Eight-fold path to attain laparoscopic totally extraperitoneal (TEP) hernia repair Nirvana - a standardized technique to reduce the learning curve of surgical residents.

INTRODUCTION: Laparoscopic totally extraperitoneal (TEP) hernia repair remains technically challenging due to the steep learning curve and unfamiliar territory. This paper describes an eight-step standardized technique of laparoscopic TEP hernia repair that is easily reproducible, thus reducing the learning curve. MATERIALS AND SURGICAL TECHNIQUE: The eight steps are as follows: (a) creation of the pneumo pre-peritoneal space; (b) identify the pubis symphysis; (c) identify the inferior epigastric vessels; (d) lateral to medial dissection of the hernia sac; (e) identification of cord structures and triangle of doom/pain; (f) herniotomy; (g) parietalization of the hernia sac; (h) placement and fixation of the mesh. DISCUSSION: The learning curve of laparoscopic TEP can be decreased by proctoring, standardization of the procedure and having a formal set of operative steps that residents can follow and easily repeat.

Microscopically Positive Resection Margins in Laparoscopic Gastric GIST Resection May Not Confer a Poorer Prognosis.

Laparoscopic resection of gastrointestinal stromal tumor (GIST) has increased popularity with studies showing good outcomes for patients with tumors <5 cm, with a shorter hospital stay, lower blood loss, and morbidity. Our study aims to audit the clinical profile and surgical outcomes of GISTs, with an evaluation of laparoscopic versus open surgery and the prognostic role of positive R1 margins. In our retrospective study, 62 GIST patients who underwent surgery were included and further analysis was made for the 48 gastric GISTs patients. In total, 33 patients underwent laparoscopic gastric GIST resection, whereas the rest underwent open resection. There was no difference in operative duration but the blood loss was lesser and length of stay shorter in the laparoscopic group. The laparoscopic group had a higher incidence of R1 resection but none developed recurrence or metastasis during follow-up. Laparoscopic resection in the management of gastric GISTs resulted in higher R1 resection rates but this did not affect recurrence rates or overall survival.