Introduction: Appendicitis is more common in children and young adults. Treatment of appendicitis is either laparoscopic appendicectomy (LA) or open appendicectomy (OA) surgery. Aim and objective: The 30-day postoperative morbidity, surgical site infection, and reoperation rate were compared between open and laparoscopic appendicectomies for complicated appendicitis. Secondary outcome measures were the length of hospital stay, duration of surgery, surgical waiting time, identification of other diseases, and patient satisfaction. Materials and methods: This retrospective study was conducted in two institutions: Hospital Selayang, Selangor, Malaysia, and HUKM, Kuala Lumpur, Malaysia. Data were collected from January 2014 to December 2015 were reviewed. Results: The mean age (±SD) for LA and OA were 32 (±15) and 30 (±14) years, respectively. The males showed predominance in LA and OA with 52 and 72%, respectively (p < 0.001). The majority of LA (73%) and OA (88%) were performed by the trainees (p < 0.001). There was a significant reduction in postoperative morbidity in LA compared to OA in terms of surgical site infection, LA vs OA [n = 8 (2.7) vs 26 (6.3), p = 0.029] and duration of surgery [LA vs OA 84 (±39) vs 68 (± 6) days (p < 0.001)]. However, for LA and OA, there were no significant differences in reoperation, 0.7 and 1.0%, respectively (p = 1.000), and length of stay in LA vs OA 3.55 (±2) vs 3.89 (±3) days, respectively (p = 0.103). Overall, patient satisfaction scores were not found statistically significant as the response rates were only 32% in LA and 30% in OA. Conclusion: LA significantly reduced surgical site infection and offered an advantage in the detection of other pathologies. Hence, a laparoscopic approach should be offered to patients whose clinical diagnoses are challenging.

Context: Hysterectomy is the most commonly performed gynecological procedure around the world. Hemostasis is of major concern in an enlarged uterus as chances of hemorrhage are more. New laparoscopic vessel sealing devices have been developed for laparoscopic tissue dissection and vessel sealing. In this study, an ALAN vessel sealer, an indigenous electrothermal bipolar vessel sealing device, is compared with ENSEAL device with respect to safety, efficacy, and perioperative outcomes in laparoscopic hysterectomy for a large uterus. Aims and objectives: This study aimed to determine the efficacy and safety of electrothermal bipolar vessel sealer (ALAN vessel sealer) vs ENSEAL in total laparoscopic hysterectomy (TLH) for a large uterus. Materials and methods: This prospective randomized case–control study included 100 women who underwent TLH for a large fibroid uterus. Of them, 50 women underwent TLH using ALAN vessel sealer, and the remaining 50 using ENSEAL. Efficacy, safety, and perioperative outcomes of both the groups were compared. Statistical analysis: Statistical analysis was done using SPSS version 16.0 software. For evaluating continuous variables and discrete variables, independent T-tests, and Chi-square tests, respectively, were used. Results: Duration of surgery in ALAN vessel sealer group was 56.90 ± 12.45 minutes and in ENSEAL group was 57.25 ± 13.54 minutes (p = 0.9) and mean blood loss in group A and group B was 111.40 ± 22.32 and 107.84 ± 20.33 mL, respectively ( p = 0.4), both of the data were not statistically significant. No significant differences were noticed in the demographic characteristics, intraoperative, and postoperative complications between the two groups. Conclusions: The ALAN vessel sealer is safe and as efficient as ENSEAL in decreasing blood loss and operative time when laparoscopic hysterectomy is performed for an enlarged uterus. It is cost-effective and a promising instrument for TLH in developing countries.

Aims and objectives: Acute appendicitis is the most common surgical disease with a lifetime risk of 7–8%. Numerous studies have shown many benefits of laparoscopic appendectomy over open appendectomies, such as better visualization and identification of other abdominal pathologies that can mimic acute appendicitis. Herein, we illustrated the current incidence of non-appendicitis pathologies during laparoscopic appendectomies in our hospital. Materials and methods: A retrospective study was carried out involving patients operated for acute appendicitis laparoscopically at the Surgical Emergency Unit, Zagazig University Hospitals, Egypt, during the period from March 2017 to December 2019. The diagnosis of acute appendicitis was based on clinical examination, laboratory findings, and ultrasonography. We drew out the patients’ demographic data, duration of surgery, and surgical procedure reports. Results: One hundred forty-five patients presented clinically, and confirmed by laboratory and ultrasonography with the diagnosis of acute appendicitis. Eighty-nine were males, 56 were females. The median operative time was 56.5 minutes. Eight cases (5.5%) showed a pathology other than acute appendicitis, including gynecological pathologies, Mickel's diverticulitis, inflamed sigmoid appendices epiploica, low-grade appendiceal mucinous neoplasm, and inflamed cecal diverticulum. Conclusion: Diagnosis of acute appendicitis is challenging up to date. We faced many conditions mimicking acute appendicitis during surgical intervention.

Background: Nowadays, the “gold standard” treatment for gallbladder stones is laparoscopic cholecystectomy but the risk of iatrogenic biliary duct injuries is increased compared to “open” surgery. Intraoperative cholangiography (IOC) can be useful to avoid biliary injuries but it can also be a no-safe procedure in center in which it is not routinely performed. Aim and objective: The aim of our study is to trust the efficacy of IOC in a patient with common bile duct (CBD) and gallbladder stones using a biliary-nose tube. Materials and methods: 135 patients with gallbladder and CBD stones were treated with sequential therapy and randomly divided into two groups. Laparoscopic cholecystectomy was performed within 24/48 h. During endoscopic retrograde cholangiopancreatography, a biliary-nose catheter was left to perform cholangiography during the following surgical procedure. Group A had also a cholangiography at the beginning of the surgical procedure in order to evidence biliary duct structure. Results: Cholangiography avoided a lesion of the biliary ducts in nine patients. Only a patient had a residual stone in the CBD. The dissection at Calot's triangle was faster in group A patients without differences between the surgeons involved. Conclusion: The biliary-nose tube can be useful in patients with gallbladder and CBD who underwent cholecystectomy for different reasons: it lets the surgeon performing IOC faster and without risk linked to the technique used; it reduces the risk of biliary injuries; and surgeons feel more safe and calm during the surgical procedure.

Background: The utilization of minimal access surgery (MAS) is rising in developing countries. Robotic surgery is rarer. The mirage surrounding operating with a telescope is completely changing the dimension of surgery. A young trainee finds it difficult to properly perform this surgery. Aim and objective: This study aimed to elucidate an experience of minimal access surgeons practicing in a developing economy with the hope of stimulating a young trainee surgeon in the same field of study. Materials and methods: This was a review of prospectively collected data of cases performed, stored electronically in an Excel spreadsheet and statistical software, Epi info, from December 2017 to March 2020. This review included laparoscopic procedures, colonoscopies, and esophagogastroduodenoscopies (OGD) performed by the author in a tertiary hospital and two private centers. It excluded all cases assisted by the author. The results were analyzed using statistical software, SPSS version 23. Results: A total of 195 cases were performed. Esophagogastroduodenoscopies consisted of a maximum of 114 cases. This was followed by colonoscopies (52 cases), and laparoscopy (29 cases). The laparoscopic cases consisted of laparoscopic cholecystectomy (6), diagnostic laparoscopy (11), laparoscopic appendectomies (8), laparoscopic fundoplication (1), and foreign body retrieval (1). This study showed a gradual shift from mild to more complex minimal access procedures. Conclusion: Performing minimal access procedures requires extensive training. Findings from this study will guide a young trainee in a developing economy to perform the easily available surgery procedures.

Introduction: Repair of inguinal hernia is one of the commonest performed surgical procedures worldwide. Usually, a seroma develops in large inguinoscrotal hernias. Generally, a seroma is a cause of significant distress for the patient since it may recur. If the possibility of seroma formation is discussed with the patient before surgery, it may go a long way in alleviating the patient's distress. Seromas are common after large hernia repair and direct hernia repair. Materials and methods: In this observational study, 50 patients were randomly selected from LG. Hospital (AMC MET Medical College, Ahmedabad, India) who went through TAPP hernioplasty for an inguinoscrotal hernia after a complete explanation of conversion to open as well as post-operative seroma formation. Since all cases were indoor patients, they were initially reviewed on the next day morning after the operation and the next examination time point was seven days later for seroma development. All the patients were followed up at 6 weeks and then every month for 6 months up to 1 year. Results: Out of 50 patients, 44 (88%) patients had an indirect hernia and 6 (12%) patients had a direct hernia. The seroma developed in only three patients (6%) who were managed conservatively with only medicines. Within the follow-up period, no patients had pain, seroma, and recurrence. Conclusion: In some cases of large scrotal hernia, the distal sac was difficult to be inversed or the hernia sac even adhered firmly to the ipsilateral testicle and other structures. In those cases, avoiding inverting the distal sac and leaving the distal sac in place means to avoid dissecting out the distal sac observed lesser occurrence of the seroma. That suggests that the laparoscopic method can help prevent or decrease the chance of the development of seroma in the unilateral inguinoscrotal hernia.

Background: Obesity is a worldwide epidemic and exercise supplemented with pharmacotherapy has poor long-term results; thus, bariatric surgery is the mainstay therapy for morbid obesity. But reduction in weight and BMI after bariatric surgery is not the same and mainly depends on the type of surgery performed. Aim and objective: To study the comparative efficacy among three bariatric surgeries viz. Laparoscopic gastric imbrication (LGI), laparoscopic sleeve gastrectomy (LSG), and laparoscopic Roux-en-Y gastric bypass (LRYGB) in morbid obese patients in relation to weight loss and reduction in BMI. Study design: Prospective study. Materials and methods: Total of 40 morbid obese patients underwent different types of laparoscopic bariatric surgery and were followed for 1 year. Reduction in weight and BMI after 1 year was correlated with the type of bariatric surgery performed. Statistical analysis: Paired t-test, analysis of variance (ANOVA), Bonferroni. Results: Patients undergone LGI, LSG, and LRYGB had a preoperative mean weight/BMI of 105.33 kg/41.07 kg m⁻², 104.07 kg/42.76 kg m⁻², and 105.8 kg/43.27 kg m⁻², respectively; and postoperative mean weight/BMI after 1 year was 87.4 kg/34.08 kg m⁻², 81.07 kg/33.32 kg m⁻², and 81.2 kg/33.18 kg m⁻², respectively. On applying ANOVA and Bonferroni, LSG and LRYGB group had greater weight loss and reduction in BMI as compared to LGI group. Conclusion: LSG and LRYGB are statistically better in weight and BMI reduction in obese as compared to LGI. Although weight and BMI reduction was more in LRYGB as compared to LSG, it was not statistically significant.

Background: Laparoscopic supracervical hysterectomy (LSH) is a minimally invasive alternative to total laparoscopic hysterectomy (TLH), which is a common procedure in developed countries. The study aimed to evaluate the safety (risks vs benefits) of LSH in the Indian scenario when compared with TLH in terms of intraoperative and postoperative outcome measures. Furthermore, quality of life (bladder, bowel, and sexual functions) was also evaluated. Materials and methods: A prospective randomized study among 30 patients with benign uterine pathology for hysterectomy was included in the study. Patients were divided randomly into LSH (n = 15) and TLH (n = 15) groups. Intraoperative outcome measures, such as operation time, blood loss, and visceral injuries were noted. Postoperative outcome measures included absolute change in hemoglobin (Hb), duration of hospital stay, pain, urinary complaints (retention, dysuria), and bladder, bowel and sexual functions for 6 months. Results: Demographic data were comparable in both groups. The operating time and blood loss were more in LSH than TLH group, (p = 0.29 and 0.37). The absolute change in hemoglobin was more in LSH group than TLH group (p = 0.001). Postoperative pain was indifferent in both the groups on postoperative day 0 and day 7 but it was significantly less in LSH group on day 1 (p = 0.03). Duration of hospital stay was similar in both groups. No patient required readmission. Patients in TLH group took a lesser number of days to return to routine activity compared to LSH group. The postoperative bladder, bowel, and sexual functions were comparable. The incidence of post-LSH vaginal bleeding was 13.3%. No vault prolapse was noted at the end of 6 months follow-up. Conclusion: Laparoscopic supracervical hysterectomy is safe and efficacious as TLH for benign uterine pathologies but has no extra benefits rather is associated with a persistent risk of developing cervical diseases and malignancy.

Aim and objective: To validate the efficacy of proposed scoring system compared to the Randhawa scoring system in prediction of difficult laparoscopic cholecystectomy (LC) preoperatively. Materials and methods: A prospective study was conducted including 102 patients who underwent LC for symptomatic cholelithiasis. Preoperatively a score was given to the patient according to both scoring systems. Final outcome was decided on intraoperative findings of operative time, adhesions, and bile spillage. Univariate and multivariate analyses of preoperative factors were done. Receiver operating characteristic (ROC) curves of both the scoring system were compared, and the results were reported as a difference in proportion (95% CI). p value <0.05 was considered as statistically significant. Results: The specificity and positive predictive value of the modified scoring system were 92 and 95.1% which was higher than Randhawa scoring system, i.e., 76 and 87.5%. Area under ROC curve was also more in modified scoring system. Also, univariate analysis found age >50 years, history of hospitalization, previous endoscopic retrograde cholangiopancreatography, diabetes mellitus, palpable gallbladder, gallbladder wall thickness, and contracted gallbladder on ultrasound to be statistically significant factors. Conclusion: The proposed modified scoring system significantly increases the specificity and positive predictive value of the Randhawa scoring system. This scoring system is easy to perform, require no additional investigation and can effectively categorize patient where LC will be difficult. Clinical significance: The proposed scoring system can effectively predict difficult preoperatively which would help in better preoperative preparation by the surgical team for a difficult laparoscopic cholecystectomy. Patients can be optimally counseled preoperatively so that they are well prepared for various outcomes of the procedure.

Background: Nausea and vomiting are one of the most common postoperative complications that cause unpleasant feelings and delays in the discharge of patients. This study aimed to compare the effect of aprepitant, ondansetron, and their combination on the severity of nausea and vomiting after this procedure for finding a safe and less indisposition regimen. Materials and methods: This study was performed on patients aged 18–50 who had been diagnosed with symptomatic cholelithiasis and who underwent laparoscopic cholecystectomy under general anesthesia. This study was done single-blinded. Patients were categorized into three groups (the recipient of aprepitant, the recipient of ondansetron, and the group receiving ondansetron and aprepitant simultaneously) and the rate of nausea and vomiting was measured at 6 and 24 hours after the operation. Results: The results of one-way analysis of variance analysis and Kruskal–Wallis showed that there was a significant difference between the treatment groups regarding the severity of nausea and vomiting after surgery (p < 0.001). The severity of nausea and vomiting in the group receiving ondansetron plus aprepitant is less than the other two groups. Conclusion: A combination of ondansetron plus aprepitant can reduce nausea and vomiting after surgery while the effect of aprepitant is much more than ondansetron.

Background: Inability of gastric contents to go beyond the proximal duodenum is termed as gastric outlet obstruction (GOO). This may be partial or complete. A multitude of causes, benign/malignant, may lead to GOO of gastric and extra gastric origins. Malignant GOO is a common condition among locally advanced gastric cancer patients. One of the relative contraindications for surgery is the presence of advanced malignancy; in these cases, in which life expectancy may be limited to a few months, palliative surgical measures may improve the quality of life. The role of the laparoscopic approach in the treatment of GOO is under investigation and may represent a valid form of therapy with low morbidity. Materials and methods: This was a retrospective study conducted in the Department of General Surgery, Government Medical College, Srinagar, from May 2018 to May 2019. A total of 35 patients who were diagnosed as cases of non-operable malignant GOO were included in the study. All patients underwent laparoscopic stapled gastrojejunostomy after diagnostic laparoscopy. This study was aimed at operative time, time for making anastomosis, hospital stay, return of bowel sounds, and postoperative complications. Results: Mean age of patients in our study was 66.8 years with male predominance. Mean operative time was 94.35 minutes with a mean time of 20.4 minutes for making stapled anastomosis. Mean hospital stay, return of bowel sounds, and resumption of orals were 7.9, 2.28, and 3.85 days, respectively. Bleeding from the anastomotic site was noted in three patients and anastomotic leak was noted in one patient. Conclusion: Laparoscopic stapled gastrojejunostomy is a viable option for palliation in advanced cases of non-operable malignancies leading to GOO. It is associated with less operative times and less immediate postoperative complications. However, further studies are needed before laparoscopic stapled gastrojejunostomy is taken up as a standard for non-operable cases of malignant GOO.

Introduction: Studies show very few articles addressed left-handed surgeons and their problems. Difficulties occur in using the tools and methods that have been invented by right-handed surgeons. Some previous studies have shown that surgical left-handed residents have much less skilled hands. This study aims to describe some changes that were made that led to 40 safe and comfortable cholecystectomy procedures. Materials and surgical technique: The most important changes compared to the standard method are about trocar placing to improve alignment for a left-handed surgeon. Result: Forty surgeries using the modified methods were done and in comparison to the standard method were much smoother, faster, and with fewer side effects. Discussion: By our modification left-handed surgeons can improve their safety and their comfort during operations and expand their skills in this regard.

Laparoscopic cholecystectomy (LC) is a widely performed procedure worldwide, and it is one of the safest surgical interventions, with few short- and long-term complications. The presentation of post-LC acute pancreatitis (AP) is quite rare and with few reports over time. This case report relates the case of a 34-year-old woman who, 12 days after surgery, presented with AP with no other apparent cause, in addition to which a right renal mass was found incidentally. This case presents us with a rare complication of a fairly safe surgical procedure; however, it should serve to carry out a good follow-up of postoperative patients in the first weeks above all in order to prevent complications.

Median arcuate ligament syndrome also known as Dunbar syndrome is caused by compression of the celiac axis by the median arcuate ligament. It typically presents with postprandial epigastric pain, weight loss, and vomiting, with the incidence being two cases per lakh in the third to the fifth decade.

Aim: Aim of reporting this case is to show the feasibility and outcomes of laparoscopic splenectomy in hydatid disease of spleen. Background: Hydatid cyst is a zoonotic disease and it can affect humans. It can involve any organ; liver is the most common organ to involve, and in rare cases spleen could also be involved. Isolated splenic involvement is even rarer. Management is splenectomy. Laparoscopic splenectomy is feasible if uncontrolled spill is avoidable. Here we are presenting a case of laparoscopic splenectomy in an isolated splenic hydatid cyst. Case description: A 41 years old lady presented with left upper abdominal Pain for six months. There was no chest or other abdominal complaints. Examination revealed a palpable spleen. Ultrasonography abdomen, contrast-enhanced computed tomography, and hydatid serology help to diagnose splenic hydatid, cystic echinococcosis type. Vaccination and perioperative albendazole were administered. She underwent laparoscopic splenectomy. Standard steps were followed to prevent spillage. The specimen was delivered through Pfannenstiel incision. Cut-section demonstrated hydatid membranes. Conclusion: Isolated splenic hydatid is rare and rarely managed laparoscopically. It should be practiced when expertise available. Clinical significance: Rare entity of isolated splenic hydatid cyst could be treated by laparoscopic method without causing any perioperative spill or complications and preserve all benefits of laparoscopic surgery in presence of expertise.

This article presents a case report of the laparoscopic removal of a large gastric trichobezoar in a 13-year-old girl. We reviewed the various laparoscopic techniques and their modifications described in the literature for removal of gastric trichobezoar. Advantages and disadvantages of various techniques were also discussed.

Background: Intestinal malrotation is a congenital anomaly, wherein the midgut fails to rotate completely or partially during the early embryological developmental phase. The rotation is usually counterclockwise at 270° around the axis of the superior mesenteric artery (SMA). Malrotation is most commonly seen in pediatric population with the majority of patients presenting in their early childhood before the first year of life. Acute duodenal obstruction due to midgut malrotation in an adult is a rare manifestation. Therefore, midgut malrotation should be the differential diagnosis in an adult with bowel obstruction. Case description: We present a case of a 26-year-old male who presented with acute-onset abdominal pain with multiple episodes of bilious vomiting. Contrast-enhanced computed tomography of the abdomen (CECT) revealed intestinal malrotation with all parts of the duodenum (D1–D4) toward the right of the midline. The patient underwent an emergency laparoscopic Ladd's procedure. Postoperative recovery was uneventful. Conclusion: Adult patients with vague abdominal symptoms should raise a high index of suspicion for malrotation. An early and prompt diagnosis will prevent fatal complications associated with this disease and can be managed laparoscopically by Ladd's procedure.

Background: The positioning of a slit mesh around cord structures during laparoscopic transabdominal preperitoneal (TAPP) hernia repair rests the mesh better without kinks, thereby minimizing recurrences. However, studies also suggest that insufficient closure of the mesh slit may lead to recurrences. Aim: This report describes a novel technique using AbsorbaTacks (Covidien) to close the mesh slit and refashion an artificial ‘deep ring’ to minimize recurrence. Technique: We report the case of a fit 82-year-old Caucasian male presenting with a recurrent large right indirect inguinoscrotal hernia (8 x 8 × 7 cm with 4 × 4 cm deep inguinal ring). The patient underwent a TAPP repair with a background of unsuccessful open repair by another surgeon previously. Following mesh deployment, the mesh was lifted up by the cord structures, which was under tension due to a large defect. A slit was made in the inferomedial aspect of the mesh. This allowed it to be wrapped around the cord structures. The overlapped trouser flaps were then stapled together encircling the cord, by AbsorbaTacks to create a secure artificial ‘deep ring’. Edges of the mesh were also standardly affixed by AbsorbaTacks to the pectineal ligament and posterior abdominal wall. This creates a secure four-point fixation of the mesh scaffold to prevent ‘windsock’ effect, which happens when the mesh is pushed into the widened deep inguinal ring, leading to early recurrences. The peritoneal incision was also closed with AbsorbaTacks. Conclusion: No complications were registered during the early postoperative period. The patient had an uneventful recovery and was discharged within 20 hours with simple analgesia. No recurrence was reported during the 6 months follow-up period. Clinical significance: The anchoring of a slit mesh with tackers around the cord structures can be used to repair large recurrent inguinal hernias laparoscopically following an open repair. This technique potentially minimizes further recurrences.