Laparoscopy requires the development of technical skills distinct from those used in open procedures. Several factors extending the learning curve of laparoscopy include ergonomic and technical difficulties, such as the fulcrum effect and limited degrees of freedom. This study aimed to establish the impact of four variables on performance of two simulated laparoscopic tasks. Methods: Six subjects including novice (n=2), intermediate (n=2) and expert surgeons completed two tasks: 1) four running sutures, 2) simple suture followed by surgeon's knot plus four square knots. Task variables were suturing angle (left/right), needle holder type (standard/articulating) and visualisation (2D/3D). Each task with a given set of variables was completed twice in random order. The endpoints included suturing task completion time, average and maximum distance from marks and knot tying task completion time. Results: Suturing task completion time was prolonged by 45-degree right angle suturing, articulating needle holder use and lower skill levels (all P <0.0001). Accuracy also decreased with articulating needle holder use (both P <0.0001). 3D vision affected only maximum distance ( P =0.0108). For the knot tying task, completion time was greater with 45-degree right angle suturing ( P =0.0015), articulating needle holder use ( P <0.0001), 3D vision ( P =0.0014) and novice skill level ( P =0.0003). Participants felt that 3D visualisation offered subjective advantages during training. Conclusions: Results suggest construct validity. A 3D personal head display and articulating needle holder do not immediately improve task completion times or accuracy and may increase the training burden of laparoscopic suturing and knot tying.

Objectives: A prospective audit of all patients undergoing laparoscopic surgery with the intention of primary colonic left-sided intracorporeal stapled anastomosis to identify the clinical anastomotic leak rate on an intention to treat basis. Methods: All patients undergoing laparoscopic colorectal surgery resulting in left-sided stapled anastomosis were included. All operations were conducted by the same surgical team with the same pre-operative preparation and surgical technique. The factors analysed for this audit were patient demographics (age and sex), indication for operation, procedure performed, height of anastomosis, leak rate and the outcome, inpatient stay, mortality, rate of defunctioning stomas, and rate of conversion to open procedure. Results: Eighty-four patients (49 females, 35 males; median age 70 years, range 19-89 years) underwent colonic procedures with left-sided intracorporeal stapled anastomosis. An intra-operative air leak was evident in one patient, whose anastomosis was oversewn intracorporeally and defunctioned by ileostomy. There were only two clinically evident anastomotic leaks post-operatively (2.9%). One patient died of overwhelming sepsis within 48h of re-operation: Seven patients (8.3%) had a primary defunctioning stoma, with two further stomas formed due to anastomotic leakage. Five cases (6%) were converted to open surgery. The median post-operative stay was six days, range 2-23. Thirty-day mortality was 50% in the leak group and 0% in the non-leak group. Conclusion: We believe that this study demonstrates that the anastomotic leak rate from intra-corporeal laparoscopic anastomosis is no greater than for open surgery or laparoscopic surgery with extra-corporeal anastomosis.

Endoscopic repair of groin hernias allows the surgeon to have a complete view of the groin and pelvis to diagnose occult hernias both ipsilaterally and contralaterally. These occult hernias can then be treated simultaneously and may reduce the incidence of recurrence and persistent symptoms. The authors present four unusual cases where occult hernias were found ipsilaterally during an endoscopic repair. All these occult hernias were treated along with the clinically diagnosed hernia at the same surgery with excellent results and no post-operative morbidity.

Vascular abnormalities are uncommon causes of uterine bleeding. Laparoscopic surgeries, however, require expertise and improper techniques can lead to major vascular complications. We report an unusual case of utero-adenexal arterio- venous fistula with arterio - venous malformation due to pelvic trauma caused during laparoscopic sterilisation procedure, which was treated by percutaneous embolisation technique. To the best of our knowledge, this is the first documentation of such a complex vascular injury caused by laparoscopic sterilisation and its endovascular management

Laparoscopic cholecystectomy is the gold standard method for treating gallstone related disease. Despite its widespread and well established application, clear consensus is not arrived at regarding the comparative risks and benefits of acute versus interval cholecystectomy. The complications of this technique are well known, with respect to both the operative intervention and the technique used. This case describes a case of cholecystitis in a 76-year-old man, who underwent acute laparoscopic cholecystectomy for cholecystitis refractory to antibiotic therapy. Postoperative complications included subhepatic collections bilaterally, eventually leading to the formation of an enterocutaneous fistula to the left chest wall - a previously undocumented phenomenon. The protracted course of the disease is discussed, with reference to investigations performed and the eventual successful outcome.

Background: The creation of extraperitoneal space with the help of balloon is helpful in the learning curve of total extraperitoneal repair of inguinal hernia. But the cost of the balloon with other disposable items is one of the limiting factors in the popularity of this operation. By using a homemade balloon, nondispoasable ports and suturing the mesh we have been able to reduce the cost considerably. We would like to present our technique of making the balloon. Materials and Methods: Between September 2005 and November 2006 we operated 65 consecutive patients of inguinal hernia using the balloon made from the 'video camera drape'. The drape was cut and fixed on a 10 mm suction irrigation cannula. The suction irrigation cannula was used as an obturator as well to inflate the balloon in the extraperitoneal space.Results: We succeeded in creating the extraperitoneal space in all patients with the help of this balloon without any complications and conversion to open. There was no leak and bursting of the balloon. Conclusion: It is cheap, strong, sterile and readily available material for making the balloon for creating the extraperitoneal space in the laparoscopic repair of the inguinal hernia.