Pradeep Chowbey

Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia.

We thank Christophe Berney for his interesting and very important Letter to the Editor, in which he addresses a number of aspects of the evidence-based technique of total extraperitoneal patchplasty (TEP) discussed in the ‘‘Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia’’ [1]. The technique must once again be clarified in more precise terms. At issue is the role of fibrin sealant for mesh fixation in TEP and the implications of the role of fibrin sealant in seroma formation. Christophe Berney reports on his own experiences with fibrin sealant for mesh fixation in 650 TEP operations with low complication and recurrence rates [2]. In the subsection entitled ‘‘Should a drain be used after a TEP repair? Should seromas be aspirated?’’ [1, p. 2794], the study by Lau [3] is cited as a level 1B statement. In that prospective randomized comparative study of bilateral inguinal hernias, it was noted that the use of fibrin sealant compared to staples for mesh fixation in TEP led to a significant reduction in the need for analgesics, but it also led to a significant rise in the rate of postoperative seromas. Here it is important to focus on the definition used by Lau [3] for a postoperative seroma: ‘‘A seroma was defined as the clinical presence of a palpable fluid collection over the groin in the absence of bruising during follow-up.’’ Also noteworthy in the Lau study [3] is that the proportion of direct hernias was very high, amounting to 56.5% in the fibrin sealant group and 58.5% in the staple group. In the Lau study [3] a clinically palpable seroma with protrusion of the skin was noted in only 5.3% of cases in which staples were used and in 17.4% (p = 0.009) of cases in which fibrin sealant was used for mesh fixation. Therefore, by virtue of the Lau study [3], it must be borne in mind that mesh fixation to Cooper’s ligament with staples tends to be more suitable for prevention of a clinically palpable seroma with protrusion of the skin in the groin after a TEP operation for direct hernias. The classification system used in the Guidelines means that queries relating to both TEP and TAPP are dealt with in separate sections. Therefore, further statements and commentaries on the issues raised by Christophe Berney can be checked in Chapter 9, ‘‘Mesh fixation modalities: is there an association with acute or chronic pain?’’ and Chapter 10, ‘‘Risk factors and prevention of acute and chronic pain.’’ On p. 2822 there is a clear statement on the scientific level 1B whereby the risk of acute and chronic pain after staple mesh fixation is higher compared with fibrin fixation or nonfixation. On p. 2817 nonfixation of mesh in TEP is then elaborated on in greater detail: ‘‘In total, seven studies have compared fixation versus nonfixation in TEP, of which only two have 1 B evidence level. They did not discover any difference in the incidence of recurrence between fixated versus nonfixated mesh. In total, 12,114 hernia repairs F. Kockerling D. A. Jacob (&) Department of Surgery and Center for Minimally Invasive Surgery, Vivantes Hospital, Neue Bergstr. 6, 13585 Berlin, Germany e-mail: dietmar.jacob@vivantes.de

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).

IFSO-APC Consensus Statements 2011

AbstractAssociations of BMI with body composition and health outcomes may differ between Asian and European populations. Asian populations have also been shown to have an elevated risk of type 2 diabetes, hypertension, and hyperlipidemia at a relatively low level of BMI. New surgical indication for Asian patients should be discussed by the expert of this field. Forty-four bariatric experts in Asia-Pacific and other regions were chosen to have a voting privilege for IFSO-APC Consensus at the 2nd IFSO-APC Congress. A computerized audience-response voting system was used to analyze the agreement with the sentence of the consensus. Of all delegates, 95% agreed with the necessity of the establishment of IFSO-APC consensus statements, and 98% agreed with the necessity of a new indication for Asian patients.IFSO-APC Consensus statements 2011Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI ≥ 35 with or without co-morbiditiesBariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome for patients who are inadequately controlled by lifestyle alternations and medical treatment for acceptable Asian candidates with BMI ≥ 30The surgical approach may be considered as a non-primary alternative to treat inadequately controlled T2DM, or metabolic syndrome, for suitable Asian candidates with BMI ≥ 27.5. Other eight sentences are agreed with by majority of the voting delegates to form IFSO-APC consensus statements. This will help to make safe and wholesome the progress of bariatric and metabolic surgery in Asia.

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 approach to pheochromocytoma : Is a lower intraabdominal pressure helpful?

Laparoscopic adrenalectomy is gaining popularity because of its well-documented benefits. The aim of our study was to see if a decreased intraoperative intraabdominal pressure during laparoscopic adrenalectomy would affect the hemodynamic variables and the serum levels of catecholamines. We randomly divided 9 patients into 2 groups, maintaining either an intraabdominal pressure of 15 mm Hg (group A) or 8–10 mm Hg (group B). Norepinephrine and epinephrine blood levels were measured preoperatively, during endotracheal intubation, carboperitoneum, surgical manipulation of tumor just before the ligation of the adrenal vein, and tracheal extubation; the hemodynamic variables were recorded. The introduction of carboperitoneum resulted in an increase in heart rate and mean arterial blood pressure (MAP), although it was statistically insignificant. The norepinephrine levels showed a statistically significant increase in group A as compared with group B (P = 0.0002). Surgical manipulation of the tumor resulted in a significant increase in MAP and norepinephrine levels in group A (P = 0.007 and P = 0.0001, respectively). The epinephrine levels did not change as much because the tumor was probably predominantly norepinephrine-secreting. Norepinephrine levels continued to be high even during tracheal extubation in group A patients (P = 0.027). We conclude that a low intraabdominal pressure of 8–10 mm Hg causes less catecholamine release and fewer hemodynamic fluctuations.

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.