First robotic pylorus preserving pancreaticoduodenectomy for Frantz's tumour in an adolescent girl.

Solid pseudopapillary tumour (SPT) is one of the uncommon benign cystic neoplasms of pancreas occurring predominantly in young females. Being benign in nature, surgical resection is the treatment of choice with excellent 5-year survival. A 14-year-old girl presented with pain abdomen for 1 week. On evaluation, she was found to have a large SPT involving head and uncinate process of Pancreas She underwent robotic pylorus preserving pancreaticoduodenectomy (R-PPPD) with da Vinci® Si Robotic System (Intuitive Surgical, Sunnyvale, CA, USA). The total operating time was 480 min. Her postoperative recovery was uneventful and she was discharged on postoperative day 6. In the era of minimally invasive surgery, robotic pancreatic resection and reconstruction are becoming more acceptable. Although the operating domain is small in younger age group, the precise movement of robotic arm and high quality magnified three-dimensional view allows the surgeons to perform PPPD on younger patients also. Young female patients suffering from SPTs can electively undergo R-PPPD with minimal morbidity and mortality. R-PPPD can become the treatment of choice for SPTs involving pancreatic head region even in paediatric and adolescent age group.

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.

Laparoscopic radical cholecystectomy for suspected early gall bladder carcinoma: thinking beyond convention.

BACKGROUND: Gall bladder cancer (GBC) is the most common and aggressive malignancy of the biliary tract with extremely poor prognosis. Radical resection remains the only potential curative treatment for operable lesions. Although laparoscopic approach is now considered as standard of care for many gastrointestinal malignancies, surgical community is still reluctant to use this approach for GBC probably because of fear of tumor dissemination, inadequate lymphadenectomy and overall nihilistic approach. Aim of this study was to share our initial experience of laparoscopic radical cholecystectomy (LRC) for suspected early GBC. METHODS: From 2008 to 2013, 91 patients were evaluated for suspected GBC, of which, 14 patients had early disease and underwent LRC. RESULTS: Mean age of the cohort was 61.14 ± 4.20 years with male/female ratio of 1:1.33. Mean operating time was 212.9 ± 26.73 min with mean blood loss of 196.4 ± 63.44 ml. Mean hospital stay was 5.14 ± 0.86 days without any 30-day mortality. Bile leak occurred in two patients. Out of 14 patients, 12 had adenocarcinoma, one had xanthogranulomatous cholecystitis and another had adenomyomatosis of gall bladder as final pathology. Resected margins were free in all (>1 cm). Median number of lymph nodes resected was 8 (4-14). Pathological stage of disease was pT2N0 in eight, pT2N1 in three and pT3N0 in one patient. Median follow-up was 51 (14-70) months with 5-year survival 68.75 %. CONCLUSIONS: Laparoscopic radical cholecystectomy with lymphadenectomy can be a viable alternative for management of early GBC in terms of technical feasibility and oncological clearance along with offering the conventional advantages of minimal access approach.

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.

Hepatic artery reconstruction following iatrogenic injury during laparoscopic distal pancreatectomy: Minimal access surgery is new horizon.

Although minimally invasive surgery has evolved in every field of surgery, its use in vascular surgery is limited to major vessel diseases only. A 23-year-old female presented with a cystic lesion in the distal body and the tail of the pancreas. Triphasic computed tomography (CT) abdomen revealed a 4.5 cm × 3.2 cm-sized mass with calcifications. A diagnosis of the mucinous cystic neoplasm in the distal body and the tail of the pancreas was made and the patient was planned for laparoscopic distal pancreatectomy. During the procedure, hepatic artery was accidentally injured due to its anomalous course. The artery was then reconstructed laparoscopically using left gastric artery as conduit. The time duration of the procedure was 45 min and blood loss was approximately 75 mL. The patient recovered well and the postoperative Doppler study revealed normal blood flow. Medium-vessel surgery through laparoscopic approach is feasible and safe in select cases, while availing benefits of laparoscopy.

Laparoscopic hysterectomy with bilateral orchidectomy for Persistent Mullerian duct syndrome with seminoma testes: Case report.

Persistent Mullerian duct syndrome (PMDS) is one of the three rare intersex disorders caused by defective anti-mullerian hormone or its receptor, characterized by undescended testes with presence of underdeveloped derivatives of mullerian duct in genetically male infant or adult with normal external genitals and virilization. This population will essentially have normal, 46(XY), phenotype. We hereby present a case of PMDS, presented with incarcerated left inguinal hernia associated with cryptorchidism and seminoma of right testes. Patient underwent laparoscopic hernia repair with bilateral orchidectomy and hysterectomy with uneventful postoperative recovery. Here we highlight the importance of minimal access approach for this scenario in terms of better visualization, less blood loss, combining multiple procedures along with early return to work and excellent cosmetic outcome.

Single incision multi-trocar hepatic cyst excision with partial splenectomy.

INTRODUCTION: Surgery has the potential to remove the entire hydatid cyst and can lead to complete cure. Presence of hydatid cysts in multiple abdominal organs imposes special challenges for laparoscopic management. The patient position and port placement for one organ may not be adequate for other and proper exposure in hydatid cyst is of paramount importance to prevent spillage and complete removal of the cyst. Single incision multi-trocar technique has a unique advantage of allowing surgeon to work in different quadrants of abdomen using the same incision and ports. We report in this paper the first Laparo-endoscopic single-site hepatic cyst excision with partial splenectomy for hydatid cyst in liver and spleen using conventional laparoscopic instruments. PATIENT AND TECHNIQUE: The procedure was performed on a 64 year old female diagnosed to have Hydatid cyst in segment VIII of liver and another cyst in lower pole of spleen a transverse 3 cm incision was made 6 cm above umbilicus and was deepened up to fascia. Two 10mm and one 5mm ports were inserted. Procedure was completed in 160 minutes without any intra-operative complication. There were no post-operative complication and patient was discharged on day 5. CONCLUSION: Single incision multi-trocar surgery has cosmetic advantage over standard laparoscopic approach. It is even more marked when two procedures are combined in different quadrants of abdomen. As this is a rare combination procedure so it remains to be determined if this technique offers additional advantages of decreased analgesia, decreased hospital stay or cost effectiveness.

Laproendoscopic single site oesophageal diverticulectomy.

Epiphrenic divericula are uncommon disorders of the lower oesophagus, which are symptomatic in only 15-20% of cases. The optimum treatment modality for such cases remains an oesophageal diverticulectomy with long myotomy with or without an antireflux operation. Recently, this is increasingly being done through the laparoscopic approach. Here we describe the first reported case of oesophageal diverticulectomy through the laparoendoscopic single site approach. A 57-year-old man presented to us with 6 months history of dysphagia and regurgitation. Patient was investigated with upper gastrointestinal (UGI) endoscopy, barium swallow, CECT chest and abdomen, oesophageal manometry and 24 hour pH study. He was diagnosed to have lower oesophageal diverticulum with mildly elevated pressure readings in manometric studies with normal peristalsis. Based on his symptoms, he was taken up for surgery. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy was done through laparoendoscopic single site technique. The procedure lasted 160 min. There was no intraoperative complication. Gastrograffin study was done on postoperative day 2 following which he was started on liquids. He made an uneventful recovery and was discharged on fourth day. He remained asymptomatic on follow up. Oesophageal diverticulectomy is possible through laparoendoscopic single site approach if necessary expertise is available.

Single incision laparoscopic colorectal resection: Our experience.

BACKGROUND: A prospective case series of single incision multiport laparoscopic colorectal resections for malignancy using conventional laparoscopic trocars and instruments is described. MATERIALS AND METHODS: Eleven patients (seven men and four women) with colonic or rectal pathology underwent single incision multiport laparoscopic colectomy/rectal resection from July till December 2010. Four trocars were placed in a single transumblical incision. The bowel was mobilized laparoscopically and vessels controlled intracorporeally with either intra or extracorporeal anastomosis. RESULTS: Three patients had carcinoma in the caecum, one in the hepatic flexure, two in the rectosigmoid, one in the descending colon, two in the rectum and two had ulcerative pancolitis (one with high grade dysplasia and another with carcinoma rectum). There was no conversion to standard multiport laparoscopy or open surgery. The median age was 52 years (range 24-78 years). The average operating time was 130 min (range 90-210 min). The average incision length was 3.2 cm (2.5-4.0 cm). There were no postoperative complications. The average length of stay was 4.5 days (range 3-8 days). Histopathology showed adequate proximal and distal resection margins with an average lymph node yield of 25 nodes (range 16-30 nodes). CONCLUSION: Single incision multiport laparoscopic colorectal surgery for malignancy is feasible without extra cost or specialized ports/instrumentation. It does not compromise the oncological radicality of resection. Short-term results are encouraging. Long-term results are awaited.

Laparoscopic Division of Median Arcuate Ligament for the Celiac Axis Compression Syndrome-Two Case Reports with Review of Literature.

Median arcuate ligament (MAL) syndrome is an uncommon condition caused by the external compression of the celiac trunk by the median arcuate ligament. In the current era of technological advancement, this syndrome may be corrected through the laparoscopic approach. We report two patients who were diagnosed as MAL syndrome and underwent laparoscopic division of MAL fibers at our institute. Both the patients improved symptomatically following the procedure and were discharged on the fourth post-operative day. Also, they remained symptom free during subsequent follow-up period of 1 year and 8 months, respectively. Laparoscopic approach to correct the MAL syndrome is feasible and safe. It may be the preferred modality of treatment in view of its superior visualization and lack of morbidity. However, adequate experience in advanced laparoscopic surgery is required before attempting this procedure.

Major venous resection and reconstruction using a minimally invasive approach during laparoscopic pancreaticoduodenectomy: One step forward.

In the current era of technological advancement, the feasibility of laparoscopic pancreaticoduodenectomy has been established. However, major venous resection and reconstruction along with laparoscopic pancreaticoduodenectomy is still considered a complex procedure. A 47-year-old woman presented with obstructive jaundice secondary to carcinoma in the pancreatic head. Triphasic abdominal CT revealed a 2.7 × 3.0-cm heterogenous mass in the pancreatic head with peripancreatic lymphadenopathy without vascular involvement. The patient was scheduled for laparoscopic pancreaticoduodenectomy. During mobilization, the tumor was found adherent to the superior mesenteric vein. Therefore, vascular resection and reconstruction was accomplished laparoscopically along with pancreaticoduodenectomy. The duration of superior mesenteric vein occlusion was 45 min. The patient had an uneventful recovery and was discharged on postoperative day 10. Major venous resection and reconstruction during laparoscopic pancreaticoduodenectomy using a minimally invasive approach is feasible in selected patients. Adequate experience in complex laparoscopic pancreatic surgery is required before attempting this procedure.

Laparoscopic Major Hepatectomy-Technique and Outcomes.

BACKGROUND: With technological innovations especially newer parenchymal transection devices, improved understanding of hepatic anatomy facilitated by better imaging, and reconstructions along with experiences gained from advanced minimal invasive procedures, laparoscopic liver surgery is gaining momentum with more than 5300 reported cases worldwide. Most of the published literature comprises nonanatomical and segmental resections with only few case series having major hepatic resections performed by minimally invasive approach. Aim of this article is to share our technique and experience of total laparoscopic major hepatectomy. METHODS: It is a retrospective analysis of prospectively maintained database of 56 patients, who underwent laparoscopic major hepatectomy for various indications during 2001 to 2013. RESULTS: Of 56 patients operated, 37 had malignant disease and 19 had benign lesions with mean size of 6.0 ± 2.8 cm. Thirty-four patients underwent right hepatectomy and 22 left with mean age of 54.8 ± 15.3 years. Mean operating time was 227.4 ± 51.8 min with mean blood loss 265.5 ± 143.4 ml and transfusion needed in 10.7 %. Pringle's maneuver was used in 19.6 % with mean occlusion time of 34.0 ± 11.4 min. Liver-specific complications were observed in 12.5 % and overall complications in 19.6 %. Mean resection margin length in malignant lesions was 2.1 ± 0.9 cm, with <1 cm margin noted in 5.4 %. Median hospital stay was 8 days (6-29) with readmission rate of 8.9 %, re-intervention rate of 5.3 % and 90 days mortality of 1.7 %. CONCLUSION: Laparoscopic major liver resection is a formidable task. It requires considerable expertise in both, advanced laparoscopy, and liver surgery. It can be feasible, safe, and oncologically adequate in well-selected cases in experience hands.

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.

Combined surgical procedures using laparoendoscopic single-site surgery approach.

INTRODUCTION: As our experience with laparoendoscopic single-site (LESS) surgeries increased, we considered how it might be employed if two or more surgeries were to be combined. LESS surgeries' cosmetic advantages, decreased parietal trauma and better patient satisfaction relative to standard multiport laparoscopy have been previously reported, but its special role in combined surgeries has never been stressed. In this series, we present the advantages of LESS procedure over multiport laparoscopy in combined surgical procedures. To the best of our knowledge, this has never been reported before. METHODS: A retrospective analysis of 27 patients was performed. The patients underwent combined LESS procedures between February 2010 and January 2012 at GEM Hospital, Coimbatore, India. All patients were of ASA grade 1 or 2. Patients with previous surgery in the umbilical region were not offered single-incision surgery. RESULTS: We successfully performed 27 combined LESS procedures over a span of 2 years. Twenty patients were women and seven were men. Mean age was 35.94 years (range, 10-66 years). Mean BMI was 27.2. There were no major intraoperative complications. Mean blood loss was 45.7 mL (range, 0.0-120.0 mL). Mean postoperative hospital stay was 3.08 days (range, 1-5 days). CONCLUSION: When a suitable case of multiple pathologies is encountered and LESS surgery is feasible for all of them, performing LESS surgery not only has cosmetic advantages over standard laparoscopy, but it also avoids the need for additional ports to achieve adequate visualization and access. All quadrants of the abdomen remain under reach through umbilicus.