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.

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.

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.

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.

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.

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.

Learning Pattern of Two-Dimensional, Three-Dimensional, and Ultra-High-Definition Endovision System on Standardized Phantom Tasks: An Ex Vivo Randomized Study.

Introduction: Three-dimensional (3D), high-definition (HD), and ultra-high-definition (4K HD) are recent additions over regular HD technology for laparoscopic surgery. The aim of this study was to evaluate the learning pattern of these systems on standardized phantom tasks. Methodology: Forty-five stereo-enabled resident doctors were randomly assigned into three groups. They performed three validated tasks, precision touch on flat surface, precision touch on uneven surface, surgical knot on rubber tube using either two-dimensional (2D) HD, 3D HD, or 4K HD Endovision systems. Each task was repeated 20 times. Data from four consecutive repetitions were pooled to make five blocks. Split group analysis by comparing the consecutive blocks in execution time and errors were made to see the learning pattern. A significant difference was accepted as continuous learning while no significant difference was accepted as learning stabilization. Result: Operating time was stabilized in two tasks after third block in 2D HD, one task after fourth block in 4K HD. There was continuous learning in all tasks with 3D HD. The 3D HD group was significantly faster than 2D HD and 4K HD in most of the tasks on fifth block. The error scores were similar between the consecutive blocks in 4K HD. It was stabilized after second block in 2D HD group and third block on 3D HD. Conclusion: The 3D HD Endovision system has more potential of faster execution of a task, but need more practice to reach similar safety profile. The 4K HD reached the safety plateau with minimal repetitions.

Laparoscopic total mesorectal excision for rectal venous malformation: A case report with a brief literature review.

Rectal vascular malformation is a rare disease on which few reports have been published. Here, we report the case of a 38-year-old woman who presented with severe weakness, dyspnea, and recurrent episodes of rectal bleeding. Her colonoscopy showed an extensive pigmented lesion in the lower rectum. CT angiography showed diffuse circumferential wall thickening of the rectum, perirectal fat stranding, tiny round foci of calcification, and no arterial feeders. Multiphasic MRI confirmed the diagnosis. The patient underwent a total mesorectal excision with hand-sewn coloanal anastomosis. The venous malformation was confined to the mesorectal tissue. The avascular plane between the ectodermal and mesodermal tissue was well maintained. Blood loss was 200 mL. The patient has had no recurrence of disease in the 18 months since surgery. Although total mesorectal excision is described for rectal cancer, it may be indicated for benign disease like rectal vascular malformation to achieve complete removal of the disease and to minimize intraoperative blood loss.

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.

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.

Coronavirus disease 2019 and laparoscopic surgery in resource-limited settings.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the use of laparoscopy has been discouraged by the Intercollegiate General Surgery because of its potential for aerosol generation and infection. In contrast, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association of Endoscopic Surgery recommend continuing to use laparoscopy but with devices to filter released CO2 aerosol particles. However, commercially available systems are costly and may not be readily available. Herein, we describe a custom-made system to safely remove surgical smoke and CO2 , as well as a case of laparoscopic cholecystectomy in which we used it. MATERIALS AND SURGICAL TECHNIQUE: The patient had had multiple episodes of biliary pancreatitis and required urgent cholecystectomy during the COVID-19 pandemic. Although India was in complete lockdown, it was decided to operate with precaution. A system was designed using underwater seal chest tube drainage and an electrostatic membrane filter with a viral retention function greater than 99.99%. The system was connected to an extra port for continuous controlled egression of CO2 pneumoperitoneum. A regular four-port cholecystectomy was performed at an intra-abdominal pressure of 12 mm Hg. The gas flow rate was 10 L/min. CO2 for pneumoperitoneum, surgical aerosol, and effluents passed through the system before collecting in the suction apparatus. The exchange of operating instruments through the ports was kept to a minimum. It was done after the abdomen was temporarily desufflated using this system. DISCUSSION: The system we designed appears safe and is cost-effective. In resource-limited settings, it will be handy in patients requiring laparoscopic surgery both during and after the COVID-19 pandemic.

Emergency Surgery during COVID-19: Lessons Learned.

Introduction The ongoing coronavirus disease-2019 (COVID-19) pandemic has disrupted health services throughout the world. It has brought in several new challenges to deal with surgical emergencies. Herein, we report two suspected cases of COVID-19 that were operated during this "lockdown" period and highlight the protocols we followed and lessons we learned from this situation. Result Two patients from "red zones" for COVID-19 pandemic presented with acute abdomen, one a 64-year male, who presented with perforation peritonitis and another, a 57-year male with acute intestinal obstruction due to sigmoid volvulus. They also had associated COVID-19 symptoms. COVID-19 test could not be done at the time of their presentation to the hospital. Patients underwent emergency exploratory laparotomy assuming them to be positive for the infection. Surgical team was donned with full coverall personal protective equipment. Sudden and uncontrolled egression intraperitoneal free gas was avoided, Echelon flex 60 staplers were used to resect the volvulus without allowing the gas from the volvulus to escape; mesocolon was divided using vascular reload of the stapler, no electrosurgical devices were used to avoid the aerosolization of viral particles. Colostomy was done in both the patients. Both the patients turned out to be negative for COVID-19 subsequently and discharged from hospital in stable condition. Conclusion Surgeons need to adapt to safely execute emergency surgical procedures during this period of COVID-19 pandemic. Preparedness is of paramount importance. Full precautionary measures should be taken when dealing with any suspected case.

Comparison of transversus abdominis plane block and intrathecal morphine for laparoscopic donor nephrectomy: Randomised controlled trial.

BACKGROUND AND AIMS: Postoperative pain following laparoscopic donor nephrectomy (LDN) is significant and no suitable analgesic technique is described. Opioid analgesia in standard doses is often suboptimal and associated with numerous adverse effects. Transversus abdominis plane (TAP) block has been evaluated in various laparoscopic procedures. Intrathecal morphine (ITM) has been seen to provide long-lasting analgesia of superior quality in laparoscopic colorectal procedures. METHODS: The present study was undertaken to evaluate the analgesic efficacy of single-dose ITM 5 µg/kg for LDN. After ethics approval, 60 adult patients scheduled for LDN were randomised to receive intravenous fentanyl, ultrasound-guided TAP block or ITM for postoperative analgesia. Postoperative 24-h patient-controlled analgesia (PCA) fentanyl consumption, visual analogue scale (VAS) score and intraoperative fentanyl and muscle relaxant requirements were compared. Statistical analysis was performed using appropriate statistical tests by using Stata 11.1 software. RESULTS: Haemodynamic stability at pneumoperitoneum and in the post anaesthesia care unit was significantly better in patients receiving ITM. Intraoperative rescue fentanyl requirement (P = 0.01) and postoperative fentanyl requirement until 24 h (P = 0.000) were significantly lower in the morphine group. Postoperative VAS at rest and on movement was significantly lower in the morphine group at all points of assessment (P = 0.000). CONCLUSION: ITM 5 µg/kg provides better intraoperative and postoperative analgesia and reduces postoperative PCA fentanyl requirement in laparoscopic donor nephrectomy compared to TAP block or intravenous fentanyl.

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.

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.

Are short-term focused training courses on a phantom model using porcine gall bladder useful for trainees in acquiring basic laparoscopic skills?

The best training method in laparoscopic surgery has not been defined. We evaluated the efficacy of laparoscopic skills acquisition in a short-term focused program. Two hundred fifty-six participants undergoing training on a phantom model were divided into 2 groups. Group 1 had no exposure and group 2 had performed a few laparoscopic surgeries. Acquisition of laparoscopic skills was assessed by operation time and the modified Global Operative Assessment of Laparoscopic Skills (GOALS) scale. A questionnaire was sent to the participants after 3 to 6 months for assessment of impact of training. There was a statistically significant improvement in the assessed parameters and in the mean score of all 5 domains of GOALS. The participants in group 2 performed better than those in group 1 in the first case. The difference between both the groups disappeared after the training. Participants who responded to the questionnaire felt that training helped them in improving their performance in the operation theater.

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.

Duodenal perforation following blunt abdominal trauma.

Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient, the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior wall. We emphasize on keeping the management protocol simple by a "triple tube decompression", i.e. duodenorrhaphy (simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

Transanal endoscopic microsurgery-based transanal access for colorectal surgery: experience on human cadavers.

Transanal endoscopic microsurgery (TEM) was described in 1983 for local excision of rectal tumors. In the context of natural orifice translumenal endoscopic surgery, we have modified the original TEM system and developed a new set of instruments. These are more curved and, in addition, steerable. After extensive studies in an ex-vivo model, we developed a novel technique for transanal rectosigmoid resection and colorectal anastomosis. The technique comprises closure of the rectal lumen by purse-string suture, transection of the rectal wall distal to the closure, circumferential mobilization of rectum and mesorectal tissue in the anatomical plane from below upward, control of the inferior mesenteric vessel, removal of mobilized colorectum through the anus, and, finally, the colorectal anastomosis by either stapled or hand-sutured technique. This procedure was performed on three alcohol-glycerol preserved well-built human cadavers (M:F=2:1). The average operating time was 190 minutes. The average length of the resected specimen was 23 cm. There was no fecal contamination or injury to the resected specimen. Postprocedure laparotomy revealed adequate mesorectal resection and no inadvertent injury to other viscera. During dissection in the pelvis, as the resected rectum was pushed upward, an unobstructed "empty pelvis" situation was developed in the operating site, thus facilitating the mesorectal resection. Transanal access for colorectal surgery seems feasible. It provides a precise definition of the distal safety margin, good view of the pelvis for meticulous mesorectal resection, and reduces the abdominal wall trauma. These may enhance the outcome of colorectal resection. However, further clinical studies can only substantiate these findings.

Single-port surgery and NOTES: from transanal endoscopic microsurgery and transvaginal laparoscopic cholecystectomy to transanal rectosigmoid resection.

Two different ways have been developed to perform endoscopic surgery. The standard way is multiport laparoscopic surgery. When entering through a natural orifice, we use single-port surgery for transanal work (transanal endoscopic microsurgery). In clinical routine, we moved from intralumenal surgery toward surgery in the perirectal area and finally the free abdomen. In the context of natural orifice translumenal endoscopic surgery, we have modified the length and diameter of optics and tube and developed new mechanisms for steering long curved instruments. This technology is then used for transvaginal cholecystectomy and transanal rectosigmoid resection. Global clinical application of transanal endoscopic microsurgery has proven superiority in preciseness and clinical results for adenomas and early cancer. The initial clinical study for transvaginal cholecystectomy is successfully performed in 6 female patients with an average operation time of 80 minutes and without major complication. Feasibility of transanal rectosigmoid resection is demonstrated in an ex vivo experimental model.