An analysis of 1-3-year follow-up results of laparoscopic sleeve gastrectomy: an Indian perspective.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become very popular nowadays among bariatric surgeons because of its surgical simplicity and good postoperative results. We present our experience on LSG as a single stage primary bariatric procedure for morbid obesity and its 1-3-year follow-up results. METHODS: Between March 2008 and March 2011, a total of 110 patients underwent laparoscopic sleeve gastrectomy. Two patients were excluded from the study and thus the prospectively maintained data of 108 patients were retrospectively reviewed and outcomes were recorded. RESULTS: The mean patient age was 39.3 ± 11.1 years, mean body mass index was 44.5 ± 6.8, mean excess body weight was 54.1 ± 16.3 kg, and the mean American Society of Anesthesiologists score was 3.1 ± 0.57. The mean operative time for the LSG procedure was 64.8 ± 10.6 min. The minimum follow-up duration was 6 months and maximum of 36 months. The mean postoperative percent excess body weight loss achieved was 67.5 ± 13.0 at 1 year, 71.1 ± 13.8 at 2 years, and 66.09 ± 14.3 at 3 years. At the end of 3 years, there was 83.3% resolution in diabetes, 85.7% resolution in hypertension, and 85.71% resolution in dyslipidemia. There were no reports of postoperative hemorrhage, gastric leak, deep venous thrombosis, pulmonary embolism, delayed gastric tube stricture, and operative mortality. CONCLUSIONS: LSG is a safe and effective bariatric procedure with low perioperative complications. Before it is considered as a single stage primary procedure, a long-term prospective comparative study with other bariatric procedures is required.

Laparoscopic ventral hernia repair: a comparative study of transabdominal preperitoneal versus intraperitoneal onlay mesh repair.

BACKGROUND: Laparoscopic ventral hernia repair is evolving rapidly worldwide to become a standard procedure. The purpose of this study was to compare the benefits, effectiveness, and postoperative outcome of laparoscopic transabdominal preperitoneal (TAPP) and intraperitoneal onlay mesh (IPOM) repair of ventral hernia. PATIENTS AND METHODS: Prospectively collected data of 279 patients who underwent laparoscopic ventral hernia repair between January 2005 and December 2009, of whom 68 underwent TAPP and 211 underwent IPOM repair, were retrospectively reviewed. For each patient demographic, preoperative and postoperative data were studied. Statistical analysis was performed by Student's t-test, Fisher exact test, and chi-square test. RESULTS: The study included a total of 279 patients, of whom 68 underwent TAPP procedure and 211 underwent IPOM procedure. Both the groups were comparable in age, sex, body mass index, American Society of Anesthesiologists score, mean fascial defect size, and mean size of mesh. Although the operating time was longer in TAPP group than IPOM group of patients, the overall cost of surgery in IPOM group ($752.3±355.7) was much higher than TAPP group ($903.6±28.0) of patients. Seroma formation was more common in IPOM group than TAPP group (8.5% versus 5.8%). There were 2 (2.9%) recurrences in TAPP group and 7 (3.3%) in IPOM group of patients. Mean postoperative hospital stay (1.5±0.6 versus 1.4±0.7 days, P=.35) and mean follow-up (22.7±13.4 versus 22.5±11.9 months, P=.90) were similar in both groups of patients. CONCLUSION: Besides the cost-effectiveness of TAPP procedure, it reduces the risk of complication related to intra-abdominal position of mesh and fixating devices. Before we label the TAPP repair of ventral hernia as the first choice, a comparative multicentric prospective trial with IPOM repair is warranted.

Sliding inguinal hernias: scope of laparoscopic repair.

BACKGROUND: Sliding hernias are an uncommon type of inguinal hernia. Very little is published in the literature regarding the outcome of laparoscopic repair of sliding hernia. The present series evaluates the feasibility and outcome of laparoscopic repair of these hernias. METHODS: Retrospective analysis of prospectively maintained data of patients with sliding inguinal hernia undergoing laparoscopic repair from January 2003 to July 2010 was done. The patient demographics, clinical presentations, operative details, and complications were studied. Related literature was reviewed. RESULTS: A total of 1136 patients underwent laparoscopic repair of inguinal hernia, of which 54 patients had sliding inguinal hernia (4.7%). Forty-one patients (76%) had left-sided hernia and 13 patients (24%) had right-sided hernias. Mean age of presentation was 63.5 years. Thirty-five patients (64.8%) presented as complicated hernias (27 irreducible, 7 obstructed, and 1 strangulated). Thirty-nine patients had sigmoid colon, 9 patients had cecum, 3 patients had ascending colon, and 3 patients had urinary bladder as the sliding component. Eight patients underwent Lichtenstein repair, 27 patients transabdominal preperitoneal repair, and 19 patients total extraperitoneal repair. Mean operating time of laparoscopic repair was 53 minutes (40-105 minutes). Five procedures (10.8%) were converted to open repair. Overall morbidity was 44.4%. Median hospital stay was 1.5 days (1-14 days). There were no recurrences in up to 7 years follow-up. CONCLUSION: Laparoscopic repair of sliding inguinal hernia is feasible and safe with good outcome. Laparoscopic transabdominal preperitoneal approach is the preferable method.

Laparoscopic transabdominal preperitoneal repair of ventral hernia: a step towards physiological repair.

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23-74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4-144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144-484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70-150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1-4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6-48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.

Laparoscopic splenectomy in patients of ß thalassemia: Our experience.

BACKGROUND: Laparoscopic splenectomy has become a standard treatment of various haematological disorders, but its feasibility in the setting of ß thalassemia has not been established. MATERIALS AND METHODS: Fifty patients of ß thalassemia underwent laparoscopic splenectomy between January 2006 and December 2008. "Anterior approach" method was practiced in all cases, with early ligation of splenic artery and delayed ligation of splenic vein. Specimen was extracted piecemeal via the umbilical port in initial 12 cases, while in 37 cases the specimen was extracted through a 7-8-cm pfannenstiel incision. Twelve patients of ß thalassemia having grade IV splenomegaly with hepatomegaly were electively operated by conventional open method. RESULTS: The procedure was completed in 49 patients. One (2%) patient required conversion to open surgery. Mean operating time in the first 12 cases was 151 minutes (110-210 minutes), while in 37 cases of splenectomy completed laparoscopically it was 124 minutes (80-190 minutes) [P < 0.05]. Mean intra-operative blood loss was 73.8 ml (30-520 ml). No major intra-operative complications occurred. No patient required per-operative blood transfusion. Mean postoperative hospital stay was 4.7 days (2-11 days). Mean preoperative blood transfusion requirement was 11.98 units per patient per year, while mean postoperative blood transfusion requirement was 4.04 units [P< 0.05]. CONCLUSION: Laparoscopic splenectomy is feasible and safe even in patients of ß thalassemia with massive splenomegaly. Removal of specimen via a pfannenstiel incision significantly saves time, carries low morbidity and is a cosmetically acceptable alternative.

Laparoscopic repair of spigelian hernia: our experience.

BACKGROUND: Spigelian hernias are rare abdominal wall hernias occurring through a defect in the spigelian fascia lateral to the semilunar lines and pose great difficulty in diagnosis due to their location and varied presentations. The treatment of spigelian hernia has evolved from open surgical repair to laparoscopic hernioplasty. In this article, we share our experience of 6 patients with spigelian hernia managed by laparoscopic mesh repair and review the related literature on the topic. METHODS: A retrospective data collection of patients of spigelian hernia operated on between January 2005 and December 2008 was done. The data were evaluated regarding patient presentation, age group, methods of surgical repair, and the outcome of the procedures. The patients had follow-up at 1 week, 6 months, 1 year, and 2 years after the surgery and were evaluated for any recurrence or mesh-related complications. RESULTS: In total, 6 patients of spigelian hernia were operated on in 4 years, from January 2005 to December 2008, with most of them presenting with either a lump or pain. All patients were operated by the transabdominal preperitoneal (TAPP) method with satisfactory results. No recurrences were found in 2 years of follow-up. CONCLUSIONS: Laparoscopic TAPP is an acceptable method of spigelian hernia repair with good results and low recurrence rates. However, long-term follow-up studies are required to assess the late recurrence rate.

Chronic Groin Pain in Athletes: Sportsman's Hernia with Bilateral Femoral Hernia.

The differential diagnosis of chronic groin pain in athletes is a long list and its evaluation is a challenging task. Sports hernia, one of the common cause of these groin pains, had been managed both with open & endoscopic repairs in the past. We report a case of sports hernia in young footballer who presented with bilateral groin pain for 5 years. Endoscopic hernioplasty was done (by totally extra-peritoneal technique) which identified bilateral occult femoral hernia and were repaired simultaneously. Post op outcome was good with excellent results.

Laparoscopic cholecystectomy in situs inversus-our experience of 6 cases.

Laparoscopic cholecystectomy is the standard procedure for symptomatic gall stone disease. Situs inversus is a condition where the visceral anatomy is reversed. Laparoscopic cholecystectomy in a patient of situs inversus is a technically difficult procedure. Six patients of situs inversus underwent laparoscopic cholecystectomy from January 2003 to December 2009. In the first patient of situs inversus, we operated by placing the ports in mirror image fashion as that of standard laparoscopic cholecystectomy. However in next five patients we modified the technique by interchanging the epigastric and left mid clavicular line ports to overcome the problem of handedness. The procedure was successfully completed in all six patients. No intraoperative or postoperative complications occurred. The mean operating time was 65 mins (45-85 mins). Laparoscopic cholecystectomy is safe in patients of situs inversus. However, extreme care and skill is required to identify the reversed anatomy and to overcome the problem of handedness. Interchanging the epigastric and left mid clavicular line ports makes the procedure easier.

Hernia endotrainer: results of training on self-designed hernia trainer box.

INTRODUCTION: Repair of groin and ventral hernias are among the technically difficult endoscopic procedures where the role of laparoscopic surgery is fast emerging. We have designed a laparoscopic simulator trainer box for hernia surgery, which closely mimics the complex endoscopic procedure, and good results can be achieved by training on these trainer boxes. MATERIALS AND METHODS: The endotrainer box was self-designed to repair bilateral groin hernia, and an incisional hernia, such that it can be used for multiple repairs. Forty candidates were trained with the trainer box for 2 days over two hernia training programs, and an objective assessment of the result was done by global and task-specific scoring for transabdominal preperitoneal (TAPP) and intraperitoneal onlay mesh (IPOM) repair of groin and incisional hernia, respectively. RESULTS: There was a significant improvement in the global (10.15 on day 1 and 12.85 on day 2) and task-specific score for TAPP (3.55 on day 1 and 5.83 on day 2) and IPOM repair (4.4 on day 1 and 6.4 on day 2). CONCLUSIONS: Cheaper endotrainer boxes can be self-designed for complex endoscopic surgeries such as hernia repair. The training with these trainer boxes under the supervision of experienced surgeons shows good results and can be used for surgical residents and practicing surgeons who are exposed to basic laparoscopic skills.

Primary access-related complications in laparoscopic cholecystectomy via the closed technique: experience of a single surgical team over more than 15 years.

BACKGROUND: Laparoscopic cholecystectomy (LC), a common laparoscopic procedure, is a relatively safe invasive procedure, but complications can occur at every step, starting from creation of the pneumoperitoneum. Several studies have investigated procedure-related complications, but the primary access- or trocar-related complications generally are underreported, and their true incidence may be higher than studies show. Major vascular or visceral injury resulting from blind access to the abdominal cavity, although rare, has been reported. Of the two methods for creating pneumoperitoneum, the open access technique is reported to have the lower incidence of these injuries. The authors report their experience with the closed method and show that if performed with proper technique, it can be as rapid and safe as other techniques. However, injuries still happen, and the search for the predisposing factors must be continued. METHODS: Between January 1992 and December 2007, a retrospective study examined 15,260 cases of LC performed for symptomatic gallstone disease in the authors' institution by a single team of surgeons. The primary access-related injuries in these cases were retrospectively analyzed. RESULTS: In 15,260 cases of LC, 63 cases of primary access-related complications were identified, for an overall incidence of 0.41%. Major injuries in 11 cases included major vascular and visceral injuries, and minor injuries in 52 cases included omental and subcutaneous emphysema. For the closed method, the findings showed an overall incidence of 0.14% for primary access-related vascular injuries and 0.07% for visceral injuries. CONCLUSION: Primary access-related complications during LC are common and can prove to be fatal if not identified early. The incidence of these injuries with closed methods is no greater than with open methods. No evidence suggests abandonment of the closed-entry method in laparoscopy.

Laparoscopic repair of recurrent groin hernia: results of a prospective study.

BACKGROUND: Recurrences continue to be seen after repair of inguinal hernias. The repair of these recurrent hernias is a more complex and demanding procedure, with a high re-recurrence rate. Definite advantage has been demonstrated with endoscopic repair of these hernias. METHODS: The results for this prospective study from January 2003 to December 2006 were evaluated after laparoscopic repair of 65 recurrent hernias in 61 patients. The patients were followed up for 1 year. Longer follow-up evaluation was performed for the patients who underwent surgery in the initial 3 years. RESULTS: In this study, 37 recurrent hernias were managed using the transabdominal preperitoneal technique (TAPP) technique and 28 using the totally extraperitoneal (TEP) technique. There was no conversion and no cases of postoperative wound infection. Of the 12 metachronous hernias repaired simultaneously, 3 were occult. Seroma developed in five patients. At a follow-up assessment after 1 year, one patient had groin pain, and there was one re-recurrence. A longer follow-up period with a mean of 35.11 months failed to show any new re-recurrence. CONCLUSIONS: Laparoscopic repair of recurrent inguinal hernia is safe and effective. The morbidity and recurrence rates for the procedure are as low as for laparoscopic repair of primary hernias. Laparoscopic repair should be the gold standard for these hernias.

Incidental carcinoma gall bladder during laparoscopic cholecystectomy for symptomatic gall stone disease.

INTRODUCTION: Carcinoma gall bladder (CaGB) is a disease with high mortality and is usually diagnosed as an incidental case among patients undergoing laparoscopic cholecystectomy (LC) for symptomatic gall stone disease. METHODS: A total of 3205 LC done between January 2004 and August 2007 for symptomatic gall stone disease were retrospectively searched for incidental CaGB (detected on histopathology). None of these cases had preoperative suspicion of malignancy and their whole data was analyzed with special attention to preoperative and intraoperative findings which could raise suspicion of CaGB. In November 2007, patients were followed up telephonically about their present status of health. RESULTS: Nineteen patients (14 female and 5 male) with incidental CaGB (incidence 0.59%) were detected. Mean age of the patients was 56 years. Only two of these patients had clinical jaundice and both had common bile duct (CBD) stones. The majority of the patients were in early pathological stages (pT) and none was in pT3 and pT4 stage. Seventeen patients could be followed up telephonically in November 2007 and of those 14 patients were alive at a mean follow-up duration of 21.2 months, with one of them having evidence of metastatic disease. CONCLUSION: Gall bladder (GB) malignancy may be curable if diagnosed in early stages as an incidental finding and LC may not worsen the prognosis in such cases. In our series, incidental CaGB was detected in 0.59% patients undergoing LC. No association could be found between preoperative and intraoperative findings that could raise a suspicion of malignancy of gall bladder and so use of retrieval bag as a routine measure in cases with bile spillage may reduce the incidence of port-site metastasis.

Perforated caecal diverticulum as a content of inguinal hernia - report of a rare case.

A tablet induced perforation of a caecal diverticulum into a hernial sac is a rare happening. The report discusses the presentation and outcome of a patient with such an unusual disease. A 55-year-old man presented with features of irreducible right sided indirect inguinal hernia. A hard swelling near upper pole of right testis was noted. Scrotal ultrasound revealed a normal testis. At operation caecum and proximal ascending colon were found in the hernial sac with the caecum adherent to the testis. As caecal malignancy could not be ruled out and enbloc Rt Haemicolectomy with Rt orchidectomy was performed. The patient had an uneventful recovery. Pathological examination of the specimen revealed a perforated caecal diverticulum with presence of multiple tablets in its lumen invaginating the upper pole of right testis without any evidence of malignancy. Tablet induced perforation of a caecal diverticulum into a hernial sac is a rare clinical entity. If malignancy cannot be negated at operation, a right haemicolectomy is a safe and feasible option.

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Endoscopic repair of groin hernias allows the surgeon to have a complete view of the groin and pelvis to diagnose occult hernias both ipsilaterally and contralaterally. These occult hernias can then be treated simultaneously and may reduce the incidence of recurrence and persistent symptoms. The authors present four unusual cases where occult hernias were found ipsilaterally during an endoscopic repair. All these occult hernias were treated along with the clinically diagnosed hernia at the same surgery with excellent results and no post-operative morbidity.

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Laparoscopic cholecystectomy is the most common surgery performed for symptomatic gallstones. However even after surgery, symptoms may persist in some patients. Various causes for such post-cholecystectomy syndrome have been noted. We report our experience of seven such patients with post-cholecystectomy syndrome where on investigations, presence of stone in the biliary tree could be confirmed along with remnant gall-bladder. All these patients underwent completion cholecystectomy with removal of the stones by laparoscopic surgery and had good post-operative result. The patients were followed-up from three months to one year and all were asymptomatic till their last follow-up.

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Inguinal hernia has a nature to surprise surgeons with its unexpected contents. Appendix epiploicae alone in the hernial sac is a rare entity and that too if hypertrophied and presenting as irreducible hernia is still more uncommon. We report a 52-year-old male with complains of irreducible inguinal mass with little pain on Left side for seven days. A diagnosis of irreducible inguinal hernia was made and the patient was treated laparoscopically by Trans-Abdominal Pre-Peritoneal Mesh Hernioplasty (TAPP). As a surprise, content of the hernial sac was enlarged / hypertrophied appendix epiploicae of sigmoid colon with appendigitis. Patient also had and incidental hernia on the other side, which was repaired in the same sitting. Postoperative recovery of the patient was excellent.

Antegrade common bile duct (CBD) stenting after laparoscopic CBD exploration.

UNLABELLED: Laparoscopic common bile duct exploration (LCBDE) has been found to be a safe, efficient and cost-effective treatment for choledocholithiasis. Following LCBDE, the clearance may be ascertained by a cholangiogram or choledochoscopy. The common bile duct (CBD) may be closed primarily with or without a stent in situ or may be drained by means of a T-tube or a biliary enteric anastomosis. MATERIALS AND METHODS: In our series of 464 patients of choledocholithiasis, 100 patients underwent closure of the CBD with an indwelling antegrade stent following LCBDE. LCBDE was performed by direct massage of CBD, saline lavage, direct pickup with choledocholithotomy forceps or by basketing. Fragmentation of impacted stones in situ was performed in a few patients. Completion choledochoscopy was performed by means of a pediatric bronchoscope. A 10-cm, 7 Fr. double-flap biliary stent was placed in situ after LCBDE. RESULTS: There was no mortality in the series. There was no conversion either. The median duration of the operation was 75 min. The mean postoperative hospital stay was 3.5 days. One patient had a minor postoperative biliary leak. One patient had a right sub-hepatic collection. Four patients developed postoperative port infection. The stents were removed endoscopically after 4 weeks. Sixty-eight patients could be followed up till 1 year. There has been no incidence of residual disease and the patients on follow-up are asymptomatic. CONCLUSION: In our experience, a single stage laparoscopic treatment of cholelithiasis with choledocholithiasis is a safe, viable and cost-effective option. Closure of the CBD over an antegrade stent is a feasible option but requires advanced skills in minimal access surgical techniques, especially endosuturing. The procedure may be performed safely in expert hands without mortality and with negligible morbidity.

Torsion of the epiploic appendix: An unusual cause of acute abdomen.

SUMMARY: Torsion of an epiploic appendix is a rare surgical entity. We present our experience in a thirty five year old female patient and a forty year old male patient. MATERIALS AND METHODS: A 35 year old lady had presented with right iliac fossa pain of 2 days duration. Guarding and rebound tenderness was present over the area. Investigations showed mild leucocytosis and neutrophilia. Diagnostic laparoscopy revealed an inflamed epiploic appendix which was excised. Other intrabdominal organs were normal. A 40 year old male patient had presented with a history of recurrent, colicky, and paroxysmal right lower quadrant pain for 2 months. At laparoscopy, an inflamed torted epiploic appendix of the ascending colon was detected and excised. Other intrabdominal organs were normal. RESULTS: Both the patients had an uneventful recovery and are asymptomatic at follow up of 10 and 7 months respectively. They have been followed up at 7 days, 4 wks and then 3 monthly. DISCUSSION: The clinical presentation of an inflamed appendices epiploicae may be confusing. CT is helpful in disgnosis. Laparoscopy may be used to diagnose and treat the condition as well. CONCLUSION: Diagnostic laparoscopy is an useful tool for surgeons in assessing abdominal pain where the cause is elusive. It may be used to diagnose and treat torsion of an epiploic appendix effectively.

Pericholecystic fistula: a study of 64 cases.

Spontaneous biliary fistulas are found quite often. Although previously considered as a contraindication to laparoscopic surgery, they are now being treated laparoscopically with all its advantages. Of 8015 patients undergoing laparoscopic cholecystectomy, 64 patients were diagnosed preoperatively; conversion to open surgery was required in 8 patients. The highest incidence of pericholecystic fistulas was found in the >60-year age group. The postoperative stay ranged from 3 to 8 days. All the patients were well at follow up. Laparoscopic management of pericholecystic fistulas is possible with low morbidity and no mortality.