Laparoscopic Roux-en-Y gastric bypass: Outcomes of a case-matched comparison of primary versus revisional surgery

Introduction:

Laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy are popular bariatric procedures. Certain complications may necessitate revision. Adverse outcomes are reported after revisional bariatric surgery. We compared patients undergoing revisional versus primary laparoscopic Roux-en-Y gastric bypass (LRYGB).

Materials and Methods

This was retrospective comparative 1:1 case-matched analysis of revisional LRYGB Group A versus primary LRYGB (pLRYGB/Group B). Matching was based on body mass index (BMI) and comorbidities. BMI decrease at 6 and 12 months post-surgery, comorbidity resolution, operative time, morbidity and length of hospital stay (LOS) were compared. Total decrease in BMI, i.e., change from before initial bariatric procedure to 12 months after revision for Group A was also compared.

Results:

Median BMI (inter-quartile range) for Group A decreased to 44.74 (7.09) and 41.49 (6.26) at 6 and 12 months, respectively, for Group B corresponding figures were 38.74 (6.9) and 33.79 (6.64) (P = 0.001 and P = 0.0001, respectively). Total decrease in BMI (Group A) was 9.8, whereas BMI decrease at 12 months for Group B was 15.2 (P = 0.23). Hypertension resolved in 63% (Group A), 70% (Group B) (P = 0.6). Diabetes resolution was 80% (Group A), 63% (Group B) (P = 0.8). Operative time for Groups A, B was 151 ± 17, 137 ± 11 min, respectively (P = 0.004). There was no difference in morbidity and LOS.

Conclusion:

Comorbidity resolution after revisional and pLRYGB are similar. Less weight loss is achieved after revision than after pLRYGB, but total weight loss is comparable. Revisional surgery is safe when performed by experienced surgeons in high-volume centres.

Stump appendicitis: A rare clinical entity

Stump appendicitis is one of the rare delayed complications after appendectomy with reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. We report an 18-year-old patient with Stump appendicitis, who underwent completion appendectomy laparoscopically.

Minimally Invasive Anal Fistula Treatment (MAFT)-An Appraisal of Early Results in 416 Patients

Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1-6) and 1.6 (0-3), respectively. Mean duration for return to normal activity was 3.2 days (2-11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.

[Not Available]

Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).

Iatrogenic enterotomy in laparoscopic ventral/incisional hernia repair: a single center experience of 2,346 patients over 17 years

PURPOSE

Iatrogenic enterotomy (IE) during laparoscopic ventral/incisional hernia repair (LIVHR) is reported to be associated with poorer surgical outcomes. We report our experience with diagnosis, management and complications in patients who had IE during LIVHR at our tertiary referral institute between 1994 and 2011.

METHODS

We retrospectively reviewed prospectively collected data of 2,346 patients who underwent LIVHR from 1994 to 2011. We identified 33 patients who had IE during LIVHR. All surgical procedures were performed by five consultants and fellows under supervision who followed a standardized operative protocol. Patients were followed up for 6 months to evaluate morbidity, mortality, additional surgical procedures, unplanned readmissions and hospital stay.

RESULTS

Mortality occurred in 2 patients (6 %). Complications occurred in 16 patients (48.5 %). Median hospital stay was 3 days (2-36). Unplanned readmission was required in 6 patients (18 %). In 18 patients, (55 %) additional surgical procedures were required within 6 months of LIVHR. In 5 patients, the enterotomy was recognized postoperatively. These patients had worst outcomes [mortality 40 %, additional surgical procedures were required in all patients (100 %) and median hospital stay was 12 days (range 7-36)].

CONCLUSION

Iatrogenic enterotomy is a serious complication during LIVHR. IE is associated with mortality, morbidity, additional surgical procedures, unplanned readmissions and prolonged hospital stay. In patients where IE was recognized postoperatively, the prognosis was worst.

Single port versus multiple port laparoscopic cholecystectomy-a comparative study

Single port laparoscopic cholecystectomy (SPLC) was introduced to minimize postoperative morbidity and improve cosmesis. We performed a comparative study to assess feasibility, safety and perceived benefits of SPLC. Two groups of patients (104 each) with comparable demographic characteristics were selected for SPLC and multiport laparoscopic cholecystectomy (MPLC) between May 2010 to March 2011. SPLC was performed using X cone® with 5 mm extra long telescope and 3 ports for hand instruments. MPLC was performed with traditional 4 port technique. A large window was always created during dissection to obtain the critical view of safety. Data collection was prospective. The primary end points were post-operative pain and surgical complications. Secondary end points were patient assessed cosmesis and satisfaction scores and operating time. The mean VAS scores for pain in SPLC group were higher on day 0 (SPLC 3.37 versus MPLC 2.72, p = 0.03) and equivalent to MPLC group on day 1(SPLC 1.90 versus MPLC 1.79, p = 0.06). Number of patients requiring analgesia for breakthrough pain (SPLC 21.1 % versus MPLC 26.9 %, p = 0.31) was similar. Number and nature of surgical complications was similar (SPLC 17.3 % versus MPLC 21.2 %, p =0.59). Mean patient assessed cosmesis scores (SPLC 7.96 versus MPLC 7.16, p = 0.003) and mean patient satisfaction scores (SPLC 8.66 versus MPLC 8.16, p = 0.004) were higher in SPLC group indicating better cosmesis and greater patient satisfaction. SPLC took longer to perform (61 min versus 26 min, p = 0.00). Conversion was required in 5 patients in SPLC group. SPLC appears to be feasible and safe with cosmetic benefits in selected patients. However, challenges remain to improve operative ergonomics. SPLC needs to be proven efficacious with a high safety profile to be accepted as standard laparoscopic technique.

Totally extraperitoneal repair of inguinal hernia: A case for bilateral repair

Inguinal hernia surgery has been one of the most extensively debated and continues to evolve in search for the ideal technique. Even though the method to diagnose hernia has largely remained clinical, recently other modalities have detected hernias that are not picked up on clinical examination or are incorrectly labeled. Laparoscopy, for the first time has given surgeons the unique opportunity to look at both sides of the groin and to detect and study the contra lateral groin in a patient of clinically unilateral hernia. This has given rise to some interesting findings. In the pediatric age group the value of bilateral detection and repair has been extensively debated. However, the same is not true for the adults despite the facts that there are better methods for detection, better understanding of pathogenesis of hernia and better repair techniques that can take care of bilateral repair without adding to morbidity.

That hernia is not a simple derivative of patent processus vaginalis or strain related cause is beginning to be better understood now. It may primarily be a disorder of collagen metabolism with genetic basis. Laparoscopy has also made us wiser in detection of type of hernia and examination of both groin areas. In several studies there have been a high percentage of undetected hernias or additional defects. This was never realized earlier as in open surgery there is no question of exploring the asymptomatic groin. Laparoscopy in bilateral repair is safe and does not add significantly to the operating time, cost or morbidity.

At our Department of Minimal Access Surgery, Sir Ganga Ram Hospital, New Delhi, India we have been performing Endoscopic Totally Extraperitoneal (TEP) repair for all simple and complicated inguinal hernia since 1994. We now routinely perform a bilateral repair based on our understanding that the pathogenesis of hernia is a complex process and any genetic basis of collagen disorder has to affect the patient bilaterally. The clinical examination may have unacceptably low sensitivity. Early identification and repair obviates the need for reoperation, reduces overall costs and eliminates further anaesthetic and operative risks for the patient

Totally extraperitoneal repair of inguinal hernia: Sir Ganga Ram Hospital technique

Laparoscopic approach for hernia has evolved rapidly over the past decade. We adopted the TEP repair early as we believe in preserving the sanctity of the coelomic cavity. Once well versed with the approach we have found it an efficient and cost effective method for groin hernia repair.

Endoscopic totally extraperitoneal hernia repair is a technically demanding procedure. Indepth anatomical knowledge, training and advanced technical skill is needed for the surgeon to perform this procedure. To make the procedure cost effective and prevent hernia recurrences, we have modified and innovated to simplify the procedure.

This modification which we have named the SGRH technique, innovates by creating the preperitoneal working space with the help of an indigenous glove finger balloon. A rolled mesh makes placement and fixation easier in the limited working space. The mesh is unrolled on the peritoneal surface (floor), a manouver which is technically simpler. On desufflation the mesh comes to appose the Fruchad's orifice covering all potential hernial sites. With the modified SGRH technique we have found TEP to be safe, cost effective, reproducible and without significant complications.

Complications in groin hernia surgery and the way out

Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery.

Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair.

Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.

Laparoscopic repair of ventral / incisional hernias

Despite its significant prevalence, there is little in the way of evidence-based guidelines regarding the timing and method of repair of incisional hernias. To add to the above is the formidable rate of recurrence that has been seen with conventional tissue repairs of these hernias. With introduction of different prosthetic materials and laparoscopic technique, it was hoped that an improvement in the recurrence and complication rates would be realized. The increasing application of the laparoscopic technique across the world indicates that these goals might indeed be achieved.

Laparoscopic transabdominal extraperitoneal repair of lumbar hernia

Lumbar hernias need to be repaired due to the risk of incarceration and strangulation. A laparoscopic intraperitoneal approach in the modified flank position causes the intraperitoneal viscera to be displaced medially away from the hernia. The creation of a wide peritoneal flap around the hernial defect helps in mobilization of the colon, increased length of margin is available for coverage of mesh and more importantly for secure fixation of the mesh under vision to the underlying fascia. Laparoscopic lumbar hernia repair by this technique is a tensionless repair that diffuses total intra-abdominal pressure on each square inch of implanted mesh. The technique follows current principles of hernia repair and appears to confer all benefits of a minimal access approach.

Endoscopic neck surgery

Endoscopic surgery in the neck was attempted in 1996 for performing parathyroidectomy. A similar surgical technique was used for performing thyroidectomy the following year. Most commonly reported endoscopic neck surgery studies in literature have been on thyroid and parathyroid glands. The approaches are divided into two types i.e., the total endoscopic approach using CO(2) insufflation and the video-assisted approach without CO(2) insufflation. The latter approach has been reported more often. The surgical access (port placements) may vary-the common sites are the neck, anterior chest wall, axilla, and periareolar region. The limiting factors are the size of the gland and malignancy. Few reports are available on endoscopic resection for early thyroid malignancy and cervical lymph node dissection. Endoscopic neck surgery has primarily evolved due to its cosmetic benefits and it has proved to be safe and feasible in suitable patients with thyroid and parathyroid pathologies. Application of this technique for approaching other cervical organs such as the submandibular gland and carotid artery are still in the early experimental phase.

Laparoscopic repair of suprapubic hernias: transabdominal partial extraperitoneal (TAPE) technique

BACKGROUND

Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder.

METHODS

We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper's ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh.

RESULTS

Mean diameter of the hernial defect was 5.2 cm (range=3.1-7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm2 (range=225-506 cm2). Mean operating time was 116 min (range=64-170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range=1.2-6.9 years) and a follow-up rate of 84.7%

CONCLUSION

A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper's ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.

Laparoscopic ventral/incisional hernia repair: a single centre experience of 1,242 patients over a period of 13 years

BACKGROUND AND PURPOSE

Laparoscopic technique is now well established for ventral/incisional hernia repair. However several issues such as optimal fixation technique, occult hernias, management of inadvertent enterotomies, postoperative seromas and recurrence require appraisal.

METHODS

A single centre retrospective review of 1,242 patients between January 1992 and June 2005 is described. All patients had laparoscopic ventral/incisional hernia repair (LVIHR) following a standardised protocol by five consultants and fellows in a dedicated minimal access surgery unit of a tertiary care hospital.

RESULTS

LVIHR was completed in 1,223 patients (98.5%). The average BMI was 32, mean defect size was 26.2 cm(2), mean operating time was 81 min and mean hospital stay was 1.9 days. The mean mesh to hernia ratio was 37.5. Occult hernias were observed in 203 (16.3%) patients and inadvertent enterotomies occurred in 21 (1.7%) patients. Mortality occurred in two patients, pulmonary embolism and cardiac dysrhythmia being the respective reasons. The most common sequel was early seroma formation (25%). Chronic pain occurred in 14.7% patients. Recurrence rate was 4.4%, which was associated with a higher BMI, use of staplers as fixation device, multiple defects and recurrent hernias. The mean follow up was 5.4 years; (range 2.4-10 years). The follow up rate was 78%.

CONCLUSION

LVIHR leads to low recurrence rates and low rates of wound and mesh infection. Occult hernias are diagnosed and optimally treated laparoscopically. However, chronic pain remains an unresolved issue.

Prospective randomized clinical trial comparing lightweight mesh and heavyweight polypropylene mesh in endoscopic totally extraperitoneal groin hernia repair

BACKGROUND

The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair.

METHODS

A prospective study was performed on 402 patients (191 in Ultrapro and 211 in Prolene group) with bilateral groin hernias who underwent endoscopic TEP groin hernia repair from March 2006 to June 2007. All operations were performed by five consultants following a standardized operative protocol. Chronic groin pain and hernia recurrence were evaluated as primary outcome measures. Secondary outcome measure were early postoperative pain, operative time, number of fixation devices required to fix the mesh, return to normal daily activities of work, seroma, and testicular pain.

RESULTS

At 1-year follow-up, incidence in Ultrapro versus Prolene group for chronic groin pain was 1.6% vs. 4.7% (p = 0.178) and recurrence was 1.3% vs. 0.2% (p = 0.078). In Ultrapro versus Prolene group, mean visual analogue score for postoperative pain at day 7 was 1.07 vs. 1.31 (p = 0.00), mean return to normal activities was 1.82 vs. 2.09 days (p = 0.00), and mean number of fixation devices per patient required to fix the mesh was 4.22 vs. 4.08 (p = 0.043).

CONCLUSION

Lightweight meshes appear to have advantages in terms of lesser pain and early return to normal activity. However, more patients had hernia recurrence with lightweight meshes, especially for larger hernias. We surmise that the lightweight meshes have greater tendency to get displaced from their intended position during desufflation at the conclusion of endoscopic TEP repair.

Laparoscopic management of cholecystoenteric fistulas

BACKGROUND

Cholecystoenteric fistulas are a rare complication of gallstone disease and affect 3-5% of patients with cholelithiasis. Most fistulas are diagnosed intraoperatively.

MATERIALS AND METHODS

Between January 1997 and June 2003, 12428 patients underwent laparoscopic cholecystectomy at our department. Cholecystoenteric fistula was diagnosed intraoperatively and treated in 63 patients: 45 patients (71.4%) had cholecystoduodenal fistulas, while cholecystogastric and cholecystocolic fistulas were found in 9 patients (14.3%) and 4 patients (6.3%), respectively; and 5 patients (7.9%) were found to have Mirizzi syndrome type I along with a cholecytoenteric fistula. The operation could be completed laparoscopically in 59 patients. An endostapler was used in 47 patients to transect the fistula and in 12 patients the defect in the bowel was repaired with intracorporeal sutures.

RESULTS

Major morbidity occurred in 3 patients (4.76%). One patient developed a loculated subdiaphragmatic collection which was treated by ultrasound guided aspiration and antibiotic therapy. Prolonged biliary drainage occurred in 2 patients. In addition, 7 patients (11.11%) had minor postoperative complications. The mean postoperative hospital stay was 5.2 days. All the patients are asymptomatic at a mean follow-up of 2.4 years.

CONCLUSION

Cholecystoenteric fistula is a difficult problem usually diagnosed intraoperatively. A high degree of suspicion at operation is mandatory. A stapled cholecystofistulectomy may be the procedure of choice since it avoids contamination of the peritoneal cavity. Complete laparoscopic management of cholecystoenteric fistulas is possible in well-equipped high-volume centers.

Laparoscopic sleeve gastrectomy: an Indian experience-surgical technique and early results

BACKGROUND

Obesity has been observed to be on the rise in the Indian subcontinent. We report our early experience with the laparoscopic sleeve gastrectomy (LSG) for treating morbid obesity in the Indian population along with description of the surgical technique.

METHODS

The data of 75 patients who underwent LSG for the treatment of morbid obesity at the Minimal Access, Metabolic and Bariatric Surgery Centre, Sir Ganga Ram Hospital, Delhi, from November 2006 to February 2009, were retrospectively reviewed from prospective database. The gastric sleeve is created laparoscopically using sequential firings of a linear stapling device applied alongside a 36-Fr calibrating bougie. The data collected included age, gender, initial body mass index (BMI) and excess weight, the co-morbidity status, and preoperative investigations. Perioperative parameters and follow-up details [weight, BMI, excess weight loss (%EWL), resolution of co-morbidities, and postoperative investigations] were noted.

RESULTS

All procedures were completed laparoscopically. There was no major procedure-related morbidity. Hemorrhage requiring blood transfusion was observed in four patients. One patient died at 2 weeks postoperatively due to pulmonary embolism. There was a steady rise in %EWL from 31.2% at 3 months to 52.3% at 6 months, 59.13% at 1 year, and 65% at 2 years. Type II diabetes was resolved in 81.2%, hypertension in 93.75%, and dyslipidemia in 85% at 1 year.

CONCLUSION

Although long-term results are necessary to determine the benefits of the procedure, early results indicate that LSG may be a safe and feasible option for treating the morbidly obese patients.

Laparoscopic adrenalectomy - a review of initial 24 consecutive patients

AIM

To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department.

METHODS

Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years (range 25-68 years). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The clinical and intraoperative characteristics, complications and outcomes of all patients were analyzed.

RESULTS

The mean operative time for laparoscopic adrenalectomy was 136 minutes. Intraoperative hypertension occurred in 8 patients. Intraoperative hypotension occurred in 2 patients. One patient required conversion due to dense adhesions and hemorrhage. Postoperative complications were seen in six patients - immediate postoperative hypotension (2 patients), features of steroid withdrawal (2 patients) and postoperative pyrexia (2 patients). Five patients with pheochromocytoma required antihypertensive drugs in the postoperative period. There was no mortality in our series.

CONCLUSIONS

Laparoscopic adrenalectomy is a safe operation that incorporates all the benefits of minimal access surgery and is associated with a satisfactory postoperative outcome. A careful preoperative preparation in functioning adrenal tumours aids in the faster recovery of these patients.

Laparoscopic cholecystostomy is a safe and effective alternative in critically ill patients with acute cholecystitis: two cases

Emergency cholecystectomy for acute cholecystitis in critically ill patients with organ failure and sepsis carries a high risk of morbidity and mortality. Temporizing interventions such as laparoscopic cholecystostomy can help the patient to recover from the critical illness by deferring the definitive procedure to a later, safer period. We describe our experience of laparoscopic cholecystostomy performed in two critically ill patients. In the first case, a 56-year-old man with hypertension, diabetes, and ischemic heart disease, was admitted for evaluation of malena. During the course of his stay, he developed acute calculous cholecystitis, acute renal failure, and right pleural effusion. In the second case, a 68-year-old man presented with diabetes, hypertension, diabetic nephropathy, acute chronic renal failure, and acute calculous cholecystitis. Both patients failed to improve with conservative measures and underwent laparoscopic cholecystostomy under local anesthesia and sedation in view of severe comorbidities and sepsis. Both patients recovered from sepsis. Laparoscopic cholecystectomy was performed uneventfully after six and eight weeks, respectively, and both patients were doing well at one-year follow-up.

Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction

BACKGROUND

To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction.

METHODS

Retrospective analysis of 253 patients who underwent therapeutic laparoscopy for recurrent small bowel obstruction from June 1996 to May 2005 was carried out. Patients with acute small bowel obstruction, bowel obstruction due to tumor, and obstructed inguinal hernias were excluded from analysis.

RESULTS

Laparoscopy diagnosed cause of obstruction in all except 3 (1.18%) patients. The etiology included adhesions (38%), incarcerated ventral incisional hernias (32%), Meckel diverticulum (7%), stricture (14%), volvulus (3%), intussusception (4%). One hundred sixty nine patients were managed totally laparoscopically with adhesiolysis. Therapeutic bowel intervention other than adhesiolysis was required in 84 patients, of which 33 procedures were performed totally laparoscopically and remaining 51 procedures were completed with laparoscopically guided target incision. Five patients required conversion to open celiotomy. Iatrogenic enterotomies occurred in 3 patients and small bowel perforation during manipulation occurred in 1 patient. Postoperative procedure-related complications were seen in 44 patients. There was one mortality due to postoperative arrhythmia and cardiac failure.

CONCLUSIONS

Laparoscopic diagnosis and treatment of recurrent small bowel obstruction is feasible, safe, and can be performed electively in selected cases.

Abdominal Wall Sinus: An Unusual Presentation of Spilled Gallstone

Gallbladder perforation and spillage of bile is common during laparoscopic cholecystectomy. We report a case of an abdominal wall sinus due to a spilled gallstone presenting 10 years after laparoscopic cholecystectomy.

A rare psoas hernia: endoscopic diagnosis and management

Of the various traumatic injuries associated with blunt abdominal trauma, traumatic hernias form a rare and small group. We present a case report of a hernia in the psoas muscle in a 26-year-old lady diagnosed during extraperitoneal repair for inguinal hernia. The hernia was managed laparoscopically by reduction of contents and mesh placement over the defect. This is the first such case reported in the literature till date.

Sir Ganga Ram Hospital classification of groin and ventral abdominal wall hernias

BACKGROUND

Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias. The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty.

AIM

All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair.

CLASSIFICATION

In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre -operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher.

CONCLUSION

Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair.

Mesh migration into the bladder after TEP repair: a rare case report

Mesh migration after laparoscopic inguinal hernia repair is an unusual complication. We report a case of a 45-year-old man with persistent discharging of abdominal wall sinus after total extraperitoneal inguinal hernia repair. The patient underwent exploration and excision of the sinus tract with removal of the embedded mesh. A part of the mesh had migrated into the urinary bladder. Partial cystectomy with excision of wall containing the mesh was performed.

Laparoscopic approach to pheochromocytoma: is a lower intraabdominal pressure helpful?

Laparoscopic adrenalectomy is gaining popularity because of its well-documented benefits. The aim of our study was to see if a decreased intraoperative intraabdominal pressure during laparoscopic adrenalectomy would affect the hemodynamic variables and the serum levels of catecholamines. We randomly divided 9 patients into 2 groups, maintaining either an intraabdominal pressure of 15 mm Hg (group A) or 8-10 mm Hg (group B). Norepinephrine and epinephrine blood levels were measured preoperatively, during endotracheal intubation, carboperitoneum, surgical manipulation of tumor just before the ligation of the adrenal vein, and tracheal extubation; the hemodynamic variables were recorded. The introduction of carboperitoneum resulted in an increase in heart rate and mean arterial blood pressure (MAP), although it was statistically insignificant. The norepinephrine levels showed a statistically significant increase in group A as compared with group B (P = 0.0002). Surgical manipulation of the tumor resulted in a significant increase in MAP and norepinephrine levels in group A (P = 0.007 and P = 0.0001, respectively). The epinephrine levels did not change as much because the tumor was probably predominantly norepinephrine-secreting. Norepinephrine levels continued to be high even during tracheal extubation in group A patients (P = 0.027). We conclude that a low intraabdominal pressure of 8-10 mm Hg causes less catecholamine release and fewer hemodynamic fluctuations.

Laparoscopic cholecystectomy in a patient with ankylosing spondylitis with severe spinal deformity

Laparoscopic cholecystectomy is the current gold standard for the management of cholelithiasis. As experience with laparoscopic cholecystectomy has increased, contraindications to the procedure have started decreasing. Kyphoscoliosis with fixed rigidity is considered as a relative contraindication to laparoscopic surgery. Ankylosing spondylitis is a challenge to the anaesthesiologist because it is associated with difficult intubation, restrictive ventilatory defects, and frequent cardiac involvement. The benefits of laparoscopic surgery can be extended to this group of patients with severe kyphoscoliosis due to advances in anesthesia and surgical expertise. We report a case of laparoscopic cholecystectomy performed in a patient with severe ankylosing spondylitis with fixed rigidity of the cervical spine and marked thoracolumbar kyphosis with severe restrictive lung disease. The purpose of this report is to describe the difficulties encountered in anesthesia and operative difficulties due to altered body habitus in terms of patient positioning and surgical access.

Videoendoscopically assisted combined retroperitoneal and pelvic extraperitoneal approach for aortoiliac occlusive disease

BACKGROUND

Laparoendoscopic surgery has emerged as a new method for the management of iliac and aortoiliac occlusive disease. This article describes a combined retroperitoneal and pelvic extraperitoneal approach to aorta and iliac arteries.

METHODS

A review was performed for 15 patients who underwent videoendoscopically assisted vascular bypass procedures between January 1999 and June 2003. A minimal access approach was used for access to the proximal anastomotic site (proximal common iliac or distal aorta) and creation of a tunnel for the prosthetic graft placement up to the distal anastomotic site. Altogether, 11 iliofemoral bypasses, 2 iliobifemoral bypasses and 2 aortobifemoral bypasses were performed. Patients with diffuse stenosis/long-segment occlusion and multiple lesions for whom percutaneous transluminal angioplasty with stenting proved to be unsuitable were included. The outcome parameters measured were intraoperative time, intraoperative blood loss, skin incision length, length of hospital stay, postoperative pain and analgesia requirement, and patency of graft.

RESULTS

Videoendoscopy was used to complete 14 procedures. The mean operating time was 258 +/- 49 min (range, 180-300 min) and the mean blood loss was 124 +/- 28.23 ml (range, 80-150 ml). The mean hospital stay was 6.7 +/- 4.46 days (range, 4-9 days). After a mean follow-up period of 14.4 +/- 3.55 months (range, 6-20 months), all grafts were patent.

CONCLUSION

Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.

Laparoscopic repair of diaphragmatic hernias: experience of six cases

OBJECTIVE

Laparoscopic diaphragmatic hernia repair is increasingly performed in adults for congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias. This study reviewed our experience with laparoscopic diaphragmatic hernia repair to evaluate its safety, efficacy and outcomes.

METHODS

Between January 1999 and December 2002, four male and two female patients presented to us with diaphragmatic hernias, three with traumatic and three with congenital hernias. The mean age of patients was 58.6 years (range, 42-83 years). Five patients presented with main complaints of postprandial retrosternal/chest discomfort and one patient had an acute gastric outlet obstruction. Dissection was performed laparoscopically to reduce the contents of the sac and the hernial defect was repaired using prolene sutures and a polypropylene mesh.

RESULTS

Laparoscopic repair of diaphragmatic hernias was completed successfully in all patients. The mean size of the defect was 6.8 cm (range, 3-12 cm) and the mean operative time was 100 minutes (range, 60-150 minutes). There were no major intraoperative complications. One patient required placement of a chest tube due to inadvertent opening of the pleura with the hernial sac and one patient had prolonged postoperative gastric ileus. The mean hospital stay was 2.3 days (range, 1-4 days) and the mean pain score was 4 (range, 2-6). All patients remained asymptomatic over a mean follow-up of 2.9 years.

CONCLUSION

Adult congenital and chronic traumatic diaphragmatic hernias are amenable to laparoscopic repair. Laparoscopic repair is safe and feasible and confers all the advantages of minimal access surgery.

Endoscopic totally extraperitoneal repair for occult bilateral obturator hernias and multiple groin hernias

INTRODUCTION

An obturator hernia is a rare hernia that is bilateral in about 6% of patients. Most patients present with chronic pelvic pain although a few patients may present with features of intestinal obstruction. Only about 10% of obturator hernias are diagnosed preoperatively.

METHODS

A 65-year-old female patient with chronic obstructive pulmonary disease presented with bilateral groin swellings associated with local pain and heaviness. She also suffered from recurrent episodes of abdominal distension. She was diagnosed to have bilateral direct inguinal hernias and a left femoral hernia. At endoscopy under epidural anesthesia she was found to have a direct inguinal, an indirect inguinal, and a femoral hernia on the left side and an indirect inguinal hernia on the right side. Additionally, the endoscopic totally extraperitoneal approach to inguinal hernias identified hitherto undiagnosed bilateral obturator hernias. The hernias were reduced and polypropylene mesh was placed bilaterally covering the myopectineal orifice and pelvic floor bilaterally.

RESULTS

The patient was discharged the next day and is symptom-free on followup at eight months.

CONCLUSION

Endoscopic repair of groin hernias allows the surgeon not only to diagnose and treat unsuspected groin hernias but also allows identification, dissection, and repair of coincidental occult pelvic hernias like obturator hernias at the same time.

Laparoscopic Splenectomy for Hematologic Disorders: Experience with the First Fifty Patients

BACKGROUND

Splenectomy is increasingly being performed by various minimal access surgical modalities for select hematologic disorders.

METHODS

A retrospective analysis was performed on the first 50 patients on whom laparoscopic splenectomy (LS) was attempted. The data studied included indications for surgery, patient demographics, intraoperative parameters, and patient outcomes. A total laparoscopic approach (TLS) was employed in 38 patients and a hand-assisted technique (HALS) was used in 12 patients with massive splenomegaly. Eight patients had concomitant surgical procedures: 7 patients underwent laparoscopic cholecystectomy and 1 patient received a kidney transplant. The most common indications for LS were idiopathic thrombocytopenic purpura (ITP) (50%) and hereditary spherocytosis (24%).

RESULTS

LS was successfully completed in 48 patients (96%). Thirty-four patients (68%) required perioperative blood or platelet transfusions. The mean spleen diameter was 17.1 cm (range, 11.2-28.4 cm) on imaging study and mean intact splenic weight was 1019 gm. The mean operative time was 188 minutes (range, 90-340 minutes) in the TLS group and 171 minutes (range, 120-240 minutes) in the HALS group. The mean intraoperative blood loss was 306 mL (range, 40-640 mL) in the TLS group and 163 mL (range, 100-300 mL) in the HALS group. The mean postoperative hospital stay was 3.2 days (range, 2-5 days).

CONCLUSION

TLS is safe and feasible in patients with nonpalpable spleens. A concomitant laparoscopic procedure for treating coexisting abdominal pathology may be performed without additional morbidity. The HALS technique may be preferable in patients with splenomegaly (palpable spleens), as it appears to offer intraoperative advantages for retraction, dissection, hemostasis, and organ retrieval.

Laparoscopic hepaticojejunostomy for biliary strictures: the experience of 10 patients

Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.

Abandoned endoscopic procedures

Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedure due to adverse prevailing conditions. A decision to abandon or defer an endoscopic procedure would necessarily result in less morbidity compared with conventional open surgery. A retrospective review of endoscopic procedures that were abandoned or deferred and subsequent patient outcomes were noted. Between January 1998 to May 2003, 48 procedures out of a total of 11,550 endoscopic surgical procedures had to be abandoned. Previously unsuspected intraabdominal malignancy was the cause in 32 patients. Anesthesia-related problems led to the decision in 6 patients. Coincidental tuberculosis and failure in accessing the target organ were the cause in two patients each. An ectopic gallbladder, an absent gallbladder, a pancreatic phlegmon, and a failure to achieve proper single-lung ventilation led to the decision in one patient each. In two patients, presence of dense intraabdominal adhesions that precluded further progress led the surgeon to abandon the surgery. The patients with intraabdominal malignancy were staged for their disease and treated accordingly. Nine patients without malignancy who had their operation deferred due to diverse reasons were operated on a later date, whereas 4 patients were lost to follow-up. The 9 patients who underwent operation at a later date are well on follow-up. Four patients with intraabdominal malignancy died, whereas the others are well in follow-up after being treated according to the stage of their disease. Certain adverse situation encountered intraoperatively may lead the surgeon to change the approach to surgery and abandon the procedure. He may consider operation at a suitable time later or consider a different treatment altogether. The morbidity consequent to such a decision is much less if the operative approach is an endoscopic one.

Endoscopic Management of a Retroperitoneal Hydatid Cyst

Hydatid cyst is a significant health problem in endemic regions. Although progress has been made in medical treatment and interventional radiology techniques, surgery is currently the treatment of choice. The hydatid cysts are known to occur at several unusual sites in the body. With increasing experience in laparoscopy and retroperitoneoscopy, attempts have been made to offer the advantages of minimal access procedures to hydatid disease patients. We present a case report of such a patient whose retroperitoneal hydatid cyst was removed endoscopically.

Combined procedures in laparoscopic surgery

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30-280 minutes). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1-21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.

Ectopic Gallbladder

An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.

Minimal access surgery for hydatid cyst disease: laparoscopic, thoracoscopic, and retroperitoneoscopic approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.

Extraperitoneal endoscopic groin hernia repair under epidural anesthesia

We performed a prospective study to evaluate the feasibility of performing endoscopic total extraperitoneal repair of groin hernia (TEP) under epidural anesthesia in selected patients considered to be at high risk or unfit for general anesthesia. Fifty-eight endoscopic total extraperitoneal hernia repairs were performed in 36 patients between January 1997 and December 1999 under epidural anesthesia since they were considered a high risk or unfit for general anesthesia. All patients received intramuscular diclofenac sodium for preemptive analgesia. Intraoperatively, all were sedated with intravenous midazolam and fentanyl. Endoscopic TEP repair was successful under epidural anesthesia in 33 of 36 patients. In the remaining three patients, the procedure had to be converted to Lichtenstein's repair due to shoulder discomfort experienced by the patients as a result of pneumoperitoneum, which was produced by incidental peritoneal tears during extraperitoneal dissection. Intraoperatively, one patient had bleeding from the inferior epigastric artery, which was controlled with clipping of the artery. The mean operative time was 48 minutes (range, 28-72 minutes) in the TEP group and 94 minutes (range, 84-102 minutes) in the converted group. All the patients received an epidural top-up dose at the end of surgery for postoperative analgesia. All patients were ambulatory the same day. Postoperative pain was assessed by a visual analogue scale (VAS). The mean pain score was 1.2 (+/- 0.8) on discharge in the TEP group. During follow-up, seven patients developed scrotal swelling with cord induration, which was treated conservatively with scrotal support and analgesics. In all patients, resolution was observed within 6 weeks. One patient was detected to have a recurrence 4 months after surgery. Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative in patients who are at high risk or unfit for general anesthesia.

Laparoscopic ventral hernia repair with extraperitoneal mesh: surgical technique and early results

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years [range, 34-70]) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25% of the mesh was exposed after the procedure. The median (+/-SD) duration of hospitalization postoperatively was 1 day (+/-0.56). One patient's hernia recurred 4 months after surgery, and one patient's infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.

Torsion of appendices epiploicae presenting as acute abdomen: laparoscopic diagnosis and therapy

We report a 65-year-old man presenting with acute pain in the abdomen. Diagnostic laparoscopy revealed gangrenous torsion in one of the appendices epiploicae in the ascending colon. This was excised with harmonic scalpel.

Laparoscopic reintervention for residual gallstone disease

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.

Recurrent hernia following endoscopic total extraperitoneal repair

BACKGROUND AND PURPOSE

A retrospective study was conducted to identify the reasons for recurrence following endoscopic total extraperitoneal (TEP) repair of inguinal hernias and to develop a strategy to prevent recurrence.

METHOD

Between January 1996 and December 2001, 1193 TEP hernia repairs were performed in 694 patients. Following reduction of the hernia sac and dissection of the preperitoneal space up to the psoas muscles laterally, a Prolene mesh (15 x 15 cm) was placed. The mesh was fixed medially to the Cooper ligament with two or three spiral tacks. In six patients, the hernia recurred following endoscopic TEP repair within the same period. Four of these patients elected to undergo laparoscopic transabdominal preperitoneal (TAPP) repair of the recurrent hernia.

RESULTS

Medial recurrences developed in three of the four patients because of medial displacement of the mesh. One patient was found to have a missed indirect hernia sac. All the patients who underwent laparoscopic TAPP repair had an uneventful recovery and are well at follow-up.

CONCLUSION

In addition to medial fixation of the mesh to the Cooper ligament, complete proximal dissection of the peritoneum from the spermatic cord and additional fixation of the mesh to the anterior abdominal wall, with careful avoidance of possible injury to the adjacent nerves, may prevent recurrences.

Laparoscopic excision of a lower posterior mediastinal paraspinal mass: technique and feasibility of the laparoscopic approach

Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in origin. The treatment comprises surgical extirpation. We report a case of a 40-year-old man with a 2-month history of pain epigastrium, radiating to the left scapula, and marked (10 kg) weight loss. Preoperative CT scan showed a paraspinal mass 8 cm in diameter at the level of the tenth thoracic vertebra. A CT scan-guided fine-needle aspiration cytologic analysis revealed the mass to be of neurogenic origin. Transabdominal laparoscopic excision of this lower posterior mediastinal neurogenic tumor was attempted and accomplished safely. The approach was through the left crural fibers, which were split to access the lower posterior mediastinum. Operating time was 122 minutes. Postoperatively, a left intercostal drain was inserted. The patient was discharged on the third postoperative day, after intercostal drain removal. Lower posterior mediastinal paraspinal tumors can be resected laparoscopically with careful preoperative investigation for tumor localization and a meticulous laparoscopic technique. A major advantage of transabdominal laparoscopic resection, as compared with open or thoracoscopic (VATS) excision, is that the patient recovers rapidly with minimal operative and anesthetic morbidity.

Complete laparoscopic management of choledochal cyst: report of two cases

BACKGROUND

Choledochal cyst is a rare congenital anomaly of the biliary tract. With increased familiarity with the laparoscopic anatomy of the biliary tract and advances in minimally invasive techniques, surgeons have ventured further to operate on technically difficult cases such as choledochal cyst that were until recently managed by laparotomy.

PATIENTS AND METHODS

We present our experience with two female patients aged 14 years and 26 years with choledochal cyst (type I according to the Alonzo-Lej classification) that were successfully excised with construction of a Roux-en-Y hepaticojejunostomy entirely laparoscopically.

RESULTS

Both patients had an uneventful recovery, with no major morbidity. The first patient had a bile leak, which resolved over 5 days. Both were discharged by the 5(th) postoperative day.

CONCLUSION

Laparoscopic management of choledochal cyst is feasible although technically difficult and may be performed in specialized institutes dealing with advanced laparoscopic surgery.

Laparoscopic intragastric stapled cystogastrostomy for pancreatic pseudocyst

BACKGROUND

Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts.

PATIENTS AND METHODS

We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst.

RESULTS

The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled.

CONCLUSION

Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.

Laparoscopic ventral hernia repair

PURPOSE

A retrospective study was carried out of patients who underwent laparoscopic ventral abdominal wall hernia repair (excluding groin hernias) between January 1994 and January 1999.

PATIENTS AND METHODS

Laparoscopic ventral hernia repair was performed on 202 patients for defects ranging from 1.5 cm to 12 cm in diameter. Of these, 35 patients had multiple hernial defects. After reduction of the hernial contents and adhesiolysis, a polypropylene mesh was used intraperitoneally in all patients, such that there was a margin of at least 3 cm from the edge of the defect as well as the previous scar.

RESULTS

The mean operating time decreased from 90 minutes in the initial 3 years to 50 minutes in the last 2 years. Postoperatively, the mean hospital stay was 1.8 days. Patients complained of somatic abdominal pain at the site of mesh insertion for a mean of 7 days. There were two postoperative hernia recurrences at a mean follow-up of 2.9 years. The incidence of seroma formation postoperatively was 32% in the first 3 years but declined to 18% subsequently with postoperative abdominal-wall pressure dressings. There were no postoperative sequelae related to bowel adhesions. Negligible wound sepsis (superficial wound infection in five patients), decreased morbidity, and all the other advantages of a minimally invasive surgical approach were evident in this group of patients.

CONCLUSION

These promising early results need to be confirmed by a prospective controlled trial, especially recurrence rates and incidence of postoperative adhesions.

Laparoscopic subtotal cholecystectomy: a review of 56 procedures

BACKGROUND AND PURPOSE

The essential surgical steps in laparoscopic cholecystectomy remain similar to those of open cholecystectomy. Positive identification of the biliary anatomy, safe clipping or ligature of the cystic duct and artery, and dissection of the gallbladder from the liver bed form the basis of cholecystectomy. Subtotal cholecystectomy is a definitive and safe operation under certain adverse conditions intraoperatively for dissection of the gallbladder from the liver bed. We reviewed our experience with laparoscopic cholecystectomy over a 2-year period between June 1996 and May 1998, when 1,680 operations were performed. The objective was to analyze the pathology, review surgical procedures, and trace the outcome of laparoscopic subtotal cholecystectomy.

PATIENTS AND METHODS

In 56 of 1,680 patients, laparoscopic subtotal cholecystectomy was performed, which constituted 3.33% of the laparoscopic cholecystectomies performed at our institution. Dense fibrosis and adhesions were present in 32 patients; 12 patients had Mirizzi syndrome, 6 patients had a sessile gallbladder, and 6 patients had a gangrenous gallbladder. The Endo-GIA 30 stapler was used in 40 patients, sequential clips were used in 9 patients, and a suture for stump closure was used in 5 patients. A subhepatic drain was inserted in 50 patients.

RESULTS

Two conversions to open surgery were needed because of gangrene of the gall bladder wall and one conversion as a result of continued bleeding from the cystic artery after application of the Endo-GIA 30 stapler. The mean postoperative stay in hospital was 2.5 days. One patient had a solitary bile duct calculus extracted at endoscopic retrograde cholangiopancreatography 3 months after surgery. Three patients had biliary drainage that lasted for a week, and four patients had epigastric port-site infections that resolved with antibiotics, dressings and postural drainage.

CONCLUSION

Laparoscopic subtotal cholecystectomy is safe, feasible, and effective and may help prevent conversion to open surgery in carefully selected patients with difficult cholecystectomies.

The management of Mirizzi syndrome in the laparoscopic era

Mirizzi syndrome is a rare complication of long-standing gallstone disease resulting in obstructive jaundice. Careful perioperative management is of utmost importance because of an increased risk of bile duct injury intraoperatively. Experience with Mirizzi syndrome over a period of 3 years, from January 1996 to December 1998, was reviewed. Twenty-seven patients were operated upon, which constituted 0.9% of 2840 patients who underwent laparoscopic cholecystectomy in the authors' department. There were 12 patients with Mirizzi type I syndrome and 15 patients with Mirizzi type II syndrome, according to McSherry classification. Six (22%) conversions were reported, all because of unclear anatomy and inherent limitations of the laparoscopic approach. For the remaining 21 (78%) patients, the procedure was completed laparoscopically. No bilioenteric anastomosis was required. A preoperative stent insertion in the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) enabled us to achieve primary closure of CBD in every case. There was no perioperative mortality, and patients remained well for an average 2.1-year follow-up. It is highly desirable to have a preoperative diagnosis of Mirizzi syndrome, and the laparoscopic approach is not a contraindication in specialized centers. Our current management protocol to treat Mirizzi syndrome consists of a high degree of suspicion at ERCP, with stenting preoperatively and a complete stone clearance with subtotal cholecystectomy intraoperatively.

Endoscopic neck surgery: expanding horizons

There have now been several attempts at neck exploration using minimally invasive surgery. These encouraging reports paved the way for the authors to attempt endoscopic neck surgery. Having the necessary technical expertise in minimally invasive surgery with an experience of more than 6000 laparoscopic procedures, they attempted endoscopic parathyroidectomy in three patients with hyperparathyroidism. Of these, two had a hyperfunctioning adenoma and one had parathyroid hyperplasia. The hyperfunctioning tissue was accurately localized using a 99Tc-thallium subtraction scan. It was possible to localize and dissect the parathyroid tissue in two of the three patients. One patient required an open hemithyroidectomy before the adenoma could be localized and excised. The total operative time averaged 113 min. The working space was found to be adequate provided good hemostasis was maintained. The magnification proved excellent in identifying and defining important neck structures. Sufficient mobilization of the lateral thyroid lobe for access to the tracheoesophageal groove was found to be technically very difficult. No subcutaneous emphysema was observed beyond the neck region, and none lasted beyond 24 h. Cosmesis was acceptable to both the patient and the surgeon.