A multi-national, video-based qualitative study to refine training guidelines for assigning an "unsafe" score in laparoscopic cholecystectomy critical view of safety.

BACKGROUND: The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery's entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding "safe" vs. "unsafe" practice. METHODS: A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a "safe" vs. "unsafe" scale. Raters were asked to provide written rationale for all "unsafe" ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. RESULTS: Of the 660 ratings, 238 were scored as "unsafe" with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of "unsafe" ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. CONCLUSIONS: A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Laparoscopic cholecystectomy critical view of safety (LC-CVS): a multi-national validation study of an objective, procedure-specific assessment using video-based assessment (VBA).

BACKGROUND: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were "poor-unsafe", "adequate-safe", or "excellent-safe". METHODS: A multi-national consortium of 12 expert LC surgeons applied the OPSA-LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet's AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of "poor-unsafe" vs. "adequate/excellent-safe". RESULTS: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. CONCLUSIONS: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation.

A review of the first 100 robotic cholecystectomies with a new cart-based surgical robot at a tertiary care centre.

Background: Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. Material and Methods: The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Results: Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Conclusion: Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available.

Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature.

With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.

The first consensus statement on revisional bariatric surgery using a modified Delphi approach.

BACKGROUND: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. METHODS: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. RESULTS: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). CONCLUSION: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Laparoscopic splenectomy for large splenic pseudocyst: A rare case report and review of literature.

Laparoscopic splenectomy is gaining popularity due to less morbidity and minimal operative complications. Nowadays, laparoscopic splenectomy is the approach of choice for both benign and malignant diseases of the spleen. Splenic pseudocyst due to non-traumatic cause has been very rarely reported in literature. We report an interesting case of a rare large splenic pseudocyst without a history of previous abdominal trauma, treated successfully by laparoscopic technique and discuss literature for the same.

Laparoscopic adrenalectomy for ganglioneuroma presenting as an adrenal incidentaloma.

Adrenal incidentaloma (AI) has now become a common finding in clinical practice with advances in abdominal imaging. The prevalence of AI as reported in the literature is 0.2%-3%. Ganglioneuroma (GN) is often a benign non-functioning adrenal tumour, which has been rarely reported as AI in literature. Confirmed diagnosis of GN can only be done by histopathological examination. GNs are often asymptomatic even if they are large, and adrenalectomy is treatment for GN, with good prognosis after surgical removal. Here, we report a patient with an incidental adrenal mass that was managed laparoscopically and diagnosed as an adrenal GN on histopathology.

Transversus abdominis plane block for pain relief in patients undergoing in endoscopic repair of abdominal wall hernia: A comparative, randomised double-blind prospective study.

INTRODUCTION: Transversus abdominis plane (TAP) block is now a well-established technique in post-operative analgesia for lower abdominal surgeries. We evaluated the effect of ultrasound-guided TAP block on recovery parameters in patients undergoing endoscopic repair of abdominal wall hernia. METHODS: Thirty adults were randomised to receive either ropivacaine with dexmedetomidine (TR) or saline (TP) in TAP block, before emergence from anaesthesia. The patients were assessed for pain relief, sedation, time to ambulate (TA), discharge readiness (DR), postoperative opioid requirement and any adverse events. RESULTS:: The median visual analogue scale pain score of the study group (TR) and the control group (TP) showed a significant difference at all time points. TA was 5.3 ± 0.5 (TR) versus 7.4 ± 0.8 (TP), P< 0.001 and DR was 7.5 ± 0.9 (TR) versus 8.9 ± 0.6 (TP), P< 0.001 in hours. No adverse events were observed in any group. CONCLUSION: This study demonstrates that TAP block is a feasible option for pain relief following endoscopic repair of abdominal wall hernias. It produces markedly improved pain scores and promotes early ambulation leading to greater patient satisfaction and earlier discharge.

Laparoscopic Roux-en-Y gastric bypass: Outcomes of a case-matched comparison of primary versus revisional surgery.

INTRODUCTION: Laparoscopic adjustable gastric banding and laparoscopic sleeve gastrectomy are popular bariatric procedures. Certain complications may necessitate revision. Adverse outcomes are reported after revisional bariatric surgery. We compared patients undergoing revisional versus primary laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: This was retrospective comparative 1:1 case-matched analysis of revisional LRYGB Group A versus primary LRYGB (pLRYGB/Group B). Matching was based on body mass index (BMI) and comorbidities. BMI decrease at 6 and 12 months post-surgery, comorbidity resolution, operative time, morbidity and length of hospital stay (LOS) were compared. Total decrease in BMI, i.e., change from before initial bariatric procedure to 12 months after revision for Group A was also compared. RESULTS: Median BMI (inter-quartile range) for Group A decreased to 44.74 (7.09) and 41.49 (6.26) at 6 and 12 months, respectively, for Group B corresponding figures were 38.74 (6.9) and 33.79 (6.64) (P = 0.001 and P = 0.0001, respectively). Total decrease in BMI (Group A) was 9.8, whereas BMI decrease at 12 months for Group B was 15.2 (P = 0.23). Hypertension resolved in 63% (Group A), 70% (Group B) (P = 0.6). Diabetes resolution was 80% (Group A), 63% (Group B) (P = 0.8). Operative time for Groups A, B was 151 ± 17, 137 ± 11 min, respectively (P = 0.004). There was no difference in morbidity and LOS. CONCLUSION: Comorbidity resolution after revisional and pLRYGB are similar. Less weight loss is achieved after revision than after pLRYGB, but total weight loss is comparable. Revisional surgery is safe when performed by experienced surgeons in high-volume centres.

Acute pancreatitis as an unusual early post-operative complication following laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) at present one of the most commonly performed surgical treatments for morbid obesity worldwide. There are some complications regarding this procedure in the literature. This report presents a patient who developed acute pancreatitis immediate post-LSG. Patient was referred to our institute on 10th post-operative day with a complaint of fever, nausea, abdominal pain and leucocytosis. A diagnostic laparoscopy showed pancreatitis. Post-operatively, the patient was managed on treatment line of acute pancreatitis and recovered well. LSG is a common procedure in bariatric, and the most common complications are leakage and bleeding from the suture line. However, we encountered pancreatitis after LSG which is a rarely reported complication after LSG. We hypothesise that the development of acute pancreatitis in patients undergoing LSG is not well recognised and reported.

Case report of ventral hernia complicating bariatric surgery.

Ventral hernias (VHs) are common in the bariatric population with incidence of around 8% of patients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB). The factors contributing to the incidence of VH includes high intra-abdominal pressures, previous histories of abdominal surgeries, defects in fascial structure and reduced healing tendency. There is a high index of suspicion in BS patients with VH for hernia complications which can be lethal after LRYGB. Here, we present a case where VH complicated the LRYGB surgery.

Epidermoid cyst at a rare location, as a content of inguinal hernia: A case report with a review of the literature.

Epidermoid cysts can occur in a variety of locations including the face, trunk, neck, extremities, and scalp. No case of epidermoid cyst as content of inguinal hernia has been reported so far; however, cases with dermoid, teratoma, lipoma, lymphangioma and leiomyoma as content of inguinal canal have been reported. A 29-year-old female presented with a lump in the left inguinal region that was clinically diagnosed as left inguinal hernia. The patient was planned for laparoscopic inguinal hernia repair after routine investigation. Intraoperatively, a cystic mass was found to be attached to the left round ligament that was excised completely. Histopathological report was consistent with epidermal inclusion cyst. Inguinal epidermoid cyst mimicking inguinal hernia is a rare entity. If such a cyst is encountered during operation, it should be completely excised.

Postlaparoscopic cholecystectomy biloma in the lesser sac: A rare clinical presentation.

Bilomas resulting as a complication of cholecystectomy are often due to a leak from an inadequately secured cystic duct stump, an accessory bile duct or a duct of Luschka in the gallbladder fossa of the liver. Occasionally, bilomas may have an unusual presentation. We describe here a rare case of biloma in the lesser sac after an uneventful laparoscopic cholecystectomy.

Residual gallbladder stones after cholecystectomy: A literature review.

BACKGROUND: Incomplete gallbladder removal following open and laparoscopic techniques leads to residual gallbladder stones. The commonest presentation is abdominal pain, dyspepsia and jaundice. We reviewed the literature to report diagnostic modalities, management options and outcomes in patients with residual gallbladder stones after cholecystectomy. MATERIALS AND METHODS: Medline, Google and Cochrane library between 1993 and 2013 were reviewed using search terms residual gallstones, post-cholecystectomy syndrome, retained gallbladder stones, gallbladder remnant, cystic duct remnant and subtotal cholecystectomy. Bibliographical references from selected articles were also analyzed. The parameters that were assessed include demographics, time of detection, clinical presentation, mode of diagnosis, nature of intervention, site of stone, surgical findings, procedure performed, complete stone clearance, sequelae and follow-up. RESULTS: Out of 83 articles that were retrieved between 1993 and 2013, 22 met the inclusion criteria. In most series, primary diagnosis was established by ultrasound/computed tomography scan. Localization of calculi and delineation of biliary tract was performed using magnetic resonance imaging/magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography. In few series, diagnosis was established by endoscopic ultrasound, intraoperative cholangiogram and percutaneous transhepatic cholangiography. Laparoscopic surgery, endoscopic techniques and open surgery were the most common treatment modalities. The most common sites of residual gallstones were gallbladder remnant, cystic duct remnant and common bile duct. CONCLUSION: Residual gallbladder stones following incomplete gallbladder removal is an important sequelae after cholecystectomy. Completion cholecystectomy (open or laparoscopic) is the most common treatment modality reported in the literature for the management of residual gallbladder stones.

Adrenal angiomyolipoma: A case report and review of literature.

Angiomyolipoma (AML) is a rare mesenchymal tumour arising from perivascular epithelioid cells. It is most commonly seen in kidney, but rarely AML can arise in extra renal sites. Adrenal AML is a very rare clinical entity, and very few cases have been reported so far. We present our experience with a 43-year-old female, who presented with right flank pain. Magnetic resonance imaging showed a right adrenal mass. Laparoscopic adrenelectomy was performed, and the histopathology report confirmed the diagnosis of AML. Patient was discharged uneventfully.

Laparoscopic retrieval of an unusual foreign body.

Ingestion of foreign body is a serious problem commonly encountered in our clinical practice. Most of them pass spontaneously, whereas in others endoscopic or surgical intervention is required because of complications or non-passage from the gastrointestinal tract. We present here a case of teaspoon ingestion, which did not pass spontaneously. Laparoscopic retrieval of teaspoon was done from mid jejunum after enterotomy and the patient recovered uneventfully. Right intervention at the right time is of paramount importance.

Stump appendicitis: A rare clinical entity.

Stump appendicitis is one of the rare delayed complications after appendectomy with reported incidence of 1 in 50,000 cases. Stump appendicitis can present as a diagnostic dilemma if the treating clinician is unfamiliar with this rare clinical entity. We report an 18-year-old patient with Stump appendicitis, who underwent completion appendectomy laparoscopically.

Laparoscopic repair of suprapubic hernias: transabdominal partial extraperitoneal (TAPE) technique.

BACKGROUND: Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder. METHODS: We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper's ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh. RESULTS: Mean diameter of the hernial defect was 5.2 cm (range=3.1-7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm2 (range=225-506 cm2). Mean operating time was 116 min (range=64-170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range=1.2-6.9 years) and a follow-up rate of 84.7% CONCLUSION: A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper's ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.

Role of DiaRem Score in Preoperative Prediction of Type 2 Diabetes Mellitus Remission After Laparoscopic Roux-en-Y Gastric Bypass: Indian Perspective.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) has emerged as the most effective treatment in reversing insulin resistance in patients with type 2 diabetes mellitus (T2DM). A number of models and statistical tools have been proposed to predict patients likely to experience diabetes remission post-RYGB. The purpose of our study was to evaluate the preoperative accuracy of DiaRem score in predicting T2DM remission at 1 year of follow-up in a retrospective analysis of diabetic morbidly obese patients who underwent RYGB. METHODS: One hundred and forty-three patients underwent RYGB between January 2018 and December 2018. We conducted a retrospective analysis in 55 patients (38.46%) with T2DM with 1 year of follow-up. DiaRem score was calculated, and patients were stratified in five groups. RESULT: At a 1-year follow-up, we found a higher proportion of patients with T2DM remission in the lower score group compared to a lower proportion of patients with remission in the higher score group. We derived a DiaRem cut-off score of 6.5 that had high sensitivity and specificity to predict T2DM remission preoperatively. We found a significant decrease in BMI and HbA1C values post-operatively at 1 year following RYGB. CONCLUSION: DiaRem score is an easy to determine score based on basic clinical parameters that could identify patients with T2DM who would achieve maximal benefit in terms of remission after bariatric surgery. The development of a suitable scoring tool would be clinically useful as it would enable clinicians to better triage patients for RYGB.

The Effect of Bariatric Surgery on Patients with Chronic Kidney Disease.

The effect of bariatric surgery on renal functions of patients with chronic kidney disease (CKD) is not well characterized. This prospective study included 13 adult patients having chronic kidney disease who underwent bariatric surgery. The primary objective was to examine the change in glomerular filtration rate (GFR) at 6 months post-bariatric surgery. Median GFR (measured by creatinine clearance) did not change significantly (55 ml/min vs 59 ml/min, p = 0.345) although there was a significant decrease in the protein excretion rate (1700 mg/day vs 900 mg/day, p = 0.001) at 6 months. An improvement in the KDIGO CKD risk category was seen in 30.7% patients. In CKD patients undergoing bariatric surgery, renal function improves over the first 6 months with a decrease in proteinuria and a stable GFR.