Laparoscopic ventral mesh rectopexy for obstructive defecation syndrome: Follow-up in the Indian population.

CONTEXT: Obstructive defecation syndrome (ODS) is a poorly understood cause of constipation. In selected patients not responding to conservative management, surgical options may be offered. Laparoscopic ventral mesh rectopexy (LVMR) is another surgical option which gained popularity in the past decade. AIM: This study aims to identify the efficacy of LVMR in the Indian population. SETTING AND DESIGN: It is a retrospective analysis of prospectively collected data of patients who underwent LVMR from January 2015 to January 2017 at a tertiary centre in India. SUBJECTS AND METHODS: Thirty patients fulfilled the inclusion criteria. Patients were periodically followed for 2 years. Pre- and post-operative modified Longo's ODS scores were recorded and compared. Furthermore, other complications were noted and evaluated. STATISTICAL ANALYSIS USED: Relevant statistical tests were used to analyse the collected data. RESULTS: Thirty patients (28 females, 2 males, mean age: 52.4 years) underwent LVMR for ODS due to anatomical abnormality like rectorectal intussusceptions (RRIs) (36.7%), rectocele (13.3%), or combined RRI with rectocele (50%). The mean pre-operative modified Longo's ODS score was 23.17 ± 4.82 which decreased to 2.37 ± 1.59 at the end of 6 months and 1.23 ± 1.14 and 1.57 ± 1.14 at the end of 12 months and 2 years, respectively. The mean modified Longo's ODS score showed a significant fall of 94.7% at 12-month follow-up and 93.2% fall on 2-year follow-up. The mean operative time was 115 min and the average hospital stay of patients who underwent LVMR was 3.26 days. CONCLUSION: LVMR is a safe surgical procedure with minimal complications and good functional results for ODS patients due to rectal anatomical abnormality. Further larger studies are required to decide the best treatment modality for ODS.

Quantitative assessment of crural closure for laparoscopic anti-reflux surgeries: A novel technique to reduce post-operative dysphagia.

BACKGROUND: Long-term dysphagia is a known complication of laparoscopic anti-reflux surgery (LARS). Of the several factors, inadequate hiatal closure is one of the major reasons for its occurrence. The aim of this study is to develop a technique for the quantitative assessment of crural closure during LARS to reduce dysphagia. MATERIALS AND METHODS: It is an analysis of prospectively collected data of 109 patients who underwent LARS at a tertiary healthcare centre in India. To identify the adequacy of hiatal closure intraoperatively, a 7 French Fogarty catheter was used, and its balloon was inflated with 1 cc air at the repaired hiatus. This inflated balloon in the repaired hiatus following cruroplasty gives an accurate quantitative assessment of the adequate closure and adequate space for food bolus to pass without causing mechanical obstruction after hiatus repair. Pre- and post-operative 12 months' DeMeester scores and lower oesophageal sphincter (LES) pressures were calculated. RESULTS: The patients had a significant reduction in DeMeester scores postoperatively from a mean of 68.5-12.3 (P < 0.0001). None of the patients had long-term dysphagia or the need for long-term proton-pump inhibitors. The mean LES pressures on post-operative manometry showed increase to 15.1 mmHg from a mean of 6.4 mmHg, which was statistically significant (P = 0.0001). None of the patients had a recurrence of hiatus hernia. CONCLUSION: Quantitative assessment of adequacy for crural closure during LARS using a 7 French Fogarty catheter balloon is a novel technique which may decrease the incidence of post-operative dysphagia or intrathoracic wrap migration or recurrence of hiatus hernia.

Laparoscopic loop cystojejunostomy: An alternative to Roux-en-Y cystojejunostomy for pancreatic pseudocyst.

Surgical internal drainage of pancreatic pseudocyst can be done into the stomach, duodenum or jejunum depending on the anatomic relation of pseudocyst with hollow viscera. For cystojejunostomy, a Roux-en-Y loop is preferred over loop cystojejunostomy as former is thought to avoid the reflux of jejunal contents into the cyst cavity. This study presents our experience with laparoscopic loop cystojejunostomy showing loop cystojejunostomy for the pseudocyst of the pancreas can be safely performed laparoscopically with simpler technique with no complications including reflux.

Laparoscopic modified lateral transabdominal preperitoneal approach for Spigelian hernia repair: An easier approach to a rare condition.

INTRODUCTION: Both laparoscopic and open approaches are well accepted for spigelian hernia (SH) repair. Several techniques for SH repair are described in literature. In our study, eight patients underwent laparoscopic SH repair. A modified lateral TAPP approach was used in four cases and then compared with the conventional TAPP approach. METHODS: From January 2015 to January 2017, eight cases of SH were treated using the laparoscopic TAPP approach. Four cases underwent surgery by the conventional laparoscopic TAPP approach (group I). For the other four, modified lateral approach transabdominal preperitoneal technique was used (group II). Postoperative pain, operative time, length of hospital stay, and complications were compared between the groups. Patients were followed up for a minimum period of 1 year. RESULT: Among the eight cases, the mean age was 52 years in group I and 50 years in group II, mean defect size was 23 mm in group I and 28 mm in group II, mean length of hospital stay was 1.50 days in group I and 1.25 days in group II, and operative time was 61 minutes in group I and 51 minutes in group II. There was no remarkable difference in complications or length of hospital stay between the groups. The groups were comparable in all other parameters, but the lateral approach was ergonomically better for the surgeon. CONCLUSION: Of the approaches described for laparoscopic SH repair, the modified lateral TAPP approach is more convenient because it provides better and more adequate lateral and inferior space access and is ergonomically better for surgeons.

Real-Time Visualization of Ureters Using Indocyanine Green During Laparoscopic Surgeries: Can We Make Surgery Safer?

Background. Intraoperative ureteral injury is rare, but a grave complication during laparoscopic surgery. Several methods for intraoperative localization of ureters are described with their own pitfalls. Intraoperative localization using near-infrared (NIR) fluorescence with indocyanine green (ICG) is an easier and assured method during laparoscopic pelvic surgeries. Method. From September 2017 to December 2017, patients undergoing laparoscopic pelvic surgeries were administered cystoscopic-guided intraureteral ICG immediately preoperatively with tip of a 6-Fr ureteral catheter. The fluorescence of ureters was visualized in the NIR mode of the camera system, localizing the ureters precisely and in real time. Results. This technique was used to visualize ureters in 30 surgeries. Median age of the patients was 46.7 years with median body mass index of 23.2 kg/m2. Mean duration between administration of dye and insertion of trocar was 10 minutes. Mean duration for insertion of cystoscopically guided intraureteral ICG was 7 minutes. Ureteral fluorescence was visualized in all cases with some variation in intensity of the brightness perceived depending on surrounding fat. Duration of the lengthiest surgery was 240 minutes, and fluorescence was appreciated till the end. There were no intraoperative or postoperative complications attributed to ICG administration. In 10 patients (33%), there was difficulty in identifying the ureters on conventional white light mode, in which ICG localization was extremely helpful. Conclusion. ICG-stained ureteral visualization under NIR light is a safe and feasible method that provides real-time ureteral demarcation. This easily replicable, sensitive, and specific method of ureteral visualization can make complex laparoscopic pelvic surgeries safer.

Combined laparoscopic and perineal approach for the management of recurrent tailgut cyst.

Tailgut cyst is an uncommon developmental anomaly arising from the embryonic hindgut in the retrorectal space. The patient frequently is asymptomatic or has vague perineal complaints that pose a diagnostic dilemma. Moreover, the patient is often misdiagnosed and therefore mismanaged. MRI is the investigation of choice for diagnosis. After the diagnosis is established, complete surgical excision is required to alleviate patient discomfort and to prevent complications such as infection, malignant transformation, and recurrence. Proper clinical examination and imaging not only establish the accurate diagnosis but also help in determining the best surgical approach for the patient (anterior abdominal, posterior sacral perineal, or combined approach). We hereby report a case of recurrent tailgut cyst managed with a combined anterior laparoscopic and perineal approach.

Redo Laparoscopic Heller's Cardiomyotomy for Recurrent Achalasia: Is Laparoscopic Surgery Feasible?

BACKGROUND: Achalasia cardia is an esophageal motor disorder with raised lower esophageal sphincter (LES) pressure. Minimally invasive procedures have become the procedure of choice compared with conventional open surgery. After the primary surgery, recurrence or persistent symptoms have been noted in almost 10%-20% of cases. MATERIALS AND METHODS: In this case series, we share our experience with a series of 7 patients who presented to us from January 2010 to January 2017 for recurrent symptoms, following Heller's myotomy for achalasia cardia. RESULTS: Commonest symptom of recurrence was dysphagia with mean duration of recurrence of 17.9 months between primary and redo surgery. Revisional Heller's myotomy with Dor's fundoplication was performed in all patients laparoscopically. Mean duration of surgery was 150 minutes. Incomplete gastric myotomy and fibrosis at previous myotomy scar were the main causes of recurrence. Mean duration of hospital stay was 3.5 days. Mean follow-up period was 23.5 months. All the patients were symptomatically better following the redo surgery. Subsequent manometry was performed at the end of 3 months with mean reduction in LES pressure of 7.5 + 1.2 mmHg. CONCLUSION: Laparoscopic redo Heller's cardiomyotomy is a possibly reasonable option with good long-term results and minimal postoperative complications in expert hands.