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Background: The critical view of safety (CVS) was incorporated into a novel 6-item objective procedure-specific assessment for laparoscopic cholecystectomy (LC-CVS OPSA) to enhance focus on safe completion of surgical tasks and advance the American Board of Surgery’s entrustable professional activities (EPAs) initiative. To enhance instrument development, a feasibility study was performed to elucidate expert surgeon perspectives regarding “safe” vs. “unsafe” practice. Methods: A multi-national consortium of 11 expert LC surgeons were asked to apply the LC-CVS OPSA to ten LC videos of varying surgical difficulty using a “safe” vs. “unsafe” scale. Raters were asked to provide written rationale for all “unsafe” ratings and invited to provide additional feedback regarding instrument clarity. A qualitative analysis was performed on written responses to extract major themes. Results: Of the 660 ratings, 238 were scored as “unsafe” with substantial variation in distribution across tasks and raters. Analysis of the comments revealed three major categories of “unsafe” ratings: (a) inability to achieve the critical view of safety (intended outcome), (b) safe task completion but less than optimal surgical technique, and (c) safe task completion but risk for potential future complication. Analysis of reviewer comments also identified the potential for safe surgical practice even when CVS was not achieved, either due to unusual anatomy or severe pathology preventing safe visualization. Based upon findings, modifications to the instructions to raters for the LC-CVS OPSA were incorporated to enhance instrument reliability. Conclusions: A safety-based LC-CVS OPSA has the potential to significantly improve surgical training by incorporating CVS formally into learner assessment. This study documents the perspectives of expert biliary tract surgeons regarding clear identification and documentation of unsafe surgical practice for LC-CVS and enables the development of training materials to improve instrument reliability. Learnings from the study have been incorporated into rater instructions to enhance instrument reliability.

Background: A novel 6-item objective, procedure-specific assessment for laparoscopic cholecystectomy incorporating the critical view of safety (LC-CVS OPSA) was developed to support trainee formative and summative assessments. The LC-CVS OPSA included two retraction items (fundus and infundibulum retraction) and four CVS items (hepatocystic triangle visualization, gallbladder-liver separation, cystic artery identification, and cystic duct identification). The scoring rubric for retraction consisted of poor (frequently outside of defined range), adequate (minimally outside of defined range) and excellent (consistently inside defined range) and for CVS items were “poor—unsafe”, “adequate—safe”, or “excellent—safe”. Methods: A multi-national consortium of 12 expert LC surgeons applied the OPSA—LC CVS to 35 unique LC videos and one duplicate video. Primary outcome measure was inter-rater reliability as measured by Gwet’s AC2, a weighted measure that adjusts for scales with high probability of random agreement. Analysis of the inter-rater reliability was conducted on a collapsed dichotomous scoring rubric of “poor—unsafe” vs. “adequate/excellent—safe”. Results: Inter-rater reliability was high for all six items ranging from 0.76 (hepatocystic triangle visualization) to 0.86 (cystic duct identification). Intra-rater reliability for the single duplicate video was substantially higher across the six items ranging from 0.91 to 1.00. Conclusions: The novel 6-item OPSA LC CVS demonstrated high inter-rater reliability when tested with a multi-national consortium of LC expert surgeons. This brief instrument focused on safe surgical practice was designed to support the implementation of entrustable professional activities into busy surgical training programs. Instrument use coupled with video-based assessments creates novel datasets with the potential for artificial intelligence development including computer vision to drive assessment automation. Graphical abstract:

The incidence of food allergy in children of south Asian heritage in the UK is increasing, but little is known about families' understanding or help-seeking. The aim of this study was to explore the experiences of mothers from the south Asian community with regard to recognising and seeking help for their child's food allergy. The study method comprised semi-structured interviews with 10 mothers with a child under 5 years with known or suspected food allergy. Interviews were audio-recorded, translated, transcribed and thematically analysed. The study found that there was uncertainty about the cause of the child's symptoms and delays in seeking medical advice. Few parents had talked to health visitors about allergy, although recognised their preventive role. In conclusion, infants from south Asian backgrounds with food allergies face inequalities in health and access to specialist services, and health visitors are missing opportunities to intervene early and promote the delivery of evidence-based care.

Background: Revisional bariatric surgery (RBS) constitutes a possible solution for patients who experience an inadequate response following bariatric surgery or significant weight regain following an initial satisfactory response. This paper reports results from the first modified Delphi consensus-building exercise on RBS. Methods: We created a committee of 22 recognised opinion-makers with a special interest in RBS. The committee invited 70 RBS experts from 27 countries to vote on 39 statements concerning RBS. An agreement amongst ≥ 70.0% experts was regarded as a consensus. Results: Seventy experts from twenty-seven countries took part. There was a consensus that the decision for RBS should be individualised (100.0%) and multi-disciplinary (92.8%). Experts recommended a preoperative nutritional (95.7%) and psychological evaluation (85.7%), endoscopy (97.1%), and a contrast series (94.3%). Experts agreed that Roux-Y gastric bypass (RYGB) (94.3%), One anastomosis gastric bypass (OAGB) (82.8%), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) (71.4%) were acceptable RBS options after gastric banding (84.3%). OAGB (84.3%), bilio-pancreatic diversion/duodenal switch (BPD/DS) (81.4%), and SADI-S (88.5%) were agreed as consensus RBS options after sleeve gastrectomy. lengthening of bilio-pancreatic limb was the only consensus RBS option after RYGB (94.3%) and OAGB (72.8%). Conclusion: Experts achieved consensus on a number of aspects of RBS. Though expert opinion can only be regarded as low-quality evidence, the findings of this exercise should help improve the outcomes of RBS while we develop robust evidence to inform future practice.

Abstract: In 2014 the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias”. Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. Methods: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Results: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Conclusion: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

In 2014, the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.” Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

This article was updated to include the middle initial of author L. N. Jorgensen’s name.

We present our experience with 10 patients with infected meshes after laparoscopic inguinal hernia repair in whom we explanted infected meshes laparoscopically.

Guidelines are increasingly determining the decision process in day-to-day clinical work. Guidelines describe the current best possible standard in diagnostics and therapy. They should be developed by an international panel of experts, whereby alongside individual experience, above all, the results of comparative studies are decisive. According to the results of high-ranking scientific studies published in peer-reviewed journals, statements and recommendations are formulated, and these are graded strictly according to the criteria of evidence-based medicine. Guidelines can therefore be valuable in helping particularly the young surgeon in his or her day-to-day work to find the best decision for the patient when confronted with a wide and confusing range of options. However, even experienced surgeons benefit because by virtue of a heavy workload and commitment, they often find it difficult to keep up with the ever-increasing published literature. All guidelines require regular updating, usually every 3 years, in line with progress in the field. The current Guidelines focus on technique and perioperative management of laparoscopic ventral hernia repair and constitute the first comprehensive guidelines on this topic. In this issue of Surgical Endoscopy,the first part of the Guidelines is published including sections on basics, indication for surgery, perioperative management, and key points of technique. The next part (Part 2) of the Guidelines will address complications and comparisons between open and laparoscopic techniques. Part 3 will cover mesh technology, hernia prophylaxis, technique-related issues, new technologic developments, lumbar and other unusual hernias, and training/education.

Abstract: Background: Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder. Methods: We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper’s ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh. Results: Mean diameter of the hernial defect was 5.2 cm (range = 3.1–7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm2 (range = 225–506 cm2). Mean operating time was 116 min (range = 64–170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range = 1.2–6.9 years) and a follow-up rate of 84.7% Conclusion: A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper’s ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.

Abstract: Background: The purported advantage of lightweight large-pore meshes is improved biocompatibility that translates into lesser postoperative pain and earlier rehabilitation. However, there are concerns of increased hernia recurrence rate. We undertook a prospective randomized clinical trial to compare early and late outcome measures with the use of a lightweight (Ultrapro) mesh and heavyweight (Prolene) mesh in endoscopic totally extraperitoneal (TEP) groin hernia repair. Methods: A prospective study was performed on 402 patients (191 in Ultrapro and 211 in Prolene group) with bilateral groin hernias who underwent endoscopic TEP groin hernia repair from March 2006 to June 2007. All operations were performed by five consultants following a standardized operative protocol. Chronic groin pain and hernia recurrence were evaluated as primary outcome measures. Secondary outcome measure were early postoperative pain, operative time, number of fixation devices required to fix the mesh, return to normal daily activities of work, seroma, and testicular pain. Results: At 1-year follow-up, incidence in Ultrapro versus Prolene group for chronic groin pain was 1.6% vs. 4.7% (p = 0.178) and recurrence was 1.3% vs. 0.2% (p = 0.078). In Ultrapro versus Prolene group, mean visual analogue score for postoperative pain at day 7 was 1.07 vs. 1.31 (p = 0.00), mean return to normal activities was 1.82 vs. 2.09 days (p = 0.00), and mean number of fixation devices per patient required to fix the mesh was 4.22 vs. 4.08 (p = 0.043). Conclusion: Lightweight meshes appear to have advantages in terms of lesser pain and early return to normal activity. However, more patients had hernia recurrence with lightweight meshes, especially for larger hernias. We surmise that the lightweight meshes have greater tendency to get displaced from their intended position during desufflation at the conclusion of endoscopic TEP repair.

Often coexisting in developing countries with under‐nutrition, obesity is a complex condition, with serious medical, social, psychological and economic implications1. This has led to the dual burden of fighting against both under and over‐nutrition. It is widely recognized today that bariatric surgery is the only safe and effective approach to treatment of morbid obesity5. This article discusses the scope, evolution and current status of Bariatric Surgery in Asia

To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction.

Laparoscopic cholecystectomy is the current gold standard for the management of cholelithiasis. As experience with laparoscopic cholecystectomy has increased, contraindications to the procedure have started decreasing. Kyphoscoliosis with fixed rigidity is considered as a relative contraindication to laparoscopic surgery. Ankylosing spondylitis is a challenge to the anaesthesiologist because it is associated with difficult intubation, restrictive ventilatory defects, and frequent cardiac involvement. The benefits of laparoscopic surgery can be extended to this group of patients with severe kyphoscoliosis due to advances in anesthesia and surgical expertise. We report a case of laparoscopic cholecystectomy performed in a patient with severe ankylosing spondylitis with fixed rigidity of the cervical spine and marked thoracolumbar kyphosis with severe restrictive lung disease. The purpose of this report is to describe the difficulties encountered in anesthesia and operative difficulties due to altered body habitus in terms of patient positioning and surgical access.

Abstract Hepaticojejunostomy is performed to reestablish bilioenteric continuity. During a 5-year period between July 1998 and July 2003, the authors attempted hepaticojejunostomy by a total laparoscopic approach in 10 patients with benign stricture disorders of the extrahepatic biliary tree. Six of these patients had type 1 (extrahepatic, fusiform) choledochal cyst and presented with pain, fever, and jaundice. Four of the patients had iatrogenic biliary strictures after cholecystectomy (2 patients after laparoscopic cholecystectomy and 2 patients after open cholecystectomy). These patients had a variable presentation 1 to 3 weeks after the primary procedure, with peritonitis and/or cholangitis or only progressive jaundice. For nine of the patients (90%), the procedure was completed entirely laparoscopically. The mean operative time was 326.6 min for the patients with choledochal cysts and 268 min for the patients with iatrogenic strictures. One patient with stricture after open cholecystectomy underwent conversion to an open repair because of severe anatomic distortion and fibrosis. Four patients drained bile postoperatively for 5 to 7 days. One patient with iatrogenic biliary stricture after open cholecystectomy required open revision of the anastomosis 18 months after laparoscopic hepaticojejunostomy because of recurrent cholangitis. The remaining eight patients (80%) were doing well a mean follow-up period of 3.1 years (range, 3 months to 5 years). Total laparoscopic hepaticojejunostomy is feasible for a select group of patients, but requires advanced laparoscopic skills, including intracorporeal suturing. It must be attempted only in centers well versed in advanced laparoscopic surgery.

Intraoperatively, it may be prudent at times to abandon or defer the intended therapeutic procedure due to adverse prevailing conditions. A decision to abandon or defer an endoscopic procedure would necessarily result in less morbidity compared with conventional open surgery. A retrospective review of endoscopic procedures that were abandoned or deferred and subsequent patient outcomes were noted. Between January 1998 to May 2003, 48 procedures out of a total of 11,550 endoscopic surgical procedures had to be abandoned. Previously unsuspected intraabdominal malignancy was the cause in 32 patients. Anesthesia-related problems led to the decision in 6 patients. Coincidental tuberculosis and failure in accessing the target organ were the cause in two patients each. An ectopic gallbladder, an absent gallbladder, a pancreatic phlegmon, and a failure to achieve proper single-lung ventilation led to the decision in one patient each. In two patients, presence of dense intraabdominal adhesions that precluded further progress led the surgeon to abandon the surgery. The patients with intraabdominal malignancy were staged for their disease and treated accordingly. Nine patients without malignancy who had their operation deferred due to diverse reasons were operated on a later date, whereas 4 patients were lost to follow-up. The 9 patients who underwent operation at a later date are well on follow-up. Four patients with intraabdominal malignancy died, whereas the others are well in follow-up after being treated according to the stage of their disease. Certain adverse situation encountered intraoperatively may lead the surgeon to change the approach to surgery and abandon the procedure. He may consider operation at a suitable time later or consider a different treatment altogether. The morbidity consequent to such a decision is much less if the operative approach is an endoscopic one.

With advancements in minimal access surgery, combined laparoscopic procedures are now being performed for treating coexisting abdominal pathologies at the same surgery. In our center, we performed 145 combined surgical procedures from January 1999 to December 2002. Of the 145 procedures, 130 were combined laparoscopic/endoscopic procedures and 15 were open procedures combined with endoscopic procedures. The combination included laparoscopic cholecystectomy, various hernia repairs, and gynecological procedures like hysterectomy, salpingectomy, ovarian cystectomy, tubal ligation, urological procedures, fundoplication, splenectomy, hemicolectomy, and cystogastrostomy. In the same period, 40 patients who had undergone laparoscopic cholecystectomy and 40 patients who had undergone ventral hernia repair were randomly selected for comparison of intraoperative outcomes with a combined procedure group. All the combined surgical procedures were performed successfully. The most common procedure was laparoscopic cholecystectomy with another endoscopic procedure in 129 patients. The mean operative time was 100 minutes (range 30–280 minutes.). The longest time was taken for the patient who had undergone laparoscopic splenectomy with renal transplant (280 minutes). The mean hospital stay was 3.2 days (range 1–21 days). The pain experienced in the postoperative period measured on the visual analogue scale ranged from 2 to 5 with a mean of 3.1. Of 145 patients who underwent combined surgical procedures, 5 patients developed fever in the immediate postoperative period, 7 patients had port site hematoma, 5 patients developed wound sepsis, and 10 patients had urinary retention. As long as the basic surgical principles and indications for combined procedures are adhered to, more patients with concomitant pathologies can enjoy the benefit of minimal access surgery. Minimal access surgery is feasible and appears to have several advantages in simultaneous management of two different coexisting pathologies without significant addition in postoperative morbidity and hospital stay.

We performed a prospective study to evaluate the feasibility of performing endoscopic total extraperitoneal repair of groin hernia TEP under epidural anesthesia in selected patients considered to be at high risk or unfit for general anesthesia. Fiftyeight endoscopic total extraperitoneal hernia repairs were performed in 36 patients between January 1997 and December 1999 under epidural anesthesia since they were considered a high risk or unfit for general anesthesia. All patients received intramuscular diclofenac sodium for preemptive analgesia. Intraoperatively, all were sedated with intravenous midazolam and fentanyl. Endoscopic TEP repair was successful under epidural anesthesia in 33 of 36 patients. In the remaining three patients, the procedure had to be converted to Lichtenstein's repair due to shoulder discomfort experienced by the patients as a result of pneumoperitoneum, which was produced by incidental peritoneal tears during extraperitoneal dissection. Intraoperatively, one patient had bleeding from the inferior epigastric artery, which was controlled with clipping of the artery. The mean operative time was 48 minutes range, 2872 minutes in the TEP group and 94 minutes range, 84102 minutes in the converted group. All the patients received an epidural topup dose at the end of surgery for postoperative analgesia. All patients were ambulatory the same day. Postoperative pain was assessed by a visual analogue scale VAS. The mean pain score was 1.2 ± 0.8 on discharge in the TEP group. During followup, seven patients developed scrotal swelling with cord induration, which was treated conservatively with scrotal support and analgesics. In all patients, resolution was observed within 6 weeks. One patient was detected to have a recurrence 4 months after surgery. Endoscopic TEP repair under epidural anesthesia appears to be safe, technically feasible, and an acceptable alternative in patients who are at high risk or unfit for general anesthesia.

Laparoscopic repair of ventral abdominal wall hernias involves intraperitoneal placement of a mesh, which may lead to adhesion formation and bowel fistulation. The first series of selected patients with ventral abdominal wall hernias treated laparoscopically by extraperitoneal placement of a polypropylene mesh is presented. Thirty-four patients (24 women and 10 men; median age, 52 years range, 34–70) were selected from among 122 patients undergoing laparoscopic ventral hernia repair. Of these patients, 18 had a primary ventral abdominal wall hernia and 16 had an incisional hernia. After reduction of sac contents and adhesiolysis intraperitoneally, a large flap of peritoneum (with extraperitoneal fat, fascia, and posterior rectus sheath where present) was raised to accommodate a suitably sized polypropylene mesh, which was then covered again with the peritoneal flap at the end of the procedure. Intraoperatively, apart from circumcision of the hernial sac at the neck, a total of 24 iatrogenic peritoneal tears occurred in 20 patients, mainly at the site of the previous scar. In two patients, it was observed that greater than 25 of the mesh was exposed after the procedure. The median (±SD) duration of hospitalization postoperatively was 1 day (±0.56). One patient's hernia recurred 4 months after surgery, and one patient's infected mesh was removed 8 months after surgery. Laparoscopic extraperitoneal placement of a mesh is feasible and appears to be an advance over laparoscopic intraperitoneal mesh placement for ventral abdominal wall hernias in selected patients. However, longer follow-up and controlled clinical trials will be necessary before any firm conclusions can be drawn.

Laparoscopic reintervention is being increasingly performed in patients who have previously undergone surgery for gallstone disease. A few patients with gallbladder remnants or a cystic duct stump with residual stones have recurrent symptoms of biliary disease. Patients with bile duct injuries were excluded from the study. We reviewed our experience in treating such patients over a 4-year period, January 1998 through December 2001. Five patients underwent laparoscopic reintervention after previous surgery for gallstone disease performed elsewhere during the period mentioned above. Of these 5 patients, 3 had impacted stones in gallbladder remnants (laparoscopic cholecystectomy, 2; open cholecystectomy, 1) and 2 had recurrent symptoms after cholecystolithotomy and tube cholecystostomy (conventional surgery) performed elsewhere. Laparoscopic excision of the gall bladder remnants was done in 3 patients and a formal laparoscopic cholecystectomy was done in 2 patients who had previously undergone cholecystolithotomy and tube cholecystostomy. The mean operating time was 42 minutes. No drainage was required postoperatively. All patients were symptom-free during a mean follow-up of 2.3 years (range, 7 months to 4 years). Reintervention may be required for patients with residual gallstones whose symptoms recur after gallbladder surgery such as cholecystectomy, subtotal cholecystectomy, and tube cholecystostomy. It is safe and feasible to remove the gallbladder or gallbladder remnants in such patients laparoscopically.

Paravertebral and paraspinal tumors in the posterior mediastinum are predominantly neurogenic in origin. The treatment comprises surgical extirpation. We report a case of a 40-year-old man with a 2-month history of pain epigastrium, radiating to the left scapula, and marked (10 kg) weight loss. Preoperative CT scan showed a paraspinal mass 8 cm in diameter at the level of the tenth thoracic vertebra. A CT scan-guided fine-needle aspiration cytologic analysis revealed the mass to be of neurogenic origin. Transabdominal laparoscopic excision of this lower posterior mediastinal neurogenic tumor was attempted and accomplished safely. The approach was through the left crural fibers, which were split to access the lower posterior mediastinum. Operating time was 122 minutes. Postoperatively, a left intercostal drain was inserted. The patient was discharged on the third postoperative day, after intercostal drain removal. Lower posterior mediastinal paraspinal tumors can be resected laparoscopically with careful preoperative investigation for tumor localization and a meticulous laparoscopic technique. A major advantage of transabdominal laparoscopic resection, as compared with open or thoracoscopic (VATS) excision, is that the patient recovers rapidly with minimal operative and anesthetic morbidity.

Mirizzi syndrome is a rare complication of long-standing gallstone disease resulting in obstructive jaundice. Careful perioperative management is of utmost importance because of an increased risk of bile duct injury intraoperatively. Experience with Mirizzi syndrome over a period of 3 years, from January 1996 to December 1998, was reviewed. Twenty-seven patients were operated upon, which constituted 0.9 of 2840 patients who underwent laparoscopic cholecystectomy in the authors' department. There were 12 patients with Mirizzi type I syndrome and 15 patients with Mirizzi type II syndrome, according to McSherry classification. Six (22) conversions were reported, all because of unclear anatomy and inherent limitations of the laparoscopic approach. For the remaining 21 (78) patients, the procedure was completed laparoscopically. No bilioenteric anastomosis was required. A preoperative stent insertion in the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) enabled us to achieve primary closure of CBD in every case. There was no perioperative mortality, and patients remained well for an average 2.1-year follow-up. It is highly desirable to have a preoperative diagnosis of Mirizzi syndrome, and the laparoscopic approach is not a contraindication in specialized centers. Our current management protocol to treat Mirizzi syndrome consists of a high degree of suspicion at ERCP, with stenting preoperatively and a complete stone clearance with subtotal cholecystectomy intraoperatively.

Of the various traumatic injuries associated with blunt abdominal trauma, traumatic hernias form a rare and small group. We present a case report of a hernia in the psoas muscle in a 26-year-old lady diagnosed during extraperitoneal repair for inguinal hernia. The hernia was managed laparoscopically by reduction of contents and mesh placement over the defect. This is the first such case reported in the literature till date.

An unusual case of ectopic retroplaced gall bladder is reported. In our patient, this congenital anomaly was detected on ultrasonography and confirmed by CT scan, MRCP, and ERCP. Laparoscopic cholecystectomy was performed without complications. The importance of proper preoperative investigations is emphasized for accurate diagnosis, to rule out biliary tract anomalies, and to properly plan surgical approach and management.

Mesh migration after laparoscopic inguinal hernia repair is an unusual complication. We report a case of a 45-year-old man with persistent discharging of abdominal wall sinus after total extraperitoneal inguinal hernia repair. The patient underwent exploration and excision of the sinus tract with removal of the embedded mesh. A part of the mesh had migrated into the urinary bladder. Partial cystectomy with excision of wall containing the mesh was performed.