Spigelian hernia occurs through slit like defect in the anterior abdominal wall adjacent to the semilunar line. Most of spigelian hernias occur in the lower abdomen where the posterior sheath is deficient. The hernia ring is a well-defined defect in the transverses aponeurosis. The hernial sac, surrounded by extraperitoneal fatty tissue, is often interparietal passing through the transversus and the internal oblique aponeuroses and then spreading out beneath the intact aponeurosis of the external oblique. Spigelian hernia is in itself very rare and more over it is difficult to diagnose clinically. It has been estimated that it constitutes 0.12% of abdominal wall hernias. The spigelian hernia has been repaired by both conventional and laparoscopic approach. Laparoscopic management of spigelian hernia is well established. Most of the authors have managed it by transperitoneal approach either by placing the mesh in intraperitoneal position or by raising the peritoneal flap and placing the mesh in extraperitoneal space. There have also been case reports of management of spigelian hernia by total extraperitoneal approach. We retrospectively reviewed our experience of ten patients between 1997 and 2007. Eight patients (8/10) presented with abdominal pain and two patients (2/10) were asymptomatic. In six patients (6/10) we performed an intraperitoneal onlay IPOM repair, in two patients (2/10) transabdominal preperitoneal repair (TAPP), and in two (2/10) total extraperitoneal repair (TEP). There were no recurrences, or other morbidity at mean follow up period of 3.2 years (range 6 months to 10 years).
Minimally invasive anal fistula treatment (MAFT) was introduced to minimize early postoperative morbidity, preserve sphincter continence, and reduce recurrence. We report our early experience with MAFT in 416 patients. Preoperative MRI was performed in 150 patients initially and subsequently thereafter. The technique involves fistuloscope-aided localization of internal fistula opening, examination and fulguration of all fistula tracks, and secure stapled closure of internal fistula opening within anal canal/rectum. MAFT was performed as day-care procedure in 391 patients (93.9 %). During surgery, internal fistula opening could not be located in 100 patients (24 %). Seven patients required readmission to hospital. Mean visual analog scale scores for pain on discharge and at 1 week were 3.1 (1-6) and 1.6 (0-3), respectively. Mean duration for return to normal activity was 3.2 days (2-11 days). Fistula recurrence was observed in 35/134 patients (26.1 %) at 1 year follow-up. MAFT may be performed as day-care procedure with benefits of less pain, absence of perianal wounds, faster recovery, and preservation of sphincter continence. However, long-term results from more centers are needed especially for recurrence.
Purpose Laparoscopy has become the standard surgical approach to surgery for gastrooesophageal refl ux disease (GERD) and hiatal hernia repair with excellent long-term results and high patient satisfaction. However several studies have shown that hiatal hernia repair, especially large hiatus are associated with high recurrence rate. Mesh reinforcement has been proposed for repair of large hiatus hernia. The objective of this study was to evaluate the role of mesh cruroplasty in management of large hiatus hernia (> 5 cm).Methods Between February 2002 to December 2007, 73 patients (28 men and 45 women) who underwent laparoscopic hiatal hernia repair with mesh cruroplasty were included in our study. Mesh reinforcement (cruroplasty) was used for repair of large hiatus hernia (>5 cms hernial defect). Mean age was 50.4 years (range 30-72 years). Follow up included barium swallow of patients at 3 months and yearly thereafter.Results Seventy-three patients underwent mesh cruroplasty for large hiatus hernia. We were able to adequately mobilise the oesophagus to achieve an intra-abdominal length of at least 3 cm in all patients. Intraoperative complication rate was 8.21% (6/73), intraoperative complications included pleural tear, bleeding from splenic capsule laceration and short gastric vessels. Postoperative complication rate was 4.1% (3/73), which included complete dyspahgia, atelactasis and pneumonia. Mean duration of hospitalisation was 3.5 days (range 3-9 days). Five patients (5/73) were lost to follow up. Four patients (5.8%) developed recurrence on routine follow up. No mesh related complications were noted on long-term follow up period. Mean follow up period was 3.2 years (range 5 months-6 years). ConclusionOur data supports the use of mesh in hiatal hernia repair, especially in large hiatus hernia as it leads to low recurrence rates. Longer follow up and more randomised controlled trials are needed to establish laparoscopic mesh cruroplasty as standard technique for large hiatal hernia repair.
Aim To analyze patient demographics, pathology, surgical procedure and outcome in initial 24 consecutive patients who underwent laparoscopic adrenalectomy in our department.Methods Twenty four patients underwent laparoscopic adrenalectomy between September 2000 and August 2005. There were 12 males and 12 females with a mean age of 44.6 years ( range 25-68 years ). The indications for adrenalectomy were pheochromocytoma (13 patients), Cushing's syndrome (5 patients), myelolipoma (2 patients), adrenal cyst (2 patients), aldosteronoma (1 patient) and adrenal incidentaloma (1 patient). Nineteen of our patients with functioning adrenal tumours were prepared preoperatively for periods ranging up to 2 weeks by the endocrinologist. All laparoscopic adrenalectomies were performed via lateral transperitoneal approach using standard four-port technique. Patients with pheochromocytoma and Cushing's syndrome were monitored in the surgical intensive care unit during immediate postoperative period. The clinical and intraoperative characteristics, complications and outcomes of all patients were analyzed. ResultsThe mean operative time for laparoscopic adrenalectomy was 136 minutes. Intraoperative hypertension occurred in 8 patients. Intraoperative hypotension occurred in 2 patients. One patient required conversion due to dense adhesions and hemorrhage. Postoperative complications were seen in six patients -immediate postoperative hypotension (2 patients), features of steroid withdrawal (2 patients) and postoperative pyrexia (2 patients). Five patients with pheochromocytoma required antihypertensive drugs in the postoperative period. There was no mortality in our series.Conclusions Laparoscopic adrenalectomy is a safe operation that incorporates all the benefi ts of minimal access surgery and is associated with a satisfactory postoperative outcome . A careful preoperative preparation in functioning adrenal tumours aids in the faster recovery of these patients.
A surgical procedure comprises of two aspects-the surgical access and surgery on the target organ. For decades, general surgeons focussed their minds to propel development in the latter, i.e., surgery on the target organ. Trauma due to surgical access was considered inevitable. Patient discomfort, debility, and disfigurement were considered to be a small price the patients were paying in the larger interest of surgical cure. The advent of minimal access surgery revolutionized the concept of surgical practice. The approach placed the patient at the center of all surgical decisions. It was for the first time that the comfort and needs of the patient were given paramount importance. Through minimal access surgery, the trauma of surgical access has been dramatically minimized, with shorter hospital stay and greater patient satisfaction. Today, minimal access surgery is firmly established in the armamentarium of surgeons worldwide.The early postoperative sequelae following management of anal fistulae in terms of postoperative pain, need for dressings, and time taken off work has not been reported much in literature. Mostly, long-term outcomes in terms of recurrence and incontinence have been addressed in studies reported so far. Traditional techniques including fistulectomy and use of cutting seton have been associated with incontinence, especially in patients who have had previous surgery. Mucosal advancement flaps are technically challenging and are associated with high recurrence rates and high rates of incontinence postoperatively.Although surgical field has undergone significant evolution over the past few decades, the surgical management of the perianal anomalies is yet to witness a technological breakthrough. Apart from treatment of hemorrhoids, there have not been many surgical innovations for perianal infective pathologies. The newer treatment options include use of fibrin glue, bio-prosthetic plugs, and ligation of intersphincteric fistula tract (LIFT) and video-assisted anal fistula treatment (VAAFT). LIFT procedure has been associated with good healing rates. The early results with the use of VAAFT have been encouraging so far.The video-assisted anal fistula treatment (VAAFT) was developed by Professor P. Meinero in 2006 [1]. However, we strongly feel and advocate the terminology of minimally invasive anal fistula treatment (MAFT), which is much more appropriate and is the correct description of the procedure. MAFT qualifies as a true minimal invasive surgical procedure. There are no iatrogenic incisions for access on the patient. Surgical access is obtained from a pre-existing pathological opening of the fistula. The technique comprises identification and secure internal closure of the internal fistula opening and visualization with cauterization of the fistulous tract using a specially designed fistuloscope. The MAFT is based on the same principles as other procedures for closing the internal opening and obliterating the tract with the innovation that allows precise identification of the fistula anatomy...
Videoendoscopically assisted vascular surgery for iliac and aortoiliac occlusive disease by a combined retroperitoneal and pelvic extraperitoneal approach is feasible and appears to confer many advantages of minimal access surgery. However, prospective randomized trials are needed to define clearly any advantages of this approach over conventional surgery.
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