'Critical circle of fundoplication' - A key concept towards creating identical, replicable and consistent fundoplication wraps.

Background: There is a significant learning curve associated with laparoscopic Nissen's fundoplication, during which, complications due to surgical errors are more likely to occur. Moreover, length of the wrap, its situation on the lower esophagus and the points of the fundus brought together to create the wrap are arbitrary and as per the surgeon's judgement and estimation. This leads to a lot of variation in the wraps created, not only from surgeon to surgeon, but also from case to case for each individual surgeon. We propose a new concept of 'Critical Circle of Fundoplication' and the new approach to construct the fundoplication based on this concept, by application of which, a mathematically precise fundoplication can be created which is consistent, accurate and optimum. Patients and Methods: A total of 132 patients were operated based on the concept of 'Critical Circle of Fundoplication' between 2015 and 2020, of which 116 patients completed one year of follow-up and are included in the paper. Results: The demographic characteristics, intraoperative findings and postoperative are described in detail. An additional average time of 10.5 minutes (range: 8-26 minutes) was required in the precise measurements and markings that were required by this approach. Conclusion: By application of the concept of 'Critical Circle of Fundoplication', precise, consistent and optimum wraps can be created. By eliminating the errors of structural construction and placement of the wrap, overall results can be improved.

Surgical practice recommendations for minimal access surgeons during COVID 19 pandemic - Indian inter-society directives.

These are inter-society guidelines for performance of laparoscopic surgery during COVID-19 pandemic that has affected the way of surgical practice. The safety of healthcare workers and patients is being challenged. It is prudent that our surgical practice should adapt to this rapidly changing health environment. The guidance issued is based on global practices and national governmental directives. The Inter-Society Group urges you to be updated with the developing situation and evolving changes.

Retrorectus sublay mesh repair using polypropylene mesh: Cost-effective approach for laparoscopic treatment of ventral abdominal wall hernias.

INTRODUCTION: Laparoscopic repair of ventral abdominal hernias has become a standard of care. The surgery involves placement of a composite mesh with 3-5 cm overlap at the edges of the defect. The disadvantage of this repair is one, the composite mesh used for intraperitoneal placement is quite costly and two, it leaves a foreign body inside the peritoneal cavity, with the potential to cause problems in the future. To circumvent both these issues, we have developed a new approach, called the retrorectus sublay Mesh (RRSM) repair, which allows placement of a plain polypropylene mesh in an extraperitoneal plane. PATIENTS AND METHODS: Patients with paraumbilical hernia and lower midline incisional hernias were included in this pilot study performed at a single centre by the same surgeon. The steps of the technique are described in detail. RESULTS: Since 2016, a total of 52 patients were operated by this technique, including both male and female patients. It included patients with para-umbilical hernias as well as incisional hernias. The RRSM repair could be successfully carried out in all the patients. In six of the patients, transversus abdominis release was added as the defect size was large to allow closure of the defect. The results were satisfactory with a low morbidity and no mortality. CONCLUSION: In our opinion, the RRSM technique is an important tool in the armamentarium of the laparoscopic surgeon dealing with ventral abdominal hernias, allowing placement of polypropylene mesh in an extraperitoneal space. It allows significant cost savings as compared to the prevalent intraperitoneal onlay mesh repair.

Randomised controlled trial of n-butyl cyanoacrylate glue fixation versus suture fixation of mesh in laparoscopic totally extraperitoneal hernia repair.

BACKGROUND: We present a randomised control trial to compare suture fixation of the mesh with non-mechanical fixation using n-butyl cyanoacrylate (NBCA) glue for laparoscopic totally extraperitoneal (TEP) hernioplasty. PATIENTS AND METHODS: After a standard dissection for laparoscopic TEP hernioplasty, the mesh was fixed using sutures or NBCA glue to the Cooper's ligament as per the randomised allocation. The primary endpoints were recurrence at 24 months and chronic groin pain. The secondary endpoints were pain scores, analgesic requirement in the post-operative period and duration of surgery. RESULTS: Group A consisting of suture fixation had 127 patients which included a total of 173 hernias while Group B consisting of NBCA had 124 patients including a total of 171 hernias. The patients' age, sex distribution, body mass indices and co-morbidities were comparable in both groups. No patient suffered any major intra-operative or post-operative complication or mortality. There were no conversions to open surgery in either of the groups. The operating time was similar in both the groups though there was a tendency toward a shorter surgery time in Group B. There was lesser consumption of analgesics in the immediate post-operative period in Group B but this did not reach statistical significance. Using visual analogue scale to measure pain, there was no difference in pain at 48 h; however, Group B patients complained of significantly less pain on day 7 as compared to Group A. Almost 98% of Group A patients and 99.2% of Group B patients completed 24 months of follow-up. There were no recurrences in either groups or was there any significant difference in chronic groin pain, in fact, none of the Group B patients complained of chronic groin pain. CONCLUSION: Using NBCA glue to fix the mesh in laparoscopic TEP hernia repair is effective and associated with less pain on day 7 as compared to suture fixation of the mesh.

Laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis.

AIM: The aim was to study the feasibility of the laparoscopic approach in the management of ulcerative colitis, to assess the functional results at 1-year and to review of literature on the topic. MATERIALS AND METHODS: All patients presenting for surgical management of histopathologically proven ulcerative colitis during the study period were included in the study. All patients presenting in a non-emergency setting were offered a two-stage procedure (Group A). The first-stage consisted of laparoscopic total proctocolectomy (TPC) with ileal pouch-anal anastomosis (IPAA) with a diverting split end ileostomy. Ileostomy was closed in the second stage. For patients presenting in acute setting (Group B), the first-stage consisted of laparoscopic TPC with end ileostomy followed by IPAA with diverting split end ileostomy in the second-stage and finally ileostomy closure in the third-stage. The technique is described. RESULTS: A total of 31 cases underwent laparoscopic TPC-IPAA, of which 28 belonged to Group A and 3 were included in Group B. All surgeries were successfully completed laparoscopically without need for conversion. The average operating time was 375 min in Group A (range: 270-500 min) and 390 min in Group B (range: 250-480 min). Oral diet was resumed at a mean of 3.4 days (range: 1.5-6 days) and the mean hospital stay was 8.2 days (range: 4-26 days). Overall morbidity rate was 16.2%; re-operation rate was 9.7% while mortality was nil. CONCLUSIONS: Laparoscopic TPC-IPAA is feasible in acute as well as non-acute setting in patients needing surgical management of ulcerative colitis.

Spillage-free laparoscopic management of hepatic hydatid disease using the hydatid trocar canula.

INTRODUCTION: This study was undertaken to demonstrate the efficacy of the Hydatid Trocar Canula system for safe and effective treatment of hepatic hydatid cysts. MATERIALS AND METHODS: All cases presenting to our centre for treatment of hydatid cyst of the liver with certain exceptions were considered for laparoscopic management using the specifically designed Hydatid Trocar Canula system. The technique of surgery and the step wise sequence of deployment of the device are described. RESULTS: Since January 2007, 16 patients compromising six males and 10 females underwent this procedure at our centre. The average age of the patients was 37.6 years and all of them had a single cyst. The average duration of surgery was 86 minutes. None of the cases suffered intraoperative mishap like spillage or anaphylaxis. Till date, follow-up has been maintained in 81.3% of the patients and no recurrence has been detected. CONCLUSION: The correct use of the Hydatid Trocar Canula system allows for spillage-free and complete evacuation of hepatic hydatid cysts.

Laparoscopic paracolostomy hernia repair: a retrospective case series at a tertiary care center.

BACKGROUND: Paracolostomy hernias are one of the most common complications of stomas. Primary repair is associated with a high rate of recurrence. The choice is between mesh-reinforced repair of the defect and relocation of the stoma to another position. The laparoscopic approach seems attractive, as it is minimally invasive, requires shorter hospitalization, and the entry is through a noncontaminated part of the abdomen. STUDY DESIGN: This study consists of a case series of 9 patients with paracolostomy hernia, of which 2 had recurrent hernias. All patients presenting with nonobstructed parastomal hernias at our clinic between October 2006 and October 2009 are included in this series. Two patients that presented with obstruction are not included. We describe our technique for this surgery using the laparoscopic approach and discuss the outcomes. RESULTS: Nine patients with permanent colostomies in the left lumbar quadrant after abdominoperineal resection presented with parastomal hernias of varying durations and were subjected to laparoscopic repair. The average operating time was 112 minutes. All the patients were mobilized postoperatively and were discharged by 48 hours. None of the patients have reported any complication, including recurrence. CONCLUSIONS: Laparoscopic repair of paracolostomy hernia using a technique involving intracorporeal suturing of defect followed by reinforcement by a tissue-separating mesh is safe and feasible.

Laparoscopic truncal vagotomy with gastrojejunostomy.

Surgery still remains the treatment of choice for patients of peptic ulceration with gastric outlet obstruction. With the advent of minimal access surgery, laparoscopic truncal vagotomy with gastrojejunostomy is an attractive option. Between September 2006 and May 2010, 18 patients underwent laparoscopic truncal vagotomy with gastrojejunostomy for gastric outlet obstruction with peptic ulcer. Four patients underwent stapled gastrojejunostomy and 14 patients had a sutured anasotomosis. There were no major intra-operative and postoperative complications. We conclude that the laparoscopic approach is beneficial and, with sufficient expertise, a sutured gastrojejunostomy can be safely performed, thus saving on the costs.

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

BACKGROUND: Familial adenomatous polyposis is a hereditary disease characterized by the presence of thousands of colonic adenomas, which, if untreated, invariably undergo malignant transformation. Because this disease manifests at a young age, the laparoscopic approach to perform surgery would be desirable due to its cosmetic benefits. We describe our experience with this procedure and review the literature on the topic. METHODS: This is a case series of 15 patients who underwent restorative proctocolectomy with ileo-anal pouch anastomosis for familial adenomatous polyposis between 2000 and 2007. The salient operative steps are described. RESULTS: There were 9 males and 6 females, 32 to 52 years of age, with an average age of 44.8 years. The median body mass index was 21.5 (range, 17 to 28). Rectal cancer was already present in 4 patients at the time of diagnosis. The median operating time was 225 minutes. Mean blood loss was 60 mL, with none of the patients requiring perioperative blood transfusion. None of the surgeries required conversion to the open approach. Bowel function resumed on the second postoperative day in 12 patients and on the third postoperative day in 3 patients. The median hospital stay was 8 days. Postoperatively, there was no mortality and no serious morbidity. CONCLUSION: Laparoscopic restorative proctocolectomy with ileal pouch anal anastomosis is a feasible surgery for familial adenomatous polyposis, and considering its cosmetic benefit, is a desirable option for this group of predominantly young patients.

Single-center experience of laparoscopic cholecystectomy.

BACKGROUND: The laparoscopic cholecystectomy procedure is considered as the gold standard for the management of benign symptomatic gallbladder diseases. In this paper, we present our experience as a tertiary reference center in the management of this disease. METHODS: A total of 9864 laparoscopic cholecystectomies have been performed in our institution since 1991. All patients undergo a routine hematologic work-up, high resolution ultrasonography, and, thereafter, a four-port cholecystectomy by the North American approach. We specifically considered 10 areas of controversy. RESULTS: The male:female ratio was 45:55, with the average age being 40.4 years (range, 1 year 4 months to 92 years). Asymptomatic patients were 986 in number and 25% had acute cholecystitis, whereas 2.28% had associated choledocholithiasis. The "fundus first" approach was adopted in 88 patients. Three patients had occult gallbladder cancer, of which 2 were in situ and 1 was of the T1 stage. Nearly one third of the patients had gallstone spillage, primarily owing to the performance of a subtotal cholecystectomy procedure in the setting of acute cholecystitis. However, only 1 patient to date has had a problem directly attributable to gallstone spillage. Nearly 13% of patients had an additional procedure along with a cholecystectomy. The average operating time was 21.5 minutes, whereas the average length of postoperative stay was 1.6 days. CONCLUSIONS: The laparoscopic approach is suitable for the management of all forms of benign gallbladder diseases. In addition, it is possible to use the laparoscopic approach for indications hitherto considered relatively contraindicated. In a dedicated center, it is possible to perform a large number of cases with low morbidity and minimal conversion rates.

Minimally invasive management of achalasia cardia: results from a single center study.

BACKGROUND: Since the performance of the first laparoscopic cardiomyotomy for achalasia cardia in 1991, the popularity of the minimally invasive approach for this troublesome disease has been growing. We present our experience of 226 patients who underwent laparoscopic cardiomyotomy and discuss the relevant issues. METHODS: A retrospective analysis was carried out of 226 patients who have undergone laparoscopic cardiomyotomy since 1993. The preoperative workup, surgical technique, and postoperative management are described. RESULTS: Patients included 146 males and 80 females; average age was 36.4 years (range, 6 to 85). Mean duration of symptoms was 1.4 years. Nearly half of the patients (112) had undergone prior pneumatic dilatation. In 20 patients, myotomy alone was done, 44 patients had a Dor's fundoplication, and 162 had Toupet's fundoplication. The average operating time was 96 minutes. Mean postoperative hospital stay was 2.2 days. Dysphagia was eliminated in 88.9% of the patients with an overall morbidity of 4.4% and nil mortality over a mean follow-up of 4.3 years. CONCLUSION: Laparoscopic cardiomyotomy with Toupet's fundoplication is a safe and effective treatment of achalasia cardia. Dor's fundoplication is done selectively, especially when suspicion is present of mucosal injury.

Intestinal malrotation with midgut volvulus presenting as acute abdomen in children: value of diagnostic and therapeutic laparoscopy.

INTRODUCTION: Intestinal malrotation is a developmental anomaly of intestinal fixation and rotation caused by a disruption in the normal embryologic development of the bowel. Normal rotation takes place around the superior mesenteric artery. Incomplete rotation and midgut volvulus is the commonest type of anomaly. Intestinal obstruction is the commonest presentation in symptomatic cases. PATIENTS AND METHODS: Between 2000 and 2006, 73 children with acute abdomen underwent a diagnostic laparoscopy procedure. In this paper, we report 7 cases (9.5%) of midgut malrotation with volvulus and acute abdomen. Age range was between 7 and 12 years; there were 4 females and 3 males. They all presented with features of intestinal obstruction. A diagnosis of malrotation was established in only 1 patient, whereas the other 6 were diagnosed on laparoscopy. A laparoscopic Ladd's procedure was successfully performed for all cases. There were no postoperative complications. DISCUSSION: Intestinal malrotation occurs at a rate of 1 in 500 live births. The Ladd's procedure is the operation of choice. In 1995, the first report of laparoscopic surgery for malrotation was published. Since then, many studies were reported. Laparoscopy is a well-established diagnostic and treatment modality for this condition, even in the presence of volvulus. CONCLUSIONS: Our study shows the diagnostic value of laparoscopy in acute abdomen in children. The other advantages include less postoperative pain, a better cosmesis, especially in children, early return of bowel movement, and early discharge.

Laparoscopic pancreaticoduodenectomy: technique and outcomes.

BACKGROUND: We describe our experience with laparoscopic pancreaticoduodenectomy, including 5-year actuarial survival rates. STUDY DESIGN: This is a retrospective study of selected patients who underwent laparoscopic pancreaticoduodenectomy at a single center between 1998 and 2006. We have described the salient features of our technique and followup protocol. Patient characteristics, histologic variety of the tumor, resection margins, morbidity, mortality, and actuarial survival rates were studied. RESULTS: The procedure could be completed laparoscopically with tumor-free margins in all patients, including patients with ampullary carcinoma (n = 24), pancreatic cystadenocarcinoma (n = 4), pancreatic head adenocarcinoma (n = 9), low common bile duct cancer (n = 3), and two patients with chronic pancreatitis with a suspicious mass lesion in the head of pancreas. Mean age of patients was 61 years (range 28 to 70 years). There was a single perioperative mortality. Overall followup rate was 95.1%, with two patients lost to followup at 22 and 36 months. Among the survivors, two patients have metastatic disease and local recurrence developed in one patient. Five-year actuarial survival rates for all patients with malignancy, ampullary adenocarcinoma, pancreatic cystadenocarcinoma, pancreatic head adenocarcinoma, and common bile duct adenocarcinoma are 32%, 30.7%, 33.3%, 19.1%, and 50%, respectively. Presence of microscopic lymph node involvement is associated with poor survival, although operations in the setting of chronic pancreatitis resulted in increased morbidity. CONCLUSIONS: Laparoscopic pancreaticoduodenectomy can be performed with safety and good results in properly selected patients. Localized malignant lesions, irrespective of histopathology, are particularly amenable to this approach.

Laparoscopic management of duodenal ulcer perforation: is it advantageous?

BACKGROUND: Surgery is the mainstay of treatment of patients with peptic duodenal perforation. With the advent of minimal access techniques, laparoscopy is being used for the treatment of this condition. METHODS: Retrospective analysis of 120 consecutive patients (mean age 44.5 years; 111 men) with duodenal ulcer perforation who had undergone laparoscopic surgery. RESULTS: 87 patients had history of tobacco consumption, 12 were chronic NSAID users, 72 had Helicobacter pylori infection and 36 had a co-morbid condition. The mean time to surgery from onset of symptoms was 28.4 hours. The median operating time was 46 minutes. All patients underwent laparoscopic closure of the perforation with Graham's patch omentopexy; 12 patients underwent additional definitive ulcer surgery. The morbidity rate was 7.5%; no patient needed conversion to open surgery or died. The mean postoperative hospital stay was 5.8 days. CONCLUSION: Results of laparoscopic management of perforated peptic ulcer are encouraging, with no conversion to open surgery, low morbidity and no mortality.

Management of pancreatic pseudocyst in the era of laparoscopic surgery--experience from a tertiary centre.

BACKGROUND: In the era of minimally invasive surgery, laparoscopy has a great role to play in the management of pseudocyst of pancreas. We present our surgical experience over the past 12 years (May 1994 to April 2006) in the management of pancreatic pseudocysts. MATERIALS AND METHODS: The total number of cases was 108, with 76 male and 32 female patients. Age ranged from 18 to 70 years. Duration of symptoms ranged from 45 days to 7 months. Fifty-nine patients presented with pain abdomen. Sixty-one patients had co-morbid illness. Ten patients had abdominal mass on clinical examination. Predisposing factors were gallstones in 58 cases, alcohol in 20 cases, trauma in eight cases and post-pancreatectomy in one case. In 21 cases there are no predisposing factors. RESULTS: All the cases were successfully operated without any significant intraoperative complication. Laparoscopic cystogastrostomy was done in 90 cases (83.4%), laparoscopic cystojejunostomy in eight cases (7.4%), open cystogastrostomy in two cases (1.8%), and laparoscopic external drainage in eight cases (7.4%). Laparoscopic cholecystectomy was done in 47 cases along with the drainage procedure. The mean operating time was 95 minutes. Mean blood loss was 69 ml. Mean hospital stay was 5.6 days. Percutaneous tube drain to assist decompression of the cyst was kept in all the laparoscopic cystojejunostomy (LCJ) group. Two patients were re-operated for bleeding and gastric outlet obstruction. We had no mortality in the postoperative period. With mean follow up of 54 months (range 3-145 months); only one patient who underwent laparoscopic cystogastrostomy (LCG) earlier in this series had recurrence due to inadequate stoma size. This patient later underwent OCG CONCLUSION: Laparoscopy has a significant role to play in the surgical management of pseudocysts with excellent outcome. It offers all the benefits of minimally invasive surgery to the patients.