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   Table of Contents - Current issue
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January-March 2021
Volume 17 | Issue 1
Page Nos. 1-140

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REVIEW ARTICLES  

Laparoscopic repeat hepatectomy for treating recurrent liver cancer Highly accessed article p. 1
Jingwei Cai, Junhao Zheng, Yangyang Xie, Mubarak Ali Kirih, Liye Tao, Xiao Liang
DOI:10.4103/jmas.JMAS_187_19  PMID:31603081
Background: Laparoscopic repeat hepatectomy (LRH) is a technically challenging procedure, so LRH for recurrent liver cancer has not been widely accepted. The aim of this study was to perform a systematic review of the current literature to identify and evaluate available data of LRH for recurrent hepatocellular carcinoma (rHCC) and metastases tumour of liver, especially of colorectal liver metastases (CRLM), focusing on the safety and feasibility. Methods: A comprehensive search of the PubMed database was performed for all studies published in English evaluating LRH for rHCC and recurrent metastases tumour of liver from 1st January, 2005 to 1st June, 2019. Results: A total of 15 studies which comprised 444 patients and reported outcomes for the efficacy and safety of LRH in the treatment of rHCC or CRLM were included in the present review. Moreover, nine studies compared the perioperative outcomes of LRH versus open repeat hepatectomy (ORH). LRH was superior to ORH with reduced blood loss, shorter operative time, shorter hospital stay and lower morbidity rates. Conclusions: LRH can safely performed in rHCC or CRLM patients with cirrhosis, previous open hepatectomy, multiple recurrent lesions and tumours located in difficult posterosuperior segments.
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Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature p. 7
Anil Sharma, Chaitanya Sinha, Manish Baijal, Vandana Soni, Rajesh Khullar, Pradeep Chowbey
DOI:10.4103/jmas.JMAS_146_19  PMID:32964882
With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.
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ORIGINAL ARTICLES Top

Enhanced recovery after surgery in laparoscopic distal gastrectomy: Protocol for a prospective single-arm clinical trial p. 14
Xinhua Chen, Yu Zhu, Mingli Zhao, Yanfeng Hu, Jun Luo, Yuehong Chen, Tian Lin, Hao Chen, Hao Liu, Guoxin Li, Jiang Yu
DOI:10.4103/jmas.JMAS_35_19  PMID:33353890
Background: The enhanced recovery after surgery (ERAS) programme is feasible and effective in reducing the length of hospital stay, overall complication rates and medical costs when applied to cases involving colonic and rectal resections. However, a recent prospective, randomised, open, parallel-controlled trial (Chinese Laparoscopic Gastrointestinal Surgery Study-01 trial), initiated by our team, indicated that under conventional peri-operative management, the reduction of the post-operative hospital stay of laparoscopic distal gastrectomy (LDG) is quite limited compared with open gastrectomy. Thus, if we could provide valuable clinical evidence for demonstrating the efficacy of the ERAS programme for gastric cancer patients undergoing LDG, it would significantly enhance the peri-operative management of gastrectomy and benefit the patients. Methods: In this prospective single-arm trial, patients who are 18–75 years of age with gastric adenocarcinoma diagnosed with cT1-4aN0-3M0 and expected to undergo curative resection through LDG, are considered eligible for this study. All participants underwent LDG with peri-operative management under the ERAS programme. The primary outcome measures included the post-operative hospital stays and rehabilitative rate of the post-operative day 4. The secondary outcome measures are morbidity and mortality (time frame: 30 days), post-operative recovery index (time frame: 30 days), post-operative pain intensity (time frame: 3 days) and the medical costs from surgery to discharge. Conclusion: With reasonable and scientific designing, the trial may be a great help to further discuss the benefit of ERAS programme and thus improving the peri-operative management of patients with gastrectomy.
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Laparoscopic versus open extended cholecystectomy with bi-segmentectomy (s4b and s5) in patients with gallbladder cancer Highly accessed article p. 21
Hirdaya Hulas Nag, Ashish Sachan, Phani Kumar Nekarakanti
DOI:10.4103/jmas.JMAS_98_19  PMID:31603079
Introduction: The outcome of laparoscopic extended cholecystectomy (EC) with wedge hepatic resection (LECW) in patients with gallbladder cancer (GBC) has been compared with that of open EC with wedge hepatic resection (OECW), but studies comparing laparoscopic EC with bi-segmentectomy (LECB) with open EC with bi-segmentectomy (OECB) are lacking. Patients and Methods: This retrospective study comprised of 68 patients with GBC who were offered either LECB or OECB from July 2011 to July 2018. Patients were divided into laparoscopic group (LG) and open group (OG), and appropriate statistical methods were used for comparison. Results: Out of the total 68 patients, 30 patients were in LG and 38 patients were in OG. Demographic, clinical and biochemical characteristics were similar except significantly higher number of male patients in OG (P = 0.01). In LG versus OG, the mean operation time was 286 versus 274 min (P = 0.565), mean blood loss was 158 versus 219 ml (P = 0.006) and mean hospital stay was 6.4 versus 9 days (P = 0.0001). The complication rate was 16.6% in LG and 31.5% in OG, but this difference was not statistically significant (P = 0.259). The median number of lymph nodes was 12 in both LG and OG (P = 0.62). Distribution of patients among American Joint Committee on Cancer stages I to IV was similar in both the groups (P = 0.5). Fifty percent of the patients in both the groups received adjuvant treatment (P = 1). In LG versus OG, the recurrence rate was 20% versus 28.9% (P = 0.4), mean recurrence-free survival was 48 months versus 44 months (P = 0.35) and overall survival was 51 months versus 46 months (P = 0.45). In LG versus OG, 1, 3 and 5-year survival was 96% versus 94%, 79% versus 72% and 79% versus 62% (P = 0.45). The median follow-up was statistically significantly shorter (24 vs. 36 months) in LG versus OG (P = 0.0001). Conclusions: The oncological outcome and survival after LECB in patients with resectable GBC is not inferior to that after OECB. Laparoscopic approach has a potential to improve perioperative outcome in patients with GBC.
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Re-interventions and re-admissions in a 13-year series following use of laparoscopic subtotal cholecystectomy p. 28
Michelle Slater, Sumit Midya, Michael Booth
DOI:10.4103/jmas.JMAS_124_19  PMID:31571673
Background: Laparoscopic subtotal cholecystectomy (LSTC) without cystic duct ligation is an alternative to conversion to open surgery in a difficult cholecystectomy, thus avoiding a potentially hazardous dissection in Calot's triangle. The long-term outcomes of this procedure are not well reported. The aim of this study is to assess the rates of re-presentation, re-admissions, endoscopic interventions and completion cholecystectomy in patients who have undergone LSTC. Methods: Details of all patients undergoing cholecystectomy over a 13-year period (2003–2015) were entered on a prospective database. Further information on subsequent hospital attendances, biliary imaging, endoscopic interventions and re-operations following the index LSTC was collected retrospectively from hospital database. Results: Overall, 2313 patients underwent laparoscopic cholecystectomy. Eighty-five patients (3.7%) underwent LSTC and the rest had standard laparoscopic cholecystectomy. A controlled bile leak was observed in 16 (19%) patients post-operatively, of which 3 resolved spontaneously. The remaining 13 were managed with an early endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent. Twenty-seven patients (32%), who underwent LSTC, were re-investigated for the upper abdominal symptoms. The time range for re-investigation was 21 days–124 months. Eight patients underwent ERCP post-discharge, for suspected bile duct stones on radiological imaging. Two patients required open completion cholecystectomy for symptomatic stones in the gallbladder remnant. Conclusion: LSTC is a feasible and safe alternative to open surgery with acceptable long-term consequences and re-interventions.
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Robotic surgery in paediatric patients: Our initial experience and roadmap for successful implementation of robotic surgery programme p. 32
Arvind Sinha, Manish Pathak, Ayushi Vig, Rahul Saxena
DOI:10.4103/jmas.JMAS_174_19  PMID:31670291
Introduction: The popularity of robot-assisted surgeries has accelerated since its advent in 1990s. Recently, we procured da Vinci surgical system in our institution; and here, we present our initial experience of robot-assisted surgeries at our hospital. We also discuss the stepwise approach for successful implementation of the robotic surgical programme at our institute. Moreover, the importance of efficient use of this advanced but expensive technology has been highlighted. Materials and Methods: Retrospective analysis of the medical record of all the paediatric patients between the age ranges of 1–18 years who had undergone robotic-assisted laparoscopic surgery during April 2019–April 2019 was done. Medical record was reviewed for descriptive data, clinical presentation, investigations, operative details and follow-up. Statistical data were also obtained from medical superintendent office. Results: During April 2018–April 2019, total of 111 cases were operated across six specialities. Approximately 73% of cases (81/111) belonged to adult urology and gynaecology speciality. Less than 5% (5/111) of patients were in paediatric age group. The department of paediatric surgery performed one pyeloplasty, 3 ureteric reimplantation and 1 bladder diverticulum excision with robot assistance. The operative duration of the cases was comparable to the standard laparoscopic techniques. All patients are asymptomatic on follow-up visits. Conclusion: The robotic surgery is feasible in paediatric population and has favourable post-operative outcomes. Detailed planning and stepwise approach is key to the establishment of new robotic surgery programme in any institute.
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Single-port laparoscopic appendectomy for acute appendicitis during pregnancy p. 37
In Soo Cho, Sung Uk Bae, Woon Kyung Jeong, Seong Kyu Baek
DOI:10.4103/jmas.JMAS_193_19  PMID:31929222
Aim of Study: Acute appendicitis is the most common non-obstetric surgical problem in pregnant patients. As minimally invasive surgery has developed, minimising surgical trauma and improving cosmetic outcomes have led to the development of single-port laparoscopic surgery (SPLS). The aim of this study was to assess the feasibility and safety of SPLS for acute appendicitis during pregnancy. Patients and Methods: Between September 2014 and May 2016, 12 pregnant patients diagnosed with acute appendicitis and having single-port laparoscopic appendectomy were included in the study. Results: The median gestational age at surgery was 16 weeks (6–30 weeks). All operations were completed safely and without vascular or visceral injury. Four patients (33.3%) required conversion to a reduced-port laparoscopic surgery with 3 patients (25%) having a 5 mm port inserted because of perforated appendicitis with drain placement, and 1 patient (8.3%) having a 2-mm needle instrument insertion. Median operation time was 60 min (32–100 min), and a drainage tube was placed in 5 patients (41.7%). Median total length of incision was 2 cm (1.2–2.5 cm). The median time to soft diet initiation and length of stay in the hospital were 1 day (0–9 days) and 5 days (2–11 days), respectively. Two patients (8.0%) developed post-operative complications: One wound site bleeding and two surgical site infections. One case of abortion (8.3%) was noted on the post-operative day 1 and one case of imperforate hymen was noted after delivery. Conclusions: SPLS appendectomy is feasible and safe for treating patients with acute appendicitis during pregnancy.
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A new manoeuvre of vascular control in laparoscopic spleen-preserving distal pancreatectomy: Retrospective review for a modified Kimura's method p. 43
Zhu Jie, Li Hong, Zhang Bin, Wang Haibiao
DOI:10.4103/jmas.JMAS_148_19  PMID:31603080
Background: The aim of this study is to explore a new manoeuvre of vascular control technique in laparoscopic spleen-preserving distal pancreatectomy (LSPDP). Materials and Methods: A total of 63 patients were diagnosed with pancreatic tumour in our hospital from January 2013 to December 2018. In these cases, Kimura technique was utilised in 33 patients and total blood flow blocked technique was used in 30 patients. The clinical data of these 63 patients of were retrospectively analysed. Results: Four groups of patients were operated smoothly. In Kimura group, 33 patients were carried out using Kimura technique. Four patients' spleens were resected because the spleen artery was damaged. Three patients among them were converted to open surgery. In the other group, one patient was converted to open and resected the spleen. When comparing the Kimura group with the last series group, the mean surgical time decreased by 27 min, the estimated blood loss decreased by 108 ml, which had a significant statistical difference, whereas postoperative haemorrhage and postoperative pancreatic fistula had no statistical difference. Conclusion: After ten patient's practice, application of new manoeuvre of vascular control technique in LSPDP is feasible and safe, with advantages of less blood loss and shorter operation time.
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Minimally invasive oesophagectomy with a total two-field lymphadenectomy after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of the oesophagus: A prospective study p. 49
Kuppusamy Sasikumar, Raja Kalayarasan, Senthil Gnanasekaran, Sandip Chandrasekar, Biju Pottakkat
DOI:10.4103/jmas.JMAS_242_19  PMID:31929228
Introduction: In the era of neoadjuvant chemoradiotherapy (NACTRT), the safety and clinical significance of radical lymphadenectomy specifically lymphadenectomy along the recurrent laryngeal nerve (RLN) has been questioned. Furthermore, the compliance to NACTRT with the CROSS regimen has not been well studied in the Indian population. This prospective study aimed to determine the compliance with CROSS regimen, feasibility and short-term outcomes of minimally invasive oesophagectomy (MIE) with a total two-field lymphadenectomy after NACTRT. Methods: A prospective study (January 2014 to December 2018) of patients with locally advanced oesophageal squamous cell carcinoma (SCC) eligible for NACTRT (cT1-4a, N0-1, M0) with CROSS regimen followed by MIE with total two-field lymphadenectomy. The compliance rate, post-operative complications and the pathological response rate were assessed. Results: Of the 166 patients with locally advanced SCC, 76 (45.8%) were eligible for NACTRT and 34 completed NACTRT followed by MIE with a total two-field lymphadenectomy (study group). Twenty-nine (38.1%) patients did not complete NACTRT due to complications or poor compliance. Median (range) blood loss was 125 (50–450) ml and the median (range) operation time for the thoracoscopic phase was 205 (155–325) min. Total median (range) lymph node count and mediastinal lymph node counts were 20 (11–33) and 12, (8–21) respectively. Most common post-operative complications were pneumonia (n = 12, 35.3%) followed by RLN palsy (n = 10, 29.4%). Of the 22 patients who had a complete pathological response of the primary tumour, 7 (31.8%) patients had a node-positive disease. Conclusion: NACTRT followed by MIE is feasible in patients with locally advanced SCC. The nodal disease is common even in patients with the complete pathological response of the primary tumour. The dropout rate with NACTRT using the CROSS regimen is high in the present study.
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Transanal total mesorectal excision for rectal cancer: Surgical outcomes and short-term oncological outcomes in a single-institution consecutive series p. 56
Irit Shimoni, Moris Venturero, Ron Shapiro, Gali Westrich, Gal Schtrechman, David Hazzan, Aviram Nissan, Douglas Zippel, Lior Segev
DOI:10.4103/jmas.JMAS_288_19  PMID:33047684
Introduction: Rectal cancer surgery is continuously evolving. Transanal total mesorectal excision (TaTME) is a relatively new surgical approach with possible advantages in comparison to current standard surgical techniques. Several studies in recent years have validated this approach regarding safety and effectiveness. We describe our initial experience with TaTME evaluating surgical parameters, post-operative outcomes and short-term oncological outcomes. Methods: This is a retrospective study reviewing all patients who underwent TaTME in a single institution from May 2015 to April 2018. Results: The cohort included 25 patients with an average age of 60.4 (range: 40–86), of which 13 (52%) patients were male. The average body mass index was 26.1. The overall 30-day morbidity rate was 40%, with 20% (five cases) being severe complications, defined by Clavien–Dindo Grade of 3b or above. There were three major interoperative complications. Four cases (16%) required reoperation during the first 30 post-operative days. The median length of stay was 8 days. The surgery duration was on average 296 min (range: 205–510). Negative resection margins were achieved in all patients. At a median follow-up period of 14 months, there were no local recurrences, and 4 cases (16%) had a distant recurrence. Conclusion: This study describes our initial experience with TaTME, which requires a substantial learning curve to minimise complications and morbidity. Oncological outcomes as expressed by the resection margins, number of lymph nodes harvested and local recurrence rates were all comparable to previously published data.
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Laparoscopic liver resection in Caroli disease: A single-centre case series p. 63
Simon Wabitsch, Wenzel Schoening, Julia-Sophia Bellingrath, Christian Brenzing, Alexander Arnold, Uli Fehrenbach, Moritz Schmelzle, Johann Pratschke
DOI:10.4103/jmas.JMAS_177_19  PMID:33353891
Background: Liver resection is the treatment of choice for patients with localised Caroli disease. While liver resection was traditionally performed as open procedure, this case series aims to evaluate the safety and efficacy of minimally invasive, laparoscopic liver surgery in these patients. Methods: A systematic review of electronic case files of patients seen between April 2015 and December 2017 at the Department of Surgery, Charité University Hospital Berlin, was conducted. Patients with Caroli disease in whom laparoscopic liver resection had been performed were identified and analysed in this single-centre case series. Results: Seven patients who underwent laparoscopic liver surgery for Caroli syndrome were identified and presented with a median age of 49 (range = 44–66) years, of which four (57%) were female. Preoperatively, six patients were classified as the American Society of Anaesthesiologists (ASA) 2 and one patient as ASA 3. Two operations were performed as single-incision laparoscopic surgery, whereas the others were done as multi-incision laparoscopic surgery. One patient required a conversion to an open procedure. The length of operation varied between patients, ranging from 128 to 758 min (median = 355). The length of stay in the intensive care unit ranged from 0 to 2 days. Two patients presented with post-operative complications (Clavien–Dindo Grade ≥3a), whereas no patient died. In histopathological analysis, all patients demonstrated characteristic findings of Caroli disease and no cholangiocarcinoma was found. Conclusion: These results indicate that minimally invasive, laparoscopic liver surgery is a safe and efficacious treatment option for patients with Caroli disease who require liver resection.
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Outcome of minimally invasive liver resection for extrapancreatic biliary malignancies: A single-institutional experience p. 69
Ken Min Chin, Darren W. Q. Chua, Ser Yee Lee, Chung Yip Chan, Brian K. P. Goh
DOI:10.4103/jmas.JMAS_247_19  PMID:31997786
Background: Minimally invasive liver resection (MILR) has been increasingly adopted over the past decade, and its application has been expanded to the management of extrapancreatic biliary malignancies (EPBMs). We aimed to evaluate the peri- and post-operative outcome of patients undergoing MILR for suspected EPMB. Methods: Forty-four consecutive patients who underwent MILR with a curative intent for EPBM at Singapore General Hospital between 2011 and 2018 were identified from a prospectively maintained surgical database. Clinical and operative data were analysed and compared to provide information and make comparisons on peri- and post-operative outcomes. Results: A total of 26, 5 and 13 patients underwent MILR for intrahepatic cholangiocarcinoma (ICC), perihilar cholangiocarcinoma (PHC) and gallbladder carcinoma (GBCA), respectively. Six major hepatectomies were performed, of which one was laparoscopic assisted and another was robot assisted. Ten patients underwent posterosuperior segmentectomies. There was one open conversion. The mean operative time was 266.5 min, and the mean blood loss was 379 ml. The mean length of hospital stay was 4.7 days with no incidences of 30- and 90-day mortality. The rate of recurrence-free survival (RFS) was 75% (at least 12-month follow-up). There was a significantly higher rate of robot-assisted procedures in patients undergoing MILR for GBCA/PHC as compared to ICC (P = 0.034). Patients undergoing posterosuperior segmentectomies required longer operative time (P = 0.018) with an increased need for (P = 0.001) and duration of (P = 0.025) Pringles manoeuvre. There were no differences in operative time, blood loss, morbidity, mortality or RFS between the above groups. Conclusion: Minimally invasive surgery can be adopted safely with a low open conversion rate for EPBMs.
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Laparoscopic adrenalectomy for giant adrenal tumours: Technical considerations and surgical outcome p. 76
Alessio Giordano, Giovanni Alemanno, Carlo Bergamini, Andrea Valeri, Paolo Prosperi
DOI:10.4103/jmas.JMAS_266_19  PMID:32098938
Background: Giant adrenal tumours are tumours with size ≥6 cm. These are rare cancer associated with malignancy in 25% of cases. Patients and Methods: A retrospective review was conducted on the medical records of patients admitted to our high-volume centre of Careggi University Hospital with a giant adrenal tumour and submitted to adrenalectomy between January 2008 and December 2018. The group of patients who underwent to laparoscopic adrenalectomy was compared with a group of patients that was submitted to open adrenalectomy. Results: In the past 10 years, we performed about 245 adrenalectomies for benign and malignant adrenal tumours. Fifty (20.4%) of these were giant tumours. The medium size was 9.9 cm (7–22 cm). The mean age was 57 years (21–81 years). Thirty-four (68%) of these cancers were laparoscopically removed and 16 (32%) with an open approach. The surgical outcomes in these patients were optimal if compared to the group of patients submitted to open approach in terms of good pain control, hospital stay, mean operative time and bloodless. No difference was observed about post-operative complications in the two groups. The follow-up after 30 months for malignant tumours did not show local recurrences. Conclusion: Our results pinpoint the advantages of performing a laparoscopic adrenalectomy for giant adrenal tumours. The tumour size is only a predictive parameter of possible malignancy, and the laparoscopic approach is a safe and feasible method in terms of surgical and oncological, only if performed by expert surgeons and in high-volume centres.
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The role of upper gastrointestinal endoscopy in bariatric procedure selection: A case series and literature reviewPaid article p. 81
Aashik Shetty, Amrit Nasta, Amit Gupte, Ramen Goel
DOI:10.4103/jmas.JMAS_139_19  PMID:33353892
Background: Bariatric surgery leads to a significant improvement in obesity and associated comorbidities. Safe surgical outcomes are especially desirable in bariatric, as most patients perceive it as an aesthetic surgery, while an intestinal/gastric surgery may be associated with morbidity. A detailed pre-operative evaluation is required to avoid surgical surprises and post-operative complications. Besides other routine investigations, pre-surgery upper gastrointestinal (GI) endoscopy has always been a topic of debate. Some surgeons perform it routinely before the surgery, whereas others perform it selectively. It is mostly accepted that pre-operative diagnosis of gastro-oesophageal reflux disease could change the plan of surgery in favour of Roux-en-Y gastric bypass although similar consensus does not exist in favour of Sleeve gastrectomy if a gastric/duodenal pathology is detected pre-operatively in a planned roux-en-y gastric bypass patient. Aim: Through this case series, we want to highlight the role of routine pre-operative upper GI endoscopy in selecting the bariatric surgery. Cases: We present four cases, from amongst many others, where endoscopy changed the course of bariatric surgery. Conclusion: Upper GI endoscopy should be performed before bariatric surgery, even in asymptomatic patients, to avoid post-operative surprise/complication.
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UNUSUAL CASES Top

Transhepatic intraperitoneally migrated biliary stent: A rare finding during laparoscopic cholecystectomy p. 85
Ahmad Ozair, Faraz Ahmad, Surender Kumar, Sumit Rungta
DOI:10.4103/jmas.JMAS_32_20  PMID:33353893
Biliary endoprostheses are increasingly being utilised across both the developing and developed world, due to growing access to endoscopic biliary stenting. Stent migration, a well-documented complication of this minimally invasive procedure, occurs in up to 10% of cases post-insertion, sometimes leading to catastrophic complications. While distal migration frequently leads to spontaneous passage of the stent, proximal migration can result in a variety of problems. We here describe a rare case of transhepatic intraperitoneal migration of a double-pigtail, plastic stent and present a comprehensive review of literature.
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Thoracoscopic resection of foregut duplication cyst in a neonate p. 88
Saurabh Tiwari, Paras Kothari, Abhaya Gupta, Shalika Jayaswal, Vishesh Dikshit, Geeta Kekre
DOI:10.4103/jmas.JMAS_58_20  PMID:32964888
Foregut duplication is more common in girls, particularly if there is bronchopulmonary involvement. The incidence of oesophageal duplication cyst is estimated to be one in 8200 live births with male prevalence. Most duplications are benign, but the presence of ectopic gastric mucosa and the potential for malignant degeneration remain a concern. A newborn female, antenatally diagnosed with right-sided thoracic mass, was diagnosed with a foregut duplication cyst of size 4.1 cm × 3.7 cm × 8 cm in the posterior mediastinum. Thoracoscopic resection was done on day of life 14. The postoperative recovery was uneventful and histopathology confirmed the diagnosis. A literature search revealed only a few cases of an early thoracoscopic intervention, and ours is the earliest reported. Thoracoscopy in the neonatal period is safe and effective.
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A complex modality of achalasia, diverticulum and paraesophageal hernia treated through three-dimensional left thoracoscopy p. 91
Eustratia Mpaili, Antonia Meropouli, Maria Mpoura, Ilias Vagios, Spyridon Davakis, Theodore Liakakos, Alexandros Charalabopoulos
DOI:10.4103/jmas.JMAS_23_20  PMID:33353894
Herein, we report a case of a patient with recurrent dysphagia after an open transabdominal hernia repair for a Type IV paraesophageal hernia performed elsewhere. Subsequent work-up and medical records' review revealed the coexistence of a large left epiphrenic diverticulum in combination with achalasia synchronous to the recently repaired paraesophageal hernia. A three-dimensional left thoracoscopic diverticulectomy with a long esophagomyotomy was conducted under endoscopic guidance intraoperatively, with no perioperative complications. At 12 months' follow-up evaluation, the patient presents well with no documented recurrence. Cumulative experience from various medical specialties regarding esophageal motility disorders and endoscopic state-of-the-art techniques, when combined with minimally invasive surgical techniques, provide an effective management of esophageal motility syndromes, overall.
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Computed tomography helps pre-operative evaluation before laparoscopic resection of retroperitoneal bronchogenic cyst: A case report p. 95
Ji Qingyu, Li Xiaolong, Zhu Ruohan, Ma Licong, Tang Zhichao, Chen Qingwei, Wang Yuan, Zhao Ying
DOI:10.4103/jmas.JMAS_72_20  PMID:32964892
Bronchogenic cysts are congenital foregut dysplasia that occur mostly in the lungs and mediastinum. Here, we report a rare case of retroperitoneal bronchogenic cyst, the location, relationship to adjacent structures and blood supply of which were determined by computed tomography (CT) recombination technology and resected by laparoscope. The case was a 41-year-old female patient. The patient came to the hospital because of intermittent lumbar back discomfort for 1 month. CT scanning revealed a cystic mass of 3.9 cm × 3.2 cm × 3.0 cm behind the left peritoneum. The mass was close to the left adrenal gland, and a branch artery from the left renal artery was revealed to supply the mass. The cystic mass was excised by laparoscopy and confirmed as bronchogenic cyst on histopathology.
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Laparoscopic resection of gastric duplication cyst containing gastrointestinal stromal tumour: A case report p. 98
Aamir Abbas, Mohammad Kermansaravi, Seyed Nooredin Daryabari, Nasrin Shayanfar
DOI:10.4103/jmas.JMAS_296_19  PMID:33353895
Gastric duplication cyst (GDC) in adults is an extremely rare congenital anomaly. Here, we report the case of a GDC containing gastrointestinal stromal tumour (GIST) in a 60-year-old male patient who presented with abdominal pain. Laparoscopic resection with safe margins was performed following endosonographic localisation of the lesion. Pathologic evaluation revealed GDC containing GIST, and all surgical margins were free from tumours. The patient was discharged with good condition after 2 days and after 3 months of follow-up, the patient was symptom free and had no complications. Gastric duplication is a rare disease and may contain heterotopic tissue or even neoplastic lesions. Definite treatment is complete surgical removal that can be achieved laparoscopically with the aid of intraoperative ultrasonography for precise localisation of the indeterminate lesions.
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Robotic transduodenal excision of duodenal duplication cyst: Case report and review p. 101
Sunil Kumar Nayak, N Anand Vijay, VP Nalankilli, E Senthil Anand, Chinnusamy Palanivelu
DOI:10.4103/jmas.JMAS_17_20  PMID:32098936
Duodenal duplication cysts are rare congenital anomalies that generally present with abdominal pain and vomiting or may have nonspecific symptoms. Surgical excision is the recommended treatment owing to possible complications, including malignancy. However, difficult locations like the periampullary region are problematic and major surgical procedures, for example, pancreaticoduodenectomy is necessary for total resection. These have a high complication rate resulting in a poor quality of life, especially in children and young adults. Here, we describe a case of duodenal duplication cyst managed by robotic (transduodenal) excision along with a brief review of the literature.
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Laparoscopic assisted balloon enteroscopy to detect obscure gastrointestinal bleeding sources missed by capsule endoscopy p. 104
Damiano Bisogni, Giovanni Alemanno, Andrea Galli, Annamaria Di Bella, Luca Novelli, Tommaso Innocenti, Paolo Prosperi
DOI:10.4103/jmas.JMAS_6_20  PMID:33353896
Jejunoileal neuroendocrine tumours (NETs) are frequently multifocal and represent a consistent source of obscure gastrointestinal bleeding (OGIB). We report the real-life case of a female presenting to our attention for severe episodes of haematochezia caused by multiple localisation of jejunoileal NETs. A discrepancy between pre-operative total body contrast-enhancement computed tomography scan and capsule endoscopy (CE) emerged, in terms of numbers of lesions, so that, as completeness, an intraoperative balloon-assisted enteroscopy (BAE) was carried out, leading to the detection of the multiple lesions missed during CE. In case of obscure gastrointestinal bleeding sources missed by capsule endoscopy, laparoscopic-assisted balloon enteroscopy plays an essential role, allowing both to assess a precise diagnosis and to resect the intestinal bleeding tract.
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Emergency laparoscopic surgery for ruptured pancreatic pseudocyst: Report of two cases and review of the literature p. 108
Yun Le Linn, Zhongkai Wang, Brian K. P. Goh
DOI:10.4103/jmas.JMAS_67_20  PMID:32964867
Pancreatic pseudocyst (PP) is a known complication of pancreatitis. When a rupture occurs, patients often become haemodynamically unstable and require emergency surgery for source control. Conventionally, such a procedure is carried out through open technique due to patient, surgeon and technical factors. We present two cases of emergency laparoscopic surgery performed for ruptured PP. Our first patient was a 53-year-old male with a ruptured 17.6 cm pancreatic body pseudocyst who underwent a laparoscopic washout, adhesiolysis, necrosectomy, distal pancreatectosplenectomy and cholecystectomy. The second patient was a 66-year-old male with a ruptured 11 cm pancreatic body pseudocyst who underwent laparoscopic surgery, subsequently converted to hand-assisted surgery. We compare our cases with the existing literature and discuss pertinent management considerations. In conclusion, we demonstrated that emergency laparoscopic adhesiolysis, necrosectomy and distal pancreatosplenectomy are feasible and safe for the management of ruptured pseudocyst when performed by an experienced surgeon. However, further studies are needed to determine the advantages or limitations of the minimally invasive surgical approach for the management of these complicated cases.
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Rectum migration of an intrauterine device p. 113
Rui Li, Hongmei Li, Jie Zhang, Huiqing Li
DOI:10.4103/jmas.JMAS_268_19  PMID:32964886
Intrauterine device (IUD) is a well-accepted means of contraception. Although it is safe and effective, some serious complications may occur. It should be paid attention to a 45-year-old female admitted to the hospital for aggravated abdominal pain and dyspareunia for 2 months. She was found to have two IUDs in her body, one in the uterine cavity and the other outside. They were removed through laparoscopic and hysteroscopy. When IUD perforation occurs, whether symptomatic or not, surgical removal is necessary. Laparoscopy is thought to be the first choice. However, when serious adhesions coexist, laparotomy would be recommended.
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HOW I DO IT Top

A new technique to avoid unintentional adhesion while deploying ProGrip mesh and its utility in the laparoscopic repair of obturator hernia p. 116
Jun Muto, Katsuhiko Murakawa, Hiroyuki Yamamoto, Saseem Poudel, Shoki Sato, Kohei Kato, Naoto Senmaru, Koichi Ono
DOI:10.4103/jmas.JMAS_285_19  PMID:33353897
The ProGrip™ laparoscopic self-fixating mesh provides advantages such as low cost and reduced pain following tack-free fixation in laparoscopic hernia repair through a transabdominal preperitoneal approach. Obturator hernia repair needs adequate fixation around the hernial orifice without the use of tacking, and ProGrip™ mesh provides options for secure fixation. However, it is often difficult to adequately adjust the mesh placement to cover the obturator hernia orifice with a ProGrip™ mesh, due to adhesion of the grips to the surrounding tissues. We introduce our technique to avoid unintentional adhesion during ProGrip mesh repair and discuss its utility in the treatment of obturator hernias. We repaired seven obturator hernia lesions in five patients using this technique without any complications. The biggest advantage of our technique is that the position of the mesh can be adjusted after it is expanded, unless the sheet is completely removed, allowing the surgeons to fix the mesh without any unintended adhesion to surrounding tissue.
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A self-designed liver circle for on-demand Pringle's manoeuver in laparoscopic liver resection p. 120
Zhenzhen Gao, Zhiwei Li, Bo Zhou, Lifeng Chen, Zhenhua Shen, Yuancong Jiang, Xiang Zheng, Jie Xiang, Qiyi Zhang, Weilin Wang, Sheng Yan
DOI:10.4103/jmas.JMAS_130_19  
Background: Laparoscopic liver resection (LLR) allows minimal incisions and relatively quicker post-operative recovery, while intraoperative massive haemorrhage led to conversion to laparotomy. This study aimed to introduce a new, safe and convenient device to serve as Pringle's manoeuver according to the demand in LLR. Methods: A liver circle consisting of a hole and a round stem with an obtuse small head was made by medical silica gel. It was applied in LLR to perform on-demand Pringle's manoeuver and developed its function in inferior vena cava (IVC) occlusion. The time of performing Pringle's manoeuver by liver circle, extracorporeal tourniquet and endo intestinal clip under laparoscopic simulator and LLR was compared. Results: The liver circle was successfully applied to perform Pringle's manoeuver, IVC exposure and occlusion. It took less time in the occluding step of Pringle's manoeuver than the extracorporeal tourniquet (4.15 ± 0.35 s vs. 9.90 ± 1.15 s, P < 0.05) and the endo intestinal clip (4.15 ± 0.35 s vs. 47.91 ± 3.98 s, P < 0.05) under LLR. The total manipulating time for Pringle's manoeuver with liver circle remained the shortest, and the advantages were more obvious with increased frequencies of intermittent Pringle's manoeuver. Conclusion: The new-designed liver circle is more convenient compared to other techniques in performing Pringle's manoeuver, especially the intermittent Pringle's manoeuver in LLR. It can be used to perform on-demand hepatic blood inflow occlusion in every LLR by pre-circling the hepatoduodenal ligament to control bleeding during surgery. It can also be applied to expose the surgical field of vision and perform IVC occlusion to reduce intraoperative blood loss.
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Laparoscopic Witzel jejunostomy p. 127
Marco Lotti, Michela Giulii Capponi, Denise Ferrari, Giulia Carrara, Luca Campanati, Alessandro Lucianetti
DOI:10.4103/jmas.JMAS_248_19  PMID:33353899
The placement of a feeding jejunostomy can be indicated in malnourished patients with gastric and oesophagogastric junction cancer to allow for enteral nutritional support. In these patients, the jejunostomy tube can be suitably placed at the time of staging laparoscopy. Several techniques of laparoscopic jejunostomy (LJ) have been described, yet the Witzel approach remains neglected, due to the perceived difficulty of suturing the bowel around the tube and securing them to the abdominal wall. Here, we describe a novel technique for LJ, using a single barbed suture for securing the bowel and tunnelling the jejunostomy catheter according to the Witzel approach.
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Indocyanine green fluorescence imaging via endoscopic nasal biliary drainage during laparoscopic deroofing of liver cysts p. 131
Akira Umemura, Hiroyuki Nitta, Takayuki Suto, Hisataka Fujiwara, Takeshi Takahara, Yasushi Hasegawa, Hirokatsu Katagiri, Shoji Kanno, Taro Ando, Akira Sasaki
DOI:10.4103/jmas.JMAS_26_20  
Laparoscopic deroofing of liver cysts is widely accepted as the treatment of symptomatic huge liver cysts. As bile leakage is a common complication of this procedure, indocyanine green (ICG) imaging has played an active role in detecting intrahepatic biliary tract. However, infusion ICG imaging needs time rag after injection due to moving from bloodstream to bile, and also, additional injection is needed when the fluorescent imaging is not clear. To cover this weakness of ICG imaging, we first applied ICG imaging via 5-Fr endoscopic nasal biliary drainage (ENBD) during laparoscopic deroofing of liver cysts. This technique promptly gives us ICG imaging after ICG injection from ENBD; in addition, direct ICG imaging sometimes reveals minor leakage from sealing line and staple lines; therefore, we believe that direct ICG imaging via ENBD helps us to prevent post-operative bile leakage.
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PERSONAL VIEWPOINT Top

COVID-19 and jeopardy of a trainee in the era of minimally invasive surgery p. 135
Harshit Garg
DOI:10.4103/jmas.JMAS_170_20  PMID:33353901
COVID-19 pandemic had a global impact on residency training and surgical training had seen the worst hit. In the current era, the minimal invasive surgery has become inherent component of any surgical speciality training and the COVID-19 crisis has affected the various components of this training including acquisition of knowledge, clinical judgement and technical competency. This impact, coupled with uncertainty in future training and job opportunities have jeopardized the current surgical trainees.
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LETTERS TO THE EDITOR Top

Comment: Personal protective equipment use in laparoscopy during COVID-19 p. 137
Aditya Baksi, Supreet Kaur
DOI:10.4103/jmas.JMAS_231_20  PMID:33353902
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Lost umbilical tape in laparoscopic surgery: Consequences and lessons learned p. 139
Saket Kumar, Nishant Kurian, Rakesh Kumar Singh
DOI:10.4103/jmas.JMAS_284_19  PMID:32098939
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04