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   Table of Contents - Current issue
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October-December 2020
Volume 16 | Issue 4
Page Nos. 297-450

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EDITORIAL  

Message from new editors p. 297
Sandeep Aggarwal, Anil Sharma
DOI:10.4103/jmas.JMAS_197_20  PMID:32978348
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SYSTEMATIC REVIEW Top

Comparison of laparoscopy combined with gastroscopy positioning and open resection for gastric stromal tumours: A meta-analysis p. 298
Hu Zhang, Jie Chen, Chen Chen
DOI:10.4103/jmas.JMAS_269_19  PMID:32978349
Background and Objectives: The aim of the study was to assess the efficacy and safety in treating gastric stromal tumours by laparoscopy combined with gastroscopy positioning surgery. Methods: I searched the randomized controlled trials (RCTs) about the efficacy and safety of laparoscopy combined with gastroscopy positioning surgery in treating gastric stromal tumours from the PubMed (1998~2018.06), Wanfang Data (1990~2018.06), China National Knowledge Infrastructure (1979~2018.06) and International Statistical Institute (1998~2018.06). I extracted the data from these trials, and I got the meta-analysis from RevMan 5.3 software. Results: Twenty-six RCTs involving 1710 patients were included (870 patients in the laparoscopy combined with gastroscopy positioning group and 840 patients in openresection group). Compared with open resection group, this meta-analysis showed that laparoscopy combined with gastroscopy positioning group could reduce the intraoperative blood (P < 0.05), shorten the post-operative time of recovery of intestinal peristalsis (P < 0.05), shorten the diet recovery time (P < 0.05), reduce the incidence of the incision infection, intestinal obstruction and pneumonia and also shorten the post-operation hospital stay (P < 0.05). However, there was no significant difference in the operation time (P > 0.05). Conclusion: Compared with open resection group, the total effect of laparoscopy combined with gastroscopy positioning group in the treatment of gastric stromal tumours is better. Laparoscopy combined with gastroscopy positioning group for the gastric stromal tumours is acceptable.
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REVIEW ARTICLES Top

Key clinical applications for indocyanine green fluorescence imaging in minimally invasive colorectal surgery Highly accessed article p. 308
Jan Grosek, Aleš Tomažič
DOI:10.4103/jmas.JMAS_312_18  PMID:31031317
Near-infrared indocyanine green (ICG) fluorescence imaging has gained solid acceptance over the last years, and rightly so, as this technology has so much to offer, especially in the field of minimally invasive surgery. Firm evidence from ongoing and future studies will hopefully transform many of the applications of ICG fluorescence into the standard of care for our patients. This review examines the current status of ICG fluorescence for assessment of bowel perfusion, lymphatic mapping as well as intraoperative localisation of ureter in light of the published academic literature in English.
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Minimally invasive video-assisted thyroidectomy and transoral video-assisted thyroidectomy: A comparison of two systematic reviews p. 315
Francesco Tartaglia, Alessandro Giuliani, Salvatore Sorrenti, Salvatore Ulisse
DOI:10.4103/jmas.JMAS_123_19  PMID:32978350
Background: We compared two systematic reviews, one focusing on transoral video-assisted thyroidectomy (TOVAT) and the other on minimally invasive video-assisted thyroidectomy (MIVAT), to highlight the pros and cons that can determine the choice of one or the other procedure. Materials and Methods: PubMed, Scopus and ISI Web of Science databases were searched for relevant articles published from 2000 to June 2018. Both searches were performed using the same keywords. All articles describing human surgical case series of any size were included, while the following were excluded: articles published in languages other than English, case reports, reviews, early cadaver and animal studies and old reports of cases now included in more recent works. Application of the above selection criteria yielded 151 articles on TOVAT and 246 on MIVAT. Of these, 34 articles were selected for inclusion in the present study: 17 for the TOVAT group and 17 for the MIVAT group. The comparison was made considering the most common variables used in evaluating thyroid surgery procedures. The statistical methods used were Cohen's delta, Student's t-test and the non-parametric Mann–Whitney U-test. Results: The variable 'operative time' was found to show a very large effect size, and 'hospital stay' also differed significantly between the MIVAT and TOVAT groups. Conclusions: TOVAT and MIVAT should not be considered in competition with each other, but seen simply as alternative choices. Both appear to be safe methods, comparable in terms of post-operative complications, although the main reason for using TOVAT seems to be purely aesthetic.
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ORIGINAL ARTICLES Top

Is a difficult gallbladder worth removing in its entirety? – Outcomes of subtotal cholecystectomy p. 323
Kushal Bairoliya, Ramesh Rajan, RS Sindhu, Bonny Natesh, Jacob Mathew, S Raviram
DOI:10.4103/jmas.JMAS_2_19  PMID:32978351
Background: Laparoscopic Cholecystectomy one of the commonest procedures performed worldwide isn't spared from the risks of disastrous iatrogenic complications. In patients with obscured anatomy, the idea of performing a safe total cholecystectomy can be hindered with a high risk of biliovascular injuries. In such a situation STC (subtotal cholecystectomy) comes to the rescue, where the diseased organ can be tackled fairly, without any further damage. Aims and Objectives: The primary aim was to look at the immediate and long-term outcomes of subtotal cholecystectomy. Subgroup analysis was done based on demographics, indications and surgical approach. Materials and Methods: We reviewed our prospectively maintained computerized operation database over nine years. STC was defined as leaving behind any portion of gallbladder other than the cystic duct. They were subclassified as per the description given by Palanivelu. Patients were evaluated with laboratory and radiological assessment. Results: A total of 70 out of 602 patients (11.6%) underwent STC. Dense adhesion at the calot's was the most important reason for STC. Subtype B was the most common. Nine patients (12.85%) had a bile leak in the postoperative period. There were no biliary/vascular injuries and 30-day mortality was zero. 22.8% developed SSI (surgical site infection). Over a median follow up of 38 months (range 5-98), clinical examination, LFT and USG revealed no abnormality in any of the patients. Conclusion: Subtotal cholecystectomy is a useful alternative during difficult gallbladder surgery. It should be considered early into the procedure preferably prior to conversion to an open procedure. Biliovascular injuries can be avoided and the Immediate and long-term outcomes are acceptable.
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Post-operative pain after laparoscopic ventral hernia repair, the impact of mesh soakage with bupivacaine solution versus normal saline solution: A randomised controlled trial (HAPPIEST Trial) p. 328
Tabish Chawla, Noman Shahzad, Khabir Ahmad, Jehangir Farman Ali
DOI:10.4103/jmas.JMAS_50_19  PMID:32978352
Background and Aims: Early postoperative pain after laparoscopic ventral hernia repair remains a concern for patients. Local application of anaesthetic agent in the surgical dissection area can potentially overcome this problem. The objective of this study was to evaluate the impact of soaking mesh in 0.5% bupivacaine solution as compared to normal saline solution on the post-operative pain. Methodology: We conducted a parallel-design double-blind randomised controlled trial. Adult patients with uncomplicated ventral abdominal wall hernias were included in the trial. Mesh was soaked in 0.5% solution of bupivacaine before application in patients in the intervention arm, whereas it was soaked in normal saline solution for patients in the control arm. Post-operative pain was assessed by trained staff at 6 h and 24 h from surgery. It was graded on visual analogue scale (VAS) from 0 to 10. Results: Trial was conducted from 16 November, 2015, to 15 September, 2017. During the study period, a total of 114 patients were randomised. Nine patients were excluded after randomisation. A total of 55 patients were analysed in the intervention arm and 50 patients were analysed in the control arm. Mean pain score at VAS at 6 h after laparoscopic ventral hernia repair in the intervention arm was 5.05 ± 1.2, whereas in the control arm, it was 5.54 ± 1.1 and the difference was statistically significant (P = 0.03-independent sample t-test). Mean pain score at VAS at 24 h after laparoscopic ventral hernia repair in the intervention arm was 3.16 ± 1.2, whereas in the control arm, it was 3.58 ± 1.4 and the difference was not statistically significant (P = 0.11-independent sample t-test). Conclusion: Soakage of mesh in 0.5% bupivacaine solution before application in laparoscopic ventral hernia repair significantly reduces early post-operative pain. Trial Registration: Trial was registered with clinicaltrials. gov (NCT03035617) URL: https://clinicaltrials. gov
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Robotic assistance in ventral hernia repair may decrease the incidence of hernia recurrence p. 335
Mitchell Andrew Goettman, Margaret Lynn Riccardi, Lucky Vang, Moe S Dughayli, Chadi H Faraj
DOI:10.4103/jmas.JMAS_92_19  PMID:31929224
Background: Since the advent of laparoscopic surgery, many studies have shown the advantages of laparoscopic surgery over open surgery for ventral hernia repair (VHR). As robotic surgery is gaining popularity, we sought to compare the outcomes of this newer robotic-assisted technique to the outcomes of established open and laparoscopic techniques to assess for any additional benefit. Methods: A meta-analysis research design was employed. Multiple databases were queried for publications over the past 10 years and 23 articles were selected based on pre-determined selection criteria. Data were extracted and the arm-based network meta-analysis method was utilised to examine the effect difference for the three arms of our study: Open, laparoscopic and robotic-assisted VHR. Results: As expected, laparoscopy had an advantage over open VHR in terms of infection rates. This advantage was also observed in the robotic group over the open group; however, there was no statistical difference between the laparoscopic and robotic groups when infection rates were compared head-to-head. The robotic group had a significant advantage over both the open and more importantly, the laparoscopic groups in recurrence rates. Conclusions: The results of this study suggest that robotic surgery maintains some of the advantages of laparoscopic surgery and may also provide the additional advantage of recurrence rate reduction. This may be explained by the ability to perform a more complex hernia repair with robotic assistance secondary to the ease of closure of the fascial defect. More research is needed to validate this finding.
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Changing trends and outcomes associated with the adoption of minimally-invasive pancreato-biliary surgery: Contemporary experience of a 'self-taught' early adopter in Southeast Asia p. 341
Brian K. P. Goh, Gerald Zeng, Tze-Yi Low, Darren W Chua, Ye-Xin Koh, Kai-Inn Lim
DOI:10.4103/jmas.JMAS_94_19  PMID:31929225
Background: Minimally-invasive pancreato-biliary surgery (MIPBS) is increasingly reported worldwide. This study examines the changing trends, safety and outcomes associated with the adoption of MIPBS based on a contemporary experience of an early adopter in Southeast Asia. Methods: Retrospective review of 114 consecutive patients who underwent MIPBS by a single surgeon over 86 months from 2011. The study population was stratified into three equal groups of 38 patients. Comparison was also performed between minimally-invasive pancreato surgery (MIPS) and minimally-invasive biliary surgery (MIBS). Results: There were 70 MIPS and 44 MIBS. Sixty-three cases (55.3%) were performed using robotic assistance and fourteen (12.3%) were hybrid procedures with open reconstruction. Forty-four (38.6%) procedures were performed for malignancy. There were 8 (7.0%) open conversions and median operation time was 335 (range, 60–930) min. There were nine extended pancreatectomies including seven involving vascular reconstructions. Major morbidity (>Grade 2) occurred in 20 (17.5%) patients including 6 (5.3%) reoperations and there was no mortality. Comparison across the three groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher ASA score patients, increasing frequency of procedures requiring anastomosis and increasing the use of robotic assistance without significant difference in key perioperative outcomes such as open conversion rate, morbidity and hospital stay. Comparison between MIPS and MIBS demonstrated that MIPS was associated with significantly longer operation time, increased blood loss, increased transfusion rate, longer hospital stay, increased readmission rate and increased morbidity. Conclusion: MIPBS can be safely adopted today with a low open conversion rate.
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Gastrointestinal stromal tumour of stomach: Feasibility of laparoscopic resection in large lesions and its long-term outcomes p. 348
Parthasarathi , Sharma Dhawal, Bhushan Chittawadagi, Bharath Cumar, Saravana Kumar, Chinnusamy Palanivelu
DOI:10.4103/jmas.JMAS_311_18  PMID:32098941
Background: Gastric gastrointestinal stromal tumours (GISTs) are rare neoplasms that require excision for cure. Although the feasibility of laparoscopic resection of smaller gastric GIST has been established, the feasibility and long-term efficacy of these techniques are unclear in larger lesions. This study is done to assess the feasibility of the laparoscopic resection of gastric GISTs and their long-term outcomes. Methods: Patients who underwent laparoscopic resection of gastric GISTs were identified in a prospectively collected database. Outcome measures included patient demographics, operative findings, morbidity and histopathologic characteristics of the tumour. Patient and tumour characteristics were analysed to identify risk factors for tumour recurrence. Results: There were 42 patients with a mean age of 56.7 years and had a mean tumour size was 4.5 ± 2.7 cm. Laparoscopic wedge resection was the most common procedure done. There were no major perioperative complications or mortalities. All lesions had negative resection margins. At a mean follow-up of 48 months, 36/39 (92.3%) patients were disease free and 3/39 (7.6%) had progressive disease. Univariate analysis showed that there was a statistically significant association of disease progression with tumour size, high mitotic index, tumour ulceration and tumour necrosis. The presence of >10 mitotic figures/50 high-power field was an independent predictor of disease progression. Conclusion: Our study establishes laparoscopic resection is feasible and safe in treating gastric GISTs for tumours >5 cm size. The long-term disease-free survival in our study shows acceptable oncological results in comparison to historical open resections.
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Higher quality camera navigation improves the surgeon's performance: Evidence from a pre-clinical study p. 355
Florentine Huettl, Tobias Huber, Matthias Duwe, Hauke Lang, Markus Paschold, Werner Kneist
DOI:10.4103/jmas.JMAS_143_19  PMID:31793451
Introduction: To objectively assess the quality of laparoscopic camera navigation (LCN), the structured assessment of LCN skills (SALAS) score was developed and validated for laparoscopic cholecystectomy. The aim of this pre-clinical study was to investigate the influence of LCN on surgical performance during virtual cholecystectomy (vCHE) using this score. Methods: A total of 84 medical students were included in this prospective study. Individual characteristics were assessed with questionnaires. Participants completed a structured 2-day training course on a validated virtual reality laparoscopic simulator. At the end of the course, all students took over LCN during vCHE, all performed by the same surgeon. The numbers of errors regarding centering, horizon adjustment and instrument visualisation as well as manual and verbal corrections by the surgeon were recorded to calculate the SALAS score (range 5–25) to investigate the influence of LCN on surgical performance. The study population was divided by the recorded SALAS score into low and medium performers (Group A; 1st–3rd quartile; n = 60) and high performers (Group B, 4th quartile, n = 21). Results: The SALAS score of the camera assistant correlates positively with the surgeon's overall performance in vCHE (P < 0.001), and the surgeon's virtual laparoscopic performance was significantly better in Group B (P < 0.001). Moreover, a significantly shorter operation time during vCHE was shown for Group B (Median (IQR); Group A: 508 s [429 s; 601 s]; Group B: 422 s [365 s; 493 s]; P = 0.001). Frequent gaming and a higher self-confidence to assist during a basic laparoscopic procedure were associated with a higher SALAS score (P = 0.013). Conclusion: In this pre-clinical setting, the surgeon's virtual performance is significantly influenced by the LCN quality. LCN by high performers resulted in a shorter operation time and a lower error rate.
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Subxiphoid robotic extended thymectomy – The first Indian report Highly accessed article p. 360
Belal Bin Asaf, Harsh Vardhan Puri, Sukhram Bishnoi, Navdeep Singh Nanda, Mohan Venkatesh Pulle, Arvind Kumar
DOI:10.4103/jmas.JMAS_34_19  PMID:31031320
Background: Minimally invasive thymectomy is fast becoming the preferred approach for myasthenia gravis and non-invasive thymoma. The most commonly employed approach for minimally invasive thymectomy is the lateral thoracic approach. Safe achievement of radical resection requires adequate visualisation of both the phrenic nerves along their entire course. In our experience, such visualisation is rather difficult with unilateral transthoracic approaches. We herein describe our technique and initial experience of 25 cases with subxiphoid robotic thymectomy (SRT) for myasthenia gravis with or without thymoma. To the best of our knowledge, this is the first such report from India. Subjects and Methods: We retrospectively analysed data of patients who underwent SRT at our centre from June 2017 to September 2018. Twenty-five consecutive patients were analysed, and demographic data, total duration of the procedure, console time, blood transfusion requirement, duration of chest drainage, length of hospital stay, pain score on post-operative day (POD) 1 and day of discharge and post-operative morbidity and mortality within 90 days were recorded. Results: A total of 25 patients underwent SRT. All our patients had myasthenia gravis with 4 of them having thymoma. There were 11 males and 14 females with mean age of 29.30 years (range 23–48). The mean console time was 102.85 min (range 88–120) while the mean total operative time was 199.14 (range 180–220). On first POD 1, visual analogue scale score average was 5, and at discharge, it was 2. There was no 30-day or 90-day mortality. All cases of thymoma had a complete R0 resection. Conclusion: Our experience suggests that subxiphoid approach offers a good operative view of the thymus in cervical region along with easy identification of bilateral phrenic nerves. Thus, SRT can be performed safely with comparable results.
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Preliminary study of short- and long-term outcome and quality of life after minimally invasive surgery for Crohn's disease: Comparison between single incision, robotic-assisted and conventional laparoscopy Highly accessed article p. 364
Daniela Zambonin, Francesco Giudici, Ferdinando Ficari, Benedetta Pesi, Cecilia Malentacchi, Stefano Scaringi
DOI:10.4103/jmas.JMAS_61_19  PMID:31031322
Background: The feasibility of minimally invasive approach for Crohn's disease (CD) is still controversial. However, several meta-analysis and retrospective studies demonstrated the safety and benefits of laparoscopy for CD patients. Laparoscopic surgery can also be considered for complex disease and recurrent disease. The aim of this study was to investigate retrospectively the effect of three minimally invasive techniques on short- and long-term post-operative outcome. Patients and Methods: We analysed CD patients underwent minimally invasive surgery in the Digestive Surgery Unit at Careggi University Hospital (from January 2012 to March 2017). Short-term outcome was evaluated with Clavien–Dindo classification and visual analogue scale for post-operative pain. Long-term outcome was evaluated through four questionnaires: Short Form Health Survey (SF-36), Gastrointestinal Quality Of Life Index (GIQLI), Body Image Questionnaire (BIQ) and Hospital Experience Questionnaire (HEQ). Results: There were 89 patients: 63 conventional laparoscopy, 16 single-incision laparoscopic surgery and 10 robotic-assisted laparoscopy (RALS). Serum albumin <30 g/L (P = 0.031) resulted to be a risk factor for post-operative complications. HEQ had a better result for RALS (P = 0.019), while no differences resulted for SF-36, BIQ and GIQLI. Conclusions: Minimally invasive technique for CD is feasible, even for complicated and recurrent disease. Our study demonstrated low rates of post-operative complications. However, it is a preliminary study with a small sample size. Further studies should be performed to assess the best surgical technique.
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Laparoscopic resection of ileocaecal duplication in children (report of 15 cases) p. 372
Jianlei Chen, Jian Wang, Zhicheng Gu, Shungen Huang, Jie Zhu, Bin Wu, Zhenwei Zhu, Peng Cai, Chao Sun
DOI:10.4103/jmas.JMAS_120_19  PMID:31929221
Background: Enteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. Ileocaecal (IC) duplications are duplications located at the IC junction, not clearly identified in all the published series. The reported treatment is IC resection and ileocolic anastomosis. The purpose of our study was to present our experience in successfully resection of IC duplication by laparoscope, thus avoiding bowel resection in children. Materials and Methods: A retrospective review was conducted of medical records of 15 patients with diagnosis of IC duplication, treated in the Department of Paediatric Surgery of our hospital, within the period from November 2013 to September 2018. Results: Laparoscopic resection of IC duplication was successfully performed in all children without bowel resection. The operation time was 50-90 min (55 ΁ 10 min), and the post-operative hospitalization time was 5-7 days (average, 6 days). The 15 patients were followed up for 6-12 months (average, 10 months). No recurrence was found by abdominal ultrasound examination. The wound had small scars with good appearance of umbilicus. Conclusions: The laparoscopic approach allows for confirming the diagnosis and accurately defining the exact site of duplication, as well as for effective and safe treatment. Laparoscopic excision of IC duplication without bowel resection is a safe option and is worth promoting.
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The effect of the body mass index on the short-term surgical outcomes of laparoscopic total gastrectomy: A propensity score-matched study p. 376
Mamoru Miyasaka, Yuma Ebihara, Kimitaka Tanaka, Yoshitsugu Nakanishi, Toshimichi Asano, Takehiro Noji, Yo Kurashima, Toru Nakamura, Soichi Murakami, Takahiro Tsuchikawa, Keisuke Okamura, Toshiaki Shichinohe, Yoshihiro Murakami, Katsuhiko Murakawa, Fumitaka Nakamura, Takayuki Morita, Shunichi Okushiba, Satoshi Hirano
DOI:10.4103/jmas.JMAS_212_19  PMID:32978353
Purpose: This study aimed to evaluate the relationship between the body mass index (BMI) and the short-term outcomes of laparoscopic total gastrectomy (LTG). Subjects and Methods: Data of patients who underwent LTG for gastric cancer at six institutions between 2004 and 2018 were retrospectively collected. The patients were classified into three groups: low BMI (<18.5 kg/m2), normal BMI (≥18.5 and <25 kg/m2) and high BMI (≥25 kg/m2). In these patients, clinicopathological variables were analysed using propensity score matching for age, sex, the American Society of Anaesthesiologists physical state, clinical stage, surgical method, D2 lymph node dissection, combined resection of other organs, anastomosis method and jejunal pouch reconstruction. The surgical results and post-operative outcomes were compared among the three groups. Results: A total of 82 patients were matched in the analysis of the low BMI and normal BMI groups. There were no differences in operative time (P = 0.693), blood loss (P = 0.150), post-operative complication (P = 0.762) and post-operative hospital stay (P = 0.448). In the analysis of the normal BMI and high BMI groups, 208 patients were matched. There were also no differences in blood loss (P = 0.377), post-operative complication (P = 0.249) and post-operative hospital stay (P = 0.676). However, the operative time was significantly longer in the high BMI group (P = 0.023). Conclusions: Despite the association with a longer operative time in the high BMI group, BMI had no significant effect on the surgical outcomes of LTG. LTG could be performed safely regardless of BMI.
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Prevalent bariatric dietary practices: Is India on the same page? p. 381
Ishitaa N Bhatia, Amrit M Nasta, Madhu R Goel, Ramen G Goel
DOI:10.4103/jmas.JMAS_205_19  PMID:31997784
Background: In the past decade, there has been an increase in the number and types of bariatric procedures in India. It is, thus, important to monitor prevalent bariatric practices. Aim: To identify prevalent pre- and post-operative dietary practices by bariatric professionals across India. Materials and Methods: Data regarding various pre- and post-surgery dietary practices were collected using an Internet-based survey. Thirty-three bariatric professionals including dietitians (n = 25) and surgeons (n = 8) across the country participated in the survey. The data were analysed, and prevalent dietary practices were identified. Results: Five (20%) dietitians were not involved in the pre-surgery consultation. Nineteen (70%) professionals put all patients on a low-calorie pre-surgery diet regardless of their body mass index, with a preference (n = 21; 77.7%) for liquid diet. Twenty-three (70%) professionals put patients on post-surgery liquid diet for 1–2 weeks. Thereafter, 28 (84.8%) professionals recommended soft diet for 2–4 weeks. Twenty-seven (81%) professionals used protein shakes (as opposed to dietary sources) as their primary source of protein for the first 3 months post-surgery. Fourteen (36%) professionals stopped protein shake supplements within 6 months post-surgery. Ten (30%) professionals reported whey protein aversions in >25% of the patients. Twenty-three (71%) professionals advocated a meal with <30% of carbohydrates for up to 1 year. Twenty-eight (84%) professionals used portion control method for meals. Conclusion: Our study reflects that prevalent dietary practices among Indian bariatricians are in line with national and international guidelines.
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Laparoscopic hybrid pyloromyotomy for infantile hypertrophic pyloric stenosis: A simplified technique p. 386
Vikesh Agrawal, Dhananjaya Sharma, Himanshu Acharya, Abhishek Tiwari
DOI:10.4103/jmas.JMAS_216_19  PMID:31670292
Introduction: Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric has advantage of smaller incisions, faster recovery, reduction in wound-related complications and better cosmesis. Various laparoscopic knives and spreaders have been used for LP, but they do not provide the depth and tissue perception as in open surgery. We describe the laparoscopic hybrid pyloromyotomy (LHP) which makes procedure simple and safe without the requirement of any special instrument. Materials and Methods: This retrospective and prospective comparative study was conducted over a period of 4.5 years in a tertiary teaching hospital in central India. All patients with infantile hypertrophic pyloric stenosis diagnosed on the basis of clinical history, examination and ultrasonography were included in the study. Retrospective data of three-port conventional LP (CLP) using monopolar diathermy hook for incision was used as control group against prospective data of 25 patients undergoing LHP. After a proper layout, LHP was done using one umbilical optical port, right paraumbilical grasper of holding the pyloric olive and an epigastric incision for hybrid pyloromyotomy using 11 no blade and blunt-tipped mosquito artery forceps. Results: Prospective group of LHP included 25 patients which were compared with a retrospective group of CLP consisting of 25 patients. On comparison of two groups, it was found that LHP reduces operative duration significantly. The outcome in terms of complications and recovery was comparable in two groups. None of the patients developed recurrence and required any redo surgery. Conclusion: LHP is a simplified approach which is easy to learn and teach, improves safety and accuracy of the procedure.
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Perioperative recovery in different urinary reconstruction approaches of radical cystectomy: Are the advantages of laparoscopy consistent? p. 390
Zhenhua Liu, Yisen Meng, Shaobo Li, Wei Yu, Jie Jin
DOI:10.4103/jmas.JMAS_227_19  PMID:31929226
Context: Radical cystectomy (RC) has complicated surgical procedures and various ways of urinary reconstruction. Aims: The aim of this study is to investigate whether the advantages of laparoscopy over open surgery were consistent in the perioperative recovery of different methods of urinary diversion after RC in the general and the elderly (>65 years) population. Settings and Design: A retrospective study reviewed 452 (elderly 261) patients who received RC from the year 2005–2012. Subjects and Methods: Of all, 88 patients underwent laparoscopic RC (LRC) and 364 patients underwent open RC (ORC). There were 325 patients received ileal conduit (IC), whereas 127 patients received cutaneous ureterostomy (CU). Statistical Analysis Used: We used different statistical methods (t-test, Chi-square, etc.) to compare variables outcomes. Results: For IC urinary diversion, the general patients undergoing LRC had less intra-operative blood loss (566.5 vs. 1320.3 ml, P < 0.001), lower blood transfusion rate (11.4 vs. 34.1%, P < 0.001), shorter gastrointestinal recovery time (5.7 vs. 6.7 days, P= 0.002) and shorter length of hospital stay (LOS) (21.7 vs. 26.0 days, P = 0.003) than patients receiving ORC. Similar trends were observed in older patients. For CU urinary diversion, the general and the elderly patients receiving LRC had a shorter mean time to gastrointestinal recovery (P = 0.017, P < 0.001, respectively) than patients receiving ORC. No differences were found between LRC and ORC in intra-operative blood loss, allogeneic blood transfusion rate and LOS. Conclusions: In the general and the elderly population, laparoscopic approach could result in more rapid rehabilitation for RC patients, especially in the IC patients.
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Modified equipment for facilitating the transoral vestibular approach to endoscopic thyroidectomy p. 399
Piyapong Bamroong, Pornthep Kasemsiri, Cattleya Thongrong, Kanokkarn Mahawerawat, Siriwan Tongwiset, Angkana Rachain, Sirikarn Khaengraeng
DOI:10.4103/jmas.JMAS_157_19  PMID:31571672
Objectives: The objectives of the study were to investigate the improvement in operation time for thyroid surgery gained using a modified endobag and suture and to accelerate the learning process for novice endoscopic surgeons. Materials and Methods: A retrospective study was conducted between 2 June 2015 and 1 November 2018. Medical records of patients who underwent transoral endoscopic thyroidectomy vestibular approach (TOETVA) were retrieved and analysed. Comparisons of operative time with or without the use of modified equipment were calculated by the unequal variance t-test in lobectomy and isthmectomy groups. Results: Medical records of 102 patients (mean age: 39.1 years) were analysed. The size of thyroid nodule averaged 4.0 cm (range: 1.0–13.0 cm). TOETVA was applied for right lobectomy (57.8%), left lobectomy (34.3%), isthmectomy (3.9%) and total thyroidectomy (3.9%). Early in our experience, TOETVA required 168 min, whereas following the introduction of the modified endobag and extracorporeal suture, operative time was reduced to 30 min (P > 0.05). Conclusions: The use of modified equipment permitted shorter operation times. The time difference was not statistically significant but does represent a significant time-saving. The use of the modified equipment will simplify and speed up the learning process for novice endoscopic surgeons.
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Changing trends and outcomes associated with the adoption of minimally invasive pancreatic surgeries: A single institution experience with 150 consecutive procedures in Southeast Asia p. 404
Brian K Goh, Tze Yi Low, Ye Xin Koh, Ser Yee Lee, Jin-Yao Teo, Juinn Huar Kam, Prema Raj Jeyaraj, Peng-Chung Cheow, Pierce K Chow, London L Ooi, Alexander Y Chung, Chung Yip Chan
DOI:10.4103/jmas.JMAS_127_19  PMID:31571669
Background: Minimally invasive pancreatic surgeries (MIPS) are increasingly adopted worldwide. However, it remains uncertain if these reported experiences are reproducible throughout the world today. This study examines the safety and evolution of MIPS at a single institution in Southeast Asia. Methods: This is a retrospective review of 150 consecutive patients who underwent MIPS between 2006 and 2018 of which 135 cases (90%) were performed since 2012. To determine the evolution of MIPS, the study population was stratified into 3 equal groups of 50 patients. Comparison was also made between pancreatoduodenectomies (PD), distal pancreatectomies (DP) and other pancreatic surgeries. Results: One hundred and fifty patients underwent MIPS (103 laparoscopic, 45 robotic and 2 hand-assisted). Forty-three patients underwent PD, 93 DP and 14 other MIPS. There were 21 (14.0%) open conversions. There was an exponential increase in caseload over the study period. Comparison across the 3 time periods demonstrated that patients were significantly more likely to have a higher American Society of Anesthesiologists score, older, undergo PD and a longer operation time. The conversion rate decreased from 28% to 0% and increased again to 14% across the 3 time periods. Comparison between the various types of MIPS demonstrated that patients who underwent PD were significantly older, more likely to have symptomatic tumours, had longer surgery time, increased blood loss, increased frequency of extended pancreatectomies, increased frequency of hybrid procedures, longer post-operative stay, increased post-operative morbidity rate and increased post-operative major morbidity rate. Conclusion: The case volume of MIPS increased rapidly at our institution over the study period. Furthermore, although the indications for MIPS expanded to include more complex procedures in higher risk patients, there was no change in key perioperative outcomes.
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UNUSUAL CASES Top

Mesh migration into the sigmoid colon after total extraperitoneal hernioplasty – Report of a case and review of the literature p. 411
Maitreyi Patel, Chetan Shenoy, Ganesh Nagarajan, Vinod Chandiramani
DOI:10.4103/jmas.JMAS_122_19  PMID:32978354
Over the past three decades, the practice laparoscopic inguinal hernioplasty has gained momentum. Mesh migration after laparoscopic inguinal hernia repair is an uncommon mesh-related delayed complication which is more common after transabdominal preperitoneal repair as compared to total extraperitoneal (TEP) repair. We report the first case of mesh migration into the sigmoid colon after TEP presenting 10 years after surgery. A 72-year-old male presented with left iliac fossa pain and diffuse lump. His computed tomogram scan showed sigmoid colon adherent to internal oblique at the site of hernia repair with a collection containing air specks and calcification. A colonoscopy revealed mesh within the sigmoid colon. He had to undergo a sigmoidectomy with Hartmann's surgery for the same. Here, we discuss the implicated pathophysiology, management and prevention of mesh migration after laparoscopic inguinal hernioplasty with literature review.
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Laparoscopic retrieval of impacted and broken dormia basket using a novel approach p. 415
Vaibhav Kumar Varshney, KS Sreesanth, Manish Gupta, Pawan Kumar Garg
DOI:10.4103/jmas.JMAS_245_19  PMID:32978355
We encountered a 73-year-old patient who presented with right upper abdominal pain and jaundice. On evaluation, he was found to have cholelithiasis with choledocholithiasis. Endoscopic retrograde cholangiography was attempted, but during the procedure, the wire snapped and the dormia basket got retained in the common bile duct (CBD). Laparoscopic CBD exploration was performed and the basket with calculus was found impacted in the lower CBD. The basket was disengaged by holding its tip through another dormia introduced through choledochoscope and basket with all calculi retrieved. Clearance of CBD was ascertained with choledochoscopy and CBD was closed primarily. He did well in the post-operative period and was discharged on the 5th post-operative day. At 1-year follow-up, the patient was doing well. Laparoscopic CBD exploration is a feasible and safe option for the retained dormia basket. We utilised the 'dormia with dormia technique' to retrieve the impacted basket which has not been reported before.
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Laparoscopic retrieval of a fishbone migrating from the stomach causing a liver abscess: Report of case and literature review p. 418
Or Barkai, Yoram Kluger, Offir Ben-Ishay
DOI:10.4103/jmas.JMAS_196_19  PMID:31793447
Ingestion of foreign bodies (FBs) is a common misfortune worldwide. Fishbone migration from the gastrointestinal tract into the liver is an unusual cause of liver abscess. We present a 66-year-old woman who presented to the emergency department with epigastric pain, with no other relevant anamnestic details. Computed tomography scan revealed a liver abscess, secondary to stomach perforation from a long, sharp object. Diagnostic laparoscopy revealed a fishbone protruding from the left lobe of the liver. The FB was extracted and the liver abscess incised and drained laparoscopically with no operative and post-operative complications. Migration of FB into the liver is a rare occurrence. Treatment of such liver abscess must include the extraction of the FB. Laparoscopy in these cases is feasible and safe and may prevent unnecessary exploratory laparotomy.
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Laparoscopic management of chylous ascites posthiatal hernia repair with Toupet fundoplication p. 421
Adele Hwee Hong Lee, Carla Gillespie, Mary Ann Johnson
DOI:10.4103/jmas.JMAS_198_19  PMID:31793456
We present a case of chylous ascites in a 69-year-old man 5 months after a laparoscopic Toupet fundoplication (posterior 270°). This was successfully treated with laparoscopic ligation of tissue adjacent to the right crus. Laparoscopic ligation is a management option that should be considered after this rare complication, offering rapid results.
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A large radiopaque appendicolith in an 8-year-old child p. 424
Rahul Gupta, Pradip Pokharia, Rahul Varshney
DOI:10.4103/jmas.JMAS_229_19  PMID:31997785
Appendicoliths are one of the most common causes of acute appendicitis. However, giant radiopaque appendicoliths are rare, especially in paediatric age group. We report a case of acute appendicitis in an 8-year-old boy due to a large 2-cm radiopaque appendicolith treated successfully by laparoscopic appendectomy.
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Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection p. 426
Carla Gillespie, Ada Ng, Richard Skipworth, Steven Leibman, Garett Smith
DOI:10.4103/jmas.JMAS_286_19  PMID:32978356
The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.
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Robotic resection of a thoracic duct cyst p. 429
Michael Andrew Napolitano, Keith D Mortman
DOI:10.4103/jmas.JMAS_169_19  PMID:31793448
A 69-year-old male presented with back tightness. Computed tomography revealed a 5 cm × 3 cm cystic para-oesophageal mass. A right robotic-assisted thoracoscopic resection was performed. Final pathology revealed a thoracic duct cyst (TDC). Robotic resection of a TDC has not been described in the literature previously but is shown in this report to be an effective and efficient way to perform the procedure. We suspect that robotic resection of mediastinal masses such as TDCs will become more common. Further studies comparing robotic to non-robotic resection of mediastinal masses would be helpful to determine the preferred treatment while minimising morbidity, length of stay and cost.
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Robotic-assisted laparoscopic common bile duct exploration with hepaticojejunostomy for primary ductal stones in nonagenarians: A report of two cases p. 431
Vivyan W. Y. Tay, Zhongkai Wang, Brian K. P. Goh
DOI:10.4103/jmas.JMAS_295_19  PMID:32098940
Experience with complex robotic-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited to few tertiary institutions worldwide. In this report, we focus on biliary bypass surgery, one of the more complex HPB surgeries. Over the past few decades, the laparoscopic approach has gained preference over the open approach, but the robotic approach is still uncommon. Biliary bypass is also not often performed in nonagenarians due to its inherent-associated morbidity and mortality, and these patients typically have higher surgical risks. We present two cases of nonagenarians who had recurrent episodes of cholangitis secondary to multiple primary common bile duct (CBD) stones and ectatic bile ducts. Both the patients were treated conservatively over many years with repeated endoscopic retrograde cholangiopancreatography and stentings. They eventually presented to us and underwent successful RAL CBD exploration with hepaticojejunostomy.
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Laparoscopic treatment of a pericaecal internal hernia p. 435
Facundo Iriarte, Agustin Buero, Daniel Enrique Pirchi, Walter Sebastian Nardi, Matias Mihura Irribarra
DOI:10.4103/jmas.JMAS_257_19  PMID:31929229
We present the case of a pericaecal hernia treated successfully with a laparoscopic approach and full recovery after surgery. A 53-year-old female patient with a personal history of depression, osteoporosis and irritable bowel syndrome consulted to the emergency department for abdominal pain and distension in the last 12 h, associated with one episode of vomit and diminished frequency in the passage of stools. The right abdomen was tender to palpation, and blood work revealed no leucocytosis. A computed tomography scan showed small bowel loops distended and displaced to the right parietocolic recess, lateral to the ascending colon. Exploratory laparoscopy was performed confirming the presence of small bowel loops incarcerated in the paracaecal fossa. These ones were reduced with gentle manoeuvres, and the peritoneal folds incised to prevent recurrence. The patient was started on an oral diet 2 days after surgery and discharged home on the 3rd post-operative day.
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HOW I DO IT Top

Indocyanine green tattooing for resection of endophytic submucosal lesions at anatomically difficult locations: Broader application of robotic platform p. 438
Akshay Pratap, Benedetto Mungo, Martin McCarter
DOI:10.4103/jmas.JMAS_246_19  PMID:32978357
Background: Endophytic submucosal masses at anatomically difficult locations such as lesser curve of the stomach, juxta-gastroesophageal junction and duodenum are challenging to resect laparoscopically due to proximity of vital structures and difficulty to visualise them. To overcome these limitations, we describe a technique of endoscopic tattooing with indocyanine green (ICG) injection into the lesion allowing easy identification and oncological resection in a minimally invasive manner. Patients and Methods: The technique of endoscopic tattooing of the lesion and robotic transgastric eversion resection technique is described in patients with gastrointestinal tumours at difficult anatomical location. Results: Gastric gastrointestinal stromal tumours at the lesser curve (n = 3) and gastroesophageal junction (n = 1) were resected using this technique successfully. Conclusion: The use of intraoperative ICG tattooing of endophytic submucosal lesions at difficult locations can facilitate minimally invasive oncologic resection. This technique allows the surgeon to be more comfortable to approach complex lesions safely to improve patient outcomes.
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915 MHz microwave-assisted laparoscopic partial splenectomy: A case series p. 441
Qiyi Zhang, Yang Tian, Jixuan Duan, Zhenzhen Gao, Weilin Wang, Sheng Yan
DOI:10.4103/jmas.JMAS_32_19  PMID:31929223
Background: Haemorrhage during the splenic parenchyma transection is a major threat for laparoscopic partial splenectomy (LPS). We here aim to evaluate the feasibility and safety of pre-coagulation of a 915 MHz microwave (MW) device during LPS. Materials and Methods: Data of four patients admitted to our hospital between November 2016 and July 2018 were retrospectively analysed. The mean age was 24 years (range, 19–33); they all diagnosed with splenic unifocal lesion with a mean diameter of 4.6 cm (ranged from 3.7 to 6 cm) and underwent LPS with pre-coagulation of a 915 MHz MW. Results: The LPS with pre-coagulation was successfully resulted in complete resection without microscopic residual tumour (R0 resection). The mean operative time was 205 min, and the minimum blood loss was at the range of 30–50 ml. No complication was observed, and the length of stay in hospital was varied from 5 to 10 days. Conclusion: Based on our observation, pre-coagulation of a 915 MHz MW during LPS is a safe and efficient technique. More studies are required before applying extensively.
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PERSONAL VIEWPOINT Top

Personal protective equipment use in laparoscopy during COVID-19 p. 445
Kaushik Bhattacharya
DOI:10.4103/jmas.JMAS_111_20  PMID:32978358
COVID-19 pandemic mandates all the laparoscopic surgeons to don the personal protective equipment (PPE) to prevent getting infected in the operation theatre. PPE has few inherent problems which makes the surgery extremely challenging for all the surgeons. Dehydration and profuse sweating along with breathing difficulty due to N95 mask with PPE increases the chances of committing surgical error during laparoscopy.
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IMAGES IN LAPAROSCOPY Top

Laparoscopic treatment of duplicate gallbladder with acute cholecystitis p. 447
Rahul A Gupta, Pradip Pokharia, Archana Khanduri
DOI:10.4103/jmas.JMAS_231_19  PMID:31929227
Duplication of gallbladder is a rare congenital anomaly of the extrahepatic biliary tract. Patients with duplicate gallbladder who develop symptoms due to gallstones require surgery. Laparoscopic cholecystectomy in such cases is challenging due to altered biliary anatomy. We report a case of duplicate gallbladder with acute calculus cholecystitis successfully treated by laparoscopic removal of both the gallbladders.
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INSTRUMENTS AND EQUIPMENTS Top

Experience in the use of a device to attach an anti-adhesion–absorption barrier film to the abdominal cavity in laparoscopic colorectal surgery p. 449
Yutaka Kojima, Kazuhiro Sakamoto, Yuichi Tomiki, Kosuke Mizukoshi
DOI:10.4103/jmas.JMAS_226_19  PMID:32098937
The use of laparoscopic surgery is widespread worldwide and is becoming the standard procedure. Postoperative adhesion, which is one of the typical postoperative complications, is considered to be less likely to occur compared with open surgery. However, once complications, such as small bowel obstruction or chronic abdominal pain, occur due to adhesion, the minimal invasiveness can be greatly impaired, and it can also become costly from a medical economics perspective. In the past, anti-adhesion absorption barrier films have been used to prevent adhesion, but there are many cases in which laparoscopic techniques are required, depending on the site of intraperitoneal attachment. Herein, we report a device that can easily attach an absorbent barrier preparation.
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2004 Journal of Minimal Access Surgery
Published by Wolters Kluwer - Medknow
Online since 15th August '04