Introduction: There is an increase in the prevalence of work-related musculoskeletal diseases among laparoscopic surgeons. Hence the assessment of ergonomics becomes important in identifying and preventing them. The use of artificial intelligence (AI) and computer vision in the assessment of ergonomics is easier and more accurate than conventional methods. Its adaptation into laparoscopic ergonomics is limited. Methodology: This was a prospective observational study conducted at Victoria Hospital. Laparoscopic surgeons were observed while performing various laparoscopic surgeries. Postures held for more than 30s and repetitive movements were photographed and imported onto an AI posture evaluation software. The software detected various facial and neck landmarks and then calculated parameters such as the craniohorizontal angle (CHA), craniovertebral angle (CVA), straight sagittal posture (SSP), upper head posture (UHP), lower head posture (LHP), and vertical posture (VP). The reports obtained from the software from various postures across multiple surgeries were tabulated. Data analysis was done using SPSS 23 software and reported using descriptive statistics. Results: The mean CHA, CVA, and SSP were 22.19 ± 7.02, 44.70 ± 18.90, and 58.90 ± 15.24, respectively. The corresponding medians were 21.75 (25.20–16.75), 44.00 (49.10–35.70), and 56.65 (68.55–44.92), respectively. The mean UHP, LHP, and VP were 8.36 ± 5.71, 9.13 ± 8.24, and 14.80 ± 12.64, respectively. The corresponding medians were 7 (11.52–3.60), 6.25 (14.12–3.07), and 11.5 (17.25–7.12), respectively. Rounded shoulder posture (RSP) was present in 53.33% scenarios, and forward head posture (FHP) was present in 93.3% scenarios. Conclusion: The technology of AI makes the assessment of ergonomics much easier and more accurate. Further developments in the software are needed for real-time assessment of postural ergonomics. The development of customized software catering to the specific needs of laparoscopic ergonomics would be ideal. Clinical significance: Artificial intelligence can open up new horizons for the assessment of ergonomics, making the assessment much easier, quicker, and more accurate than the existing methods.

Introduction: Laparoscopic cholecystectomy is the GOLD STANDARD in the treatment of symptomatic cholelithiasis which has replaced the open cholecystectomy as a treatment option since Philip Mouret did the first lap cholecystectomy in the year 1987. Despite its feasibility and acceptability in some cases it becomes quite difficult to proceed laparoscopically and is converted to open cholecystectomy which is associated with increased risk of morbidity. If we can identify the preoperative factors associated with increased risk of conversion then one can optimize operative room efficiency and improve intraoperative planning to avoid surgery-related complications. Aim of the study: To identify factors that can predict difficult laparoscopic cholecystectomy using clinical and radiological parameters which can be assessed by the Randhwa and Pujahari scoring system. Materials and methods: This was a prospective observational study conducted from July 2021 to October 2022 at the Department of General Surgery, SCB Medical College, Cuttack. Total of 150 USG-diagnosed symptomatic cholelithiasis patients were included in the study. Total 9 parameters were taken into consideration to assess the preoperative difficulty. These parameters were: (1) Age (2) Sex (3) Previous history of hospitalization for acute cholecystitis (4) BMI (5) Abdominal scar (6) Palpable gall bladder (7) Gall bladder wall thickness (8) Pericholecystic collection (9) Impaction of stone. The statistical analysis was done by Chi-square test. Results: Out of 150 patients included in this study 90 (60%) were easy, 50 (33.3%) were difficult and 10 (6.66%) were very difficult which required conversion to open. The overall conversion rate was 6.66% which was within the acceptable conversion range, i.e. 1–13%.

Background: Cholelithiasis is one of the most common problems affecting the digestive tract. Laparoscopic cholecystectomy (LC) is the gold standard treatment for symptomatic cholelithiasis. This procedure though mostly safe and uneventful can be difficult at times. A lot of problems can be avoided by correct preoperative prediction of difficult cholecystectomy. Many studies have attempted to create a scoring system to predict difficulty in LC. One such scoring system was devised by Randhawa and Pujahari. Objective: The aim of our study was to ascertain the validity of this scoring system in our hospital scenario. Materials and methods: This was a prospective study conducted at District Hospital Anantnag, a rural healthcare center located in the valley of Kashmir, India, from September 2016 to September 2018. Out of 327 patients admitted for LC were enrolled. Each patient was assigned scores preoperatively based on the history, clinical assessment, and sonographic findings as described by Randhawa and Pujahari. All intraoperative events like duration of surgery, bile stone spillage, and injury to duct/artery were recorded. Postoperatively, we defined the surgical procedure as easy, difficult, and very difficult as described by Randhawa and Pujahari. Results: The mean age of patients in our study was 43 years. In our study, we observed that age >50 years, male sex, body mass index (BMI) >27.5, history of hospitalization for acute cholecystitis, palpable gallbladder on clinical examination, and thick wall gallbladder on sonography were statistically significant predictors of difficult LC. The sensitivity, specificity, positive predictive value and negative predictive value of this scoring system as reported by us are 86.41, 79.76, 92.51, and 67%. Conclusion: We conclude that the scoring system of Randhawa and Pujahari for the prediction of the difficulty of LC applies to rural settings and has high sensitivity, specificity, and accuracy.

Aim: To study benefits and complications of continuous ambulatory peritoneal dialysis (CAPD) catheter placement laparoscopically with suture fixation technique. Patients and methods: A total of 41 cases of end-stage renal disease [chronic kidney disease (CKD) – Stage V] were admitted in Jehangir Hospital, Pune. Patients were evaluated, after explaining the procedure, the risks and benefits they were prepared for the procedure. Patients were assessed for complications and mortality as well as the reason for discontinuation of CAPD. Results: Of 41 cases studied, 39 (95.2%) had CAPD started, in 1 (2.4%) CAPD was not started and 1 (2.4%) did not have CAPD inserted. Of 41 cases studied, 28 (68.3%) had CAPD continued successfully for 2 years. Of 41 cases studied, 4 (9.8%) had catheter outflow block, 4 (9.8%) had peritonitis, 6 (14.6%) had ultrafiltration failure, 3 (7.3%) had exit site leak, 1 (2.4%) had catheter malposition/kinking, none had incisional hernia, 2 (4.9%) had hemoperitoneum. A total of 10 patients (24.4%) had catheter removed at the end of the study. Conclusion: Approximately, 68% of patients, that is 28 patients out of 41 continued CAPD for 2 years after the catheter was inserted laparoscopically. Out of the 41 patients, 20 patients developed minor complications. Out of the 20 patients, 10 patients developed major complications and needed the catheter to be removed. Mortality was 9.8%, out of which two patients died of sepsis and 2 died of comorbidity-related complications. Clinical significance: Laparoscopic CAPD catheter placement is an effective method and has good success rate with less complications and better patient tolerability.

Objective: The objective of this study was to evaluate the safety profile and efficacy of “flank-free modified supine position (FFMS)” approach for percutaneous nephrolithotomy (PCNL). Materials and methods: This study was conducted in the Department of General Surgery over 4-year period from August 2016 to August 2020 on 50 patients after institutional ethical clearance. Results: The patients in our study were in the range of 21–65 years with mean age of 35.9 SD 9.85 years. Approximately, 62% of patients were males and right kidney was involved in 54%. The mean stone size of our study group was 17.3 SD 1.81 mm with a range of 14.2–21 mm. Pelvic stones were found in 28 (56%) of patients and majority of our patients, i.e., 88% were symptomatic of their disease. The mean operative time in our study was 83.62 SD 16.95 with range of 60–115 minutes. Nephrostomy was placed in situ in 84% patients. There was no operation related mortality in our study. The mean hospital stay of our patients was 3.7 SD 1.15 days. Out of total 50 patients, success was achieved in 45 (90%) patients as 6% required auxiliary treatment and 4% was converted to prone position. Conclusion: Thus, in our study we found that FFMS PCNL surgery is a safe and an effective means of intrarenal access with high success rate and with acceptable morbidity and complications.

Aim: To describe alternative port placement techniques for three-port laparoscopic appendectomy. Background: Appendectomy remains to be the most accepted course of management for appendicitis. Alternative port placement technique described below aids the operating surgeon by providing a better working position and cosmesis. Materials and methods: A total of 50 patients from July 2021 to July 2022 were admitted to the Surgical Department of Sheth LG General Hospital, AMC MET Medical College, who fulfilled predetermined criteria and underwent laparoscopic appendectomy with this technique of port placement using one umbilical camera port and two working ports in LIF and RIF, are included in this study. Results: Of 50 patients, 28 males (56%) of mean age 24.33 (±3.25) years and 22 females (44%) of mean age 27.05 (±4.25) years were operated for laparoscopic appendectomy. In two patients (4%), appendectomy approach was converted to open. Conclusion: This technique of three-port laparoscopic appendectomy is safe and does not require a significant learning curve. It allows better ergonomics for handling the appendix, especially for transfixation of the base without compromising good cosmesis.

Background and objective: Benign neurogenic tumors are relatively rare in the pelvis and are mostly benign. These tumors are in proximity to multiple structures given the bony confines of the pelvis and its complex anatomy, thus making it a surgical challenge. From the conventional open surgical approach, we have moved on to laparoscopic excision. We sought to analyze the outcomes of surgical excision of such tumors. Materials and methods: Data of patients who underwent excision of benign pelvic neurogenic tumors either by open or laparoscopic surgery at our institution between 2016 and 2022 were reviewed and analyzed. Results: A total of seven patients underwent surgery, four by laparotomy and three by laparoscopy. Six patients had tumors located in the presacral space, and one was found in the lateral wall of the pelvis. The mean operative time was less in laparoscopy (140 vs 125 minutes), with a mean blood loss of 100 (90–110) mL. The mean duration of hospital stay was less in laparoscopy (7 vs 4 days). Three patients of open surgery had postoperative complications whereas no complications occurred after laparoscopy. Postoperative pathological examinations showed three schwannomas and four neurofibromas. No patient experienced local recurrence during a mean follow-up period of 30 months. Conclusion: Laparoscopy is a feasible alternative approach to open surgery for resection of pelvic neurogenic tumors with the advantages of better visualization and preservation of pelvic neurovascular structures, minimal operative morbidity, lesser postoperative pain, and shorter hospital stay.

Aim: To determine the difference in the rate of surgical site infection (SSI), duration of hospital stay, and cost of treatment in single-dose (SD) (2 gm cefazolin) vs multiple dose (MD) antibiotic prophylaxis in elective laparoscopic cholecystectomy. Study design: Single-center prospective observational cohort study – 160 patients (80 in each arm). Place and duration of study: Surgical Department, Kasturba Hospital, Manipal, India, from Jan 2021 to July 2022 Materials and methods: Patients of both genders age >18 years, irrespective of their comorbidity status were selected if they fulfil the eligibility criteria. They were described about the nature of the study and written consent was taken if they were willing to take part in the study and placed in their respective groups based on the antibiotic, they received according to the operating surgeon (SD grouped received SD of Cefazolin 2 g before surgery, MD received MD of antibiotics). All the surgical procedures were carried out as regular standard of care. All patients were followed up for 1 month and data was collected regarding their hospital stay, final bill and SSI. Results: There is no significant difference in the rate of surgical wound infections between SD (cefazolin 2 g) and MD antibiotic prophylaxis for elective laparoscopic cholecystectomy (p = 0.216). The single-dose group had a slightly shorter length of hospital stay (0.48 days) (p = 0.278) and a significant difference in the cost of hospitalization (Rs 7,756) (p = 0.001). Conclusion: When it comes to preventing SSIs after laparoscopic cholecystectomy, prophylaxis with an SD of cefazolin 2 g is equally effective as MDs of antibiotic prophylaxis. Moreover, the SD regime has the advantage of a comparatively shorter hospital stay as well as lower treatment costs for the patient.

Introduction: Colorectal malignancies are one of the most common cancers diagnosed globally. Minimally invasive surgery has gained importance in treating these cancers. However, there is still skepticism with regard to their oncologic outcomes compared to open surgery. With this study, we aim to compare and evaluate both modalities of therapy. Materials and methods: We conducted a prospective, observational study at Kasturba Hospital, Manipal, Karnataka, India between 15 September 2019 and 15 September 2021. A total of 79 patients were recruited in the study and considered in the final analysis, out of which 33 underwent surgery by laparoscopic technique) and 46 underwent surgery by open technique. Both groups were weighed against each other in relation to oncologic outcomes, complications of the surgery, duration of stay in the hospital, cost, and other variables. Results: Both groups were similar with respect to oncologic outcomes, surgical complications, duration of stay in the hospital, and cost. Conclusion: Laparoscopic surgeries are comparable to open surgeries for colorectal cancers with regard to outcome, complications, and cost and should be considered when planning surgery for such malignancies.

Introduction: Many factors contribute to pain after laparoscopic appendectomy. We devised a method to reduce pain after laparoscopic appendectomy by wrapping the cecum with the greater omentum. This study aimed to investigate the effectiveness of this method. Materials and methods: This study was conducted to compare the operative and postoperative outcomes in patients with omental wrapping and traditional laparoscopic appendectomy patients. The primary endpoints were the degree of postoperative intra-abdominal pain intensity evaluated by visual analogue scale (VAS), and analgesic use. The secondary endpoints were the operation time, time to pass gas, white blood cell count, C-reactive protein (CRP) on the second postoperative day, numerical rating scale for postoperative nausea, frequency of antiemetic medications frequency, and length of hospital stay. The study was registered in the International Standard Randomised Controlled Trial Number (ISRCTN) registry (ISRCTN 89363255). Results: This study evaluated 106 patients. Fifty patients were assigned to the traditional group and 56 to the wrapping group. Pain scores in the first postoperative 24 hours were significantly higher in traditional group patients (p = 0.007). Between 24 and 48 hours, pain score was also higher in traditional group patients (p = 0.01). Time to pass gas was achieved earlier in the wrapping group (p < 0.001). Conclusion: Omental wrapping of the cecum and appendix stump in laparoscopic appendectomy can provide postoperative pain relief by reducing the intensity of visceral pain.

Introduction: Complicated peptic ulcer is one of the most common abdominal emergencies presenting in our institution settings bringing patients from Eastern Odisha. The high patient load forces us to seek out another standardized method apart from the surgical intervention in our study. Materials and methods: A cohort study was conducted in a Tertiary Care Hospital with 120 patients after confirmation of a pyloro-duodenal location of the perforated ulcer and allocated to the surgical vs stent group. Results: Percutaneous drainage was required in fifteen patients due to intra-abdominal abscess (C-D 3). Postoperative leak was observed in six patients and showed leak at leakage test and received a new stent without further complication (C-D 3). Five patients needed postoperative intensive care in the ITU, requiring temporary circulatory and renal support. Unfortunately, three patients in poor condition upon admission did not survive (C-D 5). Conclusion: Stents had an affirmative role for management in complicated patients of peptic perforation.

Aims and background: Postoperative seroma is a common complication of laparoscopic mesh repair of direct inguinal hernia. Several kinds of attempts have been made to reduce its incidence though they are not without problems. The aim of this study was to evaluate the efficiency of a new alternate technique that must be safe and with fewer complications, using a widely available and inexpensive pre-tied suture loop (endoloop) for plication of the weakened transversalis fascia (TF)/pseudosac. Materials and methods: A prospective cohort study of 47 patients diagnosed with a total of 63 direct inguinal hernias during a 57-month period fit for laparoscopic tranabdominal preperitoneal (TAPP) meshplasty. Each of the M2 or M3 direct defects, according to the European Hernia Society (EHS), was systematically repaired by TAPP using pre-tied suture loop application at the base of TF. Patients were reviewed during follow-up at 2, 6 weeks, and 1 year after the operation to look for primary postoperative outcome parameters, i.e., seroma formation; secondary outcome parameters, i.e., groin pain, wound infection, and recurrence. Results: During the follow-up period, no patient presented with seroma formation and wound infection. Only two patients had complaints of groin pain at 2-week follow which was resolved by analgesics and there was no hernia recurrence after a follow-up of 1 year. Conclusion: Application of a pretied suture loop at the base of TF during laparoscopic repair of direct inguinal hernia is cost effective, safe method and does not increase the risk of seroma formation and recurrence. Clinical significance: Seroma formation is a major concern for surgeons as well as patients during postoperative period following laparoscopic inguinal hernia repair. The development of a cost-effective, reliable technique with the least or no seroma formation and recurrence prevention is needed at this time.

Aim: To analyze laparoscopic transabdominal preperitoneal (TAPP) mesh fixation and non-fixation in the perioperative outcome and cost-utility for inguinal hernia repair. Patients with groin hernias were introduced to laparoscopic TAPP repair to reduce the possibility of recurrence and other complications. Postoperative pain and nerve injury may be exacerbated by mesh fixation. Following preperitoneal inguinal hernia repair, there is controversy as to whether mesh should be fixed to prevent recurrences. Materials and methods: From the month of February 2017 to January 2018, 60 patients with inguinal hernias were studied prospectively. Using the TAPP approach under general anesthesia (GA) by the same team, thirty hernias were selected randomly and repaired with the fixation of mesh, and the other thirty ones were repaired without mesh fixation with no attention to the type of hernia (direct or indirect) or the size of the defect. Routine clinical examinations were performed for 6 months on all patients as a regular follow-up. Results: The operative time ranged from 37 to 92 minutes, (with a mean time of 60.44 minutes) in the mesh fixation group and from 40 to 83 minutes (with a mean time of 54.9 minutes). In the mesh fixation group, 15 cases were Rt indirect inguinal hernias. In the mesh non-fixation group, 18 cases were Rt indirect inguinal hernia. The length of the hospital stays ranges from 1 to 3 days with no significance. No statistical significance was noted as regards operative time, intraoperative injury, hospital stay, mesh migration, nerve entrapment, and postoperative analgesia. The significance was observed in cost-utility which represented the cost of trackers mainly. Conclusion: No recorded significance as regards operative time, intraoperative injury, hospital stay, mesh migration, nerve entrapment, and postoperative analgesia within the analysis of laparoscopic TAPP mesh fixation and non-fixation. Clinical significance: Mesh without fixation is a viable method and less costly that has the same benefits and excludes risks of fixation.

Introduction: Lymph node metastasis is one of the most important factors determining survival in most malignancies. Better lymph node yield improves survival in many cancers. We tried to analyze the laparoscopic surgical washings for the presence of lymphatic tissue/deposits to improve information on nodal involvement. Saline is instilled and washings are sucked out during laparoscopic surgeries. How much information on lymph node involvement is lost because of these washings not being analyzed is an important question we wanted to answer. Materials and methods: We prospectively evaluated the surgical washings of patients undergoing laparoscopic surgery at our institution from May 2022 to December 2022. All patients with biopsy-proven malignancies who underwent laparoscopic surgery including regional nodal assessment were included in the study. These included patients with carcinoma cervix, carcinoma stomach, carcinoma esophagus, and carcinoma rectum. The only exclusion criterion was not having proof of malignancy through biopsy. The pelvic nodes were separately removed in an endobag for patients with carcinoma cervix, minimizing spillage. The surgical wash fluid obtained from routine irrigation and suction of the surgical field with 0.9% NS (minimum of 1L) was collected. Unfractionated heparin of 1 mL was added to the fluid. After 24 hours, the solution would be centrifuged and analyzed by the pathologists. Suspicious tissues would be analyzed for the presence of lymphoid material and tumor deposits. A total of 50 patients were analyzed, which included 32 patients with carcinoma cervix, eight patients with carcinoma stomach, four patients with carcinoma esophagus, and six patients with carcinoma rectum. Results: Amongst the 50 patients studied, none of them had the presence of lymph nodes in the surgical wash fluid. Conclusion: A simple analysis of the surgical washings of patients undergoing laparoscopic cancer that included nodal dissection failed to provide better information on nodal involvement. With the background of limitations of our study, better handling of fluid irrigated and sucked out may lead to better information. But as of now, analysis of irrigation fluid during laparoscopic surgery is not useful.