Minimal Access Surgery Research Articles

Active constrained motion control for a robot-assisted endoscope manipulator in pediatric minimal access surgery.

Robot-assisted laparoscopic surgery has three main system requirements: safety, simplicity, and intuitiveness. However, accidental movement of the endoscope due to body fatigue and misunderstanding of the verbal orders between the surgeon and assistant will contribute to highly unexpected tool-tissue interactions, particularly in pediatric minimal access surgery with restricted working space. This study introduces a compact, lightweight endoscope manipulator with a mechanical remote-center-motion function. Using a custom-designed human-machine interface, the surgeon can intuitively control the movement of the endoscope manipulator over their view. In addition, an active constrained motion control algorithm is proposed to generate a forbidden-region constraint for avoiding collisions between the endoscope tip and surrounding organs in a pediatric abdominal cavity with restricted space. Simulations and experiments demonstrate the performance of the proposed compact endoscope manipulator and the active constrained surface tracking control scheme.

Challenges of minimally- invasive orthopaedic surgery practice in Nigeria - a national survey of residents’ perceptive

Background: Minimally invasive orthopaedic surgery (MIOS) practice globally has been on a gradual increase, however the current state in Nigeria is not same. Objectives: To determine the challenges of minimally invasive orthopaedic surgery (MIOS) practice in Nigeria and proffer realistic suggestions to improve the current state in Nigeria. Methodology: A descriptive cross-sectional online survey conducted among senior orthopaedic surgery residents across all specialist hospitals in Nigeria. Data was analysed with the SPSS software version 20. Significance was set at p<0.05. Mean and S.D scores were calculated for responses with Likert scales of 1-5 (5- strongly agree). Results: 48 residents completed and submitted the questionnaire, response rate of about 70.6%.The results showed that the most significant factors affecting minimally invasive orthopaedic surgery practice in Nigeria were lack of funds (72.9% of respondents), unavailability of equipment and implants (60.4%), limited number of trainers and fellows skilled in minimal access surgery (54.2%). The narrowest Standard deviation reflecting closest precisions in perspectives of the challenges was a S.D of 0.794, Mean 4.02, which stated that there are very few courses on training of MIOS procedures. Conclusion: Funds, training, equipment availability were the major challenges of minimally invasive orthopaedic surgery practice in Nigeria. Keywords: Minimally- invasive orthopaedic surgery; residents’ perceptive; Nigeria.

A comparison of surgical outcomes of endoscopic versus microscopic myringoplasty

BackgroundThere is a gradual transition from open to minimal access surgeries in Otorhinolaryngology. Myringoplasty can be done with either microscope or endoscope. Use of both the techniques has been reported in literature. However, there is no clear consensus over which is better than the other. The current study was done with the aim of comparing the hearing outcomes post myringoplasty by endoscopic versus microscopic technique. MethodsHundred patients of chronic otitis media mucosal inactive were recruited and divided into two groups, A and B. The patients in group A underwent endoscopic myringoplasty while those in group B underwent conventional microscopic myringoplasty. All patients underwent pure tone audiometry (PTA) and oto-endoscopy prior to and six months post-surgery. The study outcomes in the form of air-bone (AB) gap on PTA, successful closure of tympanic membrane perforation, pain scores, duration of hospital stay and occurrence of complications were compared. ResultsThe post-operative AB gap on PTA and pain score was lesser in the endoscopic technique as compared to microscopic technique. The reduction in AB gap post-surgery, duration of hospital stay, proportion of patients with closure of AB gap to ≤10 dB, successful closure of tympanic membrane perforation, and taste alteration were similar in both groups. ConclusionEndoscopic technique for myringoplasty can be recommended in view of similar or slightly better surgical and functional outcomes, wider field of view and better visualisation of middle ear by the endoscopes.

Comparing oncological outcomes of robotic versus open surgery in the treatment of endometrial cancer.

Robotic surgery has been incorporated in the treatment of endometrial cancer, with evidence suggesting that minimal access surgery offers advantages over laparotomy including less blood loss, lower rate of perioperative complications, and accelerated postoperative recovery. The laparoscopic approach to cervical cancer (LACC) study has recently demonstrated inferior survival outcomes in cervical cancer patients treated with minimal access surgery including robotic surgery. It is, therefore, imperative that further evaluation of the latter in endometrial cancer is performed. A retrospective analysis of clinical data was performed. We compared two different types of surgery performed for the treatment of FIGO stage 1 to 3 endometrial cancer; open surgery performed in the years 2013-2015 vs robotic surgery performed in 2017-2019, after the implementation of the robotic program in our institution. Main outcome measures were recurrence-free survival and overall survival, with secondary outcomes including surgical morbidity and postoperative recovery. We compared 123 patients who had open surgery with 104 patients who underwent robotic surgery. One case from the second group was converted to open surgery due to the inability to complete it robotically. After a median follow-up of 68months, there was no difference in recurrence-free survival or overall survival between the two groups. Length of stay after an operation was significantly different with mean hospital stay of 1.6days after robotic surgery and 5days after open surgery (p = 0.001). No significant difference was identified in the rate of complications (p = 0.304). Our analysis has demonstrated that robotic surgery offers better perioperative outcomes without compromising the oncological safety.

Anastomotic leak after manual circular stapled left-sided bowel surgery: analysis of technology-, disease-, and patient-related factors.

Anastomotic leak rates after colorectal surgery remain high. In most left-sided colon and rectal resection surgeries, a circular stapler is utilized to create the primary bowel anastomosis. However, it remains unclear whether a relationship between circular stapler technology and anastomotic leak in left-sided colorectal surgery exists. A post-hoc analysis was conducted using a prospectively collected data set of patients from the 2017 European Society of Coloproctology snapshot audit who underwent elective left-sided resection (left hemicolectomy, sigmoid colectomy, or rectal resection) with a manual circular stapled anastomosis. Rates of anastomotic leak and unplanned intensive care unit stay in association with manual circular stapling were assessed. Patient-, disease-, geographical-, and surgeon-related factors as well as stapler brand were explored using multivariable regression models to identify predictors of adverse outcomes. Across 3305 procedures, 8.0% of patients had an anastomotic leak and 2.1% had an unplanned intensive care unit stay. Independent predictors of anastomotic leak were male sex, minimal-access surgery converted to open surgery, and anastomosis height C11 (lower third rectum) (all P < 0.050). Independent predictors of unplanned intensive care unit stay were minimal-access surgery converted to open surgery and American Society of Anesthesiologists grade IV (all P < 0.050). Stapler device brand was not a predictor of anastomotic leak or unplanned intensive care unit stay in multivariable regression analysis. There were no differences in rates of anastomotic leak and unplanned intensive care unit stay according to stapler head diameter, geographical region, or surgeon experience. In patients undergoing left-sided bowel anastomosis, choice of manual circular stapler, in terms of manufacturer or head diameter, is not associated with rates of anastomotic leak and unplanned intensive care unit stay.

Laparoscopic Pancreaticoduodenectomy With Open Reconstruction: The Buddha's Middle Path.

Laparoscopic pancreaticoduodenectomy (LPD) is not universally adopted because of its steep learning curve. Its technical complexity discourages many surgeons. We believe that laparoscopic pancreaticoduodenectomy with open reconstruction (LPOR) has all the benefits of LPD without its drawbacks and combines the ease of open surgery with the benefits of minimal access surgery. We assessed the feasibility and safety of LPOR and compared it with open pancreaticoduodenectomy (OPD), with the objectives being perioperative and short-term clinical/oncologic outcomes. Retrospective review of prospectively maintained database; study period from January 2013 to December 2019. Till 2015, we did only OPD. In 2016, we started with LPD but soon switched to LPOR. The resection part was done laparoscopically and the reconstruction part was done through a 8-cm mini-laparotomy. We did 19 OPDs and 15 LPORs. Demographic data of the 2 groups were comparable. The duration of surgery was significantly longer in the LPOR group (360 vs. 410min; P =0.01), whereas the blood loss and hospital stay were longer in the OPD group (520 vs. 360mL; P =0.03 and 13 vs. 11d; P =0.08, respectively). Clinically significant complication rates, including delayed gastric emptying and postoperative pancreatic fistulas, were not different in either group. No patients in the LPOR group had wound-related/pulmonary complications. Lymph node yield was similar in both groups (20 vs. 22) and we had 100% R0 resections. LPOR was better than OPD in terms of short-term outcomes and was not inferior to OPD in terms of complications/oncologic outcomes.

Minimal Access in Pediatric Surgery: An Overview on Progress towards Dedicated Instrument Developments and Anesthesiologic Advances to Enhance Safe Completion of Procedures.

Surgical techniques are evolving in Pediatric Surgery, especially in the area of minimal access surgery (MAS) where indications for applications are expanding. Miniaturization of instruments, using natural orifices, single incisions, or remotely controlled robot-assisted procedures, promises to increase the benefits of MAS procedures in pediatrics. Many pediatric pathologies are rare, and specialized surgical and anesthesiologic instruments are necessary to manage them, defined as "orphan devices", for which development and dissemination on the market are slowed down or sometimes hindered by regulatory standards and limiting financial conflicts of interest. In pediatric surgery, it is of utmost importance to work in a multidisciplinary way to offer a surgical path that is safe and supported by technological advances. For this reason, optimizing pediatric anesthesia is also a crucial factor where technological advances have made monitoring more precise, thereby enhancing safety in the operative room. The development of customized instruments and technologies should be supported by pediatric research and should be adapted to the individualities of the small patient. This overview outlines the importance of dedicated instruments developed for the safe completion of MAS procedures in pediatrics.

A review of minimal access surgery provision and training within the United Kingdom

When combined with healthcare pressures, the exponential growth of robotic-assisted surgery (RAS) has impacted UK-based training outcomes, including the learning curve to competency. Aim: To ascertain the current provision of RAS and investigate differences in access to minimal access surgical (MAS) facilities and training across the UK. A two-armed electronic survey was conducted. The first arm questioned clinical leads regarding robotic practice and future training provisions. The second investigated trainee and trainers’ perceptions of MAS training and facilities. 64% (52/81) of responding trusts utilise a robotic system. The majority (68% [55/81]) have plans to expand or acquire a system within 3 years. 171 responses from 112 UK and Republic of Ireland hospitals were collected for Arm 2. Laparoscopic categories queried whether trainees had access to a formal curriculum, training days and sim-boxes. Most consultants (51.9%) and trainees (51.6%) reported that there was no formal local training curriculum for robotic surgery. Combined responses demonstrated 42.1% (n = 195/463) said “yes”, 39.5% (n = 183) “no” and 18.4% (n = 85) “don’t know”. For combined robotic categories (simulation, training days and operative lists) 28.3% (n = 134/473) responded “yes”, 51.6% (n = 244) said “no” and 20.1% (n = 95) said “don’t know”. This study provides insight into the current provision of robotic-assisted surgery at UK trusts and highlights the need to facilitate regular clinical training and equitable access to MAS simulation within a formal curriculum. This may aid regulation of training in parallel with the expansion of robotic practice and avoid a significant skill acquisition gap and risks to patient safety.

Presacral tumors: A systematic review of literature.

Presacral/Retrorectal tumors (RRT) are rare lesions that comprise a multitude of histological types. Data on surgical management are limited to case reports and small case series. The aim of the study was to provide a comprehensive review of the epidemiology, pathological subtypes, surgical approaches, and clinical outcomes. A PubMed search using terms "retrorectal tumor" and "presacral tumor" was used to identify articles reporting RRT of non-urological, non-gynecologic, and non-metastatic origin. Articles included were between 2015 and 2023. A total of 68 studies were included, comprising 570 patients. About 68.2% of patients were female, and the mean overall age of both sexes was 48.6 years. Based on histopathology, 466 patients (81.8%) had benign lesions, and 104 (18.2%) were malignant. In terms of surgical approach, 191 (33.5%) were treated anteriorly, 240 (42.1%) through a posterior approach, and 66 (11.6%) combined. The mean length of stay was 7.6 days. Patients treated using the posterior approach had a shorter length of stay (5.7 days) compared to the anterior and combined approaches. RRT are rare tumors of congenital nature with prevalence among the female sex. R0 resection is crucial in its management, and minimal access surgery appears to be a safer option in appropriate case selection.

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.

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis.

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

General complication of laparoscopic surgery, necesary review

Introduction: “Minimal Access Surgery” began in animal laboratories and was later studied in selected academic centers where it was imported to community hospitals only when its benefits and safety were established. Objectives: To conduct a detailed review of Complications of laparoscopic surgery with emphasis on those related to entry into the abdominal cavity and bile duct surgery given their high frequency and lethality. Subject and methods: A detailed search of literature published in Spanish and English was carried out through PubMed/MEDLINE, Cochrane's registry of systematic reviews and randomized controlled studies, using key words such as “laparoscopic entry”, “trocars injury”, “laparoscopy”. complications”, “laparoscopic injury” and “optical trocars”. Meta-analyses, randomized clinical studies, clinical guidelines, review articles and case series were mainly selected.Conclusions: Laparoscopy is a relatively safe procedure, however, great care must be taken during access to the abdominal cavity because the majority of complications occur during entry.

Implementation of Laparoscopic Nissen Fundoplications in a Developing South African Pediatric Surgical Service.

Pediatric laparoscopic Nissen fundoplication (LNF) has become the standard approach at many centers. We developed a minimal access surgery (MAS) training curriculum to enhance the delivery of MAS for pediatric patients in a resource-limited setting. We reviewed our 10-year experience in implementing and performing LNF at our institution. We described the challenges of implementing MAS training for LNF and how we addressed them. Beneficial technical considerations were described. A retrospective review was performed on all pediatric LNFs performed. We performed 268 LNFs. Specialists or trainees under supervision performed all LNFs. The trainee group performed 43 LNFs (16%). The median operative time for the specialists was 94 min (interquartile range [IQR] 50), and the trainee group was 140 min (IQR 62.5). The median number of cases performed until we improved operative time amongst the trainees was nine (IQR 3). There were seven repeat LNFs, and 11 cases were converted to open. The overall complication rate was 8.9%. A reduction in complications among specialists occurred over the years. The 30-day mortality post-LNF was 0.7%. LNF can be successfully introduced at a tertiary training centre in South Africa with good outcomes. A comprehensive quality improvement program, including MAS training, supported this.

Idiopathic Ascites after Laparoscopic Appendicectomy: a review of literature and a case report

Introduction: Minimal access surgery, encompassing laparoscopy and robotic procedures, has become the preferred choice for a wide range of surgical interventions, receiving widespread acceptance from both surgeons and patients. However, as the utilization of these minimally invasive techniques continues to grow, surgeons are increasingly confronted with unforeseen and puzzling complications. One such rare and perplexing complication is the emergence of ascites following laparoscopic procedures, particularly when no accidental injury to the bowel or urinary system has occurred, posing a challenging and distressing scenario for the operating surgeon. Aims and Objective:We have encountered a case of idiopathic ascites following a laparoscopic appendicectomy in a 10-year-old boy. The primary objective of this study is to conduct a comprehensive literature review to identify similar case reports and publications. By doing so, we aim to enhance our understanding of the causes and principles for managing idiopathic ascites occurring after laparoscopic surgery. Methods: A 10-year-old boy was admitted to the hospital with typical symptoms of acute appendicitis. Following evaluation, a nearly bloodless and uneventful laparoscopic appendicectomy was performed. However, postoperatively, he developed ascites accompanied by scrotal swelling due to scrotal edema, and despite thorough evaluation, no identifiable cause was found. The patient was managed conservatively and fully recovered without any subsequent complications. Results: The occurrence of ascites stemming from an idiopathic allergic or inflammatory peritoneal reaction during a laparoscopic procedure is exceptionally rare. During the patient's evaluation, the paramount concern was to rule out potentially significant complications such as bowel or urinary tract injuries, which can commonly result in postoperative peritoneal fluid accumulation. After the procedure, the boy underwent a thorough evaluation, but no definitive cause for the ascites was identified, further highlighting the enigmatic nature of this condition. Conclusion: Postoperative ascites without a discernible cause following laparoscopic surgery is an unexpected complication. In such cases, the leading hypothesis points to a peritoneal inflammatory reaction induced by agents utilized during laparoscopy. J Bangladesh Coll Phys Surg 2024; 42: 194-198

Laparoscopic versus open gastrectomy: Is there scope for minimal access surgery in gastric carcinomas

In the recent times, laparoscopic methods have gained popularity in management of Gastric carcinoma . There are very few studies in literature that have compared the efficacy and safety of laparoscopic and open gastrectomy in advanced carcinoma stomach. Hence we conducted this study to compare and contrast the safety and efficacy of laparoscopic vs open gastrectomy for patients with gastric carcinoma.

Outcomes of minimal access cytoreductive surgery (M-CRS) and HIPEC/EPIC vs. open cytoreductive surgery (O-CRS) and HIPEC/EPIC in patients with peritoneal surface malignancies: a meta-analysis.

Minimal Access Surgery (MAS) has shown better peri-operative outcomes with equivalent oncological outcomes in gastrointestinal and thoracic oncology. Open CRS (O-CRS) procedure accompanies inevitable and significant surgical morbidity in patients. The aim of the review article is to compare outcomes of M-CRS and HIPEC/EPIC with open procedure in peritoneal surface malignancies. Comprehensive search of databases was done and total 2,807 articles were found (2793-PubMed and 14-Cochrane review). PRISMA flow chart was prepared and 14 articles were selected. Meta-analysis was performed according to PRISMA guidelines using random-effects model (DerSimonian Laird) and fixed effect model. Publication bias was tested with Funnel plot and Egger's regression test. Quality of studies was assessed by Newcastle-Ottawa scale. Patients in both groups [total (732), M-CRS(319), O-CRS(413)] were similar in demographic characteristics. Peri-operative outcomes were significantly better in M-CRS group in terms of blood loss SMD=-2.379, p<0.001 (95 %CI-2.952 to-1.805), blood transfusion RR=0.598, p=0.011 (95 % CI 0.402 to 0.889), bowel recovery SMD=-0.843, p=0.01 (95 % CI-1.487 to-0.2), hospital stay SMD=-2.348, p<0.001 (95 % CI-3.178 to-1.519) and total morbidity RR=0.538, p<0.001 (95 % CI 0.395 to 0.731). Duration of surgery SMD=-0.0643 (95 % CI-0.993 to 0.865, p=0.892) and CC0 score RR=1.064 (95 % CI 0.992 to 1.140, p=0.083) had no significant difference. Limited studies which evaluated survival showed similar outcomes. This meta-analysis shows that M-CRS and HIPEC/EPIC is feasible and has better peri-operative outcomes compared to open procedure in patients with limited peritoneal carcinoma index (PCI) peritoneal surface malignancies. Survival outcomes were not calculated. Further studies are warranted in this regard.

Laparoscopic surgery: My Journey

For 35 years, there has been a rapid spread and evolution of laparoscopic surgery in the developed world, where this modality is now regarded as a safe and first choice for up to 98% of all surgical interventions by adequately trained surgeons. The advantages of laparoscopic surgery are now well established. Surgeons must be encouraged to undergo the required training to provide safe laparoscopic surgery. Having pursued my Master’s in Obstetrics and Gynecology at the University of Nairobi, I was posted to Kilifi District Hospital where I served for nine years. I later moved back to Mombasa and ventured into private practice. I developed an interest in and pioneered minimal access surgery in 1994. I developed an immense interest and passion in minimal access surgery and initially pursued a Diploma in Laparoscopic Surgery at the Coimbatore Institute of Gastrointestinal Endosurgery (CIGES). Subsequently, I attended dedicated workshops and additional training in Kiel, Hamburg (Germany), Clermont-Ferrand and Strasbourg (France), and various institutions in Asia and Europe, attending over 40 dedicated workshops, including advanced laparoscopic and hysteroscopic procedures. In 2000, I moved my practice to Nairobi and worked at various private institutions. To increase the awareness of laparoscopic surgery in Kenya. I organized workshops and encouraged many gynecologists and general surgeons to embrace change. I was later fortunate to be invited to several African countries where I trained and mentored numerous surgeons. In conclusion, laparoscopic surgery faces many challenges but is a safe and effective alternative to the traditional open modalities of surgery. The training of surgeons and support staff should be made a priority. I pray that my journey will be an inspiration and encouragement to many in our fraternity in the years ahead.

Perceval sutureless bioprosthesis versus Perimount sutured bioprosthesis for aortic valve replacement in patients with aortic stenosis: a retrospective, propensity-matched study

BackgroundRapid-deployment aortic valve replacement (RDAVR) is an alternative to conventional AVR (cAVR) for aortic stenosis. Benefits include a reduction in operative times, facilitation of minimal access surgery and superior haemodynamics compared to conventional valves. However, further evidence is required to inform guidelines, preferably in the form of propensity-matched studies that include mid-term follow-up data.MethodsThis was a single-centre, retrospective, propensity-matched cohort study comparing the Perceval and conventional Perimount Magna Ease valve for short- and mid-term clinical parameters and size-matched mid-term echocardiographic parameters (n = 102 in both groups) from 2014 to 2020. Data were extracted from a nationally managed dataset.ResultsThere were no demographic differences between the matched groups. The Perceval group had shorter cross-clamp time (Perceval 62 [49–81] minutes; Perimount 79 [63–102] minutes, P < 0.001), shorter bypass time (Perceval 89 [74–114] minutes; Perimount 104 [84–137] minutes, P < 0.001), and more frequent minimally-invasive approaches (Perceval 28%; Perimount 5%, P < 0.001). Size-matched haemodynamics showed initially higher gradients in the Perceval group, but haemodynamics equalised at 12 + months. The Perceval group had a more favourable % change in the left ventricular posterior wall dimension at 2 + years (Perceval − 4.8 ± 18; Perimount 17 ± 2).ConclusionsThe Perceval facilitated shorter operations, which may benefit intermediate-high-risk, elderly patients with comorbidities requiring concomitant procedures. It also facilitated minimally invasive surgery. Size-matched haemodynamic performance was similar at mid-term follow-up, with the Perceval possibly better facilitating regression of left ventricular hypertrophy.

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 repair of iatrogenic celiac artery injury during median arcuate ligament release: A retrospection and tips at troubleshooting.

Median arcuate ligament (MAL) syndrome or celiac artery (CA) compression syndrome previously treated mainly by vascular surgeons using the open approach is now being increasingly performed by general surgeons with training in advanced laparoscopy. Although this approach has all the advantages of minimal access surgery, the procedure is fraught with serious complications like injury to major vascular structures during dissection. Vascular injury by far is the major cause of conversion to open procedure. Herein, we report a laparoscopic repair of iatrogenic CA injury by intra-corporeal suturing during MAL release. We also elaborate the causes, the preventive measures that can be applied to avoid such catastrophic occurrences in future. To the best of our knowledge, this is the first report of a laparoscopic repair of CA bleed during MAL release.