Search

Background: Robotic cholecystectomy appears to be a natural evolution of the well-established gold standard procedure for gallstones, namely laparoscopic cholecystectomy. Akin to the early days of laparoscopy, robotic surgery is associated with a learning curve. We present our experiences in adapting to robotic surgery after the first 100 robotic cholecystectomies at a minimal access surgery tertiary care hospital. Material and Methods: The first consecutive 100 robotic cholecystectomies performed by a single surgeon on the Versius robotic surgical system (CMR Surgical, UK) were included in the study. Patients unwilling to give consent and complex pathologies such as gangrene, perforation and cholecystoenteric fistulas were excluded from the study. Operative time, robotic setup time, incidence and indication for conversion to manual (laparoscopic) procedure were recorded while subjective assessment of interruptions due to machine alarms and errors was made. All data were compared between the first 50 and last 50 procedures. Results: Our data revealed a gradual reduction in operative time from 28.53 min for the first 50 procedures to 22.06 min for the last 50 procedures. An improvement in draping and setup times was also noted, reducing from 7.74 to 5.14 min and 7.96 to 5.32 min, respectively. There were no conversions during the last 50 procedures, though the first 50 procedures resulted in 3 conversions to a laparoscopic procedure. In addition, we also noted a subjective reduction in the incidence of machine errors and alarms as we became more versed with the robotic system. Conclusion: Our single-centre experience indicates that newer modular robotic systems present a rapid and natural progression for experienced surgeons looking to venture into robotic surgery. The well-established advantages of robotic surgery in the form of enhanced ergonomics, three-dimensional vision and improved dexterity are validated as indispensable aids in a surgeon's armamentarium. Our initial experience reveals that robotic surgery for more common surgical procedures such as cholecystectomies will be rapidly accepted, safe and effective. There is a need to innovate and expand the range of instrumentation and energy devices available. [ABSTRACT FROM AUTHOR]

Background: Numerous classifications for groin and ventral hernias have been proposed over the past five to six decades. The old, simple classification of groin hernia in to direct, inguinal and femoral components is no longer adequate to understand the complex pathophysiology and management of these hernias. The most commonly followed classification for ventral hernias divide them into congenital, acquired, incisional and traumatic, which also does not convey any information regarding the predicted level of difficulty. Aim: All the previous classification systems were based on open hernia repairs and have their own fallacies particularly for uncommon hernias that cannot be classified in these systems. With the advent of laparoscopic/ endoscopic approach, surgical access to the hernia as well as the functional anatomy viewed by the surgeon changed. This change in the surgical approach and functional anatomy opened the doors for newer classifications. The authors have thus proposed a classification system based on the expected level of intraoperative difficulty for endoscopic hernia repair. Classification: In the proposed classification higher grades signify increasing levels of expected intraoperative difficulty. This functional classification grades groin hernias according to the: a) Pre -operative predictive level of difficulty of endoscopic surgery, and b) Intraoperative factors that lead to a difficult repair. Pre operative factors include multiple or pantaloon hernias, recurrent hernias, irreducible and incarcerated hernias. Intraoperative factors include reducibility at operation, degree of descent of the hernial sac and previous hernia repairs. Hernial defects greater than 7 cm in diameter are categorized one grade higher. Conclusion: Though there have been several classification systems for groin or inguinal hernias, none have been described for total classification of all ventral hernias of the abdomen. The system proposed by us includes all abdominal wall hernias and is a final classification that predicts the expected level of difficulty for an endoscopic hernia repair.

Laparoscopic approach for hernia has evolved rapidly over the past decade. We adopted the TEP repair early as we believe in preserving the sanctity of the coelomic cavity. Once well versed with the approach we have found it an efficient and cost effective method for groin hernia repair. Endoscopic totally extraperitoneal hernia repair is a technically demanding procedure. Indepth anatomical knowledge, training and advanced technical skill is needed for the surgeon to perform this procedure. To make the procedure cost effective and prevent hernia recurrences, we have modified and innovated to simplify the procedure. This modification which we have named the SGRH technique, innovates by creating the preperitoneal working space with the help of an indigenous glove finger balloon. A rolled mesh makes placement and fixation easier in the limited working space. The mesh is unrolled on the peritoneal surface (floor), a manouver which is technically simpler. On desufflation the mesh comes to appose the Fruchad′s orifice covering all potential hernial sites. With the modified SGRH technique we have found TEP to be safe, cost effective, reproducible and without significant complications.

Complications in endoscopic inguinal hernia surgery are more dangerous and more frequent than those of open surgery, especially in inexperienced hands and hence are best avoided. It is possible to avoid most of these complications if one follows a set of well-defined steps and principles of endoscopic inguinal hernia surgery. Complications are known to occur at each and every step of hernia surgery. Applying caution while performing each step can save the patient from a lot of morbidity. One starts by applying strict patient selection criteria for endoscopic hernia repair, especially in the initial part of ones learning curve. A thorough knowledge of anatomy goes a long way in avoiding most of the complications seen in hernia repair. This anatomy needs to be relearned from what one is used to, as the approach is totally different from an open hernia repair. And finally, learning and mastering the right technique is an essential prerequisite before one ventures into inguinal hernia repair. Although there has been an increased incidence of complications reported in endoscopic repair in the earlier series, this can be explained partly by the fact that it was in the early part of the learning curve of most endoscopic surgeons. As the experience grew and the techniques were standardized, the incidences of complications have also reduced and have come to be on par with open hernia surgery. The various complications and precautions to be taken to avoid them will be discussed.

Despite its significant prevalence, there is little in the way of evidence-based guidelines regarding the timing and method of repair of incisional hernias. To add to the above is the formidable rate of recurrence that has been seen with conventional tissue repairs of these hernias. With introduction of different prosthetic materials and laparoscopic technique, it was hoped that an improvement in the recurrence and complication rates would be realized. The increasing application of the laparoscopic technique across the world indicates that these goals might indeed be achieved.

Jejunoileal diverticulae, also referred to as non-Meckelian diverticulae, are very uncommon. These diverticulae are considered to be acquired pulsion diverticulae and they mostly occur in older people. Their prevalence increases with age. About 80% of these diverticulae occur in jejunum and are usually multiple. Patients with jejunoileal diverticulae present with nonspecific symptoms. The clinical picture of a complicated jejunoileal diverticulae can be confused with other intra-abdominal acute conditions such as appendicitis, cholecystitis, perforated ulcer, etc. Nonmechanical or pseudoobstruction is related to the dyskinesia associated with this condition. The diagnosis is made by a small bowel contrast study, enteroclysis, endoscopy or computed tomography. A surgical approach is the best form of treatment for complicated jejunoileal diverticulae. Laparoscopy is very useful in diagnosing and treating this condition. The current report is about a patient who presented with recurrent subacute intestinal obstruction and was managed by laparoscopy.

Inguinal hernia surgery has been one of the most extensively debated and continues to evolve in search for the ideal technique. Even though the method to diagnose hernia has largely remained clinical, recently other modalities have detected hernias that are not picked up on clinical examination or are incorrectly labeled. Laparoscopy, for the first time has given surgeons the unique opportunity to look at both sides of the groin and to detect and study the contra lateral groin in a patient of clinically unilateral hernia. This has given rise to some interesting findings. In the pediatric age group the value of bilateral detection and repair has been extensively debated. However, the same is not true for the adults despite the facts that there are better methods for detection, better understanding of pathogenesis of hernia and better repair techniques that can take care of bilateral repair without adding to morbidity. That hernia is not a simple derivative of patent processus vaginalis or strain related cause is beginning to be better understood now. It may primarily be a disorder of collagen metabolism with genetic basis. Laparoscopy has also made us wiser in detection of type of hernia and examination of both groin areas. In several studies there have been a high percentage of undetected hernias or additional defects. This was never realized earlier as in open surgery there is no question of exploring the asymptomatic groin. Laparoscopy in bilateral repair is safe and does not add significantly to the operating time, cost or morbidity. At our Department of Minimal Access Surgery, Sir Ganga Ram Hospital, New Delhi, India we have been performing Endoscopic Totally Extraperitoneal (TEP) repair for all simple and complicated inguinal hernia since 1994. We now routinely perform a bilateral repair based on our understanding that the pathogenesis of hernia is a complex process and any genetic basis of collagen disorder has to affect the patient bilaterally. The clinical examination may have unacceptably low sensitivity. Early identification and repair obviates the need for reoperation, reduces overall costs and eliminates further anaesthetic and operative risks for the patient

Primary lumbar hernia is a rarely encountered hernia. Surgical correction is the standard treatment for lumbar hernia, and either an open or laparoscopic procedure can be performed with equivalent success. However, open repairs are most commonly performed. Here, we present a case of a primary lumbar hernia that was successfully treated laparoscopically and discuss surgical modalities of treatment reported in the literature. There are two laparoscopic approaches: transabdominal and extraperitoneal. The main advantage of the laparoscopic approach is that it helps the surgeon to precisely locate and evaluate the characteristics of the defect. It also has a lower morbidity rate, shorter length of hospital stay, less postoperative pain, and an earlier return to daily routine activities than the open approach. In the present study, a patient with a superior lumbar hernia was treated laparoscopically by the transabdominal approach. Laparoscopic repair in such cases is feasible and achieves a good result when done by an experienced laparoscopic hernia surgeon. [ABSTRACT FROM AUTHOR]