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   2017| January-March  | Volume 13 | Issue 1  
    Online since November 30, 2016

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Clinical anatomy of the inferior epigastric artery with special relevance to invasive procedures of the anterior abdominal wall
Praisy Joy, Ivan James Prithishkumar, Bina Isaac
January-March 2017, 13(1):18-21
DOI:10.4103/0972-9941.181331  PMID:27251822
Introduction: Injury to the inferior epigastric artery (IEA) has been reported following lower abdominal wall surgical incisions, abdominal peritoneocentesis and trocar placements at laparoscopic port sites, resulting in the formation of abdominal wall haematomas that may expand considerably due to lack of tissue resistance. The aim of this study was to localise its course in relation to standard anatomic landmarks and suggest safe areas for performance of invasive procedures. Materials and Methods: Sixty IEAs of 30 adult cadavers (male = 19; female = 11) were dissected and the course of the IEA noted in relation to the mid-inguinal point, anterior superior iliac spine (ASIS) and umbilicus. Results: The mean distance of the IEA from the midline was 4.45 ± 1.42 cm at the level of the mid-inguinal point, 4.10 ± 1.15 cm at the level of ASIS and 4.49 ± 1.15 cm at the level of umbilicus. There was an average of 3.3 branches per IEA with more branches arising from its lateral aspect. The IEA was situated within one-third (32%) of the distance between the midline and the sagittal plane through ASIS at all levels. Conclusion: To avoid injury to IEA, trocars can be safely inserted 5.5 cm [mean + 1 standard deviation (SD)] away from the midline (or) slightly more than one-third of the distance between the midline and a sagittal plane running through ASIS. These findings may be useful not only for laparoscopic procedures but also for image-guided biopsy, abdominal paracentesis, and placement of abdominal drains.
  6,516 144 -
Reversal of the Hartmann's procedure: A comparative study of laparoscopic versus open surgery
Ernesto Melkonian, Claudio Heine, David Contreras, Marcelo Rodriguez, Patricio Opazo, Andres Silva, Ignacio Robles, Rolando Rebolledo
January-March 2017, 13(1):47-50
DOI:10.4103/0972-9941.181329  PMID:27251820
Background: The Hartmann's operation, although less frequently performed today, is still used when initial colonic anastomosis is too risky in the short term. However, the subsequent procedure to restore gastrointestinal continuity is associated with significant morbidity and mortality. Patients and Methods: The review of an institutional review board (IRB)-approved prospectively maintained database provided data on the Hartmann's reversal procedure performed by either laparoscopic or open technique at our institution. The data collected included: demographic data, operative approach, conversion for laparoscopic cases and perioperative morbidity and mortality. Results: Over a 14-year period from January 1997 to August 2011, 74 Hartmann's reversal procedures were performed (laparoscopic surgery—49, open surgery—25). The average age was 55 years for the laparoscopic and 57 years for the open surgery group, respectively. Male patients represent 61% of both groups. There was no significant difference in operative time between the two groups (149 min vs 151 min; P = 0.95), and there was a tendency to lower morbidity (3/49—7.3% vs 4/25—16%; P = 0.24) in the laparoscopic surgery group. In the laparoscopic group, eight patients (16.3%) were converted to open surgery, mostly due to severe adhesions. The length of hospital stay was significantly shorter for the laparoscopic group (5 days vs 7 days; P = 0.44). Conclusions: The Hartmann's reversal procedure can be safely performed in the majority of the cases using a laparoscopic approach with a low morbidity rate and achieving a shorter hospital stay.
  3,817 108 -
Is rhabdomyolysis an anaesthetic complication in patients undergoing robot-assisted radical prostatectomy?
Gulsah Karaoren, Nurten Bakan, Eyüp Veli Kucuk, Eyup Gumus
January-March 2017, 13(1):29-36
DOI:10.4103/0972-9941.181291  PMID:27251811
Background: In patients undergoing robot-assisted radical prostatectomy (RARP), pneumoperitoneum, intraoperative fluid restriction and prolonged Trendelenburg position may cause rhabdomyolysis (RM) due to hypoperfusion in gluteal muscles and lower extremities. In this study, it was aimed to assess effects of body mass index (BMI), comorbidities, intra-operative positioning, fluid restriction and length of surgery on the development of RM in RARP patients during the perioperative period. Subjects and Methods: The study included 52 American Society of Anesthesiologists I–II patients aged 50–80 years with BMI >25 kg/m2, who underwent RARP. Fluid therapy with normal saline (1 ml/kg/h) and 6% hydroxyethyl starch 200/05 (1 ml/kg/h) was given during the surgery. Charlson comorbidity index (CCI), operation time (OT) and Trendelenburg time (TT) were recorded. Blood samples for creatine phosphokinase (CPK), blood urea nitrogen, creatinine (Cr), aspartate aminotransferase (AST), alanine transferase (ALT), lactate dehydrogenase (LDH), creatinine kinase-MB, cardiac troponin I and arterial blood gases were drawn at baseline and on 6, 12, 24 and 48 h. RM was defined by serum CPK level exceeding 5000 IU/L. Results: Seven patients met predefined criteria for RM. There were positive correlations among serum CPK and Cr, AST, ALT and LDH levels. However, there was no significant difference in BMI, OT and TT between patients with or without RM (P > 0.05). CCI scores were higher in patients with RM than those without (3.00 ± 0.58 vs. 2.07 ± 0.62; P< 0.01). No renal impairment was detected among patients with RM at the post-operative period. Conclusions: It was found that comorbid conditions are more important in the development of RM during RARP rather than BMI, OT or TT. Patients with higher comorbidity are at risk for RM development and that this should be kept in mind at follow-up and when informing patients.
  2,389 65 -
Abdomino-endoscopic perineal excision of the rectum for benign and malignant pathology: Technique considerations for true transperineal verus transanal total mesorectal excision endoscopic proctectomy
Hazar Al Furajii, Niall Kennedy, Ronan A Cahill
January-March 2017, 13(1):7-12
DOI:10.4103/0972-9941.194976  PMID:27934790
Purpose: Transanal minimally invasive surgery using single port instrumentation is now well described for the performance of total mesorectal excision with restorative colorectal/anal anastomosis most-often in conjunction with transabdominal multiport assistance. While non-restorative abdomino-endoscopic perineal excision of the anorectum is conceptually similar, it has been less detailed in the literature. Methods: Consecutive patients undergoing non-restorative ano-proctectomy including a transperineal endoscopic component were analysed. All cases commenced laparoscopically with initial medial to lateral mobilisation of any left colon and upper rectum. The lower anorectal dissection started via an intersphincteric or extrasphincteric incision for benign and malignant pathology, respectively, and following suture closure and circumferential mobilisation of the anorectum, a single port (GelPOINT Path, Applied Medical) was positioned allowing the procedure progress endoscopically in all quadrants up to the cephalad dissection level. Standard laparoscopic instrumentation was used. Specimens were removed perineally. Results: Of the 13 patients (median age 55 years, median BMI 28.75 kg/m2, median follow-up 17 months, 6 males), ten needed completion proctectomy for ulcerative colitis following prior total colectomy (three with concomitant parastomal hernia repair) while three required abdominoperineal resection for locally advanced rectal cancer following neoadjuvant chemoradiotherapy. Median operative time was 190 min, median post-operative discharge day was 7. Eleven specimens were of high quality. Four patients developed perineal wound complications (one chronic sinus, two abscesses needing drainage) within median 17-month follow-up. Conclusion: Convergence of transabdominal and transanal technology and technique allows accuracy in combination operative performance. Nuanced appreciation of transperineal operative access should allow specified standardisation and innovation.
  2,227 107 -
Is mini-laparoscopic cholecystectomy any better than the gold standard?: A comparative study
Haris R Shaikh, Asad Abbas, Salik Aleem, Miqdad R Lakhani
January-March 2017, 13(1):42-46
DOI:10.4103/0972-9941.181368  PMID:27251827
Background: Mini-laparoscopic cholecystectomy (MLC) has widened the horizons of modern laparoscopic surgery. Standard four port laparoscopic cholecystectomy (SLC), which has long been established as the “Gold Standard” for gall bladder diseases, is under reconsideration following the advent of further minimally-invasive procedures including MLC. Our study aims to provide a comparison between MLC and SLC and assesses whether MLC has any added benefits. Materials and Methods: Patients with symptomatic gall bladder disease undergoing MLC or SLC during the 2.5-month period were included in the study. Thirty-two patients underwent MLC while SLC was performed on 40 patients by the same surgeon. Data was collected prospectively and analysed retrospectively using a predesigned questionnaire. Results: In our study, both the groups had similar age, body mass index (BMI) and gender distribution. No cases of MLC required insertion of additional ports. The mean operative time for MLC was 38.2 min (33-61 min), which is longer than SLC; but it was not statistically significant. There was no significant difference in mean operative blood loss, postoperative pain, analgesia requirement and mobilization. Patients who underwent MLC were able to return to normal activity earlier than patients undergoing SLC (P < 0.01). Conclusion: Our experience suggests that MLC can safely be used as an alternative to SLC. Compared to SLC, it has the added benefit of an early return to work along with excellent cosmetic results. Further large scale trials are required to prove any additional benefit of MLC.
  2,202 103 -
Comparison of short outcomes between laparoscopic and experienced robotic gastrectomy: A meta-analysis and systematic review
Zhanyu Wang, Yinghua Wang, Yan Liu
January-March 2017, 13(1):1-6
DOI:10.4103/0972-9941.182653  PMID:27251844
Objective: The purpose of this meta-analysis is to compare the short-term outcomes between experienced robotic gastrectomy (RG) and laparoscopic gastrectomy (LG). Materials and Methods: We searched the PubMed, Springer Link, Elsevier, and Embase databases for articles published in English before June 2015 using an electronic literature search and including cross-referenced articles. Three studies were eligible for the meta-analysis. The outcomes evaluated were operation time, estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay. Results: Of a total of 562 patients, 165 underwent RG and 397 underwent LG. Operation time was significantly longer in the RG group [weighted mean difference (WMD): 21.49, 95% confidence interval (CI): 12.48-30.50, P< 0.00001). Estimated blood loss, harvested lymph nodes, complication, and postoperative hospital stay were similar between the two groups. Conclusion: Experienced RG has similar short-term outcomes to LG that is performed by sophisticated laparoscopic surgeons, except for operation time.
  2,188 98 -
Clinical outcomes of single incision laparoscopic surgery and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair
Ilhan Ece, Huseyin Yilmaz, Serdar Yormaz, Mustafa Sahin
January-March 2017, 13(1):37-41
DOI:10.4103/0972-9941.181394  PMID:27251835
Background: Laparoscopic surgery has been a frequently performed method for inguinal hernia repair. Studies have demonstrated that the laparoscopic transabdominal preperitoneal (TAPP) approach is an appropriate choice for inguinal hernia repair. Single-incision laparoscopic surgery (SILS) was developed to improve the cosmetic effects of conventional laparoscopy. The aim of this study was to evaluate the safety and feasibility of SILS-TAPP compared with TAPP technique. Materials and Methods: A total of 148 patients who underwent TAPP or SILS-TAPP in our surgery clinic between December 2012 and January 2015 were enrolled. Data including patient demographics, hernia characteristics, operative time, intraoperative and postoperative complications, length of hospital stay and recurrence rate were retrospectively collected. Results: In total, 60 SILS-TAPP and 88 TAPP procedures were performed in the study period. The two groups were similar in terms of gender, type of hernia, and American Society of Anesthesiologists (ASA) classification score. The patients in the SILS-TAPP group were younger when compared the TAPP group. Port site hernia (PSH) rate was significantly high in the SILS-TAPP group, and all PSHs were recorded in patients with severe comorbidities. The mean operative time has no significant difference in two groups. All SILS procedures were completed successfully without conversion to conventional laparoscopy or open repair. No intraoperative complication was recorded. There was no recurrence during the mean follow-up period of 15.2 ± 3.8 months. Conclusion: SILS TAPP for inguinal hernia repair seems to be a feasible, safe method, and is comparable with TAPP technique. However, randomized trials are required to evaluate long-term clinical outcomes.
  2,041 108 -
Laparoscopy in children and its impact on brain oxygenation during routine inguinal hernia repair
Gloria Pelizzo, Luciano Bernardi, Veronica Carlini, Noemi Pasqua, Simonetta Mencherini, Giuseppe Maggio, Annalisa De Silvestri, Lucio Bianchi, Valeria Calcaterra
January-March 2017, 13(1):51-56
DOI:10.4103/0972-9941.181800  PMID:27251842
Background: The systemic impact of intra-abdominal pressure (IAP) and/or changes in carbon dioxide (CO2) during laparoscopy are not yet well defined. Changes in brain oxygenation have been reported as a possible cause of cerebral hypotension and perfusion. The side effects of anaesthesia could also be involved in these changes, especially in children. To date, no data have been reported on brain oxygenation during routine laparoscopy in paediatric patients. Patients and Methods: Brain and peripheral oxygenation were investigated in 10 children (8 male, 2 female) who underwent elective minimally invasive surgery for inguinal hernia repair. Intraoperative transcranial near-infrared spectroscopy to assess regional cerebral oxygen saturation (rScO2), peripheral oxygen saturation using pulse oximetry and heart rate (HR) were monitored at five surgical intervals: Induction of anaesthesia (baseline T1); before CO2insufflation induced pneumoperitoneum (PP) (T2); CO2PP insufflation (T3); cessation of CO2PP (T4); before extubation (T5). Results: rScO2decreases were recorded immediately after T1 and became significant after insufflation (P = 0.006; rScO2decreased 3.6 ± 0.38%); restoration of rScO2was achieved after PP cessation (P = 0.007). The changes in rScO2were primarily due to IAP increases (P = 0.06). The HR changes were correlated to PP pressure (P < 0.001) and CO2flow rate (P = 0.001). No significant peripheral effects were noted. Conclusions: The increase in IAP is a critical determinant in cerebral oxygenation stability during laparoscopic procedures. However, the impact of anaesthesia on adaptive changes should not be underestimated. Close monitoring and close collaboration between the members of the multidisciplinary paediatric team are essential to guarantee the patient's safety during minimally invasive surgical procedures.
  2,015 87 -
Complication reports for robotic surgery using three arms by a single surgeon at a single institution
Ching-Hui Chen, Huang-Hui Chen, Wei-Min Liu
January-March 2017, 13(1):22-28
DOI:10.4103/0972-9941.181774  PMID:27251839
Background: The aim of this study is to evaluate perioperative complications related to robotic-assisted laparoscopic surgery for management of gynaecologic disorders. Materials and Methods: Eight hundred and fifty-one women who underwent robotic procedures between December 2011 and April 2015 were retrospectively included for analysis. Patient demographics, surgical outcomes and complications were evaluated. Results: The overall complication rate was 5.5%, whereas the rate of complications for oncologic cases was 8.4%. Intra-operative complications (n = 7, 0.8%) consisted of five cases of bowel lacerations, one case of ureter laceration and one case of bladder injury. Early and late post-operative complications were 4.0% (n = 34) and 0.8% (n = 6), respectively. Six patients (0.7%) experienced Grade III complications based on the Clavien-Dindo classification and required further surgical intervention. Conclusion: Robotic-assisted laparoscopic surgery is a feasible approach for management of gynaecologic disorders; the complication rates for this type of procedure are acceptable.
  1,878 57 -
Comparison of single incision and multi incision diagnostic laparoscopy on evaluation of diaphragmatic status after left thoracoabdominal penetrating stab wounds
Mehmet Ilhan, Ali Fuat Kaan Gök, Süleyman Bademler, Ömer Cenk Cücük, Yiğit Soytaş, Hakan Teoman Yanar
January-March 2017, 13(1):13-17
DOI:10.4103/0972-9941.194975  PMID:27934791
Aim: Single incision diagnostic laparoscopy (SIDL) may be an alternative procedure to multi-incision diagnostic laparoscopy (MDL) for penetrating thoracoabdominal stab wounds. The purpose of this study is sharing our experience and comparing two techniques for diaphragmatic status. Materials and Methods: Medical records of 102 patients with left thoracoabdominal penetrating stab injuries who admitted to Istanbul School of Medicine, Trauma and Emergency Surgery Clinic between February 2012 and April 2016 were examined. The patients were grouped according to operation technique. Patient records were retrospectively reviewed for data including, age, sex, length of hospital stay, diaphragm injury rate, surgical procedure, operation time and operation time with wound repair, post-operative complications and accompanying injuries. Results: The most common injury location was the left anterior thoracoabdomen. SIDL was performed on 26 patients. Nine (34.6%) of the 26 patients had a diaphragm injury. Seventy-six patients underwent MDL. Diaphragmatic injury was detected in 20 (26.3%) of 76 patients. The average operation time and post-operative complications were similar; there was no statistically significant difference between MDL and SIDL groups. Conclusion: SIDL can be used as a safe and feasible procedure in the repair of a diaphragm wounds. SIDL may be an alternative method in the diagnosis and treatment of these patients.
  1,810 111 -
An unusual approach for the treatment of oesophageal perforation: Laparoscopic-endoscopic cooperative surgery
Haci Murat Cayci, Umut Eren Erdoğdu, Evren Dilektasli, Mehmet Akif Turkoglu, Deniz Firat, Hasan Cantay
January-March 2017, 13(1):69-72
DOI:10.4103/0972-9941.181760  PMID:27251836
Boerhaave syndrome describes a transmural oesophageal rupture that develops following a spontaneous, sudden intraluminal pressure increase (i.e. vomiting, cough). It has a high rate of mortality and morbidity because of its proximity to the mediastinum and pleura. Perforation localisation and treatment initiation time affect the morbidity and mortality. In this article, we aim to present our successful laparoscopic-endoscopic cooperative surgery in a 59-year-old female who was referred to our clinic with a diagnosis of spontaneous lower oesophageal perforation. Laparoscopy and a simultaneous oesophageal stent application may be assumed as an effective alternative to conventional surgical approaches in cases of spontaneous lower oesophageal perforation.
  1,631 71 -
Laparoscopic excision of a large retroperitoneal lymphovascular malformation in an adult
Pravin R Suryawanshi, Mohit M Agrawal, Mukesh D Rathod, Anirudha M Mandhane
January-March 2017, 13(1):66-68
DOI:10.4103/0972-9941.181773  PMID:27251838
Retroperitoneal lymphangioma is a rare benign tumour of the retroperitoneal lymphatics that usually manifests in infancy. It is worth reporting of an unexpected presentation, especially in an adult. They frequently affect the neck (75%) and the axilla (20%). Intra-abdominal lymphangiomas (<5%) have been reported in the mesentery, gastrointestinal tract, spleen, liver and pancreas. Retroperitoneal lymphangiomas account for nearly 1% of all lymphangiomas and are uncommon incidental findings usually at surgery, autopsy or lymphography. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone is often inconclusive, and surgery is frequently required for definitive diagnosis. An interesting and rare case of a retroperitoneal lymphangioma in an adult patient which was removed laparoscopically is described here.
  1,641 53 -
Laparoscopic repair of intra-abdominal bladder perforation in preschool children
Aniruddh V Deshpande, Peter Michail, Parshotam Gera
January-March 2017, 13(1):63-65
DOI:10.4103/0972-9941.181762  PMID:27143696
Intraperitoneal bladder rupture is uncommon in very young children, but its incidence may increase with increasing use of seat and lap belts. To the best of our knowledge, there are no prior reports of laparoscopic repair of this injury in children. We describe two recent cases and discuss useful technical points that facilitate a successful laparoscopic repair. Both our patients were preschool age girls who sustained seat and lap belt injuries. Contrast computed tomography scan suggested a large amount of free peritoneal fluid and cystogram confirmed intraperitoneal bladder perforation (isolated injury). The injury was repaired using delayed absorbable sutures and intracorporeal suturing (continuous in 1, interrupted in 1) using a 3 port laparoscopic technique. Meticulous peritoneal lavage was carried out to minimise urinary peritonitis and the bladder as well as the peritoneal cavity were drained. Check cystograms (day 7) revealed no leaks. Young girls appear to be at risk of intraperitoneal bladder injuries following lap belt injuries. After exclusion of life-threatening injuries and concurrent abdominal injuries which need rapid control or preclude pneumoperitoneum, a laparoscopic repair can be safely performed.
  1,614 60 -
Gastric duplication cyst in adult: Challenge for surgeons
Ozan Baris Namdaroglu, Asuman Argon, Serdar Aydogan, Ahmet Mucteba Ozturk, Savas Yakan, Mehmet Yildirim, Nazif Erkan
January-March 2017, 13(1):57-59
DOI:10.4103/0972-9941.181772  PMID:27251837
Gastric duplication cysts (GDCs) are uncommon developmental anomalies found primarily in children, being rarely seen in adults. Duplications can occur anywhere in the intestinal tract from the mouth to the anus. Accurate diagnosis of cysts before resection is difficult even using the most advanced imaging techniques. In this report, we present and discuss a case of GDC in a 25-year-old man treated laparoscopically. Patient admitted to our department with complaints of epigastric pain and swelling. Magnetic resonance imaging performed for accurate characterisation showed a 4 cm × 4.5 cm cystic lesion, with heterogeneous signal intensity on T2-weighted images, located in the posterior wall of the stomach. Pre-operative differential diagnosis including gastrointestinal stromal tumour (GIST) was made according to radiological findings. Patient underwent surgery and cyst resected laparoscopically. Histopathological examination suggesting duplication cyst. GDC can easily be mistaken for a GIST, and the clinician as well as radiologist must maintain a high degree of suspicion.
  1,547 73 -
Anomalous middle hepatic artery in laparoscopic cholecystectomy: Wolf in sheep's clothing
Johnrose John Grifson, Thirumaraichelvan Perungo, Durairaj Sengamalai, Bennet Duraisamy, Amudhan Anbalagan, Prabhakaran Raju, Devy Gounder Kannan
January-March 2017, 13(1):76-77
DOI:10.4103/0972-9941.181383  PMID:27251829
Laparoscopic cholecystectomy is a simple but dangerous operation. The complex anatomy and frequent anomalies of the hepatic arterial and biliary system are often a shocking surprise to the laparoscopic surgeon. When these vital structures cannot be identified correctly, potentially crippling serious vascular and biliary injury can occur. A very rare case of middle hepatic artery encountered in the Calot's coursing over the gall bladder and travelling extraparenchymal into segment IV is reported. Identification and preservation of the middle hepatic artery is essential to prevent the possibility of hepatic artery thrombosis and to avoid ischemic cholangiopathy of segment IV duct. A comprehensive understanding of the hepatic arterial and biliary anatomy of the liver will empower laparoscopic surgeons to avoid crippling vascular and biliary injury.
  1,477 73 -
Left thoracoscopic two-stage repair of tracheoesophageal fistula with a right aortic arch and a vascular ring
Kazuo Oshima, Hiroo Uchida, Takahisa Tainaka, Akihide Tanano, Chiyoe Shirota, Kazuki Yokota, Naruhiko Murase, Ryo Shirotsuki, Kosuke Chiba, Akinari Hinoki
January-March 2017, 13(1):73-75
DOI:10.4103/0972-9941.181771  PMID:27143697
A right aortic arch (RAA) is found in 5% of neonates with tracheoesophageal fistulae (TEF) and may be associated with vascular rings. Oesophageal repairs for TEF with an RAA via the right chest often pose surgical difficulties. We report for the first time in the world a successful two-stage repair by left-sided thoracoscope for TEF with an RAA and a vascular ring. We switched from right to left thoracoscopy after finding an RAA. A proximal oesophageal pouch was hemmed into the vascular ring; therefore, we selected a two-stage repair. The TEF was resected and simple internal traction was placed into the oesophagus at the first stage. Detailed examination showed the patent ductus arteriosus (PDA) completing a vascular ring. The subsequent primary oesophago-oesophagostomy and dissection of PDA was performed by left-sided thoracoscope. Therefore, left thoracoscopic repair is safe and feasible for treating TEF with an RAA and a vascular ring.
  1,476 54 -
Laparoscopic adrenalectomy in a patient with situs inversus totalis
Mehmet Uludag, Kinyas Kartal, Nurcihan Aygun
January-March 2017, 13(1):60-62
DOI:10.4103/0972-9941.181775  PMID:27251840
Situs inversus totalis(SIT) is a relatively rare condition involving transposition of both the abdominal and thoracic viscera. SIT typically presents as left to right reversal of the viscera combined with dextrocardia, while the individual organs function is normal. Although there are no obvious abnormalities in the function of transposed organs, anatomical irregularity causes important technical difficulties in the surgical treatment of these patients. In this study, we aim to report surgical challenges in laparoscopic adrenalectomy in a patient with SIT.
  1,459 56 -
2004 Journal of Minimal Access Surgery
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Online since 15th August '04