Laparoscopic Surgery - Science topic

There is generally a paucity of guidelines, and with good reason. This article has a list of complications, and is a good review of problems to be aware of-

1. BMC Anesthesiol. 2018; 18: 117.

Published online 2018 Aug 21. doi: 10.1186/s12871-018-0578-5

PMCID: PMC6104011

PMID: 30131061

Survey of anesthesiologists’ practices related to steep Trendelenburg positioning in the USA

This publication lists some of the protective measures relating to skin and pressure areas, but duration and angulation may still lead to problems, and do not address cardiovascular, respiratory, ocular or cerebrovascular complications.

2.Safe and Standardized Trendelenburg Positioning

Avoid skin tears, pressure injuries and other complications by paying extra attention to common problem areas.

Emma Greene

Publish Date: August 9, 2020

https://www.aorn.org/outpatient-surgery/articles/outpatient-surgery-magazine/2020/august/safe-and-standardized-trendelenburg-positioning.

Yes, the management of UTUC and bladder Ca depends on many patient-related factors, including age, grade, stage, multifocality, bilaterality or status of contralateral kidney function….

For high grade, high stage, AND unilateral UTUC, radical Nephroureterectomy is recommended.

For low grade, superficial and single tumor, solitary kidney or bilateral involvement,…nephron sparing approach including ureteric resection and reimplantation is preferable.

But in this index case, we know the status bladder Ca (high grade pT1) and that of ureteric tumor was not mentioned.

If high grade or stage tumor, Radical cystectomy with Nephroureterectomy can be an option. But we need to consider the mentioned factors to decide.

Culdolaparoscopy offers less pain and better cosmesis.

Thank you so much for your Q. If I don't have a good laparoscopic facilities, sure I will go through open repair and vice versa

Dear Dr Sunny Chu Lik Au:

Thank for raising this important question. There is a dilemma of general or subspecialty. Subspecialty is important in developing the management of cases but in the same time it created a pinhole vision of the physicians and no one is looking to the patient as one unit and look to the overall need. Each subspecialty want to put the optimum for his work regardless of the overall need of the patient or his stage need.

I support my colleagues in the importance of training in general surgery for every other surgical specialty. I suggest 1 year as minimum time spend in general surgery if not making degree in general surgery as requirement for doing subspecialty study.

The question is interesting but it starts from the assumption that there is only one possible way of contagion. In reality this has not been fully proven. Between the two techniques, the laparoscopic one is less invasive, faster and therefore should involve less exposure and less risk ...

Please be reminded that surgeons should not subordinate their patients well being to their TECHNICAL expertise!

If you can accomplish your treatment goal by Laparoscopy then do so but if you can not do so, then Open!

Do it

It looks like the posterior vagus attached to the esophagus in its proximal course, then dissected away from the esophagus above the arrow (near the plastic tube). The distal part looks like perineural tissue that is distended with oedematous fluid and/or lymph.

Dear Meng Li,

I believe Mann-Whitney U test would be a proper choice to compare two-groups, on non-normal scales.

If you consider to compare the effect of scales as well, you can convert the data on different scales into a single scale (e.g. 0-101). See below paper for an example:

Hope this helps.

They are painful and I use transracial sutures to orientate the mesh but do not tie them, but pull them out after tacking

Check the probe manual for chemical sterilization, some probes may not be compatible for all solutions.  Cidex may be an option, or you can use a sterilized arthroscopic sheat with plenty of good quality sterile jel inside. But there is always a risk of perforation of the sheath, so the probe must be sterilized anyway. 

ultrasound manufacturers have to make money from probes, therefore it is not surprising to find out in time that the sterilizing solutions  cause detrimental effects on the probes.

thanks to all of you

can it be possible to extract the stent trans anally?If this is possible we will get a higher anastamosis.I am not quite clear about the question.

Mucocele of appendix in itself is not common. Most of the cases remain silent till they   present as acute appendicitis and diagnosis is per-op or HPE. But to such a giant lump lying asymptomatic without any mass effect or pain, and not ruptured till this size is reached, is very uncommon.

Just as today's science fiction is tomorrow's science so too is today's pharmaceutical wonder tomorrow's poison. For example, Warfarin, a rat poison will soon be phased out with the APPROPRIATE introduction of DOACs - even the term has changed! A year ago they were called NOACs! They're not novel anymore. 

Personally, I would be very wary of any loco-regional recommendations, due to the fear of starting unscientific trends and vogues. I do believe while the information you provide above might be of some relevance to the Indian society, if freely and easily available (I.e. Unadulterated spices and legumes at a price cheaper than reliable pharmaceuticals) then by all means start a well- designed randomised controlled trial, with at least 5-10 years follow up, given the vast number of compounding variables. If not, one is only able to make suggestions based on personal observation to individual patients in good faith. Faith, albeit well- intended is not science! 

Please remember, all this is an international forum of communication, and it's called research gate! In the interim, thank you for providing the linked article. I will definitely go through it to look at the quality of the data provided. 

Please remember, Charaka Samhiti, the origins of Ayurveda, lists the ethical duties of the Doctor, the nurse, the patient and the drug - the drug must do what it is expected to do! There was an ethical requirement for the doctor to study all the international literature he could get hold of, and make intelligent adjustments to his prescriptions accordingly, so the nurse-compounder could mix better potions and the patient remained trusting and the doctor respected and trustworthy. 

If one has knowledge of ancient cultural practices, and if one wishes to utilise such information in treating another - human or non-human person, I believe they are duty-bound to do so in a scientific manner!

It is not without unfortunate reason that despite an exceedingly high level of knowledge and information in the East those of us from the Western scientific community do not publish our work nor rely upon information published in Eastern journals. 

Again, Dr Reddy please do source locally relevant dietary modifications and do not rely too much on surgical techniques tried and tested in a different part of the world in an area where John Bunni will tell you there remains a lot of controversy, because colleagues "treat" using techniques on which there is little consensus data. 

Dear Deborah. We have, analogously to Your experience, in our study report speculated that, besides choosing a mesh with good ingrowth features - which excludes ePTFE and biological material - a permanent fixation is advisable in immunosuppressed organ transplanted incisional hernia patients repaired with IPOM+. Additionally, allowance of a generous overlap; advises not followed in the presented case. But we are short on scientific evidence.

Dear Sir,

Many thanks for your advice and sharing your experience. I'll keep u posted, he is planned for Thursday 

I would never consider using an e-PTFE product in intraperitoneal position for at least following three reasons: excessive shrinkage (you may call it scar compression),  limited in-growth and therefore need for permanent fixation and the price. (besides the problematic behaviour in case of infection). As Prasanna said there is no ideal mesh for intraperitoneal position. Composite meshes with absorbable barrier like Ventralight ST or Parietex composite performed best in the past.

Probably the upcoming trend to avoid placement of intraperitoneal meshes even with endoscopic techniques will resolve the problem with some mesh related complications ( subacute or potential ones) faster than the industry could offer us the next best mesh ever.  

laparoscopic appendectomy is generally well tolerated with low levels of post-opetive pain. To further improve the postoperative comfort is useful to infiltrate the place of the trocars with ropivacaine 7.5%, and avoid placing pelvic tubular drain at inflated abdomen,or avoid to place it at all.

Whilst the arguments for removing a normal-looking appendix are understandable, this undermines the logic for a diagnostic laparotomy. It must be explained to the patient that the appendix will be removed, unless other significant pathology is found, regardless of its appearance. Many patients may not wish to accept this logic. 

Furthermore the reported high risk of recurrence still does not mandate surgery. The same argument used to be made for diverticulitis, but now indications for sigmoid colectomy are very much more stringent. The difference, of course, lies in the relative simplicity (and lack of complication) of appendicectomy. No studies have been made on the application, however, of Sod's Law! If appendicitis recurs (but inflammation remains clinically localized, and not complicated by bacteraemia, constitutional upset or other factors are at play, a second, or even third course of antibiotics may still be reasonable.

It is important to involve the patient in this discussion, because it is ultimately him or her that will carry the consequences. The drawback of this approach is that social reasons for or against intervention may then predominate. 

I remember well, as an SHO in UK, how a well-to-do patient persuaded the consultant to perform surgery, which was strictly not necessary, because he had an important up-coming business job interview in Cape Town. He had been on a boat holiday in the Mediterranean and no-one noted that in fact he had a tinge of jaundice. He died of the post-operative consequences of liver failure induced by halothane used for his GA.

For RIF pain without obvious clinical and laboratory signs of inflammation, of course, antibiotics are probably not indicated, and a wait-and-see policy entirely appropriate. There is rarely need for an instant confirmatory diagnosis, as has been proven by institutions which have abandoned appendicectomy operations at night.

All this said, it is dangerous to be fixed in a belief. Learned opinion in 1900 was that 5 days should elapse to allow inflammation to settle before intervening to perform an appendicectomy. Sir Frederick Treves had become the authority on the subject, having performed over 2000 appendicectomies by 1902. In that year, Kind Edward VII fell ill and developed an appendicular abscess; two days before his scheduled coronation, Treves insisted on drainage, despite  the fact that many guests had already arrived. The big event had to be postponed several weeks. Treves had learnt how conservative treatment of his daughter two years earlier, when she was suffering flagrant appendicitis, led to her death. He did not want the guests to be attending a royal funeral... 

A novel way of treating a short stricture at this level is to excise it with a CDH 33 stapler. The head of the stapler is placed in the proximal aspect of the stricture via colotomy well proximal to the stricture. The body of the stapler is placed per anus. The spike is deployed through the lumen of the stricture and the head is connected. The stapler is then closed and fired. This will only work if the stricture is less than 1 cm in length. 

Primarily to remember that the main object of a lap chole is NOT to remove the gallbladder. 1st, 2nd and 3rd objects are "Do not damage the hilar structures". As a #4 comes to remove the gallbladder. If this cannot be done safely (as in a difficult case of long standing cholecystitis) go directly for subtotal cholecystectomy/amputation of the anterior wall of the gall bladder. Do NOT attempt dome down/fundus down as this is the recipe for disaster. All extensive bile-duct & vascular injuries start with identical descriptions in the op notes "Area is so inflamed that we start dissecting from the fundus and downwards..". If you even consider this technique, change tack at once and go for limited amputation. No one dies from a remnant gall bladder where the front wall is missing!

I agree with Hamin. But if you take all these facts together it is better to have excellent training and expertize in laparosocopic appendectomy so the surgeon could have less preoperative strategic difficulties. When I started laparoscopic appendectomy it was easier for me to do open appendectomy. Now after more than 200 lap appendectomies I realise that it is more simple procedure technically (for me) and the easiest operations last 15 min and the patients recover ealier.

Therefore whatever the studies claim, my opinion is that laparoscopic appendectomy is better procedure in experienced hands.

Cold light means that the proportion of blue, green and red are approximately equal, and are produced by a source around 7000 Kelvin degrees. Domestic light has an increased proportion of red (warm) light and is produced by a source around 3000 Kelvin degrees. Cold light does not mean that its temperature is lower. If you will touch the bulb you will have a burning. 

This sounds like an ideal scenario to run a network meta-analysis with three potential treatment options (open appendicectomy, lap appendicectomy A, lap appendicectomy B); provided the patients in each of these RCTs are comparable. What I mean is that any patient in the network could have theortically been randomly allocated to open, lap A or lap B; and that the lap options A and B are not used selectively depending on a particular clinical or patient factor. This is known as the transitivity assumption for network meta-analysis, and if it cannot be met, then you should not really run an NMA.

You will then be able to use the indirect comparisons in the network to draw inferences about the effect estimate of 'lap A' vs 'lap B' using the common comparator treatment 'open'. Although you do not have any direct (lap A vs. lap B) trials, this should still provide a useful result, provided you keep in mind the known sources of clinical heterogeneity. Here are some useful links for this:

- http://www.bmj.com/content/331/7521/897 is a seminal paper by Caldwell and provides a good introduction to the theory and principles.

- http://www.mtm.uoi.gr/ which contains methodological step by step instructions, and a link to the paper by Chaimani et al with the Stata network meta package, and the graphical tools.

All the best.

The New European Surgical Academy is working in this type of robotic device.

very interesting. I also have some experience performing TEP hernia repair under spinal anaesthesia in selected patient who general anaesthesia is contraindicated. i didn't feel the different between both methods. here is the link of my own video of bilateral TEP under spinal anaesthesia in moderately severe asthma patient. 

well i strongly agree with you about the weakness of TK 13 on stratifing comorbidities therefore in current practice i routinely use PC on patients with either grade 2 AC bearing severe comorbidities and failing to responf to medical treatment after three days of high dose broad spectrum antibiotics

the following question, in my opinion, should be how to manage elderly or severely hill patients after the acute phase resolved and the dreinage remains in site

i'm curently studing the recurrence rate among patients treated by PC alone

any experience on the issue?

I have no experience in their use

Well need to find some sources for you

however there are several obvious reasons

1. longer operation times are usually associated with more complex operations or procedures where something is not fitting well and the surgeons has to take longer to complete the task at hand.

2. in long surgeries usually the staff and operating team changes again due to several reasons resulting in greater staff movement and greater risk of contamination.

3. bacterial flora flourishes back to normal in 2 hours time and double there on exponentially if the kits are not changed and surgeon does not re0scrib

4. These procedures are associated with infusion of larger amount of fluids including colloids, This change in homeostasis is a major risk factor in development of complications

5. Longer surgeries specially laparoscopy are assocaited with greater CO2 Level absorption and risk of hyper carbia and poor ventilatory effort is more common

6. recovery time from longer complex surgeries are extended and usually associated with elective or manadatory mechanical ventialtion postoperatively

I can think of these only . I think other can add a few points

regards

I think that everyone should use the technique that he is familiar with and there are no major concern in experienced hands. We should always keep in mind that in previously operated patient, if you encounter a problem with veress or direct insertion it is then so difficult to justify your approach legally. The use of the hasson technique is safer and should be advocated in these cases. 

I was trained to do laparoscopic cholecystecomies in the American position during my residency. Then when i was working in France i learned doing them in the French position. I have been using exclusively the French position ever since.

Here's a list of the pros and cons of each position (in my humble opinion):

Best ergonomics and most comfortable for the surgeon who is positioned in front of the operative field. Possibility to dissect the cystic duct from the left and the right.

Facilitates bi-manual operative technique where the left hand creates counter-traction and exposes.

Can be performed with an inexperienced assistant.

Best position for CBD exploration.

Not ergonomic for the assistant whose position is not so comfortable holding the camera with the left hand and being immobile for the whole operation.

Crossing of the surgeon's right arm with the assistant's left.

A bit tricky when performing an intraoperative cholangiogram.

Best for starting experience with laparoscopic surgery. Only the surgeon's right hand operates.

More interesting for the assistant who retracts and exposes using both hands. It's a good entry level exercise for laparoscopic surgery.

The assistant's position is more comfortable and no arm crossing occurs.

Easier to do an intraoperative cholangiogram.

The cystic duct can be approached only from the left side.

The surgeon holds the camera with his left hand and thus cannot use both hands to dissect.

Dependence on a trained and competent assistant.

Needs two monitors: one for the surgeon and one for the assistant.

I hope this list of thoughts helps.

1) place gauze square / Raytec in hepatorenal pouch and place all stones onto this; at end of operation place Raytec + stones into endocatch

2) place stones into sterile glove but be careful when extracting from umbilicus so as not to spill stones intraperitoneally

When you have over 980 DS cases you realize that DS is the most effective and also know how to lower the side-effects. None of our DMT2 remain diabetic and as afar as WL, no opertion is as effcetive as DS

Although theoretically it is possible, but i will resist from employing this technique simply because any lesion in breast can be removed cosmetically pleasing circum areolar incision and no harm has occured if lesion turns out to be suspicious for malignancy.

Even if we only have 1 to 2 cases per year I would include my patients.

Its preferable to close it as soon as the general condition allows which in most cases ranges from 2 to 4 weeks with a professional TPN  specialist as the delay never benefit 

Here in Chile we give every year Laparoscopic Courses for Gynecologist basic and advanced (www.eieschile.cl ) from 2007. EIES (www.eiesonline.com) give these courses from 2003 uo today in Latinamerica and another countries.

We use pelvic training models called "Evas" from Prodelphus: www.prodelphus.com.br from Brasil. Look at the website and you will found a lot of accesories to put into evas for training in diferent tipes of disections and sutures. Dr. Marcos Lyra the owner of Prodelphus is a Gyn who knows about laparoscopy and Hysteroscopy and he is a very Smart designer of these models for endoscopic surgery training

Diego

I could not agree with your comments more!

This is why the EGG equipment we use  is the 3CPM equipment which is the only one  with an NIST certified signal detection process .  This s also the reason why we use a water load  as  a nonnutritive  stimulant to the stomach that avoids the  activation of enzymes that affect motility when giving a nutritive meal.  In addition the standard clinical water load protocol  with this EGG device has population-based norms , based upon 60 normal patients who underwent Electrogastrography on four separate occasions. Therefore the patient's results are compared to these norms.  This provides the data for the gold standard that you are referring to.  There is no other manner to diagnose functional outlet obstruction other than the detection of  excessively high  normal range three cycle per minute activity that increases to even higher levels and percentages  following the administration of the water load stimulus.

The functional pyloric outlet obstruction diagnosis, was actually quite a different mechanism  of action compared to that of bradygastria or tachygastria.  Bradygastria is actually a lack of conduction issue  which can be affected by many metabolic conditions, thus the variability.  Tachygastria is equally difficult because that is usually mostly reentrant rhythms  or disordered rhythms that spiral out of control  which is more often associated with poor ICCs.

The ICC concept is actually one of the more exciting ones that has good  histological evidence that clearly demonstrates that poor three cycle  per minute activity in association with elevated tachygastria  positively correlates with degradation of the ICCs.

You are right, it is an annoying problem. Even in case you perform a cautious preparation it might happen that you get a leackage. In such a case we use a Verres needle via the subumbilical incision (next to the camera) as you describe, with overall good results.

As one of the steering comittee and working group  of the above mentioned Guidelines I'd like to comment: The paper of Ismail on closed suction is the only one! There are very few  groups which use systematically Drainage in TEP (e.g. Prof. Koeckerling, Berlin). There's another interesting approach to large indirect sacs described by Daes J in Hernia (2014) 18:119–122 DOI 10.1007/s10029-012-1030-2

Hi Samuel, that is an interesting input:

I have used V-Loc 180 for many years in e.g. hernia surgery, and am aware of that barbed sutures are popular for staple line reinforcement in bariatric surgery. Personally, I have been hesitant to use a permanent suture with multiple sharp points close to delicate structures suh as the esophageal wall.

You obviously have several years of experience. With how many cases? Have you never seen any long-term complications?

The best and easiest technique is the Orvil device by Covidien. The technique as described above by Dr. Kumar Reddy.

Reassure. Wait and wait and wait, but never attempt aspiration. Aspiration may induce mesh infection. Majority resrobed completely with time.

Truncal vagotomy in a diabetic pt may lead to worsening of gastroparesis.  Stenosis can also occur also by over stretching of the bowel walls between the stapled line (concertina effect)

If a foreign body is present without doubt, it should be extracted if the surgical risk is not prohibitive. Open abdominal exploration seems the best approach. Once you have diagnosed it, you have to inform the patient about what happened and what you are intending to do to help her. Failure to do so is potentially dangerous to her and to yourself.

Hasson'n method of pneumoperitoneum is rarely causing bowel injury according to the literature, however this could happened and the reasons are :1. Fixation of the bowel by previous laparotomy or peritonitis.

2. Poor trocar insertion technique. 

In this case it is not clear whether the injury happened by first trocar or right side trocar?

this can be  judged by the size and site of injury and also by knowing whether 5 or 10 mm trocars are used at which site.

It's coming without saying that bowel injury Should be always assumed as through and through injury rather than single injury.Checking the other side of the bowel to exclude this possibility is crucial.

The management of small bowel enterotomy in this case is by primary closure in majority of cases. Resection and reanastomosis would be an aggressive approach . For colonic injuries this is different and several options including bringing the site of injury as stoma , primary closure and drainage is depending on time of diagnosis ,degree of contamination ,bowel preparation status and surgeon experience .

Very interesting question, with a difficult answer. I totally agree with you, with the term "biliary cripple". Indeed, quality of life in these unfortunate patients could be ruined in the long term.

However, characterising a procedure as minor or major is the resultant of many factors. One should take into consideration not only an isolated case (or cases) of complications. Patients may die even after the most "simple" operations like hernioplasty. This does not necessarily mean that hernioplasty is a major operation. It is frequently performed by first-year residents, under local anesthesia and a day-case protocol. The days of Bassini are long gone... I mean, of course, that every procedure has to be performed in the best possible and responsible way. From that point of view, every time our scalpels touch a patient, it is a major challenge. 

However, taking into consideration the morbidity rate, the mortality rate, the complication rate, and stratifying the overall risk, then I would say that lap. cholecystectomy is an intermediate procedure. 

Insurance companies have classified surgical interventions in categories. I have found the BUPA Schedule of procedures on the internet. You may have a look there. Just for a general idea:

Skin biopsy is minor

Hernia repair is intermediate

Lap. Chole is major

Right hemicolectomy is major+

Pancreatectomy is complex

Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.

Efficacy of virtual reality versus wet-lab training is indeed a topic of interest in medical education. As a learner, I feel that wetlab using animal model has the advantage of increased realism and use of the actual surgical instruments, whereas virtual reality simulator provide automated feedback which helps identifying potential weak points/ area for improvement.

From my recent Simulation based learning workshop, I came to aware that on top of modality and/ or fidelity of the simulator, effective simulation exercise should be integrated into curriculum (not as standalone) with well planned briefing, instructional design, debriefing and feedback. I find this a good read- Simulation in Medical Education by Ker et al- http://onlinelibrary.wiley.com/doi/10.1002/9781444320282.ch12/summary

Suturing of pelvic peritoneum is life saving to avoid peritonitis in case of likage.

Usually we pu two drains. In case of leakage with stable patient, Iirrigation with betadine ghrough one drain and 

Robotic surgery, computer-assisted surgery, are terms for technological developments that use robotic systems to aid in surgical procedures. In computer-assisted surgery, the actual intervention is defined as surgical navigation. Using the surgical navigation system the surgeon will use special instruments, which are connected to the navigation system to touch an anatomical position on the patient. This position is simultaneously shown in the images taken from this patient. The surgeon can thus use the instrument to 'navigate' the images of the patient by moving the instrument.

"Wikipedia"

The purpose of this procedure was to diminish gastric acid output and to preserve the correct gastric drainage. This goals were achieved by posterior truncal vagotomy and highly selective anterior vagotomy with preservation of the vagal branches that are for the antro-piloric region. The association of fundo-plication was justified because of an extensive dissection of the hiatal region in order to discover the trunk of the  posterior vagus nerve. The anterior one was treated at the level of the superior branches before entering the gastric wall, above the gastric angle. In our department we did performed less than 10 procedures before the year 2000. it was a time-consuming procedure, with not so good results and today we have a better understanding of the mechanisms of ulcero-genesis and far better medication to heal the ulcer. As Prof. Pierre Verhaeghe has already said , today this procedure is history.

Very very excellent question! The same as what I want to ask.

It's true as indicated by above answers that in a broad sense, surgical quality could be evaluated by numerous layers of parameters: blood loss, postoperative recovery, pain, patient experience, you name it. I can assure you, viewing in this bird-view angle, it is impossible to evaluate surgical quality or the quality of a surgeon.

Answer my question first: what is a SURGEON? What makes you different from other physicians? What makes you proud of what you are doing?--- Yes! SURGERY! YOU ARE "FIXING" A LIVING PERSON AND SAVING LIFE WITH YOUR KNIFE AND NEEDLES!!!

A long time ago, it was said that a surgeon should have "eagle's eyes, a lion's heart, and women's hands". I was inspired by these words and struggled out of my country to come here to join the team of the best. I don't know how many of you guys still remember this verse, but I'm sure no one is paying any attention to it. However, from my "stupid" point of view, this is EXACTLY the parameters you MUST look for to qualify a surgery and a surgeon--- A profound vision into surgical science, a superior knowledge-based decision maker, and the finest skillful craftsman with prudent responsibility. This is the core parameter that decides the outcome of a surgery. This decides all other above mentioned measures. Yet you are asking: how to measure these?!

I tell you, it's very simple, but I'll ask: do you DARE and do you really CARE? All these properties boils down to only one element: "Surgical skill". If a surgeon, who loves surgery, looks at his operation from the point of view of a craftsman, he would die to make his surgery flawless. And a flawless operation will beat all the indirect measurements like hospital stay, patient feeling, what-so-ever! In such an advanced world, this is very easy to achieve: every surgery should be recorded with video and sound, then reviewed anonymously by a board of superior surgeons. Scores placed on intraoperative bleeding, intraoperative decision making, collateral damage level, surgical cleanliness, intraoperative patient status, suturing skill, tying skill, incision skill, fine movement of instruments, etc. I'll assure you, if you really do so, you will see a tremendous difference between our current attendings. You will be shocked to see why some guy is still working here! How he was selected to be a surgeon!? So answer my question: do you dare to?

Quality control by this means would be most efficient and cost-effective, because this catches problems in ahead, instead of wasting resources to "manage" them after they do occur, which though is the requirement of "evidence-based-medicine", correct? :) LOL

Unfortunately, the quality of surgeons is drifting downwards these years globally. We have a saying: " to attend to the superficials and neglect the essentials". Way too much emphasis placed on candidates' communication skills and their ability to handle textbook knowledge or even their research experiences, but ignoring the most important part of a surgeon: his potential on mastering surgical skills. We are producing more speakers instead of doers. I was told that surgical skill is not viewed as an essential part of surgery......

I have experience with open and laparoscopic repair of recti diverication.

Majority of these patients had associated umbilical or paraumbilical hernia.The operation will address both conditions.

The main issue is the post-operative pain. Both techniques will cause significant post-operative pain ,however it may be less with laparoscopic repair.PCA is of great help in my patients.Hospitalization can be up to 5 days,it can be shorter up to 2 days with laparoscopic approach.

Patient satisfaction is great especially for young slim women who had previous pregnancy.I agree with my colleague that recti diverication does not fit the entire definition of the hernia but it is a musckoloskeletal problem that need to be considered for correction.Not offering a solution simply because it is not  a hernia,just like saying to to the patient who has been diagnosed with cholecystitis [without stone/acalculous cholecystits] I don't operate because you don't have stone.

Selection of the patient for surgery is the corner stone.Not all recti diverications need surgery.Obese patients,patients with ASA3 and more to be avoided.

Laparoscopic or open technique will be tailored to the specific case and whther or not patients had previous laparotomy. .

Ideal method of sterilisation is autoclaving. Autoclaving takes too long and hence in between cases, it may be difficult to use unless you have many sets of instruments. An alternative to this is using gas plasma steriliser which is expensive. There are also high speed flash sterilisers which can give you rapid 15 minute cycle of steam sterilisation.

For the cables and tubings, better to put them in plastic covers or autoclaved sheaths like the camera cover to prevent damage from sterilisation and glutaraldehyde. 

Stump appendicitis are and should be very rare in laparoscopic era. This is a condition seen only in the early stage of the learning curve.

Hi everyone! does anyone knows a website that I can use to do an on line survey other than survey monkey? Please help if you do. Thanks for reading.

One of my bosses a renowned Vascular surgeon made me wait for 21 days in a patient with ileus after I had done a leaking AAA repair. Every day he kept saying, "son patience is a virtue" I was told to make sure the patients urea and electrolytes were kept corrected. To my surprise it did work. Most of us as surgeons tend to be knife happy and possibly do not give nature enough chance to seat with the problems. Thank God i have never had this problem ever again.

PRVC or VCV can be used. In most of the ventilators in anesthesia machine, PRVC mode is not available so VCV is the most common option. RR (respiratory rate) should be adjusted (increased) accordingly to keep the ETCO2 within normal range. In Trendelenburg position, head is lowered and abdominal contents pushes the diaphragm upward so small tidal volume is preferred (6-8 ml/ Kg of ideal body wt.).

Hello Frederic,

thank you so much for your reply. Surgery was postponed and the patient was accessed in an multidisciplinary board as you just mentioned.  After medical management over a 12 - week - period, laparoscopic cholecystectomy was performed. Surgery and recovery were uneventful.  

It is worth noting that patients with such conditions are not frequently candidates for elective procedures. However, i agree with you that the JACC guidelines were very helpful in this cases.

Once again, thank you for your reply.

PA

Ferdinando, I'm glad to read the same newspapers.

If you want to predict the future, try to create it yourself (with a little help of all friends) 

This is an interesting discussion. Laparoscopic procedures following transplants have been widely described in the literature .

Complications in surgery is enevitable. It is like day after night. But we have to minimize them and salvage them as early as possible if it is not possible to prevent them at all. They say prevention is better than cure!

My take on this topic is a bit different. If it is only serosal injury nothing has to be done. Unfortunately  it is very difficult to determine whether it is only serosal injury during laparoscopy for obvious reason. The most important thing here is if it is a full thickness injury than it can create great morbidity and mortality. The mortality of 3.6% has been reported for small bowel perforation during laparoscopy. This is mainly because of miss injury presenting late to the hospital after discharge.

Varoius factors are responsible for electrocautery injury during laparoscopic surgery. Like the Energy mode ( Monopolar or bipolar), Current wave form (Cutting or coagulation - coagulation causing more damage at same level of power) and Surgical Technique ( Expertise of the surgeon, dexterity, tissue proximaity and dwell time or contact time). More over instrument failure like insulation failure, coupling and direct coupling can lead to this type of  injury.

So how  to prevent them- Have basic knowledge of electrosurgical biophysics, choose the appropriate current wave and mode, improve dexterity and hand eye co-ordination, bowel preparation in advanced laparoscopic procedures, team training and education and heightened alertness and zero tolerance for repair.

If the injury is more than serosal, two layers repair of the gut is mandatory.

Dr. Suman Das is a plastic surgeon in Flowood, Mississippi and is affiliated with multiple hospitals in the area, including River Oaks Hospital and St. Dominic-Jackson Memorial Hospital. He received his medical degree from RG Kar Medical College Calcutta and has been in practice for 47 years. He is one of 14 doctors at River Oaks Hospital and one of 7 at St. Dominic-Jackson Memorial Hospital who specialize in Plastic Surgery. He also speaks multiple languages, including Hindi/Urdu and Bengali.

Dear Raza and all,]

Thank you for starting a nice topic. I will give my answer and operative strategy and reasons:

Dr. Heemskerk is making sense, but almost certainly in cases of acute incarceration I would recommend a swift (with 4-6 hrs) operation and do an open modified McEvedy approach. This without a doubt gives the best access for every contingency. Anyone doing a low Lockwood and lower midline is missing out on a much more elegant and sensible approach. A low approach that requires cutting the inguinal ligament is not ideal also, as is a Lotheissen approach which inherently weakens the inguinal canal and thus necessitates mesh in a case where translocation of gut organisms and transient bacteraemia is likely. TAPP is an option but will double the operating time I suspect in most peoples hands.

The modified McEvedy as I do it (unlike the description from Peter McEvedy from Manchester in the 1950's) is through a transverse incision about 4cm above the ipsilateral inguinal (Poupart) ligament - somewhere midway between an appendix and an inguinal hernia incision. The original description was all vertical. Unlike the description once I get down to the fascia I open it transversely, i.e. EOA and anterior rectus sheath. If you now retract the rectus abdominis muscle medially, then inferiorly with a Langenbeck retractor and you will have a great view of the extraperitoneal space and femoral canal. Palpate the bony landmarks to orientate yourself if need be. Occasionally the epigastrics appear - ligate them.

Once you see the sac, apply external pressure to reduce it. If you struggle I divide the lacunar ligament (being cognisant of the possibility of an aberrant obturator artery!). The best way to do this is to place a Lahey forceps in the lacunar ligament very superficially (i.e. immediately under it) and diathermy its most lateral edge with the hand held finger-switch diathermy (Bovie) - often this is enough to release the sac. Then open it using clips, when you'll almost certainly find a Richter's hernia and wrap in warm wet swabs, and fix the defect.

The simplest and probably best way to do this is an emergency is to use braided suture i.e. Ethibond on a J needle. Inguinal to pectineal ligament - by the time this is complete you will notice that the bowel is viable. Naturally beware the femoral vein laterally.

Then a layered closure and post-op VTE prophylaxis, mobilisation and E+D as tolerated and your patient will be ready for home soon. Of note, I give 1 shot of ABx on induction and if the bowel is viable no further doses.

In the elective setting a low Lockwood approach is sufficient, and in those cases indeed a mesh can be used, either normal polypropylene cut as a long rectangle and rolled up as a cigarette and pushed in, or a Bard plug. To be honest, I think simple sutures work fine also. As I say, Dr. Heemskerk makes a point that a co-existing inguinal hernia can exists also, in which case TEP is an option. I suspect in the most NHS trusts, for a unilateral femoral hernia, would only fund open surgery.

Hope that helps!

BW,

John.

Intracorporeal suturing of the vaginal cuff is directly under laparoscopic vision and so is technically safer. The introduction of new sutures like Stratfix and V-lock sutures have revolutionised laparoscopic intracorporeal suturing with minimal morbidity .

None. Never. Because its crazy.

In my practice, I see a lot of laparoscopic Nissen fundoplication surgery I find a very deep block is required to prevent diaphragmatic movement. By this I mean a PTC of at least about 5. Hence i don't find this that helpful- the surgeon usually can detect the recovery of the diaphragm before my monitors (Because the surgeon is operating on the diaphragm, and it is the most resistant muscle to neuromuscular blockade,)

Of course the surgery finishes very quickly and it is difficult to fully reverse the patient quickly or is very expensive as a large dose of sugammadex is required.

I find that using a remifentanil infusion suppresses the diaphragmatic movements and allows the surgery to proceed even when the neuromuscular block has worn off. In some patients, a small top up of roc is required, but frequently not. Reversal is then not a problem, and the remi wears off quickly.

I think I will. Thanks

A photo of a patient who underwent laparoscopic sigmoidectomy by an umbilical zigzag skin incision technique 1 year ago. Can you see the scar? Almost invisible!

we were one of the first to start open HSV and it"s modification Taylor"s proceedure in India.By the time laproscopic era came the incidence of ulcer disease was treated with H2 rec antagonists and then ppis.Eventhough we have done both proceedures laparoscopically with good results,but now surgery for uncomplicated DU has become outdated and patients are well aware of it.Even for GERD surgery in this part of the Globe is slowly waning away.For a nonulcer disease with APD symptoms to offer HSV presently, are we justified?Probably the cycle will turn towards HSV with increased evidence of complications due tothe use of PPIs in future.Presently I would say NO for only acid peptic symptoms.

Most of the abdominal procedures are done by minimal access surgery in all teritiory care centres,I would expect the incidence of Laparatomy wound suppurations have become less.However it is worth while going through the literature as mentiond and audit our own cases.what is the significance as this depends on contaminted feild mostly.

My colleague just published an article regarding this:

"Jategaonkar PA1, Yadav SP. Mesh/Meshless paraumbilical hernia repair with concomitant single-incision transumbilical three-port laparoscopic cholecystectomy-prospective observational study of 126 patients. J Laparoendosc Adv Surg Tech A. 2014 Feb;24(2):60-5"

I usually do systematic reviews also. However I end up finding the heterogeneity of the studies that did not allow me to do a proper meta-analysis, thus end up being less rigorous in my exclusion criteria and lose a bit with that.

Recently our group is also involved in field work and starting randomized clinical trials.

We hope to contibuir with relevant information in the near future.

Sincerely.