Strategies for closing the posterior rectus sheath during enhanced view totally extraperitoneal Rives-Stoppa repair.

Introduction: The popularity of endolaparoscopic extraperitoneal repairs has been on the rise due to advantages such as sublay mesh placement and early return to daily activities. However, the procedure requires overcoming a learning curve, and with increased adoption, new complications have emerged. One significant complication is the rupture of the posterior rectus sheath (PRS). In this article, we present our modifications of the technique to reduce tension during PRS closure. Patients and Methods: The study included 105 patients who underwent endolaparoscopic extraperitoneal repairs for ventral hernias using two different techniques. Group A (n = 68) underwent the original technique, whereas Group B (n = 37) underwent the modified technique. The modifications in Group B included preserving the peritoneal bridge between the two PRS and the hernia sac, conducting a complete dissection of the space of Bogros and adopting a transverse or oblique closure of PRS along the lines of least tension. To assess the efficacy of these modifications in preventing PRS rupture, we compared the results of both groups. Results: Our findings indicate that following all the technical steps of the modified technique resulted in a reduced need for transversus abdominis release for PRS closure and a lower incidence of PRS rupture in the postoperative period. However, to further validate the effectiveness of these modifications, a larger follow-up period and a bigger sample size are required. Conclusions: The adoption of the modified technique can help achieve a tension-free PRS closure.

Ciliated foregut cyst of the gall bladder in the Calot's triangle: A case report with review of literature.

Ciliated foregut cysts (CFCs) are rare anomalies of the foregut epithelium. The common sites in the abdomen are liver and gall bladder. There are only 16 cases of CFC reported in the gall bladder to date. A 20-year-old girl presented with pain in the right upper abdomen. There was a radiological evidence of cystic lesion in the region of Calot's triangle. A differential diagnosis of either type 2 choledochal cyst or CFC was made. Intraoperative and histopathological findings were suggestive of CFC. CFC should be kept in mind as a rare differential diagnosis when evaluating cysts in the gall bladder fossa.

Complexities in the management of a Richter's supraumbilical hernia with colocutaneous fistula in a patient with morbid obesity: A case report with a review of literature.

Abdominal wall Richter's hernia is rare. The usual presentation is with irreducibility, obstruction and strangulation. Occasionally, enterocutaneous fistula containing small bowel has been reported. Management is frequently difficult due to emergency presentation and contamination. A 60-year-old male with a history of suture repair of umbilical hernia presented with faecal discharge from a long-standing recurrent hernia in the background of obesity and history of pulmonary embolism. There were no features of peritonitis or obstruction. After optimisation, we took the patient for a diagnostic laparoscopy with curative intent. Diagnostic laparoscopy revealed a Richter's hernia containing transverse colon. The patient was treated with resection of the involved colonic segment, anastomosis, complete excision of the fistula tract along with surrounding skin, negative pressure wound therapy and delayed skin closure. To our knowledge, this is the first report of a spontaneous umbilical Richter's hernia complicated with a colocutaneous fistula. Management was challenging due to emergency presentation, multiple comorbidities as well as faecal contamination. Minimal access approach may have helped by decreasing the contamination and surgical site infection in the postoperative period.

Modified port positions for totally extraperitoneal (TEP) repair for groin hernias: our experience.

BACKGROUND: Totally extraperitoneal repair (TEP) is the preferred method of inguinal hernia repair for many surgeons worldwide. However, because of limited working space, there may be difficulties when operating on large and irreducible groin hernias and short stature patients. There are many ways in which the port positions can be modified during TEP for different kinds of hernias and according to the comfort of the surgeons. METHODS: This is a retrospective analysis of prospectively collected data. We describe two different variations in port placement for TEP in patients with large irreducible hernias and short stature patients. RESULTS: A total of 19 procedures were performed with these port positions. Most of these were large irreducible hernias or patients with short stature. With these modified port positions, difficult hernias could be completed with extraperitoneal approach. We had no recurrence and 5 seromas that eventually settled in 1-3 months. CONCLUSION: Modified port positions in TEP by shifting the ports farther away can be useful for hernias where the surgery is difficult due to limited working space and is a good alternative to TAPP.

Short- to Midterm Results After Posterior Component Separation with Transversus Abdominis Release: Initial Experience from India.

PURPOSE: Posterior component separation with transversus abdominis release is a new procedure and is quickly gaining popularity. It has shown promising results in terms of low recurrence rates for large and complex hernias. However, there are very little Indian data available on this to date. The purpose of this study was to assess the outcomes of the technique at three centers in India. METHODS: This was a retrospective analysis of the prospectively collected data. Patients with a minimum follow-up of 3 months who underwent open or minimal access posterior component separation were included. RESULTS: A total of 72 patients (open = 44, minimal access = 25, and hybrid = 3) were included in the analysis. At a follow-up ranging from 3 months to 35 months, there were two recurrences (2.78%). Surgical site occurrences were seen in 23/72 (31.9%), and surgical site infection was seen in 7/72 (9.7%). Surgical site occurrence requiring procedural intervention was 3/72 (4.2%). There were two (2.78%) mortalities in the open group due to myocardial infarction. CONCLUSION: Posterior component separation with transversus abdominis release may have advantages in terms of low recurrence in large hernias in the Indian population and can be used in carefully selected patients.

Weight Regain After Bariatric Surgery-A Multicentre Study of 9617 Patients from Indian Bariatric Surgery Outcome Reporting Group.

BACKGROUND: There is little robust data on weight regain (WR) after bariatric surgery making it difficult to counsel patients regarding long-term outcomes of different bariatric procedures. The purpose of this study was to see WR in medium and long term after SG, RYGB, and OAGB in Indian population. METHODS: In a multicentre study, data on preoperative and postoperative weights over 5 years were collected. Multiple definitions were applied to find the proportion of patients with significant WR increase of 25% of lost weight from nadir (definition 1), weight gain of > 10 kg from nadir (definition 2), and BMI gain of > 5 kg/m2 from nadir (definition 3). The proportion of those with significant WR was compared across sub-groups. RESULTS: A total of 9617 patients were included. Median WR at 5 years was 14.1% of lost weight, 1.92 kg/m2, and 5 kg. Significant WR using definition 1 was 35.1%, 14.6%, and 3% after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and mini-one anastomosis gastric bypass (OAGB) respectively. Severe albumin deficiency was highest in OAGB (5.9%) patients followed by SG (2.9%) and RYGB (2.2%) at 5 years(p = 0.023). Haemoglobin levels < 10 g/dL were seen in 8.2%, 9.0%, and 13.9% of SG, RYGB, and OAGB patients respectively (p = 0.041). CONCLUSIONS: In the first comparative study of WR, OAGB had lesser WR in comparison to SG and RYGB but had the most impact on Hb and albumin levels in the long term. Definition selection for reporting WR has a significant impact on the results. There is a need for standardising the reporting of WR in bariatric literature.

Extended totally extraperitoneal repair (eTEP) for ventral hernias: Short-term results from a single centre.

INTRODUCTION: There has been a surge of innovative procedures in the field of abdominal wall hernias. Works of pioneers such as Dr. Yuri Novitsky, Dr. Jorge Daes and Dr. Igor Belyansky have started a new era in the field of hernia surgery. Conventional and popular surgeries for ventral hernias are open onlay mesh hernioplasty, open retromuscular mesh hernioplasty (Rives-Stoppa procedure) and laparoscopic intraperitoneal mesh hernioplasty. Evidence seems to suggest that retromuscular mesh hernioplasty has advantages over other procedures regarding recurrence and surgical site occurrences. An alternative strategy has been developed for this setting where a mesh is placed in retromuscular space by minimal access technique of the extended Totally Extraperitoneal approach (eTEP). METHODS: We have retrospectively analysed the data of 21 patients who underwent an eTEP procedure with a minimum follow-up of 2 months. Their data were analysed for operative details, intra-operative and post-operative complications. RESULTS: For a total of 21 patients, we have recorded a total of two surgical site occurrences (1 seroma and 1 linea alba dehiscence) and one recurrence. One patient had chronic pain. There was no surgical site infection. CONCLUSION: Judging from our short-term results, we suggest that the eTEP technique can be adapted in centres with advanced laparoscopic skills with the careful patient selection.

Angiographic management of pseudoaneurysms of gastroduodenal artery following endoscopic sphincterotomy.

Gastrointestinal bleeding follows endoscopic sphincterotomy in 1 % to 10 % of patients. We report two cases of bleeding from pseudoaneurysms of the gastroduodenal artery occurring as a complication of endoscopic sphincterotomy.