

Most patients in our study did not have a confirmed preoperative diagnosis. Diagnostic laparoscopy through the umbilical port helped confirm the diagnosis. Port positions were then planned according to the exact position of the appendix and the technique was modified to suit each individual patient. In the surgical scenarios described here, laparoscopy is invaluable in both diagnosis and treatment.

Laparoscopic transperitoneal repair of lumbar incisional hernias: a combined suture and 'double-mesh' technique

BACKGROUND

Lumbar hernias that occur after surgery are called lumbar incisional hernias. Recently, laparoscopic repair of these hernias has been reported with excellent outcomes. This is a retrospective study of our series of patients with lumbar incisional hernias.

PATIENTS AND METHODS

We managed 11 patients with lumbar incisional hernias from 1996-2006. All the patients had undergone either nephrectomy or pyeloplasty in the past. Laparoscopic suturing of the defect and reinforcement with mesh were successfully performed for all the patients.

RESULTS

There were more males than females, the age range was 42-65 years, and mean operating time was 120 min; discharge was at 1-2 postoperative days. There was no recurrence or mortality. Three cases had seroma, out of which two required aspiration after 60 days.

DISCUSSION

Laparoscopic repair provides all the benefits of minimally invasive surgery, and the principles involved in repair of ventral hernias are applied in lumbar incisional hernias as well. Our technique involved suturing of the defect before placing a mesh over the defect. We theorize that approximating the ends of the muscles restores normal anatomy and results in functional improvement. For the larger hernias, we used two meshes to cover the defect--polypropylene and Parietex, sizes being 15 x 15 cm.

CONCLUSION

Laparoscopic repair with prosthetic reinforcement is feasible and effective in the treatment of lumbar incisional hernias. Also, suturing of the defect may provide additional benefits.

Laparoscopic surgery for perforation of Meckel's diverticulum

We report an eight-year-old boy who presented with features of peritonitis and a vague mass in the periumbilical area. Initial clinical diagnosis was an appendicular abscess. Diagnostic laparoscopy revealed an inflammatory mass with pus due to a perforated Meckel's diverticulum. Laparoscopic stapler resection of the lesion was done and the patient recovered uneventfully. Surgical resection is indicated only if the diverticulum is symptomatic or if the base is narrow. Wedge resection of the diverticulum, including anterior wall of ileum, or stapler resection can be performed. Laparoscopy is useful in both diagnosis and treatment. Laparoscopic resection of Meckel's diverticulum is feasible and ideal, especially in specialised centres.

Laparoscopic anterior resection and total mesorectal excision for rectal cancer: a prospective nonrandomized study

BACKGROUND

The purpose of this study was to present our experience of laparoscopic total mesorectal resection, including ultralow resection and coloanal anastomosis.

MATERIALS AND METHODS

Between 1993 and 2005, patients fit for general anesthesia, with resectable cancers, and with lower edge of tumor beyond 5 cm of the anal verge were subjected to laparoscopic anterior resection with sphincter preservation. Double stapling technique is used to establish bowel continuity.

RESULTS

A total of 170 patients, 88 males and 82 females, were subjected to successful laparoscopic anterior resection, which included high anterior resection (n=90), low anterior resection (n=52), ultralow anterior resection (n=20), and coloanal anastomosis (n=8). The average age of patients was 58.4 years (12-90 years). Mean operating time was 130 min and mean hospital stay was 7 days. The morbidity was 13.5% with nil mortality. With an average follow-up of 49 months (range 9 years to 3 months), 9 patients developed local recurrence and 45 patients developed distant metastasis.

CONCLUSION

In selected cases, laparoscopic anterior resection is possible for all levels of rectal tumors, allowing sphincter preservation and maintaining oncological safety.

Laparoscopic management of iatrogenic high rectovaginal fistulas (Type VI)

Most rectovaginal fistulas are acquired. Obstetrical trauma and types of surgery such as laparoscopic-assisted vaginal hysterectomy may cause high rectovaginal fistulas. The high fistulas are repaired by abdominal approach, while middle or low fistulas are best approached perineally. There are not many reports of totally-laparoscopic repair available in the literature. We present two patients who had a (Type VI) high rectovaginal fistula following laparoscopicassisted vaginal hysterectomy. Laparoscopic repair was successfully performed by suturing the defects and fixing an omental patch between the rectum and vagina. The postoperative period was uneventful. Diagnosis and exact location of the fistula is critical in the management. Laparoscopic repair of high rectovaginal fistulas is feasible in most patients. Proper identification of tissue planes and good laparoscopic suturing technique is crucial for success. The issue of rectovaginal fistulas needs to be addressed in this era of laparoscopy, with particular reference to laparoscopy-assisted vaginal hysterectomy.