Manish Baijal

Diagnosis and management of Spigelian hernia: A review of literature and our experience

Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).

Minimal Access Surgery for Hydatid Cyst Disease: Laparoscopic, Thoracoscopic, and Retroperitoneoscopic Approach

Surgery has remained the mainstay for the treatment of hydatid cyst. The rapid development of laparoscopic techniques has encouraged surgeons to replicate principles of conventional hydatid surgery using a minimally invasive approach. Several reports have confirmed the feasibility of laparoscopic hepatic hydatid surgery. We report the use of a laparoscopic approach for cysts located in the liver, lung, and retroperitoneum. Fifteen patients with hydatid cysts, including one patient with a recurrent cyst, of various organs, including the liver, lung, and retroperitoneum, were operated on laparoscopically. Sixteen hydatid cysts were drained in a total of 15 patients. The mean operative time was 84 +/- 6 minutes (60-125 minutes). The mean duration of the hospital stay was 2.3 days (1-6 days). The mean cyst diameter was 9.2 cm (6.4-13.5 cm). No conversions to open surgery were required. One complication, a trocar-induced bowel perforation, occurred, and there was no mortality. During 3 to 44 months (mean, 27 months) of follow-up, no recurrences developed. Minimal access surgery is a safe, effective, and viable option for the management of selected patients with hydatid cysts in various locations, such as the liver, lung, and retroperitoneum.

Laparoscopic intragastric stapled cystogastrostomy for pancreatic pseudocyst.

BACKGROUND Mature symptomatic pancreatic pseudocysts require surgical intervention for their management. In this era of minimal access surgery, several reports are now available of laparoscopic management of pancreatic pseudocysts. PATIENTS AND METHODS We have performed this procedure in five patients over the past 2 years. Four patients developed the pseudocyst after acute alcoholic pancreatitis and one following acute biliary pancreatitis. The diameter of the pseudocyst ranged from 8 to 12 cm. The procedure was performed using five ports. The Harmonic Scalpel was used to create two ports in the anterior stomach wall through which two balloon trocars were placed into the gastric lumen. Following balloon inflation, the trocars were used to lift up the anterior gastric wall. This created the space for the cystogastrostomy to be fashioned laparoscopically through the balloon trocar. The ball probe of the Harmonic Scalpel was used to puncture the cyst through the posterior gastric wall. The cystogastrostomy was completed by firing an Endo-GIA30 stapler across the fused posterior gastric wall and anterior wall of the cyst. RESULTS The mean operative time was 90 minutes (range 80-125 minutes). The mean postoperative stay was 3.0 days. One patient had intraoperative bleeding at the anastomotic site, which was easily controlled. CONCLUSION Laparoscopic cystogastrostomy offers a feasible and safe therapeutic option for selected patients with large symptomatic pancreatic pseudocysts.

Combined procedures in laparoscopic surgery.

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30–280 minutes.). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1–21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.

Complete Laparoscopic Management of Choledochal Cyst: Report of Two Cases

BACKGROUND Choledochal cyst is a rare congenital anomaly of the biliary tract. With increased familiarity with the laparoscopic anatomy of the biliary tract and advances in minimally invasive techniques, surgeons have ventured further to operate on technically difficult cases such as choledochal cyst that were until recently managed by laparotomy. PATIENTS AND METHODS We present our experience with two female patients aged 14 years and 26 years with choledochal cyst (type I according to the Alonzo-Lej classification) that were successfully excised with construction of a Roux-en-Y hepaticojejunostomy entirely laparoscopically. RESULTS Both patients had an uneventful recovery, with no major morbidity. The first patient had a bile leak, which resolved over 5 days. Both were discharged by the 5(th) postoperative day. CONCLUSION Laparoscopic management of choledochal cyst is feasible although technically difficult and may be performed in specialized institutes dealing with advanced laparoscopic surgery.

Laparoscopic reintervention for residual gallstone disease.

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.

Laparoscopic Repair of Diaphragmatic Hernias: Experience of Six Cases

OBJECTIVE Laparoscopic diaphragmatic hernia repair is increasingly performed in adults for congenital diaphragmatic hernias and chronic traumatic diaphragmatic hernias. This study reviewed our experience with laparoscopic diaphragmatic hernia repair to evaluate its safety, efficacy and outcomes. METHODS Between January 1999 and December 2002, four male and two female patients presented to us with diaphragmatic hernias, three with traumatic and three with congenital hernias. The mean age of patients was 58.6 years (range, 42-83 years). Five patients presented with main complaints of postprandial retrosternal/chest discomfort and one patient had an acute gastric outlet obstruction. Dissection was performed laparoscopically to reduce the contents of the sac and the hernial defect was repaired using prolene sutures and a polypropylene mesh. RESULTS Laparoscopic repair of diaphragmatic hernias was completed successfully in all patients. The mean size of the defect was 6.8 cm (range, 3-12 cm) and the mean operative time was 100 minutes (range, 60-150 minutes). There were no major intraoperative complications. One patient required placement of a chest tube due to inadvertent opening of the pleura with the hernial sac and one patient had prolonged postoperative gastric ileus. The mean hospital stay was 2.3 days (range, 1-4 days) and the mean pain score was 4 (range, 2-6). All patients remained asymptomatic over a mean follow-up of 2.9 years. CONCLUSION Adult congenital and chronic traumatic diaphragmatic hernias are amenable to laparoscopic repair. Laparoscopic repair is safe and feasible and confers all the advantages of minimal access surgery.

Laparoscopic ventral hernia repair with extraperitoneal mesh: surgical technique and early results.

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years [range, 34–70]) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25% of the mesh was exposed after the procedure. The median (±SD) duration of hospitalization postoperatively was 1 day (±0.56). One patients hernia recurred 4 months after surgery, and one patients infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.

Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction.

Background To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction. Methods Retrospective analysis of 253 patients who underwent therapeutic laparoscopy for recurrent small bowel obstruction from June 1996 to May 2005 was carried out. Patients with acute small bowel obstruction, bowel obstruction due to tumor, and obstructed inguinal hernias were excluded from analysis. Results Laparoscopy diagnosed cause of obstruction in all except 3 (1.18%) patients. The etiology included adhesions (38%), incarcerated ventral incisional hernias (32%), Meckel diverticulum (7%), stricture (14%), volvulus (3%), intussusception (4%). One hundred sixty nine patients were managed totally laparoscopically with adhesiolysis. Therapeutic bowel intervention other than adhesiolysis was required in 84 patients, of which 33 procedures were performed totally laparoscopically and remaining 51 procedures were completed with laparoscopically guided target incision. Five patients required conversion to open celiotomy. Iatrogenic enterotomies occurred in 3 patients and small bowel perforation during manipulation occurred in 1 patient. Postoperative procedure-related complications were seen in 44 patients. There was one mortality due to postoperative arrhythmia and cardiac failure. Conclusions Laparoscopic diagnosis and treatment of recurrent small bowel obstruction is feasible, safe, and can be performed electively in selected cases.

Recurrent Hernia Following Endoscopic Total Extraperitoneal Repair

BACKGROUND AND PURPOSE A retrospective study was conducted to identify the reasons for recurrence following endoscopic total extraperitoneal (TEP) repair of inguinal hernias and to develop a strategy to prevent recurrence. METHOD Between January 1996 and December 2001, 1193 TEP hernia repairs were performed in 694 patients. Following reduction of the hernia sac and dissection of the preperitoneal space up to the psoas muscles laterally, a Prolene mesh (15 x 15 cm) was placed. The mesh was fixed medially to the Cooper ligament with two or three spiral tacks. In six patients, the hernia recurred following endoscopic TEP repair within the same period. Four of these patients elected to undergo laparoscopic transabdominal preperitoneal (TAPP) repair of the recurrent hernia. RESULTS Medial recurrences developed in three of the four patients because of medial displacement of the mesh. One patient was found to have a missed indirect hernia sac. All the patients who underwent laparoscopic TAPP repair had an uneventful recovery and are well at follow-up. CONCLUSION In addition to medial fixation of the mesh to the Cooper ligament, complete proximal dissection of the peritoneum from the spermatic cord and additional fixation of the mesh to the anterior abdominal wall, with careful avoidance of possible injury to the adjacent nerves, may prevent recurrences.