Robotic Totally Extraperitoneal Hernia Repair: An Initial Experience with Cambridge Medical Robotics Versius.

Background: Total extraperitoneal approach for laparoscopic inguinal hernia repair (L-TEP) allows for better dissection, lesser chance of bowel injury, and quicker operating time. However robotic groin hernia repair is currently performed only through transabdominal route as it allows for more mobility of the arms. This study is aimed at studying the feasibility and outcomes of robotic totally extraperitoneal (R-TEP). Methods: A prospective nonrandomized comparative study was conducted to compare R-TEP with L-TEP. Out of a total of 88 patients with inguinal hernia, 44 patients underwent R-TEP and other 44 patients underwent L-TEP over a period of 15 months. All R-TEP were performed with Cambridge Medical Robotics (CMR) Versius. The outcomes were analyzed over a minimum follow-up period of 6 months. Results: All patients were males with a mean age of 45.9 years. Average body mass index was 28.7. Mean docking time for R-TEP was 12.7 minutes. Overall time taken for R-TEP (mean 60.47 minutes) was significantly higher (P < .001) than L-TEP (mean 38.45 minutes). When the console time of R-TEP and overall time of L-TEP were compared, there was no significant difference (P = .053). A RCT (RIVAL Trial) conducted by Prabhu et al. showed their robotic transabdominal preperitoneal (R-TAPP) time of median 75.5 (59.0-93.8) minutes. Kimberly et al. had their overall time of 77.5 minutes and Andre Luiz et al. had a console time of 58 minutes. When we compared the data, the overall time of R-TEP is lesser compared with R-TAPP. Postoperative pain on POD-1 showed that the robotic group had significantly lower pain. There were no recurrences noted in the study period. Conclusion: With our study, we have shown that R-TEP performed using the principle of laparoscopic triangulation technique with CMR Versius is feasible and reproducible. Although the overall time is significantly more in R-TEP when compared with L-TEP, console times of R-TEP and overall times of L-TEP were very similar. Console times of R-TEP are much lesser compared with other studies on R-TAPP. R-TEP can be a better alternative to R-TAPP and can be considered at par with L-TEP. A systematic RCT would provide a better picture.

Laparoscopic posterior rectopexy for complete rectal prolapse: Is it the ideal procedure for males?

Background: Rectal prolapse is more common in elderly women worldwide, but in India, it predominantly occurs in young- and middle-aged males. While ventral mesh rectopexy is proposed as the preferred procedure in females, the debate on the best procedure in men is still wide open. Methods: A retrospective review of all adult male patients operated for external rectal prolapse (ERP) between January 2005 and December 2019 was performed. Patients either underwent modified laparoscopic posterior mesh rectopexy (LPMR) or laparoscopic resection rectopexy (LRR). The outcome was analysed in terms of recurrence, post-operative constipation, sexual dysfunction and other complications. Results: A total of 118 male patients were included (LPMR: 106, LRR: 12). The mean age was 46.2 years (standard deviation [SD] 11.8, range: 21-88). The mean operating time was 108 min (SD: 24). The mean length of hospital stay was 4.8 days (SD: 1.4, range: 3-11 days). There was no anastomotic leak in the LRR group. Other complications included wound infection (n = 2), mesh infection with sigmoid colon perforation (n = 1), constipation (n = 4), sexual dysfunction (n = 2), urinary urgency (n = 3) and retention of urine (n = 4). There was no mortality in both the groups. During a mean follow-up of 5.2 years, recurrent ERP was noted in one patient and partial mucosal prolapse was seen in three patients. Conclusion: LPMR/LRR is a safe and effective treatment for ERP in men with very low recurrence rates. Randomised trials comparing modified LPMR with LVMR are needed to establish the better procedure in males.

Laparoscopic anterior resection: Analysis of technique over 1000 cases.

PURPOSE: Laparoscopic rectal surgery has moved from being experimental to getting established as a mainstream procedure. We aimed at analysing how rectal cancer surgery has evolved at our institute. METHODS: A retrospective review of 1000 consecutive patients who underwent laparoscopic anterior resection for rectal adenocarcinoma over a period of 15 years (January 2005 to December 2019) was performed. Technical modifications were made with splenic flexure mobilisation, intersphincteric dissection and anastomotic technique. The data collected included type of surgery, duration of surgery, conversion to open, anastomotic leak, defunctioning stoma and duration of hospital stay. The first 500 and the next 500 cases were compared. RESULTS: The study patients were predominantly males comprising 68% (n = 680). The mean age of the patients was 58.3 years (range: 28-92 years). Majority of the procedures performed were high anterior resection (n = 402) and low anterior resection (LAR) (n = 341) followed by ultra-LAR (ULAR) (n = 208) and ULAR + colo-anal anastomosis (n = 49). A total of 42 patients who were planned for laparoscopic surgery needed conversion to open procedure. Forty-one patients (4.1%) had an anastomotic leak. The mean duration of stay was 5.3 + 2.8 days. The rate of conversion to open procedure had reduced from 5.4% to 3.0%. The rate of defunctioning stoma had reduced by >50% in the recent group. The anastomotic leak rate had reduced from 5.0% to 3.2%. The average duration of stay had reduced from 5.8 days to 4.9 days. CONCLUSION: This is one of the largest single-centre experiences of laparoscopic anterior resection. We have shown the progressive benefits of an evolving approach to laparoscopic anterior resection.

Initial retrocolic endoscopic tunnel approach (IRETA) for complete mesocolic excision (CME) with central vascular ligation (CVL) for right colonic cancers: technique and pathological radicality.

INTRODUCTION: The concept of complete mesocolic excision (CME) with central vascular ligation (CVL) for treatment of right colon cancer evolved over last one decade. It decreases local recurrences and improves the survival rates. We describe our novel technique which involves first posterior sharp dissection between planes of parietal and visceral fascia of mesocolon followed by ligation of ileocolic, right colic and middle colic pedicles at their origin. We highlight the technical variations with various techniques and advantages over conventional medial to lateral approach in current study. AIM: The outcomes were measured in terms of technical feasibility, short-term outcomes and pathological radicality of current laparoscopic technique (IRETA) for CME with CVL. MATERIALS AND METHODS: Two hundred twelve patients (163 males) who underwent laparoscopic CME for right colon cancer over the period of January 2009 to December 2013 were analysed via prospectively maintained database. RESULTS: 97.16 % of patients (n = 206) underwent laparoscopic CME while six patients required open conversion. Mean operative time was 142 ± 28.4 min with median hospital stay of 5 days (range 4-11). The median count of lymph node harvested were 24 (range 10-42). The complete mesocolic excision plane was achieved in 93.8 % patients. 84.4 % (n = 179) of our patients were having (T3, N+) disease on pathological examination. The overall morbidity (<30 days) was 9.9 %. CONCLUSION: Laparoscopic initial retrocolic endoscopic tunnel approach (IRETA) for CME with CVL in right colonic cancers is safe, simpler and feasible laparoscopic approach with minimal complications. Creation of retro colic tunnel is key highlight of IRETA approach. This approach becomes especially useful in patients with late presentations where complete mesocolic excision remains essential to enhance oncological radicality as per evidence available.

A single-centre experience of relaparoscopy in complications of laparoscopic inguinal hernia repair-feasibility and outcomes.

BACKGROUND: Management of complications of laparoscopic inguinal hernia repair remains challenging as well as debatable. Relaparoscopy in management of these complications is relatively newer concept. We tried to analyse the feasibility of relaparoscopy (transabdominal preperitoneal approach) in management of complications of laparoscopic inguinal hernia repair. MATERIALS AND METHODS: The study group included 61 patients (referral cases) from a prospectively maintained database of previous laparoscopic inguinal hernia surgery with majority of the patients of recurrence (n = 39). Other complications were mesh infections (n = 15), pubic osteitis (n = 3), migration of mesh into adjacent viscera (n = 3) and meralgia paresthetica (n = 1). All patients underwent transabdominal preperitoneal approach (TAPP) between January 2007 and December 2013. RESULTS AND OUTCOME: Most of the patients had previous TEP repair (n = 49) with variable complications detected in the range of 9 days to 38 months. Small-sized mesh (n = 12) and rolled up mesh (n = 10) were the causes of recurrence in 57 % cases. Mycobacterium tuberculosis (40 %) and mixed bacterial infections (33 %) strains were detected in the infected mesh. Pubic osteitis and meralgia paresthetica were tackers induced. All patients dealt with TAPP approach. Recurrent hernia cases underwent mesh placement and infected mesh was removed in mesh infection. Tackers were removed in cases of osteitis pubis and meralgia paraesthesia. Median operative time was 62 min (42-126 min) and hospital stay 3 days (2-13 days). The relaparoscopy was accomplished in 95.1 % of cases with no major intraoperative complications and minimal postoperative morbidity. CONCLUSION: Relaparoscopy through TAPP approach remains safe and feasible option to deal with primary laparoscopic hernia repair complications. Surgical techniques during primary laparoscopic repair are important cause for aforementioned complications. Though, surgical expertize remains warranted for relaparoscopy.

Comparison of Pathological Radicality between Open and Laparoscopic Pancreaticoduodenectomy in a Tertiary Centre.

Laparoscopic pancreaticoduodenectomy (LPD) remained a formidable challenge owing to retroperitoneal location, difficult dissection near great vessels and critical intracorporeal anastomoses. Recent reviews of literature have established the feasibility and comparable short term outcomes of laparoscopic pancreaticoduodenectomy (LPD) with that of open pancreaticoduodenectomy (OPD). This study was undertaken to compare the pathological radicality of LPD with OPD. A prospective database of all patients who underwent standard pancreaticoduodenectomy from Mar 2006 to Feb 2011 was taken up for this study. 45 patients who underwent LPD and 118 patients who underwent OPD for periampullary and pancreatic head malignancy were taken up for analysis. The study groups were comparable in terms of age of presentation, ASA grades, comorbidity, type of surgery and BMI. There was no statistically significant difference with regard to tumor size, lymph node yield, node positivity rates, R1 rates and margin lengths. The pathological radicality of laparoscopic pancreaticoduodenectomy is comparable with that of open approach when performed by experienced minimal-access surgeons. Standardized protocols for evaluation of the resection margins should be mandatory in studies reporting outcomes of pancreaticoduodectomy.

Long-term results of laparoscopic pancreaticoduodenectomy for pancreatic and periampullary cancer-experience of 130 cases from a tertiary-care center in South India.

BACKGROUND: Laparoscopic pancreaticoduodenectomy (LPD), although an advanced surgical procedure, is being increasingly used for pancreatic head and periampullary tumors. We present our experience of 15 years with the largest series in total LPD for periampullary and pancreatic head tumors with data on oncological outcome and long-term survival. MATERIALS AND METHODS: Prospective and retrospective data of patients undergoing LPD from March 1998 to April 2013 were reviewed. Of the 150 cases, 20 cases of LPD (7 cases done for chronic pancreatitis and 13 cases for benign cystic tumors of the pancreas) have been excluded, which leaves us with 130 cases of LPD performed for malignant indications. RESULTS: In total, 130 patients were chosen for the study. The male:female ratio was 1:1.6, with a median age of 54 years. We had one conversion to open surgery in our series, the overall postoperative morbidity was 29.7%, and the mortality rate was 1.53%. The pancreatic fistula rate was 8.46%. The mean operating time was 310±34 minutes, and the mean blood loss was 110±22 mL. The mean hospital stay was 8±2.6 days. Resected margins were positive in 9.23% of cases. The mean tumor size was 3.13±1.21 cm, and the mean number of retrieved lymph nodes was 18.15±4.73. The overall 5-year actuarial survival was 29.42%, and the median survival was 33 months. CONCLUSIONS: LPD has evolved over a period of two decades and has the potential to become the standard of care for select periampullary and pancreatic head tumors with acceptable oncological outcomes, especially in high-volume centers. Randomized controlled trials are needed to establish the advantages of LPD.

Laparoendoscopic approach for refractory Roux-en-Y hepaticojejunostomy stricture in an acute setting: a unique case and technique.

Roux-en-Y hepaticojejunostomy stricture is a substantial problem that develops in 10%-30% of patients and requires frequent intervention. Although endoscopic/percutaneous approaches are preferred, especially for refractory stricture, open surgical reconstruction remains the gold standard. However, such an operation may be highly challenging. The recently developed covered, self-expanding metallic stent is a useful option for such difficult cases. We present a case of recurrent Roux-en-Y hepaticojejunostomy stricture complicated by densely packed intrahepatic stones and suppurative cholangitis with failed percutaneous biliary draining. Enteroscopic manipulations were unfeasible, and the case was successfully managed by the laparoendoscopic approach. If treating surgeons have the necessary expertise, this technique may be considered in such difficult scenarios.