Robotic Totally Extraperitoneal Hernia Repair: An Initial Experience with Cambridge Medical Robotics Versius.

Background: Total extraperitoneal approach for laparoscopic inguinal hernia repair (L-TEP) allows for better dissection, lesser chance of bowel injury, and quicker operating time. However robotic groin hernia repair is currently performed only through transabdominal route as it allows for more mobility of the arms. This study is aimed at studying the feasibility and outcomes of robotic totally extraperitoneal (R-TEP). Methods: A prospective nonrandomized comparative study was conducted to compare R-TEP with L-TEP. Out of a total of 88 patients with inguinal hernia, 44 patients underwent R-TEP and other 44 patients underwent L-TEP over a period of 15 months. All R-TEP were performed with Cambridge Medical Robotics (CMR) Versius. The outcomes were analyzed over a minimum follow-up period of 6 months. Results: All patients were males with a mean age of 45.9 years. Average body mass index was 28.7. Mean docking time for R-TEP was 12.7 minutes. Overall time taken for R-TEP (mean 60.47 minutes) was significantly higher (P < .001) than L-TEP (mean 38.45 minutes). When the console time of R-TEP and overall time of L-TEP were compared, there was no significant difference (P = .053). A RCT (RIVAL Trial) conducted by Prabhu et al. showed their robotic transabdominal preperitoneal (R-TAPP) time of median 75.5 (59.0-93.8) minutes. Kimberly et al. had their overall time of 77.5 minutes and Andre Luiz et al. had a console time of 58 minutes. When we compared the data, the overall time of R-TEP is lesser compared with R-TAPP. Postoperative pain on POD-1 showed that the robotic group had significantly lower pain. There were no recurrences noted in the study period. Conclusion: With our study, we have shown that R-TEP performed using the principle of laparoscopic triangulation technique with CMR Versius is feasible and reproducible. Although the overall time is significantly more in R-TEP when compared with L-TEP, console times of R-TEP and overall times of L-TEP were very similar. Console times of R-TEP are much lesser compared with other studies on R-TAPP. R-TEP can be a better alternative to R-TAPP and can be considered at par with L-TEP. A systematic RCT would provide a better picture.

Laparoscopic posterior rectopexy for complete rectal prolapse: Is it the ideal procedure for males?

Background: Rectal prolapse is more common in elderly women worldwide, but in India, it predominantly occurs in young- and middle-aged males. While ventral mesh rectopexy is proposed as the preferred procedure in females, the debate on the best procedure in men is still wide open. Methods: A retrospective review of all adult male patients operated for external rectal prolapse (ERP) between January 2005 and December 2019 was performed. Patients either underwent modified laparoscopic posterior mesh rectopexy (LPMR) or laparoscopic resection rectopexy (LRR). The outcome was analysed in terms of recurrence, post-operative constipation, sexual dysfunction and other complications. Results: A total of 118 male patients were included (LPMR: 106, LRR: 12). The mean age was 46.2 years (standard deviation [SD] 11.8, range: 21-88). The mean operating time was 108 min (SD: 24). The mean length of hospital stay was 4.8 days (SD: 1.4, range: 3-11 days). There was no anastomotic leak in the LRR group. Other complications included wound infection (n = 2), mesh infection with sigmoid colon perforation (n = 1), constipation (n = 4), sexual dysfunction (n = 2), urinary urgency (n = 3) and retention of urine (n = 4). There was no mortality in both the groups. During a mean follow-up of 5.2 years, recurrent ERP was noted in one patient and partial mucosal prolapse was seen in three patients. Conclusion: LPMR/LRR is a safe and effective treatment for ERP in men with very low recurrence rates. Randomised trials comparing modified LPMR with LVMR are needed to establish the better procedure in males.

Laparoscopic anterior resection: Analysis of technique over 1000 cases.

PURPOSE: Laparoscopic rectal surgery has moved from being experimental to getting established as a mainstream procedure. We aimed at analysing how rectal cancer surgery has evolved at our institute. METHODS: A retrospective review of 1000 consecutive patients who underwent laparoscopic anterior resection for rectal adenocarcinoma over a period of 15 years (January 2005 to December 2019) was performed. Technical modifications were made with splenic flexure mobilisation, intersphincteric dissection and anastomotic technique. The data collected included type of surgery, duration of surgery, conversion to open, anastomotic leak, defunctioning stoma and duration of hospital stay. The first 500 and the next 500 cases were compared. RESULTS: The study patients were predominantly males comprising 68% (n = 680). The mean age of the patients was 58.3 years (range: 28-92 years). Majority of the procedures performed were high anterior resection (n = 402) and low anterior resection (LAR) (n = 341) followed by ultra-LAR (ULAR) (n = 208) and ULAR + colo-anal anastomosis (n = 49). A total of 42 patients who were planned for laparoscopic surgery needed conversion to open procedure. Forty-one patients (4.1%) had an anastomotic leak. The mean duration of stay was 5.3 + 2.8 days. The rate of conversion to open procedure had reduced from 5.4% to 3.0%. The rate of defunctioning stoma had reduced by >50% in the recent group. The anastomotic leak rate had reduced from 5.0% to 3.2%. The average duration of stay had reduced from 5.8 days to 4.9 days. CONCLUSION: This is one of the largest single-centre experiences of laparoscopic anterior resection. We have shown the progressive benefits of an evolving approach to laparoscopic anterior resection.

Epidural analgesia provides effective pain relief in patients undergoing open liver surgery.

BACKGROUND: Epidural analgesia has been the reference standard for the provision of post-operative pain relief in patients recovering from major upper abdominal operations, including liver resections. However, a failure rate of 20-32% has been reported. AIM: The aim of the study was to analyse the success rates of epidural analgesia and the outcome in patients who underwent liver surgery. METHODS: We collected data from a prospectively maintained database of 70 patients who underwent open liver surgery by a bilateral subcostal incision during a period of 20 months (February 2009 to September 2010). Anaesthetic consultants with expertise in anaesthesia for liver surgery performed the epidural catheter placement. A dedicated pain team assessed the post-operative pain scores on moving or coughing using the Verbal Descriptor Scale. The outcome was measured in terms of epidural success rates, pain scores, post-operative chest infection and length of hospital stay. RESULTS: The study group included 43 males and 27 females. The indication for resection was liver secondaries (70%), primary tumours (19%) and benign disease (11%). While major (≥3 segments) and minor resections (≤ 2 segments) were performed in 44% and 47% respectively, 9% of patients were inoperable. Epidural analgesia was successful in 64 patients (91%). Bacterial colonisation of epidural tip was noticed in two patients. However, no neurological complications were encountered. Five patients (7%) had radiologically confirmed chest infection. Four patients (6%) developed wound infection. One patient died due to liver failure following extended right hepatectomy and cholecystectomy for gall bladder cancer. The median length of stay was 6 days (3-27 days). The extent of liver resection (p = 0.026) and post-operative chest infection (p = 0.012) had a significant influence on the length of stay. CONCLUSION: Our experience shows that epidural analgesia is safe and effective in providing adequate pain relief following open liver surgery.

A Randomised, Double Blind, Placebo-Controlled Pilot Study of Oral Artesunate Therapy for Colorectal Cancer.

BACKGROUND: Artesunate is an antimalarial agent with broad anti-cancer activity in in vitro and animal experiments and case reports. Artesunate has not been studied in rigorous clinical trials for anticancer effects. AIM: To determine the anticancer effect and tolerability of oral artesunate in colorectal cancer (CRC). METHODS: This was a single centre, randomised, double-blind, placebo-controlled trial. Patients planned for curative resection of biopsy confirmed single primary site CRC were randomised (n = 23) by computer-generated code supplied in opaque envelopes to receive preoperatively either 14 daily doses of oral artesunate (200 mg; n = 12) or placebo (n = 11). The primary outcome measure was the proportion of tumour cells undergoing apoptosis (significant if > 7% showed Tunel staining). Secondary immunohistochemical outcomes assessed these tumour markers: VEGF, EGFR, c-MYC, CD31, Ki67 and p53, and clinical responses. FINDINGS: 20 patients (artesunate = 9, placebo = 11) completed the trial per protocol. Randomization groups were comparable clinically and for tumour characteristics. Apoptosis in > 7% of cells was seen in 67% and 55% of patients in artesunate and placebo groups, respectively. Using Bayesian analysis, the probabilities of an artesunate treatment effect reducing Ki67 and increasing CD31 expression were 0.89 and 0.79, respectively. During a median follow up of 42 months 1 patient in the artesunate and 6 patients in the placebo group developed recurrent CRC. INTERPRETATION: Artesunate has anti-proliferative properties in CRC and is generally well tolerated.

Wound irrigation before abdominal computed tomography scanning.

The management of penetrating abdominal trauma has evolved considerably over the last 30 years. The goal of any algorithm for penetrating abdominal trauma should be to identify injuries requiring surgical repair and avoid unnecessary laparotomy with its associated morbidity. We describe a case where the infusion of povidone-iodine (Videne) and air into the wound uncovered the peritoneal breach clinically and guided the radiologist to the site of the internal injury. This case report raises an intriguing possible role for povidone-iodine and air to be used both for wound toilet and to aid identification of occult wound tracks on computed tomography imaging. We advocate the routine use of wound irrigation with a mixture of povidone-iodine and air as described, in a select group of patients, as an adjunct to diagnosis before abdominal computed tomography scanning.

Colorectal cancer in the young: trends, characteristics and outcome.

BACKGROUND: Colorectal cancer (CRC) in young patients is associated with a poor outcome due to advanced stage at diagnosis and poor differentiation. AIM: The aim of this study is to compare clinicopathological characteristics, overall survival (OS) and disease-free survival (DFS) of young (≤40 years) and older patients with CRC. METHODS: A total of 2,538 patients including 59 young patients (age ≤40 years) with CRC were identified over 20 years. The clinicopathological variables of young patients were compared with a group of consecutive older patients (n = 416) spanning both decades. Survival analysis was done using Kaplan-Meier, log-rank and Cox regression models. RESULTS: The frequency in young patients increased from 1.4% to 3.0% from first to second decade (overall -2.3%, p = 0.006). There was a higher frequency of tumours with poor differentiation (43% vs. 16%, p = < 0.001), T4 stage (47% vs. 30%, p = 0.005) and vascular invasion (VI; 38% vs. 29%, p = 0.13) in younger group. There was no significant difference in OS (p = 0.116) and DFS (p = 0.261) between the two groups. Node-negative young patients had a significantly better OS (p = 0.046). Young patients with VI had significantly reduced OS (p = 0.043), whereas young patients without VI had significantly better OS (p = 0.012). Multivariate analysis showed T4 status (p = 0.001) and vascular invasion (p = 0.002) as independent prognostic factors for OS and T4 status (p = 0.004) as independent factor influencing DFS. CONCLUSION: The frequency of CRC in young patients increased significantly. Vascular invasion is the single most important prognostic factor in young CRC. Along with vascular invasion, high proportion of T4 status in young patients increases the chances of recurrence and negates any survival advantage in young patients.

Ectopic pancreas, intussusception, and a ruptured mesenteric band: an unusual association.

Although ectopic pancreas and intussusception are not unusual conditions, intussusception caused by ectopic pancreas is extremely rare. Its presence along with a ruptured congenital mesenteric vascular band raises the possibility of an anomaly of the vitelline vascular system. We report the case of a 26-year-old man presenting with acute abdominal pain, vomiting, and diarrhea. CT scan showed a large amount of free fluid in his abdomen and an ileo-ileal intussusception. At laparotomy he was found to have hemoperitoneum with a ruptured, actively bleeding congenital band attached to the ileal mesentery, which was ligated, with ileo-ileal intussusception that was resected. Histopathology showed ectopic pancreatic tissue as the lead point for the intussusception. It was likely to be a ruptured mesodiverticular band and along with other findings suggested a constellation of anomalies of the vitello-intestinal tract.