Era Of Minimal Access Surgery Research Articles

Huge Adnexal Masses Managed by Single Port Laparoscopy: A case series

Aim: Adnexal mass is one of the most common surgical indications in gynecology clinics, and laparoscopy is generally accepted as a gold standard in the management of adnexal mass. Materials and Method: Single incision laparoscopic surgery (SILS) is an evolving endoscopic approach in the era of minimal access surgery. Recently, it has been reported that adnexal mass may also be managed by SILS. In this report, we present 3 symptomatic patients with a huge adnexal mass operated by a single port laparoscopic approach. Results: The mean duration of the operations 95 minutes (range 75-135 minutes). None of the patients converted to laparotomy. All patients discharged on postoperative day 1. None of the patients required readmission to the hospital. Postoperatively all patients were satisfied with their incision and cosmetic results. Conclusion: Single port laparoscopic management can be successfully completed via SILS PortTM in patients with large adnexal masses with better cosmetic outcomes.

Do we still need Crile or Hayes Martin approach for cervical lymphadenectomy? A retrospective study of 56 patients with minimal access neck dissection

The concept of neck dissection was introduced by Crile more than a century ago. Since then, multiple modifications have been adopted to ensure the preservation of vital structures. With the new era of minimal access surgery, the incorporation of laparoscopic, endoscopic, and robotic surgery is becoming the new normal. Over the years we have carried out neck dissections using minimal access incisions. Although there is no definitive answer about the average nodal yield required in selective or modified neck dissections, it has been reported that the average nodal yield of more than 18 is associated with better survival rate. In this publication we share the results of our three-year retrospective study of 56 patients who underwent minimal access neck dissection. We look at the nodal yield, assess operating duration, complications, outcome with a three-year follow up from a single unit. Our results demonstrate that minimal access neck dissection should be considered in head and neck lymphadenectomies.

Laparoscopic peritoneal dialysis catheter insertion: an oasis harnessed-experience and results at a tertiary care centre in India.

Peritoneal dialysis is a life sustaining renal replacement therapy for patients with end stage renal disease. In comparison to hemodialysis it offers better mobility and independence to patients. A number of techniques including open, laparoscopic and fluoroscopy guided, and their modifications, have been described for intraperitoneal catheter insertion. We describe our technique and results of laparoscopic peritoneal dialysis (PD) catheter insertion at a tertiary care centre in India. 48 patients were referred from the department of nephrology at our centre for laparoscopic PD catheter insertion. A two port technique was used in 37 patients and three port technique was implemented in the rest for simultaneous adhesiolysis and/or omentectomy. A straight tip catheter was tunneled through the rectus muscle in all patients. Two patients had incisional hernia from a previous abdominal surgery which was repaired concomitantly with onlay meshplasty. The operative time ranged between 20 and 35min under general anaesthesia. Three patients were subjected to urgent start dialysis of which one patient developed peridrain leak as an early complication which was managed conservatively. All other patients were commenced on peritoneal dialysis two weeks after surgery. There was no other surgical site occurrence or episodes of peritonitis reported in a 6month follow up period with the department of nephrology. In the era of minimal access surgery, the laparoscopic approach is feasible for widespread and safe use for PD catheter insertion. The benefits of PD can thus be made available to patients at civil hospitals even with a basic laparoscopy setup.

Intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers

ObjectiveIn the evolving era of minimal access surgery, low rectal cancers still pose a challenge to laparoscopic or robotic surgeons. Hence, at our institute we intended to demonstrate the oncological efficacy of intersphincteric resection and coloanal anastomosis in the treatment of distal rectal cancers, performing the abdominal part of the procedure which includes rectal mobilization, laparoscopically. MethodsFrom February 2017 to March 2021, 125 patients who had undergone intersphincteric resection and coloanal anastomosis via the perineal approach at Galaxy Care Laparoscopic Institute, Pune, were included in this study. Transabdominal mobilization of the rectum was performed laparoscopically. All patients had a diversion ileostomy and a pelvic drain. Patients were followed-up for a period of 18 months post-surgery. Data on clinical and oncological outcomes were collected and analysed. The pre-operative and post-operative Wexner incontinence scores were compared. ResultsThe mean time taken for surgery was 181.57 ± 30.00 min. The mean blood loss was 119.76 ± 42.53 mL. Most patients (103, 82.4%) had their tumour at a distance of 1–2 cm from the anal verge. A loco-regional recurrence rate of 12.8% (16/125) was noted in our study. For the post-surgery Wexner score, 74.4% of patients (93/125) had a score of 5 or less, depicting that three-quarters of the study population had satisfactory continence. Overall, 81.6% of patients were satisfied with the functional results of surgery. ConclusionIntersphincteric resection and coloanal anastomosis, with a 12.8% recurrence rate, can now be considered an oncological and technically feasible procedure with sphincter salvage and good continence.

Laparoscopic Intra Peritoneal Onlay Mesh Plus (IPOM Plus) repair of Ventral Hernias – Experience in a Tertiary Hospital

Introduction: Laparoscopic Ventral Hernia Repair (LVHR) was first described by Karl Leblanc in 1992 and has increasingly been gaining popularity in this present era of minimal access surgery. Laparoscopic Intraperitoneal Onlay Mesh (IPOM) repair with its modification intraoperative Onlay Mesh Plus (IPOM Plus) repair is now being well-accepted option for the treatment of ventral hernias. Objective: To assess the safety and efficacy of the laparoscopic IPOM plus modality in the management of ventral hernias. Methods: This is a descriptive observational study, carried out on 22 patients who underwent Laparoscopic ventral hernia repair by IPOM Plus technique between January 2017 to December 2018 at CMH Dhaka. Patients who had ventral hernia with a defect size> 2 cm but < 10 cm were included in this study. Primary subcutaneous transfascial suture closure of all ventral hernias with defect size >2 cm were done using prolene 1-0.Optimized composite mesh (ParietexTM) and Polymesh composite partially absorbable mesh were used as prosthesis anchored with four corner sutures and fixed with non absorbable tacking device. Follow up period was one year. Results: A total of 22 patients underwent Laparoscopic IPOM Plus repair of ventral hernias. Intraoperative and postoperative complications were negligible. No seroma, bulging of mesh, intestinal obstruction, mesh infection and recurrence observed in one year follow up time. But one patient developed de novo spigelian hernia on the right side outside the mesh system after one year. One patient (4.5%) developed post operative persisting pain requiring analgesic at 2 months. Conclusion:: Laparoscopic IPOM plus repair of ventral hernia is a safe, effective and well accepted modality. J Bangladesh Coll Phys Surg 2023; 41: 150-155

Study on impact of flexible endoscopy training course for surgeons in India.

Competence in flexible endoscopy is essential for all surgeons during this era of minimal access surgery. However, fewer surgeons have expertise in endoscopy due to a lack of training and interest. The Indian Association of Gastrointestinal Endo Surgeons devised a short-structured training course in the art and science of endoscopy. This study aimed to find the impact of the endoscopy training course (Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons [EFIAGES]) in improving the endoscopic skill of surgeons. Twenty-two-part electronic survey forms were sent to all 375 candidates who took the course between 2016 and 2019 for this retrospective observational study. The following outcome measures were noted, namely technical competence in endoscopy before the course, delegate feedback about the course modules, volume of endoscopies before and after the course and quality indicators such as reaching up to duodenum (D2) and caecum before and after the course. Statistical analysis of the impact of the course was done using Chi-square test. Responses from 262 out of a total of 375 candidates were received. Seventy-seven per cent of trainees were pleased with content and mode of conduct of the course. The quality indicator of gastroscopy with the ability to reach D2 in 90% of the caseload was achieved by only 28% of trainees before the EFIAGES. This increased to 72% of candidates after the course and similar results were seen with colonoscopy also. Most of the candidates noted a distinct improvement in their endoscopic navigation skills subsequent to the course. Endoscopy skill transfer was possible with a short-structured endoscopy course. The surgical fraternity should realise the importance of endoscopy skills in the current era of surgical practice.

A Novel Modification of Subcutaneous Onlay Endoscopic Repair of Midline Ventral Hernias With Diastasis Recti: An Indian Experience.

IntroductionA ventral hernia is a common problem in the population. Many patients with umbilical/epigastric hernia often present with diastasis recti (DR) too. Diastasis recti is the thinning of the linea alba with an abnormal increase in the distance between the recti without a concomitant fascial defect. The presence of diastasis recti complicates the repair of the existing umbilical/epigastric hernia. Repair of only the umbilical/epigastric hernia in the presence of DR results in incomplete repair and predisposes to recurrence. There are various options available for the repair of umbilical hernia with diastasis recti. Open hernia repairs often have unsatisfactory cosmetic outcomes and, furthermore, involve complications frequently associated with large incisions such as surgical site occurrences (SSO), pain, dermal flap necrosis, and delayed postoperative recovery, to name a few. The era of minimal access surgery leaves us with a vast array of creative solutions to the same. Laparoscopic onlay repair has been given various names in literature, e.g., minimally invasive linea alba reconstruction (MILAR), pre-aponeurotic endoscopic repair (REPA), endoscopic linea alba reconstruction (ELAR), subcutaneous onlay laparoscopic approach (SCOLA), and totally endoscopic assisted linea alba reconstruction (TESLAR), with similar principles for all the procedures. The average rate of seroma formation in these procedures varies from 5% to 40%. SCOLA has been used in our study, with an added modification of the operating port and limiting the extent of lateral dissection with the aid of spinal needles, resulting in restrained dissection and creation of smaller lipocutaneous flaps, leading to reduced incidence of seroma formation.MethodsPatients with symptomatic primary ventral hernia with concomitant diastasis recti were enrolled in the participating center from the period of May 2020 to December 2021. Thirty patients were enrolled for this prospective study. The patients underwent subcutaneous laparoscopic onlay repair of midline ventral hernia with diastasis recti, with plication of the defect and onlay placement of a polypropylene mesh.ResultsSix point sixty-six percent (6.66%) of the patients developed seroma and SSO. The incidence is congruent with the results available in current literature. None of the patients had necrosis of umbilical skin. There were no recurrences at the three months follow-up.ConclusionOur modification of SCOLA is an ergonomically favorable procedure and has comparable outcomes to other approaches, with minimal complications.

Assessment of Laparoscopic Posterior Mesh Rectopexy for Complete Rectal Prolapse: A Case Series with Review of Literature

Abstract Background Trans-abdominal rectopexy for complete rectal prolapse (CRP) reportedly yields more definitive results as compared with trans-perineal surgery. In the era of minimal access surgery, minimally invasive laparoscopic rectopexy has become a popular treatment option for patients with rectal prolapse (RP). Herein, we describe our preferred surgical procedure for the correction of RP and evaluate its results. We further aim to perform a comparative assessment between perioperative outcomes achieved with open and laparoscopic applications of this technique. Materials and methods This was a retrospective cross-sectional observational study conducted at a tertiary health care center in Maharashtra, India. We studied cases of RP who underwent laparoscopic posterior mesh rectopexy during the past 15 years (2005–2021), in our institution, operated upon by a single surgeon. Results Of the total 14 patients, 12 were managed with laparoscopic posterior mesh rectopexy. The remaining two underwent laparoscopic suture rectopexy. The mean operative time was 120 minutes. Constipation improved among 28.57%, remained the same among 21.42%, and worsened among 35.71% patients. No intra-operative blood transfusion was required. Mean length of hospital stay was 4 days. There were no recurrences over a mean follow-up period of 94 months, i.e., 7.83 years (range 7–197 months). Conclusions Laparoscopic posterior rectopexy can be safely performed in older patients to achieve early postoperative ambulation and significantly shorten the hospital stay. It may, therefore, be considered an effective treatment for CRP and urinary dysfunction. However, the incidence of de-novo constipation and worsening of pre-existing constipation is significantly high.

Randomised controlled study of laparoscopic versus open reversal of Hartmann’s procedure

Background: Laparoscopic reversal of Hartmann’s procedure has been increasingly practiced worldwide since the laparoscopic era. However, so far only a few studies have been published regarding the results of this procedure. Aim of this study was to compare laparoscopic reversal of Hartmann’s (LHR) versus open reversal of Hartmann’s (OHR) procedure regarding to operative time, postoperative pain, hospital stay, postoperative complications and cost.Methods: This study was conducted on 40 patients with Hartmann’s colostomy admitted to the general surgery department, Tanta university hospitals, during the period from February 2017 to August 2019.Results: Regarding operative time, it was with a mean value 274.75±80.65 min in the LHR group and 156.75±32.81 min in the OHR group. The difference in time to pass flatus was with a mean value 1.78±0.68 days in the LHR group and 2.49±0.78 days in the OHR group. The difference in the hospital stay was with mean value 6.1±2.47 days in the LHR group and 9.3±2.20 days in the OHR group. Regarding post-operative complications; 6 patients (30%) developed post-operative complications while in the OHR group 10 (50%).Conclusions: In this era of minimal-access surgery and with increasing attention to fast-track protocols, we believe the laparoscopic approach should be the standard technique for patients undergoing reversal of Hartmann’s procedure. However, laparoscopic reversal of Hartmann’s procedure needs a surgical learning curve.

Laparoscopic intraperitoneal onlay mesh repair (intraperitoneal onlay mesh plus) in 429 patients – Our experience

INTRODUCTION: Laparoscopic ventral hernia repair (LVHR) was first described in 1992 by Karl Leblanc and has increasingly gained popularity in this current era of minimal access surgery, hereby establishing itself as a well-accepted option for the treatment of these hernias. OBJECTIVE: To assess; if the repair of Symptomatic Ventral hernia using Laparoscopic IPOM-PLUS is an effective modality in the treatment of such hernias or not. AIM: The study reviews our experience in Laparoscopic Intraperitoneal Onlay Mesh repair (IPOM- PLUS) of symptomatic ventral hernia in a single surgical unit at Artemis Hospital, Gurgaon. METHODS: A Prospective observational study was conducted where in we analysed the electronic medical records of 429 patients who underwent Laparoscopic Ventral Hernia Repair between July 2012 to January 2020 at Artemis Hospital, Gurgaon, Haryana. A Follow up period of 24 months was undertaken . RESULTS: Four hundred and twenty nine patients underwent Laparoscopic IPOM in a span of 8 years. All patient's with a defect size of more than 2 cm were included in the study. Average BMI of the cohort was between 28.42 ± 4.8 kg/m2. Primary closure of all hernias greater than 2 cm was done (Trans-fascial sutures taken using Prolene No.1). Dual mesh was used as prosthesis and it was fixed using non absorbable tacking device. Hernia recurrence was found to occur in 2 of the 429 patient's (0.4%) where in one had chronic cough on account of COPD and the other showed excessive weight gain of 12 kg during the follow up period of 24 Months. CONCLUSION: Laparoscopic IPOM- PLUS is a safe, highly efficacious and accepted method for ventral hernia repair with a very low recurrence rate.

Laparoscopic Excision of Calcified Collagenous Nodule of Anterior Abdominal Wall

Collagenous nodule of anterior abdominal wall is a rare entity. Hyaline degeneration of the connective tissue is the predominant pathologic feature of a collagenous nodule. Very few reports of this have been reported uptil now. Collagenous nodules of pleura, of skin in patients of scleroderma are known. Collagenous nodules of retroperitoneum, uterus and liver have been reported which are rare. Mostly laparotomy with excision and histopathology give the diagnosis in such cases. However, in present era of minimal access surgery, laparoscopic approach serves both diagnostic and therapeutic advantage in such rare entity. We present a case of laparoscopic excision of collagenous nodule of anterior abdominal wall.

Laparoscopic stone surgery for renal and ureteric stones: an evaluation

Background: Laparoscopic pyelolithotomy and uretrolithotomy have taken the laparoscope out of the confines of the peritoneal cavity and into areas, which were hitherto inaccessible to the laparoscope. Our present study was an evaluation of laparoscopic pyelollithotomy and uretrlithotomy. Methods: This observational study was conducted at S.N. Medical College and associated hospital, Agra, India in the Department of Surgery to evaluate retroperitoneoscopic surgeries. A total of 38 patients were included with a diagnosis of ureteric calculus and renal calculus. Results: Average time of operation in laparoscopic pyelolilthotomy was 87.27 minutes and for ureterolithotomy was 58.12 minutes. Conversion was required in 3 cases, mainly because of peritoneal breach or bleeding and ureteric injury. There were complications in the form of persistent pain (15.7%) wound infections (10.52%), urinary leakage (2.6%) and ileus / vomiting (2.6%). Successful retroperitoneoscopic surgeries required lesser postoperative analgesics than the converted cases. The average duration of drain was 1.78 days. Conclusions: We are entering an exciting new era of minimal access surgery. Our patients will benefit from these new techniques, but we have a responsibility to apply it carefully and only after becoming competent in the performance of these procedures.

Robotic Colorectal Surgery: Technique, Advantages, Disadvantages and Its Impact in Today's Era of Minimal Access Surgery

Abstract The use of robotics in colorectal surgery is gaining momentum of late. Technical advances, such as three-dimensional imaging, a stable camera platform, excellent ergonomics, tremor elimination, ambidextrous capability, motion scaling and instruments with multiple degrees of freedom, have helped many surgeons adapt to it easily. There is a shorter learning curve compared to the standard laparoscopic surgery. This article helps to give an outline as to how robotic colorectal surgery can go a long way in the future of colorectal surgery.

Umbilicus: A Site for Stoma in Hirschsprung's Disease.

A 13-day-old male baby with the symptoms suggestive of HD and barium enema showing the transition zone (TZ) at the recto-sigmoid was admitted with progressive abdominal distention not responding to rectal washes. The baby was planned for sigmoid colostomy and seromuscular biopsy. A transverse skin incision of 2cms was made through the umbilicus under general anesthesia. The skin, subcutaneous tissue, and fascia were incised, and the umbilical vessels and urachal remnant were individually ligated apart from the opening in the fascia. At this point, a urethral sound was passed per rectally to guide the sigmoid loop towards the umbilicus. Stay sutures were taken and the loop of sigmoid colon was taken out. Biopsies were taken from the recto-sigmoid junction and site proximal to TZ. The bowel wall was fixed separately to the peritoneum and fascia with interrupted 5-0 absorbable sutures. The bowel was opened and everted with suturing to the skin (Fig. 1). Management of Hirschsprung’s disease (HD) has evolved in last one decade from staged procedure to single stage trans-anal pull through. But in developing country like ours, the presentation is generally late (most of them brought with severely dilated colon or enterocolitis) and where there is lack of facility for frozen section biopsy, staged procedures are still the standard of care. In this era of minimal access surgery, where a lot of stress is laid on cosmesis, role of umbilical incision for fashioning of colostomy and taking biopsies is a good alternative. Though trans-umbilical colostomies have been occasionally done in past for HD and anorectal malformations1,2,3, they are still not widely used.

Choosing the Route of Hysterectomy.

To compare the clinical results of three techniques of hysterectomy- abdominal hysterectomy (AH), non-descent vaginal hysterectomy (NDVH), and laparoscopic-assisted vaginal hysterectomy (LAVH). A simple prospective randomized study was performed in a tertiary care centre between June 2011 and Dec 2012, among 150 consecutive women indicated to undergo hysterectomy for benign and mobile uterine conditions. They were randomly assigned 50 each to three routes of hysterectomy; (abdominal, vaginal, and laparoscopic-assisted vaginal). Outcome measures including operating time, blood loss, rate of complications, consumption of analgesics, and length of hospital stay were assessed and compared between groups. As far as duration of operation, mean blood loss, analgesic requirement, length of hospital stay, P value was significant. Incidence of complications is least among VH group. Vaginal hysterectomy is the gold standard in the era of minimal access surgery. Some of the contraindications to VH can be overcome by assistance of laparoscope and a potential abdominal hysterectomy can be converted to a vaginal procedure.

Laparoscopic management of a large primary retroperitoneal hydatid cyst.

Hydatid cysts usually involve the liver and lungs, but any other organ can potentially be involved and these can mimic numerous pathologies; however, primary involvement of the retroperitoneum and presentation as a left-sided abdominal mass is quite unusual. A 30-year-old male presented with a large cystic lump in the left side of the abdomen that was diagnosed as a primary retroperitoneal hydatid cyst by a computed tomography scan and serology. The patient was managed successfully by minimal access surgery. This report highlights that a primary retroperitoneal hydatid cyst is a rare clinical entity and should be considered as one of the differential diagnoses in patients presenting with a cystic mass in the retroperitoneum. In the present era of minimal access surgery, it can be safely managed with a laparoscopic approach.

Is cholecystectomy really an indication for concomitant splenectomy in mild hereditary spherocytosis?

Background/aimThe British Committee for Standards in Haematology currently recommends concomitant splenectomy in children with mild hereditary spherocytosis (HS) undergoing cholecystectomy for symptomatic gallstones. However, splenectomy is associated with a risk...

Pediatric Inguinal Hernia and Hydrocele: An Evidence-Based Review in the Era of Minimal Access Surgery

Pediatric inguinal hernia and hydrocele share a common etiology as well as management. The era of minimal access surgery is challenging the conventional surgical management for pediatric inguinal hernia in particular. This review article aims to highlight the nature of diagnosis and treatment for both hernia and hydrocele and examines both the traditional and contemporary treatment strategies from an evidence-based perspective.

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring. Methods Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated. Results Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure ( P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy. Conclusions R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.

Axillopectoral muscle: An important anomaly in axillary surgery

The axillopectoral muscle (Langer's axillary arch) is a common, though rarely noted, anatomical anomaly causing a range of rare clinical syndromes. Knowledge of the anomaly is increasingly important in the era of minimal access surgery and sentinel lymph node biopsy (SLNB) where it might produce false negative biopsies. We describe a case and review the current literature regarding its morphology. The axillopectoral muscle is found in 6% of human subjects, typically as a musculotendinous band 7–15 cm in length running between latissimus dorsi and pectoralis major with considerable morphological variation. It has been attributed to 2/15 false negative SLNB in one series. The axillopectoral muscle is common, variable and increasingly important in the era of SLNB.