Uncommon Presentation of Hypersplenism in Adult Sickle Cell Disease Patients: A Rare Case Report.

BACKGROUND Hypersplenism, the rapid and premature destruction of blood cells, encompasses a triad of splenomegaly, cytopenias (anemia, leukopenia, or thrombocytopenia), and compensatory bone marrow proliferation. Secondary hypersplenism results from non-intrinsic splenic diseases, such as hemoglobinopathies. Sickle cell disease consists of a group of genotypes, where hemoglobin sickle C disease (HbSC) is the inheritance of hemoglobin S with hemoglobin C. Most homozygous genotypes undergo complete auto-splenectomy by age 6 years, whereas those with HbSC disease rarely do. We report a rare case of hypersplenism and massive splenomegaly in an adult with sickle cell disease, the HbSC genotype, requiring splenectomy. CASE REPORT A 41-year-old woman with known splenomegaly initially presented to the general surgery clinic for management of abdominal pain. She was found to have anemia, indicating cytopenia likely from hypersplenism. Consequently, she underwent splenic artery embolization, followed by an exploratory laparotomy and splenectomy, with an unremarkable postoperative course. CONCLUSIONS Acute splenic sequestration crisis can result from hypersplenism, a potentially fatal complication of sickle hemoglobinemia. The continuous cycle of sickled cell entrapment and stasis causes numerous splenic infarctions, forming splenic parenchymal scar tissue which reduces the spleen's size and functionality - the process of auto-splenectomy. Adults rarely experience these crises past adolescence, which are secondary to the scarring and atrophy from premature auto-splenectomy. Our patient's spleen measured 21.1 cm, larger than the average adult's spleen. In our case, adjunctive preoperative splenic artery embolization likely contributed to decreased intraoperative blood loss during splenectomy, mitigating the need for perioperative transfusions.

A SAGES technology and value assessment and pediatric committee evaluation of mini-laparoscopic instrumentation.

BACKGROUND: The TAVAC and Pediatric Committees of SAGES evaluated the current use of mini-laparoscopic instrumentation to better understand the role this category of devices plays in the delivery of minimally invasive surgery today. METHODS: The role of mini-laparoscopic instrumentation, defined as minimally invasive instruments of between 1 and 4 mm in diameter, was assessed by an exhaustive review of the peer reviewed literature on the subject between 1990 and 2021. The instruments, their use, and their perceived value were tabulated and described. RESULTS: Several reported studies propose a value to using mini-laparoscopic instrumentation over the use of larger instruments or as minimally invasive additions to commonly performed procedures. Additionally, specifically developed smaller-diameter instruments appear to be beneficial additions to our minimally invasive toolbox. CONCLUSIONS: The development of small instrumentation for the effective performance of minimally invasive surgery, while perhaps best suited to pediatric populations, proves useful as adjuncts to a wide variety of adult surgical procedures. Mini-laparoscopic instrumentation thus proves valuable in selected cases.

Knowledge, attitude, and practice of artificial intelligence in emergency and trauma surgery, the ARIES project: an international web-based survey.

AIM: We aimed to evaluate the knowledge, attitude, and practices in the application of AI in the emergency setting among international acute care and emergency surgeons. METHODS: An online questionnaire composed of 30 multiple choice and open-ended questions was sent to the members of the World Society of Emergency Surgery between 29th May and 28th August 2021. The questionnaire was developed by a panel of 11 international experts and approved by the WSES steering committee. RESULTS: 200 participants answered the survey, 32 were females (16%). 172 (86%) surgeons thought that AI will improve acute care surgery. Fifty surgeons (25%) were trained, robotic surgeons and can perform it. Only 19 (9.5%) were currently performing it. 126 (63%) surgeons do not have a robotic system in their institution, and for those who have it, it was mainly used for elective surgery. Only 100 surgeons (50%) were able to define different AI terminology. Participants thought that AI is useful to support training and education (61.5%), perioperative decision making (59.5%), and surgical vision (53%) in emergency surgery. There was no statistically significant difference between males and females in ability, interest in training or expectations of AI (p values 0.91, 0.82, and 0.28, respectively, Mann-Whitney U test). Ability was significantly correlated with interest and expectations (p < 0.0001 Pearson rank correlation, rho 0.42 and 0.47, respectively) but not with experience (p = 0.9, rho - 0.01). CONCLUSIONS: The implementation of artificial intelligence in the emergency and trauma setting is still in an early phase. The support of emergency and trauma surgeons is essential for the progress of AI in their setting which can be augmented by proper research and training programs in this area.

Laparoscopic Total Pancreatectomy for Chronic Pancreatitis.

Although minimally invasive pancreatectomy has been performed increasingly for pancreatic malignancies, many authors feel that a history of pancreatitis is a contraindication to either laparoscopic or robotic-assisted pancreatectomy. Shown here is a video (Supplemental Digital Content 1, http://links.lww.com/SLE/A172) of a laparoscopic total pancreatectomy with splenectomy for chronic pancreatitis. This patient was denied auto-islet cell transplantation because of insurance restraints. In total, 4 laparoscopic total pancreatectomies have been attempted and completed. Indications for laparoscopic total pancreatectomy have been 2 for diffuse intraductal papillary mucinous neoplasm, 1 for pancreatic adenocarcinoma, and the above-mentioned patient. No patient suffered a biliary leak, and the average length of stay was 5 days (range, 4 to 8 d). History of pancreatitis is a relative contraindication to minimally invasive pancreatectomy. It should be performed by surgeons with expertise in both open and minimally invasive pancreatic surgery.

Indocyanine green (ICG) fluorescent cholangiography during robotic cholecystectomy: results of 184 consecutive cases in a single institution.

BACKGROUND/AIM: Laparoscopic cholecystectomy is currently the gold standard treatment for gallstone disease. Bile duct injury is a rare and severe complication of this procedure, with a reported incidence of 0.4% to 0.8% and is mostly a result of misperception and misinterpretation of the biliary anatomy. Robotic cholecystectomy has proven to be a safe and feasible approach. One of the latest innovations in minimally invasive technology is fluorescent imaging using indocyanine green (ICG). The aim of this study is to evaluate the efficacy of ICG and the Da Vinci Fluorescence Imaging Vision System in real-time visualization of the biliary anatomy. METHODS: A total of 184 robotic cholecystectomies with ICG fluorescence cholangiography were performed between July 2011 and February 2013. All patients received a dose of 2.5 mg of ICG 45 minutes prior to the beginning of the surgical procedure. The procedures were multiport or single port depending on the case. RESULTS: No conversions to open or laparoscopic surgery occurred in this series. The overall postoperative complication rate was 3.2%. No biliary injuries occurred. ICG fluorescence allowed visualization of at least 1 biliary structure in 99% of cases. The cystic duct, the common bile duct, and the common hepatic duct were successfully visualized with ICG in 97.8%, 96.1%, and 94% of cases, respectively. CONCLUSIONS: ICG fluorescent cholangiography during robotic cholecystectomy is a safe and effective procedure that helps real-time visualization of the biliary tree anatomy.

State of the art of robotic pancreatic surgery.

More than a decade has passed since robotic technology was adopted for abdominal surgery, and virtually every gastrointestinal operation has since been shown to be feasible, safe, and reproducible using the robotic approach. Robotic pancreatic surgery had been left behind at the beginning, because they were technically challenging, requiring not only being very familiar with the robotic technology but also having a perfect knowledge of the anatomical variations, very frequent in this area. Nonetheless in the last few years many authors have approached the robot for pancreatic surgery with very promising results in terms of surgical and oncological outcomes. The aim of this article is to review the literature on robotic pancreatic surgery and to define the state of the art use of the robotic approach for pancreatic disease.

State of the art in robotic hepatobiliary surgery.

Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.

Aortoiliac thrombi in inflammatory bowel disease.

Isolated arterial thrombi complicating inflammatory bowel disease occurs rarely. We encountered a case of a 28-year-old man with Crohn disease who presented with abdominal pain and severe claudication and was found to have an isolated aortoiliac thrombus. Bilateral aortoiliac thromboembolectomies were performed with successful restoration of femoral blood flow. Long-term anticoagulation therapy was instituted after an extensive hypercoagulable workup, which failed to reveal an etiology for the patient's coagulopathy. We present our case and perform an extensive literature review on this topic.

Sleeve gastrectomy improves glucose homeostasis in Zucker diabetic fatty rats.

BACKGROUND: Bariatric surgery improves glucose homeostasis, but the mechanism of action is poorly understood. The aim of this study was to assess the effect of sleeve gastrectomy (SG) on glucose homeostasis in two obese populations of rats. METHODS: Two strains of rats [Zucker fatty (ZF) and Zucker diabetic fatty (ZDF)] were each divided into two groups: sham and SG. Food intake was measured daily, and weight was measured bi-weekly. Oral glucose tolerance testing (OGTT) was performed before and 45 days after surgery. RESULTS: In both strains of rats, there was no statistical difference in food intake and weight gain between the sham and SG rodents before and after surgery. In ZF rats, there was no change in fasting glucose or OGTT area under the curve (AUC) before or 45 days after surgery. In the ZDF rodents, the mean preoperative fasting glucose and OGTT AUC was 204 ± 25 and 25,441 ± 2,648, respectively. At 45 days after surgery, mean fasting glucose significantly increased in the sham (sham = 529 ± 26, p = 0.0003) but not in the SG rodents (SG = 289 ± 46, p = 0.1113). In ZDF sham animals, OGTT at 45 days showed a higher AUC compared to before surgery (44,983 ± 6,338, p = 0.006), whereas in ZDF SG rodents, the increase in AUC glucose approached but did not reach statistical significance (35,553 ± 3,925, p = 0.06). CONCLUSIONS: In ZF and ZDF rodents, SG did not influence food intake and weight evolution. In ZDF rodents, diabetes progressed in the sham group but not in the SG group.

Partial small bowel resection with sleeve gastrectomy increases adiponectin levels and improves glucose homeostasis in obese rodents with type 2 diabetes.

BACKGROUND: The aim of this study was to examine the effect of small bowel resection with and without sleeve gastrectomy on glucose homeostasis in an obese rodent model of type 2 diabetes. METHODS: Zucker diabetic fatty rats were randomized into three surgical groups: Sham, small bowel resection, and small bowel resection with sleeve gastrectomy (BRSG). Weight and fasting glucose levels were measured at randomization and monitored after surgery. Oral glucose tolerance testing was performed at baseline and 45 days after surgery to assess glucose homeostasis and peptide changes. RESULTS: At baseline, all animals exhibited impaired glucose tolerance and showed no difference in weight or fasting (area under the curve) AUC(glucose). At sacrifice, Sham animals weighed more than BRSG animals (p = 0.047). At day 45, the Sham group experienced a significant increase in AUC(glucose) compared to baseline (p = 0.02), whereas there was no difference in AUC(glucose) in either surgical group at any time point: BR (p = 0.58) and BRSG (p = 0.56). Single-factor ANOVA showed a significant difference in AUC(glucose) of p = 0.004 between groups postoperatively: Sham (50,745 ± 11,170) versus BR (23,865 ± 432.6) (p = 0.01); Sham versus BRSG (28,710 ± 3188.8) (p = 0.02). There was no difference in plasma insulin, GLP-1, or adiponectin levels before surgery, although 45 days following surgery adiponectin levels where higher in the BRSG group (p = 0.004). CONCLUSIONS: Partial small bowel resection improved glucose tolerance independent of weight. The combination of small bowel resection and sleeve gastrectomy leads to an increase in adiponectin levels, which may contribute to improved glucose homeostasis.

Laparoscopic diagnosis of annular pancreas in a patient with mucinous cystoadenoma of the body of the pancreas.

INTRODUCTION: Annular pancreas (AP) is a rare anomaly due to malrotation of the pancreatic ventral bud during embryologic development. AP has been extensively described in the pediatric population; however, in adults, the incidence has been reported to be only 1 in 22,000 patients with only a few cases presenting with simultaneous mucinous cystadenoma described in the recent literature. CASE REPORT: We report the case of a 72-year-old female patient with a mucinous cystadenoma, who was found to have a concomitant AP during laparoscopic distal pancreatectomy. DISCUSSION: The dual presentation of annual pancreas and mucinous cystoadenoma is an infrequent condition and can be managed with minimally invasive techniques; bypass in adults should only be performed in patients with symptomatic duodenal compression or recurrent bouts of pancreatitis.

Sleeve gastrectomy with ileal transposition (SGIT) induces a significant weight loss and diabetes improvement without exclusion of the proximal intestine.

INTRODUCTION: Current effective bariatric procedures such as gastric bypass generate a duodenal-jejunal exclusion, which has been implicated in the resolution of type 2 diabetes. The aim of this study was to test the hypothesis that sleeve gastrectomy with ileal transposition (SGIT), a new procedure, is as effective as Roux-en-Y gastric bypass (RYGB) to induce glucose control on an obese rat model of type 2 diabetes mellitus. METHODS: Twenty eight obese diabetic Zucker rats, weighing 571 ± 151 g were assigned into three procedures: SGIT (n = 11), RYGB (n = 7), and sham operation (n = 10). Animals were followed, evaluating weekly weight increase and food intake. We performed an insulin tolerance test after 8 weeks and measured serum peptide tyrosine-tyrosine (PYY 3-36) and ghrelin levels. RESULTS: Nine weeks after surgery, sham-operated animals increased their body weight by 24%. In far contrast, SGIT and RYGB rats weighed 21% and 18% less than sham animals, respectively (sham, 884 ± 15 g; SGIT, 720 ± 19 g; RYGB, 754 ± 14 g; p < 0.001). No significant differences were found between SGIT and RYGB. Cumulative food intake in SGIT and RYGB procedures decreased by 29.6% and 32.9%, respectively (sham, 576.3 ± 33 g; SGIT, 405.8 ± 10 g; RYGB, 386.4 ± 21 g; p < 0.001). No differences were found between SGIT and RYGB rats. Sixty minutes after oral gavage, PYY levels were increased by 185% and 74% in SGIT and RYGB, respectively (sham, 63.4 ± 2.1 pg/ml; SGIT, 192.7 ± 17 pg/ml; RYGB, 117.7 ± 4.8 pg/ml; p < 0.001). Glucose tolerance was improved after SGIT and RYGB surgery demonstrated by area under the curve analysis (sham, 27,090 ± 1,424; SGIT, 17,704 ± 1,288 mg/dl; p < 0.018; RYGB, 16,212 ± 2,522; p < 0.01). CONCLUSION: SGIT proved to be as effective as RYGB on obese diabetic rats as a weight loss procedure. Also, glucose homeostasis improved in SGIT, similar to RYGB, in spite of the absence of duodenal-jejunal exclusion. This observation does not support the theory that RYGB reversal of diabetes is due to duodenal-jejunal exclusion.

Multiple nerve blocks after video-assisted thoracic surgery (VATS).

INTRODUCTION: Epidural analgesia and/or systemic narcotics are used for pain control after video-assisted thoracic surgery (VATS) lobectomy despite side effects. We report a video of a technique to safely place subpleural catheters in order to provide multiple nerve blocks and the results from our series comparing this technique to a standard post-operative analgesia protocol after VATS. METHODS: At the end of the VATS wedge resection, two small incisions were made below and parallel to the position of the trocars, at the level of the anterior and posterior axillary line and an introducer was used to place a catheter subcutaneously. At this point, the introducer was curved, in a way to follow the anatomic shape of the costal margin of the patient, inserted into posterior incision and advanced in between the thoracic pleura and the ribs. Under direct vision from the thoracoscope and paying careful attention not to perforate the pleura, the guide was pushed toward the first rib by using a combination of blunt and hydro dissection. Once the guide reached the first rib, the introducer was removed and the catheter was left in place. RESULTS: We evaluated 64 patients (29 patient-controlled analgesia (PCA), 35 SC). Propensity weighting produced two matched groups for further analysis. Mean total morphine dose and mean total morphine dose/body mass index (BMI) were both significantly decreased in the SC group for the 0-24 h period only (mean total morphine 38.1 vs. 27.8; P = 0.024 and mean total morphine/BMI 1.15 vs 0.79; P = 0.024). Complication rates did not differ between groups. CONCLUSIONS: PCA narcotic analgesia with subpleural local anesthetic infusion provided similar pain control with less narcotic use in patients during the first 24 h after VATS lobectomy compared with PCA narcotic analgesia alone.

Laparoscopic pancreatoduodenectomy: a review of 285 published cases.

BACKGROUND: Given the difficulty level of minimally invasive pancreatoduodenectomy (MIPD), limited data exist for a comparison to open pancreatoduodenectomies. As the technique becomes more diffuse, issues regarding the adequacy of oncologic margins and lymph node retrieval need to be addressed. METHODS: All published cases of MIPD were examined. Variables analyzed included conversion rates, operating room time, estimated blood loss, length of stay, follow-up, complications, mortality, lymph node retrieval, and margins. RESULTS: Twenty-seven articles describing outcomes after MIPD were found, and a total of 285 cases were described. Main malignancy treated was pancreatic adenocarcinoma, accounting for 32% of all cases. Eighty-seven percent were performed totally laparoscopically, and 13% were performed with a hand-assisted approach to facilitate the reconstruction step of the procedure. The rate of conversion to an open procedure was 9%. Estimated blood loss had a weighted average (WA) of 189 mL. Average length of stay had a WA of 12 days, and average follow-up had a WA of 14 months. The overall complication rate was 48%, and the overall mortality rate was 2%. Average lymph nodes retrieved ranged from 7 to 36 nodes, with a WA of 15 nodes, and positive margins of resection were reported to be positive in 0.4% of patients with malignant disease. CONCLUSIONS: This review found similar outcomes with respect to perioperative morbidity and mortality rates compared to open pancreatoduodenectomies. The oncologic goals of pancreatic resection may be able to be achieved by MIPD, but longer follow-up and larger series are still needed.

Single incision diagnostic laparoscopy in a patient with sclerosing peritonitis.

INTRODUCTION: Sclerosing peritonitis (SP) is a rare disease that can cause abdominal pain and intestinal obstruction. SP can be primary (also called abdominal cocoon) or secondary (when it is mainly due to systemic diseases or the intraperitoneal instillation of medications). METHODS: We report the video of a single incision diagnostic laparoscopy in a patient with SP with the educational intent of allowing easier recognition of this rare disease. RESULTS: The patient is a 72-year-old female with a history of bladder cancer, salivary gland cancer, and squamous cell cancer of the skin. She was diagnosed with a suspicion of SP during a diagnostic laparoscopy made to rule out ovarian cancer at an outside institution. Due to worsening of her symptoms, she was presented to our hospital for a second opinion. Due to inadequate tissue from her first exploration, she was brought to the operating room for a diagnostic laparoscopy. DISCUSSION: Although SP can mimic the gross appearance of peritoneal carcinomatosis, multiple biopsies should be obtained to allow for the diagnosis of SP. This video shows how this rare disease entity can present and how an abdomen with even thick fibrosis can be managed with a minimally invasive approach.

Re-emergence of diabetes after gastric bypass in patients with mid- to long-term follow-up.

BACKGROUND: Studies have shown that type 2 diabetes (T2DM) improves or resolves shortly after Roux-en-Y gastric bypass (RYGB). Few data are available on T2DM recurrence or the effect of weight regain on T2DM status. METHODS: A review of 42 RYGB patients with T2DM and >or=3 years of follow-up and laboratory data was performed. Postoperative weight loss and T2DM status was assessed. Recurrence or worsening was defined as hemoglobin A1c >6.0% and fasting glucose >124 mg/dL and/or medication required after remission or improvement. Patients whose T2DM recurred or worsened were compared with those whose did not, and patients whose T2DM improved were compared with those whose T2DM resolved. RESULTS: T2DM had either resolved or improved in all patients (64% and 36%, respectively); 24% (10) recurred or worsened. The patients with recurrence or worsening had had a lower preoperative body mass index than those without recurrence or worsening (47.9 versus 52.9 kg/m2; P = .05), regained a greater percentage of their lost weight (37.7% versus 15.4%; P = .002), had a greater weight loss failure rate (63% versus 14%; P = .03), and had greater postoperative glucose levels (138 versus 102 mg/dL; P = .0002). Patients who required insulin or oral medication before RYGB were more likely to experience improvement rather than resolution (92% versus 8%, P

Outcomes of laparoscopic adjustable gastric banding in patients with low body mass index.

BACKGROUND: The current National Institutes of Health guidelines have recommended bariatric surgery for patients with a body mass index (BMI) >40 kg/m(2) or BMI >35 kg/m(2) with significant co-morbidities. However, some preliminary studies have shown that patients with a BMI that does not meet these criteria could also experience similar weight loss and the benefits associated with it. METHODS: An institutional review board-approved protocol was obtained to study the effectiveness of laparoscopic adjustable gastric banding in patients with a low BMI. A total of 66 patients with a BMI of 30-35 kg/m(2) and co-morbidities (n = 22) or a BMI of 35-40 kg/m(2) without co-morbidities (n = 44) underwent laparoscopic adjustable gastric banding. These patients were compared with 438 standard patients who had undergone laparoscopic adjustable gastric banding who met the National Institutes of Health criteria for bariatric surgery. The excess weight loss at 3, 6, 12, and 18 months and the status of their co-morbidities were compared between the 2 groups. RESULTS: The average BMI for the study group was 36.1 +/- 2.6 kg/m(2) compared with 46.0 +/- 7.3 kg/m(2) for the control group. Both groups had significant co-morbidities, including hypertension, diabetes, hyperlipidemia, arthritis, gastroesophageal reflux disease, stress incontinence, and obstructive sleep apnea. The mean percentage of excess weight loss was 20.3% +/- 9.0%, 28.5% +/- 14.0%, 44.7% +/- 19.3%, and 42.2% +/- 33.7% at 3, 6, 12, and 18 months, respectively. This was not significantly different from the excess weight loss in the control group, except for at 12 months. Both groups showed similar improvement of most co-morbidities. CONCLUSION: Moderately obese patients whose BMI is less than the current guidelines for bariatric surgery will have similar weight loss and associated benefits. Laparoscopic adjustable gastric banding is a safe and effective treatment for patients with a BMI of 30-35 kg/m(2).

Video. Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy.

Enthusiasm for natural orifice transluminal endoscopic surgery (NOTES) has been partly tempered by the reality that most NOTES procedures to date have been laparoscopically assisted. After safely performing transvaginal cholecystectomy in an IACUC-approved porcine model, the authors embarked on an institution review board (IRB)-approved protocol for ultimate performance of pure NOTES cholecystectomy in humans. They describe their experience performing a true NOTES transvaginal cholecystectomy after safely accomplishing three laparoscopically assisted or hybrid procedures in humans. One of the patients was a 35-year-old woman presenting with symptoms of biliary colic. Ultrasound confirmed gallstones, and her liver enzymes were normal. Pneumoperitoneum to 15 mmHg was obtained via a transvaginal trocar placed through a colpotomy made under direct vision. A double-channel endoscope then was advanced into the abdomen. To overcome the retracting limitations of currently available endoscopes, the authors used an extra-long 5-mm articulating retractor placed into the abdomen via a separate colpotomy made under direct vision using the flexible endoscope in a retroflexed position. Endoscopically placed clips were used for control of both the cystic duct and the artery. These techniques obviated the need for any transabdominally placed instruments or needles. This patient was the first to undergo a completely NOTES cholecystectomy at the authors' institution, and to their knowledge, in the United States. She was discharged on the day of surgery and at this writing has not experienced any complication after 1 month of follow-up evaluation. Performance of NOTES transvaginal cholecystectomy without aid of laparoscopic or needleoscopic instruments is feasible and safe for humans. Additional experience with this technique are required before studies comparing it with standard laparoscopy and hybrid techniques are appropriate.

Laparoscopic repair of left lumbar hernia after laparoscopic left nephrectomy.

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.