Laparoscopic necrosectomy for acute necrotising pancreatitis: Retrospective analysis of a decade-long experience from a tertiary centre.

INTRODUCTION: The objective of this study is to evaluate the role of minimally invasive surgery for the management of necrotising pancreatitis in acute settings and to propose tailor-made approaches to deal with various locations of pancreatic necrosis. PATIENTS AND METHODS: Three hundred and thirteen patients underwent laparoscopic management of necrotising pancreatitis in this study period from January 2010 to June 2021, out of which 122 patients underwent minimally invasive necrosectomy for acute necrotising pancreatitis. The remaining 191 patients underwent laparoscopic internal drainage in the form of cystogastrostomy/cystojejunostomy for walled-off pancreatic necrosis. RESULTS: Mean body mass index was 26.45 ± 3.78 kg/sqm. Mean operating time was 56.40 ± 20.48 min and mean blood loss was 120 ± 31.45 mL. Ten patients required reoperation (6 underwent open procedure and 4 underwent laparoscopic redo necrosectomy). Six patients died of multi-organ failure. The mean duration of return of bowel function was 5 ± 1.8 days. The mean length of hospital stay after surgery was 10.19 ± 7.09 days. There were no major wound-related complications. CONCLUSION: A minimally invasive approach to pancreatic necrosectomy is safe and feasible with good outcomes in centres with advanced laparoscopic expertise. It requires not only careful case selection but also proper timing and the ideal route of access to achieve optimal outcomes.

A randomized controlled trial on the effectiveness of laparoscopic-guided transversus abdominis plane block in patients undergoing laparoscopic IPOM plus.

INTRODUCTION: Ventral hernia repairs, particularly laparoscopic ventral hernia repair (LVHR), have become common procedures among general surgeons worldwide. Despite the benefits of LVHR, acute postoperative pain remains a significant concern. Transversus abdominis plane (TAP) blocks have been employed to alleviate postoperative pain in various laparoscopic procedures. This study aimed to assess the effectiveness of laparoscopic-guided TAP block in laparoscopic IPOM plus and its impact on postoperative pain and analgesic requirements. MATERIALS AND METHODS: A randomized controlled trial was conducted at a tertiary care center in India involving 72 patients undergoing laparoscopic IPOM plus. Patients were randomized into two groups: Group I received laparoscopic-guided TAP block, while Group II received standard general anesthesia without TAP block. Pain scores were assessed at 6, 12, and 24 h postoperatively using the numerical rating scale. Postoperative analgesic requirements were also recorded. RESULTS: Group I demonstrated significantly lower pain scores at 6 and 24 h postoperatively compared to Group II. The need for additional analgesics was significantly lower in Group I (13.8%) compared to Group II (72.2%). There were no significant differences in age, BMI, duration of surgery, or other demographic characteristics between the two groups. CONCLUSION: The findings of this randomized controlled trial demonstrate the effectiveness of laparoscopic-guided TAP blocks in reducing postoperative pain and analgesic requirements after laparoscopic IPOM plus.

Extended View: Totally Extra Peritoneal (e-TEP) Approach for Ventral and Incisional Hernia-Early results from a single center.

BACKGROUND: Laparoscopy for ventral hernia repair is now an established technique with its proven benefits of less pain, early recovery, low-recurrence rate as compared to open repair. Several techniques have been described such as IPOM, MILOS, TES, EMILOS, SCOLA, e-TEP. e-TEP was originally conceptualized as an alternative approach to inguinal hernia in difficult cases (obese, previous scars) and for training surgery residents. Application of this approach for ventral hernia repair has recently been reported by few surgeons. We present our experience of e-TEP approach for ventral hernia from a tertiary care center in South India over one year duration. MATERIALS AND METHODS: Electronically maintained data of patients who underwent e-TEP for ventral hernia during a period of November 2017 to November 2018 was reviewed retrospectively. Their demographic data, intraoperative details, postoperative complications and follow up data for a period of 6 months was noted. RESULTS: 171 patients underwent e-TEP approach ventral hernia repair. Mean age was 49.34 ± 10.75 years with hypertension being most common comorbidity. Mean BMI was 29.2 ± 4.1 kg/m2. Mean defect area was 51.35 ± 45.09 cm2 and mean mesh size used was 397.56 ± 208.83 cm2. Fifty patients required TAR. Mean duration of surgery was 176.75 ± 62.42 min and blood loss was 78.7 ± 24.4 ml. Mean length of stay was 2.18 ± 1.27 days. Seven cases had paralytic ileus, 5 cases had surgical site infection, and 3 cases had recurrence at 6 months follow up. CONCLUSION: e-TEP is a minimally invasive approach which is safe, feasible and also avoids placement of mesh in peritoneal cavity. Since it is a relatively new approach it requires further studies for standardization of techniques, criteria for patient selection and to study long-term outcomes.

Robotic transduodenal excision of duodenal duplication cyst: Case report and review.

Duodenal duplication cysts are rare congenital anomalies that generally present with abdominal pain and vomiting or may have nonspecific symptoms. Surgical excision is the recommended treatment owing to possible complications, including malignancy. However, difficult locations like the periampullary region are problematic and major surgical procedures, for example, pancreaticoduodenectomy is necessary for total resection. These have a high complication rate resulting in a poor quality of life, especially in children and young adults. Here, we describe a case of duodenal duplication cyst managed by robotic (transduodenal) excision along with a brief review of the literature.

Laparoscopic longitudinal pancreatojejunostomy and modified Frey's operation for chronic calcific pancreatitis.

Background: Chronic pancreatitis is a debilitating disease presenting with pain, diabetes and steatorrhoea. Surgery offers better long-term pain relief than other interventions, but there is still uncertainty about the optimal surgical procedure and approach and a lack of long-term follow-up data in patients with chronic calcific pancreatitis selected for laparoscopic surgical treatment. Methods: This was an observational cohort study of patients who underwent laparoscopic surgery for chronic calcific pancreatitis between January 2006 and April 2017, and had completed a minimum follow-up of 1 year at a tertiary-care teaching institute. Eligibility for the laparoscopic approach was main duct diameter greater than 7 mm, absence of extensive head calcification, size of head less than 3·5 cm, absence of local complications, and ASA grade I or II status. The primary outcome variable was a reduction in pain score by 1 year. Secondary outcomes were hospital stay, complications, pain score at 3 and 5 years, and the development or progression of exocrine and endocrine insufficiency. Results: Some 57 patients were scheduled to undergo laparoscopic surgery for chronic pancreatitis: longitudinal pancreatojejunostomy (39), modified Frey's procedure (15) and pancreatoduodenectomy for suspicion of malignancy (3). The latter three patients were excluded from the analysis. Conversion to open surgery was needed in ten of the 57 patients (18 per cent). The mean(s.d.) age of the analysed cohort was 34·2(3·7) years and there was a predominance of men (34, 63 per cent). Adequate pain relief was achieved in 91, 89 and 88 per cent of patients at 1, 3 and 5 years of follow-up respectively. Conclusion: Laparoscopic surgical management of chronic calcific pancreatitis with longitudinal pancreatojejunostomy or modified Frey's procedure is feasible, safe and effective in selected patients for the relief of pain.

Laparoscopic choledochoduodenostomy as a reliable rescue procedure for complicated bile duct stones.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction is generally accepted as first line management for common bile duct (CBD) stones. CBD exploration, either by open or laparoscopic approach nowadays, is usually reserved for ERCP failures, complicated stone locations, along with altered anatomical situations. The aim of this study was to highlight the increasing role of laparoscopic choledochoduodenostomy which is not only a reliable but also as a rescue procedure for those failed ERCP cases due to complicated bile duct stones. MATERIALS AND METHODS: It is a retrospective review of the database, from a tertiary care teaching institution from India, from Jan 2012 up to December 2016. RESULTS: Out of total 30 patients who underwent laparoscopic choledochoduodenostomy, 28 had failed ERC stone clearance while two patients were directly offered drainage in view of unfavorable anatomy. The major reasons for failed ERC stone clearance were as follows-multiple large calculi (42.8%), recurrent stones (21.4%), and associated stricture (21.4%). Mean operating time was 130 (± 27) minutes with mean blood loss of 60 (± 19) ml. Stone extraction was successful, primarily by milking in 13 (43.33%) patients, rest required augmentation by Dormia basket/balloon. Two patients (6.66%) developed controlled bile leak which resolved with conservative treatment. The median length of hospital stay was 5 days (IQR 3-9). Mean duration of follow-up was 17 (± 3.2) months. CONCLUSION: Laparoscopic common bile duct exploration with choledochoduodenostomy has been shown to be a safe, reliable, and efficient method for treating complex CBDS, especially after failed ERCP procedures.

Randomized clinical trial of laparoscopic versus open pancreatoduodenectomy for periampullary tumours.

BACKGROUND: Laparoscopic resection as an alternative to open pancreatoduodenectomy may yield short-term benefits, but has not been investigated in a randomized trial. The aim of this study was to compare laparoscopic and open pancreatoduodenectomy for short-term outcomes in a randomized trial. METHODS: Patients with periampullary cancers were randomized to either laparoscopic or open pancreatoduodenectomy. The outcomes evaluated were hospital stay (primary outcome), and blood loss, radicality of surgery, duration of operation and complication rate (secondary outcomes). RESULTS: Of 268 patients, 64 who met the eligibility criteria were randomized, 32 to each group. The median duration of postoperative hospital stay was longer for open pancreaticoduodenectomy than for laparoscopy (13 (range 6-30) versus 7 (5-52) days respectively; P = 0·001). Duration of operation was longer in the laparoscopy group. Blood loss was significantly greater in the open group (mean(s.d.) 401(46) versus 250(22) ml; P < 0·001). Number of nodes retrieved and R0 rate were similar in the two groups. There was no difference between the open and laparoscopic groups in delayed gastric emptying (7 of 32 versus 5 of 32), pancreatic fistula (6 of 32 versus 5 of 32) or postpancreatectomy haemorrhage (4 of 32 versus 3 of 32). Overall complications (defined according to the Clavien-Dindo classification) were similar (10 of 32 versus 8 of 32). There was one death in each group. CONCLUSION: Laparoscopy offered a shorter hospital stay than open pancreatoduodenectomy in this randomized trial. Registration number: NCT02081131( http://www.clinicaltrials.gov).

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.

Laparoscopic Management of Choledochal Cyst-Technical Modifications and Outcome Analysis.

BACKGROUND: Choledochal cyst (CDC) is a well described albeit rare clinical entity. Complete cyst excision with biliary-enteric reconstruction is the recommended treatment for Todani type I, II, and IVA cysts to prevent complications. The aim of this study is to evaluate outcomes of laparoscopic CDC excision from a tertiary care center. METHODS: This is a retrospective analysis of prospectively collected data of 110 patients who underwent laparoscopic cyst excision and biliary-enteric reconstruction for CDC type I and IVA from 1998 to 2013. RESULTS: Out of 110 patients, 55 were children (<16 years) and 55 were adults (>16 years) with mean age 21.19 ± 17.75 years and male:female ratio of 1:2.14. Abdominal pain was the most common presenting symptom (59.09 %). Surprisingly, 32.73 % of adults presented with incidentally detected cyst. Type I cyst was the most common (71.82 %) with mean size of 4.67 ± 1.59 cm. Blood loss (56.0 ± 16.62 vs. 76.55 ± 26.61 ml) and operative time (199.8 ± 44.66 vs. 251.6 ± 54.25 min) were significantly low in pediatric group. Three adults required conversion. Overall complication rate was 10 %. Re-exploration rate was 1.81 % with one patient died post-operatively. Mean hospital stay was significantly low in children (5.9 ± 1.39 vs. 7.0 ± 2.66 days). Median follow-up was 60 months (8-110). Cholangitis developed in six patients with three having anastomotic stricture requiring intervention. CONCLUSION: Laparoscopic excision of CDC is safe and feasible. Surgery should be performed early as outcomes are better in pediatric age as compared to adults.

Laparoscopic pylorus preserving pancreaticoduodenectomy in paediatric age for solid pseudopapillary neoplasm of head of the pancreas - case report.

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumour commonly seen in young women without significant clinical features. SPN is usually a lowgrade malignant neoplasm which warrants resection. Recurrence and metastasis is seen rarely after complete resection. Pancreaticoduodenectomy is indicated for SPN situated in head of the pancreas which is generally performed by open approach. Laparoscopic pancreaticoduodenectomy (LPD) is difficult to perform for this condition because of smaller size of pancreatic and hepatic ducts more so in paediatric population. We report a case of 12 years old girl having SPN arising from head of the pancreas. She underwent laparoscopic pylorus preserving pancreaticoduodenectomy. Post-operative period was uneventful. Histological examination of resected specimen confirmed diagnosis of SPN. At 6 months follow up, she was doing well without any recurrence. To best of our knowledge, no case of LPD in paediatric patients is reported in literature available to us.

Long-term results of hepatic hydatid disease managed using palanivelu hydatid system: Indian experience in tertiary center.

BACKGROUND: Incidence of hepatic hydatid disease is increasing due to globalization. Surgery is the gold standard treatment. Laparoscopy has gained enough evidence regarding its safety and efficacy. Complete evacuation of hydatid contents without spillage remains a challenge. We aimed to determine long-term results of hepatic hydatid disease managed laparoscopically using palanivelu hydatid system (PHS) at our institution. METHODS: One hundred and five patients underwent laparoscopic surgical management using the PHS at our institute from May 1997 to May 2013. Clinical presentations, surgical strategy, postoperative morbidity, and long-term recurrence rate were evaluated. RESULTS: Of the 105 patients, 76 were male and 29 female with a mean age of 32 years (range 14-71 years). The most common presentation was abdominal pain in 61 patients (58%). Sixteen patients had multiple cysts of which nine had involvement of both lobes. Seventy-seven (73.3%) cysts were uncomplicated. Nineteen (18.09%) had a cyst-biliary communication, two were ruptured cysts, and seven were recurrent cysts. All patients underwent successful laparoscopic management where conservative surgery was performed in 94 patients and radical surgery in 11 patients. Post-operative morbidity was seen in 18 (17.14 %) patients, which included deep cavity infection in two cases, post-operative bile leak in 13 cases, and duodenal injury in one case without any mortality. Mean long-term follow-up was 36 months (range 6 months-5 years) with recurrence in two cases. CONCLUSION: Our long-term results with PHS showed good outcomes in the laparoscopic management of hepatic hydatid disease with conservative surgery as the preferred approach reserving radical surgery only in selected cases.