Background: The most feared complication during laparoscopic cholecystectomy (LC) is bile duct injury. Real-time intraoperative imaging using indocyanine green (ICG) reduces the risk of bile duct injury by improving visualization of the biliary tree during laparoscopy. This effect will also shorten operative time and hence reduce the dangers of prolonged operation time. It also subserves the diagnostic value in its use in the liver function test. Aim: This study was aimed to elucidate the role of ICG as an investigative tool that aids the operative procedure of laparoscopic cholecystectomy. Materials and methods: The analysis of case series of ICG laparoscopic cholecystectomy in our hospital—the World Laparoscopic Hospital, Gurgaon, India. Results: In all the cases, fluorescent cholangiography using intravenous injection of ICG has become the optimal tool to confirm the biliary tract anatomy during LC because it has potential advantages over radiographic cholangiography in that it does not require irradiation or dissection of the triangle of Calot. This early visualization of the cystic duct and additional imaging of the common bile duct (CBD) may increase safety in LC and offers an alternative to the intraoperative cholangiogram in patients with increased risk of CBD injury. Conclusion: Laparoscopic cholecystectomy with real-time ICG fluorescence cholangiography enables a better visualization and identification of the biliary tree and therefore should be considered as a means of increasing the safety of LC.

Background: Laparoscopic surgery has changed many ways in which we as surgeons manage patients, offering better results, quicker recovery, and fewer complications using minimally invasive techniques, especially in common bile duct (CBD) surgery. Not only can laparoscopic techniques be applied to programed surgery but also emergencies and those following failed endoscopic retrograde cholangiopancreatography (ERCP). Objectives and aims: Describe and compare clinical and surgical results of the laparoscopic CBD exploration with primary closure using a 3-port vs multiport approach. Materials and methods: We present a multicentric comparative study of 197 consecutive patients who underwent a laparoscopic gallbladder removal along with CBD exploration with primary closure following failed (ERCP to extract CBD stones; 104 patients were managed by three-port vs 93 multiport laparoscopic surgery in five centers of Bogotá, Colombia, between 2013 and 2017 with follow-up of 1 year. Results: A total of 197 patients were taken to laparoscopic gallbladder removal along with CBD exploration with primary closure, 104 patients via three-port technique and 93 patients via multiport. All (100%) the patients had previously failed ERCP. The average surgical time on the three-port approach was 106 minutes vs 123 minutes on multiport. Only in the multiport technique we had an average conversion of 2%. Mean hospital stay of 2.5 days, less for the three-port approach vs multiport in 5–7 days. There was a need of reintervention in 1% of the patients who underwent three-port exploration. Conclusion: Postoperative pain, use of an additional port, complication rates, operation time, and cost of the three-port technique were similar to those of the conventional approach. Large randomized controlled trials are needed to examine the true benefits of the three-port technique.

Complex pyogenic liver abscess (CPLA) is a rare fatal disease if untreated. Complex pyogenic liver abscess is a multilocular abscess more than 5 cm in diameter. Pyogenic liver abscess (PLA) is mainly treated by percutaneous aspiration or drainage under antibiotic cover. Surgical drainage is indicated if interventional radiology fails, if ruptured, or if associated with biliary or intra-abdominal pathology. Laparoscopic drainage is a promising management option. Aim: To evaluate the safety and efficacy of laparoscopic drainage as a management of complex pyogenic liver abscesses in comparison to open surgical drainage. Materials and methods: Combined retrospective and prospective comparative study of 48 patients having complex PLA who were admitted to NHTMRI and managed by either laparoscopic drainage or open surgical drainage from January 2012 to January 2020 as regards results, complications, perioperative morbidity, mortality, and possible recurrence. Twenty-six patients were managed by open drainage, and 22 patients by laparoscopic drainage. Culture sensitivity of pus was done for all patients. Patients having small, solitary, and unilocular PLA that responded to antibiotic treatment or/and percutaneous drainage were excluded. All patients were subjected to full clinical assessment, laboratory investigations, ultrasonography, computed tomography, or magnetic resonance images for the abdomen and pelvis. Results: Forty-eight patients having complex PLA with a median age of 54.5 years were managed by either laparoscopic drainage (22 patients) or open surgical drainage (26 patients). The operation time and hospital stay were less, and oral feeding was started earlier in laparoscopic group. Wound infection was higher in open drainage group. Abscess recurrence occurred once in laparoscopic group and once in open surgery group, and both were successfully treated with percutaneous drainage. One laparoscopic operation was converted to open. Conclusion: Both laparoscopic and open surgical drainage of PLA are safe and effective. Laparoscopic drainage has less operative time, morbidity, and hospital stay; however, open drainage is considered the management of choice for patients with severe sepsis or failed percutaneous drainage.

Background: Laparoscopic cholecystectomy is considered “gold standard” for the treatment of gallstone disease. In spite of the increasing number of laparoscopic cholecystectomies being performed as day care surgery in the West, the surgeons of developing countries are reluctant to adopt this trend probably due to the inadequate resources and infrastructure which they consider a hindrance for safe discharge. Our study aims to assess the feasibility of day care laparoscopic cholecystectomies. Materials and methods: This is a prospective observational study. All patients undergoing laparoscopic cholecystectomy were assessed postoperatively for dischargeability using post-anesthetic discharge scoring system (PADSS). We assessed the factors delaying the early discharge of laparoscopic cholecystectomy patients in terms of patient factors, intraoperative factors, postoperative factors, social factors, and logistic factors. Results: Of the total 88 patients, 57 (64.7%) were dischargeable at 6 hours and 78 (88.6%) were dischargeable at 24 hours. Factors found to affect dischargeability of patients at 6 hours were acute cholecystitis and increased duration of surgery. Difficulty of surgery and the use of drain had significant association with nondischargeability at 24 hours. Eighteen patients were fit for discharge by PADSS criteria but not discharged at 24 hours. Factors, which delayed the discharge of these patients, were continuation of intravenous antibiotics, delay in processing insurance, patients’ unwillingness for early discharge, presence of drain, and surgeon's perceived fear of complications. Conclusion: Sixty-five percent of all laparoscopic cholecystectomies can be performed as day care procedure safely. Patients with acute cholecystitis and patients requiring an operative time more than 104 minutes should be observed for 24 hours.

Background: In pursuit of minimizing surgical trauma and achieving better esthetics by reducing the size and number of ports, this mini two-port technique was devised to offer an easier and safe alternative in comparison to conventional three-port technique. An easy and cost-effective mini two-port appendicectomy is made possible with a unique intracorporeal surgical knotting through a single 5-mm port with a single instrument, thus reducing number and size of ports and with a better cosmetic result. Materials and methods: Total 200 patients underwent laparoscopic appendicectomy out of which, mini two-port appendicectomy (TPA) with novel knotting technique could be successfully performed on 168 patients (84%) and remaining 32 patients (16%) required conventional three-port technique (CLA). None of the cases were converted to open. Results: Patient undergoing two-port laparoscopic appendicectomy had shorter operative time with better cosmetic result with no incidence of port-site hernia. There was no difficulty in adhesiolysis and intraoperative bleeding control. Infection rate was 0.59% and 3.12% for TPA and CLA, respectively. Incidence of intraoperative bleeding and intraoperative rupture of appendix was less in TPA (1.19% and 0%) as compared to CLA (6.25% and 3.125%). Mean hospital stay was less in TPA (1.7 days) compared to CLA (2.1 days). Conclusion: This mini two-port technique with novel knotting technique is easy to learn and helps to overcome the challenges and limitations faced during two laparoscopic appendicectomies; however conversion to conventional approach in complicated cases is still advisable. It is safe and effective intermediate option from conventional three-port to SILS/NOTES/Endo GIA staplers.

Aim: Comparisons between open vs laparoscopic surgical methods for inguinal hernia repair have yielded inconsistent results with respect to patients’ pain levels and analgesic requirements post-surgery. This study compared open vs laparoscopic inguinal hernia repair in terms of types and quantity of analgesics administered during the postoperative recovery period and the hospital stay, including the influences of patient characteristics such as age, BMI, and previous inguinal hernia repair. Materials and methods: This was a cross-sectional study of retrospective analysis of data pertaining to inguinal hernia repairs in a rural hospital in Australia. Results: Among 63 patients (60 males), 62% had undergone open and 38% laparoscopic surgery for inguinal hernia repair. Type and dose of analgesic medications given during both the postoperative recovery period and the hospital ward stay and the duration of the hospital stay were not significantly different between open and laparoscopic groups. However, there were significant influences of BMI, with significantly more overweight and obese patients requiring a combination of opioids with nonsteroidal anti-inflammatory drug (NSAID) or paracetamol during the hospital stay, and with obese patients having the longest hospital stay, followed by overweight patients. Patients who had open surgery were significantly older and less likely to have had a previous inguinal hernia repair than those who had laparoscopic surgery, and there was a significant correlation between age and duration of hospital stay. Conclusion: Patient characteristics of age, BMI, and previous inguinal hernia repair are confounding factors when comparing analgesic requirements and hospital stay duration after open vs laparoscopic inguinal hernia repair.

Background: Laparoscopic ventral hernia repair (LVHR) is currently considered the gold standard. However, the mesh selection is still controversial. The aim of this review is to look for evidence that supports the use of polypropylene mesh (PPM) in the intraperitoneal position in LVHR. Materials and methods: The literature was searched systematically using Google Scholar and PubMed for controlled studies, prospective descriptive series, and retrospective case series. Results: A total of 11 studies were retrieved. All the studies were either retrospective or animal experiments. Their outcomes are heterogeneous and they have multiple weaknesses. Conclusion: The literature clearly lacks data from controlled randomized trials in humans that can give strong evidence. The use of intraperitoneal PPM in LVHR remains an individual surgeon preference decision until well-designed prospective double-blind randomized controlled clinical trials are available.

Background: In patients presenting pelvic pathology and a placed ventriculoperitoneal (VP) shunt, there is uncertainty regarding the decision whether to use laparoscopy. The aim of the article is to examine the available literature as well as sharing our own experiences operating on a patient with a VP shunt using laparoscopy. Materials and methods: We searched online libraries (PubMed, EMBASE, and Google Scholar) for all publications published between January 1975 and December 2018 on our topic. We performed a systematic review and shared our experience with laparoscopy in a patient with shunt and ovarian cancer. Results: The age of the patients ranged from 1 to 79 years. The operations were performed by the departments of general surgery, gynecology, and urology. The time from the shunt operation to laparoscopy ranged from 5 days to 28 years. In different articles, four important points were considered and discussed: the risk of a shunt infection or complication, technical difficulties carrying out laparoscopy in patients with a VP shunt, the necessity of routine monitoring of the intracranial pressure (ICP) intraoperatively, and perioperative strategies to avoid complications. Conclusion: It seems that a laparoscopic surgery in adults with a VP shunt appears to be a safe option. Based on the results of our case and the review of literature, we consider it necessary to have a neurosurgical consult performed prior to surgery, to have the procedure be carried out by an experienced surgeon, and to avoid complications by implementing recommended precautions.

Background: Ovarian dermoid is one of the commonly occurring ovarian neoplasms in young women but the occurrence of multiple dermoid cysts is comparatively rare. Case description: This is a case of 24-year-old woman who ignored her first diagnosis and management plan for a 3 × 3 cm dermoid cyst in one of the ovaries and later returned with severe symptoms of abdominal pain and vomiting and with a CT scan diagnosis of bilateral, large (7 × 7 cm) dermoid cysts. She was prepared for laparoscopic bilateral dermoid cyst excision, until the intraoperative scenario, revealing right-sided twisted bilobed dermoid cyst and left-sided twin dermoid cysts changed the original plan. Finally, the patient underwent right-sided ovariotomy with right-sided salpingectomy and left-sided twin dermoid cysts excision. Conclusion: Laparoscopy is the surgical mode of choice in dermoid presentations. Evaluation of contralateral ovary must be carried out while dealing with dermoid cyst of one ovary. Clinical significance: Torsion of a large dermoid cyst is not an indication for ovariotomy. However, ischemic dermoid cysts require an on-table judgement for cystectomy or ovariotomy. Laparoscopic management in skilled hands favors cystectomy. Examining contralateral ovary must be a routine while operating on a patient with dermoid cysts in ovary.

Background: With the ongoing advances in the field of laparoscopy, more and more of diaphragmatic repairs are being performed laparoscopically. All forms of diaphragmatic pathologies, such as congenital diaphragmatic hernia (CDH) including diaphragmatic eventration, hiatus hernia as well as traumatic diaphragmatic rupture, can be well performed through laparoscopy. Laparoscopic repair along with the advantage of improved vision and accessibility can also avoid large incisions, thereby reducing morbidity and long hospital stay, due to pain and lung complications, with early return to work. Materials and methods: A total of five cases underwent laparoscopic diaphragmatic repair at our center in 1 year duration. All cases were followed up with immediate postoperative and quarterly chest X-rays. Results: None required conversion to open. Diaphragm was reconstructed and reinforced with mesh. None had any postoperative complications. Follow-up postoperative chest X-rays were unremarkable. Conclusion: Laparoscopic diaphragmatic hernia repair is a feasible, acceptable, affordable, superior, and safe alternative to open repair with better short-term postoperative outcomes and a recurrence rate similar to the open approach.

Background: In females, lower abdominal pain (LAP) is a common presenting complaint that has a diverse etiology. It can involve reproductive, gastrointestinal, genitourinary, and musculoskeletal systems; therefore, accurate diagnosis is a clinical challenge. Laparoscopy has become the gold standard for the diagnosis and management of LAP. Aims and objectives: To diagnose the cause of LAP with laparoscopy and to correlate it with clinical examination and ultrasound. Materials and methods: A prospective study was conducted from December 2012 to January 2015 in JNMCH, Aligarh. Laparoscopy was performed on 84 patients with complaints of LAP (acute, subacute, or chronic). Data were statistically analyzed on the basis of the epidemiology, clinical features, ultrasound findings, and laparoscopic findings. Correlation of clinical, ultrasound, and laparoscopic finding was done. Results: With laparoscopy, diagnosis was established in 94.1% (n = 79) of patients. The most common cause of LAP was pelvic inflammatory disease (PID) present in 20.2% (n = 17) of patients followed by endometriosis in 17.9% (n = 15), ectopic pregnancy in 15.5% (n = 13), ovarian cyst in 15.5% (n = 13), genital TB in 7.1% (n = 6), etc. Therapeutic laparoscopy was performed in 82.1% (n = 69) of women, which included adhesiolysis, cystectomy, cystotomy, salpingectomy, salpingostomy fulguration of endometriotic lesions, ovarian drilling, myomectomy, and salpingo-ophorectomy. Conclusion: Laparoscopy can be used as the first-line interventional investigation for LAP. Besides diagnosis, it also has a therapeutic role. Therefore, it can be considered as a “see and treat” modality.