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Background With the pandemic of obesity and the growing experience in metabolic and bariatric surgery (MBS), the number of patients with obesity and liver cirrhosis undergoing MBS is increasing. Objective To analyze the morbidity and mortality following MBS in patients with obesity and liver cirrhosis. Setting Systematic review and meta-analysis. Methods The published literature was systematically reviewed, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, for studies reporting outcomes of MBS among patients with liver cirrhosis. The predetermined endpoints were the overall complication after MBS, intraoperative complications, liver-related complications after MBS, all-cause 90-day mortality after MBS, and liver-related mortality post-MBS. The pooled weighted proportions for each of the endpoints was calculated using random effect meta-analysis. Results A total of 18 studies, including 471 patients with obesity and liver cirrhosis undergoing MBS, qualified for the final quantitative analysis. The mean age and mean body mass index (BMI) of the pooled patient cohort were 50.2 years and 47.2 kg/m2. The pooled weighted proportions of the overall post-MBS complications, intraoperative complications, liver-related complications, overall 90-day mortality, and liver failure related mortality post MBS were 22.14% (CI95%: 15.43%–29.55%), .08% (CI95%: 0%–1.02%), 4.62% (CI95%: 1.27%–9.30%), 0% (CI95%: 0%–.44%), .08% (CI95%: 0%–1.03%), respectively. Significantly lower postoperative complications were noted with sleeve gastrectomy (10.08% [95%CI: 5.14%–16%]) compared with Roux-en-Y gastric bypass (31.53% [95%CI: 18.62%–45.68%]; (P = .02). Conclusion We found an overall low postoperative surgical and liver-related mortality post MBS among patients with obesity and liver cirrhosis. The overall postoperative complications and liver-related complications were higher among patients with liver cirrhosis than in noncirrhotic patients. Sleeve gastrectomy showed lower postoperative complications compared with Roux-en-Y gastric bypass.

Vaginal vault dehiscence leading to bowel evisceration is a rare but potentially lethal surgical emergency. Various aetiologies have been reported in the literature, but the condition is most commonly seen after hysterectomy in post-menopausal women. Prompt reduction of the bowel is necessary to prevent ischaemic complications. Although most cases in the past have been managed by exploratory laparotomy, the condition may be managed laparoscopically if the prolapsed bowel is viable, giving the benefit of minimally invasive surgery to the patient. A hybrid approach of laparoscopic bowel reduction and per vaginal repair of the vault is technically simple and can be performed even by non-expert surgeons in an emergency setting.

Objectives Delayed primary closure (DPC) of the skin has been suggested to decrease superficial surgical site infection (SSSI) in patients undergoing surgery for peritonitis secondary to hollow viscus perforation, but there is no consensus. The aim of this study was to compare the outcomes of primary closure (PC) and DPC of the skin in terms of SSSI, fascial dehiscence and length of hospital stay (LOS). Material and methods Sixty patients, undergoing emergency surgery for perforation peritonitis, were randomized to PC (n= 30) and DPC (n= 30). Patients in the DPC group underwent skin closure four or more days after surgery when the wound was clinically considered appropriate for closure. Patients in the PC group had skin closure at the time of surgery. Results Incidence of SSSI was significantly less in the DPC group (7.4%) compared to the PC (42.9%) (p= 0.004). However, the median time of DPC was the 10th POD, i.e., these wounds required considerable time to become clinically suitable for closure. Incidence of fascial dehiscence was comparable between the two groups (p= 0.67). Length of hospital stay (LOS) was 13.8 days in the DPC group compared to 13.5 days in PC; the difference was not significant (p= 0.825). Conclusion DPC of the skin incision resulted in the reduction of SSSI. However, this did not translate into a reduction in hospital stay, as it took considerable time for these wounds to become appropriate for DPC, thus bringing into question any real advantage of DPC over PC.

The impact of bariatric surgery on atherosclerosis is a relatively less studied subject. Obesity has been identified as an independent risk factor for cardiovascular disease (CVD). Carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis and risk of CVD, has been found to be associated with obesity. Recent literature has shown that there is significant reduction in CIMT following bariatric surgery. The aim of this study was to evaluate the impact of bariatric surgery on CIMT and risk of CVD in an Indian population. This is a prospective study conducted in a tertiary referral centre in India. Patients undergoing bariatric surgery from December 2017 to September 2019 were included. CIMT measurements and American College of Cardiology/American Heart Association (ACC/AHA)-pooled cohort CVD risk scores were done before and at 6 months and 12 months after surgery. Fifty-four patients were enrolled, of which 70% were females. Mean age was 40.8 ± 10.7 years. Mean pre-operative weight and mean BMI were 115.2 ± 21.9 kg and 45.9 ± 6.5 kg/m2, respectively. Patients who completed 12-month follow-up were considered for analysis of outcomes. There was significant reduction in BMI to 33.1 ± 5.7 kg/m2 at 12 months after surgery (p

Encouraged by the excellent outcomes of one anastomosis gastric bypass (OAGB) reported by many authors, we added this procedure to our bariatric armamentarium in 2015. Here we present our initial experience of 68 cases and findings from routine upper gastrointestinal endoscopy at 1 year. This is a retrospective analysis of a prospectively maintained database of a single surgical unit in a tertiary referral centre. Patients undergoing OAGB from January 2015 to May 2019 were included. A fixed biliopancreatic (BP) limb length of 200 cm was used in all patients. Surveillance endoscopy was done at 1-year follow-up. Sixty-eight patients, of whom 67.6% were females, were analysed. Mean age was 40.8 ± 1 years. Mean preoperative weight and body mass index (BMI) were 131 ± 24.7 kg and 51 ± 7 kg/m2, respectively. Median follow-up was 23 months (range 9–55 months), with 88% follow-up at 6 months and 1 year. At 1 year, mean total weight loss (TWL) and excess weight loss (EWL) were 35% and 71%, respectively. Endoscopy at 1 year revealed a 9.5% rate of marginal ulcers, majority of which healed with conservative treatment. Eighty-eight percent patients had complete remission of diabetes, and 94% had complete remission of hypertension. There was no 30-day mortality. OAGB is a safe and effective bariatric procedure with excellent short-term outcomes in terms of weight loss, resolution of obesity-related co-morbidities and complications. Routine surveillance endoscopy at 1 year may detect asymptomatic marginal ulcers and, thus, prevent ulcer-related complications.

Cholecystectomy is one of the commonest general surgical procedures performed all over India. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality. BDI increases the cost of treatment and is a common reason for a medicolegal suit against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for “Safe Laparoscopic Cholecystectomy” and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects especially in small peripheral centers was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have “Safe Cholecystectomy” guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group.

Background Several studies have reported short and medium-term outcomes of laparoscopic sleeve gastrectomy (LSG) in patients with class I obesity and type 2 diabetes mellitus (T2DM). However, literature on outcomes beyond three years is scarce. The present study discusses the 5-year results of a previously reported cohort of 20 patients with class I obesity and T2DM, who had undergone LSG between March 2012 and March 2015. Materials and methods Patients were followed up in the bariatric clinic at yearly intervals as per institute protocol. Primary outcome was proportion of patients with a glycated haemoglobin (HbA1c) level of 6.5% or less, 5 years after LSG. Secondary outcomes were percentage total weight loss (%TWL), excess weight loss (EWL), weight regain and complications. Results Out of 20 patients, 9 (45%) were male and 11 (55%) were female. Mean age was 41.6 ± 9.5 years. Mean pre-operative weight and BMI were 94.8 ± 14.4 kg and 33.4 ± 1.2 kg/m2, respectively. Median duration of diabetes was 42 months. Mean pre-operative fasting plasma glucose (FPG) and HbA1c were 171.1 ± 56.8 mg/dL and 8.7 ± 1.6%, respectively. Of the 17 patients available for follow-up at 5 years, 9 (52.9%) achieved HbA1c Conclusion Laparoscopic sleeve gastrectomy is a reasonable option as a metabolic procedure for patients with T2DM and class I obesity.

Catheter malfunction secondary to omental wrapping is a frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Of the various methods of peritoneal dialysis catheter insertion (PDCI), open surgical insertion under local anesthesia is most widely practiced. Laparoscopic omentectomy is often undertaken as a salvage procedure in case of malfunctioning catheters. However, there is no randomized controlled trial (RCT) to evaluate the role of prophylactic laparoscopic omentectomy on catheter function. This pilot RCT was undertaken to evaluate the impact of laparoscopic omentectomy on the incidence of catheter malfunction.Consecutive patients were randomized into three groups: laparoscopic PDCI with omentectomy (Group A), laparoscopic PDCI without omentectomy (Group B) and open surgical PDCI (Group C). The primary outcome was the incidence of catheter malfunction at 6 weeks and 3 months.Forty-one patients completed follow-up, with 16, 11, and 14 patients in Groups A, B, and C, respectively. Incidence of catheter malfunction was 6.2%, 27.3%, and 14.3% in Groups A, B, and C, respectively, at 6 weeks and 6.2%, 36.4%, and 21.4% at 3 months, respectively. In patients with previously failed catheter insertion (Laparoscopic omentectomy may be associated with a lower incidence of catheter malfunction, especially in patients with previously failed peritoneal dialysis catheter. Data from this pilot RCT can be used to design a large trial with an adequate number of patients.

Incidental gastric and small bowel lesions are commonly encountered during bariatric surgery. Resection of these lesions with negative margins in the same sitting is curative; however, this may necessitate intraoperative change of plan. We present a 44-year-old super obese lady in whom an exophytic jejunal mass was found at 80 cm from the ligament of Treitz, which necessitated a change of procedure from one anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB). The final pathology was ectopic pancreatic tissue. Running the small bowel during initial diagnostic laparoscopy should be a routine step before division of stomach, to avoid technical complexities when operative plan is changed in order to resect an incidentaloma. Bariatric surgeons should be well versed with all the standard bariatric procedures.

There is limited data on the safety and efficacy of metabolic and bariatric (MBS) surgery in patients with advanced liver fibrosis. This is a retrospective analysis of data of patients with advanced liver fibrosis undergoing MBS at a tertiary care centre. Weight loss and complications were analysed. Transient elastography and liver biopsy findings 1 year after surgery were compared with baseline. Twenty-two patients had cirrhosis and 16 had stage 3 fibrosis; all were Child Pugh A. Majority (76%) underwent sleeve gastrectomy. Mean excess BMI loss was 65.8 ± 18.9%. There were no leaks or 30-day mortality. One patient with cirrhosis had late mortality due to liver decompensation. Preoperative and postoperative median LSM were 15.5 kPa (interquartile range IQR = 24.4–11.6) and 10.9 kPa (IQR 19.3–7.6), respectively. Preoperative and postoperative median CAP were 352.5 dB/m (IQR = 372–315.5) and 303 dB/m (IQR 331–269.5), respectively. On follow-up biopsy, nine of twelve patients had improvement in fibrosis, while three had no change. Four out of five patients in the cirrhotic cohort had improvement in fibrosis stage and LSM improved in all of them. Five out of seven patients with stage 3 fibrosis had an improvement in fibrosis stage and none progressed to cirrhosis. LSM improved in three of these five patients. MBS has the potential to ameliorate advanced liver fibrosis, including cirrhosis. Transient elastography can be used as an effective tool for screening and follow-up of liver disease in patients undergoing MBS.

INTRODUCTION: One German surgeon (Eric Muhe in 1985)* and three French surgeons** (Philippe Mouret in 1987, Jacque Perissat in 1989, and Dubois F in 1990) are credited with having performed first* laparoscopic cholecystectomy and first** video-assisted laparoscopic cholecystectomy, respectively. Laparoscopic cholecystectomy became the procedure of choice (gold standard) for benign symptomatic gallbladder disease as well as asymptomatic gallbladder stones in India. There have been adoption and acceptance for laparoendoscopic incisional/ventral hernia repair. Actually, laparoendoscopic repair of incisional/ventral hernia, laparoscopic solid organ removal (spleen and adrenal), and laparoscopic fundoplication (gold standard) have been standard of care even in the absence of Level 1 evidence over the past three decades. AIM: However, acceptance, adoption, adaptation, and performance of laparoendoscopic groin hernia surgery have been slow over the past three decades among practicing surgeons and surgical trainees. RESULTS: The laparoendoscopic groin hernia repair has yet not gained the same status as for the procedures mentioned above (VS). The reasons are multifactorial and relate to obtaining adequate and proper training covering laparoendoscopic groin hernia repair. The first and foremost reason is that endoscopic repair of groin hernia is considered an advanced laparoscopic procedure as opposed to open hernia repair. Preceptorship–proctorship (PP) model, which worked extremely effectively for teaching and learning of laparoscopic cholecystectomy, could not be established for groin hernia yet. There is no effective simulator developed for any of the standardized techniques, i.e., totally extraperitoneal (TEP) and/or transabdominal preperitoneal repair (TAPP). The complications, for example, intestinal obstruction and major vascular injury, which were never seen during open era, also brought about criticism as well hampered the growth of laparoendoscopic groin hernia repair. In emerging economies such as India and other Asian countries, high cost of laparoendoscopic repair (tacker and specialized meshes) has been responsible for reduced penetration among practicing surgeons and patients. Therefore, the laparoendoscopic repair of groin hernia has been limited to major metropolitan corporate hospitals and small number of tertiary care public hospitals in metropolitan cities. The advantages of minimally invasive approaches for the repair of groin hernias have not benefited the masses in rural and semi-urban geographic areas of India. CONCLUSION: Training opportunities for the teaching and learning laparoendoscopic repair of groin hernia have remained limited for vast majority of practicing surgeons and surgical trainees in India. With development of cadaveric (TEP and TAPP) and live anesthetized animal model (TAPP), it has been possible to establish training opportunities for practicing surgeons at few institutions. We also recommend and encourage expert surgeons to provide training opportunities for those who wish to learn the surgical skills of laparoendoscopic repair of groin hernia by giving their time for PP model. Furthermore, establishment of specialized hernia centers will go a long way to fill this void.

Laparoscopic Roux-en-Y gastric bypass (LRYGB) involves creation of a small gastric pouch by sequential firing of stapler. During stapler firing, the orogastric tube (OGT) needs to be withdrawn to avoid inclusion in the staple line. We report a rare complication of inadvertent stapling of the OGT during creation of the gastric pouch. A 37-year old man with body mass index (BMI) of 52.5 kg/m2 and type 2 diabetes mellitus, obstructive sleep apnoea, and gastro-oesophageal reflux disease, underwent LRYGB, with a biliopancreatic limb of 70 cm and an alimentary limb of 130 cm. Before firing the stapler for gastric pouch, the anaesthesia team was requested to withdraw the OGT, and they confirmed that it was done. The stapler was fired without any difficulty. Gastrojejunostomy was also done using linear stapler without any hindrance. The enterotomies were closed with absorbable sutures. Methylene blue leak test was found to be negative. Just before extubation, the anaesthesia team asked us if the OGT could be removed! To our horror, the OGT could not be pulled out on gentle tugging, confirming inclusion of the OGT in the staple line. The patient was induced again and re-explored immediately, with endoscopic guidance. Both the pouch and remnant stomach were opened, the cut ends of OGT freed from both staple lines, and the tube removed. The openings in the pouch and remnant stomach were closed with stapler. Methylene blue leak test and air insufflation test were done and found to be negative. Postoperative recovery was uneventful and the patient was discharged on day 5. Review of the recorded video was done but the OGT was not visualised through the initial gastrotomy as the OGT had possibly been stapled during the last vertical firing higher up near the fundus. Stapler firing over the OGT can occur insidiously without the surgeon’s awareness. In this case, it was only suspected when the anaesthesia team asked us matter-of-factly whether the OGT could be removed. We had presumed that it had been removed before the first firing. Some surgeons prefer to keep the OGT for a day after surgery. Had that been our practice, this complication would have mandated a re-surgery in the early postoperative period. Such complications occur when the surgeon fails to request the anaesthesia team to remove the OGT or if there is poor communication between the surgical and anaesthesia teams. Sometimes, it can be due to change in the anaesthesia team during the procedure. In our case, though the anaesthesia team was the same, there was a new anaesthesia registrar who was involved in a bariatric surgical case for the first time. Use of transparent drapes, if available, may be advantageous, enabling the surgical team to see the OGT. The openings in the pouch and remnant stomach were closed with a stapler, as it was thought to be a more secure and faster method than oversewing. However, if the pouch is too small to allow stapler closure, simple suture closure should be done. Inclusion of orogastric tube in the staple line should be a ‘never event’. This case report highlights the importance of good communication between the surgical and anaesthesia teams, not only during the staple fire, but throughout the procedure.

Acute fulminant necrotising colitis is an uncommon presentation of amoebiasis, which can be precipitated after corticosteroid therapy. Clinicians treating patients with COVID-19 with corticosteroid therapy should be familiar with this condition to avoid delay in diagnosis. The disease is associated with high mortality, and prompt diagnosis and management are essential for salvaging patients. We report successful management of a patient who developed this complication following administration of steroids for COVID-19.

Surgical infections cover a broad spectrum of infections involving various organ systems and are caused by various organisms. The common feature of all surgical infections is that they may require surgical treatment, a process called “source control”. These infections are essentially caused by violation of an epithelial barrier by surgery, trauma or any endogenous pathology like ischaemia, obstruction, etc. Thus, the term “surgical infection” encompasses all pathologies, from a minor wound infection to fatal infections like necrotizing fasciitis or bowel gangrene. Depending on the type of infection, the “source control” can be as simple as just removal of a suture to drain an infected wound, to extensive debridement or organ resection.

Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years. This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution. Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15–58 years). The mean operative time was 94 min (range 64–144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2–19 days). The mean duration of follow-up was 5.5 years (range 6 months–13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date. In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate.

The COVID-19 pandemic has added a huge strain on health care resources globally. For the developing world and low-to-middle income countries (LMIC), the burden has been even greater. Patients with COVID-19 require proper isolation and treatment. However, patients with other medical and surgical conditions should not be denied emergency treatment. While elective surgeries may be deferred, emergency surgeries should not wait. Therefore, hospitals should have a well-defined plan to allocate their resources judiciously, at the same time ensuring a safe ecosystem for health care workers and patients. Triage of patients attending the emergency department can ensure better delivery of health care in a resource-constrained set up. Based on our experience, we have formulated an algorithm for management of surgical emergencies during the COVID-19 pandemic. Guidelines from various surgical societies were referred to, and modified according to the needs and constraints of a LMIC.

Leiomyoma of the urinary bladder is a rare neoplasm of the bladder and accounts for 0.04 - 0.5% of bladder neo- plasms. Though most patients present with obstructive or irritative urinary symptoms, dyspareunia may be an un- usual presentation that should be kept in mind to avoid missing the diagnosis. Though MRI is considered to be the imaging modality of choice, cystourethroscopy with guided biopsy usually clinches the diagnosis. Surgical excision is the treatment of choice in this prognostically favourable tumour.

We report a rare case of a primary adrenal cortical malignancy presenting with spontaneous retroperitoneal haemorrhage in a young adult. To the best of our knowledge, this is the thirteenth such case to be reported in the English literature.

In the absence of trauma, perforated jejunal diverticulum (JD) is a rare entity. Perforated isolated JD is rarer. We report a case of perforated isolated JD in a 55-year-old woman who presented with features of peritonitis and had no history of trauma. Resection and anastomosis of the involved jejunal segment was performed.

Kimura disease is a rare chronic inflammatory disorder affecting young males of eastern countries. There are about 200 cases reported in the English literature , with