Laparoscopic restorative proctocolectomy ileal pouch anal anastomosis: How I do it?

Surgery for ulcerative colitis is a major and complex colorectal surgery. Laparoscopy benefits these patients with better outcomes in context of cosmesis, pain and early recovery, especially in young patients. For surgeons, it is a better tool for improving vision and magnification in deep cavities. This is not the simple extension of the laparoscopy training. Starting from preoperative preparation to post operative care there are wide variations as compared to open surgery. There are also many variations in steps of laparoscopic surgery. It involves left colon, right colon and rectal mobilisation, low division of rectum, pouch creation and anastomosis of pouch to rectum. Over many years after standardisation of this technique, it takes same operative time as open surgery at our centre. So we present our standardized technique of laparoscopic assisted restorative proctocolectomy and ileal pouch anal anastomosis (IPAA).

Techniques of laparoscopic cholecystectomy: Nomenclature and selection.

There are more than 50 different techniques of laparoscopic cholecystectomy (LC) available in literature mainly due to modifications by surgeons in aim to improve postoperative outcome and cosmesis. These modifications include reduction in port size and/or number than what is used in standard LC. There is no uniform nomenclature to describe these different techniques so that it is not possible to compare the outcomes of different techniques. We brief the advantages and disadvantages of each of these techniques and suggest the situation where particular technique would be useful. We also propose a nomenclature which is easy to remember and apply, so that any future comparison will be possible between the techniques.

Severe Colonic Complications requiring Sub-Total Colectomy in Acute Necrotizing Pancreatitis-A Retrospective Study of 8 Patients.

Colonic involvement in acute pancreatitis is associated with high mortality. Diagnosis of colonic pathology complicating acute pancreatitis is difficult. The treatment of choice is resection of the affected segment. The aim of this study is to evaluate the feasibility of aggressive surgical approach when colonic complication is suspected. Retrospectively, 8 patients with acute necrotizing pancreatitis and colonic complications (2006-2010) were reviewed. Eight patients with acute necrotizing pancreatitis requiring colonic resection were evaluated. Presentation was varied, including rectal bleeding (2), clinical deterioration during severe pancreatitis (4), colonic contrast leak on CT scan (1) and large bowel obstruction (1). Typically, patients with severe acute pancreatitis had colonic pathology obscured and unrecognized initially because of the ongoing, fulminant inflammatory process. All eight patients underwent Sub-total colectomy & ileostomy for suspected imminent or overt ischemia/perforation, based on the outer aspect of the colon. There was one mortality due to severe sepsis and multiorgan dysfunction syndrome. All other patients recovered well and later underwent closure of the stoma. Recognition of large bowel involvement may be difficult because of nonspecific symptoms or be masked by the systemic features of a critical illness. Clinicians should be aware that acute pancreatitis may erode or inflame the large bowel, resulting in lifethreatening colonic necrosis, bleeding or perforation. In our series of eight patients, we observed that mortality can be reduced by this aggressive surgical approach. We recommend a low threshold for colonic resection due to unreliable detection of ischemia or imminent perforation by outside inspection during surgery for acute necrotizing pancreatitis.

Novel Trocarless, Scarless Technique for Left Lobe Liver Retraction in Laparoscopic Upper Gastrointestinal Surgeries: Simple, Cost-effective and with Better Cosmesis.

Surgeons always look for ways to reduce the size and number of ports in laparoscopy, where in today's era, we have single-incision laparoscopic surgery (SILS). While doing so, principal 'adequate exposure' should not be compromised. For upper gastrointestinal laparoscopic surgeries, we have adopted a novel technique for retraction of the left lobe of liver, which is described here. Device can be made both single sling and double sling, with help of an infant feeding tube and any routinely used suture material. Placement of device does not require any incision, special energy source, or instrument. It can help in SILS. Detailed technique is described in the text. Operative times did not change significantly. Exposure was excellent. No special instruments or energy devices are required; thus, it is cost-effective. Reducing one port for liver retraction gives better cosmetic results. No liver injury due to the device was noticed in any of the cases. This technique is simpler and cheaper and also gives reasonable cosmetic results compared to other techniques described in the literature.

Thoracoscopic part of minimal invasive oesophagectomy in semiprone position: our initial experience.

INTRODUCTION: Surgical resection with curative intent is till the mainstay of treatment for resectable esophageal cancer. Minimal invasive oesophagectomy has the potential to lower morbidity and mortality. In all likelihood, thoracoscopic oesophagectomy in semiprone position gives all the benefits of prone position and can be converted to thoracotomy without change in patient position if needed. The aim of this study is to analyze the feasibility of thoracoscopic oesophagectomy in semiprone position. MATERIALS AND METHODS: This is a retrospective analysis of the data of thoracoscopic oesophgeactomy in semiprone position at Kaizen Hospital, a tertiary care center for gastroenterology during the period of December 2011 to December 2012. All surgeries were performed under general anesthesia with a single-lumen endotracheal tube. Esophageal mobilization was done by thoracoscopic approach in a semiprone position and an end-to-end hand-sewn cervical anastomosis was done. Abdominal part was performed by laparoscopic method in 3 patients and by laparotomy in rest of the patients. RESULTS: Total of 12 patients were included in this study. There was 1 conversion to thoracotomy and 1 surgical mortality. Mean operating time for the thoracoscopic part was 103 minutes, mean estimated blood loss for the thoracoscopic part was 110 mL, mean maximum end-tidal CO2 38.5 mm Hg, mean lymph nodes retrieved 14, and all patients had R0 resection. The median intensive care unit stay was 1 day and hospital stay was 8 days. CONCLUSIONS: Thoracoscopic part of thoracolaparoscopic oesophagectomy in semiprone position is a feasible option. It gives all advantages of prone position and thoracotomy is possible without change in patient position. However, further large-scale studies are required.

Single-incision laparoscopic percutaneous hydatid cystectomy: a novel curative approach for segment 7 hydatid cyst of liver.

Hydatid disease of the liver is one of the common cystic disease of the liver. Chemotherapy as well operative procedures are generally opted for the treatment of hydatid disease of the liver. Apart from open surgical intervention, (PAIR) Percutaneous Aspiration Injection & reaspiration, Laparoscopic hydatid cystectomy is also popularized. We have developed a novel technique for segment 7 liver hydatid cyst as a combination of single incision percutaneous technique with direct visualisation of cystic cavity under sonographic guidance.

Is oesophageal manometry a must before laparoscopic fundoplication? Analysis of 46 consecutive patients treated without preoperative manometry.

AIMS: To evaluate retrospectively the outcome of laparoscopic fundoplication in a cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD). MATERIALS AND METHODS: Forty-six patients with typical symptoms of GERD, from March 2001 to November 2009, were studied. The study was limited to patients with positive findings on upper GI endoscopy done by ourselves and "typical" symptoms (heartburn, regurgitation, and dysphagia) of GERD. Laparoscopic Nissen's fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only 1 patient, who had negative endoscopic findings, underwent a 24-hour pH-monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome and quality of life after surgery. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 85% of patients at a mean follow-up of 28 months. Thirty-nine patients were asymptomatic, 2 had minor gastrointestinal symptoms not requiring medical therapy, 3 patients had gastrointestinal symptoms requiring medical therapy/ Proton Pump Inhibitors and in 2 patients the symptoms worsened after surgery. There were no deaths. Clinically significant complications occurred in 6 patients. Median hospital stay was 3 days, decreasing from 6 in the first 10 patients to 3 in the last 10 patients. CONCLUSIONS: Preoperative oesophageal manometry is not mandatory for laparoscopic fundoplication done in selected patients with typical symptoms of GERD and upper GI endoscopy suggestive of large hiatus hernia.

Retrospective evaluation of patients of gastroesophageal reflux disease treated with laparoscopic Nissen's fundoplication.

AIMS: To evaluate retrospectively the outcome of laparoscopic fundoplication in a cohort of patients with typical symptoms of gastroesophageal reflux disease (GERD). MATERIALS AND METHODS: Forty-two patients with typical symptoms of GERD, who were operated for laparoscopic Nissen's fundoplication from March 2001 to August 2008, were studied. The study was limited to patients with positive findings on upper gastrointestinal (GI) endoscopy done by us and "typical" symptoms (heartburn, regurgitation, and dysphagia) of GERD. Laparoscopic Nissen's fundoplication was performed when clinical assessment suggested adequate oesophageal motility and length. Only one patient who had negative endoscopic findings underwent a 24-h pH monitoring before surgery. Outcome measures included assessment of the relief of the primary symptom responsible for surgery in the early postoperative period; the patient's evaluation of outcome, and quality of life after surgery. RESULTS: Relief of the primary symptom responsible for surgery was achieved in 95.24% of patients at a mean follow-up of 28 months. Thirty-five patients were asymptomatic, two had minor gastrointestinal symptoms not requiring medical therapy, three patients had gastrointestinal symptoms requiring medical therapy/Proton Pump Inhibitors (PPI) and in two patients the symptoms worsened after surgery. There were no deaths. Clinically significant complications occurred in six patients. Median hospital stay was 3 days, decreasing from 6 days in the first 10 patients to 3 days in the last 10 patients. CONCLUSIONS: Laparoscopic Nissen's fundoplication is the choice of operation for clinically symptomatic GERD patients.

Hybrid Single-incision Laparoscopic Restorative Proctocolectomy with Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Single-incision laparoscopic surgery is a rapidly evolving field as a bridge between traditional laparoscopic surgery and natural orifice transluminal endoscopic surgery. We report one of the initial clinical experiences from India for Laparoscopic Restorative Proctocolectomy and Ileal Pouch Anal Anastomosis (RPC IPAA) with this new technique. A SILSTM port was used through the curved intra-umbilical 25-mm incision. A 12-mm port was placed in the right iliac fossa at the ileostomy site. Another 5 mm port was placed in the left iliac fossa at the drain site. 10 mm 0 degree lens was used through the SILS port. Two 5 mm port were placed from the SILS port. Right iliac fossa port was the surgeon's right hand port and left hand port was 5 mm SILS port. Left iliac fossa port and 5 mm SILS port were used by the assistant surgeon for retraction. The specimen was delivered through the umbilical incision by extending the incision for 1.5 cm on either side. Ileal J Pouch was created extracorporeally and then anastomosed to the anal canal with the circular stapler laparoscopically. The diverting loop ileostomy was brought out through the right iliac fossa 12 mm port. The pelvic drain was brought out through the left iliac fossa port. The procedure was completed without any perioperative complications. Operative time was 256 minutes. Postoperative follow-up did not reveal any umbilical wound complication. Till date we have performed 26 Laparoscopic RPC with IPAA and this was the first Single Incision Laparoscopic RPC with IPAA. For experienced laparoscopic colorectal surgeons, single incision laparoscopic colectomy (SILC) is feasible. Single-incision laparoscopic colectomy is a promising alternative method as minimally invasive abdominal surgery for the treatment of patients requiring colectomy.

Left hepatic vein injury during laparoscopic antireflux surgery for large para-oesophageal hiatus hernia.

Although the advent of laparoscopic fundoplication has increased both patient and physician acceptance of antireflux surgery, it has become apparent that the laparoscopic approach is associated with an increased risk of some complications and as well as the occurrence of new complications specific to this approach. One such complication occurred in our patient who had intra-operative left hepatic vein injury during laparoscopic floppy Nissen fundoplication for large para-oesophageal rolling hernia. With timely conversion to open procedure, the bleeding was controlled and the antireflux and the procedure were completed uneventfully. However, this suggests that even with an experience in advanced laparoscopy surgery, complications can occur. Clear understanding of the normal and pathologic anatomy and its variations facilitates laparoscopic surgery and should help the surgeon avoid complications. The incidence of some of these complications decreases as surgeons gain experience; however, new complications can arise due to the increase in such procedures.

A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy.

BACKGROUND: The increase in intra-abdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of organ systems and also leads to postoperative pain. Degree of intra-abdominal pressure is directly related with such change. Laparoscopic cholecystectomy can be performed at low pressure pneumoperitoneum. However, available space for dissection is less than the high pressure pneumoperitoneum. METHODS: Twenty-six patients for elective laparoscopic cholecystectomy were studied in a prospective, randomized, patient, and surgeon blinded manner. The intra-abdominal pressure was kept either in low pressure (8 mm Hg) or in high pressure (12 mm Hg). All patients underwent two dimensional echocardiography, pulmonary function test and color Doppler examination of lower limb vessels preoperatively and postoperatively. Arterial blood gas analysis and End Tidal CO2 monitored before insufflation, during surgery and after deflation. Pain score was measured by visual analog scale and surgeon's comfort level was recorded. Postoperative analgesia requirement, complications, and hospital stay were recorded. Student t test used for the statistical analysis. RESULTS: Both groups match for the demographic parameters. Four patients required conversion to high pressure. Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were favoring low pressure pneumoperitoneum in a statistically significant manner. There was no difference between 2 groups for duration of surgery, intraoperative, and postoperative complications. However, the technical difficulties were graded more (statistically nonsignificant) with low pressure pneumoperitoneum. CONCLUSIONS: An uncomplicated gall stone disease can be treated by low pressure laparoscopic cholecystectomy with reasonable safety by an experienced surgeon. Though surgeons experience more difficulty in dissection during low pressure pneumoperitoneum, it is significantly advantageous in terms of postoperative pain, use of analgesics, preservation of pulmonary function, and hospital stay.

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The anatomy facing a surgeon during cholecystectomy is challenging as it involves complex relationship between the gallbladder, hepatic artery and extra-hepatic billiary tree. We report a case of septate gall bladder which was successfully treated with laparoscopic cholecystectomy. In this paper, we also discuss the embryology and characteristics of this rare anomaly. Lack of awareness, non-specific symptoms, signs and inadequacy of imaging methods are possible reasons for the reported problem of overlooking of this entity. Complete identification and removal of gallbladder is mandatory, as a remnant may result in recurrence of symptoms or stones.

Wegener's granulomatosis--an etiology of acute pancreatitis.

Wegener's granulomatosis is a systemic disease that usually involves the upper respiratory tract and kidneys. We report a 47-year-old man with Wegener's granulomatosis that presented as acute pancreatitis.

Dengue fever presenting as acute acalculus cholecystitis.

Classically dengue fever presents as fever with myalgia. A patient of dengue fever presented with classical symptoms and signs of acute acalculous cholecystitis. Serology and ultrasound examination identified dengue as the aetiology. Patient was treated successfully by conservative measures.