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Peritoneal involvement represents one of the major difficulties that arise during the treatment of pancreatic adenocarcinoma. In fact, currently, there is a growing interest in the administration of intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC) as an adjunct to surgical pancreatic resection, both with prophylactic or therapeutic intent. With this video, we report a case of pancreatic body adenocarcinoma treated with fully laparoscopic distal splenic pancreatectomy with intraoperative HIPEC with gemcitabine, administered initially with a prophylactic intent, based on a preliminary negative peritoneal washing cytology result. In our case, the association of HIPEC and surgical resection did not affect the postoperative recovery, and after 15 months of follow-up, the patient remains alive and has no signs of disease recurrence., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Low-grade appendiceal mucinous neoplasm (LAMN) may culminate as a mucin-secreting disease known as pseudomyxoma peritonei (PMP). Once the diagnosis of LAMN and PMP is made, cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS and HIPEC) are indicated.Herein, we present a female patient in her 50s who was diagnosed with an ovarian mass for which she underwent laparoscopic oophorectomy. As the pathology of the ovary showed a tumour of gastrointestinal origin, she then underwent CRS and HIPEC with a final pathology of LAMN. Six weeks later, a mucinous lesion confined to the abdominal wall was detected on a postoperative CT. Suspected for port-site metastasis at the laparoscopic trocar site, we treated this lesion using the same principles of treatment as the intra-abdominal disease. The abdominal wall mass was surgically resected, and the cavity created was irrigated with mitomycin C. On 30 months of follow-up, the patient had no evidence of disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Gastric volvulus is an uncommon cause of upper gastrointestinal obstruction that occurs when the stomach twists along its vertical (organoaxial) or horizontal (mesenteroaxial) axis. Its rarity combined with its non-specific presentation makes gastric volvulus a diagnostic challenge, especially when the volvulus occurs without underlying structural abnormality such as hiatal hernia. The organoaxial type comprises most cases of this rare diagnosis. Few cases of mesenteroaxial volvulus have been reported in children and even fewer in adults. Here, we present a rare case of acute, idiopathic mesenteroaxial volvulus in a patient in his 70s, that was successfully managed laparoscopically., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A colonic lipoma is an uncommon lesion that is linked with clinical symptoms in only a small portion of patients. Patients with large lipomas are often referred for major surgery, which is associated with significant morbidity and mortality. In this case, we described a female patient with recurrent episodes of gastrointestinal blood loss, abdominal pain and colocolic intussusceptions due to a large, lumen-filling, obstructive lipoma in the splenic flexure. On abdominal CT, a lesion of 3.6 cm was visualised with a fat-like density without solid components. Considering its benign nature, we intended to preserve the colon by deroofing the upper part of the lesion and then performing a colonoscopy-assisted laparoscopic wedge resection. During reassessment, auto-amputation of part of the lesion was observed, most likely as a result of long-lasting mechanical effects, which made it possible to perform solely a wedge resection with an excellent outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

The purpose of this paper is to describe a robotic surgical technique for converting a slipped Nissen fundoplication to a Toupet fundoplication. Our technique utilizes four 8 mm robotic ports placed in a horizontal pattern above the umbilicus. The robotic tools we used are a vessel sealer, bipolar forceps, and Cadière forceps. In addition, an esophagogastroduodenoscopy (EGD) is placed through the esophagus into the stomach to be used as a bougie. If a hernia is present, we dissect it from the mediastinum until the posterior confluence is identified. Next sutures from the previous Nissen fundoplication are identified and removed to mobilize the crus. All adhesions around the stomach are removed to mobilize the esophagus, ensuing 3 cm of intraabdominal esophagus is available. Using an EGD as a bougie, we used two interrupted, 0 silk suture over Teflon pledgets placed in a horizontal mattress fashion to close the hiatal defect. Using an endoscope, we identified the previous Nissen fundoplication and used a 60 mm blue load stapler to transect the wrap from the stomach. The 360° Nissen fundoplication had now been converted into a 270° Toupet fundoplication, which is confirmed with the EGD. The functionality of the wrap is confirmed if the "Stack of Coins" sign is present, and the wrap lies tight against the scope. A Nissen-to-Toupet fundoplication conversion using a robotic-assisted surgical technique may be useful in reducing reoperations and complications in patients undergoing fundoplication surgery., (© 2023. Italian Society of Surgery (SIC).)

Background: Gastrointestinal dysfunction is one of the common complaints for patient post-surgery. Acupuncture has been employed to improve gastrointestinal function and sleeping quality and has confirmed clinical efficacy for emotional problems. This study aims to evaluate the clinical effect of electroacupuncture for postoperative rapid recovery., Methods: This study design is a two-arm, parallel, double-blinded randomized controlled trial. 104 subjects, aged from 40 to 89 years old, diagnosed with gastrointestinal cancer undergoing laparoscopic surgery, will be divided into Interventional Group and Control Group. Patients of both groups receive perioperative care under the guidance of ERAS guidance. The Interventional Group receives electroacupuncture treatment starting from the first day post-surgery for a consecutive 5 days, whereas the Control Group receives placebo electroacupuncture treatment. The primary outcome will be the first flatus time whereas the secondary outcomes will be the first sign of borborygmus, recovery of defecation, laboratory tests and questionnaires including Self-rating anxiety scale, Ford Insomnia Response to Stress Test, TCM rating scale of Gastrointestinal symptoms and Gastrointestinal Symptoms Rating Scales., Discussion: This study aims to provide timely intervention for post-laparoscopic patients with gastrointestinal tumour using the ERAS concept combined with electroacupuncture, observe the efficacy of this therapy in treating PGID, and contribute reliable scientific evidence for postoperative rapid recovery., Trial Registration: Chictr.org.cn Identifier: ChiCTR2300078710. Registered on 15th December 2023., (© 2024. The Author(s).)

This case report involves an elderly woman who presented with a 3-day history of a tender groin swelling on her right side. Her admission bloods were fairly unremarkable, but a preoperative ultrasound impressively confirmed a femoral hernia containing the appendix (De Garengeot hernia) and she underwent emergency laparoscopic hernioplasty with a prosthetic mesh and appendicectomy. The procedure found an incarcerated hernia with a strangulated tip of the appendix that unexpectedly separated upon gentle manipulation and histopathology revealed appendiceal inflammation. There were no complications with the patient's recovery and she was discharged 2 days after surgery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

We present an unusual case of achalasia presenting with dyspnoea and persistent cough. These symptoms persisted for months, leading to the patient undergoing a chest X-ray by her general practitioner which showed right basal consolidation and a density extending along the right mediastinum. CT scan was done which revealed megaoesophagus with a diameter of 7 cm causing tracheal compression, as well as right basal consolidation, consistent with aspiration. Further history revealed 6-month history of progressive swallowing difficulty, retrosternal chest pain and shortness of breath which worsened when eating solid foods. After thorough workup, a diagnosis of idiopathic achalasia (type II) was made. She was treated with laparoscopic Heller cardiomyotomy and Dor fundoplication with significant improvement at follow-up. Dyspnoea and respiratory symptoms are unusual presenting symptoms, suggesting a need to consider achalasia in a wider range of presentations. Successful treatment of achalasia depends on timely diagnosis and intervention prior to oesophageal failure., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Ileal diverticula can be congenital or acquired and are rare even among the already rare entity of small bowel diverticula. What has never been reported, as far as we know, is false diverticula arising within the true non-Meckelian diverticulum with mesenteric erosion causing an occult gastrointestinal bleed. We present a patient with occult gastrointestinal bleeding from a false-in-true ileal diverticulum. Multiple investigations were required to localise the bleeding site after which the patient was taken to the operating room for a laparoscopic ileocaecectomy with complete resolution of symptoms. Preoperative localisation of the bleeding site may be difficult but is critically important in occult gastrointestinal bleeding. Procedure choice for a bleeding ileal diverticulum is dictated by the distance from the ileocaecal valve and the etiopathology of the bleed., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A woman in her 60s was referred to the hepato-pancreato-biliary clinic for further assessment of a large hepatic cyst, which was incidentally identified by echocardiography. She was being investigated for possible crescendo angina on the backdrop of a 6-month history of increasing chest pain, shortness of breath, sweating, orthopnoea and paroxysmal nocturnal dyspnoea. Coronary angiography and echocardiography demonstrated normal cardiac physiology. A CT abdomen/pelvis confirmed an 8.5 cm hepatic cyst indenting the posterior and caudate lobes and abutting the inferior vena cava. Nocturnal dyspnoea was attributed to diminished venous return. Due to worsening symptoms and their impact on her job, the patient underwent laparoscopic deroofing of the hepatic cyst. Histopathology confirmed a simple hepatic cyst. In her first postoperative review clinic, 8 months after her initial visit to the cardiology team, the patient was asymptomatic and fully functional with a considerably improved quality of life., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Background: An objective evaluation of the functional state and viability of biological tissues during minimally invasive surgery remains unsolved task. Various non-contact methods for evaluating perfusion during laparoscopic surgery are discussed in the literature, but so far there have been no reports of their use in clinical settings., Methods and Patients: Imaging photoplethysmography (iPPG) is a new method for quantitative assessment of perfusion distribution along the tissue. This is the first study in which we demonstrate successful use of iPPG to assess perfusion of organs during laparoscopic surgery in an operation theater. We used a standard rigid laparoscope connected to a standard digital monochrome camera, and abdominal organs were illuminated by green light. A distinctive feature is the synchronous recording of video frames and electrocardiogram with subsequent correlation data processing. During the laparoscopically assisted surgeries in nine cancer patients, the gradient of perfusion of the affected organs was evaluated. In particular, measurements were carried out before preparing a part of the intestine or stomach for resection, after anastomosis, or during physiological tests., Results: The spatial distribution of perfusion and its changes over time were successfully measured in all surgical cases. In particular, perfusion gradient of an intestine before resection was visualized and quantified by our iPPG laparoscope in all respective cases. It was also demonstrated that systemic administration of norepinephrine leads to a sharper gradient between well and poorly perfused areas of the colon. In four surgical cases, we have shown capability of the laparoscopic iPPG system for intra-abdominal assessment of perfusion in the anastomosed organs. Moreover, good repeatability of continuous long-term measurements of tissue perfusion inside the abdominal cavity was experimentally demonstrated., Conclusion: Our study carried out in real clinical settings has shown that iPPG laparoscope is feasible for intra-abdominal visualization and quantitative assessment of perfusion distribution., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Spigelian hernia is a rare form of abdominal wall defect. Bilateral Spigelian hernias are even less common. Surgical repair of Spigelian hernias is recommended due to their high risk of incarceration and strangulation of abdominal contents. A variety of surgical approaches to repair these hernias have been described in the literature including the traditional open approach, laparoscopic transabdominal preperitoneal approach, laparoscopic intraperitoneal repair and laparoscopic totally extraperitoneal repair. Here, we present the case of an elderly female patient with rare bilateral Spigelian hernias, the right side containing incarcerated appendix and caecal pole. The left hernia was unrecognised on preoperative CT imaging. To our knowledge, very few cases have been reported in the literature. The patient underwent bilateral laparoscopic intraperitoneal mesh repair. All technical aspects of the treatment are discussed here, in the context of the current literature, including the surgical technique and the limitations of the CT diagnosis. We aim to summarise the background of these uncommon hernias, the limitations of preoperative investigations and the differences between the available operative approaches., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

We present a patient who developed an ileocolic intussusception within a few hours of undergoing an endoscopic polypectomy found on screening colonoscopy. She underwent a laparoscopic right hemicolectomy with intracorporeal anastomosis. Final histopathological examination showed no evidence of malignancy. Intussusception after colonoscopy is a rare complication, and only 11 cases have been reported prior to this case. Laparoscopic resection with intracorporeal anastomosis is a safe and feasible option in patients who are not candidates or failed conservative management., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hyperspectral Imaging (HSI) is a reliable and safe imaging method for taking intraoperative perfusion measurements. This is the first study translating intraoperative HSI to an in vivo laparoscopic setting using a CE-certified HSI-system for minimally invasive surgery (HSI-MIS). We aim to compare it to an established HSI-system for open surgery (HSI-Open)., Methods: Intraoperative HSI was done using the HSI-MIS and HSI-Open at the Region of Interest (ROI). 19 patients undergoing gastrointestinal resections were analyzed in this study. The HSI-MIS-acquired images were aligned with those from the HSI-Open, and spectra and parameter images were compared pixel-wise. We calculated the Mean Absolute Error (MAE) for Tissue Oxygen Saturation (StO 2 ), Near-Infrared Perfusion Index (NIR-PI), Tissue Water Index (TWI), and Organ Hemoglobin Index (OHI), as well as the Root Mean Squared Error (RMSE) over the whole spectrum. Our analysis of parameters was optimized using partial least squares (PLS) regression. Two experienced surgeons carried out an additional color-change analysis, comparing the ROI images and deciding whether they provided the same (acceptable) or different visual information (rejected)., Results: HSI and subsequent image registration was possible in 19 patients. MAE results for the original calculation were StO 2 orig. 17.2% (± 7.7%) , NIR-PI orig.  16.0 (± 9.5), TWI orig.  18.1 (± 7.9), OHI orig.  14.4 (± 4.5). For the PLS calculation, they were StO 2 PLS  12.6% (± 5.2%), NIR-PI PLS  10.3 (± 6.0), TWI PLS  10.6 (± 5.1), and OHI PLS  11.6 (± 3.0). The RMSE between both systems was 0.14 (± 0.06). In the color-change analysis; both surgeons accepted more images generated using the PLS method., Conclusion: Intraoperative HSI-MIS is a new technology and holds great potential for future applications in surgery. Parameter deviations are attributable to technical differences and can be reduced by applying improved calculation methods. This study is an important step toward the clinical implementation of HSI for minimally invasive surgery., (© 2023. The Author(s).)

Internal hernias are protrusions of viscera that can cause obstructions such as small bowel obstruction (SBO). Diagnosis can be challenging, as they usually come with an atypical presentation. We report on a case of a woman in her early 40s, with no history of surgery or chronic illnesses, which came with abdominal pain associated with vomiting. CT scan revealed obstructed small bowel. On exploratory laparoscopy, an internal hernia through a peritoneal defect in the vesicouterine space was found, entrapping a limb of the jejunum. The entrapped loop of the small bowel was freed, the ischaemic part was resected, and the defect was closed. Our case presents the second reported case of a congenital vesicouterine defect causing SBO. It is important to consider patients presenting with SBO as a case of congenital peritoneal defect if they had no previous surgeries., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To prospectively compare long-term lower gastrointestinal function before and after laparoscopic surgery for deep endometriosis (DE)., Methods: In this prospective observational study we followed 149 patients with confirmed DE who were treated surgically. Patients completed the International Consultation on Incontinence Questionnaire Anal Incontinence Symptoms and Quality of Life Module (ICIQ-B) before surgery, and 6 weeks, 6 months, and 12 months after surgery. Bowel pattern, bowel control, and bowel impact on quality of life summary scores were compared before and after surgery., Results: Bowel pattern score showed an increasing improvement at all time points after surgery, from a mean pre-operation score of 4.8 ± 2.0 to 4.4 ± 1.8 at 6 weeks, 4.2 ± 1.8 at 6 months, and 4.2 ± 1.2 at 12 months. Bowel impact on quality of life significantly improved from pre-surgery mean score of 5.5 ± 6.0 to 4.2 ± 5.5 at 6 weeks and 4.4 ± 5.4 at 6 months. Direct lower gastrointestinal endometriosis involvement and worse initial function were associated with larger improvements in scores following surgery., Conclusions: Lower gastrointestinal function significantly improved after surgical treatment of DE. Further research is needed to confirm our findings and to better characterize the sub-groups of patients for whom surgery will have a beneficial effect on their bowel function., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Laparoscopic cholecystectomy (LC) is more challenging in the anatomical variation of left-sided gallbladder with the anomaly also highly related to biliary anomalies. Therefore, there has been a reluctance to operate close to the common bile duct (CBD) in left gallbladder patients, and thus choledocholithiasis is usually treated with endoscopic retrograde cholangiopancreatography (ERCP). There is emerging evidence that single stage LC and CBD exploration for choledocholithiasis may be superior to two stage LC and ERCP in terms of short-term and long-term morbidity, cost and length of stay. With the re-emergence of laparoscopic choledochoscopy, the purpose of this case report is to demonstrate the feasibility of this approach for choledocholithiasis., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

A patient with a surgical history including an historic laparoscopic adjustable gastric band (LAGB) procedure presented to the emergency department with a history of haematemesis, intractable vomiting and abdominal pain 3 days following an outpatient oesophagogastroduodenoscopy (OGD) for chronic anaemia. A day after presentation to the emergency department, following admission, the patient underwent a repeat OGD. In contrast to her previous procedure, this demonstrated abnormal fluid and food deposition within what was originally reported to be a large hiatus hernia with a tight lower oesophageal sphincter. On corroboration with CT imaging obtained, in retrospect the endoscopic findings were attributed to slippage of the patient's adjustable gastric band. The band was loosened via its subcutaneous access port, following consultation with the surgical service, resulting in complete resolution of the patients' symptoms and she was discharged. This case is an example of gastroscopy as a rare trigger for the common complication of slipped gastric band following LAGB., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Intestinal malrotation is a congenital anomaly, treated mostly during childhood. A small number of cases are incidentally found in adulthood, during operation for other abdominal diseases, such as colon cancer.Here, we present a case of caecal cancer with isolated duodenal malrotation, a subtype of intestinal malrotation, discovered incidentally during the operation for the cancer. Although the anatomical abnormality made the operation more complicated, laparoscopic resection was safely performed with oncologically adequate lymphadenectomy, owing to intraoperative confirmation of anatomy and careful dissection., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Hyperspectral imaging (HSI) during surgical procedures is a new method for perfusion quantification and tissue discrimination. Its use has been limited to open surgery due to large camera sizes, missing color video, or long acquisition times. A hand-held, laparoscopic hyperspectral camera has been developed now to overcome those disadvantages and evaluated clinically for the first time., Methods: In a clinical evaluation study, gastrointestinal resectates of ten cancer patients were investigated using the laparoscopic hyperspectral camera. Reference data from corresponding anatomical regions were acquired with a clinically approved HSI system. An image registration process was executed that allowed for pixel-wise comparisons of spectral data and parameter images (StO 2 : oxygen saturation of tissue, NIR PI: near-infrared perfusion index, OHI: organ hemoglobin index, TWI: tissue water index) provided by both camera systems. The mean absolute error (MAE) and root mean square error (RMSE) served for the quantitative evaluations. Spearman's rank correlation between factors related to the study design like the time of spectral white balancing and MAE, respectively RMSE, was calculated., Results: The obtained mean MAEs between the TIVITA® Tissue and the laparoscopic hyperspectral system resulted in StO 2 : 11% ± 7%, NIR PI: 14±3, OHI: 14± 5, and TWI: 10 ± 2. The mean RMSE between both systems was 0.1±0.03 from 500 to 750 nm and 0.15 ±0.06 from 750 to 1000 nm. Spearman's rank correlation coefficients showed no significant correlation between MAE or RMSE and influencing factors related to the study design., Conclusion: Qualitatively, parameter images of the laparoscopic system corresponded to those of the system for open surgery. Quantitative deviations were attributed to technical differences rather than the study design. Limitations of the presented study are addressed in current large-scale in vivo trials., (© 2022. The Author(s).)

A toddler presented with melaena on a background of a possible enteric duplication cyst, diagnosed in the neonatal period which 'vanished'. What was later confirmed to be a small bowel duplication cyst was not seen on follow-up ultrasounds and thus the patient was managed expectantly until presentation as an emergency. Our case highlights the challenges faced in managing cystic abdominal structures in infancy and the potential consequences of expectant management. We discuss whether cross-sectional imaging or diagnostic laparoscopy should be advocated when duplications cysts are considered amongst the differentials of a lesion on ultrasound., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

We describe the case of a woman in her 50s with abdominal pelvic masses suspected to be an ovarian lesion with metastases. At laparoscopy, it appeared as a possible abdominal location of neurofibromatosis type 1 (NF-1). A 50 cm of small bowel was resected to remove multiple nodular lesions. On histopathology, small bowel lesions (n=14) were all classified as GISTs. Clinicians should recognise and consider gastrointestinal manifestations of NF-1 in the diagnostic flow chart. Surgical treatment may resolve symptomatic cases and prevent local infiltration or malignant degeneration of abdominal neoplasms occurring in patients with NF-1., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Laparoscopic surgery has almost replaced open surgery in many areas of Gastro-Intestinal (GI) surgery. There is currently no published expert consensus statement on the principles of laparoscopic GI surgery. This may have affected the training of new surgeons. This exercise aimed to achieve an expert consensus on important principles of laparoscopic GI surgery., Methods: A committee of 38 international experts in laparoscopic GI surgery proposed and voted on 149 statements in two rounds following a strict modified Delphi protocol., Results: A consensus was achieved on 133 statements after two rounds of voting. All experts agreed on tailoring the first port site to the patient, whereas 84.2% advised avoiding the umbilical area for pneumoperitoneum in patients who had a prior midline laparotomy. Moreover, 86.8% agreed on closing all 15 mm ports irrespective of the patient's body mass index. There was a 100% consensus on using cartridges of appropriate height for stapling, checking the doughnuts after using circular staplers, and keeping the vibrating blade of the ultrasonic energy device in view and away from vascular structures. An 84.2% advised avoiding drain insertion through a ≥10 mm port site as it increases the risk of port-site hernia. There was 94.7% consensus on adding laparoscopic retrieval bags to the operating count and ensuring any surgical specimen left inside for later removal is added to the operating count., Conclusion: Thirty-eight experts achieved a consensus on 133 statements concerning various aspects of laparoscopic GI Surgery. Increased awareness of these could facilitate training and improve patient outcomes., (Crown Copyright © 2022. Published by Elsevier Ltd. All rights reserved.)

Complete mesocolic excision (CME) of colon cancer is a resection performed along embryological planes to include the completely intact mesentery surrounding the tumour with a high central vascular ligation. The aim is to remove all lymph nodes draining the cancer. Proponents of the technique cite the significantly decreased local recurrence and improved 5-year survival rates associated with CME versus conventional colectomy. Although increasingly performed in many centres, it has not yet gained widespread acceptance as it is technically more challenging and can incur an increased bleeding risk. A man in his 80s underwent a conventional right hemicolectomy for a pT4aN2aM0 ascending colon cancer at another institution. This was followed by chemotherapy. He presented to our institution 2 years later with an isolated 3.7×3.2 cm mesenteric tumour adjacent to his anastomosis. There was no intraluminal recurrence. He then underwent a repeat extended right colectomy with CME. Pathology confirmed lymph node recurrence. His case demonstrates the importance of CME in reducing carcinoma recurrence risk., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Two patients with a laparoscopic resection of the sigmoid colon in their surgical history were diagnosed with an internal hernia because of a mesenteric gap underneath the descending neocolon. While the first case demonstrated a strongly symptomatic patient with a closed-loop obstruction of the small bowel, the second case was less obvious and correct diagnosis was achieved after a few weeks by finally performing a diagnostic laparoscopy. Since internal hernias after laparoscopic sigmoid resection are a rare complication and as presented in the second case can display very unspecific symptoms, the surgeon's awareness is not immediately raised towards it. Therefore, an asymptomatic internal hernia bears a constant risk of a life-threatening outcome allowing to recommend an initial closure of the mesenteric gap. In both cases, successful treatment was achieved by surgery and intraoperatively closing the remaining mesenteric gap. Subsequently recovery and follow-up were uneventful., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

A 61-year-old woman developed neorectal prolapse after laparoscopic low anterior resection, total mesorectal excision with partial intersphincteric resection and handsewn coloanal anastomosis for rectal cancer. She presented with a 3 cm full thickness reducible prolapse, with associated anal pain and bleeding. A perineal stapled prolapse resection was performed to address the rectal prolapse, with satisfactory results., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

A 30-year-old man presented with colicky abdominal pain for 2 months, associated with occasional episodes of bilious vomiting. He had a history of similar complaints at the age of 16 and 26 years. Contrast-enhanced computed tomography abdomen was consistent with a diagnosis of left paraduodenal hernia. On laparoscopy a 3 × 3 cm hernial defect was identified in the left paraduodenal fossa (fossa of Landzert). Contents were jejunal, and proximal ileal loops which were dilated and edematous. Anterior border of the sac was formed by the inferior mesenteric vein and left branch of the left colic artery. Initial reduction of contents was easy. However, complete reduction proved to be difficult due to adhesions with the sac opening, the hernial sac instead laid open by dividing the Inferior Mesentric Vein (IMV) (anterior border of defect) using a vascular stapler. The patient was discharged on postoperative day 3 in a stable condition. On follow-up the patient is doing well., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Since the first laparoscopic cholecystectomy (LC) in 1985, there has been much advancement in laparoscopic surgery in terms of reduction in number and size of ports. We report a new technique of performing mini laparoscopic cholecystectomy using only three ports, 5 mm each. The indications of this procedure include GB polyps, GB dyskinesia, microlithiasis, and idiopathic pancreatitis., Case Presentation: In this case report, we present a new technique that has been performed safely in a 49-year-old male patient with pancreatitis caused by microlithiasis. This was performed using a novel three port procedure consisting of only 5 mm ports, and he was discharged as a day case without complications. Informed patient consent was obtained., Conclusions: The fundamentals of this mini-LC technique remain the same as that of a standard laparoscopic cholecystectomy throughout the procedure. It is a feasible option in selected cases, and it has the potential to further augment the inherent benefits of minimal access surgery namely less analgesia, improved cosmesis and faster recovery. Further trials will help ascertain its potential advantages., (© 2021. The Author(s).)

Background: Surgical site infections (SSI) are the most common healthcare-associated infection, and gastrointestinal surgery is frequently followed by a high incidence of SSI. Epidemiological analysis of the temporal trends in SSI following gastrointestinal surgery has yet to be performed in Japan. Our purpose was to descriptively investigate these trends., Methods: Extracting national surveillance data from the Japan Nosocomial Infections Surveillance (JANIS) system, we analyzed the frequency of SSI events following gastrointestinal surgery, which consisted of seven surgical procedures, from 2012-2017. We calculated the standardized infection ratio to compute risk-adjusted SSI frequency, and used the trend test to detect time-dependent changes., Results: The frequency of SSI events, except for those associated with surgery of the upper gastrointestinal tract, revealed a decreasing time-dependent trend. The use of laparoscopic surgery increased dramatically over time (p < 0.01 for the six applicable surgical sites), while the frequency of SSI events during laparoscopic surgery remained unchanged., Conclusions: The increasing use of laparoscopic surgery was identified, and the observation coincided with the decreasing trend in SSI, especially in lower gastrointestinal tract surgery. If the relationship is causal, the overall SSI incidence among previously healthy individuals is expected to decrease, because the use of laparoscopic surgery has large growth potential in Japan., (© 2021. The Author(s).)

A young adult male presented with biliary colic and intermittent jaundice for 1 year. Abdomen findings were unremarkable. Routine investigations revealed a raised total bilirubin. On abdominal ultrasonography, common bile duct (CBD) dilatation with multiple stones was noted. On further imaging with magnetic resonance cholangiopancreatography, type I choledochal cyst (CDC) was suspected. A laparoscopic approach was planned. Intraoperatively, dilatation of cystic duct was noted which constitute type VI CDC. Partial malrotation of the gut and accessory right hepatic artery were also noted as incidental finding. Laparoscopic cholecystectomy with CBD exploration and removal of stones, biliary stent placement, cystic duct cyst excision and primary repair of CBD was done. Postoperatively, the patient improved symptomatically with a fall in bilirubin to normal range. We are describing the laparoscopic management of a rare case of type IV CDC which was diagnosed intraoperatively., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Laparoscopic gastrointestinal surgery has experienced 30 years of development in China, and has now entered a high plateau stage at the technical level. Laparoscopic surgery, once an emerging technology, is gradually becoming a "traditional surgery". Meanwhile, laparoscopic gastrointestinal surgery is gradually moving towards a new situation of multi-disciplinary and multi-technical integration. High-quality clinical studies are constantly being reported, and new tools and techniques are emerging. In the next era, the development of laparoscopic gastrointestinal surgery will focus more on international research, digital surgery, high-tech operating rooms, etc. An urging requirement is to understand and face the current intensified involution and other practical problems, and to create another glorious innovation for Chinese laparoscopic gastrointestinal surgery in the next 30 years.

A 33-year-old, 8 weeks pregnant, presented with severe upper abdominal pain with vomiting on a background of a previous laparoscopic Nissen fundoplication for reflux disease. An urgent MRI had shown herniation of the fundoplication wrap through the diaphragmatic hiatus. The cause of her symptoms was attributed to hyperemesis gravidarum. The plan was to manage this patient conservatively until the conclusion of her pregnancy. This plan was revised when she presented for the second time and developed worsening pain and haematemesis. An emergency gastroscopy showed ischaemic changes in most of the stomach requiring the patient to undergo an emergency laparotomy. In pregnant patients, presenting with abdominal pain, vomiting as well as haematemesis, having had previous antireflux surgery, incarceration of the stomach must be considered as a differential. Prompt assessment and early senior decision-making is extremely important in avoiding a potentially catastrophic outcome for such patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Idiopathic megacolon (IMC) and idiopathic megarectum (IMR) describe an abnormality of the colon or rectum, characterised by a permanent dilatation of the bowel diameter in the absence of an identifiable cause. We present a 23-year-old woman with chronic constipation and excessive straining during defecation who presented at the emergency department in partial gut obstruction with a palpable fecaloma. Manual faecal disimpaction and a sigmoid loop colostomy was initially done. A full thickness rectal biopsy was positive for ganglion cells. Further workup led to the diagnosis of chronic IMC and IMR. The patient underwent laparoscopic modified Duhamel procedure, with an uneventful postoperative course., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

An 81-year-old man was referred to the colorectal surgeons for an elective laparoscopic right hemicolectomy for a caecal adenocarcinoma (T2N0M0). The operation was uneventful; however, 12 days postoperatively the patient developed symptoms of sepsis of unknown origin. After extensive investigations and work up, Candida albicans was grown as the causative organism with the site of infection being a new saccular mycotic aneurysm arising from the distal, posterior aspect of the aortic arch. The mycotic aneurysm was not initially considered as a differential diagnosis, and this case highlights the importance of consideration of mycotic aneurysm as a differential diagnosis in postsurgical septic patients., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 25-year-old patient underwent laparoscopic Roux-en-Y gastric bypass surgery with an initially uneventful postoperative course. Two weeks postoperatively, the patient presented with acute abdominal pain. CT scan revealed a gastrogastric fistula from the gastric pouch to the gastric remnant. Laparoscopic drainage was performed, and intraoperative endoscopy confirmed a large gastrogastric fistula. Due to intense adhesions between pouch and remnant, a closure by suture of the fistula was not possible. The fistula was initially treated with a fully covered metal stent. After multiple stent migrations despite clip attachment to the mucosa, the stent was changed to a partially covered metal stent. Fistula healing progress was documented every 2 weeks. After 10 weeks of stent treatment, fistula closure was accomplished.In conclusion, early fistula from the gastric pouch to the gastric remnant is a rare complication and can be managed with endoscopic stent placement., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

The use of the robotic platform for gastrointestinal surgery was introduced nearly 20 years ago. However, significant growth and advancement has occurred primarily in the last decade. This is due to several advantages over traditional laparoscopic surgery allowing for more complex dissections and reconstructions. Several randomized controlled trials and retrospective reviews have demonstrated equivalent oncologic outcomes compared to open surgery with improved short-term outcomes. Unfortunately, there are currently no universally accepted or implemented training programs for robotic surgery and robotic surgery experience varies greatly. Additionally, several limitations to the robotic platform exist resulting in a distinct learning curve associated with various procedures. Therefore, implementation of robotic surgery requires a multidisciplinary team approach with commitment and investment from clinical faculty, operating room staff and hospital administrators. Additionally, there is a need for wider distribution of educational modules to train more surgeons and reduce the associated learning curve. This article will focus on the implementation of the robotic platform for surgery of the pancreas, stomach, liver, colon and rectum with an emphasis on the associated learning curve, educational platforms to develop proficiency and perioperative outcomes.

Acute appendicitis is the most common nonobstetric condition requiring surgery in pregnancy. However, the diagnosis of acute appendicitis during pregnancy is challenging because of obscure clinical manifestations and laboratory findings. Intravenous antibiotic treatment is not preferred over operation because of the poor outcome. Here, we present a case of a 34-year-old woman in the second trimester of pregnancy who presented with suprapubic pain and an unexpected 3.5 cm-long exophytic intramural myoma on the right anterolateral wall of the uterus rather than prominent appendicitis features; thus, it took 2 days to confirm the diagnosis. Laparoscopic appendectomy was performed, and the patient was discharged without lingering reports on postoperative day 6. Acute appendicitis during pregnancy is common; therefore, attentive clinical suspicion will contribute to shorter hospital stays as well as fewer maternal and fetal complications., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Sciatic hernia is a rare pelvic floor hernia. A variety of treatment modalities were proposed, but a guideline is lacking although a mesh-based tension-free repair may be preferred. A 67-year-old woman with an uncomplicated sciatic hernia received primarily closing of the hernia orifice that was covered with a preperitoneal mesh in March 2019. Six months later, she developed a clinical and radiographical recurrence requiring remedial surgery. Due to the previous mesh fixation, the preperitoneal plane was obliterated. Therefore, the pouch of Douglas was closed, leaving the hernia sac in place, by folding two opposing peritoneal layers and covering it with a Ventralight ST mesh. After 9 months, the hernia had not recurred and the patient was symptom-free. It is concluded that recurrent sciatic hernia may be treated by obliterating the Douglas pouch and subsequent mesh coverage., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Paraoesophageal hernias are common, but symptoms are not always present nor pathognomonic of this condition, and patients may be suffering for many years before a diagnosis is made. Incarceration and strangulation are rare, but they are life-threatening complications, warranting an emergent surgical repair. Hiatal hernia incarceration causing distal oesophagus perforation is even rarer. To our knowledge, this is the first case report in adult patients. Despite many advances in care, a high grade of suspicion is needed to diagnose this condition, and the mortality rate for an oesophageal perforation remains high, achieving 50% in some series. We present the surgical management of a case of hiatal hernia incarceration with distal oesophagus perforation by combined laparoscopy and upper endoscopy., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

A young male in his early 30s presented to us with increasing swelling at the umbilicus, and an umbilical hernia was diagnosed. At laparoscopic intraperitoneal onlay mesh (IPOM) repair, an unexpected finding of a thin innocuous-looking fibrous film over the small bowel was noted. This finding presented a dilemma as to the probable pathology of this material, and a decision had to be made on whether laparoscopic IPOM could be continued. It was prudently decided to abandon the plan of placing a mesh intraperitoneally and an open repair of the umbilical hernia was done. In retrospect this was a wise decision, as, after 7 months he had to have a laparotomy for intestinal obstruction, when the classic thick fibrous encapsulating abdominal cocoon was seen. Hence here we have followed the evolution of the abdominal cocoon from its original asymptomatic phase to the classic encapsulating sclerosing peritonitis with probably laparoscopic gas insufflation being the precipitating factor., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Abdominal cystic lymphatic malformations are rare pathological entities of uncertain aetiology that usually present in early childhood with indolent abdominal distention. We report the case of a 17-year-old man who presented to our hospital with acute right lower quadrant pain, nausea and anorexia. His blood tests revealed a raised white cell count and elevated inflammatory markers. Clinical examination revealed signs of localised right lower quadrant peritonism. A diagnosis of clinical appendicitis was made, and in keeping with local management protocols, the patient proceeded to theatre for a diagnostic laparoscopy without radiological investigations. Operative findings yielded a normal appendix and a large abdominal cystic malformation. This article highlights the need to keep a broad differential diagnosis when performing surgery on patients with clinically presumed appendicitis and the importance of radiological investigations in clinical decision-making, we also review abdominal cystic lymphatic malformations as a rare diagnostic pitfall., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

We present a 71-year-old man who developed left calf pain after an elective laparoscopic assisted anterior resection. A clinical picture with a raised creatine kinase and negative Doppler ultrasound was suggestive of compartment syndrome. Successful surgical management was performed with two incisional fasciotomies to release all four compartments of the left leg. The patient recovered well postoperatively. The lateral incision was closed primarily while the medial incision required vacuum-assisted closure dressings and healed by secondary intention. Neither wound required skin grafts. The patient recovered well but had an extended hospital stay due to extensive physiotherapy requirements and mild foot drop. This report is intended as a guide for clinicians when considering differentials in calf pain following surgery and to keep in mind the small risk of developing compartment syndrome after pelvic surgery., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

A 61-year-old woman was seen by the emergency general surgical team with a 2-week history of right iliac fossa pain. Imaging revealed the possibility of a distal ileum perforating foreign body. Using a single incision laparoscopy surgery (SILS) approach, this diagnosis was confirmed at operation. This emerging technique meant a much smaller incision could be used than traditional exploratory laparotomy, with the benefit of less postoperative pain and a faster recovery. This case highlights an uncommon cause for abdominal pain and the importance of close liaison with radiologists and the low threshold for use of laparoscopy as a diagnostic tool. We advocate the use of SILS in the emergency setting for appropriate cases., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.