Background: Laparoscopic cruroplasty and fundoplication have become the gold standard in the treatment of hiatal hernia and gastro-oesophageal reflux disease (GERD). The use of a mesh-reinforcement of the cruroplasty has been proven effective; although, there is a lack of evidence considering which type of mesh is superior. The aim of this study was to compare recurrence rates after mesh reinforced cruroplasty using biological versus synthetic meshes. Methods: We performed a systematic review of all clinical trials published between January 2004 and September 2015 describing the application of a mesh in the hiatal hernia repair during Nissen fundoplication for both GERD and hiatal hernia. The primary outcome was the recurrence rate, and secondary outcomes were complication rate, mortality and symptomatic outcome. Results: We included 16 studies and extracted data regarding 1089 mesh operated patients of whom 385 received a biological mesh and 704 a synthetic mesh. The mean follow-up was 53.4 months. The recurrence rate in the synthetic mesh group was 6.8% compared to 16.1% in the biological mesh group (P < 0.05). The complication rate was 5.1% and 4.6% (P = 0.694), respectively, and there were 12 mesh-related complications. No mesh-related mortality was reported. Conclusion: Mesh reinforcement of hiatal hernia repair seems safe in the short-term follow-up. The available literature suggests no clear advantage of biological over synthetic meshes. Regarding cost-efficiency and short-term results, the use of synthetic nonabsorbable meshes might be advocated.

Background: This study performed a literature analysis to determine outcomes of laparoscopic management in Müllerian duct remnants (MDRs). Patients and Methods: Literature was searched for terms 'Müllerian' 'duct' 'remnants' and 'laparoscopy'. Primary end points were age at surgery, laparoscopic technique, intraoperative complications and postoperative morbidity. Results: The search revealed 10 articles (2003–2014) and included 23 patients with mean age of 1.5 years (0.5–18) at surgery. All patients were 46XY, n = 1 normal male karyotype with two cell lines. Explorative laparoscopy was performed in n = 2 and surgical management in n = 21. The 5-port technique was used in n = 10, 3-port in n = 9 and robot-assisted laparoscopic approach in n = 1 (n = 1 technique not described). Complete MDRs removal in n = 9, complete dissection and MDRs neck ligation with endoscopic loops in n = 11 and n = 1 uterus and cervix were split in the midline. After MDRs removal, there were n = 2 bilateral orchidopexy, n = 3 unilateral orchidopexy, n = 1 Fowler–Stephens stage-I and n = 1 orchiectomy. Mean operative time was 193 min (120–334), and there were no intraoperative complications. Mean follow-up was 20.5 months (3–54) and morbidity included 1 prostatic diverticula. There were 13 associations with hypospadias, of which 3 had mixed gonads and 3 bilateral cryptorchidism. Other associations were unilateral cryptorchidism and incarcerated inguinal hernia n = 1, right renal agenesis and left hydronephrosis n = 1 and n = 2 with transverse testicular ectopy. Conclusion: This MDRs analysis suggests that the laparoscopic approach is an effective and safe method of treatment as no intraoperative complication has reported, and there is low morbidity in the long-term follow-up.

Introduction: Single-incision laparoscopic cholecystectomy (SILC) is widely used as a treatment option for gallbladder disease. However, obesity has been considered a relative contraindication to this approach due to more advanced technical difficulties. The aim of this report was to review our experience with SILC to evaluate the impact of body mass index (BMI) on the surgical outcome. Patients and Methods: Between May 2009 and February 2013, 237 patients underwent SILC at our institute. Pre- and post-operative data of the 17 obese patients (O-group) (BMI ≥30 kg/m²) and 220 non-obese patients (NO-group) (BMI <29.9 kg/m²) were compared retrospectively. SILC was performed under general anaesthesia, using glove technique. Indications for surgery included benign gallbladder disease, except for emergent surgeries. Results: Mean age of patients was significantly higher in the NO-group than O-group (58.9 ± 13.5 years vs. 50.8 ± 14.0 years, P = 0.025). SILC was successfully completed in 233 patients (98.3%). Four patients (1.7%) in the NO-group required an additional port, and one patient was converted to an open procedure. The median operative time was 70 ± 25 min in the NO-group and 75.2 ± 18.3 min in the O-group. All complications were minor, except for one case in the NO-group that suffered with leakage of the cystic duct stump, for which endoscopic nasobiliary drainage was need. Conclusion: Our findings show that obesity, intended as a BMI ≥30 kg/m², does not have an adverse impact on the technical difficulty and post-operative outcomes of SILC. Obesity-related comorbidities did not increase the risks for SILC.

Objective: This study aims to investigate the feasibility of single-port video-assisted thoracoscope (SPVATS) in treating thoracic oesophageal squamous cell carcinoma (TESCC) using McKeown approach. Materials and Methods: Totally 10 McKeown approach-based SPVATS surgeries (8 males and 2 females, aged 42–68 years) were carried out from January 2015 to December 2015 to treat TESCC, including one case in upper thoracic segment, 5 cases in median thoracic segment and 4 cases in inferior thoracic segment. All the cases were pathologically diagnosed as SCC pre-operatively. SPVATS was performed to free thoracic oesophagus and dissect the lymph nodes, and laparoscopy was performed to free stomach and to perform oesophagus-left gastric collum anastomosis. Results: All the patients were successfully completed SPVATS, with average thoracic surgery time as 150 min, intra-operative blood loss as 30–260 ml (average 90 ml), and post-operative hospital stay as 9–16 days (average 12 days). Conclusions: SPVATS was technically feasible and safe in treating TESCC using McKeown approach, with less trauma and rapid post-operative recovery, and hence, it could be used as a new surgical option for McKeown approach-based TESCC treatment.

Aims: Even with the use of nerve-sparing techniques, there is a risk of bladder and sexual dysfunction after total mesorectal excision (TME). Laparoscopic TME is believed to improve this autonomic nerve dysfunction, but this is not demonstrated conclusively in the literature. In Indian patients generally, the stage at which the patients present is late and presumably the risk of autonomic nerve injury is more; however, there is no published data in this respect. Materials and Methods: This prospective study in male patients who underwent laparoscopic TME evaluated the bladder and sexual dysfunction using objective standardised scores, measuring residual urine and post-voided volume. The International Prostatic Symptom Score (IPSS) and International Index of Erectile Function score were used respectively to assess the bladder and sexual dysfunction preoperatively at 1, 3, 6 months and at 1 year. Results: Mean age of the study group was 58 years. After laparoscopic TME in male patients, the moderate to severe bladder dysfunction (IPSS <8) is observed in 20.4% of patients at 3 months, and at mean follow-up of 9.2 months, it was seen only in 2.9%. There is more bladder and sexual dysfunction in low rectal tumours compared to mid-rectal tumours. At 3 months, 75% had sexual dysfunction, 55% at median follow-up of the group at 9.2 months. Conclusion: After laparoscopic TME, bladder dysfunction is seen in one-fifth of the patients, which recovers in the next 6 months to 1 year. Sexual dysfunction is observed in 75% of patients immediately after TME which improves to 55% over 9.2 months.

Conventional open thyroidectomy is often associated with post-operative complications including nerve damage, voice disturbances, paraesthesias, adhesions and prominent scarring. Several endoscopic surgical techniques have been reported as alternatives to conventional thyroidectomy. Natural orifice transluminal endoscopic surgery is a promising approach which leaves no scar, produces few complications and affords faster discharge from care. Several studies have explored its utility in total thyroidectomy in patients with benign or malignant thyroid disease. Herein, we present a case series on the successful application of transoral endoscopic total thyroidectomy vestibular approach (TOETVA) in benign and malignant diseases of the thyroid. We performed TOETVA in 11 patients presenting with benign or malignant thyroid nodules in our hospital, between 1^st January 2015 and 30^th June 2016. The surgery was completed successfully in all patients with a pre-operative diagnosis of multinodular goitre. The surgery was performed under general anaesthesia and the mean operative time was 130 min. The mean blood loss was 2–3 cc. No incidence of recurrent laryngeal nerve injury, damage to mental nerve, parathyroid damage or peri-incisional adhesion occurred in the study participants. No visible scarring occurred in the patients following surgery. The patients had an uneventful recovery after the surgery and were discharged after 4 days. TOETVA is safe and effective in the surgical management of multinodular goitre and offers a scar-free alternative to conventional surgery.

Background: Laparoscopic hepatic bisegmentectomy (s4b and s5) with regional lymphadenectomy (LHBRL) for patients with gallbladder cancer (GBC) is rarely reported. Aims: The aim of the study was to describe the technique of LHBRL in patients with GBC and to present our initial experience. Patients and Methods: This retrospective study was conducted on twenty patients with GBC who were considered for LHBRL by the described technique. These patients either had a suspicion of GBC (SGBC) or had an incidental diagnosis of GBC (IGBC). Appropriate statistical methods were applied. Results: Twelve patients (60%) had SGBC and eight patients (40%) had IGBC. Eighteen patients (90%) were females and median age was 50 (range: 28–70) years. Median (range) surgical blood loss was 120 ml (80–400), operation time was 300 (200–480) min and hospital stay was 5.5 (2–10) days. No patient had iatrogenic complication during LHBRL. Five (25%) patients required conversion to open method. Four patients (20%) who developed complications were managed conservatively. All but three patients (25%) with SGBC had a benign disease on final biopsy. TNM stage of 17 patients (85%) with adenocarcinoma was T1bN0 in 3 (17.6%), T2N0 in 6 (35.3%), T3N0 in 2 (11.7%) and T1-3N1 in 6 (35.3%). The median lymph node count was 10 (range: 4–24) and resection margins were negative (R0) in all. The overall survival was 82.3%. During a median follow-up of 22 months, two patients died due to disease recurrence and one patient died due to myocardial infarction. Conclusion: The described technique of LHBRL is safe and feasible for patients with GBC without extrahepatic involvement.

Introduction: Laparoscopic management of giant hydatid cyst has limitations such as spillage, poor control, difficulties in suctioning the contents through special ports which are not easily available, difficulty in the obliteration of residual cavity and recurrence. We describe single-incision trocar-less endoscopic (SITE) technique which simplifies enucleation and management of residual cavity. Method: Inclusion criteria for these cases were patients having single uncomplicated giant hydatid cyst >5 cm present at the surface of the liver and palpable on clinical examination. The cysts which were <5 cm, multiple, deep-seated and impalpable were excluded from the study. Technique: An incision of 1 cm is marked over the site of the maximum bulge and deepened to open peritoneum, cyst is held with two stay sutures, injection of scolicidal agent and aspiration is done and suction of the cyst content is done. After suction of the contents, 5 mm telescope is inserted, and the cyst cavity is inspected, clearance and cyst procedure is done. Results: In 6 years, 62 cases of giant hydatid cyst fulfilling the inclusion criteria and were taken for SITE technique. SITE was successful in all patients and none needed a conversion. Twenty-nine (46.77%) underwent omentopexy and three (4.83%) underwent SITE capitonnage. There was post-operative biliary leak in one (0.016%) patient who underwent capitonnage, which was managed by prolonged drainage which resolved in 10 days. Mean operative duration was 52 min (30 min to 85 min). Mean follow-up was for 18 months (12–36 months). One (0.016%) patient had cyst recurrence. Discussion: SITE has advantages of endoscopic clearance and does not require special ports which are expensive, technically difficult to use and often unavailable. It allows controlled handling, effective suction and easier management of bile communication. SITE can be a preferred procedure for endoscopic management of giant liver hydatid cysts. Conclusion: SITE management of giant liver hydatid cyst seems to be a reliable treatment modality as it is minimally invasive, efficient, easy to perform and effective.

Purpose: Body mass index (BMI) may not be appropriate for different populations. Therefore, the World Health Organization (WHO) suggested 25 kg/m² as a measure of obesity for Asian populations. The purpose of this report was to compare the oncologic outcomes of laparoscopic colorectal resection with BMI classified from the WHO Asia-Pacific perspective. Patients and Methods: All patients underwent laparoscopic colorectal resection from September 2006 to March 2015 at a tertiary referral hospital. A total of 2408 patients were included and classified into four groups: underweight (n = 112, BMI <18.5 kg/m²), normal (n = 886, 18.5–22.9 kg/m²), pre-obese (n = 655, 23–24.9 kg/m²) and obese (n = 755, >25 kg/m²). Perioperative parameters and oncologic outcomes were analysed amongst groups. Results: Conversion rate was the highest in the underweight group (2.7%, P < 0.001), whereas the obese group had the fewest harvested lymph nodes (21.7, P < 0.001). Comparing oncologic outcomes except Stage IV, the underweight group was lowest for overall (P = 0.007) and cancer-specific survival (P = 0.002). The underweight group had the lowest proportion of national health insurance but the highest rate of medical care (P = 0.012). Conclusion: The obese group had the fewest harvested lymph nodes, whereas the underweight group had the highest estimated blood loss, conversion rate to open approaches and the poorest overall and cancer-specific survivals.

Introduction: This study aims to study the changing trends and outcomes associated with the adoption of minimally invasive distal pancreatectomy (MIDP) at a single centre. Materials and Methods: Retrospective review of sixty consecutive patients who underwent MIDP from September 2006 to November 2016 at a single institution. To study the evolution of MIDP, the study population was divided into three groups consisting of twenty patients (Group I, Group II and Group III). Results: Sixty patients underwent MIDP with 11 (18.3%) requiring open conversions. The median operation time was 305 (range: 85–775) min and the median post-operative stay was 6 (range: 3–73) days. Fifteen procedures were spleen-saving pancreatectomies. Major post-operative morbidity (>Grade 2) occurred in 12 (20.0%) patients and there was no mortality or reoperations. There were 33 (55.0%) pancreatic fistulas, of which 15 (25.0%) were Grade B fistulas of which 12 (20.0%) required percutaneous drainage. Comparison between the three groups demonstrated a statistically significant increase in the frequency of procedures performed, increase in robotic-assisted procedures and proportion of asymptomatic tumours resected. There also tended to be non-significant decrease in open conversion rates from 25% to 5% between the three groups and increase in tumour size resected from 24 to 40 mm. Conclusion: Comparison between the three groups demonstrated that MIDP was performed with increased frequency. There was a statistically significant increase in the frequency of resections performed for asymptomatic tumours and resections performed through robotic assistance. There was also a non-significant trend towards a decrease in open conversions and increase in the size of tumours resected.

Here, we report a case of repeated laparoscopic resection of extra-regional lymph node metastases in a patient after laparoscopic surgery for rectal cancer. A 72-year-old woman was diagnosed with upper rectal cancer and underwent laparoscopic low anterior resection and D3 dissection. The pathological stage was considered as T3, N2b, M0, Stage IIIC. Six months after the operation, positron emission tomography-computed tomography (PET-CT) showed fluorodeoxyglucose (FDG) accumulation in the infra-renal para-aortic lymph nodes (PALNs). Systemic chemotherapy was administered; however, chemotherapy was discontinued due to hemoptysis related to her pulmonary disease. Therefore, we performed laparoscopic PALN resection. Pathologically, one lymph node was diagnosed with a metastasis. Three months after the second operation, PET-CT identified FDG accumulation in the left lateral pelvic lymph nodes (LPLNs) and a PALN. Laparoscopic LPLN dissection and PALN resection through minilaparotomy were performed. Pathologically, lymph node metastases were diagnosed in both fields. Sixteen months after the 3^rd operation, there is no recurrence.

Curative endoscopic resection of non-ampullary duodenal lesions, although possible, is challenging. In recent years, although a novel surgical technique named laparoscopic-endoscopic cooperative surgery (LECS), which combines laparoscopic and endoscopic techniques, has made the resection of nonampullary duodenal lesions relatively easier, closure of the defect is still controversial. We report two cases of the duodenal lesion which were closed using a novel technique for primary closure utilising the free wall of the duodenum. Two cases of the duodenal lesion in the second portion of the duodenum were undergone full thickness resection using the LECS technique. The defect is designed spirally to ensure maximum use of the free wall of the duodenum. The mucosal layer is closed using a running suture, and the seromuscular layer is closed using interrupted sutures. The suture line is then reinforced with omentum. There were no intraoperative complications and had uneventful post-operative courses with no leakage, stenosis, or relapse.

Laparoscopic and robotic hernia surgery offers advantages over open herniorrhaphy including faster recover and lower wound infection but is associated with rare but serious complications such as visceral injury and intestinal obstruction. We describe two cases of small bowel obstruction with strangulation that occurred shortly after routine robotic hernia surgery. We define this rare type of strangulating internal hernia as a peritoneal pocket hernia and call attention to its diagnosis and management.

The incidence of idiopathic muscular hypertrophy of oesophagus (IMHE) is low, and <100 cases of IMHE have been reported. IMHE is a benign oesophageal disease, characterised by hyperplasia of all layers of the wall and in particular, muscle layer. Only a few cases have been reported regarding its clinical symptoms and images. In this present case, we report a cardia cancer with IMHE, showing significant hypertrophy of muscular layer of middle part of the oesophagus and successfully treated with minimally invasive thoracoscopic surgery.

A 63-year-old man with a history of a conventional cholecystectomy was referred to our department for an incisional subcostal hernia and chronic back pain. Physical examination also showed an umbilical hernia and diastasis recti measuring 6 cm that was confirmed with a computed tomography scan. Subcutaneous video-endoscopic repair was done repairing all defects simultaneously.

Laparoscopic sleeve gastrectomy (LSG) at present one of the most commonly performed surgical treatments for morbid obesity worldwide. There are some complications regarding this procedure in the literature. This report presents a patient who developed acute pancreatitis immediate post-LSG. Patient was referred to our institute on 10^th post-operative day with a complaint of fever, nausea, abdominal pain and leucocytosis. A diagnostic laparoscopy showed pancreatitis. Post-operatively, the patient was managed on treatment line of acute pancreatitis and recovered well. LSG is a common procedure in bariatric, and the most common complications are leakage and bleeding from the suture line. However, we encountered pancreatitis after LSG which is a rarely reported complication after LSG. We hypothesise that the development of acute pancreatitis in patients undergoing LSG is not well recognised and reported.

Introduction: Mesh fixation in laparoscopic ventral hernia is accomplished using tacks or tacks with transfascial sutures. This is a painful operation and the pain is believed to be more due to transfascial sutures. We describe a method of transfascial suturing which fixes the mesh securely and probably causes less pain. Method: Up to six ports may be necessary, three on each side. A suitable-sized mesh is used and fixed with tacks all around. A 20G spinal needle is passed from the skin through one corner of the mesh. A 0 prolene suture is passed through into the peritoneum. With the prolene within, the needle is withdrawn above the anterior rectus sheath and passed again at an angle into the abdomen just outside the mesh. A loop of prolene is thus created which is tied under vision using intra-corporeal knotting. Conclusion: This method gives a secure mesh fixation and causes less pain than conventional methods. This technique is easy to learn but needs expertise in intra-corporeal knotting.

Introduction: The use of laparoscopic surgery for liver resection and the management of abdominal emergencies has been well established. However, the value of this technique for post-operative haemorrhage in liver resection has not been characterized. Case Description: We describe a case of post-operative haemorrhage following an elective totally laparoscopic liver resection that was treated with emergency hand-assisted laparoscopic haemostasis. Discussion: Emergency hand-assisted laparoscopic haemostasis in the setting of post-operative haemorrhage after laparoscopic liver resection is feasible and should be considered as a treatment option in suitable patients.