Long-term outcomes of laparoscopic Heller's myotomy with angle of His accentuation in patients of achalasia cardia.

BACKGROUND: Laparoscopic Heller's myotomy (LHM) is an established treatment for achalasia cardia. Anti-reflux procedures (ARP) are recommended with LHM to reduce the post-operative reflux though the optimal anti-reflux procedure is still debatable. This study reports on the long-term outcomes of LHM with Angle-of-His accentuation (AOH) in patients of achalasia cardia. METHODS: One hundred thirty-six patients of achalasia cardia undergoing LHM with AOH between January 2010 to October 2021 with a minimum follow-up of one year were evaluated for symptomatic outcomes using Eckardt score (ES), DeMeester heartburn (DMH) score and achalasia disease specific quality of life (A-DsQoL) questionnaire. Upper gastrointestinal endoscopy, high resolution manometry (HRM) and timed barium esophagogram (TBE) were performed when feasible and rates of esophagitis and improvement in HRM and TBE parameters evaluated. Time dependent rates of success were calculated with respect to improvement in ES and dysphagia-, regurgitation- and heartburn-free survival using Kaplan-Meier analysis. RESULTS: At a median follow-up of 65.5 months, the overall success (ES ≤ 3) was 94.1%. There was statistically significant improvement in ES, heartburn score and A-DsQoL score (p < 0.00001, p = 0.002 and p < 0.00001). Significant heartburn (score ≥ 2) was seen in 12.5% subjects with 9.5% patients reporting frequent PPI use (> 3 days per week). LA-B and above esophagitis was seen in 12.7%. HRM and TBE parameters also showed a significant improvement as compared to pre-operative values (IRP: p < 0.0001, column height: p < 0.0001, column width: p = 0.0002). Kaplan-Meier analysis showed dysphagia, regurgitation, and heartburn free survival of 75%, 96.2% and 72.3% respectively at 10 years. CONCLUSIONS: LHM with AOH gives a lasting relief of symptoms in patients of achalasia cardia with heartburn rates similar to that reported in studies using Dor's or Toupet's fundoplication with LHM. Hence, LHM with AOH may be a preferred choice in patients of achalasia cardia given the simplicity of the procedure.

Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. METHODOLOGY: This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. RESULTS: Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. CONCLUSION: LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.

Comparison of inflammatory markers in low-pressure pneumoperitoneum with deep neuromuscular block versus standard pressure pneumoperitoneum among patients undergoing laparoscopic cholecystectomy for gallstone disease: a randomized control trial.

BACKGROUND: Low-pressure pneumoperitoneum (LPP) is an attempt to improve laparoscopic surgery. Lower pressure causes lesser inflammation and better hemodynamics. There is a lack of literature comparing inflammatory markers in LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB in laparoscopic cholecystectomy. METHODOLOGY: This was a single institutional prospective randomized control trial. Participants included all patients undergoing laparoscopic cholecystectomy for symptomatic gall stone disease. Participants were divided into 2 groups group A and B. Group A-Low-pressure group in which pneumoperitoneum pressure was kept low (8-10 mmHg) with deep Neuromuscular blockade (NMB) and Group B-Normal pressure group (12-14 mmHg) with moderate NMB. A convenience sample size of 80 with 40 in each group was selected. Lab investigations like CBC, LFT, RFT and serum IL-1, IL-6, IL-17, TNF alpha levels were measured at base line and 24 h after surgery and compared using appropriate statistical tests. Other parameters like length of hospital stay, post-operative pain score, conversion rate (low-pressure to standard pressure), and complications were also compared. RESULTS: Eighty participants were analysed with 40 in each group. Baseline characteristics and investigations were statistically similar. Difference (post-operative-pre-operative) of inflammatory markers were compared between both groups. Numerically there was a slightly higher rise in most of the inflammatory markers (TLC, ESR, CRP, IL-6, TNFα) in Group B compared to Group A but not statistically significant. Albumin showed significant fall (p < 0.001) in Group B compared to Group A. Post-operative pain was also significantly less (p < 0.001) in Group A compared to Group B at 6 h and 24 h. There were no differences in length of hospital stay and incidence of complications. There was no conversion from low-pressure to standard pressure. CONCLUSION: Laparoscopic cholecystectomy performed under low-pressure pneumoperitoneum with deep NMB may have lesser inflammation and lesser post-operative pain compared to standard pressure pneumoperitoneum with moderate NMB. Future studies with larger sample size need to be designed to support these findings.

Comparison of three-dimensional (3D) endovision system versus ultra-high-definition 4K endovision system in minimally invasive surgical procedures: a randomized-open label pilot study.

BACKGROUND: Experimental work comparing 3-Dimensional (3D) and 4K ultra-high-definition endovision system (4K) indicates that the latter with double the resolution of standard 2D high-definition systems may provide additional visual cues to compensate for the lack of stereoscopic vision. There is paucity of studies comparing 3D and 4K system in clinical settings. This randomized study compares 3D and 4K systems in three laparoscopic procedures of increasing complexity. METHODS: 139 patients undergoing laparoscopic cholecystectomy (60 patients), transabdominal preperitoneal (TAPP) repair (49 patients) and laparoscopic Heller's cardiomyotomy with anti- reflux procedure (30 patients) between May 2018 and February 2020 were randomized to undergo surgery using either 3D or 4K systems. Primary objective was to measure total operative time. Secondary objectives were to compare workload perceived by surgeons using SURG-TLX and surgeon satisfaction score. Timings of key surgical steps and peri-operative course of the patients was also recorded. Data were analyzed using Stata Corp. 2015. RESULTS: Patients undergoing surgery with 3D and 4K systems were comparable in their clinical and demographic profiles. The mean total operative time in 3D and 4K groups was comparable in cholecystectomy (52.7 vs 56.2, p = 0.50), TAPP (63.8 vs 69.6, p = 0.25) and Heller's cardiomyotomy (124.7 vs 143.3, p = 0.14) with faster hiatal dissection in 3D group (8 min, p = 0.02). Operative time was better in patients undergoing Heller's myotomy with Angle of His accentuation with 3D by 28 min (p = 0.03). Total workload was similar in 3D and 4K groups in all the procedures but mental & physical demand was lower in 3D group in Heller's cardiomyotomy (p = 0.03, p = 0.01), Surgeon satisfaction score was comparable in all three procedures. CONCLUSION: Overall, 3D HD and 4K systems are comparable in performing laparoscopic cholecystectomy, TAPP and Heller's Cardiomyotomy. Hiatal dissection time, mental and physical task load was better with 3D in Heller's Cardiomyotomy.

Development and use of low-fidelity, low-cost, animal tissue-based simulators for surgical training during the Covid-19 pandemic.

Background The Covid-19 pandemic severely affected surgical training as the number of surgeries being done was reduced to a bare minimum. Teaching and training of clinical skills on a simulator are desirable as they may have an even larger role during the Covid-19 pandemic. Commercially available simulators with optimum fidelity are costly and may be difficult to sustain because of their recurring cost. The development of low-cost simulators with optimum fidelity is the need of the hour. Methods We developed animal tissue-based simulators for imparting skills training to surgical residents on some basic and advanced general surgical procedures. Porcine tissue and locally available materials were used to prepare these models. The models were pilot-tested. Standard operating procedures were developed for each skill that was shared with the participants well before the 'hands-on' exercise. An online pre-test was conducted. The training was then imparted on these models under faculty guidance adhering to Covid-19-appropriate behaviour. This was followed by a post-test and participant feedback. The entire exercise was paperless. Results Sixty residents were trained in 10 sessions. Most of the participants were men (44; 73%). The mean pre-test and post-test scores were 40.92 (standard deviation [SD] 6.27) and 42.67, respectively (SD 4.06). Paired sample t-test suggested a significant improvement in the post-test score (p<0.001). The activity and the models were well appreciated by the residents. Conclusion The animal tissue-based indigenous models are easy to prepare, cost-effective and provide optimum fidelity for skill training of surgical residents. In addition to skill acquisition, training on such modules may alleviate the stress and anxiety of the residents associated with the loss of surgical training during a time-bound residency period.

Performance of three-dimensional and ultra-high-definition (4K) technology in laparoscopic surgery: A systematic review and meta-analysis.

Background: The technology in the field of laparoscopy is rapidly evolving and is primarily focussed on increasing the quality of image and depth perception in the form of 4K and three-dimensional (3D) technology. There has been no conclusion yet regarding the better technology. Methods: A systematic search was performed independently by two authors across MEDLINE, Google Scholar and Embase using the PRISMA guidelines. All randomised control trials comparing 3D and 4K technologies were included. Meta-analysis was conducted using random-effects statistics for time taken for different tasks across the studies. Results: The search strategy revealed a total of 1835 articles, out of which nine studies were included. Three studies showed no superiority of 3D over 4K, while the remaining six did. Meta-analysis for the time taken for peg transfer favoured 3D over 4K (overall effect: Z = 2.12; P = 0.03). Forest plots for time taken for suturing (Z = 1.3; P = 0.19) and knot tying (Z = 1.7; P = 0.09) also favoured 3D over 4K; the results however were statistically insignificant. Path length was reported by two studies and was found to be lesser in the 3D group. Two studies measured the workload by NASA/Surg-TLX score, which was lower in the 3D group. Visual side effects were found to be higher in the 3D group. Conclusion: 3D technology is likely to result in a shorter operative time and better efficiency of movement as compared to the 4K technology by the virtue of its better depth perception.

Comparison of two-dimensional high-definition, ultra high-definition and three-dimensional endovision systems: an ex-vivo randomised study.

BACKGROUND: Two-dimensional high-definition (2D HD) endovision system is preferred for laparoscopic surgery. Recently, new generation three-dimensional (3D) HD and ultra-HD (4K) endovision systems are introduced to improve the safety and efficacy of laparoscopic surgery. There is limited evidence on superiority of one technology over the others. This experimental trial was designed to evaluate 2D HD, 3D HD and 4K HD endovision systems in performance of standardized tasks. METHODS: This was a randomized, cross-over experimental study. Twenty-one surgical residents who were exposed to laparoscopic surgery were enrolled. Participants were randomly assigned into three groups. Each group performed standardised tasks i.e. peg transfer, precision cutting, navigating in space and intra-corporeal suturing using 2D HD, 4K HD and 3D HD endovision systems on a box trainer. Procedures were recorded as 2D HD videos and analysed later. Participant's perceived workload was assessed using Surg-TLX questionnaire. Primary endpoints were execution time in seconds and error score. Secondary endpoint was workload assessment. RESULTS: The 3D HD had shorter execution time compared to 2D HD and 4K HD in all tasks except precision cutting (p = 0.004, 0.03, 0.001, 0.001 and p = 0.002, 0.191, 0.006, 0.005 in peg transfer, precision cutting, navigating in space and intra-corporeal suturing respectively). The 4K HD was significantly faster than 2D HD only in navigating in space task (p = 0.002). The error score between 3D HD and 4K HD were comparable in all tasks. The 2D HD had significantly more error scores compared to 4K HD, 3D HD in peg transfer task (p = 0.005, 0.014, respectively). 3D HD had significantly less workload than 2D HD and 4K HD in most of the dimensions of Surg-TLX CONCLUSIONS: 3D HD endovision system in comparison to 2D HD and 4K HD, may lead to faster execution without compromising safety of a task and is associated with less workload.

Effect of structured training in improving the ergonomic stress in laparoscopic surgery among general surgery residents.

BACKGROUND: Minimal access surgery has fast become the standard of care for many operative procedures, but is associated with lot of ergonomic stress to the surgeons performing these procedures, which may result in reduction in surgeon's performance and work capacity. In this study, we evaluated the impact of structured training program in improving the ergonomic stress in trainee laparoscopic surgeons. METHODS: Laparoscopic surgeons were divided in 2 groups: trainee surgeons (ten) and expert surgeons (three). Baseline surface electromyography (sEMG) data were collected from bilateral deltoid, biceps brachii, forearm extensors, and pronator teres during a predefined suturing task on Tuebingen trainer with integrated porcine organs in both the groups. Trainee surgeons underwent 20 h of laparoscopic intra-corporeal suturing training and surface electromyography data were recorded at the end of training again and compared with baseline. RESULTS: Experts were found to have lower muscle activation (p < 0.05) and muscle work (p < 0.05) and better bimanual dexterity than the trainee surgeons at baseline. After training, the trainee surgeons showed significant improvement (p = 0.01), but still did not reach the values of the expert surgeons (p = 0.01). Right deltoid and pronator teres muscles were found to have maximal activity while performing intra-corporeal suturing. CONCLUSION: Structured and focused training outside operation theater can significantly reduce unnecessary muscle activation of trainee laparoscopic surgeons and better dexterity leading on to lesser ergonomic stress and thus possibly may reduce the risk of development of future musculo-skeletal disorders.

Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial.

BACKGROUND: The incidence of shoulder pain (SP) following laparoscopic cholecystectomy (LC) varies between 21 and 80 %. A few randomised controlled trials and meta-analysis have shown lesser SP in LC performed under low-pressure carbon dioxide pneumoperitoneum (LPCP) than under standard-pressure carbon dioxide pneumoperitoneum (SPCP). However, the possible compromise in adequate exposure and effective working space during LPCP has negatively influenced its uniform adoption for LC. MATERIALS AND METHODS: All consecutive patients undergoing elective LC for gallstone disease who met the inclusion and exclusion criteria were enroled. Fourty patients were randomised to SPCP group (pressure of 14 mmHg) and 40 to LPCP group (pressure of 9-10 mmHg). Primary outcome measured was incidence of SP and its severity on visual analogue scale (VAS) at 4, 8, 24 h and 7 days after LC. Secondary outcomes measured were procedural time, technical difficulty, surgeons' satisfaction score on exposure and working space, intra-operative changes in heart rate and blood pressure, abdominal pain and analgesic requirement. Analyses were performed using Stata software. RESULTS: There was no conversion to open surgery, bile duct injury or need to increase intra-abdominal pressure on either group. Twenty-three patients (57.5 %) in SPCP group and nine patients (22.5 %) in LPCP group had SP (p = 0.001). The severity of SP was significantly more in SPCP group at 8 and 24 h (p = 0.009 and 0.005, respectively). Both the groups had similar procedural time, surgeons' satisfaction score, intra-operative changes in heart rate and blood pressure. CONCLUSION: The incidence and severity of SP following LC performed at LPCP are significantly less compared to that in SPCP. The safety, efficacy and surgeons' satisfaction appear to be comparable in both the groups. Hence, a routine practice of low-pressure carbon dioxide pneumoperitoneum may be recommended in selected group of patients undergoing laparoscopic cholecystectomy. CLINICAL TRIAL REGISTRATION NUMBER: CTRI/2016/02/006590.

Transferability of laparoscopic skills acquired from three-dimensional high-definition and ultra-high definition endovision system to two-dimensional high-definition endovision system: an ex-vivo randomized study.

Three-dimensional high-definition (3D HD) and ultra-high-definition (4 K HD) endovision systems are rapidly adopted in academic setting. However, transferability of laparoscopic skills acquired from these systems to two-dimensional high-definition (2D HD) endovision system is not known. Forty stereo-enabled surgical residents were randomized into two groups. They performed three standardized surgical tasks, Task 1(Peg transfer), Task 2(Precision touch on uneven surface) and Task 3(Surgical knotting on rubber tube) for 15 repetitions using either 3D HD or 4 K HD. Both groups then performed the same tasks using 2D HD for 5 repetitions. Their performances were evaluated for execution time (speed) and error scores (safety). The residents in 3D HD group performed all three tasks significantly faster than residents in 4 K HD group with comparable error scores. The time taken to complete the tasks on 2D HD were comparable between residents trained in 3D HD and 4 K HD in two out of three tasks (p = 0.027, P = 0.115, p = 0.368 in task 1, 2 and 3 respectively). However, in two out of three tasks, residents trained on 3D HD committed significantly more errors than residents trained on 4 K HD (p < 0.0001, p < 0.001 in task 1 and task 2 respectively). Skill acquired on 4 K HD seems transferable to 2D HD environment. Participants trained in 3D HD made more errors while performing the tasks in 2D HD. It may be prudent to offer additional training on 2D HD to residents trained on 3D HD for safer laparoscopic surgical practice.

The EURO-NOTES clinical registry for natural orifice transluminal endoscopic surgery: a 2-year activity report.

BACKGROUND: The EURO-NOTES Clinical Registry (ECR) was established as a European database to allow the monitoring and safe introduction of Natural Orifice Transluminal Endoscopic Surgery (NOTES). The aim of this study was to analyze different techniques applied and relative results during the first 2 years of the ECR. METHODS: The ECR was designed as a voluntary database with online access. All members of the European Society for Gastrointestinal Endoscopy and the European Association for Endoscopic Surgery were requested to participate in the registry. Demographic and therapy data as well as data on the postoperative course are recorded in the ECR in an anonymous way. RESULTS: A total of 533 patients who underwent NOTES procedures were included in the study. Four different hybrid techniques for 435 cholecystectomies were described, registering postoperative complications in 2.8% of patients, addition of a single trocar in 5.3%, and conversions to laparoscopy in 0.5%. Both flexible endoscopic and rigid laparoscopic cholecystectomy techniques proved to be safe and effective with minor differences. There was a shorter operative time in the rigid laparoscopic group. Thirty-three appendectomies were reported by transgastric and transvaginal techniques, with transvaginal techniques scoring shorter operative time and hospital stay, but with a frequent need to add more trocars. Overall complications occurred in 14.7% of patients but they did not differ significantly among the different techniques. One transvaginal and 31 transanal sigmoidectomies were included for prolapse and diverticulitis, with four postoperative complications (12.5%), but none needing further treatment. Twenty peroral esophageal myotomies were included with three postoperative complications (15.0%), but none needing further treatment. CONCLUSIONS: Five years since the introduction of NOTES into clinical practice, hybrid techniques have gained considerable clinical application. Several NOTES hybrid cholecystectomy and appendectomy techniques are practicable and safe alternatives to laparoscopic procedures. Also, sigmoidectomies and peroral esophageal myotomies were described, proving feasibility and safety. Nevertheless, the real benefit of NOTES for patients still needs to be assessed.

Illness wellness scale: novel grading system for performance status of patients under surgical care.

BACKGROUND: Grading the illness using clinical parameters is essential for the daily progress of inpatients. Existing systems do not incorporate these parameters holistically. The study was designed to internally validate the illness wellness scale, based upon clinical assessment of the patients requiring surgical care, for their risk stratification and uniformity of communication between health care providers. METHODS: Prospective observational study conducted at a tertiary care hospital. An expert panel devised the scale, and it was modified after feedback from 100 health care providers. A total of 210 patients (150 for internal validation and 60 for inter-observer variability) who required care under the department of surgical disciplines were enrolled. This included patients presenting to surgery OPD, admitted to COVID/non-COVID surgical wards and ICUs, aged ≥16 years. RESULTS: The response rate of the final illness wellness scale was 95% with 86% positive feedback and a mean of 1.7 on the Likert scale for ease of use (one being very easy and five being difficult). It showed excellent consistency and minimal inter-observer variability with the intra-class correlation coefficient (ICC) above 0.9. In the internal validation cohort (n = 150), univariate and multivariable analysis of factors affecting mortality revealed that categorical risk stratification, age ≥ 60 years, presence or absence of co-morbidities especially hypertension and chronic kidney disease significantly affect mortality. CONCLUSIONS: The Illness wellness scale is an effective tool for uniformly communicating between health care professionals and is also a strong predictor of risk stratification and mortality in patients requiring surgical care.

Age adjusted Charlson comorbidity index (a-CCI) AS a tool to predict 30-day post-operative outcome in general surgery patients.

INTRODUCTION: Age adjusted Charlson comorbidity index (a-CCI) is an established scoring system to predict long-term mortality. However, its role in predicting 30-day post-operative outcome in general surgery patients is not well elucidated. METHODS: This was a prospective observational study. Consecutive patients operated under general anaesthesia between January 2019 and December 2020 were enrolled. Their a-CCI was calculated and stratified as Grade 0 comorbidities (a-CCI score = 0), Grade A comorbidities (a-CCI score = 1 and 2) and Grade B comorbidities (a-CCI score ≥ 3). Post-operative complications were graded according to Clavien Dindo (CD) grading system and classified as minor complications (CD Grades I and II), major complications (CD Grades III-IV) and mortality (CD Grade V). Binary logistic regression and multi-nominal logistic regression analysis were done and relative risk ratios were calculated. RESULT: A total of 925 patients were enrolled. The mean age was 42.75 (14-85 ± 10) years. 31% of our patients had complications within 30 days of surgery which included mortality in 2.7%. Compared with patients with Grade 0 comorbidities, the odds of getting complications is 1.2 times more in patients with Grade A comorbidities and 1.84 times more in patients with Grade B comorbidities (P = 0.205, 0.001 respectively). In comparison to patients with Grade 0 co-morbidities, risk of mortality is 3 and 17.86 times more in patients with Grade A and Grade B comorbidities (P = 0.121 and < 0.001 respectively). CONCLUSION: a-CCI has clinical relevance in general surgical patients and can predict early post-operative outcome. It should be a part of our armamentarium for pre-operative assessment of surgical patients.

Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute.

INTRODUCTION: Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications. MATERIALS AND METHODS: All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted. RESULTS: Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%. CONCLUSION: This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.

Laparoscopic suturing skills acquisition: a comparison between laparoscopy-exposed and laparoscopy-naive surgeons.

BACKGROUND: Laparoscopic suturing is a difficult skill to master but can be acquired with extensive training outside the operating room. This study was done with the primary aim of assessing whether prior exposure to laparoscopic surgery helped trainees in acquiring laparoscopic suturing skills more quickly than trainees with no prior exposure to laparoscopic surgery. MATERIALS AND METHODS: Twenty laparoscopy-exposed and 20 laparoscopy-naïve surgeons performed 5 laparoscopic gastrojejunostomies each on a phantom porcine model. The performance was evaluated for operation time, overall anastomotic score (calculated by adding scores of anastomotic leak, size of the anastomosis, suture placement, and mucosal approximation), and the level of difficulty. The performance at the beginning of training (baseline) was compared to the performance at the end of training. RESULTS: All participants showed statistically significant improvement in operation time, overall anastomotic score, and difficulty level. Laparoscopy-exposed surgeons had a significantly better operation time than laparoscopynaïve surgeons at the beginning of training; however, the difference became insignificant by the end of training. The difference in overall anastomotic score was not significant between laparoscopy-exposed and naïve-surgeons. Laparoscopy-exposed surgeons showed significant improvements in anastomotic leak rate and size of the anastomosis, whereas laparoscopy naïve surgeons showed improvements in all the parameters, although these were not significant statistically. CONCLUSION: Training improves the laparoscopic suturing skills of laparoscopy-exposed as well as laparoscopy-naïve surgeons. Prior experience in laparoscopic surgery does not seem to influence the acquisition of laparoscopic suturing skills as laparoscopic-naïve surgeons manage to catch up with the skills of the laparoscopy-exposed surgeons.

Late Local and Distant Recurrence of Apparently Benign Paraganglioma.

Paraganglioma-pheochromocytoma (PPGLs) are relatively rare catecholamine-secreting tumors of chromaffin origin. Due to the sympathetic effects of catecholamine excess, their presentation may range from non-specific symptoms to dangerous hypertensive crises. We present the case of a 36-year-old lady with recurrent paraganglioma (PGL) who presented in emergency with hypertensive crisis. She had a history of surgery for left-sided PGL 18 years earlier. Imaging showed local recurrence with pulmonary metastases and blood biochemistry showed raised urinary metanephrines. In view of her poor general condition, we undertook a staged surgical approach for management. She first underwent en-bloc excision of recurrent PGL with left nephrectomy. Nine weeks later, she underwent a pulmonary metastasectomy. This staged surgical approach resulted in the stabilization of blood pressure and normalization of urinary catecholamine. Although most of these tumors are indolent by nature, this case highlights the metastatic potential of apparently benign PGL. This case explores the possibility of a staged surgical approach in a high-risk patient and emphasizes the need for long-term follow-up in these cases.

Impact of clinical parameters and vascular haemodynamics on arterio-venous fistula maturation in patients with end stage renal disease: A prospective study on Indian patients.

BACKGROUND: About 18%-65% of Arterio-Venous fistula (AVF) made to facilitate haemodialysis in end stage renal disease patient fail to mature. This study was designed to evaluate the impact of clinical parameters and vascular haemodynamics on maturation of AVF on Indian patients. MATERIAL AND METHODS: This was a prospective observational study. Eligible patients' clinical profiles and vascular haemodynamics by Doppler ultrasonography were noted. All patients underwent radio-cephalic AVF on the non-dominant arm under local anaesthesia. Clinical definition was used to assess success rate of AVFs which is defined as successful six settings of satisfactory dialysis. Data were analysed using Stata/12.0 software. Independent t-test, chi-square test, logistic regression analysis and multivariate analysis were used. The p-value of <0.05 was considered significant. RESULTS: A total of 205 patients were enrolled and analysed. Among clinical factors, age, sex, serum creatinine, hypertension had no significant association with failure (p = 0.5, 0.08, 0.76 and 0.74). Patient's BMI and presence of diabetes had significant impact on outcome (p < 0.001 and 0.02 respectively). Among vascular haemodynamics, radial vein diameter of >2.5 mm and radial artery flow rate >40 ml/min had no significant association with failure (p = 0.12 and 0.28). Diameter of radial artery (>2 mm) and intra-operatively immediate thrill were independent predictor of success (p = 0.002 and <0.001). CONCLUSION: In the present study rate of fistula, maturation was 73.2% without any post-operative radiological intervention. Radial artery diameter >2 mm and presence of immediate thrill post-operatively were significantly associated with successful cannulation.

A novel single-port technique for transanal rectosigmoid resection and colorectal anastomosis on an ex vivo experimental model.

BACKGROUND: In the context of natural orifice translumenal endoscopic surgery (NOTES), we developed a new set of rigid instruments according to the principles of transanal endoscopic microsurgery (TEM).These instruments are long, curved, and steerable by rotating two wheels near its handle. Our success in transvaginal cholecystectomy in human with these instruments motivated us to explore the feasibility of rectosigmoid resection through the anus. METHODS: The young bovine large bowel with attached organs is collected en bloc and reintegrated into an anatomically designed trainer to reproduce the human anatomy. The technique comprises the following: (1) closure of the rectal lumen by an endolumenal pursestring suture; (2) transection of the rectal wall 1 cm distal to the pursestring suture and continuation of the dissection toward the fascia and upward excising the mesorectal tissue; (3) inferior mesenteric artery is divided near its origin; (4) the colon is mobilized up to the splenic flexure; (5) the mobilized colon is brought down to the pelvis, ligated twice at the intended proximal resection site, and divided between the ligatures; (6) specimen is delivered transanally; and (7) intestinal continuity is restored by stapled or hand-sutured anastomosis. RESULTS: Twelve rectosigmoid resections, 20 stapled, and 27 hand-sutured anastomoses were performed in two experimental setups. Mean operation time for the resection part was 78.6 min (standard deviation (SD)=9.9). The average specimen length was 37.2 cm. During dissection in the pelvis, as the specimen was pushed upward and toward abdomen, an "empty pelvis" view of the working field was achieved, facilitating dissection. The mean operation time for hand-sutured and stapled anastomoses were 47.7 (SD=6.9) and 43.3 (SD=7.1) min, respectively. Both groups had one anastomotic leak. CONCLUSIONS: Transanal rectosigmoid resection is feasible with TEM technology. The unobstructed "empty pelvis" view is likely to enhance the quality of mesorectal dissection.

Thoracolaparoscopic repair of diaphragmatic hernias.

Complex long-standing diaphragmatic hernia presenting in adults is often managed through an open approach. Minimal invasive approach by either laparoscopy or thoracoscopy is limited by its ability to tackle these complex hernias with large defects and thoraco-mediastinal adhesions. Thus, standard laparoscopic or thoracoscopic approach is associated with high conversion to open approach. We herein describe a novel combined thoraco-laparoscopic approach to repair complex diaphragmatic hernias in a series of three adults.

Solitary pelvic primary intraperitoneal hydatid managed with a minimal access approach: A case report.

Solitary primary pelvic intraperitoneal hydatid cysts are rare. We report the case of a 22-year-old women who presented with a dull ache in her lower abdomen for 2 years and increased urinary frequency over 3 months. Ultrasonography and CT indicated a solitary primary peritoneal pelvic hydatid cyst. Hydatid serology was positive. Perioperative albendazole was prescribed and laparoscopic cystectomy planned. Intraoperatively, dense adhesions to the omentum, urinary bladder, and left fallopian tube were taken down laparoscopically. A small Pfannenstiel incision was made to separate the bladder's left lateral edge and deliver the cyst externally. This report details our experience of managing this case and reviews pertinent literature.