Mukund Khetan

Single-incision multi-port laparoscopic appendectomy: How I do it

INTRODUCTION: Single-incision laparoscopic surgery (SILS) appendectomy seeks to further minimise the trauma of parietal access of laparoscopic appendectomy. METHODS: We present our initial experience of 17 cases of SILS appendectomy which were completed using conventional laparoscopic instruments. We utiliesd a single-incision multi-port laparoscopic appendectomy (SIMPLA) technique. RESULTS: The operative time was 63 ± 20 min, blood loss 6.5 ± 5 mL, bowel movement (passing stool) occurred in 2.6 ± 0.6 days. Most patients were discharged on the first operative day on oral diet. The analgesic usage and pain scores were similar to multi-port laparoscopic appendectomy. No complications were noted at follow-up till 4 weeks and the surgical wound healed in all patients with an inconspicuous scar. CONCLUSION: Our initial experience with SILS appendectomy demonstrates its feasibility and supports the promise of minimising further the access of laparoscopic surgery. The clear advantage is its cosmetic benefit.

Review of contemporary role of robotics in bariatric surgery

With the rise in a number of bariatric procedures, surgeons are facing more complex and technically demanding surgical situations. Robotic digital platforms potentially provide a solution to better address these challenges. This review examines the published literature on the outcomes and complications of bariatric surgery using a robotic platform. Use of robotics to perform adjustable gastric banding, sleeve gastrectomy, roux-en-y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch and revisional bariatric procedures (RBP) is assessed. A search on PubMed was performed for the most relevant articles in robotic bariatric surgery. A total of 23 articles was selected and reviewed in this article. The review showed that the use of robotics led to similar or lower complication rate in bariatric surgery when compared with laparoscopy. Two studies found a significantly lower leak rate for robotic gastric bypass when compared to laparoscopic method. The learning curve for RYGB seems to be shorter for robotic technique. Three studies revealed a significantly shorter operative time, while four studies found a longer operative time for robotic technique of gastric bypass. As for the outcomes of RBP, one study found a lower complication rate in robotic arm versus laparoscopic and open arms. Most authors stated that the use of robotics provides superior visualisation, more degrees of freedom and better ergonomics. The application of robotics in bariatric surgery seems to be a safe and feasible option. Use of robotics may provide specific advantages in some situations, and overcome limitations of laparoscopic surgery. Large and well-designed randomised clinical trials with long follow-up are needed to further define the role of digital platforms in bariatric surgery.

Endoscopic TEP inguinal hernia repair in the management of occult obturator and femoral hernias.

Purpose: The gold standard technique for the repair of groin hernias has always been a controversial issue. Richard Ger introduced the endoscopic approach for the repair of groin hernias in 1991.The endoscopic technique follows the basic principle of preperitoneal placement of a polypropylene mesh over the myopectineal orifice. During the course of dissection of the preperitoneal space, occult obturator and femoral hernias were discovered. Methods: Patients who underwent endoscopic totally extraperitoneal repair of inguinal hernias over a period of 2 years were included in this retrospective study. Results: A total of 305 cases of groin hernias were operated in 208 patients over a period of 2 years from January 2010 to January 2012 in a single institution. Eleven synchronous clinically occult obturator hernias were found in 8 patients (3.84%) and 5 synchronous clinically occult femoral hernias were found in 5 patients (2.40%) during repair. Conclusions: Preoperative and perioperative findings were discordant in quite a few cases. Preperitoneal dissection discovered coincidental occult hernias in 6.25% of patients.

Laparoscopic management of Spigelian hernias

Spigelian hernias, also known as spontaneous lateral ventral hernias, are rare primary ventral hernias arising in the Spigelian, or semilunar, line located at the lateral border of recti. Because of its varied presentation, clinical examination is often inconclusive. Traditional repair of such hernias use the open approach. Herein we report on three cases of Spigelian hernias. All were diagnosed and treated laparoscopically at our institution between March 2011 and June 2012. Multiple surgeons performed the repairs using the laparoscopic transabdominal preperitoneal technique of mesh reinforcement and reperitonization. There were no perioperative or postoperative complications. All three were discharged 1 day postoperatively. A complete resolution of preoperative symptoms was observed at follow‐up at 1 week, 1 month and 6 months. Laparoscopic transabdominal preperitoneal repair of Spigelian hernia is safe, easy, and feasible for experienced laparoscopic surgeons.

Primary laparoscopic cholecystectomy in patients with portal cavernoma and non-obstructive portal biliopathy: Two case reports

A laparoscopic cholecystectomy can be technically challenging with co-existing portal hypertension, as commonly seen with cirrhosis of the liver. Extra hepatic portal vein obstruction (EHPVO) although less common, is a significant cause of portal hypertension in India. EHPVO has a unique clinical profile, which differentiates it from portal hypertension associated with cirrhosis of the liver. This impacts therapy in EHPVO algorithmically and operatively. We report two cases of symptomatic gall stones with portal cavernoma. Further evaluation revealed non-obstructive portal biliopathy. Both underwent a successful laparoscopic cholecystectomy. We highlight the importance of careful operative strategy, diligent haemostasis and the feasibility of performing a laparoscopic cholecystectomy in patients with symptomatic gall stones associated with a portal cavernoma.

Double rolling and center hitch technique for laparoscopic ventral hernia repair

BACKGROUND: Intraperitoneal onlay mesh repair is an established modality to treat large ventral hernias. Various techniques of laying the mesh are utilized. We present the Double Rolling and Center Hitch technique to lay a large intraperitoneal onlay mesh. OBJECTIVE: The aim of the study is to devise and adopt a method to reduce the difficulty in manoeuvring a large mesh inside the peritoneal cavity. It should also help in correct placement of mesh and decrease the operative time. MATERIALS AND METHODS: The DRACH technique was used in eighteen patients with large ventral hernias between May 2010 and September 2011. The Mesh size used was 15x20cm and more (considered to be large mesh). RESULTS: All the procedures were completed successfully. Mesh handling was significantly easier with the DRACH technique. The average mesh deployment time (MDT) was 15mins. In all cases the mesh was adequately centred with a margin of 3-5cm from the defect. CONCLUSION: The DRACH technique can be employed to lay large intraperitoneal meshes in order to reduce the handling difficulties associated with large meshes, and to aid in better placement of meshes so as to centered over the defect.