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BACKGROUND The use of local anaesthesia infiltration techniques may attenuate pain following endo-laparoscopic inguinal hernia surgery. We aim to reduce post-operative pain and the subsequent need for analgesia using a novel technique of local anaesthesia infiltration 'NATURE' (Nerves And Transversalis-fascia Using RopivacainE). METHODS This is a retrospective study of patients who underwent endo-laparoscopic inguinal hernia repair in two institutions in Singapore. Patients who received the local anaesthesia according to the new technique (intervention group) were compared to patients who received local anaesthesia only over their surgical incisions (control group). RESULTS Data on 97 patients were analysed. There were 50 (51.5%) patients in the intervention group and 47 (48.5%) patients in the control group. No significant differences were observed in the two patient population's baseline characteristics, operative time and cumulative need for medications. The intervention group reported lower pain levels immediately after surgery (1.4 ± 1.7 versus 2.4 ± 1.9, p

Objective:To explore motivations, self-regulation barriers and strategies in a multi-ethnic Southeast Asian population with overweight and obesity.Design:Qualitative design using semi-structured face-to-face and videoconferencing interviews. Data were analysed using thematic framework analysis and constant comparison method.Setting:Specialist weight management clinic.Participants:Twenty-two participants were purposively sampled from 13 April to 30 April 2021. Median age and BMI of the participants were 37·5 (interquartile range (IQR) = 13·3) and 39·2 kg/m2 (IQR = 6·1), respectively. And 31·8 % were men, majority had a high intention to adopt healthy eating behaviours (median = 6·5; IQR = 4·8–6·3) and 59 % of the participants had a medium level of self-regulation.Results:Six themes and fifteen subthemes were derived. Participants were motivated to lose weight by the sense of responsibility as the family’s pillar of support and to feel ‘normal’ again. We coupled self-regulation barriers with corresponding strategies to come up with four broad themes: habitual overconsumption – mindful self-discipline; proximity and convenience of food available – mental tenacity; momentary lack of motivation and sense of control – motivational boosters; and overeating triggers – removing triggers. We highlighted six unique overeating triggers namely: trigger activities (e.g. using social media); eating with family, friends and colleagues; provision of food by someone; emotions (e.g. feeling bored at home, sad and stressed); physiological condition (e.g. premenstrual syndrome); and the time of the day.Conclusions:Future weight management interventions should consider encompassing participant-led weight loss planning, motivation boosters and self-regulation skills to cope with momentary overeating triggers.

PURPOSE The ideal location for mesh placement in minimally invasive ventral hernia repair (VHR) is still up for debate. We undertook a systematic review and meta-analysis (SRMA) to evaluate the outcomes of patients who received intraperitoneal mesh versus those that received extraperitoneal mesh in minimally invasive VHR. METHODS We searched PubMed, EMBASE, Cochrane, and Scopus from inception to May 3, 2021. We selected studies comparing intraperitoneal mesh versus extraperitoneal mesh placement in minimally invasive VHR. A meta-analysis was done for the outcomes of surgical site infection (SSI), seroma, hematoma, readmission, and recurrence. A subgroup analysis was conducted for a subset of studies comparing patients who have undergone intraperitoneal onlay mesh (IPOM) versus extended totally extraperitoneal approach (e-TEP). RESULTS A total of 11 studies (2320 patients) were identified. We found no statistically significant difference between patients who received intraperitoneal versus extraperitoneal mesh for outcomes of SSI, seroma, hematoma, readmission, and recurrence [(RR 1.60, 95% CI 0.60-4.27), (RR 1.39, 95% CI 0.68-2.81), (RR 1.29, 95% CI 0.45-3.72), (RR 1.40, 95% CI 0.69-2.86), and (RR 1.22, 95% CI 0.22-6.63), respectively]. The subgroup analysis had findings similar to the overall analysis. CONCLUSION Based on short-term results, extraperitoneal mesh does not appear to be superior to intraperitoneal mesh in minimally invasive ventral hernia repair. The choice of mesh location should be based on the current evidence, surgeon, and center experience as well as individualized to each patient.

Smoke generated by cautery devices used during surgery may contain infective particles and may cause transmission of airborne viruses. This study determines whether live viruses are present in surgical smoke and evaluates the effectiveness of several proposed methods of removal so as to improve safety of healthcare workers.

Hemostasis is the term that refers to the typical response of the vessel to injury by activation of the blood clotting mechanism to limit bleeding. It has been an essential goal in any surgery to maintain hemostasis by restricting the blood loss thus reducing the need for blood transfusion and its complications. Hemostasis is more prudent during laparoscopic surgery where the intervention is performed through small incisions using the camera and specialized instruments, as even minor bleeding may affect visualization, the safety and quality of the procedure, and patient outcome.

Obesity is a rapidly rising problem worldwide in both developed and developing countries. It is not only reducing the quality of life but also shortens the duration of life with the comorbidities it brings [1]. Studies show that a two-point rise in the Body Mass Index (BMI) reduces one’s life expectancy by almost 10 years, and it also significantly affects the quality of life in morbidly obese patients [2]. Obesity is a serious medical problem as it links directly to many common comorbidities such as

Laparoscopic splenectomy has gained popularity as an option for patients having benign and malignant diseases as well as for trauma patients who are stable. Studies have shown that this procedure is prone to bleeding but with advanced technology and good anatomical knowledge of vasculature, the procedure is not only feasible but can be performed safely. Poulin who did the first laparoscopic partial splenectomy for ruptured spleen in 1995 proved it was possible. The inherent abundant blood supply and proximity of spleen to vital organs make it prone to 5–60% complication during its dissection, and hence utmost care and skills are needed during surgery [1].

Despite the best surgical techniques and measures, we still see recurrence rates between 0.5 and 15% in the current literature, following primary hernia repair and this depends on the hernia site, method of repair as well as circumstances of the timing of surgery [1]. With such a growing number of patients presenting with hernia recurrence, it is imperative that general surgeons are familiar and comfortable with various modalities of repair [2].

Very few surgical entities have fascinated surgeons over centuries than the complexity of inguinal hernia repair. Despite being one of the commonest procedures performed, the surgical fraternity all over the world is still in the quest for the final word on the best type of repair. Similarly, treatment of complex groin hernia remains the same [1]. Complex groin hernia can be defined as those with large size, e.g., inguinoscrotal hernia, sliding hernia, multiple recurrences, infected mesh and strangulation, etc. The approach to these hernias involves a great deal of preoperative preparations and decision-making that is carried through the operation and postoperative period. The laparoscopic approach in these cases is feasible and with good outcomes provided that the surgeon adheres to three M’s; mastery of the anatomy, meticulous dissection, and modus operandi [2]. No wonder hundreds of procedures have been described for the treatment of complex groin hernia. There has been always a concern about whether complex groin hernia can be treated with laparoscopy or not but more favorable outcomes have been found with laparoscopy than in open surgery [1].

Ventral incisional hernia is one of the most common log-term surgical complications after open midline surgeries and accounts for almost 20–30% of the cases [1, 2]. Repair of this incisional hernia is always challenging for general surgeons, especially for complex abdominal wall hernia (CAWH) which also have a major physical, social, and mental repercussions on patients [3]. Ramirez et al. devised a component separation technique (CST) which aims medicalization of rectus abdominis muscles by complete division of bilateral external oblique aponeurosis [4].

Laparoscopic liver resection was introduced as a surgical technique more than two decades ago. The initial successful laparoscopic anatomical hepatectomy was reported in 1996 by Azagra et al., who performed a left-lateral segmentectomy in a patient with a benign adenoma of segments II and III. The technique has grown from a novel procedure to an essential component of the highly specialised hepatobiliary unit armamentarium. Amongst the advantages of laparoscopic liver surgery are: reduced hospital stay, reduced postoperative pain, lowered risk of peritoneal adhesions, better cosmetic outcomes, and much shorter convalescence.

Lateral ventral hernia (LVH) repair is a challenging procedure for surgeons because of the difficult anatomy, the difficult location, the little knowledge on treatment as compared to midline defects, and the scarcity of cases and experience. Till now the poor outcomes including the potential risks of postoperative pain, infection, and higher risk of recurrence have compromised the success of several approaches [1–5].

There has not been a consensus on the superiority of a surgical approach for minimally invasive ventral hernia repair. This systematic review and meta-analysis (SRMA) aims to compare clinical, and patient-reported outcomes of robotic-assisted ventral hernia repair (rVHR) to traditional endo-laparoscopic ventral hernia repair (lapVHR). We searched PubMed, EMBASE, Cochrane and Scopus from inception to 16th March 2021. We selected randomised controlled trials and propensity score matched studies comparing rVHR to lapVHR. A meta-analysis was done for the outcomes of operative time, length of hospital stay, open conversion, recurrence, surgical site occurrence and cost. A total of 5 studies (3732 patients) were included in the qualitative and quantitative synthesis. Significantly shorter operative times were reported with the lapVHR as compared to rVHR (weighted mean difference (WMD): 62.52, 95% CI: 50.84–74.19). There was also significantly less rates of open conversion with rVHR as compared to lapVHR (WMD: 0.22, 95% CI: 0.09–0.54). No significant differences in patient-reported outcomes that was discernible from the two papers that reported them. Overall, rVHR is comparable to lapVHR with longer operative times but less open conversion. It is, therefore, important to have proper patient selection to maximise the utility of rVHR.

Value driven outcome (VDO) initiative is a value-based, patient-focused tool which utilizes a clinical outcome-based approach to optimize value of care based on clinically relevant quality indicators and costs required to achieve the care. In this study, we evaluate the impact of a VDO initiative on groin hernia repair, a commonly performed elective surgery in our hospital.A VDO initiative was implemented in 2019 to encourage elective inguinal hernia repair to be performed at a day surgery setting. A comparison of outcomes was made between hernia surgeries performed in 2019 with those in 2020 and 2021. Pre-defined criteria were used to select patients that can be operated at a day surgery setting. Patients' expectations were addressed preoperatively about day surgery procedure and postoperative recovery. Day surgery bundles were used to standardize pre- and post-surgery protocols. Pain control was optimized using a specialized local anesthesia regime.A total of 263 laparoscopic hernia surgeries were performed between May 2019 and December 2021. After implementation of VDO initiative, the percentage of patients discharged within 24 h increased from 78% in year 2019 to 97% in year 2020 and 99% in year 2021. Conversion rate for day surgery to short stay decreased from 9% in year 2019 to 1% in year 2020 and 2% in year 2021. In 2019 to 2021, there were no 30-day readmission, no hernia recurrence in 90 days, no conversion to open surgery.VDO initiative is a promising tool to deliver better value-based care for patients undergoing endo-laparoscopic inguinal hernia repair.

Objective: The aim of this work is to formulate recommendations based on global expert consensus to guide the surgical community on the safe resumption of surgical and endoscopic activities. Background: The COVID-19 pandemic has caused marked disruptions in the delivery of surgical care worldwide. A thoughtful, structured approach to resuming surgical services is necessary as the impact of COVID-19 becomes better controlled. The Coronavirus Global Surgical Collaborative sought to formulate, through rigorous scientific methodology, consensus-based recommendations in collaboration with a multidisciplinary group of international experts and policymakers. Methods: Recommendations were developed following a Delphi process. Domain topics were formulated and subsequently subdivided into questions pertinent to different aspects of surgical care in the COVID-19 crisis. Forty-four experts from 15 countries across 4 continents drafted statements based on the specific questions. Anonymous Delphi voting on the statements was performed in 2 rounds, as well as in a telepresence meeting. Results: One hundred statements were formulated across 10 domains. The statements addressed terminology, impact on procedural services, patient/staff safety, managing a backlog of surgeries, methods to restart and sustain surgical services, education, and research. Eighty-three of the statements were approved during the first round of Delphi voting, and 11 during the second round. A final telepresence meeting and discussion yielded acceptance of 5 other statements. Conclusions: The Delphi process resulted in 99 recommendations. These consensus statements provide expert guidance, based on scientific methodology, for the safe resumption of surgical activities during the COVID-19 pandemic.

AIM To assess the outcomes of metabolic surgery in overweight and obese patients in Asia with type 2 diabetes (T2D). MATERIALS AND METHODS The treatment outcomes of 1999 patients from the Asian Diabetes Surgery Summit database were analysed. The changes in treatment effects across time were assessed with respect to the surgical procedures performed by using generalized estimating equations. RESULTS The most commonly performed procedure was the single-anastomosis gastric bypass (32.6%). Weight (from 106.2 ± 25.1 to 77.9 ± 18.8 kg), body mass index (BMI; from 38.7 ± 7.9 to 28.5 ± 5.9 kg/m2 ), blood sugar (from 9.3 ± 4.1 to 5.7 ± 1.8 mmol/L) and HbA1c (from 8.4% ± 1.8% to 6.0% ± 1.1%) significantly improved from baseline to 1 year (P

The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias.Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed.41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up.Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

Background The COVID-19 pandemic has resulted in significant changes to surgical practice across the worlds. Some countries are seeing a tailing down of cases, while others are still having persistent and sustained community spread. These evolving disease patterns call for a customized and dynamic approach to the selection, screening, planning, and for the conduct of surgery for these patients. Methods The current literature and various international society guidelines were reviewed and a set of recommendations were drafted. These were circulated to the Governors of the Endoscopic and Laparoscopic Surgeons of Asia (ELSA) for expert comments and discussion. The results of these were compiled and are presented in this paper. Results The recommendations include guidance for selection and screening of patients in times of active community spread, limited community spread, during times of sporadic cases or recovery and the transition between phases. Personal protective equipment requirements are also reviewed for each phase as minimum requirements. Capability management for the re-opening of services is also discussed. The choice between open and laparoscopic surgery is patient based, and the relative advantages of laparoscopic surgery with regard to complications, and respiratory recovery after major surgery has to be weighed against the lack of safety data for laparoscopic surgery in COVID-19 positive patients. We provide recommendations on the operating room set up and conduct of general surgery. If laparoscopic surgery is to be performed, we describe circuit modifications to assist in reducing plume generation and aerosolization. Conclusion The COVID-19 pandemic requires every surgical unit to have clear guidelines to ensure both patient and staff safety. These guidelines may assist in providing guidance to units developing their own protocols. A judicious approach must be adopted as surgical units look to re-open services as the pandemic evolves.

Introduction Obesity is a risk factor for pregnancy-induced hypertension, preeclampsia, gestational diabetes, and large gestational age pregnancy. Bariatric surgery is widely accepted to treat obesity but associated with small for gestational age fetuses. Objective To report maternal and fetal outcomes after bariatric surgery in morbidly obese Asian females. Setting University Hospital, Singapore. Methods We maintain a prospective cohort of patients who underwent bariatric surgery in our institution. Maternal and fetal outcomes are compared with a control group of 31 pregnancies matched for age, parity, presurgery weight, and year of delivery. Results Twenty-four pregnancies occurred in 16 patients in our postoperative cohort. Morbidly obese women in the control group were more likely to develop gestational diabetes (19.3% versus 5.0%, P = .150) and pregnancy-induced hypertension/preeclampsia (32.2% versus 0%, P = .003) compared with the postoperative group. Of fetuses, 37.5% in the bariatric group had low birth weight compared with only 9.4% fetuses in the control group (P = .016). Preoperative body mass index, short interval between conception and surgery, and poor weight gain during pregnancy did not predict for small for gestational age fetuses. Subsequent weights were available for 37.5% of the children in the surgical cohort and none of these children exhibited growth retardation. Conclusion Bariatric surgery lowers the risk of maternal co-morbidities and large gestational age fetus during pregnancy. Asians are at high risk of small for gestational age pregnancies after bariatric surgery and should undergo close monitoring for fetal growth throughout their pregnancy.

The COVID-19 pandemic has affected surgical education and training significantly. The main impact to surgical residency training is the reduction in number of patients (in caseload and case mix) and the conversion of face-to-face meetings into virtual ones for CME and clinical governance-related events. Assessment of surgical residents by examination (namely the Joint Specialty Fellowship Examination with the College of Surgeons of Hong Kong and the Royal College of Surgeons of Edinburgh) was cancelled at the peak of the pandemic, with resumption after acceptable COVID compatible adjustment was made to the format. The migration of CME events into a web-based one has resulted in greater connectivity with more audience. The potential and challenges of virtual format in surgical education include strategy and resources for sustainability; choice of optimal model for effective learning and surgical skills acquisition. In a post-COVID world, the model of blended learning is likely to remain., Surgical education; COVID-19: teleconference; Surgical assessment.

Objective Laparoscopic appendectomy is a common operation that is frequently performed by junior surgical residents. We investigated the effect of a structured training program on the proficiency of junior residents in acquiring skills necessary in this operation. Design and Participants This is a randomized pilot trial. Between December 2014 and July 2018, twenty junior residents were recruited for this study. 11 were randomized to receive a structured training program of supervised, task-specific training. Each resident subsequently performed ten cases of laparoscopic appendectomy with their performance assessed for the last 5. The GOALS scale was used as the primary endpoint. Secondary endpoints were perioperative outcomes. The effect of intervention on these outcomes were evaluated assuming a linear mixed effect multi-level model. The study was single-blinded as the assessors did not know which group each resident belonged to. Results There were no statistically significant differences in the total GOALS score or any of its individual domains. After adjusting for the number of operations done within the trial, the mean difference between the total GOALS score was 0.07 (95% CI -0.76 to 0.90, P=0.866). Blood loss, hospital stay and postoperative complication rates were similar. There was suggestion of a shorter operative time (effect estimate -9.03, 95% CI -19.56 to 1.50) in the intervention arm although statistical significance was not achieved. No avoidable adverse events due to this study were recorded. Conclusion Structured training program did not significantly improve surgical performance and outcomes in laparoscopic appendectomy in this pilot trial. Despite these findings, residents can still potentially mount their learning curves in laparoscopy earlier in a safe environment with such a program which is especially important in the era of minimally invasive surgery.

Morbid Obesity is increasing worldwide at fast pace with associated co-morbidities also on the rise. Considering that Obesity is one of the main risk factors for developing a Ventral Hernia this will results that in the future we will experience a rise in those hernia in patients undergoing any abdominal surgery. There is no clarity on the best timing and choice for procedures. We are well aware also on the difficulties in hernia repair surgery and the relative outcome so adding obesity as co-factors amplify the challenges. In fact, today both general surgeons with expertise in abdominal wall repair and bariatric surgeons are faced with a new dilemma: the obese patient with an abdominal wall hernia. This article will briefly review the impact of obesity on the natural history of hernia, its associated complication, management strategies and outcome.

Surgical techniques for inguinal hernia repair have evolved rapidly from open methods to conventional laparoscopic totally extra-peritoneal (CTEP) and recently single-port TEP (STEP). As there is currently no randomized controlled trial (RCT) reporting long-term patient-reported outcomes between CTEP and STEP, we reviewed patients who were randomized to CTEP or STEP 5 years after surgery. Telephone interviews were administered to patients with primary unilateral inguinal hernia recruited for the RCT comparing CTEP and STEP in 2011. The modified Body Image Questionnaire was used to measure long-term patient-reported outcomes. Forty-two out of forty-nine of the STEP group and forty-one out of fifty of the CTEP group responded to phone interviews. Median follow-up time, demographic data and clinical outcomes were comparable between both groups. The Body Image Score (5–20: 5—least dissatisfied, 20—most dissatisfied; BIS score ± SD, STEP vs. CTEP, 5.33 ± 0.90 vs. 7.17 ± 1.87, p

The high recurrence rate of conventional open repair in the treatment of ventral hernias has caused some surgeons to adopt a paradigm shift in the treatment towards laparoscopic approach. Since its introduction in 1993, laparoscopic ventral hernia has offered a minimal invasive approach to repair of ventral and incisional hernias. It borrows many of the tenets of the traditional Rives-Stoppa-Wantz repair and places the mesh in a sublay position, usually placed one layer deeper in the intra-peritoneal position, often on an intact peritoneal layer. With time, several innovations and modifications to the laparoscopic repair have been developed. In this chapter we explore the indications, contra-indications, options of minimally invasive abdominal wall repair and reconstruction and the post-operative care.

Introduction Laparoscopic sleeve gastrectomy (LSG) outcomes among adolescents and factors associated with adolescent obesity in Singapore were evaluated. Methods Prospectively collected data of patients aged 16-19 years who underwent LSG was retrospectively reviewed. A lifestyle questionnaire, Berlin and Epworth scores, and Patient Health Questionnaire-9 scores were collected. Preoperative anthropometrics, comorbidities, weight loss and body composition outcomes were recorded. Results Among 208 LSGs, 13 (6.3%) were performed on obese adolescents. Mean age and body mass index (BMI) at first presentation were 19.1 ± 0.9 (range 16.8-19.8) years and 46.2 ± 6.3 (range 36-57) kg/m2, respectively. There was family history of obesity (n = 7) and regular consumption of high-calorie drinks (n = 12). Most patients had comorbidities (n = 12), including hypertension (n = 5), asthma (n = 4), diabetes mellitus (n = 3), hernia (n = 3) and obstructive sleep apnoea requiring continuous positive airway pressure support (n = 3). At one year, excess weight loss was 64.3% ± 34.7% (range 21.8%-101.5%), while BMI and fat mass dropped to 31.2 ± 7.6 (range 23-40) kg/m2 and 17.4 kg, respectively. Pain score was 2/10 at 24 hours after surgery. Mean postoperative stay was 2.7 days. No complications or readmissions occurred. Remission of diabetes mellitus and hypertension was reported in two of three and four of five adolescents, respectively, within one year of surgery. Conclusion LSG is a safe option for adolescents with good short-term weight loss outcomes and remission of metabolic comorbid conditions.

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.

Background Laparoscopic sleeve gastrectomy (SG) is a popular bariatric procedure in morbidly obese Asians. Objectives To investigate the effect of initial weight loss on midterm weight maintenance and remission of co-morbidities after laparoscopic SG in morbidly obese Asians. Setting University Hospital, Singapore. Methods Data of patients who underwent laparoscopic SG were analyzed. Change in body mass index (BMI), percentage of total weight loss (%WL), and of excess weight loss (%EWL) was calculated and remission of obesity-related co-morbidities was examined. Linear regression analysis was performed to determine the effect of initial weight loss on successful weight maintenance. Receiver operative characteristic curve analysis was used to define optimal cutoff values. Results Two hundred and seventy-two patients were included in this study. Mean preoperative weight and BMI were 115.4±25.5 kg and 42.5±8.0 kg/m 2 , respectively. Mean follow-up duration was 27.6±16.4 months. Successful weight loss of>50% EWL was achieved by 65.7%, 65.5%, and 50.8% of patients at 1, 2, and 3 years, postoperatively. There was a significant correlation of %EWL at 3 months with %EWL up to 3 years ( P ≤.005). Receiver operative characteristic analysis showed initial EWL of 35% at 3 months best predicted successful weight loss at 1 year (sensitivity 73.1%, specificity 81.4%). Patients achieving>35% EWL were significantly more likely to achieve remission of co-morbidities ( P ≤.005) at 1 year after surgery. Conclusion Early weight loss at 3 months predicts weight maintenance up to 3 years and remission of co-morbidities at 1 year after laparoscopic SG in Asians.

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed procedures for the treatment of obesity. Patients with obesity are more prone to experience opioid-related adverse events (ORAE). The objective of this study is to determine if a multimodal analgesia protocol (MAP) reduces ORAE and provides effective pain relief for patients after LSG. This study was conducted at University Hospital, Singapore. The MAP consists of mandatory pre-operative etoricoxib, intra-operative acetaminophen, and post-operative acetaminophen with optional post-operative tramadol. We identified and collected data for patients who underwent LSG between May 2010 and November 2015 and compared patients before and after the implementation of the MAP. One hundred fifty-eight patients were included and 68 patients were treated with the MAP. There were no differences in age, gender, body mass index, ethnicity, or comorbidities between the two groups except for the incidence of hypertension (p = 0.015). There was a significant reduction in the incidence of ORAE from 33.3 to 8.8% (p

Neurobiological feedback in surgical training could translate to better educational outcomes such as measures of learning curve. This work examined the variation in brain activation of medical students when performing laparoscopic tasks before and after a training workshop, using functional near-infrared spectroscopy (fNIRS). This single blind randomised controlled trial examined the prefrontal cortex activity (PFCA) differences in two groups of novice medical students during the acquisition of four laparoscopic tasks. Both groups were shown a basic tutorial video, with the “Trained-group” receiving an additional standardised one-to-one training on the tasks. The PFCA was measured pre- and post-intervention using a portable fNIRS device and reported as mean total oxygenated hemoglobin (HbOµm). Primary outcome of the study is the difference in HbOµm between post- and pre-intervention readings for each of the four laparoscopic tasks. The pre- and post-intervention laparoscopic tasks were recorded and assessed by two blinded individual assessors for objective scores of the performance. 16 Trained and 16 Untrained, right-handed medical students with an equal sex distribution and comparable age distribution were recruited. Trained group had an attenuated left PFCA in the “Precision cutting” (p = 0.007) task compared to the Untrained group. Subgroup analysis by sex revealed attenuation in left PFCA in Trained females compared to Untrained females across two laparoscopic tasks: “Peg transfer” (p = 0.005) and “Precision cutting” (p = 0.003). No significant PFCA attenuation was found in male students who underwent training compared to Untrained males. A standardised laparoscopic training workshop promoted greater PFCA attenuation in female medical students compared to males. This suggests that female and male students respond differently to the same instructional approach. Implications include a greater focus on one-to-one surgical training for female students and use of PFCA attenuation as a form of neurobiological feedback in surgical training.

Indocyanine green (ICG) fluorescent angiography has been routinely applied for various laparoscopic procedures to evaluate the tissue blood supply. A promising branch for this technology is represented by bariatric surgery, especially to estimate the risk of gastric leak after laparoscopic sleeve gastrectomy (LSG), which seems mainly related to ischemia of the stomach. 43 consecutive patients from January 2018 to March 2019 underwent in our institution LSG with intravenous injection of 5 ml ICG after the realization of gastric tube to evaluate the blood supply of the gastric tube. In all 43 cases, there have been no adverse events related to ICG. The vascular supply to stomach was estimated “satisfactory” along the stapled line in all cases. However, one patient showed signs and symptoms indicative of gastric leak in the fifth post-op day and diagnosis was confirmed by CT scan with Gastrografin. From our preliminary data, the intraoperative view of the blood supply of the stomach does not seem to represent a prognostic factor for the risk of gastric leak, suggesting a complex multifactorial etiology (intragastric hypertension? Abnormal inflammatory response?) which needs further data to be established.

Incidence of non-alcoholic fatty liver disease (NAFLD) is on the rise and is one of the most common causes of chronic liver disease worldwide. Obesity and metabolic syndrome are considered the most significant risk factors. Bariatric surgery is the only treatment modality in morbid obesity which allows long-term weight loss with improvement in associated co-morbid conditions. However, the effects of bariatric surgery on NAFLD are not well established. NAFLD fibrosis score (NFS) is a validated non-invasive scoring system used to assess advanced fibrosis. We used the NFS to analyse the impact of weight loss on NAFLD following sleeve gastrectomy.174 patients who underwent bariatric surgery between 2010 and 2016 were retrospectively reviewed. Multivariate analysis was performed using pre-operative patient characteristics, biochemical markers and TANITA body analysis measurements to determine significant risk factors for NFS 0.675. Additionally, the NFS was calculated at 6 months, 1 year and 2 years post-operatively to determine correlation with weight loss.Pre-operatively, 13.8% of our patients had significant fibrosis by NFS. Mean change in NFS was - 0.46 ± 1.02, - 0.55 ± 0.98 and - 0.55 ± 1.12 at 6 months, 1 year and 2 years respectively. This was significantly correlated with percent of total weight loss with R coefficients of 0.253, 0.292 and 0.274 respectively (P 0.05). 79.2% of patients with NFS 0.675 achieved resolution by 2 years post-operatively.Based on our study, we conclude that sleeve gastrectomy may be a viable treatment option for management of NAFLD in the obese.