Laparoscopic totally extraperitoneal management of giant inguinoscrotal hernia with loss of domain.

ABSTRACT: A giant inguinoscrotal hernia extends below the level of the midpoint of the thigh, in an upright position. They are usually due to the neglect of the patient and fear of surgical intervention. Patients typically present with lower urinary tract symptoms, ulcers over the scrotum caused due to dribbling of urine and rarely with obstruction or strangulation. Here, we present a similar case of an uncomplicated giant inguinoscrotal hernia with a Tanaka index of 74% who was preoperatively optimised with BOTOX (BOtulinum TOXin-A) and pre-operative progressive pneumoperitoneum and was managed laparoscopically with enhanced totally extraperitoneal repair. This signifies the importance of optimisation of the patients, especially with loss of domain help in managing such cases without any resection of bowel or omentum. Moreover, this proper pre-operative optimisation also helped us in managing such a case laparoscopically.

Laparoscopic D2 gastrectomy in advanced gastric cancer: Postoperative outcomes and long-term survival analysis.

INTRODUCTION: Data on laparoscopic treatment of operable gastric cancer from India is sparse. This study aims to document outcomes of laparoscopic D2 gastrectomy in an Indian population. MATERIALS AND METHODS: Data of patients who underwent laparoscopic D2 gastrectomy for operable advanced gastric cancer between February 2012 and January 2017 were collected from electronic hospital records supplemented by telephonic interviews and analyzed. Survival was evaluated using Kaplan-Meier survival analysis curves. RESULTS: In total 121 patients were included. Conversion to open gastrectomy was 5.7%. One hundred and fourteen patients (73 laparoscopic subtotal gastrectomy and 41 laparoscopic total gastrectomy) were included for analysis. D2 lymphadenectomy was done in all cases; mean number of dissected lymph nodes was 23.12 ± 9.14 (12-45). Major complications (Clavien-Dindo Grade III and IV) was seen in 6.1% of cases with reoperation rate of 3.5% (4/114). Stage 3 disease was seen in 60.6% cases and stage 2 disease in 32.5%. Follow-up data were available for 76.3% of patients with mean follow-up of 29.5 months. Overall survival across all stages was 38.7 months. Five-year disease-free survival and overall survival were 36.7% and 55.9% respectively, across all stages. CONCLUSION: Laparoscopic D2 gastrectomy is safe, feasible with similar postoperative complications and comparable survival outcomes across all stages when compared to available literature on open gastrectomy cases.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center.

BACKGROUND: Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration. MATERIALS AND METHODS: Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted. RESULTS: 171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m2. Mean defect area was 51.35 ± 45.09 cm2 and mean mesh size used was 397.56 ± 208.83 cm2. Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up. CONCLUSION: e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

Gastrointestinal stromal tumour of stomach: Feasibility of laparoscopic resection in large lesions and its long-term outcomes.

BACKGROUND: Gastric gastrointestinal stromal tumours (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of laparoscopic resection of smaller gastric GIST has been established, the feasibility and long-term efficacy of these techniques are unclear in larger lesions. This study is done to assess the feasibility of the laparoscopic resection of gastric GISTs and their long-term outcomes. METHODS: Patients who underwent laparoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics, operative findings, morbidity and histopathologic characteristics of the tumour. Patient and tumour characteristics were analysed to identify risk factors for tumour recurrence. RESULTS: There were 42 patients with a mean age of 56.7 years and had a mean tumour size was 4.5 ± 2.7 cm. Laparoscopic wedge resection was the most common procedure done. There were no major perioperative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 48 months, 36/39 (92.3%) patients were disease free and 3/39 (7.6%) had progressive disease. Univariate analysis showed that there was a statistically significant association of disease progression with tumour size, high mitotic index, tumour ulceration and tumour necrosis. The presence of >10 mitotic figures/50 high-power field was an independent predictor of disease progression. CONCLUSION: Our study establishes laparoscopic resection is feasible and safe in treating gastric GISTs for tumours >5 cm size. The long-term disease-free survival in our study shows acceptable oncological results in comparison to historical open resections.

Morbid obesity with ventral hernia: is concomitant bariatric surgery with laparoscopic ventral hernia mesh repair the best approach? An experience of over 150 cases.

BACKGROUND: Obesity has been consistently associated with a higher incidence of ventral hernia. It is preferable to treat both obesity and hernia in such patients because, with weight loss, the risk of recurrence of hernia is reduced. Bariatric surgery offers the best treatment for obesity and its associated co-morbidities and in combination with intraperitoneal onlay mesh repair (IPOM) provides the best treatment in such patients. The bariatric surgical team often faces the dilemma of whether to offer concomitant bariatric surgery with IPOM or a staged procedure in such patients because the safety of a concomitant procedure still creates doubt. OBJECTIVES: In this study we present our long-term results of the concomitant approach in such patients to analyze its long-term safety and efficacy. SETTING: Tertiary care teaching hospital, India. METHODS: We have performed a retrospective evaluation of all patients who underwent concomitant bariatric surgery with IPOM for primary or recurrent ventral hernia from January 2003 to July 2017 who completed a minimum follow-up of 12 months. RESULTS: A total of 156 patients of underwent concomitant bariatric surgery with IPOM, 120 patients (body mass index : 43.64 ± 6.8) underwent sleeve gastrectomy, and 36 patients (body mass index: 42.49 ± 8.57) underwent Roux-en-Y gastric bypass. One-hundred and seventeen patients were operated for primary hernia and 39 for recurrent hernia. There were no postoperative mesh infections and only 1 patient had recurrence. CONCLUSION: Bariatric surgery with IPOM provides the patient with a 1-stage treatment for both obesity and ventral hernia along with reduced risk of recurrence as a result of weight loss. It is safe to do a combined procedure in high volume centers with adequate expertise.

Robotic-assisted minimally invasive oesophagectomy for cancer: An initial experience.

BACKGROUND: The morbidity related to radical oesophagectomy can be reduced by adopting minimally invasive techniques. Over 250 thoraco-laparoscopic oesophagectomy (TLE) was done in our centre over the last 15 years, before adopting robotic surgery as the latest innovation in the field of minimally invasive surgery. Here, we share our initial experience of robotic-assisted minimally invasive oesophagectomy (RAMIE) for carcinoma oesophagus. METHODS: A prospective observational study conducted from February to December 2017. A total of 15 patients underwent RAMIE in this period. Data regarding demography, clinical characteristics, investigations, operating techniques, and post-operative outcome were collected in detail. RESULTS: There were 10 (66.7%) male patients and the median age of all patients was 62.9 (range 36-78) years. The median body mass index was 24.4 (range 15-32.8) kg/m2. Twelve (80.0%) patients had squamous cell carcinoma (SCC) of the oesophagus and 3 (20%) patients had adenocarcinoma (AC). Five (33.3%) patients received neoadjuvant therapy. All 15 patients underwent RAMIE. Patients with SCC underwent McKeown's procedure, and those with AC underwent Ivor Lewis procedure. Extended two-field lymphadenectomy (including total mediastinal lymphadenectomy) was done for all the patients. The median operating time was 558 (range 390-690) min and median blood loss was 145 (range 90-230) ml. There were no intra-operative adverse events, and none of them required conversion to open or total thoracolaparoscopic procedure. The most common post-operative complications were recurrent laryngeal nerve paresis (3 patients, 20.0%) and pneumonia (2 patients, 13.3%). The median hospital stay was 9 (range 7-33) days. In total, 9 (60%) patients required adjuvant treatment. CONCLUSION: Adequate experience in TLE can help minimally invasive surgeons in easy adoption of RAMIE with satisfactory outcome.