Journal of Minimal Access Surgery最新文献

Abstract: We report two cases of successful oesophageal diverticulectomy through uniportal video-assisted thoracoscopic surgery (VATS). In both cases, a chest computed tomography showed huge mid-oesophageal diverticulum. Gastrointestinal endoscopy confirmed a diverticulum on the right wall. Surgical treatment through uniportal VATS was planned and performed successfully. We recommend that uniportal VATS could be a feasible method for oesophageal diverticulectomy.

Introduction: Conventional umbilical access can be time-consuming, surgically challenging due to inadequate 'Critical View of Safety' and pneumoperitoneum maintenance for high body mass index (BMI) patients undergoing laparoscopic cholecystectomy (LC). The aim of the study is to assess the feasibility, safety and outcome of our modified access for patients of BMI ≥30.

Patients and methods: A prospective study of 1762 consecutive patients undergoing LC in a large district general hospital (2007-2023) that included age, sex, BMI, American Society of Anesthesiologists (ASA), grade of operation with stay and complications were analysed. Group A: Veress needle pneumoperitoneum through Palmer's point. After 2 L (minimum) insufflations, an optical port was introduced at the intersection of two imaginary lines: A 15-cm oblique line starting from where the right mid-clavicular line cuts the right lower costal margin and directed medially meeting the other vertical line running 3 cm to the right of midline. Remaining 3 ports at standard positions (10 mm epigastric port [I] at or just right of midline below the xiphoid process, 5 mm port [II] at the midclavicular line below the costal cartilage and another 5 mm port [III] between 5 cm and 10 cm lateral to port II) as used in LC. Group B (BMI <30): Conventional umbilicus entry followed by 3 standard remaining ports for LC (as above).

Results: Group A: 549 with female: male 4:1, the median of age 49 (16-83) years, BMI 36 (30-65), ASA 2 (1-3), Grade 1 (1-4), operating time 50 (15-200) min and post-operative (PO) stay 0 (0-15) day. One conversion, 2 bile leaks, 5 collections and 4 wound infections. Group B: 1213 with female: male 3:1, the median of age 53 (16-89) years, BMI 26 (17-29), ASA 2 (1-3), Grade 1 (1-4), operating time 45 (15-240) min and PO stay 0 (0-12) day.

Conclusion: Our modified abdominal access is quick and safe that maintains sustained pneumoperitoneum and provides an excellent 'Critical view of Safety' for obese patients undergoing LC with a good outcome.

Abstract: Inverted appendicitis is a rare surgical event, which mostly leads to the wrong pre-operative diagnosis. Nevertheless, the therapy is usually correct. In case of clinical acute appendicitis, we usually proceed to surgery without further examinations. We report about a 65-year-old woman who presented with abdominal pain for 4 days and typical pain at the McBurney's point. Blood examination showed only a slight elevation of the C-reactive protein with 4.62 mg/dl. The ultrasound strengthened the suspicion of acute appendicitis. Laparoscopy was performed, and a severe purulent pericaecal infection was detected, but the appendix was absent. However, the caecum had typical palpatory aspects of cancer. Consequently, we converted to laparotomy and performed a radical right hemicolectomy. The pathology report revealed the inverted appendicitis without any signs of malignancy. It remains difficult to make the correct pre-operative diagnosis. The type of treatment has to be chosen individually.

Objective: The objective of the study was to explore the feasibility of ordinary laparoscopic instruments for completing laparoscopic intragastric resection of mass near the cardia and pylorus without endoscopic assistance.

Patients and methods: From March 2018 to October 2022, laparoscopic intragastric resection was performed to remove submucosal masses near the cardia (7 cases) and antrum (3 cases) that were difficult to remove under gastroscopy. The diameter of the tumour is 1.0-4.0 cm, with an average of 2.75 cm. The results showed that all 10 cases underwent surgery smoothly, with a surgical time of 66-134 min, an average of 97.6 min, intraoperative bleeding of 10-30 mL, an average of 18 mL and post-operative hospitalisation of 3-7 days, an average of 4.3 days. No complications were occurred.

Conclusion: It is safe and feasible to complete transabdominal and transgastric resection of gastric masses using ordinary laparoscopic instruments without the assistance of endoscopy.

Abstract: Traumatic diaphragmatic hernia (TDH) is a rare acquired condition usually occurring due to blunt thoracoabdominal trauma, most commonly in road traffic accidents (RTAs). It may also occur due to penetrating trauma. Diagnosis may be delayed due to the masking effect of other severe injuries in a patient with polytrauma. Here, we present the case of a 23-year-old male patient having a history of thoracoabdominal injury due to RTA before 3 months, presenting with severe vomiting, respiratory discomfort and weight loss. He was treated at other places symptomatically for gastritis and flatulence. He was diagnosed with gastric outlet obstruction due to left-sided TDH. He was successfully treated with laparoscopic repair and mesh placement. He needed thoracotomy for left lung decortication in post-operative period owing to persistent pleural effusion and lung collapse. He recovered well and remains asymptomatic on follow-up. Upon asking detailed history, he remembered that he had trauma following being struck by a vehicle. We aim to present this case to highlight the importance of detailed history taking for arriving at a timely diagnosis.

Introduction: Bariatric surgery (BS) is the most effective treatment for morbid obesity. Despite a high number of BS performed in India, there is limited research on post-operative nutritional follow-up. The study aimed to assess patient compliance and adequacy of nutritional supplementation protocols in the post-operative period.

Patients and methods: This prospective, single-centre observational study (August 2022-July 2023) assessed post-operative nutritional status in the Indian patients undergoing BS. Baseline and follow-up nutritional assessments (serum albumin, ferritin, B12, calcium and D3) were performed, and patients were given a supplementation regimen based on the American Society for Metabolic and BS guidelines. Compliance with prescribed supplementation was monitored. Patients were considered compliant if they took ≥80% of the prescribed doses.

Results: The study involved 32 patients, with 65.6% (21) undergoing sleeve gastrectomy and 34.4% (11) undergoing Roux-en-Y gastric bypass. Over 6 months, the mean body mass index decreased from 47 to 36.1 kg/m2. Compliance rates for supplementation varied, with high rates for iron (96.9%) but lower rates for protein (28.1%) and Vitamin B12 (43.7%). However, compliance with supplements did not statistically affect deficiencies for most nutrients, except for Vitamin B12. After 6 months post-surgery, Vitamin B12 deficiency was significantly higher in non-compliant patients than in compliant ones (50% vs. 0%, P = 0.001).

Conclusion: This study suggests that the prescribed supplements are adequate in maintaining nutrient levels post-surgery. Compliance is particularly important in preventing Vitamin B12 deficiency, as non-compliant patients tend to show persistent deficiency. The level of other nutrients improved regardless of compliance.

Introduction: Umbilical hernias are a frequent subset of ventral hernias. Although laparoscopic intraperitoneal onlay mesh with defect closure (IPOM-plus) repair is widely used, concerns remain about mesh contact with viscera and associated pain. The transabdominal pre-peritoneal with defect closure for umbilical hernias (TAPPu-plus, where 'u' denotes umbilical) approach attempts to mitigate such complications by placing the mesh in a pre-peritoneal pocket. This study compares the feasibility, operative time, post-operative pain, hospital stay and recurrence rates between TAPPu-plus and IPOM-plus techniques for small-sized (≤4 cm) umbilical hernias.

Patients and methods: A prospective, single-centre randomised controlled trial was conducted on 50 symptomatic patients with primary umbilical hernias measuring ≤4 cm. Patients were randomised in a 1:1 ratio into Group A (TAPPu-plus, n = 25) or Group B (IPOM-plus, n = 25) using block randomisation with sealed opaque envelopes. Mesh repair was performed in all patients. The primary outcome was procedural feasibility. Secondary outcomes included operative time, estimated blood loss, post-operative pain visual analogue scale, analgesic use, hospital stay and 1-year recurrence.

Results: All procedures were completed laparoscopically. Two patients in the TAPPu-plus group were converted to IPOM-plus due to restricted dissection space, resulting in 23 patients in Group A and 27 in Group B for final analysis. TAPPu-plus was associated with a longer operative time (117.3 ± 14.9 min vs. 80.5 ± 19.7 min), but significantly lower post-operative pain scores throughout follow-up. Estimated intraoperative blood loss was lower in the TAPPu-plus group (mean 1.68 vs. 2.55 soaked gauze pieces [6 cm × 6 cm]; P < 0.01). The mean hospital stay was also shorter in the TAPPu-plus group (5.4 vs. 6.9 days, P < 0.01). No recurrences were observed in either group at 1-year follow-up.

Conclusion: Both techniques were safe and effective for laparoscopic repair of small umbilical hernias. TAPPu-plus, although more technically demanding, demonstrated superior outcomes in post-operative pain control and recovery. It represents a promising alternative to IPOM-plus in appropriately selected patients when performed by experienced surgeons.

Abstract: Brunner's gland hyperplasia (also referred to as adenoma or hamartoma) is a rare, benign proliferative lesion of the duodenum. Although often asymptomatic, it can occasionally present with gastrointestinal (GI) bleeding, anaemia or obstructive symptoms. We report a case of a 65-year-old woman who presented with melena and symptomatic anaemia. Upper GI (UGI) endoscopy revealed multiple sessile polyps in the duodenum, with the largest measuring 2 cm. Given her history of a recent myocardial infarction and ongoing antiplatelet therapy, an endoscopic approach was chosen. Endoscopic mucosal resection (EMR) was successfully performed after temporarily withholding antiplatelets. Histopathology confirmed Brunner's gland hamartoma with no dysplasia or malignancy. The patient's haemoglobin levels improved, and follow-up endoscopy at 1 and 6 months showed no recurrence. Brunner's gland hyperplasia is a rare but important differential for upper GI bleeding. EMR or endoscopic snare polypectomy is a safe and effective treatment modality, particularly in high-risk surgical candidates.

Abstract: Caecal volvulus is a rare complication in the post-operative period which if missed can result in fatal complications. We present our experience with a 50-year-old female with complex ventral hernia (L3L4 W2 as per European Hernia Society Classification) who underwent extended view totally extraperitoneal repair with unilateral transversus abdominis release and developed post-operative caecal volvulus with acute small intestinal obstruction. She was taken up for emergency surgery and underwent diagnostic laparoscopy with open right hemicolectomy and mesh explantation. Surgeons must be aware of the possibility of such a rare complication, the means of diagnosis and modalities of treatment available for the treatment of caecal volvulus.

Introduction: The pathogenesis of diverticular disease varies significantly and so does its clinical presentation. The procedure for left-sided diverticular disease is standardised, but there is still no consensus on the level of arterial ligation. In 2021, our group initiated the Diverticular Disease Registry (DDR) Trial, a multi-institutional registry on diverticular disease. The aim of this study is to analyse patients enrolled in the DDR who underwent elective laparoscopic sigmoidectomy to determine if different arterial ligations result in differences in bowel function.

Patients and methods: Patients enrolled in the DDR from June 2021 to January 2024 were reviewed. Inclusion criteria included elective sigmoidectomy for diverticular disease, reported pre-operative bowel preparation and availability of data on the level of the arterial section. Patients were grouped according to the level of artery ligation: the superior haemorrhoidal artery transection (SHA-T) group and the superior haemorrhoidal artery preservation (SHA-P) group.

Results: A total of 242 patients were enrolled at 8 hospitals. One hundred and ten patients were included in the analysis. Hospital stay was shorter although not significantly in the SHA-P group compared to the SHA-T group (5 ± 2 vs. 6 ± 1.5; P = 0.062). The first flatus occurred earlier in the SHA-P group, approaching the level of significance (1 ± 0.5 vs. 2 ± 0.8; P = 0.057). Bowel function restored significantly earlier in the SHA-P group (2 ± 0.4 vs. 3 ± 2.1; P = 0.041).

Conclusions: Our study reported improved bowel function in patients undergoing SHA preservation during elective sigmoidectomy for diverticular disease.